close-neighborhood
S O C I A L T R A D I T I O N S
9 pages —1—
INTRODUCTION
“The greatness of America
lies not in being more enlightened than any other country,
but rather in her ability to repair her faults.”
“I cannot help fearing that men may reach a point
where they look on every new theory as a danger,
every innovation as a toilsome trouble,
every social advance as a first step toward revolution,
and that they may absolutely refuse to move at all.”
Alexis de Tocqueville (1805 – 1859)
“When it’s better for everybody
it gets better for everybody.”
Eleanor Roosevelt (1884 – 1962)
Alexis de Tocqueville traveled in our country for two years beginning in 1831. After returning to his home in France, he wrote Democracy in America and published it in 1835. His observations represent a carefully nuanced and widely respected study of our nation’s early heritage. As noted by the first quotation cited above, our nation’s commitment to solving the faults of our social contract was evident then, now 185 years ago during 2020.
Our nation’s long-standing preoccupation with the HEALTH economics of its scientific mandate has created a national healthcare industry that is marginally unstable because of its high cost. As predicted by the second quotation, institutional paralysis has now prevented any meaningful reform of this industry. The most important strategy for planning meaningful reform requires a recognition that equitably available, enhanced Primary Healthcare does not exist for the Basic Healthcare Needs of each resident person, neighborhood by neighborhood in every urban, suburban, and rural community.
To consider a measure of the availability and accessibility problems, I have chosen our nation’s maternal mortality ratio as the basis to monitor the quality of our nation’s healthcare. From 2005 through 2014, the average maternal mortality ratio (MMR) for each state is known. New Jersey had the highest maternal mortality ratio at 30.2 and Massachusetts had the lowest at 5.6, 81% lower. Using rank-ordering, Pennsylvania was 25th at 15.3. The maternal mortality ratio measures how often women die with a health condition related to a pregnancy. Specifically, the MMR represents the number of maternal deaths associated with a pregnancy per 100,000 living infant births during one calendar year within each state or all states. The maternal mortality ratio does not include certain deaths such as accidental events. In the past, the United States has had a slightly different definition for this event to define it as a rate, as opposed to the definition for a ratio used by the World Health Organization and the United Nations.
In 2015, the World Health Organization published an analysis of worldwide maternal mortality ratios, nation by nation. The analysis represented a collaborative project involving the World Health Organization, the United Nations, and the World Bank. Our nation ranked 42nd among the 43 developed countries in 1990. By 2015, our nation was still 42nd out of the 51 then classified advanced/developed countries of the world. To rank among the 15 developed nations with the lowest MMR, the United States would need to reduce our nation’s maternal mortality ratio by 70%. Furthermore, our nation’s maternal mortality ratio steadily worsened from 1990 thru 2015, the only worldwide, advanced/developed nation with that 25-year statistic. Many factors are probably at fault with poverty as the top factor.
Without a doubt, our nation’s maternal mortality ratio is a profoundly discouraging attribute of our nation’s HEALTH. Also, I would argue that it is the most comprehensive HEALTH outcome representing the paradigm paralysis afflicting our nation’s Population Health and its Primary Healthcare. — 3 —
My judgment is that our nation’s worsening Population Health has occurred partially because the Primary Healthcare that is offered to each resident person does not communicate the importance of an equitably available and ecologically & culturally accessible, caring relationship with a Primary Healthcare Team as the ultimate basis for achieving, day-to-day, Stable HEALTH. Every resident person should have a connection with a source of enhanced Primary Healthcare that has existed for at least 2 years for it to become trustworthy. This level of responsive healthcare then becomes more easily transferable to a specialist physician, especially for a resident person who suddenly develops Complex Healthcare Needs (such as a pregnancy).
Any new HEALTH Condition needs responsive medical TRIAGE for its health care to stabilize the possibility of rapidly worsening progress. A uniform emphasis on this tradition for the healthcare of each resident person would then be more likely to benefit a resident person with Complex Healthcare Needs who encounters an unstable HEALTH Condition. The 3. EXECUTIVE SUMMARY “PAGE” includes a ‘SUB-PAGE’ for a further discussion of AVAILABILITY & ACCESSIBILITY issues.
