Question: What existing national healthcare models do you admire?
David Goldhill: I think the most interesting case study is Singapore, which has similar levels of income. Obviously [it is] a lot smaller from both a geographical and population point of view, but is spending under 4% of its GDP on healthcare, has a full national safety net, scores much higher than we do on almost any measure of care, and delivers very high tech care. Singapore has a parallel government and consumer based system, but the consumer-based system is genuinely consumer-based. And I think there offers some promise there. I understand as well that the first studies of how health savings accounts with high deductible insurance policies affect people’s choices of care have proved quite positive. Have proved there is a reduction of costs, a greater sensitivity to price without give up in some of the important measures of health. It may be too early to know. And there is a lot of resistance, I should point out, to that working. A lot of people, who are employed in the healthcare industry either as providers or as experts, don’t want to see that work, of course, because it does put pressure on prices. And it also puts pressure on one of the key elements of the consensus, which is that all healthcare is needed.
Question: Who has influenced your views on healthcare?
David Goldhill: I was very influenced by a book written by Shannon Brownlee called Overtreated, in which she makes an interesting argument that a substantial amount of American healthcare is excessive and wasteful, some of it for familiar reasons relating to defensive medicine liability, but a lot of it because there is a lack of choice in the system. One of the elements she adds that I think is most interesting and makes the book really worth thinking about, is that we think of this as a financial waste, but it’s also a medical issue. There’s not a single procedure in healthcare, not a single drug, not a single test that doesn’t involve some cost to your health. Whether it’s the low percentage of disastrous negative side effects that go with almost every procedure or test, or whether it’s the regular exposure to radiation we have now from all the MRI’s and that source that we get, and her point, which I think is interesting, is that – and she has a very different approach by the way to how she would fix it than I do, but I think her basic findings that there is an enormous amount of waste in the system and that a lot of the structural issues make it, wasted care, an actual too much excessive care, is something that is going to have to be addressed by anything that’s adopted that hopes to not, again, not just address pricing, but also address quality. There is real resistance to that concept that some healthcare may be negative. And I think we all know from our own lives but some healthcare is negative. There are some pills we think to ourselves, I'm not sure that’s really worth it. There is some tests we think, all right, if I took that test and found out I have a greater propensity to something, nothing changes. So why am I exposing myself to the x-ray's and having to test? And I think there's a question of how these HSA's combined with high deductible policies may get at that. I actually think the author of the book would disagree that they help, but there may be some evidence that they do.
Recorded on: September 11, 2009