Best Care Anywhere

by Phillip Longman

  Best Care Anywhere

  Best Care

  Anywhere

  Why VA Health Care

  Would Work Better for Everyone

  THIRD EDITION

  PHILLIP LONGMAN

  Best Care Anywhere

  Copyright © 2012 by Phillip Longman

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  Third Edition

  Paperback print edition ISBN 978-1-60994-517-6

  PDF e-book ISBN 978-1-60994-581-7

  IDPF e-book ISBN 978-1-60994-582-4

  2012-1

  Designed and produced by BookMatters

  Edited by Tanya Grove

  Proofread by Janet Reed Blake

  Indexed by Leonard Rosenbaum

  Cover design by Nicole Hayward

  Contents

  Preface to the Third Edition:

  After Obamacare

  Introduction

  ONE Best Care Anywhere

  TWO Hitting Bottom

  THREE Revenge of the Hardhats

  FOUR VistA in Action

  FIVE The Kizer Revolution

  SIX Safety First

  SEVEN Who Cares about Quality?

  EIGHT When Less Is More

  NINE Open-Source Medicine

  TEN Growing the VA

  ELEVEN VA Care for Everyone

  Notes

  Acknowledgments

  Index

  About the Author

  PREFACE TO THE THIRD EDITION

  After Obamacare

  The cause of health-care reform has taken great leaps since the last edition of Best Care Anywhere went to press in late 2009. Yet we seem farther away than ever from achieving resolution to our health-care crisis.

  After a prolonged and rancorous debate, the nation passed the landmark legislation known inevitably as “Obamacare.” Today, progressives continue to grieve its compromises. Conservatives, energized and empowered by populist suspicions and resentments of the bill, have meanwhile set furiously to work on its repeal in the courts and Congress.

  Adding to the sense that passage of Obamacare has done little to resolve our health-care crisis, federal health-care spending—or more precisely, political brinksmanship over how to control it—has become the major cause of the nation’s long-term deficits, which now have compounded sufficiently to earn the United States its first-ever credit-rating downgrade. Responding to this reality check, mainstream opinion now holds that one way or another the nation must soon take strong action to rein in entitlement spending; and the largest drivers by far are Medicare and Medicaid.

  Even a progressive Democratic president, whose signature legislative accomplishment was to attack the problem of the uninsured, has signaled that he’d go along with raising the Medicare retirement age to 67.1 Meanwhile, at a time of high unemployment and a burgeoning growth in the numbers of low- and moderate-income elders, the Republican Party has voted to end Medicare as we know it and so far lived to tell about it.

  With lightning speed, the politics of health care are shifting in ways that were unimaginable only a year ago. Yet while it is a moment of unnerving divisiveness, it is also a moment that vastly expands the realm of the politically possible. Ideas for solving the mounting health-care crisis that once seemed too bold and unfamiliar to be politically viable, including the policy prescription contained in Best Care Anywhere, now have new currency, if only because of the exhaustion of plausible alternatives.

  This is far different from the climate of opinion that existed when Best Care Anywhere first appeared in January 2007. That same month, for example, the Washington Post began an exposé on problems at Walter Reed Army Medical Center in Washington DC—a series for which it later won the Pulitzer Prize. The facility is a U.S. Army hospital, and as its name indicates, it is run by the Department of Defense, not by the separate cabinet agency—the Department of Veterans Affairs (VA)—whose virtues I had described in my book. Nonetheless, this distinction was lost in much of the reporting on the scandal, leaving many Americans with the impression that the VA was neglecting grievously wounded warriors. As media and congressional investigations mounted, my first publisher and editor pretty well gave up on the book, as they later told me. Meanwhile, I endured blogosphere ridicule for having written one of the worst-timed books in years.

  Slowly, by word of mouth, the book and its paradoxical message did, however, begin to gain some influence behind the scenes. For example, in an odd loop-the-loop, when reporters around the country started visiting their local VA hospitals looking for scandalous conditions like those described by the Post at Walter Reed, they often came away as impressed as I had been in researching the book. The VA received an unexpected burst of positive coverage, in which Best Care Anywhere was often cited. That coverage has continued to build; by now, most organs of the mainstream media have weighed in with stories extolling the virtues of the VA’s model of care, including Fortune, CBS News, the Wall Street Journal, and USA Today.

