The stories reminded me that, for the last 21 years of my Pitney Bowes career, I dealt continuously with the encroachment of state capitalism in the postal sector.  In the late 1980’s and throughout the 1990’s, we successfully fought a series of battles with the U.S. Postal Service to keep it from becoming another entity with all the powers and privileges of the federal government, but with none of the regulatory constraints associated with federal government agencies.  Several senior postal officials aspired to create a power base similar to many government-owned entities, such as the Tennessee Valley Authority (which Marvin Runyon, the Postmaster General from 1992 to 1998, had led) or the New York-New Jersey Port Authority.

Fortunately, we defeated efforts by the Postal Service to regulate the mailing industry and compete unfairly with it at the same time.  The Postal Service leadership teams succeeding Runyon and members of his senior team generally tried to operate within the boundaries set by Congress. We had a very collaborative, and mutually respectful, relationship with the Postal Service during most of my tenure as CEO.

The story was very different outside the United States.  While we had similarly respectful and collaborative relationships with the postal officials in the UK, Canada, Spain, Denmark, and Norway, we had a variety of challenges with postal authorities in many other countries.

We saw three distinct challenges:

• Some postal operators, which had appeared to become privatized, acted in very anti-competitive ways in their own nations, and also secured rights and privileges from their national governments that stacked the deck against partners and competitors.  The most extreme example was Germany, during the leadership of Deutsche Post by Klaus Zumwinkel, who resigned in early 2008 for reasons unrelated to his work-related performance.  Throughout Zumwinkel’s 18-year tenure as CEO, Deutsche Post acquired companies all over the world, including a disastrous acquisition of Airborne, a major package shipper, and the worldwide operations of DHL.

In Germany, where Deutsche Post realized most of its profits, postal rates were exceptionally high (well above $.60 per piece), service was not exceptional, but competition was ruthlessly suppressed.  At the end of 2007, a few weeks before Germany had committed to open its market to full competition from within the EU, Zumwinkel successfully prevailed on German legislators to pass a law that created a minimum wage for postal sector employees only, a wage pegged at Deutsche Post’s minimum pay grade.  The immediate result was to destroy its two largest mailing competitors, since neither could secure labor cost advantages over Deutsche Post.

In Italy, Poste Italiane took advantage of complex and onerous labor laws to fend off competition, since these laws made part-time and temporary workers prohibitively expensive.

• In many countries, postal operators expanded into businesses in which the marketplace was amply served by the private sector, but in which the postal operators would immediately have a competitive advantage, because of the implicit protection from national governments.  Australia, Belgium, Ireland, China and New Zealand all started retail banks.  Japan had always had a sizable postal banking system which paid almost no interest to depositors, but which became a huge source of loans to projects favored by politicians.  Prime Minister Koizumi staked his political career on an initiative to privatize the Japan Post, not because there was ferocious opposition to privatizing the mail or package business, but because the heavy governmental control of the flow of bank loans would be jeopardized. He barely avoided receiving a vote of no confidence because his initiative upset the way government favors had been delivered for generations.

Postal operators have played heavily in the money transfer business (competing with Western Union), in retail government services, in the sale of greeting cards and stationery, and in the sale of gift items often transmitted through the mail.  Postal operators like Australia, China, Finland, and Sweden moved seamlessly into mail services businesses. In countries with a strong tradition of state capitalism, these postal operators were able to operate freely in more businesses in which they competed unfairly with the private sector.

• The postal operators often carried mandates and missions inconsistent with a business focused on cost-effective customer service.  France and Canada were prime examples of this problem, as were Japan, Spain, and Portugal. In these countries, postal operators were saddled with explicit and implicit requirements that they keep a minimum number of people employed, even if the demands of the business would not justify such employment.  For Pitney Bowes, the government employment mandates made many of our productivity enhancement tools unusable by these postal operators.  They could not improve their productivity, even if they wanted to, because they were fulfilling social mandates.  Postal ratepayers paid more, in the form of a disguised tax, to create a welfare system for workers who probably could not have secured employment at comparable wage and salary rates.

I was able to experience the ugly underside of state capitalism for over two decades.  It made me realize that the United States should think long and hard about migrating down the path these other countries have followed.  It also is a cautionary tale for large multinational corporations that aspire to compete fairly in major markets in which one or more of the competitors are state-owned or state-controlled enterprises, or in which the state considers a particular industry strategically important.

Employees who do not have high levels of education and technical skill will be continually insecure and will be displaced if they are not continually keeping ahead of the marketplace.  The most painful point the reporter makes is that anyone who starts his or her work career with major family or other responsibilities will have difficulty keeping current with the skills needed.  Maddie Parlier is 22 years old, has completed high school, but has not gone beyond it, is a single mother, and has no spare time or money to take courses and upgrade her skills.  She will be vulnerable to a future replacement by technology.

The problem with the increasing inequality of outcomes in our society in a time of global competition, continuous price pressure, and technology advancement is that continuous education and skill development are more important than ever.  However, achieving this goal is particularly difficult for those individuals who enter the workforce with the handicap of obligations that make continuous learning extremely difficult.

The story about Maddie Parlier begs two questions:

• Why did a woman who is obviously smart and a hard worker not continue her education beyond high school?
• How does someone like Parlier, with time-consuming family responsibilities, find the time to continue to upgrade her knowledge and skills outside of work hours?

When we consider these questions, we are inevitably led to a different way of defining the problem than is customarily used in analyses like these.

Why individuals like Maddie Parlier do not continue in school

My dad, who died in 2001, was a very intelligent person, with great wisdom and insight, and a continuous learner as an adult, but he dropped out of school after the 9^th grade.  My mom, also a person of great intelligence who was a continuous reader and learner all her adult life, dropped out of school after the 11^th grade during the early part of the Depression.  Why?

For them, going to school was an unpleasant and unproductive experience.  The classrooms experience did not engage either of my parents sufficiently to keep them in school, so they dropped out at the earliest possible opportunity.  While it is easy to say that we need better teachers and schools, the bigger problem is that schools do not teach people how to learn.  The educational paradigm is fundamentally flawed. Educators make the judgment that individuals have varying learning abilities, and assume that some people will learn, and others will fail to learn.

I can relate to my parents’ experience by what happened with subjects in which I did not do exceptionally well, like biology, chemistry and physics.

These subjects were taught in a standardized way.  I did not master them, but got good, although not exceptional, grades by sheer hard work and will power.  However, as an adult, I saw their value, and became genuinely excited to learn about the underlying principles of each subject. My daughter even gave me a brief chemistry tutorial on equation balancing recently.

Every one of us gets interested in a subject for different reasons, and we learn in different ways.  I think metaphorically and structurally, and recall information most effectively when I can engage multiple senses in learning the subject.

People have told me I have a photographic memory.  That is not true. I have a photographic memory on certain selective categories of information, but have a below-average memory on others.  My wife can remember the location of a house by a visual map of the color and style of the house and the houses around it.  She remembers foods she ate at a restaurant decades ago, and can even discern differences in the taste of an item from what she ate years ago. I cannot remember what I ate last Saturday night at the local tapas restaurant.

Why do I learn and retain information?

