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Center for Public Integrity on the Medicare Advantage Money Grab

Center for Public Integrity on the Medicare Advantage Money Grab

The Medicare Advantage Money Grab

The Center for Public Integrity, June 4, 2014

Why Medicare Advantage costs taxpayers billions more than it should

By Fred Schulte, David Donald and Erin Durkin

(Medicare Advantage) plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show.

The Center’s findings are based on an analysis of Medicare Advantage enrollment data from 2007 through 2011, as well as thousands of pages of government audits, research papers and other documents.

Federal officials who run the Medicare program repeatedly refused to be interviewed or answer written questions.

Key findings:

  • Federal officials have made billions in “improper” payments to Medicare Advantage plans traced to risk score errors.
  • Medicare Advantage risk scores rose much faster than the national average in hundreds of counties nationwide between 2007 and 2011. That rise in risk scores cost taxpayers more than $36 billion; critics attribute that more to aggressive billing than sicker patients.
  • Though federal health officials have recently disclosed some Medicare billing data, key financial records of Medicare Advantage plans have been kept under wraps.
  • The failure to crack down on health plans that overbill doesn’t bode well for the Affordable Care Act, which relies on a similar risk scoring system.

Thomas Scully, who helped get the program running under President George W. Bush, said rates were generous in hopes of enticing insurers to expand their Medicare business and not shy away from people in poor health.

“We very intentionally tried to overpay them a little bit,” said Scully, now a Washington lobbyist with numerous health care industry clients.

http://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-c…

“The Medicare Advantage Money Grab”:http://www.publicintegrity.org/health/medicare/medicare-advantage-money-…

Medicare Advantage is a program in which our government has conspired with insurers to privatize Medicare, even though it costs far more when private insurers are inserted as intermediaries than it does when Medicare is administered as a public program. This report from The Center for Public Integrity is just the latest that has exposed this outrageous use of our tax funds.

The program was set up to deliberately overpay the plans so that they could offer additional benefits that would entice Medicare beneficiaries into the private plans (see Scully’s comment above). Recognizing these overpayments, Congress included in the Affordable Care Act gradual reductions. Not to be outdone, the insurance industry has conspired with the Obama administration and has enlisted individual members of Congress to fight these reductions. In response, the Obama administration has used dishonest budgetary manipulations to offset a portion of the reductions for 2013, 2014 and 2015.

Even more outrageous is that the private insurance industry has used “innovations” to selectively enroll healthier beneficiaries, yet used “touch of illness” serious diagnostic codes to game risk adjustment, which has rewarded the insurers handsomely for claiming that their beneficiaries were much sicker than they really were. According to this report, federal Medicare officials refused to answer questions about these perverse practices.

The insurance industry has been very successful in framing this as “cutting payments for Medicare,” while mobilizing citizens to demand that these cuts be prevented. The cuts are not in Medicare, but they are a reduction of overpayments to private insurers. Yes, those who sign up with the private plans often have lower out-of-pocket costs, but the rest of us are paying for that through higher taxes and through our Part B Medicare premiums that are partially transferred to the private insurers.

Since we are paying for it, we should be receiving in the traditional Medicare program the same benefits of reduced out-of-pocket expenses. Let the people enrolled in Medicare Advantage keep the same level of benefits, but increase the benefits in the traditional Medicare program to the same level, then fire the private insurers that have been responsible for most of the cost overruns in the Medicare Advantage program.

The politicians seem to agree that we should be spending these excess funds on Medicare, so let’s be fair and spend them equitably on an improved Medicare, but not on insurer profits and waste. While we’re at it, let’s make that an improved Medicare for all.

Large variation in cost-sharing reductions in silver plans harms patients

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

  • Cost-sharing reductions are more often applied across multiple types of benefits
  • in 94% and 87% AV plans compared to 73% AV plans. 
  • Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law. 
  • Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
  • Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
  • Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report: http://avalerehealth.com/expertise/managed-care/insights/avalere-analysis-cost-sharing-reductions-unevenly-applied-across-services-i

****

Comment:

By Don McCanne, MD

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.

Retired doctor reflects on his 90 years in new book

By Ross Forman
Windy City Times (Chicago), June 3, 2014

Quentin Young offers his take on a variety of topics, including people, politics and policies, in his new book: “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause.”