PARADIGM SHIFT PARALYSIS
Ultimately, any resident person who encounters accessibility, as well as availability, barriers for their Basic Healthcare Needs, will eventually receive healthcare that is possibly less likely to be both efficient and effective. To emphasize the importance of equitably available Primary Healthcare, 20% of our resident persons with the most expensive healthcare accounted for 80% of our nation’s total health spending. Furthermore, the list of these 33 million persons who required this level of healthcare changes substantially from year to year. By comparison, 60% of our resident persons who required the least level of healthcare accounted for just 5.5% of our nation’s total health spending. This data was for 2017 as reported by the Medical Expenditure Panel Survey (Agency for Healthcare Research and Quality 2020).
For anyone’s health, the risk of encountering Complex Healthcare Needs is unpredictable. Sponsoring equitably available as well as ecologically & culturally accessible, enhanced Primary Health Care for each community’s resident persons will be the basic requirement for improving not only the efficiency of our nation’s healthcare industry but also its effectiveness. Unlike most of the other developed nations, our country has not invested in the collaborative processes necessary to promote enhanced Primary Healthcare, neighborhood by neighborhood within every community. In effect, the analysis of State by State maternal mortality incidence demonstrates the seriousness of this deficiency. Our nation is alone among the developed nations without a commitment to this level of Primary Healthcare.
TRADITIONS
HISTORY
The resident persons who wrote our nation’s Constitution shared a commitment to restrict the powers of the Federal government. They were especially aware of the dangers associated with feudalism and its highly centralized, authoritarian, and often coercive form of government. With a written document, our Constitution represented a new social contract as a basis to form our nation’s government. Its governance structure was specifically intended to prevent the uncontrolled concentration of power within the central government. The resultant emphasis on individual and community responsibility for HEALTH also led to a national healthcare tradition based on economic privilege. In effect, if you could pay for it, you could obtain it. To mitigate the resultant disparities, most communities established humanitarian healthcare through religious institutions and community “poor farms.”
Beginning in 1969, the effectiveness of these altruistic efforts for helping our resident persons with financial barriers to healthcare had become increasingly futile. As measured by our nation’s maternal mortality ratio, the responsiveness of our nation’s healthcare has especially neglected our resident persons who are 1) infants, 2) disabled or homeless, and 3) all women before and during a pregnancy.
Given the heritage of our nation’s pioneer spirit, a philosophical tension has evolved between the considerations of healthcare as an economic privilege versus healthcare as a human right. The issue is particularly difficult to reconcile since health care represents an extension of the basics for all caring relationships. Given our highly complex society, how would any altruistic person ever know for sure when the “good Samaritan standard” for a resident person applies to healthcare?
ALTRUISM
If I was still a practicing Primary Physician and by nature a committed but imperfect Good Samaritan, should I accept patients who have no insurance to pay for their health care? A survey of office-based physicians in 1999 and 2008 (40a) and (40b) in 2015 by the National Center for Health Statistics revealed that 95% of these physicians said YES in the 1999 survey. Subsequently, the 2008 survey revealed a decrease to 89% in 2015. At the same time, the number of Office-Based Physicians accepting Medicaid dropped from 73.5% to 64.5% between 1999 and 2008 returning to 72% in 2015. — 5 —
In effect, the surveys suggest that the answer is really: “It depends.” The most recent Medicaid result may reflect business practices by hospital systems as a means to manage market-share. Another explanation for the over-all disparity for Medicaid might reflect a practical judgment by many physicians about their ability to care for resident persons who often have very difficult psycho-social problems complicating their HEALTH. Without adequate reimbursement for appropriate levels of office staff, the ability to serve their needs becomes insurmountable. This contributes one factor for the rationale to justify a national certification process for supporting enhanced Primary Healthcare. No State would be willing to increase Medicaid reimbursement for Basic Healthcare Needs without a means to assure that it was not being used just solely for augmented physician income.
