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.

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.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

17 replies »

  1. Right you are not a Doctor or a Veteran. Also you do not have a terminal illness with a life expectancy of 6 – 16 months, depending on how effective chemo is. So bug off.

  2. It would not come close to the cost of the huge VA budget. You know not what you speak. I can tell you never served your country. By you use of “Them” All of “them” who are service connected had their illness caused by defending your rights.

  3. According to the first DR’s it was put down as agent orange exposure. Do not know year ago, had not had biopsy. A year ago I was told I had three small nodules and that “there is nothing wrong with our lungs”. The yearly CT scans indicated the size increase in the nodules and the presence of “numerous” new small nodules. After that they did a PET scan and the nodules ‘LIT UP” that is when they ordered biopsy. Prior to last year I had an oncologist and pulmonary DR’s who worked together. The Pulmonary Dr. left to be replaced by idiot. Now Oncologist has left and replaced by another IDIOT. I would use my MEDICARE plan for treatment but due to the MEDICARE Cut that went into effect this year the co-pay for chemo is prohibitive. In other words I do not have the case to cover Obama Care Co-pay. Thankfully I am a Christian and leave justice to God. Otherwise my prognosis and theirs could be measured in hours. Last question, NO I do not expect to survive. Have resigned to the Death Sentence imposed by VA MD’s. Only regret is that will not get to spend more time with wife, daughter and grandchildren.

  4. What is the cause of the lung cancer? A year ago did you have stage 4? What was your prognosis a year ago? If no PET scan then how do you know the nodules have increased in size?

    Do you expect to survive this disease?

  5. I am a disabled veteran with a total permanent designation. I have bee a victim of VA health care since 2004. I have received some of the finest health care at the VA system. I have also received Abhorrent care. You are at the mercy of your assigned provider. Getting to change a provider is an administrative night mare. My current condition is stage IV lung cancer. A year ago my oncologist wanted a PET scan and was overruled by Pulmonary. A year later the three small nodules had increased in size 4 times and spread. I now have a prognosis of between 4 and 16 months. I tried to change providers and was ignored. The idea of doing away with the VA system has my support. The idea of a card with which to choose any provider definitely has my support.

  6. My thought about the VA Healthcare system is simple if isn’t broke don’t fix it. I’m A VetI served on Active duty and reserves. What bothers/d me is the fact that medical care for veterans and accessabitlity through having what is available to veterans at all VA medical facilities and clinics. It should be the available to them without question for all vets everywhere. I think that they have suffered enough to have to worry about their healthcare, all the cuts that have been made to date.

    I agree that the civilian healthcare system should be setup the same as the VA system. There to would apply it is broken lets fix it. maybe the VA Healthcare System as a whole should be used model for the current healthcare system we have available to everyone now. We should focus on the idea of quality healthcare for all without bearing major expense to do it, or having private health insurances determine what gets paid for what doesn’t, after all we are all paying for it in the long run.

    I am personally very grateful that I have the use of the VA healthcare system, without I would not be able to afford any other Insurances to receive the care I need, specialized or not. They/we deserve it at the cost incrued at obtaining our freedom, freedom isn’t free it comes with a price and Vets have paid theirs.

  7. I’m assuming you have. Why did you not ask John Goodman if he’d ever been (and received care) in a VA facility?

    I have never been, but my father-in-law has and I can tell you he received much better caring care with the VA than in the private sector under Medicare, which was HIS option to use. In fact my wife (an RN) and her sister spent a number of years trying to coordinate care for their father in private facilities and with PCPs. The VA was a breath of fresh air and great care for their father, especially during hospice care in his last days.

    Maybe you can tell us your direct experiences with free VA care?

  8. As a vet, both enlisted and officer, and a physician I would note that there are many, many problems with John’s piece. He clearly does not understand or ignores which vets actually get care at VA facilities. The study he cites makes no allowance for gender differences and baseline levels of health. He cites a few problems at a few VA hospitals, as if one could not cite problems at many civilian hospitals. In trying to craft a hit piece on VA hospitals, he just comes out sounding stupid. (While going after the VA on mental health care, note how he avoids mentioning coverage for psych care by private plans.)

    That said, he could have written a much better piece and retained much of the basic idea. The VA system has very limited facilities in some areas. There is variability in quality of care. I would support vets having the option of care at private facilities when it is closer or they would prefer it. If we do this, it should be understood that it will most likely increase the costs of caring for vets since private sector care virtually always costs more. The Weeks study is weak.


  9. rbaer,
    Giving veterans a voucher aimed at cost reduction is not freedom. It is cheating.
    I am all for freedom. I would have no problem with giving veterans an open ended medical credit card they can use in any private or public facility of their choice. I am not concerned with footing the bill for veterans’ medical care, any more than those veterans were concerned with being maimed and killed for me.
    We should find something else to skimp on. Defense contractors come to mind as a good place to start.

  10. My post wasn’t really serious. I assume that Mr Goodman advocates enrolling vets into insurance plans because I would be extremely surprised if the “corporations” funding his cozy think tank http://www.ncpa.org/about/financial-statistics
    do not include a healthy share of health insurance companies.

    Mr. Goodman almost certainly is a storebought thinker (like this fellow NCPAer http://www.desmogblog.com/h-sterling-burnett
    who is a philosopher and Fox “Global warming expert”. I am very surprised that THCB chooses to continue to give him a forum. If the research was more sound and original and his referencing less circular, sure … but the NCPA has its own funding and website.

  11. “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.”

    Excuse me, but what’s stopping them? I’m not aware that anybody is locked in to VHA (or Medicare, for that matter). I’m a veteran and when I got old enough for Medicare I checked to see if my veteran’s status qualified me to have VA care instead. We have several friends who are quite happy with their VA care, one of whom is an insulin-dependent diabetic and another who needs several meds. (They get prescription drugs at for pocket change compared with Medicare Part D.) And as an agency assigned non-medical caregiver I have had more than one VA assignment for respite care (which may account for some of the expenses for vets not available to Medicare beneficiaries, which gives me little to no confidence that the per patient comparative expenses are meaningful).

    In any case I am not eligible because there are some six or seven ascending categories of care and I scrubbed out with the means test. My income is too great to be covered by the VA.

    All this discussion of private sector care makes me tired. Let a thousand concierge practices bloom and prosper. And those who can afford to keep their beloved family member forever alive with PEG tubes, catheters, pacemakers and whatever other equipment is available are welcome to use their fortunes any way they choose. (It’s a good way to generate much needed jobs in a down economy.) Cosmetic and reconstructive professionals never have to worry much about costs anyway. For those into risk management there are gold-plated insurance policies to go along with HSAs and such. I think the private sector is doing just fine, thank you.

    The carriage trade will always be well cared for, well beyond and not dependent on yet another revenue stream of TAX DOLLARS. I think everyone deserves decent health care, not just veterans. I guess that first sentence is what got me started.

    When Medicare Advantage starts costing fewer tax dollars than original Medicare, let’s have the conversation again. Meantime, let’s give ACA a few years to clean up some of the five areas that Dr. Berwick pointed out before we toss the system out to the private sector. Meantime, I’d be curious to know how many “dual eligibles” there are with VA and Medicaid and if there might be a way to save a few tax dollars there.

  12. Sure rbaer, we’re going to set them free with a voucher that will give them greater access, better care, and higher spending limits – using private care. Or are we just going to give them an open ended medical credit card where the government will pay the monthly bill?

  13. Margalit, Peter,
    Why do you hate freedom? And for that matter, after reading Peter’s posts, why do some vets appear to hate it, too?

  14. “That’s why I like Mitt Romney’s idea of setting the veterans free.”

