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NATIONAL HEALTH

"It's better for everybody when it gets better for everybody." Eleanor Roosevelt

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* a RATIONALE

community  driven      healthcare  reform

 

 

 

 

a    R A T I O N A L E

 

T o    b e g i n    a      n e w  s t r a t e g y      f o r    t h e    r e f o r m

o f    o u r    n a t i o n ‘ s    H E A L T H c a r e ,

c o m m u n i t y    b y    c o m m u n i t y

 

 

 

 

 

 

INTRODUCTION

 

 

” Consideration  for  others  is  the  basis

for  a  good  life,  a  good  society. “

Confucius      (  551  –  479  BC  )

 

 

 

” I  shall  pass  this  way  but  once;

any  good  that  I  can  show  to  any  human  being,  let  me  do  it  now.

Let  me  not  defer  nor  neglect  it,  for  I  shall  not  pass  this  way  again. “

Etiene  de Grillet      (  1773  –  1855  )

 

 

 

” It’s  better  for  everybody

when  it  gets  better  for  everybody. “

Eleanor  Roosevelt      (  1884  –  1962  )

 

 

 

” The  language  of  citizenship  suggests

that  self-interests  are  always  embedded  in  communities  of  action  and

that,  in  serving  neighbors,  one  also  serves  one-self. “

Benjamin  R.  Barber      (  1939  –        )

 

 

 

”  Well-Being,  when  defined  as  a  person’s  highest  prudential  good,

represents  Happiness  In  An  Objectively  Worthwhile  Life. ” (70)

Neera  K.  Bradhwar      ( 1947 –      )

 

 

Before getting started, please take a moment to read  again  the quotations cited above.  As represented by these authors, their view of a person’s life is similar to my own.  Do you also share their view of life? If so, you’ll probably agree with the next sentence about our nation’s healthcare.  The current efforts to reform our nation’s healthcare will not improve the health care offered for the Basic Healthcare Needs of every citizen.  This health care is often hard to locate or difficult to use because of its cost, the travel time to arrive at its location, or the need to pass through multiple institutional and emotional doors to arrive at its source.

For truly lasting healthcare reform, any new nationally sanctioned strategy must promote enhanced Primary Healthcare that is “equitably available” to each citizen within the  Survival Commons  of their own community.  Every other developed nation of the world has a nationally sanctioned strategy to assure the equitable availability of Primary Healthcare for each of their citizens, most for a long time. The absence of this priority contributes substantially to the failure of our current healthcare reform to achieve broad improvement in the over-all cost and quality problems of our nation’s healthcare.

For healthcare reform, I use the words “nationally sanctioned” to mean locally initiated, community sponsored, regionally promoted and nationally instituted.  And, I use the word  “enhanced”  to mean that this Primary Healthcare offers lasting  Caring Relationships  as the basis for promoting  Stable HEALTH  For  Each  Citizen.

Next, please accept a concept that fundamental healthcare reform must also require an improvement of its  social cohesion.  As its most defining character,  healthcare reform must improve the  social capital  within community of  @400,000  citizens.  Each community’s local commitment to improve its own  social capital  asset, simultaneously by nearly  800 separate communities, may represent just too many unknowns.  However, if a community focused strategy to improve its own  Survival Commons  could represent a plausible platform for our nation’s healthcare reform, please read on.

The remainder of this  Sub-Page  takes about  20-30  minutes to read.  It describes a plan to release the paradigm paralysis that is currently strangling our nation’s healthcare industry.  A focused paradigm shift will be required to release the unfocused power and disciplined sophistication of our nation’s healthcare. To achieve this paradigm shift, a  new strategy  should begin by slowly building momentum.  And then, more rapidly over 5-10 years, it should reconcile the  humanitarian  and  scientific mandates  for our nation’s healthcare with a renewed focus on the Basic Healthcare Needs  of each citizen.  Locally originated and maintained  collective action  will be required to improve the  Survival Commons  of their own community. 

               

TEN   BASIC  CONCEPTS  —  LET’S   BEGIN

 

Ten concepts should represent the basis for any discussion about healthcare reform. Each one of these concepts has not achieved a widely affirmed basis for their precise definition, especially for their individual inter-connection with the other  9  concepts.  To improve our understanding and ability to implement healthcare reform, each of the concepts should be defined with precise terminology that achieves a concise and powerful connection among the basic concepts.  As you will eventually perceive, these basic concepts represent the basis for promoting a new nationally instituted and implemented strategy, community by community.

Beginning with the definition for a  PERSON,  the other nine concepts, alphabetically listed, are:   CARING  RELATIONSHIP,   COLLECTIVE  ACTION,   CLUSTER,  COMMUNITY,   FAMILY,  HEALTH,   INSTITUTION,   SOCIAL  CAPITAL   and   SURVIVAL  COMMONS.   Together, they form a ‘new beginning’ to broadly reconfigure our nation’s strategy for healthcare reform, community by community.

 

 

P E R S O N      may  be  defined  as

^

a  fertilized  ovum  of  the  species   Homo Sapiens,

with  its  own  individually  unique   Clusters of Human Capabilities,

that  is  transformed  during  maternal  gestation

to  achieve  sufficient  perinatal   resilience   for  survival  at  birth.

