humanitarian mandate
V I N T A G E T R A D I T I O N S
13 pages — 1 —
INTRODUCTION
“The roots of a child’s ability to cope and thrive,
regardless of their circumstances,
lie in that child’s having had at least a small, safe place
(an apartment? a room? a lap?) in which,
in the companionship of a loving person, that child could discover
that he or she was lovable and capable of loving in return.”
Fred Rogers (1928 – 2003)
^
^
Throughout the worldwide community, a nation’s humanitarian mandate for the HEALTH of its resident persons should, at least, include a strategy to promote and sustain the maternal health and early childhood development of every newborn. Without resident persons who eagerly pursue life-long learning and who also care about and for each other, how else could a nation ultimately survive and prosper? Truly, is it remotely possible for any Family to nurture the caring and learning capabilities of their children without a committed Extended Family, responsive micro-social networks, and a high level of social capital within their community’s Survival Commons? My answer is: “probably not.” What better leader than “Mr. Rogers” to have set the basic priorities for our nation’s humanitarian mandate, neighborhood by neighborhood within every community?
This Blog, of course, is about the reconfiguration of our nation’s Population Health and its Primary Healthcare. This reform strategy is especially important as our nation struggles to maintain its economic autonomy within the worldwide community of nations. Between 1960 and 2019, our nation’s health spending as a portion of our national economy increased from 5.0% to 18.0%. Among the other well-developed nations of the world, their health spending as a portion of their national economy during 2019 represented 13.0% or less. For 2019, the difference between 13% and 18% for our national economy represented $1.0 Trillion.
During 2018, our Federal government’s expense for health spending represented 58% of its fiscal deficit. It represented a succession of several years during which our nation’s excess health spending averaged nearly 100% of our nation’s annual Federal deficit. Our nation’s autonomy within the marketplace for the world’s Resources is in substantial jeopardy as a result of our nation’s level of health spending as a portion of our national economy.
There are honest differences of opinion about which of the various reform strategies is preferable for adapting our nation’s priorities to achieve healthcare reform for resolving its cost and quality problems. Amid the conflicting priorities for healthcare reform, we should ignore most of these distractions and acknowledge the ultimate importance of a vibrant Family for each person including its Extended Family, their Family Traditions, their Family Home’s neighborhood, and their community’s Survival Commons, viz., augmented safety net. This Family priority becomes the basis for improving our nation’s Population Health as well as the efficacy of our nation’s healthcare, especially its Primary Healthcare.
What then are the options for healthcare reform that will support the Families who are unable to assume the obligation to care for their dependent persons, especially during early childhood? Similarly, how do we select correctly the options for supporting all of our nation’s Families? These priorities represent the millstone question for amending our nation’s current humanitarian mandate. For now, the reform of our nation’s healthcare and its VINTAGE TRADITIONS has become the essential domestic problem for our nation’s governance. This is an especially prominent issue given the gaps in quality currently characterizing our nation’s healthcare. The gaps in quality are especially unacceptable for certain persons, such as young children, the homeless or disabled, and especially every woman who requires or may soon require maternal healthcare. The quality and “health spending” problems for these resident persons and their Families, with no foreseeable means of resolution, are profoundly unacceptable.
Unfortunately, the distractions of the worldwide community have also interfered with our nation’s ability to promote the future needs of our nation’s Families. As the Bayou saying in Louisiana goes, “When you are swimming in water up to your neck full of alligators, it’s hard to think about draining the swamp.” To extend the alligator analogy to healthcare, the swamp has many inlets and outlets to control its depth, the weather is unpredictable, and the shores in every direction require different methods for their reconstruction. If you can acknowledge this analogy between reconstructing a Bayou swamp and healthcare reform, you will understand why the current efforts for healthcare reform seem so unpredictably chaotic.
This “PAGE” represents an attempt to define the Bayou “level of complexity” that will be required to understand the basis for reforming our nation’s healthcare industry. Its ‘Sub-Pages’ take it a step further. They represent an attempt to define the root causes requiring a combined solution to implement a successful strategy for healthcare reform. To understand the context of these root causes, I begin with one view of our nation’s current survival issues.
21st CENTURY — AN ERA OF WORLDWIDE CHANGE
In 2007, there were 17 Nebraskans who died in the combined Iraq and Afghanistan war zones. For my own state of Nebraska, this represented 1.1 deaths per 100,000 citizens. During the same year, 42 Nebraskans living in Omaha died from violent conflict. In 2010, the homicide rate for the city of Omaha alone was 7.5 per 100,000 residents. For cities of similar size in the mid-west, the homicide rate ranged from a low of 2.5 for Des Moines to a high of 40.4 for St. Louis. Profound violence affects the immediate neighborhood of each resident person, all children, their surrounding community, our nation as well as the entire worldwide community.
