The title of this blog is meant to provoke thinking about a fundamental dilemma that elected officials in any democracy face: when serving the public broadly means that jobs of a small number of people could disappear, what happens?

We have known for a long time that government is more responsive to a well-organized single-issue constituency, even if the vast majority of voters would oppose the position the single-issue group is taking.  For example, that is why government officials have consistently been reluctant to take on the National Rifle Association, even though the vast majority of Americans favor a more aggressive regulation of guns than is the case today.  I am not making a value judgment about this issue, other than to say that elected officials think of the electorate as a collection of well-organized, passionate special interest groups than they do a mass of voters to which they have to respond.

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Recently, I published a lengthy blog responding to Congressman Chris Murphy, a blog in which I took the position that the national health insurance reform legislation was flawed because it simultaneously increased the guaranteed access to health insurance nationally, but left critical cost management components to future actions by the Secretary of Health and Human Services and to states and localities.  To me, that was exceptionally risky for two reasons:

• It’s no different from any other situation in which you commit to spend money before you have it, and when you have confidence that you can get it, which, by the way, is why Bear Stearns and Lehman Brothers went bankrupt: they had fixed debt and contractual commitments, but found the short-term markets for getting cash temporarily closed to them.
• The obstacles to the cost reductions that could take health care spending down are formidable and, perhaps, unconquerable.

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I am a big fan of Thomas Friedman, so I avidly read everything he publishes.  In the April 4, 2010, Sunday’s New York Times, he published an op-ed piece entitled “Start-Ups, Not Bailouts.” His main argument:

“Good-paying jobs don’t come from bailouts.  They come from start-ups.”  Will start-ups address our structural unemployment problem?

Yes and no.  They will be a great solution for well-educated, enthusiastic young people who are currently unemployed and perhaps discouraged about prospects for jobs and careers.  Without some additional interventions, they are not a good short-term or even medium-term solution for older workers who have lost their jobs at big companies or government agencies.  As the former CEO of a big company and the current chairman of one start-up business, Dossia, and a board member or investor in several other start-ups, big company or government and start-up jobs and work situations are radically different.

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In the Friday, March 26, 2010, issue of The Wall Street Journal, there was a very thought provoking article entitled “Reynolds Faces Very Tough Test with Smokeless Tobacco Lineup.” The article specifically details the strategic intent of the tobacco companies to address the public’s concern with the harm created by smoking by moving their customers toward forms of tobacco ingredient ingestion that do not require the inhalation or the creation of smoke.  The article identified lozenges and other forms of orally ingested nicotine products.  In effect, the product becomes nicotine and the other addictive ingredients of tobacco, not the cigarette, cigar, or other delivery system for that nicotine.

The theory behind this strategy is that smoking, not ingestion of harmful ingredients, is the health risk both to the user and to bystanders.  Clearly, when someone orally ingests nicotine, there is no second-hand smoke problem for others, and, for the user, there is no problem with small particulate matter in the lungs.  The remaining hazard is the chemical alteration of the body from the ingestion of nicotine and other substances.  Smokeless ingestion systems are less harmful than traditional cigarettes, but some degree of harm remains.

Even more interesting, Altria recently acquired a company that markets smoking cessation products, which positions it to offset the decline of sales of cigarettes.

This article poses two big strategic questions in the battle to improve health:

• Can we enlist those who have produced unhealthy products and services to transition to healthy or, at a minimum, less unhealthy offerings?
• Should we support the marketing of transitional products that retain addictive behaviors which are still harmful, but are less harmful than what they replace?

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