Young certainly speaks from experience. He celebrated his 90th birthday last September.

Born and raised in Chicago, and still calling the Hyde Park area home, Young is now in California, opting out of the Chicago cold and snow.

“I’ve lived a long life, so there’s a lot to tell. I like the book; it really tells the story of [my] 90 years,” Young said.

The book was published in late 2013.

Written in collaboration with Steve Fiffer, Young’s memoir offers a rare glimpse inside the mind of a fearless advocate for a single-payer health system, following his path through the civil-rights movement on through his stint as the head of Cook County Hospital.

Young retired in 1985.

“We’re in deep trouble in terms of health care, at least that’s my point of view,” said Young, who spent about 18 months writing the book that travels his 90 years. “I think the book does a pretty decent job of tracing the fight for national health insurance. We’re a country of 50 states, and there’s a different story in every state.

“The thing I like the most about the book is, the success of the senior component, Medicare. It’s been a dramatic economic change [over the years].”

In fact, Young added, “We’ve had a century of progress, and I’ve seen so many changes,” in the medical world.

The medical world of 2014 is seemingly at a paradox, trying to figure out what’s the best plan, he said. “Every polls seems to show that American people want to be covered against health-care costs. No one wants to go bankrupt because of a major illness,” he said.

Young attended Northwestern University Medical School in the 1940s and interned at Cook County Hospital, where he also did his residency. He was a founder and served as national chairman of the Medical Committee for Human Rights, which was formed in 1964 to provide medical care for civil rights workers, community activists, and summer volunteers working in Mississippi.

He also was noted for providing emergency medical care to protesters at the 1968 Democratic National Convention in Chicago.

He retired from private practice in 2008.

Then, in 2009, Young was appointed by Illinois Governor Pat Quinn to Chair the Illinois Health Facilities Planning Board.

Young said he still remains active in medical world, particularly on the economics of health care.

So where do you see health care in the future?

“It’s a question of whether we will have a single-payer system, or we’ll have a chopped up system with all different kinds of various benefits, depending on where you work, or whether you work, and how old you are. People don’t like that uncertainty.

“I’m hopeful, before I leave this world, that I’ll see national health insurance.”

Young tagged it as a 50-50 odds that a national health insurance program will materialize.

“I think the next five years will tell the story,” he said.

When asked about the early days of the HIV era, of about 33 years ago, Young said, “That’s a very delicate subject; it was a very important time. In the … early 1980s, that was a time when so many people would get [diagnosed] and then die within three or four years, or sooner. It was a horrible death. Eventually, people were able to live with HIV, if they took the proper medication.”

Young treated HIV/AIDS patients, and prominently promoted prevention, most notably through safe sex.

http://www.windycitymediagroup.com/lgbt/Retired-doctor-reflects-on-his-90-years-in-new-book/47674.html

Privatization won’t fix the VA

By Suzanne Gordon
The Boston Globe, May 27, 2014

First it was Social Security, then Medicare and Medicaid, and then the public health care option under Obamacare. Now, in the wake of recent allegations that veterans hospitals put patients on secret wait lists, Republicans are calling for the privatization of the Veterans Health Administration, the nation’s largest public health care system which provides cost-effective and high quality care to 6.2 million veterans.

It is of course unacceptable if patients suffered as a result of any delays. But regardless of what went wrong at any VA facility, turning veterans over to private sector insurers and for-profit hospitals is not the solution.

With its salaried staff of nearly 280,000, the VA has long been a model for health care delivery. The VA’s 152 hospitals, 900 clinics, 300 mental health centers, and other facilities — many located in rural areas that the private sector ignores — care for more than 230,000 people a day. In a recent survey of veterans for the American Customer Satisfaction Index, patients rated the system’s services as equal to or better than private sector health care facilities.

One reason is the VA’s systematic efforts to improve quality care and patient safety. The VA computerized medical records long before private hospitals. The VA conducts widespread training on inter-professional communication and teamwork that decreases patient deaths and injuries due to the kind of medical mistakes and problems that kill over 400,000 patients a year. In 2007, the VA launched a successful initiative to dramatically reduce the dangers of one the deadliest hospital superbugs — methicillin-resistant Staphylococcus aureus.