For children and adolescents who were 1 year and 19 years of age during 2016, the second most common cause of death among all the deaths of these children and adolescents was a combination of suicide (14%) and homicide (11%): 25%. By comparison, the largest cause of death among all the deaths in this age group was accidental injuries: 35%. Conceivably then, most deaths among all the deaths for children between 1 and 19 years of age were preventable: 49%. (Cunningham et al 2018) Similar data ending in 2020 is unchanged other than two trends that began @ 2013: 1) an annual termination of a prior long-standing decline of motor-vehicle mortality and 2) an annually occurring increase in firearm-related mortality. (Goldstick 2022) One more time, healthcare reform should ultimately focus on the Population Health needs of each person’s Family, their Extended Family, its Family Traditions, its Family Home’s neighborhood, and their community’s Survival Commons. — 3 —
GLOBAL CHANGE
Throughout our country, every resident person experiences a variable level of pervasive violence. Most cities have a large number of resident persons who are homeless. Our nation’s capital markets are periodically unstable. In the world’s financial arena, our country has become a debtor rather than a creditor nation. For many years, a consistent and manageable immigration policy has not been pursued. The current financing for the education of our nation’s children produces unequal educational opportunities. Between 1985-1999 and 2000-20015, the total number of mass shootings increased by 234%. And, MOST importantly, our nation spends 18.0% (2019) of its gross domestic product (GDP) on healthcare. None of the other 50 advanced/developed countries of the world spend more than 13.0% of their GDP on health spending and most are clustered near 12.0% or less. For Japan, it has been less than 10%.
In the 21st century, there are intractable, deep-seated problems challenging our nation: homelessness, a worsening level of armed conflict within our major cities, a foreign policy dominated by the Machiavellian tactics leftover from historical feudalism, inefficient capital markets, a large international balance of payments deficit, pockets of entrenched poverty with loss of social mobility, variably unequal primary education for our nation’s children, an evolving environmental disaster from global warming, and the world’s most inefficient healthcare industry as compared to all of the other advanced, developed nations. This Blog is only about healthcare. But, NONE of the other issues facing our nation can be stabilized without first “FIXING” the very high level of health spending for our nation’s healthcare. There is absolutely no reason to believe that the current level and scope of healthcare reform will ever achieve a fundamental solution, especially for our nation’s declining Population Health.
During 2019, our nation may have spent $1.0 Trillion more than necessary for its healthcare. The excess cost to the Federal government represented 58% of the Federal fiscal deficit that year. Beginning in 2023, fixing the inefficiency of our nation’s healthcare without onerous rationing will be absolutely necessary for the future financial stability of our country. The fundamental concepts necessary for starting a solution come from the Federal Reserve System Act and the Smith-Lever Act passed by the 1913-14 Congress, Thomas Kuhn in 1962, Lawrence Weed in 1963, Elinor Ostrom in 1990, and Peter Drucker in 1993. The Sub-Pages of this VINTAGE TRADITIONS Page and the NATIONAL HEALTH Proposal Page introduce supplementary concepts from Eric Hofer, Carl Rogers, Stephen Covey, and Michael Tomasello.
THOMAS KUHN — SCIENTIFIC REVOLUTIONS
Thomas Kuhn (1922-1996) was a philosopher with a special interest in the history of science. Professor Kuhn formulated the results of his studies by writing a book, The Structure of Scientific Revolutions. In his book, Kuhn argued that science does not progress via a steady accumulation of new knowledge, but undergoes periodic revolutions. (Kuhn 1962) Kuhn described these periodic revolutions based on his analysis of major changes within the scientific understanding of physics over many centuries. Since the original description by Kuhn, his concept of periodic scientific revolutions has been widely applied to other physical and social sciences. — 5 —
Kuhn’s concept of a scientific revolution refers to an unexpected, progressively evolving change in the overall understanding of a complex concept. When this occurs, the mutually supportive and widely accepted problem-solving traditions associated with a traditional complex concept become much less useful for understanding the complex concept. Now, some 50+ years later, Kuhn’s concept of a scientific revolution is most often described as a paradigm shift. When a time-honored paradigm becomes more precisely explained by a revised set of problem-solving traditions, a paradigm shift has occurred. Also, paradigm paralysis can occur if there is widespread resistance to acknowledging that a paradigm shift has already occurred.