  And, to be sure, some people in high places also became aware of the quality revolution at the VA that I had described. For example, in the spring of 2007, I was twice summoned to brief the health-care staff of the leading Democratic presidential candidate at the time, Hillary Clinton. Afterward, her standard speech on health-care quality came to include two paragraphs on the transformation of the nation’s long-tarnished veterans’ health-care system and its lessons for improving quality in health care generally.

  Through a well-placed friend and colleague, a copy of the book was also slipped to candidate Barack Obama before he boarded a long flight to Hawaii. Whether he read it, I do not know, but he, too, began making positive references to the VA in his health-care addresses. Peter Orszag, then director of the Congressional Budget Office (CBO) and later Obama’s head of the Office of Management and Budget, began ordering up studies from his staff on the lessons of the VA’s quality performance.

  Interest stirred in some Republican circles as well. Michael Cannon, director of health policy studies at the libertarian Cato Institute, took exception to the idea that the VA—the nation’s one undeniable example of fully socialized medicine—should stand as
a model of twenty-first-century health reform. But he acknowledged the VA’s emergence as a quality leader in health care and wrote thoughtfully for the National Review about how the agency’s performance might be replicated in the private sector.2

  The number of speaking invitations at Yale, the University of Pennsylvania (Wharton School of Business), and other universities, as well as increasing sales to university bookstores, also signaled a growing academic interest. Through the initiative of academics in Beijing University, the book was also translated into Chinese. (As the United States’s prime creditor, China is particularly interested these days to learn if a model exists, such as a civilian version of the VA, for containing the spiraling cost of the U.S. health-care system, because otherwise, China worries, we won’t be able to repay our mounting debts.)

  Interest in the book also began to spread among the larger veterans’ community. Organizations such as the American Legion are often heard in the media and in Congress complaining about the VA’s shortfalls, as is their role. They are particularly upset, and rightly so, about how difficult it can be for veterans to establish eligibility for VA care. But they are also tenacious in their advocacy for the VA and its ongoing quality revolution in ways that offer fascinating soundings into the deeper currents of American health-care politics.

  During the summer of 2009, I had the great honor of addressing a large audience of American Legion officials at their annual convention in Louisville, Kentucky. Looking back at me was an assemblage of many middle-aged and older vets, mostly drawn from small-town, Red-State America. Steeped in patriotic traditions and bedecked with its symbols, they spontaneously stood and cheered when I suggested that they tell their neighbors about today’s VA—and about the ability of “socialized medicine” to deliver the “Best Care Anywhere.”

  Yet it is fair to say that outside of the very different worlds of health-care policy wonks and veteran service organizations, the VA’s reputation remains mixed at best. This divided reputation is partly due to the VA’s long history, particularly during the Vietnam era, as a deeply troubled institution. That legacy still affects its image. Many Americans simply have not heard of the VA’s quality transformation, and even when they have, they remain skeptical because of their generally dim view of government.

  The VA’s mixed reputation is also partly due to the fact that its mistakes tend to become national news. Medical errors are demonstrably less common in the VA than elsewhere in the health-care sector, and study after study demonstrates the VA’s superior quality of care and high rates of patient satisfaction. Many of the ideas most often discussed by today’s experts for improving the quality of U.S. health care—from deploying integrated electronic medical records to adhering to quality metrics based on hard science—were pioneered by the VA as far back as two decades ago. But because of the public nature of the VA, and because the VA systematically looks for and reports its mistakes, its errors are much more likely to come to public attention, through congressional hearings, press reports, and investigations by veterans advocacy groups and the VA’s own inspector general. The cumulative effect on the average news consumer can be an impression that the VA is limping along from one scandal to the next, even as its patients and health-care quality experts applaud its quality, safety, and cost-effectiveness.

  Reflecting this mixed reputation, when the Obama Administration set to work selling the legislation that became the Patient Protection and Affordable Healthcare Act of 2010, or “Obamacare,” political operatives in the White House were careful to freeze the VA out of their public deliberations. The concern, I’m told by multiple sources, was to avoid giving the public the impression that anything like a civilian VA was under contemplation. This was true even though the tangible example of the VA’s quality and cost performance was one big reason why many health experts were able to give at least qualified endorsements to Obamacare. The story of the VA’s remarkable turnaround allowed for at least the possibility of what would otherwise seem absurd: that it just might be possible to expand access to health care for tens of millions of uninsured Americans, as Obamacare promises to do, while at the same time saving money and improving quality. If the rest of the U.S. health-care system could become as efficient in the production of high-quality medicine as the VA, then it would indeed become possible to expand coverage, improve quality, and reduce cost at the same time.

