Editore"s Note
Tilting at Windmills

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September 14, 2007
By: Phillip Longman

LONG-TERM CARE AND THE VA....Kevin wonders why, in "Best Care Everywhere," I say that the VA's near lifetime relationship with its patients, which it has always had, is a key to its current success.

In part the answer is that the VA was never as bad as portrayed in movies such as Born on the 4th of July. As detailed in my book, Best Care Anywhere: Why VA Health Care is Better Than Yours (Polipoint 2007), activists long ago admitted to stage setting at least some of the outrageous conditions chronicled in the media during the post-Vietnam era. It's also true that as a very large, public institution the VA is routinely subject to high levels of scrutiny. Failings that go unreported elsewhere in the health system become instant headlines and the subject of congressional hearings when they occur at the VA. Opponents of "socialized medicine" also long have had a high stake in pointing to any shortcomings in its only actual example in the U.S. The VA thus has a built in PR problem, as do all government run health care systems around the world. Yet even when the VA's reputation was very low compared to today, veterans groups strongly resisted proposals to replace VA health care with vouchers. Most vets who use VA health care prefer it to private sector health care, and always have.

So the VA never was that bad. Still, why did it get so much better during the 90s, both compared to its past performance and to other providers? Partly it's a matter of inspired leadership. In larger measure, it's a matter of the changing nature of illness. The improvements the experts are talking about are largely in the realm of preventing and managing long-term chronic disease, which have become the leading causes of death in modern populations. This change is key to understanding the VA's superior performance. In the treatment of acute care injuries and infections like pneumonia, it doesn't matter much if there's a long-term relationship between patient and provider. You either get the right short-term treatment or you don't, then recover or die. But now that more and more of us are living long enough to die of heart disease, cancer, and especially diabetes, which by their nature require long-term, highly coordinated care to prevent and manage, it has come to matter a lot if we are treated by an institution that has a stake in our health five or twenty years down the road.

Phillip Longman 5:51 PM Permalink | Trackbacks | Comments (21)

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Comments

I would respectfully disagree with the author--I worked in a VA in the late 70s, and went to a school that housed a VA hospital in the early 80s (UC San Diego).

Everything about it was shoddy. Schizophrenics and alcoholics--urine soaked and untreated--wandered the premises. Patients were not well treated, and the quality of doctor at the time was awful--several of the doctors at the VA hospital I worked at had lost their licenses in different states.

It was a treater of absolute last resort, for patients of last resort. It performed only warehousing functions, and not very well.

In short, it fully earned it's reputation of the period for sucking.

Posted by: Osama Von McIntyre on September 14, 2007 at 6:17 PM | PERMALINK

Here in the U.S., we have the best emergency care in the world. While developing the technology to make this possible, though, we have almost completely ignored the technology that would make long-term care more effective. This isn't medical technology so much as information technology - technology to track and coordinate care. The VA has developed effective strategies for this, and the rest of the country needs to follow in their footsteps.

Posted by: Craig Wilcox on September 14, 2007 at 6:19 PM | PERMALINK

...activists long ago admitted to stage setting at least some of the outrageous conditions chronicled in the media during the post-Vietnam era.

That's interesting. Are activists still doing this?

Posted by: harry on September 14, 2007 at 6:38 PM | PERMALINK

I'm a retired USAF officer. With Medicare and Tricare for Life, I have very good insurance, and I've been receiving very good treatment on the civilian market. Nonetheless, and largely because of reading you and Ezra, yesterday I switched all my care over to the VA. I already receive dental care there, and my experience has thus far been very good. My objection to the otherwise excellent care I was receiving from the community was simply a realization that every little facet of it was treating me apart from all the other little facets. With the VA, I feel I have a chance to receive care for the whole package.

Posted by: terry in az on September 14, 2007 at 6:41 PM | PERMALINK

terry in az: yesterday I switched all my care over to the VA. I already receive dental care there, and my experience has thus far been very good.

Please keep us posted on how it works for you.

