Americans Stand in the Gaps

Discussions of state or federal budgets draw much attention, but it is the American people who make America work, fill in the gaps, and accomplish far more than the dollars expended. 

Ideally the designs for dollars, people, and services all align for best result. A divided nation will accomplish far less, and this will often result in a widening gap impacting most people. M Scott Peck wrote a book on "community" and noted that you knew community existed when it happened. Happening worth having is togetherness.

We are not together. Our inefficiency rocks the core of our nation, what we hope to accomplish, and how we can accomplish it. Infrastructure is a popular word. Embedded in infrastructure is the ability to facilitate more efficient and effective function. There are multiple types of infrastructure in a nation. America is made up of physical infrastructure, spiritual infrastructure, and human infrastructure. Rarely have these all aligned except for major wars and for a period of time after 9/11. 

A great nation requires a proper balance between all three types. Some attempts at balance resulted from the tragedies of the early 1960s with attempts to address widening divisions. Changes in the decades since 1980 have seen marginalization of the human infrastructure. The nation continues to be divided along political/spiritual lines and the consequences are seen in the lack of investments in physical and human infrastructure. 

Not surprisingly this has required more Americans to step up and do even more. Their efforts would be more efficient and more effective if our designs supported their important work across communities, people, patients, students, and children. Their contributions are outstanding, but this is also because they stand out. Even more important would be many more of us stepping up, so many that it would be hard to seen any standing out. The results would be most important, not the players.

Readers of this blog will commonly see my posts about the wasted 100 million dollar grants by CMS and by various foundations. These grants are often about areas that people are already addressing. Dollars are best spent to support people doing what needs to be done and there is certainly plenty that needs doing in the area of health access.
Health and education are areas that are difficult to reduce to dollar values. There are so many sacrifices made by so many. The best sacrifices are made with few noticing. This is quite common in teachers and health care team members. 

On principle alone, health and education should resist the reduction into dollar values. 

Clearly efforts to measure these areas have worsened matters by consuming dollars that are needed to support team members - and by transferring scarce dollars away from where needed.

The messages of the media are commonly about dollar contributions, high costs, or lack of investment. Volunteer and other contributions can be given a dollar value although some contributions do rate the term "priceless."

These following contributions represent a collection that is a work in progress. Government health and education data were converted to estimates. These are measured in terms of additional teacher, nurse, parent, caregiver, and community efforts. Experts in education, public service, and other areas of health care could add even more support by many more Americans.

Health Care Is a 3 Trillion Dollar Expenditure but Actual Contributions Exceed
4 Trillion Dollars When Including Unpaid, Underpaid, and In-Kind Efforts
  • 500 billion is contributed by Caregivers - In a recent annual report by CMS, the 1 trillion dollar budget sum from Medicaid and Medicare was listed along with the contributions estimated to arise from caregivers. Caregivers providing for family, friends, neighbors, or those in the community contribute at least 500 billion dollars a year or right between what Medicaid and Medicare contribute to health care at 600 billion and 400 billion - and without one hundred billion in waste, fraud, and abuse. This compares to 3 trillion dollars for overall health care contribution equal to about 16 to 20% of health care. Additional contributions from nurses, physicians, and other team members easily reach over 500 billion dollars.
Hospital Care Is 1 Trillion Dollars of Expense But Actual Contributions Are Greater
  • 182 billion - One of the problems not addressed is what happens when professionals are trained to do a job, and then receive less support to do that job. They still do the job, but are more strained in doing the work. Nurses have been devalued since the 1980s. They still do the job but with fewer while forced to do it in a shorter time. Changes in payment design accelerated the compromise. Diagnosis Related Group payment changes resulted in a fixed and lower payment to hospitals. This forced hospitals to get by with less and send patients out faster, in some cases too fast. The patients and families have often been unprepared for the discharge - resulting in greater efforts outside of the hospital. Inside of the hospital, nurses were put on the chopping block due to their prominent role as the largest hospital cost. Too few nurses have been forced to do too much for too little for decades. The calculations of their additional contributions include the additional efforts beyond hourly pay (quite priceless actually) rated at the figure of at least $25 more per hour for 38 hours a week for 48 weeks a year. 
  • The nursing figures compare to hospital spending at 1 trillion a year for a value of 18% of hospital spending. Consequences of the design include nursing shortages and less experienced nurses. Inclusion of more personnel would result in 25 - 30% for the contribution. 
  • Volunteers easily contribute 10 - 30 billion in efforts and additional billions in fund raising.
With over 200 billion in revenue cut since 2010, hospitals will continue to face more challenges. Those doing the health care designs have decided to do more for less cost - a design that most compromises those that deliver the care. The additional strain placed on hospitals has long resulted in more overwhelm for patients, families, caregivers, outpatient resources, and primary care clinics. 

