Friday, August 29, 2014

Veterans aren’t the only ones waiting for health care

Charles Ommanney/Getty Images

In 2005, Phillip Longman, a senior fellow at the New America Foundation, published an article entitled "Best Care Anywhere" in the Washington Monthly. The article, which later became a book (which I blurbed), made an unexpected argument: the Veterans' Administration's health-care system had quietly become one of the best — if not the best — health systems anywhere.

Longman's evidence was expansive. A 2003 New England Journal of Medicine compared the VA with Medicare on 11 measures of quality. "On all 11 measures, the quality of care in veterans facilities proved to be ‘significantly better.'" The Annals of Internal Medicine published a study that compared VA facilities with private managed-care systems in their treatment of diabetes patients. "In seven out of seven measures of quality, the VA provided better care." The National Committee for Quality Assurance ranks health-care plans on 17 different performance measures. "In every single category," Longman wrote, "the VHA system outperforms the highest rated non-VHA hospitals."

Then there was the testimony of the veterans themselves. "The quality of care is outstanding," Peter Gayton, deputy director for veterans affairs and rehabilitation at the American Legion, told Longman. A survey found that 81 percent of VA hospital patients were satisfied with the care they received compared to 77 percent of Medicare and Medicaid patients.

The VA's reputation isn't nearly as good right now. Secret waiting lists in Phoenix are alleged to have contributed to the deaths of 40 veterans. VA hospitals across the country are under investigation for similar malpractice. Some are calling for Department of Veterans' Affairs Secretary Eric Shinseki's resignation. (Read Vox's explainer on the VA scandals here.) So I asked Longman: was he wrong about the VA then? Or are we getting the story wrong now? A lightly edited transcript of our interview follows.

Ezra Klein: You titled your book on the Veteran's Health Administration "The Best Care Anywhere." Do you still believe that's true?

Phil Longman: To the specific issue at hand on whether or not there were secret waiting lists at Phoenix and possibly other hospitals, we just don't know. There's strong evidence that employees at those facilities engaged in some kind of gaming of their performance metrics. But we're still waiting for the investigation to finish.

But the big question with these stories about the VA is, "compared to what?" This scandal wouldn't exist if the VA didn't have performance metrics on its employees. If it didn't measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that's far better than what goes on in the rest of the health-care system where no one is accountable for this at all.

EK: What's the metric the VA is using here?

PL: The metric here is they tried to get vets in for non-urgent appointments for care within 14 days. Compare that to a survey done in 2009 on average wait times outside the VA to see a family physician. In Los Angeles, people waited an average of 59 days. In Boston, they waited an average of 63 days. In Washington DC, they waited an average of 30 days. The average wait time in major metropolitan areas is about 20 days. The VA is attempting to create a performance metric by which it would be substantially superior to the rest of the health-care system. It might have missed that mark and some employees might have been cheating.

EK: A point you made in testimony before the Senate Committee on Veteran's Affairs is that this is a problem of access to care rather than quality of care. What do you mean by that?

PL: When you hear the Veteran's Service Organization testify, as they all did last week, that the quality of care at the VA is excellent but access is a real problem, they don't mean access the way most people think of it. They mean how long it takes to qualify for VA benefits generally. And that is a problem.

We have a system that reflects a deep ambivalence among the American people about what vets are owed. On the one hand there's a consensus that any vet hurt in the line of duty should be put back together by the VA for free. But we're conflicted about whether everyone in the military should get health care for free. So the way it stands now is most veterans have to provei s that the health-care complaints they have are the direct result of military service. And so if you look at what the bureaucracy at the VA is doing most of the time, it is trying to adjudicate questions like whether someone who's 58 years old is losing their hearing because of the artillery fire they heard while deployed in Vietnam or because of all the Who concerts they went to in 1968. That's a real example, by the way.

Another typical case would be someone in Vietnam in 1972 and who worked on a base with lots of Agent Orange and has now come down with Parkinson's disease. There's been some evidence in recent years that Agent Orange might be related to early-onset Parkinson's. And we spend enormous amounts of effort trying to litigate questions like that.

The current administration has made progress in lowering the VA backlog but the largest single cause is not that we have all these guys coming back shot up from Iraq and Afghanistan and no one is around to do the paperwork. It's that we have all these aging veterans with chronic problems and we can't decide whether we want to give them health care or not. With Parkinson's disease they recently decided to just assume that anyone in Vietnam was exposed to Agent Orange and so that's brought in a whole new group of people.

EK: One thing that frustrates me a bit about this conversation is that there's a selectivity to when people become outraged over access issues in health care. What's happened in Phoenix is, if it holds together, a scandal. But we have millions of people who are eligible for federal Medicaid benefits but live in states that refuse to accept the Medicaid expansion. And a lot of those people, well over 40, will die or face serious medical consequences because they're uninsured. And both before and after Obamacare there will still be millions of people who can't afford health insurance and no one will make sure they get timely appointments and there'll be no headlines when they suffer.

PL: The VA puts ideological and political positions in play. People think it proves their worldview is right and other people's worldview is wrong. And there are allegations of criminality. The lack of Medicaid coverage for huge portions of the population is horrible and it is, ultimately, a much bigger scandal, but it is not illegal.

EK: An interesting point you made in your congressional testimony was that publicly run health-care systems have a dilemma in which they actually track these quality measures and, when they fall short, it's a scandal. But when private systems fall short, no one even knows. The result is an asymmetry in public perceptions of how well different systems actually work.

PL: Put yourself in the position of these veterans service organizations. They are simultaneously charged with pointing out the defects of the VA when and where they occur and defending the VA from its ideological enemies. Those two aspects of their mission are often in conflict. If the American Legion, which has spent the last 15 years extolling the quality of VA health care and pressing to get more vets into the system, now has to call for the resignation of the head of the VA, that plays into the hands of those who want to torpedo the whole system.

There's this section in my book about the VA's pioneering effort to really show how many medical errors there were. They created these registries patterned on things the FAA did for pilots. They allowed people in the VA to report medical errors anonymously and tried to create a no-blame culture that looks for structural reasons for errors and leads to a real safety culture in the VA. That meant publishing statistics on how many medical errors occurred at the VA.

When they first did that the press pounced on those reports. It led to all these headlines like second-rate medicine for first-rate men and the perils of socialized medicine and all this. But the VA was actually admitting there was a problem and they were trying to fix it. The rest of the health-care system was doing nothing.

I would like to imagine a world in which the hospital where my late wife was treated for breast cancer had an inspector general looking over that hospital and two committees of congress charged with scrutinizing quality of care in that hospital and there were broad-based citizens groups that had their rank-and-file going to that hospital and reporting on anything that went wrong and making it national news. I think if we had that we would find a lot of dysfunction in that system — but we would also make American health care better.

EK: What would cause you to revise your belief that the VA is still providing excellent care?

PL: The only thing that would cause me to revise that would be if it is proven that people who are enrolled in the VA system are unable to make timely appointments with their doctors on a scale that remotely threatens the performance of the system as a whole. I am sure wait times are an issue. But there's been no evidence yet that wait times at the VA aren't shorter than they are outside the VA. We know veterans, when surveyed, have overwhelmingly positive consumer satisfaction with the VA. We know all the major veteran service organizations salute the VA's quality of care. And we know veterans are piling up at the door because they've heard from other veterans that the VA is a great place to get care.

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