• The subject matter has to be important enough to want to retain it.  I tune out on information that will not matter to me, or that does not strike me as interesting.
• I take copious notes.  Contrary to popular belief, I do not file the notes, but review them once and discard them.
• When I take notes, my handwriting is highly legible, so that I can re-read what I have written.
• If a particular note is important, I underline it.  If it is exceptionally important, I place an asterisk next to it.
• After taking the notes, I re-read them, and I recite what I have written, so that I can hear from what I have written, in addition to seeing it.
• If the notetaking on a subject reveals a particular way of organizing and structuring the information, I create a visual structuring on the page of the notebook, either in the form of a graph, a flow diagram, or a chart.

The more of these tasks I perform, the more likely it is that I will remember what I have written.

My mother used to joke that the reason she dropped out of school was because she was required to do a paper on Sir Walter Scott’s Ivanhoe in her final semester as a junior in high school. I am sure that no one engaged with my mother in a way that helped her find meaning in the assignment.

Rather than trying to shoehorn every student into a one-size-fits-all educational system, let’s try to figure out the different ways in which to engage increasingly diverse populations in the art and the technique of learning.  The goal is “learning,” not “education.”

How do people with overwhelmingly complex lives carve out time for continuous learning, particularly of highly technical subjects?

How does someone like Maddie Parlier possibly carve out time to upgrade her skills?

• We have to create learning processes that provide more flexible self-learning opportunities.  It would be unfair to expect Parlier to attend a classroom course outside work hours, given her single-parent responsibilities, but she can learn online or in other ways.  If there are fees for such courses, she should be reimbursed under a company’s educational assistance program, just as she would if she were attending a class.  We need to make continuous learning as convenient and cost-free as possible.
• We have to teach people how to use small blocks of time as effectively as possible. A single mother holding down a job does not have big blocks of time for learning.  She might get a series of 5-minute blocks of spare time. We need to figure out how she can use them for learning exercises.
• We have to teach people how to multi-task more.

Alternative learning methodologies

Learning can happen anywhere, any time.  I love the text-to-speech feature of my Kindle, especially when I am in my car and can have the experience of listening to an audio book, even if it is in a computer-generated voice. I learn from online demonstrations of subjects.  I also have found that certain TV programs have presented subjects with far more impact than I have ever learned them in a classroom. My friends showed me about the many free tutorials on YouTube. I have even learned from a casual face-to-face encounter, such as a cooking demonstration at a supermarket or a restaurant.  We should test individuals to determine how they learn best, and should draw from their insights and experience, even at an early age, to figure out what is most likely to excite them. Courses should be created in ways that enable them to be delivered remotely and in a multiple ways.

What always amazes me about learning is what we discover about how people of all ages engage with the world.  Some people learn through video games and master complex subjects.  Others gain a great deal of insights from friends, work colleagues, peers, and even online communities.  Even today, I find that my best learning about potential applications for my I-Phone comes from other users.  One of my nephews told me about a new application called Soundhound, which enables my phone to pick up music sounds in a public place and identify the song and the artist.

In essence, everyone can learn, and we should figure out how to make that learning process happen.

How does learning fit into a busy schedule?

It is easy to criticize people who do not take time to improve their skills.  However, in the real world, people have multiple jobs, are juggling time-consuming family responsibilities, and often have challenging commutes to and from work.  Moreover, many jobs are physically and mentally draining. For many people, the ability to take time to learn simply does not appear to be there.  How can we help people carve out the time to learn?

• We need to show people how to simplify their lives, reduce the wear-and-tear of daily activity, and create learning time.  Too many people drive to work alone every day.  Even when public transportation is unavailable, there are many underutilized carpooling, vanpooling, and ride-matching services available to people.  I gained an extra 90 minutes a day of reading time when I commuted by train between New York and Connecticut. When shuttle services between the train station and the office were unavailable, many people gave me rides to and from the train, and I learned a great deal from them.
• Buying hot, healthy pre-prepared food virtually eliminates cooking time, and frees up time for other activities.
• If I were a young parent today, I would be looking for tools to order groceries, clothing, supplies, hardware and other items online for home delivery to save on shopping time.

If large blocks of time cannot be created, then we have to coach people how to use smaller time blocks more effectively.  I always felt that one of my advantages over other people was the use of 1-5 minute time blocks.  When I watch live television, I put the set on mute during commercials, set an alarm for 3 minutes, and do something productive. More and more, I record programs to reduce the watching time from the original running time by fast-forwarding through commercials. I recapture that time for other purposes.

How do I use 5-minute drives to and from the coffee shop? I turn my Kindle into an audio book and listen to a few pages while driving.  The Kindle also can be read outside while I am walking and even while I am waiting in line at the grocery store or some other retail outlet.  I have done a lot of reading in the security lines at airports, while I watch other people stare into space.  I also remember doing work during the many times I waited with my children at the pediatrician’s offices as they were growing up.  I took my own materials, rather than relying on what the doctor’s office had available.

Everyone has spare time. The only question is how to take advantage of it.

We need to teach people how to multi-task more.

When my children were young, I used to take them to the local doughnut shop, get a cup of coffee, browse the newspaper, and talk with them.  It was a great bonding experience for us, and I typically read to them and talked about whatever I was doing.  I also used to take them to museums on Saturdays and Sundays and learn as they were learning.

Today, the shoe is on the other foot.  When I am with my adult children, I ask them about what they are learning, what books they are reading, what movies or videos they have seen, and what places they would like to visit, and why.  My daughter is great in the sciences, so she continually directs me to good resources.

Also, as I noted above, we have a lot of waiting time in our lives that can be usefully deployed. Today, many people use their cell phones to talk or do text messages while they are waiting for someone, but it is easy to convert some of that time to learning time.

We have to change the paradigm from schooling to learning.  We have to change the paradigm from learning as a highly standardized activity to a highly customized one. We have to change the paradigm from learning as a process that takes place within specific certified courses to one that can occur anywhere.  I have no problem with testing people to see what they have learned, and rewarding them for having achieved a certain level of competence, but we need to make it as easy for them as possible.

This skill and knowledge gap is solvable. We can help the Maddie Parliers of the world compete in the global economy and support their families.

There were several noteworthy insights from the program:

• The German and Central European film-makers were incredibly innovative, and they sparked the development of many features of American cinema that changed the films Americans saw, especially after World War II, when the industry was free to resume its normal kind of film-making.  Most noteworthy was the development of the “film noir” style of movie.  “Film noir” was a genre of film that usually was done in black-and-white, as opposed to color, presentation.  It was set in harsh urban settings, was a type of drama and action film, and often involved criminals or gangsters.  Films like The Asphalt Jungle, Dark Passage (which starred Humphrey Bogart and Lauren Bacall), and even On the Waterfront could be considered “film noir” movies.
• The filmmakers who emigrated from Germany and Central Europe created funds to help others trapped back in Europe come to the United States.  They not only sent money back to people trying to escape from Nazi-occupied countries, but helped them with contacts and created the equivalent of an “underground railroad” to enable people to get help crossing borders, hiding inside Nazi-occupied countries, and eventually finding their way to friendly countries.  Germany and the countries it occupied saw a huge drain on their artistic talent, but it would not have been as big of a drain as it turned out to be, had not American-based exiles provided a considerable amount of financial support.

