Why the VA scandal is a red flag for single-payer advocates

Why the VA scandal is a red flag for single payer advocates

“I will not stand for it.”

That’s what President Obama said about the deepening VA health care crisis.  It’s also a lightening rod for how partisans want to frame the ongoing health debate.

Some are eager to link the VA scandal to Obamacare, and more broadly, government-run health care.

Others extol the virtues of the VA, holding it as an ideal of what our health care system should look like.

The truth, as always, probably lies somewhere in the middle.

In USA Today, internist Katherine Chretien reminds us that the VA still does good, and that the scandal shouldn’t overshadow that.  She points to various studies showing that the VA outperforms private insurers in various quality metrics (assuming, of course, that those numbers haven’t been doctored):

Researchers found that the VA outperformed Medicare fee-for-service care on all 11 quality measures chosen in a study published in The New England Journal of Medicine in 2003. A study published in 2005 by the RAND Corporation compared VA care with a national sample and found that VA patients were more likely to receive recommended standards of care. A 2011 study, focused primarily on whether there were racial differences in care, showed that overall quality of care in the VA continued to increase from 2000 to 2009.

My first clinical rotation as a third-year medical student was in the VA, and I have done many rotations there, as well as shifts in the emergency room.  I saw first-hand the benefits of an integrated system, and more important, the strengths of a unified electronic medical record.  No question that the VA has some good things going for it.

On the other side are those who want to use the VA scandal to indict Obamacare.

In a Boston Herald column, commentator Adriana Cohen writes, “If you want to know what your future on Obamacare looks like, look no farther than the Veterans Administration nightmare that’s unfolding in real time.”

It’s not quite an apples-to-apples comparison, as the Affordable Care Act doesn’t convert our health system to a single-payer model that the VA represents.  Perhaps eventually, but not now.

However, I do think that single-payer advocates (like those proposing a Medicare-for-all scheme) should be a bit worried about the VA debacle.

While there are certainly advantages to a single-payer system, what happens if that single-payer doesn’t adequately fund the system?  Lengthy waiting times and rationed care.  The VA is a case study of that scenario.

In a Wall Street Journal column, William A. Galston notes, “Roughly 42% — $66 billion — of the VA’s budget is subject to annual appropriations,” and that, “the Congressional Budget Office’s latest budget projections showed that between 2013 and 2024, discretionary spending — defense and nondefense — is scheduled to fall from 7.2% of GDP to 5.1%, the lowest share since at least 1962.”

This is at a time when the VA health system will be stretched even further as more troops from Iraq and Afghanistan return home.

The Cato Institute’s Michael Tanner seconds that:

Enrollment in VA services has increased by 13% from 2007 to 2012. Despite a 76% increase in expenditures ($24 billion) over that period, the program still suffers from chronic budget problems. In fact, the Congressional Budget Office estimates that it would require as much as a 75% increase in inflation-adjusted funding for the VA to treat all veterans.

The government has a track record of underfunding their single-payer health models.  Consider the Indian Health Service.   A 1787 agreement between tribes and the government obligated the U.S to provide American Indians with free health care on reservations.  But the government hasn’t kept up its end of the bargain.

In a 2009 Associated Press story, “About one-third more is spent per capita on health care for felons in federal prison according to 2005 data from the health service,” and “American Indians have an infant death rate that is 40 percent higher than the rate for whites. They are twice as likely to die from diabetes, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease.”

So, do the troubles at the VA portend a bleak Obamacare future?  Not necessarily.

However, it should be a red flag for those who want a national single-payer system in the United States.

Why the VA scandal is a red flag for single payer advocates

Kevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • ninguem

    So…….the VA proves they are really good at following checklists.

    And when they don’t, they are very good at using the sovereign immunity of government to hide the truth.

  • SteveCaley

    Unfortunately, Kevin, it may be too late. The die is cast. When/if the crash happens, and American Healthcare collapses, there will be no requests for opinions or smiles in debate. There will be a single-payer, a national payer, if the planes hit the building. I hope that we don’t have another 9-1-1 moment, but if healthcare does that, it’s all Federal, and no more ands ifs or buts.

