As a person who majored in political science and has been engaged actively in public
The title of this blog is meant to provoke thinking about a fundamental dilemma that elected officials in any democracy face: when serving the public broadly means that jobs of a small number of people could disappear, what happens?
We have known for a long time that government is more responsive to a well-organized single-issue constituency, even if the vast majority of voters would oppose the position the single-issue group is taking. For example, that is why government officials have consistently been reluctant to take on the National Rifle Association, even though the vast majority of Americans favor a more aggressive regulation of guns than is the case today. I am not making a value judgment about this issue, other than to say that elected officials think of the electorate as a collection of well-organized, passionate special interest groups than they do a mass of voters to which they have to respond.
We also know that elected officials and the media are much more likely to respond to a single dramatic event or story than they are to a gradual, broad-based, statistically significant trend, even if the broad trend has profound societal impact. For example, although the statistical evidence of the deterioration of our transportation infrastructure is overwhelming and has been for several decades, it took a dramatic event, the collapse of the bridge on I-35 across the Mississippi River between Minneapolis and St. Paul to get Minnesota to act on its infrastructure problems.
Finally, we know that closing or shrinking a major community facility, even one which has outlived its usefulness, is extremely difficult. That is why it is very difficult to close military bases and post offices.
Put all three of these observations together, and it becomes clear that it will be extremely difficult to take the steps that would flow logically from true health care payment and delivery reform and from meaningful prevention initiatives. If government officials are successful in developing a healthier population that uses the health care system less often, and a health care delivery model that is smaller and more efficient, the logical consequence is that much of the capacity we have today will be unneeded.
However, the three issues will come into play:
- Unionized health care workers, physicians trade groups, hospital associations, and pharmaceutical companies, although they represent a small part of the voting population, are single-minded in protecting and expanding what they have.
- Closing a badly performing hospital produces benefits that are hard to dramatize, even though the whole population will get better care. The story of a hospital worker who may be a single parent who loses her job is a highly visible and dramatic event.
- Closing a hospital in a community is harder than closing a military base or a post office, because it is a vital resource.
What do we do about this set of dilemmas?
- Acknowledge the problem. When there are debates about the proper payment and delivery architecture of the health care system, let’s recognize what’s really at issue, and accept the fact that we need to think of transition plans. Let’s cut through the rhetoric and get to the real issues.
- Take advantage of the natural personnel attrition that takes place in any marketplace. The U.S. Postal Service has shrunk its employment significantly since 1996 and has improved its quality of service. Trying to recruit more people into health care other than making sure we do not drop below critical mass is not a good decision.
- Make changes in such a way that they do not radically and abruptly disadvantage any existing interest group.
- Get the institution to redefine its mission and find other markets for its services. For example, the highest and best use of a hospital may be to provide remote telemedicine services to smaller, less equipped facilities in rural areas here and abroad.
- Find a higher and better use for the capacity that would otherwise be closed, and think through how those who lose their jobs can be redeployed.
This last point deserves a little more explanation. Health care facilities are like any other organized activity: they are a collection of assets that have been assembled to accomplish specific tasks and purposes. Those assets have the potential to be repurposed and other assets can be substituted in their place. They also have far more potential marketing and delivery reach because of the Internet.
The best example of which I am familiar is the closure of St. Joseph’s Hospital in Stamford, Connecticut, and the construction of a wellness center on the same site back in the late 1990’s. To accomplish this closure was not simple, because many stakeholders had to buy into the opportunity. Moreover, getting the wellness center in place required significant philanthropic contributions, a process in which I assisted. However, the end result was the creation of a more appropriate, more modern, and higher value community resource than the hospital.
This kind of process will have to be repeated in thousands of cases around the United States if we are going to bend the health care cost curve and migrate to a higher quality health care system.