State capacity and keeping promises
How it affects healthcare
This newsletter is mostly about healthcare, policy, tech, and the intersections between those topics. But I recently wrote about PR in the age of AI for Chrissy Farr’s Second Opinion newsletter. If you’re interested in PR/comms and how I think healthcare founders should be thinking about that, check it out. And if you’re interested in hearing more, reach out to me at oliviakosloff@gmail.com. I’m doing a few consulting projects here and there, and I’d love to talk about it.
Now for this week’s newsletter.
Lately I’ve been reading and thinking about state capacity — or the ability of the government to fulfill its policy promises — in terms of healthcare. As I wrote in my first newsletter back:
I’m convinced at least 60% of current issues in healthcare trace back to a lack of state capacity. Poor access to care in rural areas? State capacity challenge. Not enough innovation in antibiotics? State capacity challenge. Pharmaceutical shortages? State capacity challenge.
Then, in the early morning hours of the Fourth of July, communities along the Guadalupe River in central Texas were deluged with flood waters. I heard about it early, from our neighborhood Facebook group, because we live less than two hours from the epicenter of the flooding. The river rose so high, so fast, that it knocked one Texas Monthly writer’s family home off its concrete stilts, a rise of more than 20 feet, taking the life of his twenty-month-old nephew in the process.
The natural human response is to want to help, and indeed many people have volunteered to help search for the missing. But the official government sources of help have reportedly fallen short — of all stupid things, because of a failure to renew the contract for the call center.
After a disaster, the Federal Emergency Management Agency (FEMA) traditionally goes door-to-door in affected communities, helping survivors apply for assistance. In 2024, though, a FEMA employee was fired for instructing other employees not to approach homes with Trump signs in the front yard. After this (and the cuts because of DOGE), the Trump administration cut FEMA funding, including the door-to-door program. Now survivors on the ground can go to assistance centers nearby to apply for aid, but it requires an extra step of getting to the assistance center.
Another way for survivors to get access to aid is to call FEMA. After disasters, the number of these calls reach into the thousands or tens of thousands, so FEMA contracts with call center providers to handle the volume. Except Department of Homeland Security head Kristi Noem didn’t renew the contracts (which were apparently up, in a moment of terrible timing, the day after the July 4 floods) — and thousands of calls reportedly went unanswered.
I’ve been thinking about that in terms of another story, from ProPublica, about how federal vouchers for free therapy for Utah dairy farmers were accepted (and ran out) much faster than anticipated.
This is a lot of lead-in to say that I’ve been thinking about state capacity in the context of what we owe fellow Americans after a disaster, whether that disaster is acute or chronic. Jen Pahlka, the founder of Code for America, has written about state capacity and how it limits the government’s ability to fulfill its legislated policy goals: once a policy exists, can the government keep up its end of the bargain? Put another way, is the government actually working? (If the goal of government is to enable individuals’ lives, not pass more laws to sustain itself.)
This is a healthcare newsletter, but I’m increasingly convinced that this is a vital component that’s missing in healthcare right now too.
I think we’re in a new era of healthcare. I’m sure there’s a better way to put it, but I don’t think either political party has an answer for the challenges that the system, and the people on the ground, are facing right now. The uninsured rate is lower than ever but things still feel dysfunctional. Meanwhile, Medicare for All has fallen by the wayside as a policy option because — well, we don’t have the capacity to hand out vouchers to Utah dairy farmers or answer phones for Texas flood victims, so why would we have the capacity to administer healthcare for nearly 350 million Americans?
I’m working on a newsletter that goes deeper into what’s going on with rural hospitals (which surprisingly, isn’t all bad!). But the story of healthcare in America is also a story of FEMA not picking up the phones when people call, or dairy farmers looking for vouchers that used to exist but then the money ran out. And the new era of policy has to address that, or else we’re just spinning in circles.