 

 

 

C A R I N G    R E L A T I O N S H I P      may  be  defined  as

^

a  variably  asymmetric,  social  interaction  between  two   persons   that

begins  with  a   beneficent   goal  to  enhance  each  other’s   autonomy   and

flourishes  from  a  mutually  shared  obligation  to  communicate   in harmony

with   warmth,   non-critical acceptance,   honesty   and   empathy.

 

 

 

 

 

C L U S T E R      may  be  defined  as

^

a  grouping  of  two  or  more  components  representing

a  pivotal  capability  that  occurs  from

the  functional  contributions  of  each  component,

the  proximity  attributes  between  the  components  and

the  situational  conditions  surrounding  the  grouping.

 

 

 

 

 

 

C O L L E C T I V E    A C T I O N      may  be  defined  as

^

a    Cluster   of   persons   who  collaborate  to  define  a  vision  and  mission

for  improving  their  status  with  a  time-line  of  completed  tasks

that  the   persons   selectively  delegate  to  one  or  more  of  the  following:

the   Cluster’s  persons   themselves,  an  institution  chosen  by  the   Cluster   and

the  representative   persons   appointed  by  the   Cluster.

 

 

 

 

 

C O M M U N I T Y      may  be  defined  as

^

a   Cluster   of   persons   who  share  certain  uniformly  identifiable  attributes,

typically  as  the  citizens  of  a  geographically  defined   Municipality,

who  also  share  a  valued  awareness  about  their  interconnected  identity

that  is  borne  out  of  “mutually experienced events”  and

each   person’s   memory  of  the  ecological  and  cultural  traditions

associated  with  these  “mutually experienced events.”

 

 

 

 

F A M I L Y      may be defined as

^

a  Cluster  of  persons  that

^

      A.  Configures  itself to promote each  person’s  HEALTH  during their generational survival,  when  either

            1.  two  originating Independent persons  express a dedicated obligation to each other as affirmed by their marriage certificate or its common-law alternative   OR

            2.  one  additional Dependent person  becomes the custodial responsibility of an  originating Independent person  who is not married and has no current custodial responsibility for any other  Dependent person or persons;

^

      B.  Sponsors  the expression of kindness and respect by the  Cluster’s  persons  during their social interactions with the other  persons  who live within the same ecological niche;   AND

^

      C.  Pursues  a commitment to honoring a constellation of  Family Traditions  as a guide for the responsibilities of the  originating Independent person or persons  to:

            1.  Select and maintain a primary residence, usually located within a community neighborhood, as their Home for the housing capabilities required by each  person  of the  Cluster,

            2.  Promote  

                  a.  Caring Relationships  among the  persons  living within their Home and the  persons  living outside their Home who are each a member of either their  Extended Family  or a  Micro-Neighborhood Network  of their  Cluster,

                  b.  gatherings by the  persons  of the  Cluster  and their  Extended Family  to affirm the evolving ecological and cultural character of the  Cluster’s  Family Traditions,

                  c.  an individualized  Personal Survival Plan  for the  HEALTH  of each  person  within the  Cluster,

            3.  Accept  additional Dependent persons  into their Home, if a current  originating Independent person or persons  has an established custodial responsibility for each  additional Dependent person  as defined

                  a.  biologically through birth such as a parent, child or sibling  OR

                  b.  legally through adoption, guardianship, foster care or divorce,  AND

            4.  Accept  additional Independent persons  into their Home, if each  additional Independent person

                  a.  has the consent of the current  originating Independent person or persons  beginning on or before the date of the  additional Independent person’s  initial residence within their Home  and

                  b.  has a written  Personal Survival Plan  or a next-of-kin approved equivalent that includes:

                        i.  a notarized Will, power of attorney and medical power of attorney  and

                        ii.  provisions to manage the  additional Independent person’s  HEALTH  in the event the  additional Independent Person  becomes, or is possibly becoming, a  Dependent Person  who would not qualify as an  additional Dependent person  within their Home.

 

 

 

H E A L T H      may  be  defined  as

^

a   person’s   daily  expression  of   Well-Being   during  their  life-long  survival  that  is

^

Endowed  by  the   person’s   maternal  gestation  and  its  formation

of  sufficient  perinatal   resilience   for  the   person’s   continuing  survival  after  birth

as  a   Dependent Person   with  their  own  uniquely  adaptive

baseline homeostasis   and   innate temperament;

^

Nurtured  by  the   Caring Relationships   originating

before birth  within  the   Dependent Person’s   Family

to  encourage  the   person   explore  the  broadest  portrayal

of  their   reflective-cognition  Cluster of Human Capabilities

for  becoming  an   Independent Person   and

after birth  within  the   Extended Family   and

Micro-Neighborhood Networks   of  the   person’s   Family

to  offer  kindness  and  respect  for  enhancing

the   person’s   innate temperament,   especially  during  early  childhood;

^

Challenged  by  the  nearly  continuous  encounter  with  modest   Disruptive Processes

beginning  before birth  and  occurring  as  interacting  combinations  and  patterns

to  cause  reversible  or  irreversible  and  variably   beneficent   or   maleficent   effects

on  the  developmental   resilience   of  the   person’s   combined   reflective-cognition

Cluster of Human Capabilities,   baseline homeostasis   and   innate temperament

as  ameliorated  concurrently  through  the   Caring Relationships   originating

within  the   person’s   Family,   its   Extended Family   and

its   Micro-Neighborhood  Networks;

^

Matured  by  the  episodic  encounter  with  substantial   Disruptive Processes

beginning  before birth  and  occurring  as  interacting  combinations  and  patterns

to  cause  reversible  or  irreversible  and  usually   maleficent   effects

on  the   resilience   of  the   person’s   combined   Clusters of Human Capabilities,

baseline homeostasis   and   innate temperament   as  mitigated  concurrently

through  the   Personal Survival Plan   of  the   person;   AND

^

Sustained  by  the   Survival Commons   of  the   person’s   community  and

by  the   Family Traditions   of  the   person’s   Family   and   Extended Family

until  the   resilience   of  the   person’s   combined

Clusters of Human Capabilities,   baseline homeostasis   and   innate temperament

becomes  insufficient  for  survival  from  the  cumulative,  irreversible  effects

of   maleficent  Disruptive Processes   encountered  during  the   person’s   life-time.