As an aside, we underestimate the importance of support from abroad in almost every attempt to rebel against totalitarian governments.  I saw this in the early 1980’s when I walked by the Holy Name Church in the South End of Stamford, Connecticut, a Polish church that was clearly soliciting money from both parishioners and members of the public to support the Solidarity movement in Poland.

• The exiles from Germany and Central Europe brought a particular passion to their roles in certain kinds of films.  Perhaps the most insightful part of the documentary was the presentation of different scenes in Casablanca, and the description of the actor or actress in that scene who had emigrated from Germany or another Nazi-occupied country and their passion for portraying the European experience.  The saddest ironies in films like Casablanca  were that the Nazi characters were often portrayed by Jewish actors, such as Richard Ryen, a German who played Major Strasser’s Nazi aide Captain Heintz, in Casablanca.

The Casablanca stories were inspiring and tragic.  Madeleine LeBeau, who played Yvonne, the lover spurned by Rick, fled France, along with her Jewish actor husband Marcel Dalio, who played the croupier.  They had a very circuitous route to America, having to get to Portugal, to Mexico, and to Canada, before having the opportunity to enter the United States.  S.K. Sakall, who played Carl, the waiter, fled Hungary and lost three of his sisters in concentration camps.

However difficult our lives are in America or in other parts of the world, we should remember that there are individuals today who are living far away from where they started or would like to be living.  Moreover, most of us are not living in a war zone, and we have far more creature comforts than people living middle or even upper middle class lives had 1-2 generations ago.  As I write this, I am sitting in a very comfortable Starbucks restaurant in Darien, Connecticut, and enjoying a great morning cup of coffee (I usually go to another coffee shop, but it is New Year’s Day and nothing much is open here.)

The other lesson I took from this documentary is that we should reconsider our ridiculously restrictive immigration policies.  We should be able to distinguish between criminals and terrorists, whom we do not want to admit to America, and those with great skills and capabilities, who will enrich our country and create opportunities for many Americans lacking those opportunities today.  That is the argument persuasively made in the book Borderless Economics: Chinese Sea Turtles, Indian Fridges and the New Fruits of Global Capitalism by Robert Guest.

Finally, we should recognize that an untapped source of support for people in developing economies is the direct transfer of money from individual to individual.  The major, centralized government programs, or even the programs developed by not-for-profit organizations often have too much waste, too many centrally-imposed conditions, and too many intermediaries to be as effective as direct money transfers.  Let’s encourage more efficient money transfer from rich to poor than we do today.

Most of all, as we look ahead to what is often an uncertain and somewhat frightening future, we should take stock of how blessed we are, and how grateful we should be, for those who fought for our freedom generation after generation.

In this case, the employer is the Port Authority of New York and New Jersey, an entity created by a contract between New York and New Jersey and jointly owned by the two states.  This entity is not accountable to elected officers or voters, except for the indirect influence that elected officials from the two states sitting on its board of directors have on the entity’s operations.  Oddly enough, entities like the Port Authority were created over several decades in the 20^th century because elected officials believed that they would operate in a more business-like fashion and not be subject to the corrupting influences of elected officials trying to “buy” votes by bestowing favors on constituents. However, the lack of public accountability means that the customers of the Port Authority, namely those who travel in the New York Metropolitan area, will bear the brunt of the abuses of the pension system.

In one sense, it should be easy to solve this problem: abolish this “pension spiking” scheme in the next collective bargaining session.  However, we get a hint of why these kinds of schemes are so hard to uproot. A toll collector named Princesella Smith is quoted as saying: “I’m blessed. I have a great job, and, in this economy, it’s great that I can cover everything with my eight hours a day and overs.”

Executives and union leaders who both know that paying a toll collector like Ms. Smith $89,599 per year is absurdly excessive also have to confront the fact that, but for her oversized compensation package, she probably would be living in a much more difficult economic situation.  She is a human face to the problem of reducing the government budget deficit.  I found that, at Pitney Bowes and at other large organizations, no matter how well these organizations were managed and how tightly costs were controlled, it was difficult to bring pay into line with what made sense for customers.

The overpaid employee is a real person, often well liked and appreciated for his or her organizational commitment.  While I do not know how good an employee Ms. Smith might be, she is clearly doing a job, collecting tolls on the George Washington Bridge, that few people would choose to do if they had other choices.

Not only are overpaid employees often liked and appreciated, but senior executives often know the families of these employees and the tragedies and challenges the employees face.  At Pitney Bowes’ Connecticut operations, there really are no executives living in enclaves that totally separate them from coming into contact with ordinary employees.  I was highly likely to interact with company employees outside the office. When my second son was younger, the president of the Little League baseball program was a product manager at the company. Our housekeeper’s husband worked at the company. When we went to school events, we would meet parents who were company employees and whose children were friends of our children.

It is easy to blame militant labor unions for fighting to preserve the jobs of overpaid and under-skilled employees.  However, my experience is that these problems would exist in any organization in which executives, voluntarily or otherwise, build close personal relationships with people up and down the organization.

Over time, I developed the skill of confronting people I knew and liked, but who had to leave the company.  I had to convince them that it was not only in our best interest, but in theirs, that we were taking them out of a job, reducing their pay, or in some other way taking an adverse employment action.  I operated on the simple principle that if I could not look them in the eye across a table and justify what we were doing, the action was indefensible.  Thankfully, I never had to make the judgment that an adverse employment action was indefensible when I used that test.

When we teach senior executives to care about employees as individuals, then we create a different problem.  It becomes challenging to look those overpaid and under-skilled employees in the eye, meet them in the coffee shop and deli, see their families in the school events, or run into them on the street, and tell them that you either have to eliminate their job or reduce their pay to bring it into line with what the market pay should be for their job.

Think about the job of a postal worker who manages mail sorting machines.  At Pitney Bowes, we were able to employ and retain people who would do this work at about 1/3 the rate that the Postal Service was paying for the same work.  We were consistent in our pay practices with the real market for this job.  The Postal Service’s pay rates were artificially high, both because of a collective bargaining agreement, and because of the political pressure that postal union workers could bring to bear on elected officials.

The concept of a “living wage” is that people must earn enough in any job to be able to afford a standard of living above the federal poverty line.  However, what “living wage” advocates forget is that the “living wage” movement would result in fewer jobs and more expensive products.  As I look across our economy, I see many candidates for job eliminations if wages for that job get too high, not the least of which is the toll collector job.

When I go to large retail grocery stores and pharmacies, I am increasing seeing self-service stations, including some at the checkout counter.  When I go into bathrooms, I see electrical hand driers, which clearly replace the job of transporting and stocking paper hand towels. Postal sorting machines have replaced most postal clerks who sort mail.  Automated banking kiosks replace tellers, as other vending machines provide 24×7 service in place of retail clerks.

The largest job elimination trend, which particularly comes into play at this time of year, is the substitution of online shopping for retail purchases.  In past years, my wife frantically traveled from store to store to buy Christmas gifts.  Today, she sits with her computer and orders everything online.  While the merchants that deliver in response to online orders certainly employ people, fewer people are needed for online transactions, compared with their retail counterparts.

In essence, the labor union and “living wage” movements, whether they want to admit this or not, are hastening the elimination of the jobs they are trying to protect and enhance. They will win for a few years, but eventually the desire for consumers to get the highest level of convenience and value at the lowest cost will override the desire to protect someone else’s overpaid job.

