I have strongly believed that CEOs should make employee health a high priority and have been bewildered when they delegate that responsibility to their Benefits departments.  I successfully created a culture of health at Pitney Bowes, but relatively few CEOs have followed my path.

However, some smart and rational CEOs, whose scarcest resource is time, believe that they can deliver shareholder value by putting their priorities elsewhere.  Their reasoning may be as follows:

• Traditional population health improvement programs have not worked in large organizations; and
• The best path to reduced healthcare costs may be to reduce U.S. employee headcount.

Few employees use wellness, disease management, and care management programs. Since employers usually pay a vendor fee for these programs over their entire population, they generally fail to produce a population-level economic return. Why do so few employees use them? The most obvious reason is that the vendors have no incentive to maximize participation, since it increases their costs and reduces profitability.

However, these programs fail to draw widespread participation even when employers and vendors aggressively market them. Understanding why is critical to improving population health.

Most people only use wellness programs when they can be fit into their daily life routines.  Moreover, many employees consider mandatory wellness program participation to be an unwarranted intrusion on their private lives, and a bad example of the “nanny state.”  How can employers get buy-in from all those who should use the programs?

First, employers need to educate employees that increased healthcare spending reduces the amounts available for salary increases and other cash-based benefits.  They also need to explain that uncontrollable labor costs make a wide range of headcount reduction strategies more economically viable.  What are CEOs who do not attend to improving population health doing instead?

Unfortunately for already insecure employees, one answer is that they are aggressively looking for ways to reduce U.S. headcount.  How are they doing it?

• They will substitute technology for labor wherever possible. Automated voice response systems replace human operators. Robots instead of people move physical items. Heavy equipment replaces construction workers in moving dirt.  We will also see an evolution toward the eventual penetration of self-driving automobiles, which will eliminate jobs for millions of truck, bus, taxicab and limousine drivers.
• More tasks will be offloaded to offshore workers in low labor cost markets.
• More tasks will be outsourced to more technologically efficient and enabled third party administrative services.
• More tasks will be done by contract workers of short duration, employees who are being tested in a 30-90 days “probation” period, or even unpaid interns.  Companies also refer more work to teams of undergraduate or graduate students who will trade compensation for school credit.
• Businesses create more customer self-service opportunities, as airlines have done for over two decades in creating automated reservations systems, and, more recently, automated systems for securing boarding passes.  Retailers will expand customer-managed checkout processes.  Even restaurants will move slowly, but surely, toward more automated ordering and food pick-up systems.
• Big data analytic systems will replace highly skilled human tasks, such as Amazon.com and Netflix have employed in building recommendation systems for book and movie acquirers.  Even law firms are now authorized to use technology to sort documents for responding to certain government document production requests, saving client money and lawyer labor.
• Healthcare will move from face-to-face human interactions to technology that automates physical examination, and non-invasive self-administered biometric monitoring will reduce the need for more skilled healthcare professionals.

However, CEOs are employing two other strategies as well for reducing healthcare cost burdens:

• Companies locate facilities in areas with better-educated and healthier populations, and lower healthcare costs. They require higher levels of education for each job and benefit from the fact that higher educational attainment correlates with better health.
• Finally, they substitute part-time employees for full-time employees to reduce the population for which they have healthcare benefit responsibility.

However, after they exhaust all low-hanging fruit that enables them to avoid having to improve employee health, they will realize that, for the core of their stable, mission-critical, full-time U.S. workforce, they will need a robust population health and healthcare cost management strategy.

For that population, they will need to reinforce a culture of health inside an organization by executing on strategies and tactics that improve health. They can change the daily environment in which employees function, either directly at work, or using their influence, indirectly in the community and at home.  Well-respected public health researchers like Sir Michael Marmot and Dr. Anthony Iton, (the author of a wonderful study called Death by Unnatural Causes, when he was the Public Health Director for Alameda County Californida) have demonstrated that 85-90% of what determines our health happens outside the healthcare system.  Our daily living environment drives our health outcomes much more than access to high quality healthcare.

