If you are short on examples of what’s wrong with the health care debate, consider David Goldhill, CEO of GSN, an entertainment media company owned by DirecTV and Sony. This self-styled deep thinker is certain – absolutely and impenetrably certain – that the whole problem with the health care system is that his employees have no clue what it costs.
In his most recent diatribe, an NYT OP ed piece entitled The Health Benefits That Cut Your Pay, Goldhill proclaims with gimlet-eyed precision that health benefits are nothing more to him than a bit of compensation, a bit that is inexorably taking money that–he doesn’t quite swear to this point–he’d otherwise be paying in cash. Ignorance is the problem, he says, so deep that even the disclosure of actual money spent on benefits is meaningless:
But even with greater awareness, many Americans still might not understand that the largest effect of the cost of our health care system is to reduce the amount of money they actually take home.How arch. Even with all the information we’re too stupid to figure it out.
He then goes on to dismiss considerations like social equity, an aging population bubble (the boomers, a cohort to which I arrived late and with little fanfare), the costs (and profits) of medical technology, single payer systems (only look good in comparison to our broken system), the tendency of players to game the system and so on. Ignorance, it turns out is not just a matter of what you know – you are apparently ignorant if you are not on the frontline of actually paying the bills.
But wait, there’s more! He has a solution:
Let’s give every American health insurance, but only for truly rare, major and unpredictable illnesses. ... eventually the most routine and expected medical treatments, from checkups and minor illnesses all the way to common chronic conditions and expected end-of-life care, would be funded from our individual health savings; only the most major needs — for example, cancer, stroke and trauma — would be paid out of insurance.Ummm how does that work?
Defining insurable events more narrowly and enabling Americans to use the premium savings to build health savings would reduce the distortions inherent in our insurance approach.Oh, that’s right, we’re going to save all that extra money you are going to pay us just in case our death is a little costly.
Poor man. Needs medical help immediately. My diagnosis: CEO Derangement Syndrome.
Delusion #1: Buying Health Care is No Different than other consumer purchases. His contention is summarized thus:
We manage health care as if our needs were always urgent and unpredictable, ignoring how deeply this industry is integrated into our lives, with a vast amount of care now devoted to treating ongoing, chronic conditions.So, I take it that treating ongoing, chronic conditions is somehow wrong; or a least it is wrong if the costs are not directly taken from your purse. Obviously, this point is a stalking horse for the fact-free conviction that a significant, if not sole, reason for medical spending is a failure to take responsibility for yourself. In his opinion (what medical school did you attend, Mr. Goldhill?) cancer, stroke and trauma (not heart disease? how about autoimmune disorders?) are sufficiently “unpredictable” to be worthy of economic pooling in some form. God help you if your child is born with Cystic Fibrosis.
Its easier to live in a fact-free world than the real world. There is a reason why medical events and outcomes are discussed in terms of probabilities: medicine is not an algebraic science, and biology is adaptive and dynamic. So, you could maintain a healthy weight, take drugs to control serum cholesterol, and still one day drop dead with a myocardial infarction. You can be overweight and completely disregard your health, and still live to a decent old age. It is not possible to know the future with certainty. It is not possible to act in a way the guarantees a desired medical outcome; at best you can play it as the odds suggest and hope you don’t get unlucky.
Purchasing a TV, automobile or internet services lacks one itsy, bitsy little trade-off that is unique to medicine: life and death. I dare Mr. Goldhill to face the 3 am call from the US Consulate in Kathmandu that I faced 14 years ago: a consular official [a shout-out to all US diplomatic staff worldwide – God bless you, you are the best] telling me that my mother–who was just traveling with a Yale Alumni tour group for God’s sake–was lying deathly ill with an unknown respiratory disease in a hospital where the only source of erythromycin–a common antibiotic–was a group of Canadian charity doctors. What would you say, on a salary of $60k, if you were told that medical evacuation was necessary and would cost $25,000 (credit card, please), and would only get her to a slightly more first world location, still half the planet away. You are not done spending yet, let me tell you. If Mr. Goldberg thinks that any normal person would abandon their mother to death if the resources could be found to fight back, then I pity his family.
I presume for Mr. Goldhill love has no power when money is at stake. I hope he did not breed.
Delusion #2: It’s possible for a simple middle class family to save enough.
To say that any member of the 1% has any clue about what it means to be at or near the median, is to put greater faith in empathy and imagination than is usually deserved. On the contrary, my friends, the only way Goldhill gets to his argument is through willful ignorance of the difference between his resources and those he grudgingly pays out to his employees. I suppose there is a certain irony to that since his accusation is that the rest of us are ignorant.
Even with insurance coverage, families go bankrupt because of uncovered medical costs all the time. So lets take away the coverage, but give them the money and tell them to save in case of medical expense. Well, Junior needs new shoes for the third time this year (when WILL those feet stop growing?), and the tires on our 7 year-old car are looking pretty bald, and oh, yeah, we gotta save for college and the goal posts keep receding. All of that is after the 40% or more of income that goes to housing, food and gas to get to work. Retirement? Don’t bet on it. Extra money? Let me see, what to do first.....
Let’s say that our hypothetical family is able to set aside at least some of that money just for medical expenses, maybe $5,000 per year. Sounds like a lot, but it isn’t.
As far as seeing your family doctor, if you are not treating a chronic condition in any one family member, you’ve got it covered. The routine, one-off treatments, vaccinations, etc. No Problem. But honestly, most people without any chronic conditions don’t even manage to exhaust their deductible in most years.