Moreover, their fee structures would kill individuals and small businesses.  For example, UPS and FedEx charge over $10 for improperly addressed letters and packages.  This is a profitable source of revenue for both organizations.  They also have residential delivery surcharges, especially for more remote residential areas.  If they are to take on the responsibility for more mail delivery currently done by the Postal Service, they cannot use their current fee structure to do so.

How can the U.S. Postal Service take costs down?

Use self-service retail more aggressively

The Postal Service is far behind the banking industry, as well as the travel industry, in employing self-service kiosks, as well as online retail purchase systems.  You can do virtually all your banking at self-service kiosks, but the Postal Service has nowhere near the deployment of self-service kiosks it can and should have.

Share bricks-and-mortar retail with other retailers

There is no earthly need for dedicated bricks-and-mortar post offices anywhere in the United States.  Postal retail operations should be inside major grocery retail operations, rail stations, airports, gas stations, general stores in rural areas, and major shopping malls.

Reduce street collection boxes and replace them with shared mail collection systems

The letter carriers can collect a significant part of the mail currently going to collection boxes, when the letter carrier is still doing residential delivery to the doorstep or dedicated mailbox.  However, there should be collection boxes at the self-service kiosks, similar to what banks do with ATMs that collect deposits as well as dispensing withdrawals.

The Pitney Bowes shipping kiosks at Staples and Office Depot are paired with package collection systems at both stores.  The retail outlets that sell greeting cards should also have kiosks and mail collection boxes for people that want to write and send an individual card.  The types of mail used today need to be analyzed to determine the most efficient mail collection systems to reduce the number of mail collection vehicles and employees.

The mail processing functions should be completely outsourced to the private sector, with rate discounts that enable them to be profitable.

Pitney Bowes became a leading provider of mail sortation and processing services, and delivered mail into the Postal System faster, less expensively and more reliably than the Postal Service could have done with the same mail.

To be fair, Pitney Bowes and other companies offering presorting worked with more standardized and easy-to-process letter mail, as opposed to the bulkier and less standardized mail the U.S. Postal Service workers have to handle.  However, the biggest issue with the mail processing centers is not the non-standardized part of the mail, but the inflexible, high cost labor rules under which the Postal Service operates.  Mail volumes vary by day, week, month, and time of year.  Labor staffing needs to be flexible and part-time.  Over time, facilities need to be built, moved, and either reduced or increased in size.  Because the Postal Service is government-owned, its ability to react quickly to changes in mailing patterns is non-existent.  It takes years to build and move a post office, and it is virtually impossible to close a post office.  It is even extremely difficult to remodel a postal facility that remains in the same place.

Change delivery economics to increase the use of clustered boxes

When I co-chaired the Mailing Industry Task Force with John Nolan, then the Deputy Postmaster General, one of the dumbest rate comparisons with which the Postal Service was stuck by its universal service mandate was that it was required to deliver mail free of charge every day to the bottom of the Grand Canyon, but was required to charge a mail recipient who could save it money for a post office box rental.

The economics of mail delivery need to be reversed.  Those who give up expensive residential delivery should be rewarded.  Those who secure a conveniently located delivery mailbox should get that service without charge.  Over time, the mail delivery should gravitate toward moving the mail to where people spend their waking hours, not where they live or do business.  We are a more mobile society than ever, and the Postal Service delivery system should recognize this.

Other observations

I have not discussed pricing for mail products because this is an infinitely more complex subject. Cost-based pricing has some perverse effects, such as increasing the cost of mailing for those direct marketers who are more selective in mailing to prospects in a ZIP code.  It is cheaper to deliver to every address than to honor “Do not mail” requests and cull out certain addresses for discontinued mailing, but we should encourage the Postal Service and direct marketers to stop mailing to people who no longer want to receive marketing mail. Rate structures should encourage, not discourage, more selective mailing and higher direct mail response rates.

The discounts given to not-for-profit mailers, and for certain classes of mail, such as books and other educational materials, have broader societal purposes.  Mail addressed to and from elected representatives and other government officials needs to stay at low rates, especially for people living in remote areas.

However, within existing rate structures and subsidies, there are potential improvements.  For example, there should be a discount for mailers who use self-service kiosks and get bar codes printed on single pieces of mail, such as greeting cards.  There should be a discount for mailers who drop mail at post offices or bulk pick-up services, as opposed to those who continue to use dispersed street collection boxes.  There should be discounts for those who use pre-printed envelopes to pay bills, versus those who create a hand-written envelope to do so. Finally, there needs to be a discount for metered, versus stamped, mail, which is happening in many countries in the world.

Final thoughts

I have seen no business succeed in the long run by saving money through causing its service and brand to deteriorate.  We need to prevent the Postal Service from following the path taken by Amtrak, which has become marginalized over a long period of time and required repeated government subsidies because of its deteriorating services and declining revenues.

Finally, let’s eliminate the inflexibility with which the Postal Service has to manage its medical benefits.  Years ago, in conversations with one of the Postal Service labor union leaders, I learned that there was an opportunity to save hundreds of millions of dollars a year by taking postal employees out of the federal health benefits system.  The Postal Service did not believe it had the freedom to withdraw from the federal system, even though it receives no taxpayer subsidies and it is an off-budget agency. That has to change.

Traditional mail volumes will decline further, but there are many opportunities, including those I have not described in this blog, for the Postal Service to be economically viable.  We need a better model, one with considerably less political interference, with which the Postal Service can operate.

I do not believe we can solve the deficit problem without raising taxes.  I also do not think that all tax increases on wealthier people are inherently bad.  I do not think the proposed tax rates are inherently bad relative to their effect on economic growth.  Furthermore, although I think we have a certain amount of “crony capitalism” in our country at all levels, money that gets redirected from the general public to a few favored corporate and union welfare systems, I think a certain amount of that will happen in any democract.

However, I have three fundamental issues with our tax system:

• Everyone should pay income taxes, except for the very poorest members of our society, and, for them, only for the period of time in which they remain below the federal poverty level.  Today, over 50% of Americans pay no income taxes.  That is wrong.  It disconnects over half of Americans from any economic stake in how income tax dollars are spent.  It has the psychological effect of deluding those not paying taxes that money will always be available from “the rich.”  Everyone should pay something.
• We need far tighter controls on how our tax dollars are spent.  I understand that, in a democracy, some uses of our tax dollars will go to causes that I would not personally support.  The majority of the voting public should help guide elected officials on the allocation of tax revenues.
• We need much more common sense in the way governments account for what they are spending, and what the long-term costs of that spending might be.  The whole issue of excessive retirement benefits has arisen because governments have hidden the long-term costs of these retirement obligations by using accounting rules that were prohibited for private businesses over two decades ago.  The Congressional Budget Office “scoring” of legislation is fundamentally flawed in two respects: first, it limits its evaluation to the ten-year period after the law is passed; and, second, it does not take into account the highly likely behavioral responses to a piece of legislation.  For example, any tax increase on businesses headquartered in the United States will cause some businesses to shut down U.S. operations and move investments and jobs abroad.  That kind of highly likely reaction to a tax increase is not factored into the CBO scoring model at all, even though any common sense evaluation of a tax law would take it into account.

