IS THE VA THE MODEL?….The VA is currently a wonderfully operated system and delivers excellent care largely because it has integrated IT and quality assessments into its delivery model much better than other health care providers.

First, though, it should be recognized that the VA was not always this good. It went through a long period of being terrible medicine. Having a captive population for a long time does not guarantee anything about quality care unless the incentives are right to continue to deliver that care. A guaranteed government establishment does not necessarily guarantee that incentive. Indeed, many of the VA’s innovations were possible precisely because it was perceived to be delivering bad care before.

Second, although the long term nature of the VA relationship promotes investments in prevention, this is something that can be obtained in other ways. I have already suggested that there might be significant advantages to enrollment every three years rather than annually, which is costly without many benefits as an incentive. In addition, key preventive strategies that are a benefit to the system but not to any individual insurer could be mandated by the Federal Health Board.

Third, there is simply no way to make the VA system applicable to the whole country. There is simply a scale problem. We have a few million vets and scaling up to 250 million Americans is impossible in less than two decades. Furthermore, this is like the British National Health Service. Can you imagine Americans accepting that? Dead on arrival, as they say in Washington.

But there might be ways to let the VA compete as a health plan and accept vouchers from people who want service in the VA system. We could allow the VA to compete with Kaiser and others. This seems to me eminently reasonable.