Catastrophic Care Review
I really wanted to like this book, but I didn’t. It succeeds in theory and fails in practice due to the overwhelming evidence organized against it. It viciously and repeatedly attacks the same issues to the point of exhaustion and provides levels of details that are not only unnecessary but sometimes misleading. The worst part is that the first 252 pages of ranting aren’t wrong, but they are so unnecessary as to explain the cause and symptoms of the system. When David does finally dig into the details of the solution to healthcare communism, it lacks the organization and thoughtfulness required to support an idea so radically opposed to our current direction of policy and care. I was so thoroughly disappointed in his approach that I’ll try to dissect it below so the arguments are more accessible. This whole book could have been condensed into a 1000-word blog post or 16 minute TED talk which would have gotten an A from me, but I’d give it an F in communicating the way it did, so this book gets a C overall.
Technicalities
I dislike sloppy writing. Writing organization and consistency is a key part of persuasion and enjoyment for me. This book was so clearly cobbled together I’d like to propose a reason for its existence: every one of David’s friends was so sick of hearing him rant on the problems in health care that he had to find a new outlet, and over a few years he finally managed to put enough words on a page that made it attractive to bind and sell. David’s passion for healthcare and business clearly shines through what is a mess of full-page footnotes, inconsistent dates (is it 2010 right after the ACA passes or is it 2012?), and a litany of appendices that have only a passing relationship with the subject material. I might be a stickler for these things, but it does change the digestibility of the material and what the reader walks away with.
I hope that his source material is better organized or that he’s a more structured communicator in-person because I love the content he presents, but his skills as a writer leave much of the most interesting details for such a technical matter unaddressed. It’s unsurprising that Malcolm Gladwell would write a review for this book, as it suffers from the same gaping holes that his pop psych books use to sell unsound but appealing ideas. As a supposed bridge book from healthcare policy to an every-man pulp, I don’t know how this got any acclaim other than for its friendly anecdotes. He creates his own lexicon and applies mixed metaphors in order to talk down to the reader at multiple points. In researching this book I’ve found more illuminating reviews and talks than the entirety of this book provides.
On Revolution
In trying to frame a revolutionary concept as balanced, I think David does his position a disservice. Instead of trying to evangelize his gospel to produce some believers to change the discussion in healthcare, he wallows in the weeds trying to provide hard evidence and logic based reasoning to our way out of a problem that came about because we didn’t do the math and behavioral economics research right in the first place. Sadly, logic is not rhetoric and has difficulty convincing anyone who didn’t already agree with you. No number of facts are going to convince someone that they should pay more for something they feel they are getting for free. Repetitiveness does have a place in explaining difficult to comprehend topics, but problems in healthcare aren’t hard to understand on the surface (it’s expensive!). The path to a solution is what needs repeating because that’s the part that’s going to make a difference.
David has taken a huge topic and attempted to document all sides of it to make it seem even bigger, then proposes a ‘simple’ solution. For someone who runs a business deeply entrenched in marketing and advertising, where is the critical eye on selling this revolution? Turning this ship around will be nearly impossible with the amount of momentum built-up around it. If the ACA was a small change to coverage rules and regulations that took 2 years to pass and another 5 to implement, what hope does a change that undoes all of that and more stand in terms of progress and timeline? The problem and solution are described, but the few details he provides fly directly in the face of current policy pushes (less HSA and no high-deductibles). This whole movement needs a rallying cry “Take back healthcare!” and this book provides only fuel for change without enough direction, leading to the deep sense of helplessness while I read the book.
Plan Dissection
David’s BALANCE plan leaves much to be desired and skips over the toughest parts in proposing a change to our current system. I like the intent, the proposed results, and the rough outline, but as David derides the detailed rulemaking process of the current government programs his own don’t fare much better in terms of complexity to reach parity.
TruCat
If it’s a lifetime deductible, can everything health related count against it?
Are mandatory premiums allowed to discriminate based on pre-existing conditions?
Government administered, so what kinds of treatments are approved?
He admits this is basically Medicaid that spends less, so I’m not sure how it’s going to get any support if people who count on this see it in danger of not providing the current support it does.
HSA
Tax-free mandatory contributions sound great for those already employed, but what benefit is it to others? It’s just another pool of money to manage.
The ability to pay out or entrust savings to others, so another tax shelter if engineered so
The ability to leverage debt against it
Private debt forgiveness? What kinds of interest rates do you expect then?
HSAs are widely criticized for providing great care that can already afford it without helping those who are already poor at managing money. The debt part has widely complex implications and has been rightly identified as a weak point in this.
Alternatives
David slams the financial engineering that was the ACA when the incentives remained the same, but the fundamental jump that David makes is that Medicare-style customers will become more price-conscious when provided with similar resources. I have little faith that this change in belief and behavior will come about with the above financial engineering, where people are willing and expected to pay anything to providers they already trust. All this really solves is moving large amounts of government debt to an equal total of small pools of private debt.
In Summary
David sets out to destroy your trust in the current system, which is what he needs to do to incent the revolution that would be required to implement any of his proposed reforms. He constantly extolled the virtues of a deregulated market, but then for every concern, there’s a specific regulation he has to fix. If this sounds exactly like the solution he’s railing against, then you understand my concern with the voice of the book.
From my brief reading, there are clearly at least two paths in this space. The first is the one we are in now, where healthcare is sacred and needs to be managed by the government to ensure its social equity. This obviously has massive efficiency downsides, as every public-private partnership has shown to be true. The upside (at least to those who support it), is a not-so-subtle wealth redistribution program without explicitly infringing individual liberty (which is what those who would fight this approach argued in the Supreme Court). The other path is that healthcare deserves to be treated like any other market, and the emotional allowances we’ve made for it so far aren’t truly reflective of our values as a society. The gains here are theoretically obvious and immediate but require a broad re-think of many other societal problems that we’re currently at odds with.
My biggest problem with the book is that I didn’t take much away from it. I already knew that any government managed system was inefficient, as most would admit. I didn’t get a clearer picture of the problems, because the level of detail provided was either too granular or too-high level to make a cohesive narrative, and when anyone asks me what the book was about I don’t have a good response that can communicate what the book proposes without immediately getting caught in the details. So I’ve come up with Healthcare communism is bad, but we still need it?!