However, at all levels of government, but particularly at the state and local level, taxes and bond proceeds are solicited for one purpose, and diverted from a completely different one, usually the enrichment of union leaders and other state employees.  When Connecticut created a fund for transportation improvements in 1984, most Connecticut residents would gladly support tax increases to upgrade our badly maintained transportation system.  However, year after year, the Special Transportation Fund has been raided for “general revenues,” which is a euphemism for paying rich retirement benefits to unionized and militant state employees.

Similarly, Connecticut established a fund for smoking cessation programs when it received a major settlement from the tobacco companies in 1998.  It has never used a penny from that fund for its intended purpose.  Every year, the fund has been raided for “general revenues.”

Connecticut is not alone in this regard. Diversion of funds from one budget line item to others is a regular practice of many states and localities, as noted in the Monday, November 14, 2011, issue of The Wall Street Journal, in an article entitled “Cities Hit as Funds From Bonds Pay Other Bills.” In that article, reports Ianthe Jeanne Dugan, Justin Scheck and Bobby White recount many examples of cities like Miami that routinely divert funds from their intended purposes.  The reporters stated:

“Cities and states across the country are using money designated for specific purposes—such as fixing roads or sewers—in order to fill financial holes elsewhere, according to public officials and records.”

We cannot allow governments at any level to use these “bait-and-switch” tactics, which, if used by large public companies, would subject them to SEC fines and penalties and investor lawsuits.

Governments need to clean up their acts before I feel comfortable with tax increases on anyone.  This is not about  dissatisfaction with uses of public money with which I disagree; it is about corrupt and dishonest uses of public money.

Finally, I believe all of us should know how our money will be spent and what the consequences of a particular government spending decision would be.  The projections and predictions about government spending are so flawed, as has been seen in the retirement benefits area, that I do not feel confident that we are getting the straight story.  This is not a result of dishonesty, unlike the fund diversion issue; it is just bad accounting.

For all these reasons, I would like to see some fundamental changes made in our taxing and spending policies before I would support any tax increases at any level.  At that point, I would be very comfortable paying my fair share of taxes.

Each of the experiences I have described above has shaped my thinking, but each has done so in a different way.

The data center visit

I visited a large data center, in which the operators are using state-of-the-art monitoring systems for electrical power, climate control, and the performance of its computer and server systems.  A company on whose board I sit, Eaton Corporation, is a leader in providing comprehensive power management solutions for data centers. What is remarkable about the large data centers is the degree to which these centers no longer need human beings to monitor many system components.  The central control hardware devices and software programs provide data on thousands of points within the system.  There are less than 10 employees for a huge data center.

What insight does this have for health care?  To the degree that we are designing a system that enables remote and comprehensive monitoring of the state of health of a patient population, we can do so with relatively few healthcare professionals.  Although we talk about a serious labor shortage, the labor shortage assumes an indefinite continuation of the face-to-face diagnosis and treatment systems we now have, as opposed to the remote monitoring systems toward which we are heading.

The term the data center people when describing a center monitored predominantly by sophisticated hardware and software technology is a “lights out” system.  We must evolve to a “lights out” healthcare system on the same model.

The medical school advisory board meeting

As we think about healthcare professionals being trained in modern medicine, it becomes clearer than ever that healthcare professionals not only need to learn traditional human biology and body chemistry, but to be steeped in the field of bioinformatics.  Bioinformatics is a relatively young field of knowledge and skill in which diagnoses and treatments are developed through both onsite and remote data collection and the computer-generated analyses that use the data.

There will never be a complete loss of human judgment by trained health care professionals, but their efforts can be focused on those cases in which human judgment can make the biggest difference.  Getting good data on biometric indicators, health and healthcare history, and the foods, beverages, prescription drugs, over-the-counter drugs, and other items ingested by an individual is critical to enabling the human judgment factor to work best.

Medical schools are beginning to understand the importance of bioinformatics, and to incorporate course material on this field.

The visits with biometric device producers and health plan administrators

The Dossia Health Manager now is able to aggregate not only the comprehensive clinical history on an individual, but biometric and daily activity data that enables the healthcare professional to get a much more complete picture of the individual’s state of health.

Even better, there is an increasing effort to integrate biometric data tracking and management into health plan designs.  Employers and health plans have been providing services and incentives to get individuals to participate in health risk assessments, but these have been one-time exercises, as opposed to a program of capturing and tracking health data all the time.

There was a 2010 Kaiser Permanente study which supported the view that someone who regularly tracks blood pressure is 50% or more likely to control blood pressure.  This is consistent with a broad principle, often articulated about business objectives, that what gets measured gets managed.  The ability to capture blood pressure data with wearable devices is better than ever, and should be stimulated with incentives and rewards.

Shopping at the local pharmacy

Perhaps the most interesting learning I have done over the past month has come from wandering through several pharmacies while I was shopping for a few items.  Near the pharmacy counter at every counter is an increasing variety of home health test kits which are getting close to laboratory accuracy.

One which particularly caught my eye was a kit costing about $30, marketed by Bayer, which enables a user to draw a drop of blood and get a quick reading on his or her Hemoglobin A1c level.  Hemoglobin A1c is a leading indicator of Type II diabetes.  In the past, someone like me, who monitors this biometric indicator as closely as possible because of a family history of Type II diabetes, a genetic predisposition to the disease, and a slightly elevated level of blood sugar, would have had to get a physician to write an order for a laboratory test.  I would have had to schedule an appointment to get blood drawn, and would have had to wait at least one day, and possibly longer, to get my A1C reading.

Today, I can buy my own kit, draw my own blood, and get a same-day reading of my A1C level.  While I would not rely on a home test kit for a definitive diagnosis, I can track general trend information and can do so far more frequently than would be the case if I relied on a physician’s order and on having to schedule an appointment at a lab.

The next step in the evolution of these biometric devices is to make them able to communicate automatically with either a smart phone or a laptop or desktop computer, so that the data can be communicated directly back to a personal health record controlled by the patient.  Once that happens, the productivity of healthcare professionals will increase dramatically.

Instead of having nurses reside at a physician’s office or visit each patient at home, the nurse can work from either a home-based desktop computer or a mobile laptop or I-Pad device to track the health status of a much larger patient population than ever before.  Physicians would write orders to that nurse relative to what biometric indicators are most relevant for a particular patient.

Final comment

The biggest obstacle to adoption of this “lights out” healthcare system is the resistance of those who have built strong capability and income from face-to-face diagnosis and treatment systems.  If I operate a large medical practice based on the assumption that I must see every patient I treat, it will be very difficult to put into place systems and processes that operate as if I am not there.  The biggest challenge in diminishing this resistance is not technological or educational; it is the fear of losing income, jobs, or status.

“High consumption of care is driven by the crowd of academic medical centers, specialists, and equipment needed to perform tests. The Bay State has one doctor for every 267 citizens — versus one doctor for every 425 people in the nation as a whole. Supply drives demand. “

Supply-driven demand happens for two reasons, often overlapping:

• Healthcare providers believe in a particular treatment or therapy, and try to maximize the number of people who access it.  This is often reduced to the saying that “If you have a hammer, every problem is a nail.”  Supply-driven demand occurs when people who should not be customers for a particular service become customers because the provider of that service force it beyond its natural market.
• Healthcare providers have excess capacity, and try to get that capacity in use.  This happens with expensive diagnostic imaging equipment, hospitals, and outpatient centers.  It is even arguable that physicians react to reduced usage of their services by patients who become healthier by increasing the frequency with which they see other patients.