Our Constitution creates a legal right for certain attributes of citizenship such as due process. We have added a legal right for certain other aspects of citizenship such as non-discrimination but not for healthcare. At this point, I would suggest that equitably available and ecologically & culturally accessible healthcare that is justly efficient and dependably effective should also be a right of citizenship. This is necessary for each resident person, if not as an extension of the Bill of Rights, then at least for improving the economic efficiency and scientific effectiveness of our nation’s healthcare industry. Ultimately, it’s a Human Dignity issue.
EMTALA (Emergency Medical Treatment and Labor Act of 1986)
There is essentially only one attribute of a resident person’s healthcare that has become a legal “right:” the health care for an emergent HEALTH Condition. In effect, the EMTALA law initiated a guarantee that healthcare for an emergent HEALTH Condition should be offered to any resident by a hospital at any time regardless of their ability to pay. However, the effect of this law merely deferred any national awareness of the importance of enhanced Primary Healthcare. The cost of health care for resident persons who endure availability and accessibility barriers to Primary Health Care substantially increases its aggregate financial cost.
It is likely that the “ER mindset” of many resident persons has actually worsened our national sense of accessibility: don’t go until you’re convinced that you are in trouble. Unfortunately, the state-by-state maternal mortality ratios may represent the resultant quality outcome of the “ER mindset” for too many of our nation’s women during a pregnancy. Minutes, not hours, must be responsively managed. The fear of the unknowns associated with childbirth must be profound for many, if not most, women.
“WORKING TOGETHER”
This book, written by Professor Elinor Ostrom, became available in 2010. Its subtitle is “Collective Action, the Commons, and Multiple Methods in Practice.” It describes the benefits to a local community when the community plans for its own needs. For NATIONAL HEALTH, the book describes a theoretical basis for mobilizing community resources with a responsibility to sponsor enhanced Primary Healthcare, community by community. In effect, a new nationally promoted institution, NATIONAL HEALTH, would mobilize the local resources for ensuring that Primary Healthcare is equitably available to as well as ecologically & culturally accessible by each resident person, community by community. Each community of approximately 400,000 resident persons would locally initiate and sustain their own Community HEALTH Forum to mobilize the local social capital required to achieve Stable HEALTH For Each Resident Person. Numbering nearly 810, these Forums would be initiated locally and mobilized by the leadership accountabilities of NATIONAL HEALTH.
The NATIONAL HEALTH Proposal “PAGE” and its 5 Sub-Pages describe the formation and functions of a new institution, NATIONAL HEALTH. It is proposed as having the design attributes defined and validated by Professor Ostrom, especially the importance of decentralized governance. Promoting the formation of a Forum by each of 810 communities through collective action represents a New Strategy for meaningful healthcare reform for both its Population Health as well as its Primary Healthcare.
Certain provisions of Federal and State Laws regarding anti-competition activities may need adjustment when truly collaborative and transparent commitments occur as a result of decisions by a Forum. Each Forum may need to satisfy certain rules for their functions, as would be defined by Federal Law. The legal basis to establish these rules does not currently exist. Ultimately, the Design Principles of Elinor Ostrom, Nobel Prize winner in 2009, would be necessary as the basis to define these rules by a Congressionally Chartered, semi-autonomous institution. — 7 —
PARADIGM SHIFT REVERSAL
Even if not defined within our nation’s Constitution or by Federal statute, healthcare in A NEW ERA should be a right for each resident person. Our healthcare industry should be held responsible for promoting the means to offer healthcare for the Basic as well as the Complex Healthcare Needs of each citizen. With improved availability and accessibility, health spending, as a portion of our national economy, would decrease from 17.9% of the GDP (Gross Domestic Product) in 2019 to 13% or less within 10 years after the establishment of NATIONAL HEALTH. A Sub-Page, initial GOVERNANCE, under the GOALs Page describes a possible process for establishing NATIONAL HEALTH.
