It was difficult for me to watch my brother Phil testify before Bernie Sanders’ Senate Veterans’ Affairs Committee last week because he talked about the death of his wife, Robin, and how that experience led him to investigate the nation’s health care system. Robin was younger than I am now when she died of an aggressive form of breast cancer. Her loss was a brutal and unfair blow to both my brother and our entire family, and seeing him testify about her in front of the whole nation made me very emotional.
Phil’s journey into our health care system began with that tragedy, and he concluded that the Veterans’ health care system was the best-performing system in the country. He still feels that way.
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.
The Veteran’s health care system actually has an Inspector General. They have a degree of accountability that you won’t see in the private sector. It’s also a single-payer system that could serve as a model for the whole county.
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.
According to Phil, the primary reason that Veterans’ hospitals outperform the private sector “is better adherence to the protocols of evidence-based medicine, and the lack of any motive to engage in unnecessary surgery and other forms of over-treatment.”
The current problem is caused not by lack of quality care but by delays in access to care. And that problem isn’t unique to Veterans’ hospitals.
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 prove is 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.
When you lose a family member early in their life, you want to make their lives have some meaning. If Robin’s death can contribute in some small way to helping the country understand what’s really at stake in the current debate about our Veterans’ hospitals, I think our whole family will be grateful for that.