Let’s now assume one of your two point five children has asthma. Well, breathing is pretty fundamental to living so you have to treat it, and thankfully medicine has effective treatments that give most asthma sufferers (yes, I am one) a normal life. At a US pharmacy, those meds will run upwards of $500 month at full price; you can get that under $250 if you shop Canadian online pharmacies. Do the math: at minimum playing the role of the price-conscious consumer half of your savings in any given year are expended to treat one condition in one family member. If you can’t buy the same goods at better prices, your budget is blown. Oops.
A hospitalization, even a one-day stint in the out-patient ward for a routine but necessary bit of surgery, will generate bills well in excess of $20,000. How many years did it take to save enough to pay for that?
Apparently, GSN’s CEO is mathematically inept. His plan only works if you have a lot of resources to draw on. Its arithmetic, stupid.
Delusion #3: Retail Price Discovery and Competition Fixes the Problems.
If only it were a simple price/quality trade-off where most of the “quality” is perception instead of substance. Then its just Walmart vs. Neiman Marcus.
Only a few things consumers purchase have life or death implications (at least distantly):
a. Food - You die without it. However, food is plentiful in general (at least to us lucky duckies in the US) so long term costs (versus seasonal supply/demand) are primarily driven by production and transportation costs; seasonal supply variations allow consumers to optimize their diets by what is most readily available at a given time of year. At least in theory.
b. Housing – You gotta have something, but much depends on where you live. A tropical environment requires minimum shelter to survive; Minnesota, not so much. But even if you cannot move, you can still make choices related to “subjective quality” elements, such as the size and style of your home or the neighborhood you live in. With few exceptions, you won't die because you moved into a less expensive neighborhood.
C. Water – You die without it, and it is subject to seasonal and locational scarcity. There is a reason why water utilities are usually public and among the most heavily regulated.
Beyond that, the consumer always has the alternative of foregoing things that do not determine whether you live or die. Many people live without cars. Some live without clothes.
Without medicine you may die; or at least you may live in a state of misery or worse. You can’t move to slough off a disease (save environmentally related diseases, but even then moving is a difficult decision). You can’t permit (assuming you have an actual choice, which usually is not the case) a debilitating condition to make it impossible to earn a living. You have to act to avoid consequences that may be totally non-economic, or have economic consequences that transcend the cost of the care. When you enter the market for health care you are usually not free to back away, never mind the impossibility of adequately comparing services, providers and costs. Let’s face another fact, that all medical treatment is subject to the “shit happens” principle where things can go wrong and turn ugly without so much as a “by your leave.” While it is worthwhile pointing out that the lack of a meaningful cost/benefit relationships in health care costs is an indicator of the sickness of the system (in this respect, Mr. Goldhill is like every other stopped clock on the planet, and understands that the system is broken), most of us have neither the factual knowledge nor the training and experience that allows us to compare doctors and hospitals in the same way we compare banks. Actually, it apparently doesn’t work with banks either, but I digress.
That in the end, puts all the power in the hands of the health care vendor. Do you get it yet, Mr. Goldhill?
As has become so common in the 30+ years of right-wing political dominance, Goldhill’s position boils down to a factual delusion that is disingenuously promoted in the service of socializing costs and privatizing profits. His factual delusion is that putting money in consumer hands and insisting that they make text-book cost/benefit judgments is the magic sauce that solves all the problems of 21st century health care. The cost he wishes to socialize* is his employee’s health care, a cost he just does not approve of. How employee health plays into his bottom line is ignored; any business that does not measurably benefit from a healthy workforce has probably already reduced employment to disposable bits, done even more cheaply in India and China. The path to profit is always clear, especially when it means running right over someone else. This has become a habit of mind and action among the one-percent that we must crush; or as a free society we will die.
Every time US industry objects of the cost of a regulation–and it really doesn’t make much difference if the regulation is environmental or financial–what it is really objecting to is the ending of the free ride. When a company dumps waste into the air or a stream, they are socializing the waste disposal (and environmental poisoning) problem to maximize the profit flow to their pockets. That the waste is a direct cost of their operations seems to go over their head as too complex a concept. Corporate freeloading of this sort is far more common than welfare queens.
Health care is a cost of having human employees. Yes, it has gotten expensive, especially in relation to stagnant middle-class wages. Yes, we have a serious cost-containment problem. Yet, I observe that Goldhill and others as employers just throw up their hands rather than using their own market power to push back against excess costs being levied by insurers and profiteers. I guess market mechanisms really dont work in this realm.
While it was cheap and (relatively speaking) ineffective, everyone was happy to throw it into the compensation package. Now that it is expensive (and much more effective), Goldhill and others don’t want to pay. Of course we know we (the middle class workers) are paying for it all–we have to show up at work, rain or shine, to get it. It’s no great privilege working for Scrooges like you, sir, especially when you could care less whether we are supporting sick family members.
Very well then. Here’s the trade off: we will treat your income with the same respect you treat our lives. None. Get out you checkbook, now its really going to cost you.
* socialize” in this context is not used to mean “socialism.” Rather, it denotes a process where a private expense is evaded so that it randomly lands on some or all other members of the society. Meanwhile, in profit making activities expense avoidance flows right to the bottom line private profit of the company.
Feb 22, 2013 Update:
Goldhill showed up on The Colbert Report this week, promoting his new book-length justification for exacerbating the haves/have not divide in healthcare. Check out the clip and notice how he slithers around the truth of his ideas:
The week has not been without professional refutation of Goldhill's thinking. Steven Brill, whose latest Time cover story rips open the myths about any relationship between costs and medical billing, showed up on The Daily Show: