Ted S. Warren/AP Photo
U.S. Army veteran Gene Moy, 103, is helped out of a building at the VA Puget Sound Health Care System campus in Seattle after receiving a COVID-19 vaccination, February 23, 2021.
The recent reintroduction of a Medicare for All bill in Congress, with the promise of hearings in the House Energy and Commerce Committee, offers another step on the path to providing health care for all citizens. But as the conversation continues, policymakers and single-payer advocates could take lessons from the successful system already within our borders.
More than a decade’s worth of scientific studies have established that the Veterans Health Administration (VHA) delivers care that is not only equal, but often superior, to that available in the private sector. Although studies have consistently documented that veterans with cancer, hypertension, diabetes, renal failure, and mental-health problems get better care from the VA than non-veterans with private insurance or Medicare, this data trail was missing one piece of evidence. There was no apples-to-apples study that compared the outcomes of veterans getting care from the VA with care veterans receive in the private sector.
Now, we have the crucial evidence that should settle the debate about VA privatization once and for all. This, along with many other studies, should also become part of the arsenal of Medicare for All boosters, who often rely on examples of international health care systems to argue for the public funding of our own.
The latest study on VHA care was done by three academic economists from Stanford, UC Berkeley, and Carnegie Mellon University, and affiliated with the National Bureau of Economic Research. The study categorically demonstrates that veterans who get their care at the VA live longer during and after a medical emergency than those receiving non-VA care. This trend holds not just for the VA system overall, but at every single one of the 170 VA hospitals. The economists were so impressed with the VA’s results that they coined the term “the VA advantage” to describe it.
To uncover this “VA advantage,” the economists analyzed seven-day, 28-day, and one-year outcomes of 400,000 emergency ambulance rides of veterans aged 65 and older who were “dually eligible,” able to receive care at either a VA or non-VA hospital. Ambulance drivers independently picked whether to transport to a VA or non-VA. This quasi-random assignment of patients allowed a direct comparison of the effects of VA versus non-VA care on health outcomes.
The results in the VA and private sector could not have been more different. Veterans who were treated inside the VA system for an emergency had a 46 percent reduction in 28-day mortality. Wondering whether these results might fade over time, the researchers tracked the death rates every week after the initial ambulance ride. They found that the survival advantage remained stable for the entire year. This “VA advantage” was, importantly, as large for Black and Hispanic veterans as for non-minority ones—a pivotal finding that should inform the debate about the pronounced and long-standing health care inequalities that are rampant in the private-sector system.
What was even more impressive was the fact that the VA spends less than private-sector providers in producing such markedly better outcomes. The VA reduces per-patient cumulative spending at 28 days by $2,548, approximately 21 percent less than the private sector. In short, the VA is more productive and achieves better outcomes at lower costs.
What produces this VA advantage over private-sector care, the authors ask? The two main factors are elaborate systems of care coordination, and “more effective information retrieval.” Patients at the VA are not subject to what the authors describe as “the high degree of fragmentation across providers in the US private health care sector.” At the VA, health care information technology makes it far easier for VA providers to communicate through a common electronic medical record (EMR). While a ten-year EMR modernization effort at the VA is going through some early growing pains upon its initial deployment in Spokane, Washington (in part, because of the way the contract was awarded), as a whole the VA’s system is far more comprehensive, robust, and efficient than at private-sector providers.
This first VA advantage is amplified by the second one—elaborate models of care coordination that extend beyond notes in a chart. Dr. Rebecca Shunk, a primary-care provider at the San Francisco VA Medical Center and co-director of its Center of Excellence in Primary Care Education, explains just how care coordination works at the VA during a medical emergency: “When one of my patients is admitted to an emergency room, the patient-aligned care team (PACT) in the ER immediately contacts the PACT team in primary care. Primary-care providers, nurses, and medical assistants are immediately notified that the patient has had a medical emergency, and get a discharge summary for the patient.”
Whether the patient is in the hospital or at home, a member of the team calls the patient 48 hours after their ER visit, makes sure they get needed follow-up care, sets up appointments with primary-care providers and specialists, determines any post-hospital home care needs, and may even arrange video visits via the VA’s well-developed telehealth system.
The VA spends less than private-sector providers in producing markedly better outcomes.
“Because we work in a coordinated system,” Shunk continues, “if a patient has a cardiac or other problem we can contact subspecialists. We can tag them on our notes. We can call them by phone. We can consult with them in person or via an e-consult. None of this can be done with private-sector providers. In fact, it’s hard to even get a patient’s record from a private-sector provider.”
The ultimate message of this study, combined with more than a decade’s worth of other scientific evidence, is crystal clear: Privatizing VHA care by outsourcing more services to the private sector is not only irresponsible policymaking, but actually may cost veterans their lives. As the economists argue, VA privatization would “lead to both higher spending and worse health outcomes.”
This is a message that both Democrats and Republicans in Congress, as well as the Biden administration, should take to heart. Rather than being privatized, the VA should be strengthened and expanded, with benefits available to all veterans and their families.
In fact, studies like these shouldn’t only inform political and ethical debates about veterans’ health care but also broader policy discussions about much-needed reform to our fragmented, market-driven system. You don’t have to look to Canada, or the U.K., or Sweden for an example of a government-funded health care program that works. There’s often a homegrown one just around the corner. This isn’t just a political talking point; it’s an ethical imperative. If “VA advantage” coordinated care saves lives, improves health outcomes, and saves money, the same type of care should be available to all of us.
