Free the Vets

Don’t you think our military veterans deserve decent health care? I certainly do. That’s why I like Mitt Romney’s idea of setting the veterans free. Give them the opportunity to choose private health care alternatives to the Veterans Health Administration (V.H.A.), a system that too often fails them.

Why can’t we do for veterans what we do for seniors? About one in every four Medicare beneficiaries is not actually in Medicare. They have enrolled instead in private health insurance plans operated by such entities as Aetna, United Health Care, Cigna, etc. Why can’t we give people who risked their lives for the rest of us similar options?

You would think this idea is a no-brainer. But, just like the Grinch at Christmas time, you can always count on Paul Krugman of The New York Times to argue that being trapped is good, free to choose is bad, and government medicine is all anyone should ever have or need.

Silver wings upon their chests,
These are men — America’s best

According to Krugman, “the V.H.A. [is] providing better care than most Americans receive” and it does so at a lower cost. He doesn’t stop there. Here is Krugman’s view of health care, worldwide:

The most efficient health care systems are integrated systems like the V.H.A.; next best are single-payer systems like Medicare; the more privatized the system, the worse it performs.

In other words, in the best of worlds we all would be getting veteran’s care, courtesy of the U.S. government!

Before you buy that idea try a Google search. I found these unsettling headlines: “Vets Not Getting the Care They Need, “One Million Vets Waiting on VA for Disability Claims,” “‘Never Event’ Occurs at VA Hospital,” “Federal Court Challenges VA Mental Care,” and “Veteran Suicides Becoming Epidemic.”

Did you know that one in every five suicides in the U.S. last year was a veteran? Last May, the 9th U.S. Circuit Court of Appeals in San Francisco said that with an average of 18 veterans killing themselves each day, “the VA’s unchecked incompetence has gone on long enough; no more veterans should be compelled to agonize or perish while the government fails to perform its obligations.”

A Miami Herald investigation (using the Freedom of Information Act) discovered that:

  • Despite a decade-long effort to treat veterans at all V.H.A. locations, nearly 100 local V.H.A. clinics provided virtually no mental health care in 2005; the average veteran with psychiatric troubles gets almost one-third fewer visits with specialists than he would have received a decade ago.
  • Mental health care is wildly inconsistent from state to state; in some places, veterans get individual psychotherapy sessions while in others, they meet mostly for group therapy.
  • In some of its medical centers, the V.H.A. spends as much as $2,000 for outpatient psychiatric treatment for each veteran; in others, the outlay is only $500.

As for efficiency, the V.H.A. fails that test as well. According to a recent study in the Journal of Health Care Finance, “V.H.A. health care costs 33 percent more than it would if purchased in the private sector… [and] inpatient care costs were 56 percent higher.”

To the V.H.A.’s credit, a RAND study concluded that overall the V.H.A. is providing higher quality care than other patients receive, although it also noted that the system does best on the quality metrics it measures than on the ones that go unmeasured. Unfortunately, these quality metrics tend to be inputs (was a certain test ordered?) rather than outputs (did the patient get well?). On the most important quality measure of all — did the patient survive? — V.H.A. patients appear to do no better than other patients.

A Kaiser Health News analysis revealed that surgical patients in V.H.A. hospitals are just as likely to be readmitted for post-surgical complications as patients at non-V.H.A. hospitals.

And let’s not forget about amenities, including basic cleanliness. As health economist Linda Gorman writes:

Private hospitals tend to have private rooms and lots and lots of plumbing. These features help control infections and make hospitals safer for patients. Because governments can shut down private hospitals that fail cleanliness standards, private hospitals also spend a lot on maintenance and housekeeping. Government hospitals tend to do things differently.

An investigation of the Kansas City VA Medical Center revealed that things were so bad that clinicians felt compelled to clean their own areas. Management embarked on a hand washing campaign, but with limited success. The review found that many soap dispensers were empty and noted one clinician’s hope that one day “sinks should actually work.”

 An investigation of a V.H.A. system in Dallas reported that “Most patient rooms and bathrooms we inspected were unclean…the rooms had foul odors, suggesting that they had not been thoroughly cleaned over a significant period.”

Outside commentators consistently praise the V.H.A. for keeping patient records electronically. In principle, all the doctors in the system should be able to access the same records and practice “integrated care,” rather than the piece meal approach that often characterizes health care generally. Also, the system is doing something else rarely seen: it is publishing outcomes data (mortality rates, infection rates and readmission-after-initial-surgery rates) on procedures at its 152 hospitals so vets will have information about the quality of care to expect. But because rationing-by-waiting is endemic throughout the system, it’s not clear what patients can do with this knowledge.

Here is the bottom line: The V.H.A. may be good at some things and not at others. Quality and service levels apparently vary around the country. So, let the V.H.A. compete in the marketplace against private doctors, private hospitals and private insurance, instead of trapping veterans in a system that may or may not meet their needs.

