Articles by "health workforce"
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In family medicine we most need change agents and least need those who remain stagnant and unable to change the course of health access, of primary care, and of health outcomes for most Americans. We fail in training and in family medicine workforce because we fail in selection and preparation in ways that training cannot address.

The STFM blog highlighted the quality improvement potential of family medicine residents. There is so much more potential for those that begin efforts much earlier and work throughout their lives as change agents.

The Social Beginning Is the Beginning of Change Agents

Potential medical students and others preparing for health and education careers should spend age 14 to 30 years working in their communities improving health, education, and local resources in their communities. These important interactive life experiences should be the most important determinants for selection as nurses, public health officers, or family physicians. Selections should be based on the demonstrated ability to reshape lives toward better health, education, situations, environments, and relationships. 
 


Studies demonstrate difficulty if not impossibility with regard to training medical students in service orientation and empathy. These areas have been linked to primary care careers, but many still lack these important characteristics most important for changing people. It is likely that change agent characteristics are shaped long before medical training.
As soon as humans become social and most interactive, their interactive abilities should be developed by opportunities to facilitate people change - starting age 14 for some and later in others. 
 
The Culture of Health Required to Change Outcomes Requires Change Agents
 
The Culture of Health that we most need to improve health outcomes, requires entirely different culture shaping the needed change agents.  
 
Why do experts discover this at the end of their careers, after watching another 300 million dollars in grants fail to improve much more than process? 
 
We have enough data to know much about disparities, but still lack the local focus to address them.
 
Just a few local projects include child development, facilitation of education, enhancements of parent involvement from the earliest years of life, development of community resources, projects mentoring youth, and Community Oriented Primary Care interventions working with local health care and local leaders on specific areas as guided by community needs, preferences, and readiness. Unless you experience the awesome power of community mentorship and community outreach, you will never understand the true assets and resources of even the most underserved and disadvantaged communities.

Our nation cannot be fixed from above.
It can only improve from the ground up.
Anyone who says they can fix America from above
is selling something Americans have bought too much of already.
 
Culture, Context, Continuity, and Commitment
 
Only preparation, selection, training, and payment design specific to health access within the context of local community, culture, and practice can address the basic needs of most Americans most behind as well as facilitating the higher primary care, community health, public health, child development, education, and similar functions.

When students are prepared and selected the ways that are best for most Americans, their thoughts and actions and reflections can reshape an entire nation. Lack of making a difference for decades indicates our continued failure by design.
 
We completely lack the focus on continuity at the highest levels and the focus on commitment at the highest levels for impact at the local level. 

Family Medicine Needs a New Beginning

Learning the Most from Those Most Different and Those Making a Difference

I have learned the most from those with different backgrounds and those who have experienced different training, often self-engineered (rural, accelerated FM residents, older students or FM grads, previous nursing or public health, activist students and residents, qualitative researchers, faculty that practiced where needed before becoming faculty). At STFM, these were generally seen in the 5 or 10 minute presentations - not the big ticket areas. Much learning occurs when you meet with these individuals and learn from them, between sessions or during sessions. As with curricula, it is the extracurricular that can be most enlightening.

Sadly our nation learns the least from most Americans most behind - and fails them most by designs shaped by those who know them least. They are damaged by lack of awareness to some degree, but mostly by those who focus on "their version" of quality efforts not realizing that what they do is most damaging where outcomes are already worst. The fact that we tolerate Pay for Performance designs is most revealing.

The P4P designs lack evidence basis for health outcomes and have evidence basis for discrimination against providers who care for those most complex with lesser health and most in need of care. Those with different backgrounds, preparation, selection, training, and careers would never tolerate this. Leading a nation to change requires us to change who we are in ways that can help our graduates change others and an entire nation. 
 
Shame on us for accepting the rescue plans of any political party and the sellout of American health care by corporate greed and the many misguided CMS designs. Shame on us for not addressing the substantial error in the literature - particularly regarding medical error and quality improvement.  Why do we tolerate the literature shaped by bandwagon assumptions and beliefs? Where is the critique and logical reasoning that should have protected us and most Americans?
 
Less Focus on Parties and More Focus on People

Political parties obviously have little focus on most Americans. Parties are most important to parties who have parted with people. 
 
Party atmospheres are also promoted by Family Medicine Party associations. I must admit enjoying family medicine parties, otherwise known as STFM Regional and Annual Meetings and Annual Meetings of the Students and Residents. But parties often distract from needed change.
 