To accomplish this improvement, a unique effort to plan and implement enhanced Primary Healthcare for each resident person will be necessary. Another list of enhancements would be necessary to achieve the full 27% reduction in the portion of our national economy allocated to health spending. These other enhancements will not be possible without enhanced Primary Healthcare that is equitably available to as well as ecologically & culturally accessible by each resident person. Depending on our nation’s economic growth, the absolute change in our nation’s annual health spending might not need to actually decrease. Remember, the problem is really the portion of our national economy allocated to health spending. Basically, we will need to decrease health spending from 18% to 13% at a rate that is -0.5% less than economic growth annually for 10 years.
Looking at the character of every nation’s economic activity, there is one industry that is more efficient within our own economy than the same industry’s level of efficiency within the economy of any other developed nation. It is agriculture. The Cooperative Extension Service, established by Congress in 1914 by the Smith-Lever Act, is likely the most important reason for the success of our nation’s agricultural industry. The Cooperative Extension Service maintains a connection between the local urban and rural farmers with their nearest land-grant College of Agriculture. County by county, the Cooperative Extension Service maintains this national connection.
The farmer learns about “best practices” and, just as importantly, the University learns about the current problems faced by the local, “front line” farmer. In effect, the Extension Service ensures that each “Ag College” prepares its students with an understanding of the current agricultural realities they will encounter on the first day after graduation. With the Extension Service, we have the most efficient agricultural industry in the world. In the absence of a similar university collaboration with the “front line” of Primary Healthcare, we also have the least efficient healthcare industry among the advanced/developed nations.
A similar institution could be created for healthcare as managed through each local, community-wide commitment to promote a collaborative effort by their locally responsible stakeholders to arrange equitably available and ecologically & culturally accessible Primary Healthcare for each resident person. NATIONAL HEALTH would be required to sponsor a real-time connection between this Primary Healthcare and their regional Medical School. The Design Principles formulated by Professor Ostrom would apply as a basis for the use of collective action as a strategy for healthcare reform.
This strategy could also augment the legacy of Senator Robert Kennedy. During his Presidential campaign in 1968, he stressed the need to reduce our nation’s “mindless menace of violence.” Remember also the special legacy of Rodney King who died in June of 2012. In the midst of the 1993 Los Angeles riots, he said: “Can we all get along?” We should, we can, and we must not only to reduce our nation’s “mindless menace of violence” but also to reform our nation’s healthcare.
SOCIAL URGENCY
Returning to our nation’s maternal mortality ratio (MMR), it is important to understand the social reality of our nation’s MMR. Let us assume that our nation’s maternal mortality ratio was 25 in 2015. Also, let’s assume that there were 4 million children born in 2015. It was 3.9 million in 2013. What the estimates mean, in reality, is that 1000 women may have died in the United States during 2015 as a result of a pregnancy. Possibly 700 of these women would still be alive in 2019, if they had lived in one of the 15 developed nations of the world with the lowest/best MMR at the time of conception. Most importantly, the loss of a mother to those 700 families and their children is irreplaceable (nearly 2 daily). The numbers may be arguable, but as a continuing and poorly acknowledged tragedy for our nation’s families, it is not arguable.
In 2013, the United Nations identified 46 nations as a developed nation. The WORLD HEALTH ORGANIZATION 2013 Report on worldwide Maternal Mortality lists the following 15 developed nations as having a maternal mortality ratio of 5 or less: Austria, Belarus, Bulgaria, Czech Republic, Denmark, Finland, Greece, Ireland, Italy, Israel, Norway, Poland, Spain, Sweden, and Switzerland. For the 2013 Report, the United States ranked 45th worst among the 46 developed nations of the world.
The same report for 2015 identified 51 nations as an advanced/developed nation. For that report, the United States ranked 42nd worst among these 51 nations. The list of nations with a maternal mortality ratio of 5 or less was still 15, although slightly different: Austria, Belarus, Bulgaria, Czech Republic, Denmark, Finland, Greece, Ireland, Israel, Italy, Japan, Kuwait, Norway, Poland, Spain, Sweden, and Switzerland. The United States remains alone as the only advanced/developed nation with a worsening maternal mortality ratio since 1990, now for more than 30 years. — 9 —