Comments (14)

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  1. Vicki says:

    I like this one. Also, good song pairing.

  2. Grace Debold says:

    As the daughter of a 30-year career military vet (WWII and Korea), I have believed for 40 years that the government should be out of the business of medical care and the VA hospitals should be closed. Don’t misunderstand the intent here. I absolutely support our men and women serving in the military and actually would like to see their benefits INCREASED. Most local community hospitals in our country are half empty and an increasing number are receiving Critical Access designation by CMS. There are thousands of empty beds in the private sector….why not have our vets stay closer to there homes and enjoy access to community medical care? The VA can use the CMS system of reimbursement and bend their total expense curve by 35% while availing the vets to better care closer to their home.

  3. Brian says:

    As a general rule, people should be allowed to choose private sector alternatives. Vets especially. The VA fails to many of them .

  4. Devon Herrick says:

    The VA was touted as an example of a low-cost, high-quality health care system until the war in Iraq. Once strained with returning soldiers, it became apparent that the VA was not able to meet the diverse needs of soldiers with multiple health problems.

  5. steve says:

    May I assume you never served and do not know much about the care of vets John? As a physician and a vet (both enlisted and officer), you get a lot of things wrong here. Most vets are not treated by the VA. Most of those vets killing themselves are not being treated by the VA. I dont receive care at a VA facility. You need to look at the eligibility rules for VA care and realize that it is much different than a general population. TBH, I am surprised that you would cite the Weeks paper. It is much too crude to be especially useful. Shouldnt you control for population factors like gender? If a significant percentage of VA patients were discharged from the military due to medical disability, could that mean they start with an inherently different population?

    All that said, I actually agree with the general idea of letting vets have access to care in other hospitals. Vets often have to travel pretty far to receive care in a VA facility. I like the idea of having more choice. I dont really think it will lower costs, but I would be willing to put it to a test. Individual VA hospitals have problems just like individual private hospitals. Let vets choose.


  6. Rick says:

    If you are over 65, on medicare and a military retiree, private health insurance would be your primary which may intail co-pays and also only Drs approved by the company. Second payer would be medicare. If you do not have private health insurance your primary is medicare and next is tri care for life. Since I dropped my private health insurance I have not paid one cent for private medical care including specialists. The other problem is the VA is 80 miles away. Also my experiences with VA hospitals in two states have not been very good.

  7. Dennis Byron says:

    Good points but basically inaccurate. You say:

    “Why can’t we do for veterans what we do for seniors? About one in every four Medicare beneficiaries is not actually in Medicare.”

    Actually it’s more than nine out of 10 seniors (and non seniors eligible for Medicare) that are “not actually in Medicare” by your definition of “actually.”

    — 25% — and rising — choose Part C as you indicate (but they are “actually” in Medicare by most people’s definition of “actually;” not only is Part C an “actual” Part of Medicare but the senior has to “actually” sign up for A and B to get C).

    — Almost half — but falling –get their real coverage from their former employer. But the former employer usually makes them “actually” sign up for A and B too.

    — And almost 20% of us choose a Medigap Plan to make the terrible insurance that is Original Medicare (“Medicare as we know it” to Krugman) into decent coverage. However, again, you “actually” have to actually sign up for Medicare first before getting MediGap.

    Original Medicare (Parts A and B) are simply the ante for seniors to get decent healthcare insurance.

    And yes, vets get these same options as the rest of us seniors are getting. Most vets however get their prescriptions through the VA, which is a better deal than Part D (and they deserve it).

  8. Mike Balfe says:

    “But, just like the Grinch at Christmas time, you can always count on Paul Krugman of The New York Times to argue that being trapped is good, free to choose is bad, and government medicine is all anyone should ever have or need.”

    Great line, Mr. Goodman.

  9. wanda j. jones says:

    John–In the decades before the recent Middle East Wars, the VA and the military shut down middle-aged hospitals so as not to have to replace them. In the Nine-County San Francisco Bay Area alone, Letterman, the Navy hospital and several military clinics were closed. One regional hospital, Travis Air FOrce Base, was re-built because it was meant to be used as the first stop for wounded vets from the Pacific Rim. Current wars are considered temporary, so otherwise new capacity has not been built.

    The military accepts delays as a feature of their healthcare system, as it knows it is at risk for over-charging if they were to channel vets to private providers. If vets were to get all the care they need, plus be subjected to as much over-treatment as the private sector can do, the Federal budget would go eve more bust than it is.

    The big short-coming in patient care capacity is not the hospitals per se, is in professional manpower. During a big war, such as WWII, doctors can be drafted. Today, they have to be volunteers. There are just too few of those for the demand, so waiting lists are inevitable. To come to parity with and in the private sector would require checking on manpower state by state, as there are some waiting lists for some specialists in the private sector, too, depending on whether there is enough population to keep a specialist busy.

    But this is about more than doctors and hospitals. To have a well-functioning system of any kind, there have to be excellent executives. And there has to be an operating budget that can cover janitors, and all the other support staff that make good care possible.

    Ultimately, this comes back to the “Who’s in Charge?” question. If that is Congress, then we know a lot about how the VA has been neglected.

    It is worth noting that while the mental health services are quite limited, as they also are in the private sector, the technology of prosthetics has moved along quite well and spills over to benefit the private sector.

    Now, there is a health problem of people still in service–sexual assaults on women in uniform. This is a command problem in a culture that does not acknowledge testosterone as a risk factor.

    And–you are right: Paul Krugman does not understand anything that is market-based. Why is he still being paid?

    Wanda J. Jones, President
    New Century Healthcare Institute
    San Francisco

    PS: When I was in the Air Force, I was stationed in Paris for two years, when I was referred to the American Hospital in Paris, a private institution, because the military clinics were not set up for women. But, single and in uniform, I had to sit in the waiting room under a sign that said “OB-GYN.” Well, it didn’t kill me.

  10. Greg says:

    Great post.

  11. Eric says:

    Interesting post John. I never thought I’d see the day where somebody on this blog would cite a Dartmouth researcher in support of their point after all the flak they get here.

    The high incidence of veteran suicides is certainly a significant problem, but I’m not necessarily sure that you can directly implicate the VA. The people served by the VA tend to be sicker and have a higher incidence of mental illness than the typical population, so comparisons with other hospitals that don’t serve veterans may be difficult. Comparisons of cost are also potentially problematic when veterans can access care at other hospitals (as a Kaiser article from September mentioned that about 1/2 of the VA population does). There may be some selection problem in terms of getting their most expensive care at the VA (where it would be free).

    Additionally, the income threshold for accessing VA health benefits is fairly low (under $30,000 with 0 dependents), which would mean that the population served is relatively poor, and more likely to have disabilities and chronic illnesses. This combination of factors does not bode well for their ability to access private insurance.

    I certainly don’t know enough about technical methodology to know if the findings in the Weeks paper are valid (the methods seem fairly crude considering the complexity of the comparison), but if they are true then it should definitely make us raise our eyebrows. Weeks did not recommend dismantling the entire system, but rather, recommends “outsourcing surgical and other
    outpatient services” which may be costly. There may be value in the VA system in terms of providing primary care and care coordination, even if certain specialty services may be cheaper to provide elsewhere.

    Regardless, there is not much evidence that the quality of care provided by the VA is lower than the what this patient population would get in the private market, just that it is more costly (if the Weeks findings are legitimate). Rather than just eliminating the VA (as you seem to suggest) which is a valuable service for many veterans, it might make sense to look for ways to make the existing system more efficient.

  12. Glenn Smith says:

    Hello John,

    Back in the early 1980s I wrote to then-Senator Rudy Boschwitz along the same lines. Veterans whose families live in rural area have to travel long distances to see the vets and it can be very expensive. So often, they could have their vet in a local hospital and being treated by the local family doctor. I think this is a great idea.

    Glenn Smith

  13. Bernard Edelman says:

    John Goodman:- Normally, I don’t read your stuff, but your “Free the Vets” caught my attention. IF I had the time, I would send you a full essay on why your position is not only half-baked, but completely wrong-headed. The health care provided by the VA is not only first rate, for the most part, but it is far more cost-effective than health care in the private sector. Twenty years ago we couldn’t say this. Now we can.

    Two-thirds of veterans do not use the VA. They have private health insurance, go to their own doctors. It’s the indigent who use the VA – and the severely wounded, the blinded, those with spinal cord injuries, amputated limbs. They get specialized care they cannot get in the private sector.

    So . . . like Romney’s ideas all you want, but it ain’t the way to go.

    Bernard Edelman
    Deputy Director for Policy and Government Affairs
    Vietnam Veterans of America

  14. Chris Ewin, MD says:

    The big short-coming in patient care capacity is not the hospitals per se, is in professional manpower.
    To Dr. Steve, Wanda Jones and Bernard Edelman:

    Ya’ll have experience and great knowledge about the system…I would like to pick your brains about a possible solution.

    Do you think a veteran (and/or family of a vet) would pay $150.00/month to a family physician to have him on retainer. They could guide them through the system and probably keep them away from the system since they take care of 85% of their needs…

    It’s a manpower problem…but it’s hard to find med school grads to not only do primary care….but also have a career in the military…

    If the government gave the vets a voucher that they could give to fp’s with a small (concierge) practice, I bet it would save the military lots of $…
    More importantly, we help the patient…particularly with mental health problems, addictions, alcoholism, etc…
    All you can eat for one price….

    What say you?