Healthcare Fixed: No Insurance Needed, Same Doctors, 60% Less - David Goldhill
Episode of Proven Podcast · September 9, 2026 · 59 min
Charles Schwartz talks with Sesame founder David Goldhill about why American healthcare costs so much and how cash-price markets and telemedicine could lower costs.
Summary
Charles Schwartz interviewed David Goldhill, founder and CEO of the cash-pay healthcare marketplace Sesame and a former television executive at Universal Studios and the Game Show Network. Goldhill argued that the United States, with about 3 percent of world population and 40 percent of world healthcare spending, funds most global medical innovation, comparing the arrangement to NATO defense spending. He contended that a move to a British- or Canadian-style system would destroy the profit engine behind innovation, and that the real problem is third-party payment, which he said prevents competition from driving prices toward marginal cost.
Goldhill cited figures from his 2012 book Catastrophic Care, estimating that a typical employee would put about $1.2 million into the healthcare system over a lifetime, with 10 to 15 percent going to payment administration. He used his own open-heart surgery and a $35,000 annual family premium to argue that insurance is a poor deal even for those with major procedures, and pointed to falling GLP-1 drug prices outside insurance coverage as evidence that markets lower prices. He described Sesame's model of listing appointments at upfront cash prices and claimed 95 percent patient satisfaction.
The two discussed telemedicine ending the geographic limits on access to top doctors, AI's so-far limited impact (Goldhill said it has mostly been used in revenue management), and incentive problems, illustrated by Schwartz's hospice experience and Goldhill's account of early Medicare hospice payments. Goldhill argued that incentives, not villains, drive the system's failures, and predicted that general hospitals have a poor business model and that private insurers have become dependent on Medicare and Medicaid. The episode closed with discussion of consumer responsibility and Sesame's partnership with Costco.
Chapters
- 0:00
Introduction and Goldhill's background
Goldhill introduces Sesame and describes his career as an entertainment executive before moving into healthcare.
- 1:23
America subsidizes world healthcare
Goldhill argues the US free-enterprise system funds most global medical innovation, comparing it to NATO and citing the 40 percent spending figure.
- 9:07
Drug pricing and third-party payers
The two discuss why high-fixed-cost drug development works only because third-party payers shield prices from competition.
- 11:48
Lifetime cost of healthcare and insurance math
Goldhill explains why one-size-fits-all payment is flawed and shares lifetime spending estimates from Catastrophic Care and his own surgery costs.
- 17:21
Sesame's marketplace and GLP-1 lesson
Goldhill describes Sesame's cash-price model and cites falling weight-loss drug prices as evidence of market forces.
- 20:45
AI and who the customer is
Goldhill says AI has mostly been applied to revenue management because insurers and governments, not patients, are healthcare's customers.
- 27:21
The Joe's Stone Crab model
Schwartz and Goldhill use the Miami restaurant and its takeaway shop to illustrate serving different customer types.
- 30:11
Telemedicine breaks geography
Goldhill argues remote care removes real costs and will let patients reach the best doctors anywhere.
- 36:57
Hospice incentives and the absence of villains
Schwartz recounts shrinking hospice stays and Goldhill argues incentives, not evil people, drive bad outcomes in an outdated system.
- 43:25
Biggest shifts in the market
Goldhill outlines more sophisticated patients, consolidating doctors, struggling general hospitals and insurers dependent on government programs.
- 47:21
Consumer responsibility and conventional wisdom
The two discuss consumer-driven markets, personal health responsibility, and skepticism Sesame overcame about doctors posting prices.
- 56:57
Closing and how to reach Sesame
Goldhill explains how to use Sesame, mentions its Costco partnership, and the episode wraps up.
Key points
What was said, by whom, with the exact words. Timestamps jump to the moment.
- David Goldhill
Goldhill argues that because the US has the only free-enterprise healthcare system, almost all global medical innovation is designed for the American market.
“that's why almost all of the innovation in health care on Earth is designed for the American market”
- David Goldhill
Goldhill states that the US accounts for 40 percent of world healthcare spending while having 3 percent of world population.
“the United States is 40% of world health care spend. We're 3% of world population”
- David Goldhill
Goldhill argues that adopting a British- or Canadian-style system would destroy the engine of medical innovation.
“If we just go to a sort of socialist system, a British-style system, a Canadian system, we'll simply destroy the engine of innovation”
- David Goldhill
Goldhill argues Americans pay 70 to 80 percent of the cost of innovation while receiving a small fraction of the benefit.
“We're paying 70%, 80% of the cost of innovation and getting 3%, 4%, 5% of the benefit, maybe 10% of the benefit”
- David Goldhill
Goldhill contends that third-party payers ask for a 'fair price' rather than letting competition drive prices to marginal cost.
“there's almost no corner of healthcare in which we let good old-fashioned competition drive people's prices down to marginal cost”
- David Goldhill
Goldhill recounts that despite having open-heart surgery costing about $120,000-130,000, his $35,000 annual family premium makes insurance a bad deal for him.