    • DeceasedMD1

      I am less optimistic but interested in how you see this coming with your crystal ball. We have had great discussions on Shelley and the Byzantine Empire.
      A federal program would require some ability for the federal govt to function and stand up to privaTE industry. And I just don’t see all the Corp Med types giving up or going broke with nearly 20 percent of the GDP.

      • Arby

        They’ll find a way to pay them off and still let them run things. See Sallie Mae.

        • DeceasedMD1

          unfortunately that is what I was thinking too. Let’s hope we’re wrong.

  • QQQ

    Great article to read
    “The Myths of Single-Payer Health Care” By David Hogberg
    http://jenkinsfamilyblog.wordpress.com/2009/08/23/the-myths-of-single-payer-health-care/

  • QQQ

    Read about Dr. Jacques Chaoulli that you won’t read about in mainstream media. From Wikipedia, it says the following,

    “In 2005, Chaoulli launched a court challenge against the Quebec government with the Supreme court of Canada arguing the Canadian implementation of publicly funded health care was not effective at delivering an adequate level of care.[1][3] After losing in two lower courts, he won the Chaoullii v. Quebec (Attorney General), the Supreme Court’s decision on the case, causing a change in the Quebec government’s policy on wait times and privatization”.

  • Patient Kit

    Sigh. I’m not deluded enough to think it would be easy or perfect, but I’m one of those single payer advocates if the only alternative is that millions of Americans can’t access medical care at all. The human collateral damage of our current “we just can’t help everybody” profit-driven system is just too brutal for me to accept.

    Right now, I feel like the only real guarantee, in our current system, of being able to get good medical care is to have enough money. It’s worth noting that the people making the most money off our current profit-driven corporate healthcare system — and, no, I don’t mean doctors — can afford all the good healthcare they and their families need. To those overpaid corporate executives, not being able to access needed healthcare is, at best, an abstract concept. They and everyone they know can afford good healthcare. And they have a real personal interest in keeping it that way.

    I know that Medicare, the VA and Medicaid (which I’ve had the dubious “pleasure” of experiencing this past year firsthand and which saved my life) are far from perfect. But I bet you don’t find many Americans totally opting out of those programs either.

    With all the brainpower in this country, can’t we learn from what is and isn’t working in those programs and in single payer systems across the world and somehow come up with a single payer system that will work for everybody, including for Congress members and the President? Or do we just have to accept that there isn’t enough to go around and in order to get ours, somebody else has to have none. Maybe some people can evolve and learn to chew their own wounded body parts off.

    What? You did expect me to pop up in this thread, yes?

    • Lisa

      Amen!

      • Patient Kit

        At least I can acknowledge that a single-payer system won’t be easy or perfect. Some of the recent posts here advocating DPC have nearly sent me over the edge with their uber enthusiastic, almost evangelical, hard sell promotional, healthcare is a business but the money should go directly to me, too-good-to-be-true tone.

        • Lisa

          DPC sounds like it could work for individuals and small business. But I don’t think it will work for larger employers, unless it some insurance company figures out a way to bundle membership in a DPC practice (or clinic?) with insurance that covers items beyond the scope of a DPC practice. From the limited amount of poking around I’ve done on the internet, I think that maybe beginning to hapen in certain markets. Cigna was one insurance company that is doing this and as DPC is allowed under the ACA I suspect more insurance companies will be interested. The other thing I noticed is that some coporations are starting direct care practices.

          If DPC is such a great way to run a business, I think insurance companies will find a way to make money off of it.

        • ErnieG

          You’ll have to get over problem with “profit motive”. Very few work for free, and physicians will never do so. If the ideas of a physician profiting scares you, then perhaps you will have a hard time understanding solutions.
          What you need to ask is this: how can profit motives of provider align with the particular goods or services provided by that providerl? How can that individual protect himself from “greed” of the provider of goods and services? A free market is the best way, where buyer and seller exchange goods and services. We all know that medical care is not a perfect market, nor should it strive to be so. But DCP is very close to creating a market for most outpatient management of medical problems, with insurance picking up higher costs.

