National Health Service
The best way to manage our health care rationally, and to provide for good healthcare for everything, is to put at least a component of it under a National Service Framework. The education, training and minimum provisioning "arming" of healthcare providers all should be organized at a National level and also carried out in each State.
- National Service would ensure that we have enough of the right kind of doctors, nurses, nurse practitioners, and other providers, to meet the public need,
- also provide a surge capability via a reserve component to meet domestic and international emergencies and serve the military in regular order or exigency.
- Reduce the cost of service to under-served, stressed, or out of the way places in the United States by training and staffing enough doctors to serve those communities through the reserve system.
- Provide Universal Standards which would reduce the urge to import doctors, train capable providers and provide a more uniform standard for accrediting providers across the country; allowing them more flexibility in residence and location of service.
Doctors in private practice, could be available via reserves for emergencies and we can use such a system to ensure that people in rural, remote or under-served locations get healthcare service. We can also use this system to ensure that all providers get paid reasonable wages.
Not a New Idea
This is not a new idea. Essentially this was the vision of people like Sigerist, Truman and FDR. Privateering ideologues, inconvenienced and blind interests and pirates have been fighting this vision, on specious, often "red baiting" grounds, and their success has been our healthcare systems subversion and sometimes undoing.
Privateering is not an Option
Health Care is not a place where some should profiteer on human suffering. But that has been the specific intent of many of those seeking to privatize and take down what health services we were once providing in favor of private profits. Even so, at various times we've had elements of a good, though imperfect system.
If the Grifters Opportunists and Pirates have their way it will get worse before it gets better. But it will get there.
Private versus Public Government
We have to manage our health care nationally. There is no choice between Government management of these things and "markets." There is no such thing as a "market for healthcare" that covers all the services and necessities required for the health, safety and security of the average citizen. Healthcare has to be governed, paid for, resourced and provided in a sane manner managed in a networked fashioned by institutionalized places where providers can work, be paid or congregate in emergencies."
Management in the Public Good versus No Good
The only real choice is between management in the public good or private management for private, separate advantage, which is the definition Tyranny according to John Locke, See Concept of Commonwealth as Antidote to Tyranny) Privateering rarely saves real costs, just transfers them to those who can least afford them – while enriching the few. In the case of health care, misallocation means no care for the masses of people.
Health Service as a fundamental Role of Good Government
The fundamental role of Government is to provide for our defense from internal and external threats. Such threats include weather related, epidemics as well as human threats. Our founders envisioned the relationship between the Federal Government and State government to be analogous to the relationship between State Government and county and local government. It is supposed to be collaborative. Hamilton foresaw that there would be "infinite"
Collaborative Government with WE the People
There is no separate "Federal" government from "these United States." We are one nation sharing a corner of one planet. Many government functions need to be distributed between local and Federal authority and execution. A collaborative government was the original vision, not one where States were pitted against the Federal Government. Epidemics and illness threats to public security. Health Care should be a right where it is available at all.
Such a health service should include national, Statewide and local institutions and service. It should knit together the public and private institutions already existing, emergency response capabilities nationwide, and provide training for stabilization, palliative care and first response personnel as reservists, "militia" as well as military and civilian providers. Very little new needs to be stood up except where years of neglect and ideological hatred for what FDR has degraded, privatized or torn down and removed from communities that once had these capabilities. What we have needs to be funded according to the constitution's militia clauses, of which the second amendment is one.
Emergency Response Services ARE Militia
Health Services are Militia. At one time the Militia was an all purpose body, connected to the right of the people to assemble and petition for redress of grievances and democracy itself. The militia was called out to respond to fire, weather or health emergencies as well as other security emergencies. Present day bodies involved in police, fire, rescue and emergency response all derive their origination in the militia and should derive their authorities and constitutional guidelines from the militia clauses of the Constitution which spell out the respective State, local and Federal roles..
