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.