          • Patient Kit

            I do not think doctors should work for free. My problem with the profit motive being the main driver in our system is more about the profit motives of hospital corporations, pharma, insurance companies overriding the well-being of patients (and doctors). Right now, our healthcare system is a big business — one of the biggest buisinesses in our country. And I don’t believe healthcare should be a big business. In big business, the bottom line and maximizing profits for the few top dogs is the priority.

            I’m all for a fair salary for all doctors and I’m in favor of subsidizing medical education for docs. What do you think would be a fair salary for a primary care doc? Last year, the median income (after expenses, before taxes) was $176,000. You may not think that’s enough but you’re going to have a hard time selling it to the American people that an income of $176,000 (after expenses) is working “for free”. It will be an especially hard sell to those Americans who wouldn’t have access to this better care.

    • Mike Henderson

      “I feel like the only real guarantee, in our current system, of being able to get good medical care is to have enough money.”

      My take on this is that there is plenty of money in the system – so much is misdirected in many different directions.

      So far as the current health care system goes, I don’t believe it is free-market. If it is free-market, it is very unbalanced. Insurance companies and the government hold too much power and what is needed to appropriately redistribute money is a level playing field between patients, physicians, insurance companies and the government. That’s where DPC comes in – it cuts out the insurance companies and the government in the primary care setting.

      So far as working for free, it can be argued either way as you do that $176k is plenty or as others physicians post in response. I would frame it this way – if I were to practice medicine as trained and really put the patient first, I would literally be practicing for free. The only way I can get paid a salary in a typical clinic is to see twice as many or more patients per day than is reasonable to provide optimal care.

      Anyway, keep posting. ;)

      • Patient Kit

        I agree that there is plenty of money in the system. There has to be since Big Health is one of the biggest industries in America. But too many individuals don’t have enough money personally to access our system.

        I also agree that the power imbalance is out of control and the playing field does need to be leveled. Re DPC, I like the idea of cutting out the too powerful insurance companies and government that get between patients and doctors. But I think, if the majority of primary care converts to direct pay/cash only, it will leave too many people without any access to primary care. My mind is not totally closed to DPC but it’s presented here as a little too good to be true and any real questions are met with talking point sales pitches. That makes me suspicious and wary. I’m not saying that a single payer system is the only answer or one without problems. I just want a system that does not leave out millions of Americans.

        As for the median $176,000 income (after expenses) for primary care docs, I’m not saying that it’s enough or not and I acknowledge that you have to see far too many patients to make that. I’m just saying that with that income figure out there as public info, you will never sell the idea to the American people that you are working for free. All my years as an activist and strategist, tells me that that is just not a good strategy for docs to go with if you want to build a strong coalition with patients.

        I don’t pretend to have all the answers, but I am passionately committed to finding and implementing
        answers together that will work for both docs and patients.

        LOL!, I’ll keep posting here, much to the annoyance of some of the docs here, I’m sure. I don’t mind being an unpopular minority voice of dissent if it sparks good discussion. When I first started posting here a few months ago, I was told (by patients) that, in general, docs don’t respond to patients’ comments here on KMD. I don’t find that to be the case at all. I can’t keep up with you guys. I find the discussions here to be mostly intelligent, important and open-minded and very very difficult. I often sob as I post here. There is a lot at stake for all of us.

        • Mike Henderson

          “I don’t pretend to have all the answers, but I am passionately committed to finding and implementing answers together that will work for both docs and patients.” …Ditto.

          If the entire primary care system was DPC, that would leave out people, but we of course have no way of knowing the percentage. That is a legitimate concern. But if one thing leads to the next, what if 75% of people were on DPC, costs were driven down (of course this is unknown as well), then it would be a lot easier to get those at the low end of the income scale a lot easier, somehow, access. There certainly isn’t a single solution.