The other reason hospital capacity drives demand is that, even when it makes sense to close or shrink a hospital, there is a strong reluctance to shrink or close a facility that appears to be a strong job preservation engine in a community.  However, we must confront the issues associated with repurposing healthcare facility and provider assets, because our current healthcare architecture is unsustainable.  Too many Americans, probably now in excess of 15 million, are employed in healthcare, and too much of our GDP, now around 17%, is devoted to healthcare spending.  We need to redeploy a significant percentage of healthcare assets toward alternative uses.

Closing a hospital can be done in the situation in which there are other hospitals that can absorb the patient population the closed hospital used to serve.  In Stamford, Connecticut, St. Joseph’s Hospital was closed and most of its patient population migrated to the Stamford Hospital in the late 1990’s.  The Stamford Health System, which owns the Stamford Hospital, created a new wellness, outpatient diagnostic, and outpatient surgery center on the old St. Joseph’s Hospital site.

However, there are less drastic alternatives to closing a hospital, especially when there is one hospital in a community and closing it completely is not a viable option for the served population.  Repurposing big chunks of hospital campuses is an option that healthcare policy makers have to consider, and for which they need to develop an expertise. Although the examples I have found around North America all relate to redeploying complete hospital sites, as opposed to partial redeployment, they are instructive on what could be done with separable parts of hospitals.

In Vancouver, British Columbia, the unused hospital space became an Arts Center.  In Rogers, Arkansas, the closed St. Mary’s Hospital became a Center for Nonprofits.  At Virginia Commonwealth University, a former hospital was converted to student housing.  At the Tufts Medical Campus, unused hospital space became a café and fitness center.

The repurposing of hospital space that is no longer needed for patient care can also take into account the needs of medical residents, who could live in the space, which, in some cases, has been converted to residential and retail space.  Given the exorbitant cost of medical school and medical residency programs, subsidized housing could be a great alternative to more hospital beds.

I could also envision an innovation incubator, in which there are small offices for entrepreneurs of start-up businesses.  In downtown Stamford, Connecticut, there is an attempt to use an old government building as an incubation center.

While hospitals will lose revenue potential by shrinking, the overall healthcare system needs to look at what benefits society as a whole, as opposed to what will maximize an individual hospital’s revenue and jobs.

What happens to those no longer working at the hospital?

• Those working as healthcare professionals, doctors, nurse-practitioners, nurses, physician’s assistants and nurse’s aides can be redeployed to the remote or the onsite care of patients in their homes.
• Those working in clerical and administrative jobs could also be redeployed in organizations that provide care, but in a less capital intensive organization.
• Those who provide facilities related services can provide those services to whatever uses are substituted on the site.  There are some facilities services, such as hazardous medical waste management, that will go away completely, but food service, maintenance and repair, and delivery services will survive.

Who loses when a hospital is repurposed?

• Providers of expensive diagnostic technology will see a significant volume drop.  Eventually, Medicare and other payers will create payment systems that reduce payments to a level at which unconstrained use of diagnostic imaging tests will not be able to be reimbursed.
• Doctors who rely on scheduled surgeries will lose opportunity because the hospital will do fewer surgeries.  However, one alternative to a portion of a hospital is an outpatient surgical center, which can absorb a portion of the supply.
• Providers of ambulance and emergency medical technician services will see a volume drop only if there is not alternative hospital to which to take patients, so emergency departments will not be automatically reduced to handle real emergencies.  However, there are emergency department transactions for non—urgent care that can be taken out of the hospital altogether, and can be managed through remote care.
• Labor unions which represent certain groups of employees that will be scattered when redeployed among a number of employees will lose, to the degree that their collective bargaining agreement is narrowly targeted at a specific employer.

The bigger challenge in closing or repurposing a hospital is political.  Elected officials intervene on behalf of any group, which believes it will be disadvantaged.  This is especially the case if the apparently disadvantaged group is organized to effect powerful political advocacy, such as a labor union, or if there is a high proportion of people of color in the groups affected by the decision.

The biggest skill set required in repurposing healthcare assets is the ability to envision a future that is better for the community, better for the community patient population, and not unduly disruptive to the various stakeholders, which benefit from having the hospital remain intact.

Having leaders who can think through and implement a game plan to transition elected officials and the communities they represent toward an alternative future that reduces the footprint of the healthcare system is our biggest challenge.

Some large self-insured employers will move their employees to the newly created state and federal health exchanges.  They will pay taxes or penalties to do so, but it will be better economically, in the short term, for them not to have responsibility for employee health care costs.

However, many employers will invest in the health and wellbeing of their employees, and derive competitive advantage from doing so.  Why?  For employers free to design an optimal healthcare system, including onsite clinics providing comprehensive primary care and developing a selective specialist provider and hospital network, the ability to design a good healthcare system gives them much more control over their employees’ health status, sense of wellbeing, and health benefits costs.

Some employers, like American Express, are even building care delivery networks outside the United States, in countries that have single-payer systems and that have government-employed doctors and government-owned hospital networks.  The staff physicians for these employers provide far better care, which is very attractive for talent recruitment and retention.

What employers will opt out of offering direct health care coverage?  Companies that have lost control of health care costs, such as those with exceptionally generous collective bargaining agreements, will welcome the chance to offload their entire population to health exchanges.  In many companies, CEOs simply do not understand that they can manage employee health and wellbeing and deliver shareholder value.  In others, corporate benefits departments do not want to assume responsibility for health care cost reduction.

Employers who retain health care coverage will develop better provider networks, and may even create multi-employer consortia.  This is happening in Southeastern Wisconsin, with Quad Med, Briggs & Stratton, Miller Coors, and Northwestern Mutual Life.  It is also happening with a consortium of labor unions in the New York City in the UNITE Here Health Center.

What will these employer-based health plans look like?

• They will migrate toward consumer-directed plans with high deductibles and co-pays for plan participants;
• Plan participants will be given significant incentives for making the best choices for their health, health care, and health benefit plan spending;
• Plan participants will be given continuously improving tools for self-managing health, including consumer-controlled personal health management systems like Dossia, clinical decision support tools, choices among health and wellness vendors, and good information and technology tools for continuously monitoring health; and
• Employers will put more decision power into the hands of plan participants and will force health plans to market directly and successfully to consumers to secure revenues.

These employer-based “accountable care” systems will be among the world’s best health care systems.

The wealthiest Americans will leave the core systems of which they are a part and pay extra for concierge medicine. They will consult with physicians who accept no Medicare patients and who direct their patients to the world’s best care, wherever available.  These Americans may actually be consumers of medical tourism, when that care is superior outside U.S. borders.

There is precedent for this.  In the UK, the top layers of UK society initially acquired supplemental health insurance through BUPA and, more recently, seek out care wherever it can be best delivered, including India, Singapore, and the United States.  Medical tourism started to meet the demand from single-payer systems abroad, but it will get bigger here.

There will even be increased medical tourism within the United States.  Concierge doctors will refer patients anywhere in the country in which they can secure the best care.  This system will also deliver exceptional care.

