VOUCHERS AND THE VHA… Kevin asked me if I had any final questions for Zeke Emanuel about his and Victor Fuchs’ proposal to create universal health care vouchers. I have two. Both stem from a piece we ran by Phil Longman on the astonishing success the Veterans Hospital Administration (VHA) is having in controlling costs and improving quality.

First, Phil demonstrated pretty convincingly that the VHA owes its success to the fact that it has clients it knows will (almost certainly) not leave for another health care provider. Thus, it knows that its upfront investment in quality control and case-management-based information technology and preventive care and so forth will pay off economically for the VHA in the long run. That’s something most health insurers and providers can’t count on. They know the opposite: that their patients will flit about from provider to provider, insurer to insurer, based on which insurer their employer chooses. Under Zeke’s plan, it seems to me, that flitting about will continue, even accelerate, as families change insurers to get better deals or to fit their changing life stage circumstances. Doesn’t that mean there will be no incentive for these insurers to invest in the technology and systems we know are crucial to controlling costs and improving quality?

Second, Phil argues that because the VHA is so good at what it does, and because there are so many empty VHA hospitals in certain parts of the country, and more empty beds coming as the GI-heavy World War II generation leaves us, that it would be in our national interest to expand eligibility for VHA to other categories of patients besides vets. For instance, do two years of AmeriCorps, and you’re in ? or you can deed your benefits to your parents. Or how about letting the VHA take over bankrupt inner-city hospitals? My question is, would Zeke’s voucher plan allow for this kind of expansion? Or, as one commenter to this debate noted somewhere, what’s wrong with letting government-provided healthcare and private healthcare compete? Advocates of school vouchers say parents should get to choose between public and private schools. Why not afford the same kind of choice to patients?

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Paul Glastris is the editor in chief of the Washington Monthly. A former speechwriter for President Bill Clinton, he is writing a book on America’s involvement in the Greek War of Independence.