In addition to physics, the concept of a paradigm shift characterizes many complex concepts and the poorly recognizable changes in these concepts that can occur over extended periods of time. This Blog is based on an observation that a paradigm shift has occurred within our nation’s healthcare industry. It began in 1969 coincidentally with the initial use of a safe vaccine for measles, the last very common, very dangerous contagious infection to undergo substantial epidemic control with a vaccine. By 2009, the allocation of healthcare resources preferentially to Complex Healthcare Needs has produced an under-capitalized level of healthcare for Basic Healthcare Needs. The uneven distribution of capital has also aggravated the widespread level of adversity regarding the availability and accessibility of Primary Healthcare within every community.
PARADIGM PARALYSIS
A special attribute of an established Paradigm is the tendency for its true believers to actively resist acknowledging new information that can not be explained by their traditional paradigm. New information is especially ignored if it would invalidate the traditional theories associated with the well-established paradigm or its evolving iteration. Long ago Eric Hofer described his concept of a true believer as it applied to political and religious mass movements. (Hofer 1951) The actions of a true believer associated with a mass movement would explain the resistance to change that characterizes the proponents of an established paradigm or its evolving variants. The result is paradigm paralysis.
OUR NATION’S HEALTHCARE INDUSTRY — A PARADIGM SHIFT
To understand our nation’s healthcare, it is necessary to identify the historic traditions affecting the healthcare industry. This Page and its Sub-Pages describe how these historic traditions currently interact and how this interaction creates resistance to acknowledging the reality of a paradigm shift. In fact, a paradigm shift for our nation’s healthcare industry has been progressively evolving for the last 50+ years. Since 1969, the health care that is available for Complex Healthcare Needs can achieve spectacular results. Unfortunately, our nation has not simultaneously sponsored an improvement in the health care necessary to serve the Basic Healthcare Needs of every community’s resident persons. With this paradigm shift, the resulting paradigm paralysis has prevented the formulation of a New Strategy to successfully improve our nation’s Population HEALTH as well as its Primary Healthcare.
Most importantly, enhanced Primary Healthcare should be equitably available, ecologically & culturally accessible, justly efficient, and dependably effective for every community’s resident persons. Absent these quality attributes of enhanced Primary Healthcare, the resident persons most affected are young children, the disabled, the homeless, and any woman during a pregnancy. In effect, the improved occurrence of Stable Health for every Resident Person will slowly but steadily occur from a New Strategy that is locally focused on overall Population Health, community by community, and Four National Projects to eventually assure that the human capital is available for enhanced Primary Healthcare.
GEORGE HARDIN — TRAGEDY OF THE COMMONS
Long ago, Professor Hardin wrote thoughtfully about the problems associated with worldwide population growth. (Hardin 1968) Nearly 200 years earlier, a similar concept was identified by Thomas Malthus in 1798. Both wrote about the capacity of the world’s resources to sustain the needs of the world’s future population growth. For Professor Hardin, the planet earth and its resident persons represented the “commons,” and the “tragedy” would occur as a result of the combined 1) inability to determine an optimal population of resident persons for our planet and 2) the difficulty of determining how population growth, reaching 7 billion persons in 2011 and 8 billion in 2022, could be sustained. Professor Hardin, as well as Thomas Malthus, proposed that the world’s resources would eventually be unable to sustain its population growth. As a result, a “Tragedy of the Commons” would occur from the occurrence of worldwide starvation and epidemic infections, now more apparent with the Covid-19 pandemic and global warming. — 7 —
To successfully prevent this or any other “Tragedy of the Commons,” Professor Hardin proposed a strategy based on adjusting the social contract binding each worldwide resident person and the Common Good of their nation. The strategy he described would foster a widespread, mutually agreeable consensus achieved through political processes and educational systems. It is deeply hypothetical, at best. For now, a continuing increase in the cost of our nation’s healthcare is not sustainable. A “Tragedy of the Commons” has become evident.
The underlying paradigm shift and its implications for the reform of our nation’s healthcare prompted this online Blog site in 2008. The Blog reflects the formation of a reform strategy based on a newly formulated New Strategy for the improvement of our nation’s Population Health and its Primary Healthcare. The New Strategy would be associated with a steady reduction of our nation’s health spending as a portion of our national economy, viz., 18% to 13% over 10-15 years. Professor Hardin focused on the world’s agricultural capacity to sustain its future population growth. His concept of a “Tragedy of the Commons” is equally applicable to the national cost issues of our nation’s current and future healthcare industry.