 

 

I N S T I T U T I O N      may  be  broadly  defined  as

^

“…the  rules  that  humans  use  to  organize  all  forms  of  repetitive  and

structured  interactions  including  within  families,  neighborhoods,  markets,  firms,

sports  leagues,  churches,  private  associations,  and  governments  at  all  scales.

Individuals  interacting  within  rule-structured  situations  face  choices

regarding  the  actions  and  strategies  they  may  take,  leading  to  consequences

for  themselves  and  for  others.   The  opportunities  and  constraints  individuals  face

in  any  particular  situation,  the  information  they  obtain  or  are excluded  from,  and

how  they  reason  about  the  situation  are  all  affected  by  the  rules  or

absence  of  rules  that  structure  the  situation.   Further,  the  rules  affecting

one  situation  are  themselves  crafted  by  individuals  interacting

in  deeper-level  situations.   For  example,  the  rules  we  use  when  driving  to  work

every  day  were  themselves  crafted  by  officials  acting

within  the  collective-choice  rules  used  to  structure  their  deliberations  and

decisions.   If  the  individuals  who  are crafting  and  modifying  the  rules

do  not  understand  how  a  particular  combination  of  rules  effect

actions  and  outcomes  in  a  particular  ecological  and  cultural  environment,

rule  changes  may  produce  unexpected  and,  at  times,  disastrous  outcomes.”  (45)

 

 

 

S O C I A L    C A P I T A L      may  be  defined  as

^

a  community’s  norms  of   Trust,   Cooperation   and   Reciprocity   that

its  citizens  are  more  likely  to  apply  for  resolving  the   social dilemmas

they  encounter  daily  within  their  community’s   Municipal Life

WHEN   Caring Relationships   increasingly  permeate

the  social  networks  of  the  community’s  citizens,

especially  the  generational   Caring Relationships   occurring  within  the

Extended Family   and   Micro-Neighborhood Networks   of  each  citizen’s   Family.

 

 

 

S U R V I V A L    C O M M O N S      may  be  defined  as

^

a      C O M M U N I T Y ‘ S      C A P A B I L I T I E S

for  reducing  the  occurrence  of   Unstable HEALTH

for  a  substantial  portion  of  the  community’s  citizens

from  the  sudden  or  sustained  occurrence

of  certain   Disruptive Processes

that  are:

^

Instituted  by  the  community  to  “…promote  the  general  Welfare…”

of  its  citizens  in  accord  with  their  nation’s  laws  and  regulations

that  are  concurrently  applicable  to  the  community’s

private  and  public  institutions  at  all  scales;

^

Enhanced  by  each  citizen’s  responsive  recognition  of  kindness  and  respect

during  the  brief,  social  interactions  they  encounter  daily

within  the   Municipal Life   of  their  community;

^

Offered  by  the  community  to  each  of  its  citizens  who  may  select,

from  among  its   Clusters of Benefits and Obligations,

the  specific   Benefits and Obligations   most  suitable

for  the  needs  of  their  own   Personal Survival Plan

within  the  ecological  and  cultural  environment  of  the  community;

^

Promoted  by  the  citizens  who  volunteer  with  an  awareness

about  their  community’s   Clusters of Benefits and Obligations   and

its  needs  for  continuing  improvement  to  assure  their

equitable availability,   ecological accessibility,   just efficiency   and   reliable effectiveness;

^

Augmented  by  the  various  forms  of   collective action   initiated

from  among  the  community’s  institutions  and  social  networks

that  are  intended  to  ameliorate  a   “newly recognizable adversity“

affecting  its  citizens  from  a  locally  prominent  discontinuity

within  their  community’s   Clusters of Benefits and Obligations,

especially  if  the   “newly recognizable adversity“   represents

an  impairment  of  the  opportunities  for  improved   social mobility

within  a  citizen-group  of  the  community;

^

Protected  by  the  community’s   Master Disaster Planning Strategy   to

prevent,  mitigate  and  ameliorate

the  occurrence  of  certain  locally  predictable  disasters,  especially

their  associated   Disruptive Processes   and  the  resultant  impairment

of  the  capability  to  maintain  a   Personal Survival Plan

by  a  significant  portion  of  the  community’s  citizens;   AND

^

Supported  by  the  community’s

public  and  private  institutions  at  all  scales  and

by  their  Nation’s  level  of   autonomy   within  the  world-wide,

market-place  arenas  for  its   Resources,   Knowledge   and   Human Dignity.

