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'Catastrophic Care' In America's Health System


This is WEEKEND EDITION from NPR News. I'm Scott Simon. David Goldhill's been called one of the country's most original thinkers about health care, and he is not a physician, academic or health care executive. He's president of the Game Show Network. After his father died in 2007 of infections that he contracted after surgery in a famous New York hospital, which nevertheless charged hundreds of thousands of dollars for their care, Mr. Goldhill was moved to try to rethink medicine in America. He wrote an influential article; it became a best-selling book: "Catastrophic Care: Why Everything We Think We Know About Health Care Is Wrong." It has been praised for bringing fresh thinking into the arena and it's just been published in paperback. David Goldhill joined us from New York. And we asked how he viewed the rollout, so far, of the Affordable Care Act.

DAVID GOLDHILL: The problem is the actual legislation is a very complex series of incentives and penalties and subsidies sitting on top of an already-existing complex system. And really, the honest thing to say is we can't be completely sure how this will turn out. I wrote in my book, I thought there was as good a chance that the number of uninsured increased under the Affordable Care Act as declined, something a lot of people found surprising.

SIMON: And let me get you to follow up on that. Why?

GOLDHILL: The Affordable Care Act is a very big and complex bill. Much of it seems to make health insurance more affordable to people. There are other provisions that will make health insurance less affordable to people, and frankly less interesting and valuable for companies to give. You know, what we're seeing now is an attempt to make health insurance not just more universal but also more comprehensive, cover more for everybody. Well, a lot of people in a lot of jobs could afford health insurance only because it covered less - covered only the catastrophes and the disasters and not the more routine care. So, if you've got a job that pays $30,000, can you really burden that job with comprehensive insurance that for a family might cost 14, 15, 16 thousand dollars? It's one thing for a high-paid executive or even an upper-middle-class person to bear that kind of expense for comprehensive health insurance, but do we really expect employers of lower-middle-income people to bear that? And if they choose not to - and I suspect many won't - and put their employees on the exchange, the employees may decide themselves that, you know what, this level of coverage is not necessary for me compared to all the other things in life I want to buy or need for my family.

SIMON: Should the president have said if you like your medical plan, if you like your doctor, keep 'em?

GOLDHILL: Well, he shouldn't have said that even before proposing the Affordable Care Act. It wasn't even true before the act, right? We were already seeing massive disruption in the health insurance industry. And as long as health care gets more expensive without the normal breaks on price and quality and value that we see in everything else, you will not be able to keep your health insurance plan. It will be endlessly changing to compensate for expense and demand and all the rest. So, it was a false statement even without the Affordable Care Act. I actually think the president should have said if you are happy with your health insurance plan, you don't know what it costs, and that would have been an honest statement that I think would have gotten the discussion on a completely different track.

SIMON: If the Affordable Care Act winds up covering more people - I'm not even going to say, despite the name, making care more affordable - but if it winds up covering more people, isn't that good for the country?

GOLDHILL: It may well wind up being good for the country. It depends on the kind of care they get. I think if you look at the Medicare program, for example, you'll see the sort of double-edged sword of the sort of unique American approach to health care, which is to say that anything could be covered. If you look at what we see amongst our seniors, we see an enormous amount of excess care being performed. And some of it quite extreme. I don't know if you're aware, but there's a study that says one out of every five Medicare patients over 90 has surgery in the year of their death. And there's a lot of literature that suggests that people over 90 should almost never be getting surgery for anything - not 'cause of cost; forget about money - for their health. When you take money out of the equation, one of the things you notice about our health care system is it performs tons of care on people. Well, all health care isn't the same. And, you know, a system that drives excess care and care that is of marginal benefit to the patient is of health harm to the patient. The average senior in good or excellent health is spending $6,000 a year on health care in the Medicare system. I'm not sure that's good for them, and that's a fear we need to have in our current approach.

SIMON: David Goldhill, president of the Game Show Network and health care thinker. His book, "Catastrophic Care: Why Everything We Think We Know About Healthcare Is Wrong," has just come out in paperback. Thanks so much for being with us.

GOLDHILL: Thank you, Scott. Transcript provided by NPR, Copyright NPR.