Professor Elinor Ostrom has described an extensive evaluation of multiple and diverse instances of a common-pool resource that had been successfully managed by a group of individuals who had benefited from their management of a common-pool resource or “commons.” (Ostrom 1991) She identified the local relationships among its users as necessary to prevent the exhaustion of their commons. Irrigation systems, forests, fishing grounds, and regional water rights have all been successfully managed without the intervention of a centralized government, several for more than 300 years. Professor Ostrom proposed and validated a set of Design Principles for Managing a Commons, now applicable to stabilizing the cost of our nation’s healthcare. In 2009, Professor Ostrom received a Nobel prize in economic science as a recognition of her research. She was the first woman to have been awarded the Nobel prize in economic science.
OUR NATION’S PRIMARY HEALTHCARE — THE NEXT STEP
The Canadian and British experience of their own nation’s healthcare may be instructive. For Great Britain, there have been several attempts over the years by their Parliament to achieve the large system changes necessary to improve the efficiency and effectiveness of their nation’s healthcare. Most recently, Parliament has mandated that the Primary Health Care segment of the National Health Service assume greater financial responsibility for managing the overall healthcare cost of their patients. For our healthcare industry, this would represent capitation. Similarly, the Canadian Province of Ontario began in 2002 to offer capitation reimbursement alternatives to Primary Physicians in return for a commitment to a medical home model. Like Great Britain and Canada, most of the western countries of the world have initiated special adaptations for Basic Healthcare Needs to promote efficiency as well as the effectiveness of their entire healthcare industry. The United States has not!
We suspect that the various developed nations of the world have evolved their own version of a social contract as a basis for the structure of their nation’s healthcare. These are certainly instructive, but the future paradigm for our nation’s healthcare will eventually be unique. Creating a basis for universal health insurance is important and may produce equally important gains for its efficacy. The intended benefits of universal health insurance from the 2010 Affordable Care Act (ACA) legislation to lower health spending has not occurred. It is unlikely that this legislation will eventually change the character of our nation’s healthcare sufficiently so that it will promote enhanced Primary Healthcare for every resident person. The improvements fostered by the ACA have not improved the overall financial efficiency of our healthcare, nor our nation’s Population Health. As of 2022, the ACA of 2010 has not fulfilled its equitable availability obligation to promote universal health insurance. Also, there is evidence that our nation’s longevity at birth became stagnant during 2010-2018 and our nation’s maternal mortality ratio continues to worsen, especially during the pandemic.
“Stable HEALTH for Each Resident Person” is at stake. A Congressional mandate will be necessary to authorize a New Strategy for averting the worsening paradigm paralysis within our nation’s healthcare industry. This Blog represents one possible alternative for the reform of this healthcare. This reform strategy would support a new healthcare paradigm based on promoting enhanced Primary Healthcare that is equitably available to and ecologically & culturally accessible by each resident person of every community.
When Primary Healthcare increasingly achieves collaboratively-established quality standards, the “Tragedy of the Commons” afflicting our nation’s healthcare will begin to unravel and reveal a new self-perpetuating paradigm for our healthcare. In addition, this new paradigm could indirectly help improve our nation’s entire political, social, and economic vitality. The New Strategy would steadily mobilize our nation’s ability to improve the Population Health within every community by improving the resilience of their Survival Commons, viz., augmented safety net. Finally, the reduction of health spending could then support the focused importance of maternal health and early childhood development. — 9 —
VINTAGE TRADITIONS
The Sub-Pages of this Page describe why our nation’s healthcare has evolved into its current, sad state of affairs. In combination, the PROLOGUE, LEGAL, MEDICAL, SOCIAL, ECONOMIC, and INNOVATION Sub-Pages describe the root causes producing the paradigm paralysis afflicting our nation’s Population Health and its Primary Healthcare. Understanding these root causes will be necessary for implementing any long-term, goal-directed reform of our nation’s healthcare. Our young children as well as the disabled, the homeless, and women requiring maternal healthcare deserve no less. Also, healthcare reform represents the millstone for achieving the stability of each community’s Survival Commons, neighborhood by neighborhood. A new Paradigm for the healthcare of each resident person will be especially vital for our nation’s future autonomy within the worldwide community, especially within its marketplace arena for Human Dignity.
