Whatever the VHA’s Flaws,
Private Healthcare’s Worse
Tuesday, January 22, 2019
Injuries incurred by service members are covered by the Veteran Administration. (Photo credit: Wikipedia)
This post is a follow-up to my last post on the troubled Veterans Health Administration (VHA), which is under renewed scrutiny following revelations of patient treatment delays that were concealed to make some VHA services look better and generate bonuses for select administrators.
This has created sufficient scandal to prompt the resignation of the former Secretary of Veterans’ Affairs. And, predictably, it’s rekindled the usual bromide of our purported need for more private sector options for our veterans.
While useful as a temporary measure to alleviate patient backlogs while a new Secretary attempts to find more permanent solutions, any long-term shift of veterans health services to America’s private sector would be a mistake on several fronts.
Bad For Them, Bad For Us
For starters, our private medical system already has too few physicians to accommodate the increase in patient demand from the Affordable Care Act (Obamacare). Compounding this shortfall with another influx in patient demand from the VHA will only exacerbate the predictable access problems all patients are now facing in America’s private healthcare system.
And from the perspective of our veterans themselves, our private healthcare system has nowhere near the level of medical sophistication as the VHA when it comes to veterans’ unique healthcare needs. This is especially true in the areas of physical rehabilitation and post-traumatic stress injury that disproportionately affect veterans.
This is why I’ve decided to risk jeers and dismissal by excerpting the following from one of my books. It’s especially timely and – the current brouhaha notwithstanding – I’m sticking to my brazen position that we’d be far better off with an EXPANDED VHA than the path we’re now on with our private healthcare system (see Our Healthcare Sucks for elaboration).
And the fact that there was such a substantial turnaround in the VHA in the 90’s under Bill Clinton shows that it can be done – and done again. Indeed, it will far easier – though hardly easy – to return the VHA to its proper functioning than it will be to repair our more fragmented and unmanaged private healthcare system that’s in every bit as great a need of restructuring.
The premise of those advocating for privatizing the VHA – and these would be the usual private sector apologists – is that our private healthcare system functions much better than the VHA. It does not – and the evidence to that effect is overwhelming.
It’s important to remember that the VHA controversy is about inhibiting access to care rather than the care itself, which appears to outperform private healthcare in America on a number of fronts.
Which is why what we actually need is…
MORE VHA Health
When it comes to medical care, the VHA – whatever its faults – performs better, on average, than private sector American medicine. It has ample room for improvement, of course, but it’s far better than our fragmented private medical “system”.
The VHA’s biggest problem is the chronic underfunding it shares with America’s public health system. The Congressional Budget Office reported that, from 1999 to 2005, per capita spending on private healthcare in the U.S. increased 29.4%, while per capita spending for VHA enrollees increased only 1.7%.
Despite this financial disadvantage and the drag of a cumbersome bureaucracy, the VHA has undergone a remarkable transformation and now provides better quality care than private sector medicine in America.
In fact, despite having a patient population that is older and sicker, a study of cardiac bypass (open heart) surgery at a VHA hospital vs. private hospitals found that the VHA mortality rate was about half that of the private hospitals (1.6% vs. 3.0%).
This is especially remarkable considering that the VHA patients had rates of comorbidities like diabetes, heart failure, and prior heart attacks that averaged almost double that of the private hospitals’ patients (that means they were twice as sick yet had only half the deaths.)
Another study of preventive, acute, and chronic care indicators…found that the VHA “Performed significantly better on all eleven similar quality indicators…the V.H.A. outperformed Medicare (private fee-for-service) on 12 of 13 indicators”.
A more recent study compared use of 17 recommended ambulatory care services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention and found that “Adults receiving VAMC (VHA) care remain more likely to receive recommended ambulatory care” compared to patients receiving care in private sector American healthcare”.
Examples include 10% greater use of cholesterol screening and 40% greater use of colorectal cancer screening.
Government-supplied healthcare at least eliminates the profit incentives that drive excess medical treatments and spending that are responsible for much of our poor medical performance in private sector healthcare in America.
Private Healthcare’s WORSE
Again, it’s not that the VHA is ideal, by any means – it’s that the private sector is worse.
While the VHA was found in a RAND Corporation study to provide “appropriate care”, as defined by medical experts, to 67% of patients, the private sector of medicine in America provided it only 55% of the time. That’s over 20% better performance.
One out of three odds of getting inappropriate care with the VHA isn’t great, but it sure beats the almost one out of two odds found in private practice in America.
The VHA is better organized, less fragmented, and better automated with electronic medical records than private medicine is or is likely to become over the next decade. A comprehensive study of error rates found government hospitals had 77% fewer medication errors that affected patient outcomes compared to private hospitals.
The VHA has already undergone the transformation that policy analysts prescribe for private medicine, but that few anticipate actually occurring anytime soon. Most importantly, it’s better organized than private medicine – which continues to mostly operate as independent fiefdoms – and can therefore be more readily improved than a private medical system focused primarily on personal and institutional profit.
Better Access Than the ACA?
Opening a beefed-up VHA network to the uninsured for non-emergency medical needs (under Obamacare) would be a quantum leap forward for the uninsured at a more affordable cost than dumping them into our chaotic private medical “system”. They would be less likely to be exposed to unnecessary procedures and hospitalizations that pose high risk for treatment-induced disease and even premature death.