My father also receives good non-VA care, but I've wondered if he mightn't benefit from the more comprehensive VA care, including the dental (for which he pays out-of-pocket).

Are there any requirements other than being a vet? He's ex-army (1946-47).

Posted by: alex on September 14, 2007 at 7:29 PM | PERMALINK

I work at a university associated with a VA. The care used to be pretty bad.(I'm talking about the 1980's) Most units were staffed by aides, with one RN covering a couple of floors. Many surgical cases were performed by residents on their own with attendings on-call. Bureaucracy was overwhelming, for instance, to not lose money on building budgets painters were always painting. For some reason there wasn't enough money for adequate supplies. There was no oversight, no staff, no quality benchmarks. There was a time in the 70's and 80's where homeless veterans could spend half the winter with some kind of chronic condition in the hospital.
My father died in the 70's because of a VA snafu.
What was wonderful about the VA was the camaraderie among the veterans--they were there for each other.
My brother currently gets excellent care for his diabetes at the VA, and I'm a big advocate of the system now. It has always been there for the vets, more in the past than now. But it has had it bleak days

Posted by: Ravinia on September 14, 2007 at 7:51 PM | PERMALINK

I agree with the first comment -- I tried to get treatment at the VA hospital in NYC in the early 80's - the place looked and felt like the backdrop for Blade Runner. I now live in rural NC and have nothing but praise for the care rendered locally, and I've been told the improvement is system-wide, but the problems of the past were more than just anecdotes.

Posted by: minion on September 14, 2007 at 8:12 PM | PERMALINK

Maybe this is Bush's healthcare plan - get everyone to join the military, then after they get back from invading Canada and Iceland, they get VA care.

Brilliant!

Posted by: craigie on September 14, 2007 at 8:13 PM | PERMALINK

"First, unlike the 1993 Clinton health care plan, the Vista proposal does not directly take on the medical/industrial complex. It would not require any changes to the private insurance market, for instance, or place any costly mandates on employers. At least in the short term, Vista would be focused on customers who aren't now part of the private health insurance market."
::
"Similarly, imagine that Vista is put into place and works as advertised. Over time, word gets out that the quality of treatment in Vista is pretty good—indeed, better than what most people with employer-provided health care receive. Pretty soon, individuals who are not eligible for Vista start clamoring for the right to buy into the system. And employers, realizing that Vista is doing a better job of controlling costs than their own private-sector health providers, start pressuring Washington for permission to contract with Vista to provide health care for their employees."
----------

PHILLIP,

1) Ok, so what's to stop employers from terminating their health insurance coverage on their employees and telling them to go get VISTA (in effect creating an increased pool of uninsured)?

2) Without a mandate on employers, and "not directly taking on the medical/industrial complex", HOW is this going to be FUNDED should this event take place in quick real time?

3) Wouldn't VISTA be just a tad bit overwhelmed in such a scenario, especially since they are *providing* the health care? It looks to me like an easy way to let employers and private insurers off the hook here.

I'm just asking because you appear to be promoting the VA as a *model* for universal health care not just the cost savings and merits of particular things about the VA such as their medical records system and lifetime patient management system.

Posted by: Doc at the Radar Station on September 14, 2007 at 8:18 PM | PERMALINK

'...why did it get so much better during the 90s, both compared to its past performance and to other providers?
-- Phillip Longman

Two words - Bill Clinton. An elected president who actually had a functioning brain.

Posted by: The Conservative Deflator on September 14, 2007 at 8:37 PM | PERMALINK

Yes, I fully approve of electing wonks to leadership roles. The devil IS in the details !