 

 

a  NEW  STRATEGY

 

Given the heritage of our nation’s healthcare and these ten definitions, I offer a new view of meaningful healthcare reform.  This  new strategy  for the reform of our nation’s healthcare must continuously promote a renewal of the  Survival Commons  within each citizen’s community.  There are nearly endless priorities that might be identified with this view of healthcare reform.  Among these many priorities, I propose that only two priorities are important for true healthcare reform.

First, our nation’s healthcare industry must eventually offer enhanced Primary Healthcare that is equitably available for each citizen within their own community.  This health care should offer  Caring Relationships  as defined above, thoughts spanning more than 2,500 years.  A community commitment to equitably promote an enduring  Caring Relationship  between each citizen and a Primary Physician should be the essential attribute for this new view of healthcare reform.

The eventual improvement of healthcare, community by community, will require three nationally sanctioned projects.  These national projects are necessary to successfully support community driven healthcare reform.  They are:  1) an evolving comprehensive statement of “best practices” to achieve and sustain the career-long educational preparation of sufficient Primary Physicians for the Basic Healthcare Needs of all citizens;  2) a set of minimum definitions to use as the basis for the optimal economic reimbursement of enhanced Primary Healthcare and  3) a  HEALTH SECURITY certification process for enhanced Primary Healthcare as the basis for its eligibility to receive  optimal economic support.

Second, successful healthcare reform should promote an assessment of Primary Healthcare, community by community, to assure that it is equitably available.  To support this obligation, each community averaging about  400,000  citizens would support the formation and functions of a  Community HEALTH Forum.   Nearly  800  of these Forums, nation-wide, would each be responsible for a  Community HEALTH Plan  to report an annual assessment of its equitably available Primary Healthcare and the results of a monitoring process for the efficiency and effectiveness of its healthcare.  The report should include the options in place to promote continuous improvement of this Primary Healthcare to qualify for  HEALTH SECURITY  certification.  Eventually, a mature  Community HEALTH Plan  would also include:

  1. a section devoted to achieving equitably available and HEALTH SECURITY  certified Primary Healthcare for each citizen as planned from among the relevant community stakeholders;  this section would eventually be augmented by a community, data-driven monitoring process for assessing the improvement of the community’s  level of  Stable  HEALTH;
  2. a Special Projects section to identify the locally prominent adversities affecting their community’s  Survival Commons;  this section would also include a community focused assessment of its current Social Capital  asset and the  collective action  Special Projects currently in place for mitigating the discontinuities that exist within the community’s  Survival Commons;  and
  3. a section to describe the local community’s annual review of its  Master Disaster Mitigation Strategy  for  *) the likely occurrence of predictable disasters as a basis for mitigating, where possible, the effects of these disasters and, indirectly, of unpredictable disasters;  *) the applicable preparation in advance of and recovery efforts immediately following these disasters and  *) the community’s connection to their City, County, State and Federal governments’ disaster preparedness strategies.

 

A  Community HEALTH Plan  offers the best opportunity, annually revised, to highlight certain Special Projects in addition to the usual array of public health needs within each community. The Special Projects might include early childhood education, adolescent health, obesity, mental-health emergency-responsiveness or homelessness.  Disaster preparedness is difficult since the timing and severity of disasters vary considerably.  The options available before and after a disaster to mitigate its adverse effects are the most important attribute of these plans.  Furthermore, the preparedness for predictable disasters then establishes the basis for unpredictable events.

After a few years, the character of these local  Plans  are likely to reflect the diversity of local attributes but could eventually coalesce nationally on the importance of certain details.  Finally, the benefits of disaster planing are less obvious for the predicted disasters than it is for the unforeseen disasters.  The resiliency of the community’s  Social Capital  commitment to advance its  Survival Commons  would be the most profound underlying component for the success of its disaster planning benefits.

Each  Community HEALTH Forum  would be formed from within the locally prominent, community-benefit stakeholders.  As ADVOCATES within the over-all umbrella of NATIONAL HEALTH,  each Forum  would participate along with the other nearly  800 Community HEALTH Forums  to pursue the collaborative options among their healthcare institutions already in place.  A specific obligation for each Forum  would engage and initiate “trust, cooperation and reciprocity” among their existing community institutions.  Beginning more than  500  years ago, the enduring level of locally mobilized volunteerism may be our nation’s most important heritage for sustaining our nation’s world-wide  autonomy  and for the continuous reform of our nation’s healthcare.

 

MISSION  TO  THE  MOON

 

Unintentionally, the traditions of our nation’s healthcare industry have interacted since 1969 to paralyze its capacity to initiate and perpetuate its own reform.  To reverse this paralysis, a supreme national commitment will be required to implement a thoroughly reconsidered basis for healthcare reform.  The commitment required for this level of reform should represent our nation’s next, “mission to the moon.”

Ten years after starting this newly considered “moon-shot,” I propose three very specific, National GOALs  for healthcare reform:  1) reduce the 2018 spending for our nation’s healthcare from  18.0%  to 13.0%  of our nation’s economy;  2) reduce the annual number of women dying from a pregnancy in 2016 from  24.6  to  5.0  deaths per  100,000 live births, i.e., its maternity mortality ratio; and  3) ratification by all States of a Congressional Charter to establish a new nationally constituted, semi-autonomous institution to guide this reform.  Over ten years, these  GOALs  beginning in 2019 and ending in 2028 would: 1) reduce the annual health spending within our nation’s GDP by 28%,  2) reduce the number of women dying with a pregnancy by  70%,   and  3) achieve ratification by all  50  States of a Congressional Charter for the new semi-autonomous institution,   NATIONAL HEALTH. 

