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June 03, 2014 11:42 AM VA Care: Still the Best Care Anywhere?

By Phillip Longman

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title Best Care Anywhere, Why VA Health Care would be Better for Everyone, it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominant media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of health care delivery system reform.

I don’t mean just the fulminations of the right wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as, Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.

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