One change that should have been done long ago is breaking up a very expensive Student Resident Faculty party in August in Kansas City. Students going to the meeting are already committed with few going that have yet to decide. There is great potential for intervention before medical school and at state or regional levels. 
 
Changes should include: 
  • Making it regional or state
  • Making it a celebration of Doctors Ought to Care or COPC projects involving age 14 up student projects.
  • Making it a health career orientation for secondary education students. 
There is great power in Rural High School Career Fairs or matching up students to community mentors and projects. 
 
Even a focus of the Kansas City party on medical students just admitted to medical school would be better than those already committed to FM. Some of the best FM interventions were timed before medical school - timing prior to formal curricula that often retards the most important learning. 
 
The focus of early and often interventions would be attracting change agents to family medicine. The benefits at the community level would be enormous, and communities would learn to appreciate local students and their activities. They may also be more willing to support them as students, medical students, or local family physicians. 

Isn't it quite clear over 100 years that our nation 
  • has moved away from the health care needs of most Americans, 
  • has moved away from the health workforce needed by most Americans,  
  • has moved away from the support of that workforce
  • has moved away from the preparation and selection needed for that workforce
  • has moved away from the specific training needed for that workforce
  • has moved away from community level resources, projects, promotions, and performance.
Why not spread the focus on the Culture of Health and focus on the change agents to bring about such a culture?
 
Best Beginnings for Health Access Careers Are Quite Different. Medical Students Remain a Poor Choice for the Health Care Needs of Most Americans - too exclusive in origin, background, medical school, training, and distribution.


Are Departments of Family Medicine Necessary?
 
Rural Medical Education Rearrangements of the Deck Chairs
 
Why More Federal Dollars for Graduate Medical Education Still Not Able to Produce the Workforce Needed for Most Americans Now and Especially Not in the Future?
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Annual graduates continue to increase at rates must faster than population growth or growth of the elderly, yet more sources all expanded have failed to address shortages. Where did the graduates go? Not surprisingly they follow the dollar directions shaped by health policy. GME training produces the wrong physicians for the wrong specialties and the wrong places.
Residency expansions could increase the physician workforce but will not address shortages of workforce, poor retention of graduates where needed, health outcomes improvements, or access to care for Medicaid and Medicare populations falling most behind. Residency expansions will worsen health care costs and will further marginalize physicians in their contracts with employers. New medical schools, residency programs, or nurse practitioner/physician assistant programs should not be promoted as a solution for health access woes. Only substantially more dollars to support more team members in lowest concentration settings will address health access deficits.

Graduate Expansions Fail for Relief of Shortages
  • Residency expansions cannot address shortages. Too few dollars go to the places to allow adequate team members. Only payment changes can address shortages.
  • Residency expansions cannot address poor retention and higher turnover where payments are least, support is least, and complexity is highest. Only payment changes can address these areas. 
  • Residency training continues to produce the wrong specialties for the wrong places. The payment design prevents MD DO NP and PA from remaining within primary care careers and prevents residency graduates from staying within general specialties as taking a fellowship or two results in a great deal more support with less complexity and more team members to share the load.
  • Uses of Medicare and Medicaid dollars for training are not specific to the needs of Medicare and Medicaid patients most left behind. The designs prevent graduates from going to places where such patients are concentrated and prevent the specialties that they most need.
Health Care Cost Acceleration
Expansions of residency positions are promoted by those who most benefit from such expansions. Fewer graduates can help to prevent runaway health care costs.  Nurse practitioners and physician assistants have long been promoted as excellent contributions for primary care, but do as well or better in subspecialty teams. More patients can be seen in more settings and the physicians can focus on the highest revenue areas.
Accelerations of health care costs are a primary mechanism resulting in across the board cuts - cuts that hurt the lowest margin practices. The lowest margins are seen in generalist and general specialty workforce.

Overproduction  
Too many MD DO NP and PA graduates are being produced. The growth far outstrips population growth and growth of the elderly. The result has been employer dominated workforce. This tips the balance greatly toward employers, particularly in areas with the least payment support. Various sources are played against one another and this prevents understanding of the damage done by too many graduates.

Inequities Contribute to Disparities and Poor Outcomes
Residency funding is distributed most inequitably, adding to disparities directly in dollar distributions with further contributions in the products produced. Only 6.5% of residency positions are found in lowest physician concentration counties with 40% of Americans and 43 - 47% of the elderly, poor, and others most left behind.