The recently released State of Oregon study on its Medicaid population, demonstrated that while those citizens on Medicaid had easier access to healthcare and avoided financial ruin, they had no better health-related outcomes than those not participating in the Medicaid program and the total amounts spent on their healthcare were not lower.

How can an employer alter the daily working environment of employees to make it better?

• Make healthier foods and beverages and lower portions of them more affordable and accessible than junk food, although employees are less likely to rebel if they retain the choice to eat less healthy foods.
• Make all facilities tobacco free.
• Create facility plans and work processes, which induce more walking during the day.  Eliminate desktop printers, reduce the number of private offices, and create attractive stairways in place of elevators to induce walking.
• Have fewer meetings of shorter duration to reduce forced sitting down, since prolonged sitting is one of the least healthy activities in which we engage every day.
• Have more ergonomically friendly furniture and furnishings and LED lighting in all workspaces.

Even if employers do not particularly care about the per-employee cost of healthcare, under ObamaCare, the non-deductible 40% excise tax, sometimes called the “Cadillac tax.” is based on the per-employee cost, not the total healthcare cost budget.  That tax will hit all employers who fail to manage their per employee healthcare costs below $10,200 in 2018.

ObamaCare has many conceptual flaws, but if it forces employers who have the best ability to influence employee health and healthcare cost management, to tackle the problem, it will have at least that as a positive, if unintended, outcome.

James B. Stewart, a reporter and author wrote on Op-Ed piece in the Saturday, February 16, 2013, issue of The New York Times, entitled “The Myth of the Rich Who Flee From Taxes.”  His major argument is summarized in the following statement:

“At least three recent academic studies have demonstrated that the number of people who move for tax reasons is negligible, even among the wealthy.”

As a person who knows many wealthy people who have moved to states with no income or inheritance taxes, and many who have chosen not to do so, I am often asked by many people why we do not leave Connecticut and establish a primary residence in a state like Florida, where I could save millions of dollars in taxes over the rest of my life.  My view is that Stewart is only partially correct and partially wrong in his assertion that higher taxes do not drive people to change where they live.

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Every once in a while, a single comment in a book or article prods us to think very differently about a broadly discussed issue.  One that comes to mind is a statement in Steve Coll’s essay in the online version of The New Yorker magazine.  That essay, entitled “Is Chaos a Friend of the NFL,” posted on December 26, 2012, discusses two issues that have the potential to damage the NFL’s brand and economics over the long term: the “bounty” issue and the injuries that have led to many cases of long term damage to present and former players, including dementia, depression, alcohol and drug abuse, suicides and murders.

http://www.newyorker.com/online/blogs/comment/2012/12/is-chaos-a-friend-of-the-nfl.html

The comment that caught my attention was about the “bounty” issue, that is, the practice of coaches or players paying other players for success in injuring opponents so badly that they had to be removed from games or, worse yet, unable to play in future games. The practice is bad enough in creating injury risks for individual players and is offensive on that basis alone.  Indeed, it becomes another source of the second problem, causing long-term injuries to players in order for a team to win a game or to secure a better position in an individual season.

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As we end 2012 and enter 2013, I have some observations about the world as I see it.

The economic environment

This is a very difficult economic environment for people of all ages, but particularly for young people leaving college, graduate school, or professional schools, except for those with very specific trade-based skills in which demand exceeds supply or for men and women with science, technology, engineering and math degrees.

Our colleges and universities are run highly inefficiently and tuition, book, room and board costs are wildly inflated.  They burden our students with huge debt loads and force them into long term financial servitude with education that, in many cases, is of marginal value in terms of their earning power.