    Not so the veterans:

    “Sen. John McCain (R-AZ) introduced a similar proposal during the 2008 presidential campaign, but veterans groups panned the initiative, which would have given veterans “the option to use a simple plastic card to receive timely and accessible care” outside of the VA system. AMVETS, Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars argued that while veterans should have access to private care, providing “rural veterans greater access to VA-sponsored care exclusively through private providers” would undermine the existing health care system. In their annual report, “The Independent Budget,” the groups argued:

    – “The VA’s specialized health-care programs…would suffer irreparable impact by the loss of veterans from those programs.”

    – “The VA’s medical and prosthetic research program…would lose focus and purpose were service-connected and other enrolled veterans no longer present in VA health care.”

    – If veterans turned to private practice, “they would lose the many safeguards built into the VA system through its patient safety program, evidence-based medicine, electronic medical records and bar code medication administration,” resulting in “lower quality of care for those who deserve it most.”

    Indeed, the fully integrated veterans’ health care structure of doctors and hospitals provides veterans with benefits that are the envy of the rest of the health care system. A study by the RAND Corporation found that “VA patients were more likely to receive recommended care” and “received consistently better care across the board, including screening, diagnosis, treatment and follow up. Rather than taking veterans out of a system that consistently delivers “higher quality of care,” Romney should expand its services and improve access.

    The RAND study concludes, “if other health care providers followed the VA’s lead, it would be a major step toward improving the quality of care across the U.S. health care system.” And Paul Krugman writes today, “the V.H.A. is a huge policy success story, which offers important lessons for future health reform.”

    “Why can’t we do for veterans what we do for seniors?”

    What, and bankrupt us even faster? John, aren’t you always arguing that Medicare is broken? Do a search of private health care and you’ll find the same failings.

    Surgeon General:

    “Financing and Managing Mental Health Care
    History of Financing and the Roots of Inequality

    Private health insurance is generally more restrictive in coverage of mental illness than in coverage for somatic illness. This was motivated by several concerns. Insurers feared that coverage of mental health services would result in high costs associated with long-term and intensive psychotherapy and extended hospital stays. They also were reluctant to pay for long-term, often custodial, hospital stays that were guaranteed by the public mental health system, the provider of“catastrophic care.” These factors encouraged private insurers to limit coverage for mental health services (Frank et al., 1996).

    Some private insurers refused to cover mental illness treatment; others simply limited payment to acute care services. Those who did offer coverage chose to impose various financial restrictions, such as separate and lower annual and lifetime limits on care (per person and per episode of care), as well as separate (and higher) deductibles and copayments. As a result, individuals paid out-of-pocket for a higher proportion of mental health services than general health services and faced catastrophic financial losses (and/or transfer to the public sector) when the costs of their care exceeded the limits.

    Federal public financing mechanisms, such as Medicare and Medicaid, also imposed limitations on coverage, particularly for long-term care, of“nervous and mental disease” to avoid a complete shift in financial responsibility from state and local governments to the Federal government. Existence of the public sector as a guarantor of“catastrophic care” for the uninsured and underinsured allowed the private sector to avoid financial risk and focus on acute care of less impaired individuals, most of whom received health insurance benefits through their employer (Goldman et al., 1994).”

  15. I’m sorry, but I don’t quite understand.

    For the sake of argument, let’s assume that there is something wrong with VA care facilities and veterans would be better off if they received treatment in private hospitals and clinics. Why can’t the military just pay for private care just like traditional Medicare? Why should they go through Aetna, United Health Care, Cigna, etc.? What is there to gain other than wasting money on obligatory extraction of corporate profits from the already insufficient funds allocated to veterans’ health care?

    Not to mention the “little” detail of vouchers, which are not likely to cover all veterans’ needs for very long (just like the proposed Medicare vouchers). I believe veterans, who already “enjoy” the freedom to be destitute and homeless, are not seeking the additional freedom of having to go without health care.