  • ErnieG

    A few things

    1)
    The VA is not really a “closed health system.” The VA is not often able to provide the appropriate services to its patients, and often has to source out care. At my local VA which is a hospital with specialty services, hemodialysis (chronic and acute) and acute coronary services are sent down the road to a local community hospital and tertiary academic center, respectively. Furthermore, many VA patients who can often have “civilian” docs as well as VA docs. Any talk about the VA as a model for care can’t forget how the VA and its vets non VA services.

    2)
    The real scandal, in my mind, about the recent “fraud”
    is who, in their right mind, knowing how any VA works, would think that the goal of having vets evaluated within 14 days for specialty services is
    reasonable, and would not expect “fraud” to take place. The VA is a complacent, bureaucratic and sclerotic institution with short sighted middle and upper managers who have little vision or incentive on how to solve problems. In my part time tenure there, and as a resident, the VA management fails to impress. Individual Orthopods could not do more than 1-2 knee replacements a day because it took 2-3 hours to clean a surgical suite. Obama, in classic ignorant politician phenotype, vows to make heads roll; he should be asking why such “fraud” had to take place. (As an individual expression of cognitive insufficiency, he has no clue on the delivery of medical care, other than what his former hospital administrator wife can babble to him) Top down management
    with no real incentive to provide quality care is rampant in the VA.

  • QQQ

    We can’t have Single Payer in America. Medicare and Medicaid are
    breeding grounds for crooks to take advantage with fraudulent claims and
    steal hundreds of millions (if not billions) of the tax payers money!
    California has a greater population than the country of Canada, and the
    state is broke! If that is from one state ALONE, what do you think about
    the other states that are in a financial crisis as well?

    Plus, the latest scandal with the VA is another fine example how the government cannot handle a single payer system!

    With over 318,000,000+ in the U.S., the government is broke, MASSIVE
    fraud, millions of Americans and illegals not working and/or paying
    taxes its not theoretically possible in this multicultural society to
    have that type of healthcare system!!

  • Vikas Desai

    i don’t understand why we even talk about single payer health systems?? does anyone really think well point and aetna and united will just say goodbye?? really? what you need is more oversight on the existing insurance companies and that they pay their docs a fair wage…

    • Lisa

      I hate to say it, but I think you are right.

    • ErnieG

      I think what will happen is that this system will be so unsustainable for physicians and patients, that corporate profits will soar (and hence create a target), and that the pubic mood will be so discontented that there will be political pressure to move into a single payer structure.

      • Patient Kit

        Enter Hillary Clinton to clean up the Obamacare mess?

        • ErnieG

          Maybe, but I think it will take a little bit longer than the present 2016 election cycle, perhaps 8-10yrs.

          • Patient Kit

            I agree that it will take some time to clean up our current mess. Hillary Clinton’s second term? ;-)

  • Patient Kit

    I agree. Whatever system we have, there will be people exploiting and defrauding it for their own personal financial gain. If the potential for fraud is a reason to reject the idea of a single payer system, then it follows that rampant unnecessary prescriptions and procedures and upcoding (corporate fraud) for the “good” of the corporate bottom line, is a reason to reject Corp Med. We need a better healthcare system and to crack down on the criminals who exploit it.

  • DeceasedMD1

    The VA has always had a reputation of being incompetent. I think it is a cultural thing as well with the attitudes of bureaucratic admins and gov’t workers who run the system. But i dont know if it has gotten even worse then when i rotated there but it was never pretty shall we say. According to the news it sounds that way but I am sure there have been a lot of mistakes never reported prior.

  • Thomas D Guastavino

    First, I am glad to see that the public may be finally waking up to the fact that the VA scandal may have been greatly aggravated by their attempt to follow some “quality” metric. Second, we physicians would be more then happy to work in a single payer system as long as at the same we can have a union. It would be the only way to level the playing field.

    • Patient Kit

      I would whole-heartedly support a strong doctors union as a condition of a single payer system in the US. You really should be organizing that movement and support for a union among yourselves now. Start by reaching out to unionized doctors who work in single payer systems in other countries to tap their experience, advice and solidarity. And reach out to other strong professional unions in the US for help navigating labor law specific to the US. Doctors could have the power you deserve in our healthcare system, if you’d only get organized and start working together as a group on your work condition issues. Someone among you needs to step up and provide some strong and courageous leadership. The sooner, the better.