Some Americans will receive world-class care because of the lucky accident of where they are living.  Those Americans in the seven states in which Kaiser-Permanente is licensed to do business, or in Utah, where Intermountain Healthcare is based, or in Washington state, where Virginia Mason is based, or in Southeastern Pennsylvania, where Geisinger is based, will get excellent healthcare.

Other systems around the country will attempt to copy them, and some will succeed, but most will have difficulty, because, for the most part, world-class accountable care organizations will have been created in business models in which the primary care physicians are staff doctors paid a salary and in which there are tightly controlled specialist networks.  These systems work because they effectively limit patient choice by steering patients into a single managed care network.  They will stop seeming like a satisfactory alternative when the limitation on patient choice produces bad outcomes in a handful of high visibility cases.

There is precedent for this.  Back in the 1990’s, payers were effectively controlling healthcare costs and utilization through tightly managed care networks.  These systems also delivered a reasonable level of care quality.  However, they were dismantled because there were a variety of high-profile cases in which it appeared that the healthcare delivered was of inferior quality because the patient could not select the provider of choice.

Most government-run systems outside the United States use some form of provider choice control or give patients no choice as to providers.  Some have “gatekeeper” systems in which the patient cannot directly consult a specialist.  In the United States, such systems can survive only if they can avoid getting legislated or regulated out of existence because of the appearance of delivering inferior care.  They survive, but are highly vulnerable to being dismantled.

Many people have used the Veterans Administration and Military Healthcare systems as models for great healthcare at an affordable cost.  They have electronic health record systems.  They take advantage of broad clinical learning.  They deliver convenient and low-cost care through staff physicians and nurses paid on salary, and they develop long-term relationships with their patients.

However, because premiums paid by users are so low, and raising the prices paid by veterans and military families is politically suicidal, the federal government will reduce the financial burden of this system by quietly reducing the supply of care, rather than working to reduce demand.  They will shrink the size of facilities, the size of their staffs, or the hours of service, rather than increase the cost of accessing them.  Although shrinking a hospital or outpatient center is politically challenging, demanding that users increase their premium payments by several thousand dollars a year would be politically suicidal.  For example, the military health care system charges a 60-year-old military retiree $426 per year in premiums, a ridiculously low payment, considering that this type of retiree costs the system in excess of $10,000 per year on average.  However, raising premiums to even $1,000 per year is the metaphorical “third rail” issue; politicians will not touch it.

The best place for low income Americans dependent on Medicaid or other safety net health care programs is at community health centers.  These centers are generally better equipped to handle the complex problems low-income Americans face, particularly those with language and cultural barriers.

The top community health centers have expert resources to assist patients in applying for government benefit programs, in managing transportation and childcare issues, in addressing related social service issues, such as domestic violence, and overcoming language and cultural barriers.  They also tend to manage appointments for patients with more unpredictable schedules far better than a traditional private health practice.  Finally, they develop expertise in managing the different kinds of health problems very poor people have, compared with their non-indigent counterparts.

The Medicaid legislation passed in 1965 contemplated that Medicaid and Medicare patients would be part of mainstream health care systems and that Medicaid and other safety net programs were simply ways of paying for health care for poor people. We now know, from nearly five decades’ experience, that low income people have other overwhelming life challenges.  Their health care, economic and family needs are different, and are interrelated.  They need expert care a community health center is better equipped to deliver.

Medicaid and other safety net programs could have paid more for health care, and enabled private practice physicians to handle Medicaid patients, but the reimbursement rates for Medicaid providers are so low that private practice physicians have increasingly stopped seeing Medicaid patients.

Therefore, the community health centers will end up handling them, and will actually do a reasonably good job delivering care.

In trying to address budget deficit issues, the Obama administration and its successors will try to reduce what Medicare pays for health care.  This will cause even more medical practices to drop Medicare patients, because these patients have more complex health challenges for which the doctors will be paid less.

We continue to see a hemorrhaging of primary care physician populations, which leaves the Medicare populations even more poorly served by private practice physicians.

Medicare patients will seek out more care at retail clinics for minor illnesses or injuries, at urgent care centers for serious conditions, at emergency rooms for acute conditions.

We will see shrinkage of the physician population with the skill and will to take on older patients with more complex health care challenges.

Most Americans who work in small businesses, who freelance or are self-employed, who are unemployed, or who work for large companies that have abandoned health care coverage will end up in health exchanges.  They will get a progressively poorer quality of care from private practice physicians. They will wait longer for care, have long waiting times in doctor’s offices and hospitals, have short visits with healthcare providers, get too many diagnostic tests in place of more careful physical examinations because the fee-for-service system will survive and drive dysfunctional behavior by physicians and hospitals.

They will also visit urgent care centers and emergency departments more than they should, because these parts of the healthcare system will be accessible to them.

While the quality of care delivered through this government-regulated system will decline, the cost for patients will increase significantly.  There will be high deductibles and co-pays, and the risk pool in this population will get worse over time.  The state-run exchanges and any other system created and managed under the Affordable Care Act or any regulations emerging from it will receive those members not wanted in other systems.  For example, employers with already healthy populations will retain their health plans; employers with unhealthy populations will happily dismantle their health care coverage and drive employees to the exchanges.  There will be an “adverse selection” problem.

The titanic battle between proponents and opponents of the individual mandate, that is, the requirement that individuals either purchase health insurance or pay a penalty for not doing so is constitutionally and politically critical, but arguably irrelevant to whether our country will end with everyone insured.

The individual mandate design created by the Affordable Care Act, as well as the Massachusetts design, both are flawed in driving individuals to secure health insurance because the penalties an individual has to pay if he or she does not elect to secure insurance are inadequate.  I have commented on this more than once: if an individual driving into New York City were to have a choice between paying $40 to park legally in a garage or paying a $20 parking ticket for parking illegally on the street, the vast majority of individuals would elect to park illegally.  It’s nice to have a symbolic penalty, but such a penalty works only if the cost of noncompliance is close to, or better yet, greater than, the cost of following the law.

Because our elected officials did not have the courage of their convictions to create meaningful incentives or penalties for getting every individual covered by health insurance, a significant part of the population, many of whom will be young, healthy people who usually subsidize older, less healthy people, will remain outside the health insurance system.

They will actually have more attractive health care options available to them.  They will access retail clinics for treatment of minor illnesses and injuries. They will have more retail choices for both immunizations and periodic screenings.  They may even be able to access medical tourism options for surgical procedures that would otherwise be prohibitively expensive, even in an insured health care system. They will continue to access acute care at emergency departments.

They really do not need to secure health insurance until they have a condition that is both expensive and chronic, one in which emergency department care is inadequate.  In the past, they would not have risked waiting to get health insurance until getting a chronic condition, but the Affordable Care Act eliminates any barriers to them securing insurance whenever they can no longer operate in the uninsured system.

Oddly enough, absent a much more punitive individual mandate, the Affordable Care Act may actually drive more individuals into the uninsured system for longer stretches of their lives.

Final Comments

It is very difficult to reform the multiple health care systems that, in aggregate, employ over 15 million people, most of them in middle-class jobs, that contribute almost $3 trillion per year to our economy, and that are perceived to deliver two public goods, healthcare and insurance protection against catastrophically high healthcare expenses. Change will come from a combination of evolutionary development of better care for those who can acquire it outside the systems heavily regulated by the government and increasingly complex and dysfunctional government interventions.

