Downsizing is not merely letting workers go. Downsizing means streamlining organizational processes and reducing the input costs of an enterprise. For example, in today's environment of corporate downsizing, sending jobs oversees to be filled by cheaper workers in developing nations has enabled corporations to cut costs. This form of downsizing maximizes the corporation's ability to use globalization to a cost and strategic advantage by reducing the input costs of labor, land, and the overhead costs of running a facility in the United States. Making use of low-wage Chinese laborers in manufacturing facilities and English-speaking Indian citizens at call centers in offshore locations has become routine. But what about downsizing on the 'demand' side of things? This may sound impossible -- but not for health insurance companies.

Blue Cross & Blue Shield noticed the phenomenon of 'medical tourism,' or individuals going abroad for cheaper medical care, and decided that it was missing out on a potential profit boom. In the future, Blue Cross may begin pressuring its policyholders to travel abroad to nations where medical costs are less expensive. "Getting covered employees to leave the U.S. won't be that hard...An insurance company could waive all deductibles and co-pays, offer to cover travel costs for the patient and family members, even throw in a cash incentive, and still save tens of thousands of dollars," enthused one of its vice-presidents (Einhorn 2008). "Americans haven't come to grips with having their heart surgery in Thailand," admitted the American CEO of one of the Blue Cross affiliate hospitals abroad, "but that will change" (Einhorn 2008).

What this will also change, undeniably, is the corporate culture of the Blue Cross organization, as it must establish relationships with nations as diverse as Turkey, Thailand, and Ireland. The insurer argues that "foreign hospitals in such arrangements are typically approved by Joint Commission International, part of the same nonprofit organization that accredits American hospitals," but one can only wonder if this is yet another example of how profits are taking a priority over consumer health and comfort at one of the nation's major insurers. Interestingly, at Blue Cross, no doctors 'weighed in' on the issue, only executives were quoted in the BusinessWeek article on the new policy, and the implication was that this was a cost-cutting, managerial decision, rather than one rooted in any concern about expanding patient choice or improving care.