However, what makes the situation worse is that what we reward throughout traditional education, including college, is the mastery of a bodies of knowledge as defined by school boards and individual teachers and professors, not the skill to use that knowledge to solve problems and propose solutions.  Our young people coming out of school are generally clueless on how to navigate the worlds they enter, whether those are business, government, the educational sector, or the nonprofit sector.  Part of this navigation process is recognizing that knowledge gets obsolete fast, but adaptability and emotional intelligence skills need to continue to improve.

The most destructive aspect of our education system is that it teaches both conformity and the creation of regulatory and legal obstacles to engineer risks out of our lives, and, while it achieves destructive conformity, it can never succeed in getting rid of life’s inherent risks.

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Many people have asked about the status of our From the Rough film project.  It is alive and well, and we have taken most of 2012 to take a fresh look at every component of the project. We are getting close to finalizing it, and expect the film to be released in 2013.

We looked more closely at the origin of our title, which came from a quote by Seve Ballesteros, the late, great Spanish golfer, who, when asked about what he would have wanted to be different about golf, said: “I’d like to see the fairways more narrow. Then everyone would have to play from the rough. Not just me.”

Initially, we understood his comment to be half-kidding and half-serious.  The serious part of his comment arose from the fact that he was the best player of his time, maybe the best of all time, in designing and executing on shots from the rough, or from any difficult lie or location.  What we did not understand was how these unique skills were foundational to who he was and why he succeeded.

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Many of my Republican friends (I am registered as an Independent) are bewildered that President Obama won. However, I believe in the voters’ collective wisdom, and would offer observations about some of the reasons Americans chose President Obama over Governor Romney.

The Republican Party platform and its U.S. Senatorial candidates frightened many people who would otherwise consider voting Republican because of harsh, insensitive positions on issues like immigration, abortion, and contraception.  Governor Romney’s path to winning the nomination forced him to support positions he probably would not have supported in a general election campaign.

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We think of extreme climatic events as happening only in this past few decades, but there were events that fundamentally altered our country’s demography in the 1920’s and 1930’s and 1950’s, and were more devastating than what we are now experiencing.

The Mississippi River flooded in 1927 and had short and long term impacts.  In those floods, 700,000 people lost their homes and Herbert Hoover became a hero for his leadership in flood relief efforts, which propelled him into the Presidency in 1928. The flooding disaster triggered acceleration in the migration by African Americans from the Southern delta farm areas to Northern cities, which was part of a major migration by African Americans from South to North between 1915 and 1970.  It also resulted in a significant increase in federal control of waterways and flood control systems across the country.

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Vocational and Technical Education

As we just observed the Labor Day weekend, there is a tendency for the media and for elected officials to reinforce obsolete views of labor and of vocational and technical skills required to compete in the global economy. There is also a tendency to celebrate the wrong qualities of people they would generally characterize as being part of the “working class.” As a result many of us have image of “blue collar jobs,” the skills required to do them well, and vocational and technical education required to prepare people for them that is wildly out of date.

Why What We Celebrate is Obsolete

Blogger David Burr concisely described why the Labor Day holiday was created:

“The holiday originated in 1882 as a result of the labor movement and was intended to be a day of rest to recognize the efforts of the average working man.”

We need to reinvent what we honor for this holiday.  Labor Day was designed to recognize the value of the “average worker,” collective activity, labor union membership rights, and “hard work.”  The typical image of the “blue collar” worker is someone using muscular power to do a physically demanding, backbreaking task.  When I think of Labor Day as it has been celebrated historically, I am more likely to think of either the folklore of John Henry as a “steel driver” or the cleaning woman celebrated in Donna Summer’s great song “She Works Hard for the Money.”

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Joseph Stiglitz, a renowned economist, has just published a book entitled The Price of Inequality, in which he directly tackles the cost and root causes of societal inequality. While I do not agree with his broad recommendations or his overall view of the world, I believe that he correctly identifies inequality of political access and influence as the source of economic inequality.