The goal of universal healthcare equitably available to all Americans will not happen.  Those smart, rich, or resourceful enough to demand great care will get it; the remaining Americans, overwhelmed in trying to manage their daily lives or not sufficiently “street-smart” or rich will be lucky to get adequate, affordable care.  The more government tries to intervene to achieve fairness or to correct fraud, waste, and abuse, the more the system will create new opportunities for fraud, waste, and abuse. Moreover, as noted above, the government’s misguided attempt to eliminate denials of coverage for preexisting conditions will provide a perverse incentive for more individuals to drop out of the health insurance system until it becomes economically untenable for them to stay out. Every government intervention will result in a new set of “gaming” opportunities.

Some people would say that we have a crisis in health, healthcare, and health insurance, and that the crisis should be a call to action.  Unfortunately, the history of our representative form of government would suggest that crises are noticed and acted upon when they are triggered by highly visible events, coupled with strong leadership and large movements to take advantage of them.

Moreover, even when there is a crisis, there has to be an agreed-upon paradigm for how to think about the issue.  We do not have that:

• We do not have a consensus on how to resolve the healthcare crisis.
• We want everyone to have health insurance, but are not prepared to take the hard steps to penalize those who refuse to buy it.
• We support the goals of unlimited patient provider choice, unlimited access, very limited penalties for irresponsible and destructive patient behavior, and the belief that more access to care always yields better care and better health.
• We know that unlimited access and unlimited choice yield bad economics, but do not fully understand that most of the cost of healthcare comes from preventable and controllable decisions that should be penalized more; and
• We have exceptionally little understanding of the degree to which more care often means worse care and poorer health.

Our system will simultaneously improve in certain respects and deteriorate in many others for the next decade, but I am confident that it will settle into a complex, multi-segmented system like what I have described.

On the morning of September 11, 2001, I was in Pitney Bowes Stamford Main Plant building, having a difficult meeting with a group of factory employees, explaining why we needed to outsource much of the low-end product then manufactured in that facility.

I received a call a little bit after 9 am from Karen Garrison, then President of Pitney Bowes Management Services, who had seen the video footage of an airplane crashing into the first of the World Trade Center buildings.  I immediately began to return to the World Headquarters, a few blocks away. During my brief trip back to the Headquarters, an airplane crashed into the second World Trade Center building, One World Trade Center.

As I tried to absorb what had happened, I reflected on the fact that my wife Joyce had worked at One World Trade Center when we first lived in New York City in 1981 and 1982, and that I had been in the building many times over the years to visit customers.  By 10 am that morning, we had set up a command center in our boardroom, from which I ran the company for two weeks after that.  I left the boardroom many times, to address groups of employees both in the Headquarters and in other buildings, and to visit our New York offices.

Pitney Bowes lost four employees, all members of the Pitney Bowes Management Services team, all of who were serving clients on the upper floors of One World Trade Center.  All four employees were initially directed to leave the building, but returned back to their work areas between the times the first and second buildings were hit.  They felt a need to be with their customers and to do the work assigned to them.  They paid with their lives.  One of them, David Vargas, left two teenage children behind, and I met with his widow and the children at the memorial service that took place several days later.

It was the best and worst of times.  We had profound problems comforting those grieving about the loss of loved ones.  Dr. Brent Pawlecki, then our Associate Medical Director, took the initiative to create a compassion center at our Midtown New York offices and staff it for several weeks to comfort not only our employees, who had lost colleagues, but their families and our customers, who had also lost colleagues.  His efforts were recognized and celebrated in an NBC special report a few days after 9/11.

We also had to locate our missing employees, which was more difficult than it first appeared, because many did not have cell phones or dedicated land lines, and lived in remote parts of New York and its suburbs. The surest sign that the four employees lost their lives occurred when they failed to come in on Friday, September 14, to collect their paychecks.  One of our top-rated sales professionals was scheduled to visit a client on an upper floor of one of the buildings, and we feared that he had lost his life when we did not hear from him later that day.  We were relieved when his manager found him at home the next day.  He had cancelled the appointment the morning of September 11 because of a dental emergency.

We had challenges getting remote employees paid all over the country, because the airplanes that normally transported their checks were unable to fly to their destinations between September 11 and 17. We knew that many of our employees lived from paycheck to paycheck, so getting them paid on them was critical. We had employees stranded all over the world who could not get back to the United States, and some who drove from as far away as San Diego within the United States to return to their homes in Connecticut.

We had to deal with the abject fear our employees felt about the future, to enable us to keep doing our business.  We came through all of this stronger, more united, and more confident of our ability to cope with crises, which turned out to be important, given the fact that the anthrax bioterrorism crisis hit us a few weeks later and preoccupied us during October and early November, 2001.

Several permanent changes happened to our business and our industry as a result of both 9/11 and the anthrax crisis that followed it:

• We communicated more frequently and in more depth with employees, because we learned about the value of frequent communications as a result of the daily voicemails we released during these crises.  We created a weekly Power Talk process in early 2002. Through it, we delivered a 4-minute message on a subject of interest every week.  Initially, I delivered every message, but over the years, we had different executives deliver messages of broad importance to the company.  Emails are very powerful communications tools as well, so we took the same message and emailed it simultaneously to employees on our email system.  We never forgot that our intensive communications processes helped us weather what could have been a devastating set of crises.
• We developed a sophisticated crisis management capability to deal not only with terrorist events and reputational risk issues like anthrax, but also with hurricanes, floods, earthquakes, and other natural disasters.  That capability was tested and improved upon many times, with such events as the 2003 Northeastern U.S. power outage, the 2004 Tsunami, and, obviously, the most challenging event, Hurricane Katrina in 2005.
• We had created a charitable foundation to provide temporary assistance for employees devastated by Hurricane Andrew in 1993.  We replenished that Foundation’s assets, which came in very handy in 2005, when we had to help dozens of employees affected by Hurricane Katrina.
• We recognized that, in times of disaster, traditional communication channels break down rapidly.  Landlines become harder to use, especially toll-free lines; cell phone systems become unusable; Internet service via email becomes harder to us.  Face-to-face communications become more difficult. We even experimented with walkie-talkies in offices likely to have hurricane-driven evacuations.  We also found that a toll-free number got overloaded, so we offered an additional toll line for employees to get through to us.
• As mailing industry leaders, the CEOs of the major companies came together in the Fall of 2001 to request that Congress assist the Postal Service because of the huge losses it experienced both during the aftermath of 9/11 and the anthrax crisis.  The unified industry became a significant advocacy force for comprehensive postal reform that occurred five years later.
• The Postal Service had used commercial aircraft to deliver mail long distances.  When commercial air travel was suspended for six days, the Postal Service decided to enter into a partnership with FedEx to have FedEx use its planes to do long haul mail transport, which was more reliable and secure. The partnership became a model for other partnership relationships into which the Postal Service entered over the past decade, and which helped it immensely.
• Pitney Bowes and other companies started to enhance their risk management processes to address a broader range of risks and opportunities.  We became far more systematic in assessing reputational, political and environmental risks.

Most of all, 9/11 was a time in which everyone pulled together and got out of their siloes and parochial views of the world.  They thought of themselves in terms of what was needed to achieve the greater good. They rose to the highest levels of compassion and love.

We need to find a way to recreate that feeling without another tragedy like 9/11.