Reducing the cost of our nation’s healthcare will be especially important for our nation to retain its autonomy  within the market-place arenas for the world’s  Resources  as well as for its  Knowledge  and Human Dignity.   Between 2011 and 2021, continuing our nation’s current deficit spending will eventually achieve a debt per citizen that is the same as it was for Greece in 2011.  As of 2014, their nation was no longer able to arrange loans to support the deficits of its national government without dramatic changes in its governance.

For 2017, total health spending for our nation’s healthcare was  $3.50  Trillion.  It represented  18%  of our national economy.  ALL of the other developed nations spend 13%  or less of their nation’s economy on healthcare.  Using a benchmark of  13.0%  as a goal, the excess health spending in 2017 could be estimated as the difference between 13.0%  and  18.0%  of our nation’s economy in 2016.  This  excess  health spending for our nation’s healthcare in 2017 would have been  $1  trillion or the equivalent of fighting  10  Iraqi/Afghanistan wars in 2005, simultaneously.

To finish this analysis, the Federal government pays cash for  40%  of our nation’s healthcare, representing  $400  Billion of its excess cost in 2017.  Most importantly, this $400 Billion represented  60% of our Federal deficit of  $666  Billion in 2017.  The excess cost of our nation’s healthcare currently represented the largest contribution to the 2017 deficit of our nation’s Federal government.  Furthermore, there is absolutely no evidence that the current over-all strategy for healthcare reform will do anything to improve the over-all efficiency and effectiveness of our nation’s healthcare.

As for its effectiveness, our nation’s maternal mortality ratio (MMR) is the most representative measure of its effectiveness.  The MMR number represents the number of women within our nation who died during a year from most causes related to a pregnancy per  100,000  living births.  The best analysis for the national statistics was most recently published in October of 2016 (60) for annual data that go back to 2000. This same publication also reported state by state data for 2005-2014.  For perspective, there were  3,978,497  live births nationally in 2015.

The USA is the only developed nation in the world that has had a worsening maternal mortality ratio for  30+  years.  And, our Nation’s MMR ranked  42nd  worst among the  51 advanced developed nation’s of the world as reported by the United Nations for 2015. Based on a current analysis of the marginally different statistics, at least  700  women died during 2016 in the USA related to a pregnancy who would still be alive if they had lived in Iceland, Finland, Poland, Sweden, Austria, Italy, Czech Republic, Greece, Kuwait OR Norway when their pregnancy started.  These  10  of the  51  advanced, developed nations had an average MMR of  3.8  according to the U.N. report of 2015.

Finally, the last data set for MMR levels, state by state, listed the average of each state for the years of 2005 through 2014, nationally it was  11.3 .  The  best  5  states had an average MMR of  7.2 .  One of these best  5  states was Alaska.  If Alaska with all of its geologic, seasonal and Alaskan Native adversities could still achieve this result, shouldn’t it be possible for all the other  44  States and the District of Columbia to work toward that goal?  The other  4  ‘best states’ were Massachusetts, Colorado, Maine and California.

Beginning today, “lift off” for  NATIONAL HEALTH  could be  6  months away.   Our nation’s  autonomy  within the world-wide community is at stake.  Established by a Congressional Charter for the benefit of our nation’s future, each citizen would eventually recognize the  V I S I O N  of the new institution by its name.  I propose the following envisioning statements for  NATIONAL HEALTH:  

 

 

 

V I S I O N    –    Stable HEALTH   For  Each  Citizen

^

 

MISSION    –    To  plan  healthcare  reform

with  a  continuously  renewed  understanding  of  our  nation’s

Resources,    Knowledge    and    Human Dignity

^

VALUES    –    Altruism  .  Trust  .  Cooperation  .  Reciprocity  .  Excellence

 

 

 

GETTING   STARTED

                 

To understand the basic dimensions for the future of healthcare reform, I begin with a brief history lesson. The history lesson begins with the following question. What is the heritage of our nation that has evolved from the passions of the immigrants who have come here from foreign lands?  To be sure, many passions have motivated the men and women who have chosen, and continue to choose, emigration from their homeland to North America.  Among these motivations, three passions probably represent the essential heritage underlying emigration.  One passion has been a desire to leave their homeland’s authoritarian, autocratic, centralized and coercive government.

A second passion has been a desire to become a citizen of a nation with constitutionally defined and enforced, freedom of speech.  To be comprehensive, our First Amendment rights also include freedom of religion, print, assembly and petition.  Since 2001, the world’s continuing and rapidly evolving events represented the beginning of a new era for the world-wide community.  This new era clearly represents an evolving threat to each person’s  Human Dignity  when living in a nation with an autocratic, authoritarian, centralized, coercive government and, frequently, large-scale military violence. According to the  NEWSEUM  in 2014, only  9%  of the world-wide population, who live outside of the USA, are citizens of a nation with our level of  First Amendment rights.

The third passion that motivated immigrants has been, and still is, a chance to start a new way of life. Starting a new way of life was especially prominent for the early immigrants who came to North America and endured life-threatening hardships.  Most early immigrants accepted, in advance, the profound and unknown dangers of these hardships. It was a small price to pay for the chance to achieve a substantially and permanently better quality of life.  Relocating to North America and leaving “taxation without representation” was, and continues to be, worth these life threatening risks.