Duty of All Citizens to Respond to Emergencies
The concept of Militia derives from the fact that it is the duty of all citizens to assist one another to the extent they can in emergencies; personal, local or national. It is a Government role to respond to emergencies; National, local, Natural disaster, invasion and epidemics because such responses must be organized and that is a governing function. When the citizenry respond to emergencies spontaneously that is a demonstration of democracy in action and evidence of the virtue of true democracy.
Mandated by The constitution
Thus Emergency Services, and healthcare services managed by the government are not only completely constitutional, they are mandated by the Constitution, and the guidelines for their management spelled out in the Constitution. Emergency Services are what was meant by providing for a "militia." It was understood as for that purpose in the 18th Century, and so when we refer to "Militia", we are talking about our Emergency Response capabilities, today.
Modern Emergency Response
When there is a hurricane or a tornado, people aren't secure until they've been stabilized, power is up, water, transportation and services are flowing, food supplies are unlocked from blockages. These are as much part of emergency response today, as men with a flintlock were in 1800. And people in 1800 often used the militia to respond to natural disasters then as now.
Therefore Modern National and local Service should include:
- Rescue and Disaster Response.
- Emergency Medical Response
And by implication:
- Health Service, Military and Civilian
- Emergency Services to maintain vital infrastructure.
All these services are implied by the constitution and should be Collaborative down to local Government. After all, many emergencies are almost over by the time Federal or even State response is organized. If confidence artist lawyers can parse the interpretation of the Constitution to deny this obvious fact, then we need a constitutional Amendment to protect it from our Corrupt SCOTUS. The argument is clear
Constituting the Health Service under Militia Guidelines
The Constitution gives Congress, and by implication, the USA Government the power to:
"To provide for calling forth the Militia to execute the Laws of the Union, suppress Insurrections and repel Invasions" [Constitution Article 2 Section 8]
This power is shared with the States, and by intention with local government, where appropriate in Article Two to:
"provide for organizing, arming, and disciplining the Militia, and for governing such Part of them as may be employed in the Service of the United States, reserving to the States respectively, the Appointment of the Officers, and the Authority of training the Militia according to the discipline prescribed by Congress" [COTUS]
Application to HealthCare
This section of the constitution has been used to organize our military forces, but is also a guideline applicable to where-ever we use forces historically derived from the militia and where those are necessary to execute the laws of the Union. And thus should be used to organize our healthcare delivery.
Organizing National Service
The constitution tells us that the Federal Government is responsible for "organizing, arming, and disciplining the Militia,"
but gives the states the role of appointing officers and a role in the training.
"...governing such Part of them as may be employed in the Service of the United States,:
There should be Shock Trauma Units in every census district where people live. It should never take more than 20 minutes to get to a Shock Trauma Unit. There is a limit to how long a trauma victim can survive without treatment and that limit should define the location of shock trauma emergency rooms. There should be local clinics that can double as emergency rooms if needed in pretty much every community across the country. These should have expansion capability to double for shock trauma in the event of major disaster.
Provisioning, "Arming", the Health Service
The "arms" of health care are medical materiel, and these should be distributed according to demographics and epidemiological analysis. Personnel should reflect local needs. Any local losses that can't be addressed through efficiency measures, or proper fees and taxes, should be subsidized by central government. Delivery ought to be free to the user and charged through appropriate payroll taxes or other taxation. Providing cadres of providers in National Service can address the needs of under-served areas.
Training and Disciplining the Militia
"reserving to the States respectively, the Appointment of the Officers, and the Authority of training the Militia according to the discipline prescribed by Congress" [Art 2, Sec 8 Constitution]
Thus every State should have at least one University with the ability to train health care providers, including doctors, nurses, nurse practitioners, etc... These should also be associated with at least one teaching hospital per state, and preferably one teaching hospital within 100 miles of the next one. Doctors are the Officers of the medical professions and providers ought to be trained under uniform national standards, but in each State. The Federal Government could designate special teaching universities for advanced training to ensure those standards and to save money on specialties. But each state should have a role in this and no state (or US Possession) should be neglected from serving the needs of all its citizens.
