Reflections on the VA Scandal

KevinMD — Dr. Kevin Pho — the popular physician blogger, suggests that single-payer advocates reevaluate the single-payer idea in light of the scandal now unfolding within the Veterans Health Administration. He calls the scandal “a red flag for those who want a national single-payer system in the United States.”

While his thoughtful essay teases out crucial details hidden in the mainstream discussion over the failures at the VA health system, the conclusion he draws seems to point in a direction opposite from the observations he makes.

Dr. Pho offers a succinct and powerful analysis of what led to the inability to keep up with the needs of many VA patients: “underfunding.” He adds several statistics (including data compiled by the libertarian Cato Institute) to demonstrate that the VA has been underfunded.

“While there are certainly advantages to a single-payer system, what happens if that single-payer doesn’t adequately fund the system?” Dr. Pho asks. “Lengthy waiting times and rationed care. The VA is a case study of that scenario.”

“The government,” Dr. Pho further observes, “has a track record of underfunding their single-payer health models.” Also, like many people, he equates “single-payer” with any publicly funded health care system.

Some of us might take pains to characterize the VA system as a publicly owned, publicly funded health system, analogous to the Scottish National Health Service, in order to distinguish it from a privately owned but publicly funded delivery system, like Canada’s Medicare. But KevinMD still has a point — if the public chooses not to provide adequate funds for its own system, it won’t work for its patients or its caregivers.

It is true that government austerity programs — programs to reduce taxes upon the wealthy that we’ve seen across the world and over several recent decades — have gutted a panoply social programs. Like millions of recipients of public health and safety-net programs worldwide, VA patients (and caregivers) have suffered the consequences of austerity.

But it is not true that “the government” always and everywhere underfunds public health programs. Take two very recent examples: the Scottish National Health Service and the health system in Madrid, Spain.

In February 2014, Scotland’s territorial health boards, which run the Scottish NHS, found their funding raised by an amount equal to the rate of inflation plus 1 percent. Announcing the funding increase, Health Secretary Alex Neil said, “The Scottish Government is committed to protecting spending on health.”

In January 2014, in Madrid, following months of sustained and vigorous public rebellion, the region’s government abandoned efforts to privatize the health system, a scheme to cut public funding for health care by over 700 million euros annually.

Dr. Patricia Alonso of the Madrid Physicians Association explained the essence of the matter on behalf of patients and caregivers alike when she said, “We were not going to allow somebody else to sell our system.”

Dr. Alonso’s remark illuminates an important aspect of taxpayer-financed health programs (in any democracy worthy of the name):  the patients and caregivers within the system are also its owners.

Dr. Pho introduces his piece saying that “Some are eager to link the VA scandal to Obamacare, and more broadly, government-run health care. Others extol the virtues of the VA, holding it as an ideal of what our health care system should look like. The truth, as always, probably lies somewhere in the middle.”

He concludes that the narrow political goal of Republicans fanning the flames of scandal is to “indict Obamacare” — and points out that this make little sense. KevinMD also recognizes a larger ideological goal — to use the VA scandal to impugn the idea that “the government” can provide healthcare (or anything worthwhile to the public.)

Right-wing ideologues often assert that “the government” is the enemy of “the public” — for in their view, there is no social or personal issue that the profit motive can’t fix, if only the hidden hand of the market could be free of government regulation.

And yet no one has been calling for the closure of the VA — nor has anyone suggested that either the public or the government abandon veterans by forcing them to purchase their care on the “free market,” individually, with their own money, instead.

The starting point for all sides in the debate over the VA scandal is the remarkable idea that every veteran deserves ready access to comprehensive health care, without a personal financial burden. It is significant that public funding for veterans’ healthcare is assumed. The idea that all the patients in the system deserve care — that no one deserves to be left out — is also assumed.

Some leading Republicans have called for a system that would allow veterans to use VA resources to purchase their care privately — with public funds — in addition to getting care from the VA hospitals and clinics. This would be change the VA into a system more analogous to the way that Medicare works (in the U.S. as well as Canada) than, to repeat the example, the Scottish National Health Service. Even this proposal would keep (and perhaps expand) public funding for veterans’ healthcare.

It is overall quite significant Dr. Pho (and many others) see so clearly that the fundamental problem for patients at the the VA amounts to underfunding. And true to form as a blogger, KevinMD traces the contours of the mainstream debate from a doctor’s point of view. In doing so he helps reveal that within the United States establishment, an important shift is underway when it comes to the debate over healthcare.

To use a NASCAR analogy, it may well turn out that the VA scandal really suggests a green flag moment for single payer.

Dr. Andrew D. Coates practices hospital medicine in upstate New York. He is president of Physicians for a National Health Program.