If I live to be 100 years old, I don’t think I’ll EVER understand how my brain processes information. I definitely have trouble staying in my lane when it comes to how I visualize and analyze things. Here’s a perfect example:
My wife and I were on a trip, and we stopped to eat at a medium-price, family restaurant. This particular place has lots of entrees in the $10-$15 range, all very tasty, with healthy options, too. I had walked by a salad bar on my way in and noticed that it looked full and well-kept.
In fact, for $3 you can add unlimited salad bar to any order, according to our server, Tess. My wife and I both added the option. When we got to the bar, this is what we saw:
Almost immediately, my wife had problems. She’s about 5’5” and her arms were not long enough to make it past the LARGE sneeze guard and the first two rows of salad greens, olives and dressings to get to the third row. Being taller and with longer arms, I helped her out by reaching some of the protein choices in the back, like the bacon, turkey and cheese.
To me, it seemed this ONE-SIDED SALAD BAR was designed to force you to access it from the side with the cheapest ingredients. Easy to see this design allowed the restaurants to keep costs to a minimum by making the more expensive, protein-laden choices much more difficult to access. Entirely rational, if a little sneaky.
As we carried our plates back to the table, I could NOT get that image out of my mind. And then it hit me… that SINGLE-SIDED SALAD BAR was a really good analogy for how health systems like the provincial programs in Canada or the National Health System in the United Kingdom control costs as well. It also applies to Medicaid here in the U.S., but for entirely different reasons.
Wherein Cheese = Neurosurgery
Check out this image:
The Single-Sided Salad Bar Rationing Model Applied to Universal Healthcare (Canada, U.K. NHS)
“Rational” healthcare systems, like those found in other developed countries, tend to establish gatekeepers over all care, but some care that is inexpensive and good for many people is put within easy reach.
In this version above, you can see Primary Care Provider (PCP) visits, Employee Assistance Program (EAP)-type mental health visits, generic drugs and vaccines are very easy to access. Advanced imaging (like MRIs and CT Scans), specialty care or biologic drugs are much tougher to reach, and the PCPs are the gatekeepers of the entire system.
Since care is rationed by strict cost control, wait times for many procedures can get pretty lengthy, much longer than most people would tolerate here in the U.S (See my Straight Talk Article “Baseball, Cataracts, and Single Payer”). But there is only one way in, so people who aren’t satisfied with the wait have no other options.
Care in the U.K. is free once you get it, but it is funded by an embedded 20% sales tax on every transaction, even wholesale. To get that care, you have to be registered with a PCP and give him/her control over all your healthcare decisions, including referrals up to specialty care. PCPs are employed by the government (health districts) and have obligations to both their patients and their employer as gatekeepers of the entire healthcare system.
Is Medicaid a Single-Sided Salad Bar?
So if this is how it looks in the U.K., what about here in the U.S.?
The first system I thought about was Medicaid. Now that more than 73 million people on our government-funded single payer free healthcare system, it’s important that we understand how it differs from both the European/Canadian models and our other U.S. systems like Medicare.
Here’s what Medicaid looks like in comparison:
The Single-Sided Salad Bar Rationing Model Applied to Medicaid
Notice that here in the U.S., our Medicaid program is a SINGLE-SIDED SALAD BAR just like in the U.K. or Canada, but for very different reasons. Instead of rationing based on very tight treatment protocols via gatekeeper primary care, the rationing here is unintentional. It is a by-product of the fact that Medicaid’s reimbursement levels to medical providers are so low. In fact, they are 30-40% below the WHOLESALE cost of providing treatment.
This means as a medical practice fills up with Medicaid patients, its financials slowly deteriorate until it begins to ration or limit the slots available for Medicaid patients. It’s already happening at smaller hospitals and at least one not-for-profit nursing home.
Patients on Medicaid can go to a PCP or a Federally Qualified Health Center (FQHC) and get primary care, even an appointment with a specialist. But that specialist appointment may be for six months from now, or longer, because so few specialists can operate on what Medicaid pays.
So, in the U.S., we have rationing by underpayment, which means longer wait times for the patients.
UNLIKE the U.K., or Canada, you’ll notice I put the “Hospital ER” box in the easy-to-access, first row of the Medicaid model. That’s by design. In the U.S., Medicaid patients are MUCH more likely to use the ER or urgent care center than they are to visit a doctor’s office. It turns out that the MOST expensive care a Medicaid patient can get is the easiest to access.
The U.S. Is a Double-Sided Salad Bar
Now, let’s take a look at the part of our system that is unique in the world and drives a significant portion of the costs that separate us in terms of spending. Here in the U.S., the 200+ million people on Medicare or private insurance are enjoying the DOUBLE-SIDED SALAD BAR model. Looks like this:
The Double-Sided Salad Bar Model Applied to Medicare, Private Coverage
Notice that these happy people can access the healthcare salad bar in a variety of ways. In most cases, there are no requirements that they go through a gatekeeper; easy access and total control of their healthcare comes from the DOUBLE-SIDED SALAD BAR. If I have Medicare or private insurance, I can access whatever care I want, pretty much whenever I want. There are tons of resources in specialty care, surgical care, labs, imaging centers, pharmacies and the like, just waiting to fulfill my needs immediately.
I recently experienced this myself when my eye doctor told me I would benefit from cataract surgery. I wrote about that extensively here. In most countries, this is considered a luxury, non-essential surgery and eight or 10 months of wait time is not out of the ordinary. Plus, your PCP has to approve your specialist appointment ahead of time, or you don’t get to see the eye doctor at all.
Here in the U.S., I went straight to an ophthalmologist who scheduled my first surgery for five days later, then APOLOGIZED FOR THE WAIT BECAUSE THEY WERE BACKED UP! That’s the power of the double-sided salad bar of healthcare. Of course, all that choice comes with two big problems: high costs and complexity. And the73 million Medicaid patients pay $0 for care but don’t have access to a rich slew of choices and prompt service.
Are We Ready to Give Up the Double-Sided Salad Bar?
Now we are at the crux of this discussion. Much is being made of creating new healthcare insurance choices for Americans called “single payer,” “Medicare for all” or some other name for a government-run and managed system. So, I ask you this:
Are the 200 million people in the U.S. (including you) with access to the double-sided salad bar ready to surrender that access? Are you ready to wait? Are you ready to surrender even more authority to a large government agency and give up your own authority?
And the biggest question of all: How do you respond when a politician promises you can keep your double-sided salad bar but only pay the price of access to the single-sided salad bar?
Because that’s what is happening: a siren song that “Your government can do a better job, keep you happy, save you money and ask nothing of you.”
You know what they say: if it sounds too good to be true, it probably is.
Consider that two-thirds of the 55 million people on government-run Medicare buy private insurance to fill in the gaps OR a private policy that completely replaces Medicare. Coincidentally, the privately insured Medicare patients are the ones who report they are MOST SATISFIED with Medicare!
The federal agency that manages Medicare/Medicaid has only 4,000 employees to manage healthcare for 130 million people. How are they doing? The Government Accountability Office says they lose $60 billion each year due to fraud, waste and abuse; that’s around 10% of the U.S. government’s total healthcare budget. What happens if we give them MORE money and responsibility?
And finally, it’s worth noting that the federal agency that manages Medicare hasn’t processed a claim, enrolled anyone or done any of their own auditing since 1965 when they were formed. They outsource ALL of these functions to existing private insurance companies.
Which salad bar do you want to use?
Just food for thought! And the Straight Talk on Single-Payer/Medicare-for-all.