(From Hospitals and Health Networks Online, January 15, 2008)

The attempt to create the Next Health Care faces a much greater threat than politics.

[The growing influence of money in politics and regulation is so pervasive that it drowns out most real discussion of practical solutions for the good of the whole system, and for all of us as citizens.]

We all want to change health care. While the national debate focuses on how to pay for health care for everyone—a goal regularly approved by a majority in almost every public opinion poll since 1948—much of the effort within the industry focuses on changing processes to make health care better, faster, cheaper, more efficient, more available and more effective. But this great effort to build the Next Health Care faces a growing and seemingly immovable obstacle at the political level.

The obstacle is not liberal or conservative, nor is it Democratic or Republican. It is simply the growing influence of money in politics and regulation, an influence so pervasive that it drowns out most real discussion of practical solutions for the good of the whole system, and for all of us as citizens. The problem is most vivid in the United States, but it is operating with increasing force in most national systems, because its roots are deeper and wider than national politics.

Market Competition

Over the last decade, a number of books by authors as diverse as Robert Bork (Slouching Toward Gomorrah, 1997), Robert Kuttner (Everything For Sale, 1997), Lou Dobbs (War on the Middle Class, 2006) and Robert Reich have described the problem of money and influence.

Reich’s Supercapitalism: The Transformation of Business, Democracy, and Everyday Life (New York, Alfred A. Knopf, 2007), especially, is no partisan diatribe. Reich shows how the problem has grown through administrations and Congresses of either party and of all persuasions. It is not that corporations have become more greedy, or have turned evil in recent decades. They are simply doing what corporations are built to do, that is, look out for the interests of their shareholders.

But the problem is simpler and more intractable than that: Over recent decades, the growth in new communications and transportation technologies, new fluidity of capital and other largely technical changes have greatly increased competition in almost all industries, through globalization, automation and deregulation. This has benefited us as both consumers and investors, as we shop for the best deal at Wal-Mart or Nieman Marcus, and as we shift our investments from one mutual fund to another with a mouse click. But it has not benefited us as citizens.

Era of the Lobbyist

In the fever of the new era, competition spreads farther into every part of civic life. The election cycle, the courts, regulatory and legislative processes—all become arenas of competition between economic interests. Corporations cannot avoid being drawn into the battle at all levels. Google, for instance, with its slogan “Don’t be evil,” tried to stay apart from the fray and had only a token presence in Washington. Once it went public in 2004, however, it began pouring money into both Brussels and Washington, even opening its own office complex in Washington’s Penn Quarter, to stave off the competition.

In 2006, for instance, Microsoft prepared to deploy Internet Explorer 7 with a built-in search engine—Microsoft’s Live Search, not Google. Google deployed lawyers and lobbyists to convince the Justice Department that this was an antitrust problem. Microsoft (already stung by antitrust fights in both Washington and Brussels) backed down a bit: In the event, only IE7 on brand-new machines carried Microsoft Live Search as the default. As The New York Times quoted lobbyist Lauren Maddox, “The policy process is an extension of the market battlefield.”

This competition tends to drown out the voices of citizens concerned about issues that affect all of us. The lobbyist becomes a central figure in civic life. Ten times as many registered lobbyists roamed the halls of government in Washington in 2005 as in 1975. Five times as many lawyers were registered to the DC bar in 2004 as in 1972. What it costs you to engage a Washington lobbying firm in your behalf has doubled just since 1995. The average opening salary of a congressional staffer who becomes a lobbyist has mushroomed to $500,000; of a former congressional committee chairman, to $2 million.

Influencing government rivals government as the biggest business in Washington. Increasingly, actual public discussion becomes limited to “hot button” issues such as gay marriage and abortion (around which there are few, if any, economic interests), and to generalities about war and terrorism, environmentalism and global warming, while the details behind these generalities, and the real nuts-and-bolts issues that affect our daily lives as citizens, are increasingly decided under the radar, in contests between corporations.