Primary Care Is a 170 Billion Expenditure But 70 Billion in Additional Contribution Is Required

Primary care has been in decline for decades with lowest payments kept stagnant and accelerating cost of delivery. It might have collapsed but for the efforts of dedicated advocates who have preserved and protected this basic access care asset across America. This has not been an easy task because of the seriously flawed payment design. The underpayment and the overwork is most likely found in the places where 50% of Americans are most left behind. 

  • 20 billion - The calculations of additional contributions include 20 billion for primary care team members undersupported and overworking by $10 per hour and 
  • 20 billion more for primary care physicians due to stagnant payment plus another 
  • 20 billion for the additional uncompensated time to do electronic records plus at least 
  • 10 billion in additional adjustment efforts during this time of rapid change of regulations, changes in regulations, reorganizations, switching payment, and insurance barriers to needed care. 
This 70 billion compares to 170 billion or a contribution equal to about 40% of primary care delivery capacity. More detailed contributions involving the broader community, families, and others could indicate 90 billion. One of the true threats to basic health access is burnout. Morale continues to worsen.

If primary care personnel delivered care based on the level at which they were compensated, primary care would collapse. Primary care and other basic health and education functions actually require substantial human supplementation just to continue the effort.

Considering the declines in mental health, public health, and general surgical specialties plus increasingly complex patients, the challenges of primary care will be even greater.

Other Health Care Contributions In Lieu of Adequate Support
  • 100 billion - This is the requirement to invest in sufficient mental health care 
  • 50 billion - General surgical services require substantial increases to maintain the active workforce and team members - now shrinking at 2 to 3 percentage points a year by national designs
The period since 2010 has been one of the costliest in health care with regard to rapid changes, adjustments, additional duties, and various distractions to address with government and payers driving this costly train. In addition to the 30 billion above, about 50 billion additional has been required from non-primary care physicians and their team members to address EHR and measurement focus. Many estimates would be much higher.

Education for Primary and Secondary Education - 620 Billion Costs in 2016 Exceeds 1 Trillion Effort For All Source Contributions
  • 115 billion - Teachers have suffered the same austerity cuts as seen across those who serve where most needed. An additional 5 hours a day for 180 days a year should be paid at $50 for 115 billion. 
  • 92 billion - Raising teaching pay to $50 per hour would be 92 billion. Based on other nations this would still be small in comparison. 
  • 50 - 100 billion - The additional contributions of parents of the 50 million students add another 50 - 100 billion. 
  • 48 billion -  Homeschooling contributions of parents involve about 3 hours a day for 200 days at 40 dollars an hour.
  • 5 - 20 billion - Before and after school and weekend contributions 
  • 2 - 10 billion - community, church, and other organization contributions
  • This 340 billion compares to 620 billion for formal education spending for primary and secondary education.  for a contribution equal to half, or one-third of the total education contribution. This would be much higher considering contributions by teachers and parents prior to formal education and the contributions of community and church groups. The contribution of the federal government is only about 25 billion dollars and is limited to efforts in the early years of life and for special needs students - another area where half of the contribution may be provided by in-kind efforts.
Tax Day or Tax Break Day

The stimulus for this blog is the upcoming tax day - or tax break day for the Americans doing best. The studies clearly indicate that you cannot count on the wealthy for contributions, but you can count on those lowest income to give the most of their few remaining dollars. 

Your tax dollar goes for the following. Those in Green Contribute more per dollar for outcomes. Those in red do not contribute as much. Social Security contributes to outcomes but is taxed and paid differently. Health care spending is high cost for little improvement in outcome. It has the double effect of collapsing other spending.

29.1 cents Medicaid, Medicare, Child Health 
23.4 Military and Pentagon
13.2 Debt
7.5 Unemployment and Labor
6 Veterans Benefits
4.5 Food and Agriculture
4.2 Government - Jobs on the border via Border Patrol can contribute, other spending not so much
3.2 Transportation
2.8 Education
2.1 Housing and Community
1.6 Energy and Environment
1.3 International Affairs
1.0 Science

Health outcomes as well as education and other outcomes proceed from patient and population situations. They are not shaped from clinical interventions and certainly are not reflected in the usual health data. Health care spending is so much that little remains for investments in younger to youngest humans or investments in resources to help the elderly through the most challenging decades of their lives. Too much spent for too little in too few settings is a bad design for best outcomes for most Americans. 

Humans must be supported from the earliest months and years of life. Human infrastructure should reinforce the local influence of parent, school, and community. So much of a life course is set by age 8 when the velocity of learning slows. The focus soon changes to environment and social interactions. Environments are too often least supportive for young humans to learn to interact as well as they need for their health and the health of others.


The Least Healthy Counties point the way as they have least investments despite needing the most - and they involve the most Americans and those increasing the most. 

Austerity Focus Magnified by Runaway Health Costs are compromising most Americans

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