Unfortunately, some immigrants have come to our nation for other reasons.  Human trafficking, “slavery,” has forced and continues to force many immigrants to emigrate for the profit motives of their captors.  In 1865, the 13th Amendment to our nation’s Constitution prohibited overt slavery.  The forced loss of  Human Dignity  for the African emigrants was and continues to be a devastating failure of our nation’s commitment to uniformly honor the  Human Dignity  of all persons. Other immigrants have come to our nation only to serve their own predominantly self-centered economic or social values.  And, finally, the early immigrants forced our Native Americans to emigrate and, as a result, become immigrants on their own land.

Our nation’s legal tradition of assumed property rights drove the forced immigration of our Native Americans.  In 1879, Native Americans achieved protection under the law from a Federal Court decision by Judge Elmer Dundy for Chief Standing Bear of the Ponca Tribe.  To achieve this decision, two attorneys had prevailed with a writ of “habeas corpus ad subjiciendum.”  The two attorneys were employees of the Union Pacific railroad in Omaha and members of a Congregational church community who had supported their commitment.

Despite the reasons for immigration, successful survival in North America required self-discipline, hard work and altruism – a desire to help others.  For  500  years, this dedication to individual survival was associated with an expectation that each community would function better if its citizens survived primarily on their own in spite of life’s tragic events.  For the  12  million immigrants who arrived in New York City at Ellis Island, any healthcare that was eventually available to them was a privilege based on the  economic success  of their own survival.  The immigrants who passed through Ellis Island represented the ancestors of nearly  40%  of our nation’s current citizens when it closed in 1954.   They included my own grandparents from Sweden.

 

PARADIGM   SHIFT  —  historical origin

 

Between 1850 and 1900, the origins of anesthesia and infection control began to evolve. This meant that the benefits of surgery needed a specific location outside of a person’s home.  Prior to this combination of newly evolving technology, health care almost always occurred within a person’s home as offered by members of the person’s  Extended Family  and  Micro-Neighborhood Networks.   Except for war-time or travel away from home, the only persons who did not receive this level of healthcare were the persons without a  Family,  now recognized as homeless.

Almost every community beginning around 1700 began to have rudimentary hospitals for the homeless, now more appropriately labeled as “nursing homes.”  Most of these were community established through county and city levels of government or religious institutions.  With the evolution of surgery, some of these early nursing homes adapted to eventually become modern-day hospitals.

Most importantly, the early and eventually profound evolution of life-saving healthcare beyond the confines of a  person’s  home removed a powerful focus on  Family Traditions  to empower the mutually shared commitments within a  Family  to care for each other. Originating slowly during the aftermath of the Civil war ending in 1865, newly constructed hospitals became more common after World War I and especially after World War II.

Along with the shift of healthcare to a location ‘foreign’ to most citizens, the ecologic character of each  person’s  HEALTH  became exposed to many newly evolving changes, e.g.,  travel, communication, urbanization and industrialization.  A continuing cycle of violence, world-wide and neighborhood by neighborhood, has evolved since the end of WWII in 1945.  And amid the cultural adaptation to these changes, we have arrived at a time whereby a  person’s  Extended Family  and their  Family Traditions  no longer offer the traditional life-style resources for supporting each  person  during episodes of Unstable HEALTH.

All of this has led to a diminished commitment within each community to sustain the Stable HEALTH  of its citizens through its  Survival Commons.   Beginning in 1969, the  Disruptive Processes  that contribute to the causes of  Unstable HEALTH  are increasingly beyond the control of our healthcare industry.  Given the vast social and economic changes of the last  150  years since the Civil War, we have arrived at level of turmoil within our world and our nation that is unprecedented by almost any definition.

Disruptive Processes  refers to any event that decreases the stable expression of a  person’s  survival.  This could represent the obvious physical injuries of broken bones and head injuries. But, it also refers to pneumonia, emotional stress, poor diet, lack of sleep or anything else that in combination decreases the stability of a  person’s  HEALTH.

 

PARADIGM  SHIFT  with  PARALYSIS

 

Beginning in  1969,  a rapidly evolving improvement began to occur in the sophistication of healthcare that is now available for Complex Healthcare Needs.  Unfortunately, the improved quality of health care for Complex Healthcare Needs has not been matched by a similar improvement in the health care for the Basic Healthcare Needs of each citizen.  This change in the last  50  years means that self-discipline, hard work and altruism no longer guarantee that health care is equitably available for the Basic Healthcare Needs of each citizen, even for the citizens who have achieved  economic success.   Inadequately available health care for Basic Healthcare Needs can be especially profound  *) for any woman prior to and during a pregnancy  and  *) for any citizen who is an infant, disabled or homeless.

By 2009, the poorly recognized imbalance that had evolved between the health care for Basic Healthcare Needs and for Complex Healthcare Needs represents a root cause for the problems within our nation’s health care.  Furthermore, the health care for  Basic Healthcare Needs  has deteriorated without a strategy to assure that Primary Healthcare is  equitably available  and  ecologically accessible  by each citizen within every community. The effect of this deficiency has led to severe problems within our healthcare industry, as in its preventable maternal deaths.