They would be more likely to receive coordinated care due to the VHA’s extensive experience with electronic medical records – automation that much of private medicine continues to evade in defiance of safety concerns and the automation of other professions.
Funneling many of the uninsured through a beefed-up VHA network would also avoid the increase in patient demand in the private sector that Obamacare will produce – an increase with no off-setting increase in physician supply.
Expanding the VHA for this population would increase their access to medical care without penalizing current Medicare and Medicaid beneficiaries whose medical access is likely to suffer as providers cut back on serving them due to more patient demand than they can handle.
The VHA is also better prepared to care for aging consumers’ than private physicians, many of whom refuse to accept Medicare patients and are ill-prepared for diseases of aging. The VHA also has a much better balance of primary care to specialty physicians than the private sector, which all the evidence supports as offering both better quality and less expensive care.
Further, VHA doctors are employees – much like those at the successful private sector delivery models like the Mayo Clinic and Cleveland Clinic and a score or so of the most efficient, cost-effective, and highest quality private providers. They obviously aren’t paid as well in the VHA, but capital invested in upgrading their incomes and capabilities would likely prove more productive than the billions we’ll waste in further subsidizing our fragmented and error-prone private medical sector.
VHA’s Unmatched National Network
The VHA infrastructure is unmatched in private medicine – a national network, fully integrated, with years of electronic medical records experience that’s fully integrated with its clinical, financial, and research processes.
Developing a viable electronic medical system that positively affects quality, coordination, and costs isn’t as simple as installing the technology. It takes years of developing “buy-in” among the affected physicians and developing a clinical culture that embraces and enhances the practical utility of the technology.
Investing in building on our VHA infrastructure to better serve the uninsured, and perhaps others, may be the only viable solution to our seemingly overwhelming medical challenge.
This common sense measure wouldn’t negate our need to actually reform the way we currently deliver and pay for private-sector medical care.
But at least it wouldn’t compound the problem as Obamacare is likely to do – and as free-market healthcare would do in spades. And the upside potential of developing a national integrated delivery model for chronic diseases that consume 75% of our medical spending is unmatched by anything the private sector has to offer.
Expanding a dysfunctional medical market instead of leveraging the only national delivery model in existence – one the federal government controls without relying on the goodwill and income priorities of private providers and insurers – is irrational and counterproductive.
But that is what we have with health reforms of either political party’s doing.
Common Sense Has No Place in Politics
Investing a fraction of the amount Obamacare will cost into expanding the VHA to accommodate a substantial share of the newly-insured – perhaps in coordination with the national network of community health centers to augment the VHA’s own network of ambulatory care clinics – would likely yield a far better return on investment without compounding the problems found with expanding the private sector of American medical care.
But such an obviously superior solution would raise hackles on both political extremes. Imagine the consternation a “public provider option” like an expanded VHA would provoke – true government-run healthcare – when the relatively tepid “public option” for mere insurance managed to provoke such political backlash.
And the left would castigate it as second-class care even though it’s good enough for our veterans and their families, who deserve the best we have to offer (infusing the VHA with the kind of funding needed for such an expanded role could also serve to improve care for current VHA beneficiaries, whose needs often remain neglected due to underfunding).
The right would cry “government-run healthcare”, and they’d be correct. But it wouldn’t be government-run healthcare for everybody, only the uninsured – meaning it would have no impact on the insured’s freedom-of-choice. And our veterans and their families do quite well with this “government-run healthcare” every day, at least compared to our error-riddled private medical sector.
Others would find something else to criticize and Washington would feel the need to placate every last critic instead of taking the kind of bold measures that common sense – and financial necessity – dictate.
Government healthcare policy in this country is shaped by ideological extremes when the vast majority of Americans subscribe to neither extreme. This results in the half-hearted measures found in Obamacare that are simply inadequate for what’s needed to redirect our healthcare system on a more sustainable path.
The aggressive approach outlined here would build a stronger public infrastructure to handle our newly-insured – as well as better manage much of our chronic disease burden.
And unlike Obamacare, it’s a sure path to reining in our unsustainable medical spending.
And Obamacare’s antithesis – unproven free-market ideology – is virtually guaranteed to accelerate us into medical hyperinflation that will hasten our national bankruptcy. The evidence from the states that have deregulated their healthcare most aggressively proves it.
Both on paper and in reality, expanding our proven VHA network instead of throwing trillions more into our dysfunctional private medical sector is a “no brainer”. This would prove far superior to compounding all the flaws in our private medical system by exposing millions more Americans to its risks of treatment-induced disease and financial exploitation.
“I Love My VHA Health”
Let me close with a bit of anecdotal evidence…back when Obamacare was being most vociferously debated, a conservative friend echoed the chorus of woes it would bring, socialized medicine being paramount among them.
When I asked him how he liked his healthcare with the VA, he told me he loved it and wouldn’t think of trading it for the private care the rest of his family receives. When I informed him he was the beneficiary of the only true form of socialized medicine in America, you could hear a pin drop.
Are we supposed to laugh or cry that this kind of misinformed dopery is what’s driving our healthcare decision-making?
Feel free to weigh in with your own thoughts below.