VA for All!

We hear a lot these days about Medicare for All.  It has gone from being a fringe idea to being the litmus test for Democratic Presidential contenders, advocated most fiercely by long-time proponents Senator Bernie Sanders and Senator Elizabeth Warren.  A majority of Americans now support the concept, although what they think it means and how much they are willing to pay for it are less clear. 

The arguments for Medicare for All are simple: the current system generates too many profits (especially for health insurers and pharma), has too much administrative complexity, and exposes too many people to high cost-sharing and premiums.  Medicare for All would take care of all those, proponents assert.

So, I wonder -- why would people be calling for a new system that would still have thousands of private hospitals/facilities and millions of healthcare professionals, practicing FFS medicine using countless systems and data structures?  In short, why aren't people calling for VA for All?

Like Medicare, the VA -- more specially, its healthcare component, the Veterans Health Administration -- is charged with providing healthcare to a designed population, in this case, veterans.  Unlike Medicare, though, it does so as an integrated health system (by far the largest in the U.S.), with 170 VA Medical Centers, over a thousand outpatient facilities, and somewhere over 10,000 physicians.

Despite what you might read about problems with wait times (which may, in fact, be overstated) or poor care, studies have found that, generally, "The Veterans Affairs health care system generally performs better than or similar to other health care systems on providing safe and effective care to patients."  For some conditions -- PTSD or prosthetics come to mind -- it offers some of the finest care in the world. 

It offers a range of services that Medicare can only dream of, and it does so at, it is believed, lower costs than private coverage or even Medicare.  Plus, it also was an innovator in electronic health records and is today in telehealth. 

What's not to like?

Well, of course, the VA has capacity issues already, which has led to the Choice program, and we'd need to figure out what happens to all those current health care organizations and professionals.  Some of them would end up as part of the VA -- of course, with lower salaries and fewer administrative functions -- but many others simply wouldn't be needed.  It couldn't happen overnight, of course, but neither could Medicare for All. 

But, hey, as with driving health insurers out of business, some healthcare job losses are a small price to pay for better coverage for more people at lower costs, right? 

Skeptics might think this is just another way of saying the U.S. should adopt something like the U.K.'s National Health Service (NHS), but that can't be true, because those skeptics think NHS is socialized medicine but only have good things to say about the VA.  So what's the problem extending the VA to more of us?

The truth is that Medicare for All isn't really about lowering administrative costs or expanding coverage, but about picking two of the least popular parts of the healthcare system to criticize.  Health insurers and pharmaceutical companies are seen as big, faceless corporations, usually located somewhere else.  They're not your local hospital or personal physician, and they don't directly deliver care, so people feel free to criticize them at will. 

Credit: Patrick George/Kiplinger

But there's nothing that Medicare for All could do that an expanded VA for All couldn't do better.  It's just a simplistic, easily packaged catchphrase as a "solution" for a fiendishly complex mess of a healthcare system.

I don't think "VA for All" is the right solution either, but I also think that proponents of Medicare for All are not being quite honest about what they are proposing, or what it most likely do (as I've outlined previously).  Political campaigns are probably not the best time to have serious health reform debates, but it seems that that is when we usually try to have them. 

There's a lot wrong with our current healthcare system, and that includes with both Medicare and the VA.  I like a good health reform discussion as well as the next person, but I don't have much patience for "solutions" that gloss over realities and don't really address the true underlying problems. 

The core problems, I believe, are that we often don't really know what "works" in healthcare, or how to truly gauge quality of care. Wake me when we get to reform discussions that address those.