Commander In Chief
The President is "Commander in Chief" of the "Militia of the several States," "when called into the actual Service of the United States." The Militia were the origin of most of our policing, fire, and emergency powers. Indeed the word police was originally a synonym for executive power to enforce the law and keep order. And health Services are a part of the requirements to keep order and public services. For instance enforcing quarantines is a place where health and police power meet.
The case for Police as Militia is obvious, as is the case for them as Emergency Response. The case for police as the "standing Armies" founders like Hamilton and Madison wanted to avoid, is equally obvious.
An Alternative to Bureaucracy
The purpose of the militia clauses was to organize an alternative to top down unilateral executive power. It was meant to provide a degree of the principle of subsidiarity to local authorities to respond to their own emergencies. Congress currently puts the Federal Government in a support role, in most cases, and that is appropriate, but the constitution gives the US not only the power but the duty to provide uniform regulations or "discipline prescribed by Congress." And latent in the constitution are the emergency powers that one day might enable some executive to disregard separation of powers. Fear of too much Federal Power has led to the enabling of too much State power. But fear of amorphous threats has too often led to tyranny at both Federal and State Level.
National Service, Virtue, as an Alternative to Standing Armies
Now it was the contention of Jefferson that the powers of the Federal Government should be limited. However, even Jefferson eventually had to admit that a national service was preferable to standing armies. Hamilton was more explicit in his recommendation:
“The circumstances that endanger the safety of nations are infinite, and for this reason no constitutional shackles can wisely be imposed on the power to which the care of it is committed. This power ought to be coextensive with all the possible combinations of such circumstances; and ought to be under the direction of the same councils which are appointed to preside over the common defense.” [Federalist 23 to 26]
Hamilton had the vision to see the potential of threats from Zika Virus, or Malaria, Earthquakes or Tsunamis in the phrase "circumstances" [of endangerment] ... "are infinite". We've learned that the health of any nation is as serious a threat to a country as foreign invasion. Examples abound in recent and ancient history.
We should use the constitution to form both a National Health Service and a Reserve Police Service; both of which would be part of the National Guard and available to Governors and the Federal Government alike. I'd also include a Teaching Service and infrastructure Units in this, but that is a bit of a stretch for this post.
Subsidiarity and Emergency Response
The Founders knew that while the service is to the nation, it is usually also to one's own home and neighborhood. The principle of subsidiarity, wherein locals are more competent most of the time, applies to responding to emergencies. The people closest to a problem should have charge of it. They should also own the resources they need to solve the problem. We've let private companies usurp the ownership of valuable communications spectrum. It should belong to our Emergency Response Services and to local government.
The founders were resisting the East India Company. They had seen the pernicious results of Robert Clive's use of a private army to subject the Mogul Emperor of India to his companies looting. [See: Pirates, Loot and the East India Company for more] They saw Democratic governance, republican forms and the principles of commonwealth as an alternative to the absolute tyranny of private government, privatization and private tyranny as exercised in East India. Indeed the original Tea Party Revolt was a revolt against Oligarchy and monopoly. The East India Company was seeking to enforce its monopoly on Tea by taxing tea brought in by other than Company Authorized Ships. The colonists saw where privatization goes and rejected it.
The National Health Service should be led by the Surgeon General with a General Staff composed of Force Surgeon Generals, the Joint Surgeon General, and Deputies from each State, Territory and Region, reserve or State Health Department. Only those functions best conducted nationally should be performed at the national level. The rest should be distributed where they can best be carried out. Private non profit institutions should also have a presence in the General Staff. The National Health Service should serve the military, Veterans, use the University and National Academy system for training. It should be governed as much as possible by the providers (including nurses, lab techs and similar), with input also from consumers and consumer groups and oversight nationally from congress and the President and locally from local government.
I've written on this subject before so this will get reviewed and edited again later, but it is being published 8/8/2017
- Why we need a National Health Service
- Federalist 23-on and benefits of Federalism
- What Founders Meant By Militia
- Pirates Loot and the East India Company