Health Care Service and the Militia
We currently have shortages of Doctors and health care service in much of the country, while we have a surplus of people needing healthcare. This at the same time as some folks flock to what seem like high paying specialties of healthcare because they are more lucrative, and these jobs concentrate where people with wealth live. The result is that much of the country (urban poor and rural poor) are neglected. This reflects "bad constitution" of our healthcare service and Utility.
Public Healthcare is, and should be treated as a strategic public utility vital to the National Security. We've dealt with this before. We treated healthcare as a utility until privateers sold us the bright idea (but costly) that freebooting competition could somehow reign in costs and that running healthcare companies at a profit was a sane idea. It is possible to standup a healthcare service that meets the needs and traditions of our country by associating that service with the national guard and principles derived from militia and voluntary service.
We Established Healthcare as a Utility Before
The Crisis of Healthcare in the 20s and 30s
We established the health care system using principles of volunteerism and programs based on our long tradition of "The Militia of the Whole" combined with ideas of public utility that led to the creation of the Non Profit Blue Cross Blue Shield corporations and of a hospital system. We used these principles and the soft subsidies associated with them to build an infrastructure of rural and urban healthcare that has served us well to this date.
Prior to the 1930's much of the country did without adequate healthcare. We dealt with that crisis with a variety of measures that effectively subsidized health care service in under served areas without doing so explicitly. We built an infrastructure of health-care provision using the Works Progress Administration and the Public Works Administration. These programs provided soft subsidies to non profit health care organizations, local and State Government and provided an infrastructure that enabled progress for the next 50 years. That is aging in many areas, but still the foundation of our current system.
During the Great Depression we used the tax code to subsidize companies to provide healthcare for their employees, to encourage the creation of non-profit health clinics and hospitals around the country. And we used Workers from the Works Progress Administration to build schools, post offices and repair roads, but we also used the Public Works Administration to build about 1/3 the Hospitals during the same period. These projects put people to work, but they also were a soft subsidy for healthcare and education.
Health Service and National Security
There is also a national security component to a National Health Service. In the modern world, many of our foreign and internal interventions are entirely or partly humanitarian in nature. Epidemics and poor public health are issues in military readiness, ability to respond to crisis, and in whether or not our country can produce what it needs to produce to have a successful economy.
Using the National Guard and Reserve System to provide adequate staffing of HealthCare
A National Health Service in addition to serving poorly served places in the United States provides a ready reserve, and should provide a surge capability for handling domestic and foreign disasters. Integrating the Joint Military Health Service with Veterans and Civilian Services could be a cost effective way to provide sufficient health care providers around the country, within the military and for emergencies. Volunteers would commit to service in exchange for their education and training. We would pay such volunteers for their service in a way similar to how we pay the National Guard. The Security of this country depends on a healthy military age workforce and population. The history of our Health Care System demonstrates this is not a new idea. It simply needs to be acted on. Anyone who has any involvement with the health care field knows that most providers have an attitude of service already. The pirates are few but very destructive.
Using the Constitution to Improve Healthcare delivery
A National Health Service should be run using the militia provisions of the Constitution similar to how they currently are used through the National Guard, with a reserve Health Service where we provide free education and training to health service members in return for serving where the country needs them as providers for a term and being available thereafter for emergencies. A Reserve Health Service, a Homeland Health Service, both should supplement the Military Health Service and work alongside paid doctors.
Emergency Service is National Security
We need to re-establish Reserve Emergency Hospital Centers in each major region. Nobody should, backed up by Research Hospitals in each State. We also need to soak the privateering out of the system by taxing excessive profits from private hospitals and encouraging them to return to non-profit status. And advance the principle that there should be a reserve hospital and clinic available to every neighborhood in the country. To do that we have to emphasize the need to have both active health care providers and surge capability. And we have to make sure that private healthcare providers are integrated into the surge capability. This is justified both on a national security basis and an economic one.
Trauma and Emergency Response
And it is also justified on the basis of "life". The Physician Dr Cowley back in the 60s promoted the notion that there is a "golden hour" in the treatment of trauma from accidents or similar. If the nearest clinic is an hour away, that hour is lost and people who are hurt are Stuck Out of Luck (SOL). Closing neighborhood and rural clinics and hospitals is a lethal decision.