Residency training design is a great fit for the highest physician concentration places. These include 6 states, 100 counties, and 1100 zip codes that already have top concentrations of physicians. 
Residency is the dominant factor in practice location. About half of residency positions and 45% of physicians are found in 1% of the land area in 1100 zip codes that have the most lines of revenue and the highest reimbursements in each line. These are crafted by payment designs that leaders in top concentrations have largely shaped and protected.

Research has long established that physicians will crowd in to higher concentration places rather than to distribute to places of need.
Too Many Graduates Already

By the end of 1980 the US had 20000 physicians entering the workforce with 1500 for PA and 1500 for NP. Now 30,000 physicians enter the workforce with 20,000 for NP and 9000 for PA. In only a few years there will be more NP and PA than physicians. Each year brings a few thousand more NP graduates with no sign of slowing. New medical schools are being added and new PA programs as well.
The US will never resolve shortages by producing more graduates. Massive expansions have long failed as demonstrated with a 12 times increase in nurse practitioners since 1980 along with a 6 times increase in PA and two doublings of DO graduates plus 25% from international sources plus a 30% increase in MD graduates.



These increases have resulted in little or no increase in primary care and a massive increase in non-primary care workforce. 
Health care institutions, corporations, and businesses prefer to generate more revenue from services, tests, procedures, and evaluations that are paid at much higher rates. It is even better if this has lower overhead. Primary care and basic services are high in overhead and low in revenue. Businesses invest where profit is most likely and payment designs have take away the profit in primary care for decades.

Expansions Fail for Primary Care, Mental Health, and General Surgical Specialties

Despite recent expansions, the collapse of internal medicine primary care, family medicine down to 70% primary care result, and pediatrics down below 40% have resulted in less physician primary care. Each year the US gets less primary care result despite more graduates.

The last doublings of physician assistant and osteopathic graduates resulted in no net gain in primary care workforce. The entire expansion was devoted to non-primary care.




The last few decades of workforce expansion have entirely been in non-primary care highly specialized workforce areas in places with higher concentrations of workforce - where we already overutilize and have costs too high. Too Many and the Wrong Clinicians. The dollars expended follow the workforce to more spent for procedural, technical, hospital, and highly subspecialized leaving less for primary care and basic services.
Primary care spending and spending where people need care has remained stagnant for decades by design. NP and PA also add more specialties and more are added to each new specialty - leaving family practice positions behind - the predominant primary care form for NP PA and DO. 
Even family medicine is no longer immune to payment paucity with over 90% active in FM dropping to less than 70% in the last 15 class years. Family medicine may soon break the 50% mark with less than a majority remaining active and in primary care over their careers. This could begin in the next few class years due to insufficient primary care support, costly complications, and rapid increases in complexity. Burnout is at record high levels due to payment design. 

Primary care turnover costs are estimated to be over $300,000 per lost primary care physician or about twice the cost of loss of NP and PA clinicians, but clinicians turn over at twice the rate of primary care physicians. Worsening morale, productivity, burnout, and turnover result in negative margins.

Flexible workforce follows funding. Once primary care training physicians had no other options, but now they have many hospital, urgent, emergent, and specialty options. NP and PA graduates once had few options, but this is no longer the case. As with physicians, they have more support and more team members and more specialized roles with less complexity and higher salaries - all set up by payment design.

The Evidence All Points to Payment Failure

The evidence points to shortages as the result of payment design. Only the academic community clings to workforce as being shaped by training. Without the dollars injected into the services provided by basic specialties, there can be no resolution of shortages.
The nation needs generalists, mental health, and general surgical specialties now and for decades to come due to aging changes. This is even more important where most Americans are found with lowest concentrations of workforce as there are few other types of specialties. 

These basic services are lowest paid services and remain so by design. The MD DO NP and PA expansions do not reflect any movement toward addressing these workforce areas because of payment design. The failure of massive expansions should have long ago pointed to payment failure.

Payment Failure Fails Most Where Workforce is Most Needed.

Demand increases are greatest in 2621 lowest physician concentration counties that are growing the fastest
  • In population (30% faster for decades)
  • In elderly
  • In chronic diseases
  • In complexity
The Role of Affordable Housing

Americans in higher concentrations are being displaced by city, county, developer, and government designs. Land is most valuable in higher concentration settings. Converting areas of lowest value (affordable housing, older housing, public housing) to highest value is quite profitable. Many participate in these schemes. Articles indicate the worsening shortages of affordable housing across metro areas of the nation.