Based on the experiences of being involved with both government and private sector marketplaces in which individuals have gotten very rich or successful, I would make four broad observations about economic inequality:

• More complex customer procurement rules or political systems increase inequality;
• More intensive government regulation to redistribute opportunity increases inequality;
• “Stimulative” government programs to increase opportunity increase inequality; and
• Many well-intended, but flawed, rating, ranking and measurement increase inequality.

Complexity, over-reaching government regulation, stimulus programs and badly designed rating, ranking, and measurement systems benefit people with pre-existing advantages and widen their advantages, and, in some cases, they become obscenely rich.

Increasing system complexity increases inequality.

When I was at Pitney Bowes, we were investigated several times for having achieved leadership positions in mail-related markets.  The Justice Department assumed that we must have done something wrong to have a leadership position that spanned several decades.  They were wrong, and, eventually, after five investigations in 22 years, they implicitly admitted that something other than bad conduct was behind our leadership position.

The technical and process complexity of how we evidenced and collected postal revenues, both through postage meters and mail service operations, gave us a huge advantage.  The postal rate structure for work-sharing discounts was extremely complex.  Success depended on successfully making arguments that caused the Postal Service and the Postal Regulatory Commission to approve increases in particular discounts of as little as .1 cents.  Every .1 cent discount increase we received gave us over $10 million of operating income.  To make these arguments required us to hire and educate postal economic specialists, who understood the unique economics of postal mail processing.  Without the complexity of postal economics, which few economists could master, we would not have the significant competitive advantage that enabled us to grow and be profitable.

There was nothing sinister about this complexity.  It was no different from the economics of other public utility pricing systems, but, because postal mail economics was a smaller perceived business opportunity, few economists attempted to master it, which gave us a big opportunity.

The more complex the discount structures became, the more difficult it became for our smaller competitors, many of whom were anxious to have us acquire them. Our experience is replicated every day as large private sector companies create very complex procurement processes that benefit incumbents or large, resource-rich vendors, at the expense of start-up businesses.

More intrusive government regulation and attempts to redistribute wealth, income, and opportunity have exactly the opposite effect.

This is the point at which I most completely diverge from Stiglitz and others sharing his point of view.  When governments try to “level the playing field” between those they believe to be advantaged and disadvantaged, they are more likely to increase inequality.

Complex and comprehensive laws and regulations that attempt to micromanage the economy to redistribute wealth increase inequality in two ways:

• They give advantages to those with more know how and resources to figure out how to play more effectively within the new rules.

New York City rent control laws have been in place since 1947. They have benefited wealthy people who can maintain a New York apartment and spend their own money for capital improvements, since no honest landlord can afford to invest in upgrading rent-controlled apartments for lower-income tenants. They also benefit unscrupulous landlords, because they are designed to protect absurdly low rents only while the existing tenant is in place.  Instead of improving the housing stock to increase the value of the property, landlords finding creative ways to force out or buy out rent-controlled tenants, either by renting adjacent apartments to rock musicians or motorcycle gangs, refusing to make basic repairs, or engaging in noisy construction. The rent control laws induce this dysfunctional behavior because they create a wide gap between the market rate and the rent control rate.  Wealthy tenants can fight these abuses, but the lower-income tenants rent control laws are designed to protect cannot fight back easily.

• They create a new class of people who thrive on being intermediaries, consultants, or other service providers in the marketplace created by these redistribution schemes.  Addressing the needs of these various intermediaries adds cost, complexity, and inequality to any marketplace these intermediaries touch.

Public sector labor unions clearly thrive when the government creates more jobs to “redistribute” wealth, since more government employees are needed in such an environment.  Civil service professionals do well by “monitoring” the disbursement of funds from government to “disadvantaged” people. Major agricultural corporations benefit from highly profitable food stamp programs.  Firms that provide specialized software for managing government social service programs make a lot of money licensing that software to non-profits that have to comply with complex government requirements.  Ross Perot became a billionaire because he mastered the intricacies of serving government programs, first at EDS and later at Perot Systems.  Not surprisingly, an individual, a small business, or an under-resourced large business will have an even greater disadvantage the more of these intermediaries with which they have to deal.