Posted by: Osama Von Mcintyre on September 14, 2007 at 9:18 PM | PERMALINK

Sorry to burst your bubble, Deflator, but you got no clue.
The attitude of the general public, government beauracrats and elected officials toward Vets in the 70's and early 80's was driven by VietNam.
VA Benefit Claims Officials thought their job was to deny benefits, many VA hospital employees looked at Vets as an interruption of their day that might cause them to actually do some work, and few elected federal officials took up their cause. The Vets and their cause were not popular.
Slowly, improvements were made during Reagan's tenure. However, the one event that was primarily responsible for the turn around in attitudes and treatment of Vets was Desert Storm. The effect was demonstrated in airports, bars, schools, the media, entertainment, bus and train stations, parades, malls, football games, Congress, local politics, and yes, at the VA and its hospitals.
The improvements continue today.

Posted by: majarosh on September 14, 2007 at 9:32 PM | PERMALINK

Yes. The VA improved because veterans were more warmly received at parades and football games. Cogent analysis.

Posted by: Majarosh Deflator on September 14, 2007 at 10:22 PM | PERMALINK

Deflated wrote:
" Yes. The VA improved because veterans were more warmly received at parades and football games. Cogent analysis."


If that's your analysis, I have to disagree with you. If that's your way of making a point, again, I must disagree. If that's you condescending method of proving your superiority, it definitely needs some work. If you believe that was my analysis, try reading again, this time without moving your lips.

Posted by: majarosh on September 14, 2007 at 10:44 PM | PERMALINK

majarosh, dude, he totally nailed your "analysis" and your smug words don't change that. What he said is what you said, only his version was meant to be funny. Yours, apparently, was not.

Posted by: craigie on September 15, 2007 at 12:58 AM | PERMALINK

Well, the simple fact is that all hospitals were kinda sucky in the 70s. I could expand on that theme but I'd rather make breakfast.

Posted by: serial catowner on September 15, 2007 at 8:10 AM | PERMALINK

Apples and Oranges, especially of the Agent kind, majarosh.

Health care at the VA and benefits claims are two different topics - While health care has vastly improved since Clinton became President, benefit claims are still horrendous. There are veterans today, some suffering from Agent Orange, who are racing the Grim Reaper against the stubborness and snail paced reviews of the claims section of the VA - VA claims has become a dumping ground of DoD - DoD encourages and shoves current returnees from the Middle East into the VA claims system - Huge backlogs. By the way, is Clinton still in office? I believe that the VA has hired a slew of "Good Hands" folk from State Farm - Must be the ones who denied so many claims following Katrina - Yeah, Shrub, the Bottom Line President.

Posted by: thethirdPaul on September 15, 2007 at 9:06 AM | PERMALINK

*

Posted by: mhr on September 15, 2007 at 12:13 PM | PERMALINK

Dudes,
I believe the Inflator is capable of speaking for himself.
If one is going to argue against someone's opinion, it would be prudent to counter what was actually opined, not some manufactured, idiotic, obviously erronious theory that was never stated, held, or contemplated. Putting words in someone else's mouth is not playing nice.
Checkout the definition of "demonstrated." Ponder the effect of "attitude" on leadership, mission and progress. Does the sentence "The improvements continue today" indicate there's no room for improvement? I think not. On the contrary, there remains much that needs to be improved. The current attitudes toward Vets creates an atmosphere that is condusive for improvements.
The claims system is slow and often complicated, however there is excellent assistance available to help guide veterans through the system. Also, there are abuses and outright fraud committed by a small number of veterans that harms the legitimately disabled veteran. The Agent Orange Registry and growing list of conditions that automatically qualify any veteran that could have been exposed is another improvement.

Finally, sarcasm, though often humorous, is a poor tool for debate and should not be attempted by the unskilled or those taking certain medications.

Respectfully

Posted by: majarosh on September 15, 2007 at 12:20 PM | PERMALINK
Finally, sarcasm, though often humorous, is a poor tool for debate and should not be attempted by the unskilled or those taking certain medications.

This sentence makes my head explode.

Posted by: Majarosh Deflator on September 15, 2007 at 9:26 PM | PERMALINK

In Need of Ego Deflation: "This sentence makes my head explode."

I'm sorry to hear that. I was trying to get you to laugh.

Posted by: majarosh on September 15, 2007 at 10:52 PM | PERMALINK
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