  • QQQ

    The nine most terrifying words in the English language are,

    ‘I’m from the government and I’m here to help.”

    -Ronald Reagan-

  • Patient Kit

    What amazes me is when I hear senior citizens say that they are dead set against government involvement in healthcare and that they hate the idea of a single payer system — BUT they would never want to give up their own Medicare coverage themselves.

    • EmilyAnon

      Many people oppose government “give-aways” after they’ve got theirs.

      • Patient Kit

        Yup. It’s truly amazing/annoying/frustrating/angering how the generation that benefited so much from the GI bill and Medicare are so adamantly against government “handouts” for other people. Other people, being the key phrase in that thought process. It’s like they don’t even think of the government programs that helped them as government programs. >:-(

        • EmilyAnon

          And look at all these other government programs that many just take for granted without a thought how they’re funded:

          • Patient Kit

            Those are some truly mind boggling stats, Emily. For starters, roughly 40% of Social Security, GI Bill, Veteran’s Benifits and Medicare beneficiaries say they have not used a “government social program”? And the list goes on. How is it possible for the human mind to work — or not work — that way? Where do they think the money came from?

          • ninguem

            Fair enough, though I’ll quibble with a few things.

            I’d say the GI bill is a quid pro quo. To say the GI bill is some sort of government handout is like saying the soldier’s pay is a handout. It’s part of the deal for that soldier’s military service.

            Many of the programs you mention can be summarized as the government saying “I will steal less of your money if you do what I say.”

            Some of the other programs, tax deductions for behaving in certain ways, such as 529′s, the various tax credits. “We will confiscate all your money, and if you behave in certain ways, we will take less of it.” Hardly a handout.

            And I would extend that to Social Security. If offered the choice of paying Social Security taxes versus getting to keep my money and paying into a private retirement plan with a disability policy, I’d take the private coverage in a heartbeat.

            Of all the ways to organize retirement financing, I can’t think of a worse system than Social Security.

          • EmilyAnon

            I agree that the GI bill doesn’t belong on that list. But what do you do with people who woudn’t be responsible with saving for retirement. It would probably take a couple generations before people would fear being left out in the cold if they didn’t get on board. Interestingly when the concept of means testing for SS was floated, the biggest squawkers were well-to-do folks..

          • ninguem

            They say Social Security is the Third Rail and all that, touch it and you’re dead politically.

            I don’t think so. The Baby Boomers will be the last generation to benefit from Social Security, and I’m not so sure about the Boomers at the tail end of the generation. Beyond that, the subsequent generations will be paying through the nose for my benefits, and little left for them when it’s their turn.

            What to do about the irresponsible?

            General relief.

            I don’t know why we have to set our policy based on stupid people.

  • disqus_sBKZDGKiG8

    The VA is inefficient. Ask anyone who works in that system.

    The biggest aspect of this scandal is not a health care system under stress and not meeting its goals. It is a story of corruption. These facilities were destroying data to hide their short comings.

    Government corruption. Short and simple.

    If it were not for bitter partisan politics, this corruption would continue unabated.

  • EmilyAnon

    Lots of people are taxed and get nothing for it. How about property taxes funding schools when the taxpayer has no children. In California this is easily thousands of dollars a year on a mediocre house. The rationale is that in a civilized society everybody should contribute toward the public good, whether they personally benefit or not. Unfortunately fraud, corruption and political shenanigans always get a foothold in any public program and understandably create cynics.

    • Paul C. Norton

      Social security wasn’t and isn’t a tax. You contribute in to receive it. That why you didn’t see it means tested.

  • Paul C. Norton

    We have one thing that is single payer, government. See how efficient that is.

  • Jenny Jackman

    The VA is where military goes after they have left service. What about Tricare, which is what active duty members, retirees, and their families receive? This is also a single payer system run by the government.

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