Market-Driven Medicine

In health care, this phenomenon extends into scientific papers, the shape and development processes of the biotech industry, the strategies of the pharmaceutical industry, the committees and grant-making processes of the National Institutes of Health (NIH), the rule-making and drug approval processes of the Food and Drug Administration, and the regulatory processes of the Centers for Medicare & Medicaid Services. In 2004, for instance, a series of congressional hearings and an award-winning series of investigative articles in the Los Angeles Times detailed the intricate (and often unreported) interweaving of pharmaceutical companies’ consulting payments to NIH staffers and members of key NIH committees.

Al Gore, given a Nobel Prize for his attempts to save the world from global warming, was in the headlines in 1999 for a different and less honorable reason: his threats of trade sanctions against South Africa for attempting to compel generic licensing of AIDS drugs from U.S.-based pharmaceutical companies. At the time, he was taking substantial campaign contributions from those very companies.

The imbroglios of recent years over allowing generic drugs, and over importing drugs into the United States from Canada and elsewhere, have been framed as public discussions over the right way to provide health care, but were actually decided in legal and regulatory warfare between different parts of the pharmaceutical industry, armed with lawyers and lobbyists. Examples teem in every daily paper, from orthopedic surgeons battling to make sure that Medicare continues to fund back surgery that has been shown to be ineffective, to the huge squabbles before and after the passage of the Medicare drug benefit over which drugs would be covered. More and more of the details of how we run health care becomes dictated by corporate battles in Washington.

Fighting the Good Fight

What do we do with this thought? The fact that such economic competition is pernicious and destructive of democracy, and that hospitals and health systems tend to see themselves as the good guys, does not at all exempt us from jumping into the fray. Quite the contrary. In all the struggles with state and federal governments, with pharmaceutical companies, with health plans, with employers, and with organizations like WalMart eager to enter the health care field, it means that we need to gather our resources—as individual hospitals, as larger systems, as state associations and as an industry—and fight the good fight in every arena.

But it means something more profound. Despite the “mission, vision and values” that we thrash out so earnestly in board retreats and enshrine on plaques, we can easily be seen by our communities as just another economic interest, looking out for its own good. In most communities, a hospital or hospital system is the largest or one of the largest employers, a vast, intricate, powerful and seemingly impenetrable entity—and one that is of great importance to the citizens. This sense has greatly increased as more hospitals have linked up in larger networks and chains. We can no longer presume the trust of our citizens.

We have two things going for us: One is the very fact that we are so important to our constituents. They may or may not care for the way we are managing this great community asset, but they care very much about the survival and vigor of that asset. The other is that, more than any other entity in health care, our interests as institutions really do align, most of the time, with those of our constituents.

So what do we do, in this atmosphere of febrile competition? We focus on four things, in the following priority:

  1. Align our strategies truly with the needs of our constituents. Jettison unceremoniously any strategies, tactics or corporate policies that help the institution without really adding value to the lives of the citizens.
  2. Fight the fight. Use every tool and resource that we have to represent the health and health care needs of our constituents well and fiercely.
  3. Examine the strategies and processes that we use to provide that health care, continually working toward providing it better, faster and cheaper, so that citizens feel that they can trust us with their resources, that we do the job well—and so that we can gain maneuvering room by bringing our costs below the reimbursement level.
  4. Communicate constantly and well, getting the story to citizens, to government on all levels, to employers, to legislatures, while understanding that this is the final step, not the first. People who work at untrusted institutions almost invariably believe that “We just have to tell our story better.” But lipstick on a pig fools no one. Communities are rarely fundamentally wrong over a long period of time about who we are and how well we are doing our jobs. Actually, they usually get it mostly right. We need to be better first, and only then make a better story out of it, and better communicate that story.

This atmosphere of fevered corporate competition is unlikely to abate anytime soon. It is a long-term trend, rooted in deep, structural changes in the national and global economy. The coming years and decades will likely see an intensification of this trend. We must bring to the task of reforming health care not only the Buddha’s compassion and Baryshnikov’s grace, but also the ferocious heart of the warrior.