  The decision by the champions of Obamacare to ignore or downplay the VA’s example may well have been politically necessary at the time. I say this not just because of the VA’s mixed reputation, but also because the country’s political system was then still caught up in a protracted debate that for the most part willfully ignored reform of the actual practice of medicine. Almost all the public arguments about health care over the last generation have really been about health care insurance—who should get it, and who should pay for it. Until very recently, the country was just not ready to talk seriously about fundamental reform of the health-care delivery system itself.

  When Best Care Anywhere was first published, for example, a Republican White House was arguing that unsustainable health-care inflation could only be checked if Americans came to “have more skin in the game,” that is, to pay more of the cost of their health care out of their own pockets. Measures such as health savings accounts and high-deductible insurance plans were supposed to encourage patients to do more comparison shopping and haggling with their doctors and therefore create more market discipline within the existing system. Essentially, this remains the Republican position on health care.

  The most recent example is the budget proposal introduced by Rep. Paul Ryan in 2011 (for which all but five Republicans in the House have voted) that would transform Medicare into a much less generous voucher program. Under the Ryan plan, each senior would receive only a fixed amount of money (about $8,000 on average in 2022) to spend on private health-care insurance each year, regardless of what his or her health-care needs and costs might actually be (which, given current rates of health-care inflation, will be astronomical going forward). The CBO estimates that under the plan, seniors would pay about 68 percent of their health-care costs out of their own pockets in 2030, as compared to 25 to 30 percent under traditional Medicare.3

  Meanwhile, the dominant idea for health-care reform among centrist Democrats became the “individual mandate” at the heart of Obamacare. Assuming it survives Supreme Court scrutiny and Republican rule, this mandate will require, starting in 2014, that all Americans who are not already covered by health insurance purchase a policy from a private insurance company, either directly or through government-created market “exchanges”; those who cannot afford the premiums are to get subsidies.

  The individual mandate would, by fiat, end, or at least substantially reduce, the ranks of the uninsured. By enlarging the pool of Americans contributing to the cost of their own health care, and by offering subsidies to those of modest means, the measure could also reduce, at least for some people, the cost of buying comprehensive health coverage on the individual market. The individual mandate also carries with it a provision that will end discrimination against people with pre-existing conditions. What the individual mandate will not do, however, is create any measures or incentives to improve the quality, safety, or cost of health care itself, including, most notably, the vast amounts of unnecessary surgery, redundant testing, and other forms of overtreatment and mistreatment that mark the U.S. health system.

  Lest you think that is no big deal, numerous studies now confirm that about a third of all health-care spending is pure waste, or worse, mostly in the form of unnecessary and often harmful care—amounting to some $700 billion a year.4 Meanwhile, estimates by the Institute of Medicine (IOM) put the number of people killed by medical errors in American hospitals as high as 98,000 a year. Even the IOM’s most conservative estimates rank hospital medical errors as a bigger cause of death than motor vehicle accidents, breast cancer, or AIDS.5 Adding to these unnecessary deaths are hospital-acquir
ed infections, few of which are counted as “errors,” but nearly all of which are preventable. The result is the death of approximately another 100,000 Americans each year.6 Though there are other provisions buried deep within the Affordable Care Act that might eventually lead to improvements in the practice of medicine, they are, as we shall see, indirect at best while also being highly vulnerable to being defunded or repealed.

  Further to the Left are people who have argued, and still argue, that health-care reform simply entails creation of a “single-payer system,” specifically a policy that would extend Medicare-like insurance coverage to everyone. Short of that policy, the progressive cry has been for a “public option” that would give at least some Americans the opportunity to purchase government-provided health insurance, though not government-provided health care.

  Those who argue for this approach have been largely silent, however, about how to rationalize the health-care delivery system itself, as opposed to its paperwork, and thus their solution is grossly inadequate to the problem. While they are able to point to considerable administrative costs that would be reduced if all the redundant bureaucracy and marketing costs of private insurance companies were replaced by a single government program, the savings involved would be modest compared to the challenge we face.7

  Given this spectrum of opinion, the VA model’s advantages in the hands-on delivery of health care have hardly been part of the national debate. Many insiders have said that this low profile was necessary. Political logic dictated, they have argued, that first we insure the uninsured, and later we worry about what that entails—that is, what protocols of health care will be followed for different conditions, and how to ensure their effective delivery. Less charitably, future historians may look back at the terms of our recent health-care debate and view them as part of a larger, darker cultural phenomenon of our time.