• Title IX has created a whole new cottage industry of parents, coaches, guidance counselors, college counselors, and providers of athletic equipment that benefit from building girl’s sports teams at the K-12 level. Wealthy, resourceful people “game” the college applications process at top-rated schools by getting their daughters into Title IX-induced sports like lacrosse, equestrian sports, squash, and rowing. Greater governmental intervention to redistribute wealth, income, and opportunity simply creates new opportunity for those who are already rich.  Title IX has created new opportunity for women, but has significantly skewed all sports toward wealthier women and men.  The sports programs that get cut to support a new women’s sports program in lacrosse, squash or equestrian sports are inevitably sports that are more accessible to lower income students, like baseball, track and field, or swimming.

Government “stimulus” programs get burdened by the inevitably costly, onerous and time-consuming audit and compliance programs that accompany them.  Wealthy, resourceful people are far smarter in navigating through these expensive requirements.

Elected officials so completely distrust those to whom they give money for stimulus purposes, and are so concerned about failing to catch fraud, waste, and abuse that they insert requirements that slow up the flow of money and siphon off money that should go toward stimulus.  This was amply documented in Michael Grabell’s comprehensive analysis of what went right and wrong with the stimulus legislation in Money Well Spent?  Many well-intended programs were delayed and costlier because of an excessive preoccupation with government rules and processes.

One example was the weather-stripping program that was going to reduce energy costs for homeowners, reduce environmental pollution, and provide middle-class jobs for people of moderate skills. Despite the program’s obvious merits, it was delayed for several months in communities that did not apply the resources to get the government to define “prevailing wages” for determining compensation.  Wealthier communities were far better able to drive the government to act than their economically challenged counterparts.

Major infrastructure programs end up in wealthier states and localities and major government spending programs often are disproportionately spent in wealthier communities, because these communities can marshal the resources to do what it takes to get the money, especially when the program requires matching funds.

My favorite example of this last point (although it did not arise from any stimulus legislation) was the case of Westhampton Dunes, a community formed in the early 1990’s at the western end of a barrier island in a super-wealthy resort area on Long Island.  A group of very wealthy real estate speculators bought up beachfront homes that had been severely damaged by ocean wave surges during storms in the late 1980’s, at prices ranging from $50,000 to $100,000 per property.  The damage to beaches and homes was caused by a shortsighted county supervisor decision not to fund the construction of protective barriers along several miles of beach (because he thought it only helped wealthy homeowners.)  The speculators petitioned the Army Corps of Engineers and the state of New York for 91% of the funds required for beach replenishment and the construction of protective barriers, and then assessed the wealthy owners of the beachfront properties for the remaining 9%.

After the Army Corps of Engineer project was completed, each property was worth millions of dollars.  The homeowners got very rich from this well-intentioned government program, because they had the capital and the network to assemble the property, the money and the lobbying strength.  The real estate speculators who benefited were far wealthier than those who sold their homes at $50,000 to these speculators.

Many well-intended rating, ranking, and measurement systems have the unintended consequences of increasing inequality.

Given the apparent importance of a college degree from a “good school,” the competition to get into “good schools” is more ferocious than ever.  Schools appear to be more exclusive than ever is that schools actually have the incentive to increase the number of applicants they reject.  The U.S. News & World Reports college ranking and rating system ranks schools higher, based on their “exclusivity.” As a result, many schools encourage applications from many students who, realistically, have no chance to be admitted.

The flood of applications creates additional complexity and risk for those who actually are qualified, but might be rejected, simply because admissions officers have too many applications to review and have to use shortcuts to screen out applicants.  Wealthier people spend a considerable amount of money and time working with college counselors, who help their children “game” the applications process.  The ranking system helps create the conditions that make this “gaming” necessary and more effective.