It is also likely that an investment in social capital for young children would produce a far greater return-on-investment for our nation’s future than any other comparable national investment. (Heckman 1965) Remembering “Mr. Rogers,” caring relationships for young children who, in turn, can most fully explore their uniquely-endowed, human capability may be the only commitment that truly matters for our nation’s humanitarian mandate. Improving our nation’s Social Cohesion by a New Strategy for healthcare reform, community by community, could be the ultimate strategy to sustain the underlying needs of each newborn person. To become a self-sufficient person, every newborn requires a fully functioning Family, its Extended Family, its Family Traditions, the micro-social networks of their Family Home’s neighborhood, and the Survival Commons of their Family Home’s community.
AS A UNIQUELY – ENDOWED PERSON,
EVERY CHILD
^
Believes they are worthy of being loved when
they have always been nurtured,
and as a result, believes
they can and should have caring relationships with others.
^
Enjoys learning about life when
they have always been taught better ways of thinking,
and as a result, enjoys
sharing their knowledge with others.
Paul J. Nelson (1942 – )
S U B – P A G E S
PROLOGUE
The history of our nation’s healthcare can be divided into separate eras. Certain events have characterized the evolution of healthcare from one era to the next, such as anesthesia and public health policies or antibiotics and advanced technology. This ‘Sub-Page’ describes these transitions.
LEGAL
For our nation’s social contract, the Federal government distributes and defines the responsibilities among the federal, state, county, township, and city juridical levels. This Sub-Page describes the essential attributes of these responsibilities that apply to our nation’s healthcare industry. Certain attributes of these responsibilities specifically contribute to the paradigm paralysis that prevents spontaneously driven reform from within the healthcare industry.
MEDICAL
Briefly stated, the structure of healthcare decision processes has not basically changed for 250 years. Correspondingly, the representation, i.e. health record, of these decision processes has also not changed. If anything, the electronic health record has aggravated the evolution of the traditional medical record because of the functional accessibility of its data files. The implications are difficult to define. At a minimum, the electronic medical record (EMR) rigidly lacks adaptability for enhancing the healthcare decision sequence that underlies the increasingly complicated character of Complex Healthcare Needs. In short, it does not support a uniformly organized comprehensive care plan for each resident person. — 11 —
SOCIAL
The essential character of our nation’s healthcare problems can be summed up by the following: “if it’s available and you can get access to it, it’s very good.” By emphasizing the economic mandate to pay for Complex Healthcare Needs, we have not provided for each resident person’s Basic Healthcare Needs, especially its equitable availability and its ecological & cultural accessibility. Hence, there are unacceptable gaps in outcomes, such as our nation’s maternal mortality ratio. This Sub-Page reviews the dimensions for the humanitarian mandate underlying our nation’s healthcare, especially its obligation to be, at a minimum, available and accessible.
ECONOMIC
This Sub-Page represents a view that our nation’s obsessive preoccupation with the scientific mandate for healthcare has triggered the sequence of events that are primarily responsible for the paradigm paralysis afflicting our nation’s healthcare. Clearly, the humanitarian mandate for our nation’s healthcare to offer equitably available healthcare has been largely ignored. In response, the NATIONAL HEALTH Proposal is based partially on the need to carefully balance the scientific and humanitarian mandates for our nation’s healthcare industry, community by community.
Currently, the institutions that pay for healthcare also determine the health benefits eligible for this payment, a colossal conflict of interest. By using the same concepts to structure the reimbursement of healthcare for Basic as well as for Complex Healthcare Needs, the obligation to pay for the accessibility and coordination of care skills by a Primary Physician is poorly funded and largely ignored. To promote the availability of Primary Care Providers, Four National Projects will be necessary. To implement the Four National Projects, the voluntary involvement of certain national institutions would be important, such as the Association of American Medical Colleges, the American Medical Association, the American Board of Medical Specialties, or The JOINT COMMISSION.
In addition, re-arranging benefits, structuring co-payment systems, requiring electronic health records, starting payment for quality measures, and bundling reimbursement are unlikely to substantially reduce the cost of our nation’s healthcare. At most, a reduction in our nation’s health spending by as much as 2% of the Gross Domestic Product might be possible. Remember, a 33% reduction will be necessary. This Sub-Page reviews these issues and their implications.
INNOVATION
Large system change will produce adjustments that will be difficult to fully anticipate. Certain requirements for adjusting to these changes can be known. Chief among these is the importance of promoting the professional assets of the physicians who are the essential “human capital” for each healthcare institution. Driving a reform process to attain a maternal mortality ratio for our nation to be among the best 11 developed nations of the world will require a level of collaboration, trust, and transparency never before expressed throughout the healthcare industry, community by community. It should begin with the career planning strategies and personnel training systems applicable to all healthcare personnel. — 13 —
This page has the following sub pages.