“So roughly every four years, I pay for an open heart surgery, and I guarantee you we're not using one every four years”
- David Goldhill
Goldhill argues that no one in healthcare can become more profitable by lowering prices, unlike in other businesses.
“Nobody in the healthcare system can make more money, can be more profitable by lowering their prices”
- David Goldhill
Goldhill says his 2012 book estimated an employee would put $1.2 million into the healthcare system over a lifetime, with 10-15 percent going to payment administration.
“in 2012, the amount she would put into the healthcare system over her lifetime was $1.2 million into the healthcare system”
- David Goldhill
Goldhill argues that weight-loss drug prices fell because insurers did not cover them, forcing direct-to-consumer sales.
“The insurers didn't cover them, and the prices came down. There's an important lesson to that, right?”
- David Goldhill
Goldhill says the biggest impact of AI on healthcare so far has been in revenue management between providers and insurers.
“To date, the biggest impact on AI on healthcare has been in revenue management”
- David Goldhill
Goldhill predicts telemedicine will be highly disruptive because fewer conditions require a doctor to be physically present.
“Telemedicine and remote medicine generally are going to be extraordinarily disruptive to healthcare if we allow”
- Charles Schwartz
Schwartz argues that doctors' incomes have eroded and many long-serving doctors seek to exit their practices.
“Doctors don't make what they used to make. they're they're nickel and dime and their insurance is astronomical”
- Charles Schwartz
Schwartz recounts that after VITAS entered his market, average inpatient hospice stays fell from about two weeks to 47 hours and later under 16 hours.
“the patients went from being there for two weeks to being there for 47 hours”
- David Goldhill
Goldhill notes that when Medicare first covered hospice on a per-day basis, providers admitted patients who were not dying, the opposite problem.
“They were paying per day And people were taking hospice patients who weren't really dying”
- David Goldhill
Goldhill argues that government and insurance workers are trying to do well, and that incentives rather than villains cause the system's failures.
“People who work in insurance companies overwhelmingly are trying to do well. It's the problem is incentives always win”
Linked moment · 43:25Skip to 43:25 using a listen link in the info box.
David GoldhillGoldhill argues general hospitals lack economies of scale or scope outside reimbursement rates and are unlikely to win over time.
“Outside of reimbursement rates, hospitals don't really have economies of scale or of scope. They're kind of a senseless institution”
- David Goldhill
Goldhill says big insurers have become 'wards of the government' because much of their revenue comes from running Medicare and Medicaid.
“the big insurance companies now are basically wards of the government”
- David Goldhill
Goldhill argues consumer-driven markets work because sellers chase consumers, not because consumers do extensive research.
“Consumer-driven economies aren't driven by consumers. They're driven by sellers chasing consumers”
- David Goldhill
Goldhill says many top doctors want to leave the third-party payment system because they spend too much time on insurance paperwork.
“Because I didn't go to medical school to spend 20% of my time as an insurance clerk”
People
In the conversation
- Charles SchwartzEntrepreneur and host of The Proven Podcast
- David GoldhillFounder and CEO of the healthcare marketplace Sesame, former entertainment executive, and author of Catastrophic Care
Discussed
- Winston ChurchillBritish prime minister during the Second World War
Topics
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From the publisher
Charles goes one on one with David Goldhill, founder and CEO of Sesame, former president of television at Universal Studios, and author of Catastrophic Care, to tear apart why American healthcare costs so much and what it would actually take to fix it. They walk through why the United States covers 40 percent of the world's healthcare spending while making up just 3 percent of the population, why insurance companies and government payers killed normal pricing, and why the fix isn't one big policy swing. It's a shift back to treating patients like customers. The conversation covers the real economics behind a $900 million pill, why Sesame borrows its pricing model from a stone crab restaurant in Miami, why hospitals are stuck with a broken business model, and why the doctor in your neighborhood is about to compete with the best doctor on the planet. KEY POINTS: 00:34 – Entertainment executive to healthcare founder: David walks through his path from Universal Studios and the Game Show Network to building Sesame, and why Charles calls it a classic swap from one broken industry to another. 01:57 – America is subsidizing world healthcare: David explains why the US pays 70 to 80 percent of the cost of medical innovation while capturing a fraction of the benefit, and why cutting that funding would collapse care standards everywhere. 04:04 – The NATO of medicine: David compares American healthcare spending to defense spending in NATO, and lays out the number that stops most people cold. The US is 3 percent of world population and 40 percent of world healthcare spend. 09:13 – Why the first pill costs $900 million and the second costs a penny: Charles and David break down drug pricing, and why a business model that looks terrible everywhere else works in healthcare because normal competition never gets the chance to bring prices down. 14:42 – The real lifetime cost of healthcare: David shares the number that shocked him while writing his 2012 book, what one employee puts int…
Summary, chapters and key points were generated from the episode transcript on October 5, 2026. Quotes are checked word for word against the transcript.