Destruction of affordable housing in higher concentration settings forces Americans who are older, less healthy, disabled, Veterans, Medicare, Medicaid, and Dual Eligible to go to lowest concentration counties - counties with the least resources and workforce. They bring their worst paying, least locally supportive insurance plans with them. These plans now exclude local providers, often pay less than cost of delivery, and require numerous hoops to jump through to address patient and payer needs. Those who do not want to take care of them include state, federal, and insurance payers. Providers caring for them get penalized by payment design because they care for them.

Concentrations of Patients with Lowest Paying Plans Shape Shortages of Workforce

The lowest concentration counties are shortest in workforce with 40% of the population and less than 13% of health spending. Only 22 - 26% of physicians, clinicians, internists, pediatricians, and general surgical specialties are found in this 40% segment.

In these counties about 46% of local workforce is primary care and 25% are found in general surgical specialties. Practices in these counties tend to have the oldest physicians - also an indication of lack of replacement. These counties have been hit hardest by recent designs that have compromised small practices - particularly the MD DO NP and PA that remain in family practice despite the design.
The specialties important for lowest concentration counties are in decline or are disappearing. In the following graphic the ratio of concentration is noted, followed by active physicians per 100,000, the proportion of the local workforce provided by the specialty, and expected changes.
Family medicine distributes most equitably at 1.18. Psychiatrists are 7 times more likely to be found in the 79 top physician concentration counties as compared to the 2621 lowest physician concentration counties. Family medicine remains at 26 to 32 active family physicians per 100,000 across the US and various divisions. In the very lowest concentration counties, only family practice is found. In top concentrations FM is only 3 - 5% of local workforce. Where policies are most shaped, family medicine is a small fraction. Where health access is most important, family medicine most matters. Family practice NP and PA have similar distribution, but only when staying in family practice positions. 


Only the general specialties provide much care in lowest concentration counties 
and only when they stay general and do not go on for one or more fellowships. 
Note that residents are 150 per 100,000 in the 79 top concentration counties - a level much higher than 115 active physicians per 100,000 from all specialties as found in the 2621 lowest physician concentration counties. It is a great advantage to design a new line of revenue specific to higher concentration settings.
General specialties are in decline and some are collapsing. In recent years, new specialties have replaced old as seen in pulmonary, oncology, and radiology. The new forms of oncology and pulmonary critical care and radiology do not distribute well at all and are replacing the older more general types. This is a reflection of differences in training and lack of distribution of those younger. 

Hospital closures are predominantly in these lowest concentration counties and the closures force the departure of 20 - 30% of local workforce. Care of challenging populations with lesser health results in more penalties - a known consequence of Pay for Performance. 

The loss of a hospital also forces delays in the care of urgent and emergent care needs such as involving trauma, falls, sepsis, acute vascular events, respiratory failure, asthma, allergic reactions, dehydration, burns, and other conditions.There are more ways for children, infants, new mothers, pregnant women, toddlers, teens, and older Americans to die - by design.
Demographics, Distributions, and Discriminations All Around

Poor Fit All Around

Resident training depends upon medical school selections. Medical schools select the wrong origins for these careers and locations. Medical schools train wrong for these careers and locations. An initial residency is just a stepping stone past these careers and locations. Payment design prevents these careers and locations. 

Just one fellowship that greatly benefits the teaching hospital allows the residency graduate to bypass what is needed to a place with better support, more team members, and less complexity along with higher salary and opportunities for income beyond salary.

The dollars flowing to these lower concentration places are too few to support the workforce - regardless of any training intervention. NO Training Intervention can help until payments are increased for generalist and general specialty services. Only then can more be hired and better supported along with the team members to address the massive and growing shortages.

Movement from 6% of health spending to 12% for primary care is required with nearly all of the additional dollars going to lower concentration counties - and without requirements for additional tasks that distract team members from restoring access.
Additional Funding Is Not Needed for Residency Positions
The last decades of residency expansion have been funded teaching hospitals and the VA.
Once again the most lines of revenue and the top reimbursement in each line goes to teaching hospitals. They have demonstrated the ability to create and sustain residency positions.

Teaching CHCs - Close But No Cigar for care where needed
What is Stunning About Primary Care Is No Change By Design


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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.

Senior Corps Provides 78 Billion in Support  “As local organizations experience increased demands with fewer resources, older Americans are stepping up to fill in the gaps, and their service is more important now than ever,” said Erin McGrath, acting director of Senior Corps. Celebrating Seniors who Serve


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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