The imbalance is the partial result of an inadequate level of financial capital for the Basic Healthcare Needs of each citizen as compared to the financial capital that is available for their Complex Healthcare Needs.  It is not the fault of any one citizen or group of citizens. It began to occur, more prominently, after Congress authorized Medicare and Medicaid in 1965.  Between 1960 and 2016, the portion of our nation’s economy allocated to healthcare has more than tripled.  Unfortunately, the flow of these resources preferentially into health care for Complex Healthcare Needs has produced a deeply entrenched and pervasive co-dependency between the institutions paying for Complex Healthcare Needs and the institutions offering healthcare for these Complex Healthcare Needs.  These institutions are largely medical school, affiliated hospitals.  The institutional co-dependency is a root-cause of the Paradigm Paralysis afflicting our nation’s healthcare industry, one of many.

The Paradigm Paralysis means that the heritage of our nation has produced a healthcare industry that is unable to start or sustain its own reform.  Since 2009, this industry has now required a new and widely supported institution to guide its reform.  Our nation’s agriculture industry has had its Cooperative Extension Service since 1914, and our nation’s monetary policy has had its Federal Reserve since 1913. As a result, our nation’s agriculture is the most efficient and effective among the world’s nations, by a wide margin, and our nation’s dollar is still the most prominent basis for asset transfer among nations ( in spite of our nation’s increasing indebtedness ).  Now, 100+ years later, a similar institution for the healthcare industry must begin by promoting Primary Healthcare, community by community, that is equitably available by each citizen within their own community.

Ultimately, our nation’s healthcare industry must begin a tradition to establish its capacity to re-energize a local  ‘collective thrust’  heritage within each community.  This heritage would sustain a nation-wide, community by community tradition for recognizing each community’s obligation to promote  Stable HEALTH  for each of their citizens.  The  new strategy  should also focus on the  HEALTH  of its citizens with special needs, especially every child and their mother.  Thirty years from now, our nation’s autonomy  within the world-wide community will depend on the strength of each community’s  Survival Commons  necessary to foster our nation’s caring and learning generations of citizens, year after year.  A newly enriched definition of  HEALTH  helps to explain this assertion.  It is one of the  10  new definitions listed above.

 

“GOVERNING   THE   COMMONS”

 

Because of its profound inefficiency, our healthcare industry is no longer affordable within our nation’s economy.   A  “Tragedy of the Commons”  has occurred. (30)   The traditions of our national heritage have led to this crisis.  Exploring the basis for remodeling these traditions is the central theme for  NATIONAL HEALTH.  The  TRADITIONS  Page and its  Sub-Pages  explore this theme in greater detail.  They attempt to explain why the problems are so difficult to define and so resistant to implementing any solutions originating from within our nation’s healthcare industry.  An over-all strategy has not been considered within the mainstream of our nation’s healthcare industry.

Professor Elinor Ostrom points the way with her studies described in nine books published between 1990 and 2010.   “Governing the Commons” (31)  is the first book in the series.  Within this series, she describes an analysis of shared use strategies applied with an intent to preserve a natural resource, such as the fresh water aquifer under the city of Los Angeles, California.  Her studies, along with the research of numerous colleagues, have defined the Design Principles for the successful governance by a group of institutions with a responsibility to preserve a common-pool resource.  In 2009, Professor Ostrom received a Nobel Prize in economics for her research.

 

NEW   CONCEPTS

 

For lasting healthcare reform, its strategy should include a continuing search for new concepts that would be uniquely applicable to the future reform of our nation’s healthcare industry.  The search for these concepts should not necessarily represent an intent to start a new tradition or to match the institutional heritage of another nation. Among the world’s developed nation’s, the traditions of our own healthcare industry are unique.  Given our own traditions, this proposal for  NATIONAL HEALTH or any other reform proposal should refine these traditions rather than replace them.  The other developed nations of the world have adopted a variety models for their own healthcare. They are instructive but do not easily provide a specific model to duplicate for our nation.

The search for concepts that are possibly applicable to healthcare reform for this Blog covers primarily the last  70  years.  Within the public arena, I have selected a set of concepts for healthcare reform based on how they would jointly interact for a larger impact.  These concepts represent realms of knowledge from a diverse group of scholars. I propose that, taken together, they represent a pragmatic basis for the comprehensive reform of our nation’s healthcare.  It is described by the  Initiative  Page  and its  Sub-Pages  for the new institution,  NATIONAL HEALTH.

 

HEALTH   CARE   versus   HEALTHCARE   —   A   NEW   ERA

 

Given our nation’s pioneer heritage, the historic traditions of our nation’s healthcare industry have evolved, especially since 1969, into a diverse mix of institutions.  This industry has become increasingly unstable since 2010.  In 2011, an unexpected number of critical medications were suddenly no longer available.  One year later, a failure to maintain quality control standards by a compounding pharmacy in Massachusetts led to more than  75  deaths throughout our nation.  Their state’s Public Health Department failed to monitor the quality control standards maintained by the compounding pharmacy. The regulatory failure ultimately contributed to the disaster.  Similar disasters involving compounding pharmacies in Tennessee and Texas began to unfold at mid-year in 2013.

In spite of a rapidly worsening incidence of accidental and intended opioid-overdose related deaths in 2018, our nation’s healthcare industry endured a shortage of an intravenous form of narcotics at mid-year.  An underlying observation further mystified the simultaneous occurrence of the death rate and hospital inventory supplies.  The opioid related mortality incidence was much higher in the States who had implemented a Medicaid expansion policy through Obamacare as opposed to the States that had NOT implemented Medicaid expansion in 2017.