Emergency Response inherits from Militia Service
A reserve Hospital system is there for emergencies, and all emergencies should be considered both local and Federal. They must be addressed rapidly and collaboratively, by dedicated and well trained providers. Traditionally the Militia was the democratic response of the people to emergencies. The constitution suggests how to accomplish this!
"To provide for organizing, [provisioning], and disciplining a healthcare system, 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 [Providers] according to the discipline (regulations and requirements) prescribed by Congress."
National Payment
Congress should provide for the cost of complying with those regulations, providing such training and discipline. It can do this through dedicated taxes. It can also do this by recognizing the Utility of a Health Care Service and organizing the VA, Military Health, and National Health Systems under collaborative system.
We Don't need Pirates
What we don't need is privatization, profiteering or privateering. We don't need pirates. In Ancient Rome Firefighters allegedly set fires in buildings that didn't pay for a medallion to protect them, as much from the firefighters as fires. Health care as a for profit private system is a pirate system. It has to be non-profit and it has to be run for the public good. Yes, those providing such services should be well compensated.
Argument for Single Payer
A single payer system of some sort is the best way to fund such a system for two reasons. One is that it reduces the impact of free-riders on the system. The Young and Healthy have less odds of needing the service, but when the system depends on voluntary insurance to pay for it, the young try to play the odds. The general public is then forced to choose between letting them die or treating them when they get hurt. Those treated for free, without any contribution to the system, are free riders. At the same time the wealthy and connected benefit from everyone working for them or serving them being healthy, "free riders" shouldn't be an issue, but everyone should pay to the extent they can. This is an argument for paying for healthcare with taxes. Premiums are basically private taxes. So the choice is between people paying taxes to many rent seekers (insurance companies as private government) or to a single public utility (government).
Argument for A Distributed System
At the same time the principle of subsidiarity means that Henry George's suggestions need to be taken seriously too... i.e. "proper government, local State or National as May Be." Government of healthcare should be collaborative with local, state and Federal involvement and not a "one size fits all" approach. As with the militia the Federal Government should provide general requirements, rules and funding distributed fairly. But the execution should be as local as possible. A Hospital is local government as much as a neighborhood should have local government by right. Centralization of either Government or Corporations is an evil because it leads to excessive abstraction while concentrating and wasting (hoarding) resources. See [Utility Versus the Pirates]
Further Reading
- Sanity in Healthcare
- http://holtesthoughts.blogspot.com/2017/07/utility-versus-pirates.html
- http://holtesthoughts.blogspot.com/2017/05/free-competition.html
Appendix
I have a lot more to say, but that is enough for this post. I think I've outlined some important principles here.
The Public Works Administration:
"the PWA funded the construction of more than 34,000 projects, including airports, electricity-generating dams, and aircraft carriers; and seventy percent of the new schools and one third of the hospitals built during that time."
Works Progress Administration:
- *1.2 billion school lunches served
- *650,000 miles of new or improved roads (enough roadwork to go around the Earth 26 times)
- *124,000 new or improved bridges
- *1.1 million new or improved culverts
- *39,000 schools built, improved, or repaired
- *85,000 public buildings built, improved, or repaired (excluding schools)
- *8,000 new or improved parks
- *18,000 new or improved playgrounds & athletic fields
- *2,000 swimming & wading pools
- *4,000 new or improved utility plants
- *16,000 miles of water lines installed (enough water line to extend from New York to India…and back again)
- *24,000 miles of sewer lines installed (nearly enough to circle the globe)
- *950 airports/airfields built, improved, or repaired
- *1,500 nursery schools operated
- *225,000 concerts performed
- *475,000 works of art
- *276 full length books
I started this post in 2016. Published it on July 6 2017. I actually thought I'd posted it in 2016. I'm glad I didn't because I've learned a lot in the last year and my ideas on the subject have become more concrete and what is covered here is related to other ideas I've posted about. Updated it to make it a little clearer at the beginning of 2019.
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