Should We Be Concerned About Privatization of the V.A.?

Yesterday, the House passed a bill to address problems at the Department of Veterans Affairs on a 421-0 vote, a kind of unanimity usually reserved for resolutions honoring astronauts or declaring Necrotic Hangnail Awareness Week. The Senate's version is likely to be voted on in the next couple of days. It happened because of some features of this particular scandal: that both sides sincerely wanted to fix the problem, and that the opportunities for demagoguery were limited. While the bill has a number of provisions including steps to replace the outdated intake system and to hire more doctors and nurses, the one most directly intended to address the backlog of patients would allow veterans who haven't been able to get an appointment, or who live 40 miles from the nearest VA medical facility, to get care at private medical providers. Is this something for liberals to be worried about? Since we embrace nuance here at the Prospect, the answer is: maybe.

It's important to remember that the actual medical care veterans receive from the V,A. is considered by the medical community and by veterans themselves to be of extremely high quality; the problem they face is in getting in to receive the care in the first place. It seems like a reasonable stopgap measure to allow vets to get reimbursed for private care if they find themselves on an endless waiting list (an internal V.A. audit released on Monday found that the department's goal of giving all patients an appointment within 14 days was simply unattainable given the huge numbers of veterans seeking care, and 57,000 vets had waited at least 90 days for their first appointment). Because right now, unless a few thousand doctors are going to suddenly quit their jobs elsewhere and come to the V,A., there doesn't seem to be another alternative.

But there is a down side to this private option. As Philip Longman argues, outsourcing V.A. medical care compromises the very thing that makes it so good: coordination. The V.A. was a pioneer in the development of electronic medical records, and its record of quality care comes in large part from the fact that it's a unified system. If you're a veteran who lives in Florida and you walk into an ER at a veteran's hospital in Oregon, in seconds the doctors and nurses there will know every medication you're on and every procedure you've had:

Because the VA truly is a system, it can coordinate among all the different specialists and other health care providers who are necessarily involved in patient care these days. And because it operates as a system, the VA can also make sure that all these medical professionals are working from a common electronic medical record and adhering to established, evidence-based protocols of care—not inadvertently ordering up dangerous combinations of drugs, or performing unnecessary surgeries and tests just to make a buck.

In short, as I explain further in my book Best Care Anywhere, the VA can treat the whole patient as opposed to one body part at a time. And due to its near lifelong relationship with its patients, which often extends to long-term nursing home care at the end of life, the VA also has incentives for investing in prevention and patient wellness that are largely absent elsewhere in U.S. medicine.

As strong a case as Longman has, there's still an immediate problem that requires a solution, and in the short run the V.A. just isn't going to be able to hire enough medical professionals to solve it. There are certainly many things the department needs to do to make itself more efficient, but in places where there are lots of veterans, they just don't have the capacity to serve everyone in a timely fashion, at least not at the moment.

Nevertheless, it sure looks as though Republicans are using the V.A. scandal as an opportunity to push privatization of medical care, a key goal for them when it comes not only to the VA but also to Medicare and Medicaid. As Ed Kilgore said: "They know a camel's nose under the tent when they see it." And the consequences of V.A. privatization could be more serious than with Medicaid or Medicare. Those are insurance programs and not health-care programs; privatization could make them more costly and less efficient, but privatizing V.A. health care would lead more directly to worse care for the veterans everyone says they care so much about.

The lesson is that once we deal with this immediate backlog, the department, Congress, and veterans' advocates have to work to make sure the V.A. really does improve its systems, finds ways to become more efficient, and hires more medical professionals. That way it can continue to do what it's already doing well, and forestall the threat of a Republican effort to undermine it.

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