To bring greater “rationality” into the reimbursement system for physicians, Medicare and Medicaid adopted a system developed by a Harvard Medical School professor called the “Relative Value Resource Based System” in the late 1980’s.  Payments for clinical encounters were determined by a complex points system, which over-rewards complex procedures undertaken by highly-trained specialists, as opposed to simple cures through consultations by primary care physicians.  The end result: American has so lopsided a reimbursement in favor of subspecialists versus primary care physicians that we only see 4% of medical school graduates go into primary care.  This is one reason why our healthcare costs are so high relative to other developed countries.  We excessively reward skill and inadequately reward cost-effective performance.

Final comments

Stiglitz and others are correct that persistent and widening inequality is dangerous and destructive of the American dream.  However, the notion that government intervention is the “cure” for this inequality is misguided.  Government has done a great deal, in the interests of eliminating inequality in the past, to create the conditions that have led to the inequality we face now.  I do not believe that the future would be any different.

President Obama’s recent quote that “If you were successful, somebody along the line gave you some help” justifiably is getting a great deal of publicity and commentary.  The statement is true, but incomplete in its understanding of what it takes to succeed. It is being used by many people to justify redistributing income and wealth from successful people who are simply more “fortunate” in having better support systems to those whom these individuals consider to have been “less fortunate.”

When I think of his remark, I remember the scene at the end of Superman II, in which Lex Luther, the master criminal  played by Gene Hackman, attempts to curry favor with the evil General Zod, played by Terence Stamp, by directing him to put Superman in an enclosed chamber in which Superman will lose all his powers.  Superman tricks Luther and Zod and ends up retaining his powers, whereas Zod and the two evil creatures with him lose theirs.  After this happens, Luther approaches Superman and says: “Wasn’t it great how we fooled them?  I was with you all the time, Superman.”

External resources can support, hinder, or be neutral in someone’s quest to achieve a goal.  In most cases involving transformational change, the individual has to work smartly and hard to steer those resources toward helping him or her, rather than being hindrances.  Essentially, there are five flaws with the implications of the President’s statement:

• Great leaders and innovators “connect the dots” in ways that others do not. Malcolm Gladwell’s book Outliers uses the example of Bill Gates having access to a computer lab at his school when he was growing up to illustrate that Gates’ success was clearly attributable to that unique set of circumstances, and to the support the school provided.  That’s true, but Gates was not the only student in that school.  His family was not the wealthiest in the school, and he had no unique privileges that gave only him the ability to take advantage of the free resource that triggered his success.  Gates was unique in taking the initiative and having the vision to understand and use the available asset.  Great leaders find or create assets and support that others cannot imagine, much less use.
• Most successful people have the passion and the tenacity to pursue their goals under circumstances and against obstacles that discourage other people.   This is especially true of entrepreneurs who transform a marketplace.  Years ago, I read the story of Intuit, a great company that brought innovative consumer-controlled financial management software to the marketplace.  On many occasions, founder Scott Cook encountered obstacles that put him very close to going out of business, but he kept going.  Most people would not attempt to start a new business, much less endure the multiple setbacks it takes to succeed.  Great leaders and innovators have more tenacity and patience to realize the benefits of whatever support systems they can use.
• Unfortunately, most leaders who make a difference have the moral courage to take unpopular positions, even to the extent of being ridiculed by others.  Working hard is a virtue, but being willing to work hard often leads to a militant conformity with the status quo, not breakthrough successes.  Great leaders and innovators are unusually good at being immune from the discouragement that comes from external resistance from the so-called “support resources.”
• Great leaders and innovators find a way to win over neutral or even change-resistant people.  They are unusually gifted at finding common ground to move people toward their point of view.  Great leaders and innovators are accomplished at turning adversaries into supporters.
• Transformational change is never a linear, standardized process.  It requires a great deal of adaptation.  Great leaders and innovators are comfortable with being adaptable, not adhering to rigid rules and processes.