The latest salvo in a series of books seeking solutions to reform health care comes from American businessman David Goldhill, president and chief executive officer of the cable network GSN.
In a 2008 Atlantic magazine article, Goldhill chronicled his father’s death from an infection acquired after five weeks of hospitalization in the intensive-care unit of one of New York City’s leading hospitals. Frustrated by this tragedy, Goldhill was inspired to trace the evolution of the daunting problems plaguing the financing and delivery of care.
Applying his business background, Goldhill deftly dissects the peculiar origins of health care financing in America. In doing so, he draws an analogy between our system and the Galapagos Islands. American health care, he says, is disconnected from reality (as opposed to a mainland) by the lack of natural-selection pressures to evolve, particularly from a lack of consumer input into the pricing and assessment of the quality of care delivered.
His book dismantles myths, challenges assumptions, explains the unintended consequences of policy mandates over the decades and searches for solutions to tow our health care system back into the “mainland” of sanity.
Goldhill is convinced that the solution is a balance of health accounts, health loans and a mandatory high-deductible catastrophic insurance program. He doubts the Affordable Care Act will solve our problems, speculating extensively throughout the book that it may actually worsen the crisis by simply propping up a collapsing system.
Ultimately, the book suffers from blind spots similar to those of many previous books on this topic. It works around the edges, seeking indirect solutions without fully attacking the central challenges. Goldhill’s father’s bills were paid for by the same Medicare system that he criticizes, referring to it, along with Medicaid and the private insurance industry, as the surrogates that are fueling the crisis in health care.
I understand how Goldhill feels. Four years ago, my 69-year-old mother was admitted to a hospital through the emergency room. The plan was for her to start receiving blood-thinning medications to prevent a blood clot that might cause a stroke, and to undergo procedures the next day (a Friday), to correct her abnormal heart rhythm. A hospital bed was unavailable, so she was “boarded” and spent the entire night sleeping on a gurney in the emergency room.
Only when other patients had been discharged from the hospital on Friday was my mother admitted to a regular hospital bed. Because of the delay, her planned procedures were postponed until Monday. On Saturday, she suffered a severe stroke that would claim her life. She had not received the blood thinners as planned while she spent the night in the emergency room. Key treatments are often missed while patients are boarded this way.
My mother’s story highlights how perverse business incentives lead to undesirable compromises in the quality of care, for it is business forces that lead hospitals to allocate precious beds and resources in this illogical manner, and to board patients in the emergency department.
The primary limitation of Goldhill’s solution is that business itself also needs to be reformed, as greed and profiteering plague both our financial sector and its intrusion into medicine.
He does not discuss the business factors that spurred the development of modern financing, and how business has profited enormously in perpetuating this flawed construct.
He falls into the trap of using failed business arguments to justify repeating the mistakes of the past, applying the same arcane arguments used in the 1940s to expand an employer-based health care system, and in 1965 to introduce Medicare and Medicaid. To simply reuse these failed business principles and arguments to reform health care in 2012 is to repeat the mistakes of the past.
Goldhill comes close to the real solution when he raises the topic of rationing, but he stops short. Business forces contributed to my mother’s death, and business forces are what need to be dismantled in health care, as they drive the flawed system. It is unclear to me how the changes Goldhill suggests would have prevented the deaths of either of our parents.
John Maa is an assistant professor of surgery at the University of California-