Next, the opening phase of the National Health Insurance Exchange in October of 2013 was disheartening, at best.  And finally in 2014, the problems with the Veterans Administration represented a recurring theme of institutional leadership problems.  This subsequently reached a new peak when its was announced in 2017 that several of their hospitals had lost inventory control of their narcotic medication supplies.

Any reform strategy to promote a broad improvement throughout the diverse institutions of a nation’s large industry must proceed with caution.  The balance of improving the daily  HEALTH  of individual citizens must be balanced by an evolving continuum of  ‘healthcare’  over time and how it fits together for the seamless  ‘health care’  needs of each citizen.  Hopefully, the unstable series of events, noted above over 7 years, was only an isolated occurrence.  The evolving reality of the ACA 2010 could worsen this turmoil given is inability to fundamentally unravel the Paradigm Paralysis strangling our nation’s healthcare.

To formulate a  new strategy  for a carefully defined and implemented healthcare reform strategy, the TRADITIONS  Page  and its  Sub-Pages  analyze the essential traditions of our nation’s healthcare. Five of the  Sub-Pages  propose a solution for specific root-causes within the Paradigm Paralysis of our nation’s healthcare.  Based on this analysis, the  Initiative  Page and its  Sub-Pages  describe a new institution,  NATIONAL HEALTH,  Chartered by Congress.  See  OVERVIEW  Page  for further details.

If you appreciate the fundamental value of concepts and ideas as a basis for shaping the future course of events, then you also have a unique perspective for considering the character of our nation’s healthcare. Overall,  NATIONAL HEALTH  integrates concepts originating from the traditions of thought underlying the social contract for the governance of Western nations.  They are: sociology, economics, physics, psychology, biology as well as medicine.  Let me introduce you to:  Eric Hoffer, Leon Festinger, Carl Rogers, Thomas Kuhn, Lawrence Weed, Garrett Hardin, Peter Drucker, Steven Covey, and Elinor Ostrom.  As a basis for healthcare reform, the cohesion of their concepts as well as the concerns of many persons expressed to me during their personal healthcare represents the essential momentum guiding the conceptual priorities for this healthcare reform proposal.

 

REPRISE   &   RECAPITULATE   —   “The  Future  As  History”

 

The brief quotation above represents the title of a book written by Robert L. Heilbroner. (61)   It was printed in 1960.  He reviewed the essential trends within our nation before 1960 as a basis to describe a view of our nation’s near term, future evolution.  He was substantially correct.  The knowledge for assessing future options was known then, as it probably is knowable now for the future of our nation’s healthcare reform.

To continue a sense of our nation’s heritage over the last  500  years, isolated episodes of supreme commitment and purpose have defined our nation’s history.  Remember, especially, the voyage of the Mayflower in 1620, the Declaration of Independence in 1776, the 13th Amendment to the Constitution in 1865 as the Civil War ended, the national commitment to WWII after the Pearl Harbor attack in 1941, our nation’s Mission to the Moon after Sputnik in 1957 and our nation’s sudden awakening to global terrorism after the World Trade Center attack in 2001.

I propose that the knowledge and  Social Capital  already exists to reform our nation’s healthcare.  With a “Moon Shot” level of precision and resolve, fundamental healthcare reform could reduce the cost of our nation’s healthcare from  18.0%  of the national economy to  13.0%.   Remember again that it was  5.0% in 1960.  This same strategy could reduce our nation’s number of women who died in 2016 with a pregnancy, from  24.6  down to  4.9  deaths per  100,000  living births.  The improvement in maternal health would have prevented at least  700  maternal deaths in 2016, assuming  4  million births.

It is highly unlikely that our nation’s current strategy for healthcare reform could achieve these results, or even come close.   Indeed, we must begin by first acknowledging the pervasive paradigm paralysis afflicting our nation’s healthcare.  Importantly, this paradigm paralysis increasingly compromises our nation’s  autonomy  within the world-wide market place for its  Resources  and  Human Dignity.   Now is the time for a  new strategy  to promote the  Social capital  for each community’s  Survival Commons,  as the basis for improving the  HEALTH  of each community’s citizens.

There are validated Design Principles that apply to the use of  collective action  for managing a common pool resource, as in the portion of our nation’s economy devoted to healthcare.  Since 1960, our nation’s health spending has increased from  5.0%  of the GDP to  18.0%  in 2016.  It represents an increase of  5.0%,  compounded annually as corrected for economic growth and inflation.  Using the Design Principles defined by Elinor Ostrom and validated by many colleagues,  NATIONAL HEALTH  could achieve the widely supported authority necessary to implement the strategies required at the national, regional and local levels for healthcare reform.

Our currently evolving progress for healthcare reform continues to focus primarily on universal health insurance.  The Affordable Care Act of 2010 was a magnificent accomplishment, in spite of its deficiencies.  Unfortunately, it is actually worsening the level of efficiency within our nation’s healthcare industry.  And, it does very little to sponsor the fundamental reforms necessary to achieve equitably available, enhanced Primary Healthcare for each citizen.

To begin true healthcare reform, it should be locally implemented and nationally promoted, community by community.  As cited above, former Senator Barber reminds us that  “The language of citizenship suggests that self-interests are always embedded in communities of action and that, in serving neighbors, one serves one-self.”   NATIONAL HEALTH  represents a means to achieve  ‘Stable HEALTH  For Each Citizen’  through communities of action.

 

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