The VA has singular expertise in the treatment of post-traumatic stress disorder. Many injured soldiers have returned from Iraq and Afghanistan with what is known as poly-trauma — PTSD plus traumatic brain injury and limb amputations. Few primary care physicians — or even specialists — have much experience treating such cases in the private sector. In fact, without the VA, vets would have trouble getting any primary care services given the serious shortage of primary care providers in this country.

Because the VA is a public entity, its facilities actually display greater accountability — and more transparency to patients and their families — than private health care systems. When veterans have a VA-related beef — or in-house whistle-blowers a tale to tell — they are quick to notify their elected representatives. Such complaints regularly trigger individual constituent service queries from members of Congress or, as is the case today, oversight hearings by House and Senate committees. (Good luck triggering a similar rapid response to patient or staff complaints in the private sector.)

The US Inspector General now has a task force probing the VA in Phoenix, which is accused of hiding long delays before veterans could see doctors. As Senator Bernie Sanders of Vermont, chairman of the Senate Veterans’ Affairs Committee, said, “It’s imperative that we uncover the problems that exist and address them boldly.” What’s already known is that the VA system in Phoenix cares for 80,000 vets, many of them older and with serious, chronic health conditions. If some waited too long to be seen, maybe it’s time for Congress and the White House to figure out how to free up funds to care for veterans who are living longer with more complex conditions.

Doing this would be far better for them and the nation than privatizing a system that is, in fact, a model for broader health care reform.

Suzanne Gordon’s latest book is “Beyond the Checklist: What Else Health Care Has to Learn from Aviation Teamwork and Safety.”

http://www.bostonglobe.com/opinion/2014/05/27/privatization-won-fix/OyQgH0er1VXFNfkQTy01tI/story.html

Large variation in cost-sharing reductions in silver plans harms patients

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

  • Cost-sharing reductions are more often applied across multiple types of benefits
  • in 94% and 87% AV plans compared to 73% AV plans.
  • Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law.
  • Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
  • Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
  • Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report:http://avalerehealth.com/expertise/managed-care/insights/avalere-analysi…

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.

Selected letters on the VA scandal

The following four letters to the editor represent a sampling of opinion by single-payer advocates across the U.S. on the recently exposed wait-time problems in the Veterans Health Administration. For more on the current VA situation, see PNHP’s Articles of Interest and Dr. Don McCanne’s Quote of the Day.

The VA scandal, and the ones beyond

By Inge De Becker, M.D.
Star Tribune (Minneapolis), Letters, May 31, 2014

True, the VA has waiting lists, real and fake. We spend fortunes to send youngsters to war, yet underfund their care when they come home. They suffer for no good reason.

That is unacceptable.

Here’s what else is unacceptable. Even with the Affordable Care Act, 30 million U.S. people will remain uninsured. No one keeps their waiting lists, but each year tens of thousands will die because they lack adequate access to medical care. Nearly half of the states refuse to expand Medicaid, effectively condemning more than 7,000 uninsured each year to preventable deaths. Medical bills remain the leading cause of bankruptcy. We don’t have enough primary care physicians, both inside and outside the VA.

Even the best programs could be better, and doctoring waiting lists must stop, but patient surveys still make the VA the highest-rated health care program in the country. Let’s face it. The VA is a public, single-payer health care program. The day the United States and Minnesota choose an adequately funded, public single-payer system, everyone will have access to timely care, and everyone will be protected from financial disaster in time of illness.

Now that is acceptable.

Dr. Inge De Becker resides in St. Paul.

http://www.startribune.com/opinion/letters/261324261.html

*****

We need improved Medicare for all

By G. Richard Dundas, M.D.
Bennington (Vt.) Banner, Letters, June 4, 2014

We read in the Banner that as many as 40 veterans may have died in Phoenix because they could not get needed care at the VA hospital. This is truly outrageous (surely an overused adjective but probably better than disgraceful). We must do better for our veterans.

Here is another statistic that you may or may not want to know depending on your political mindset. It is estimated that in 2013 there were over 40,000 Americans (not a misprint) who died because they had no health insurance and could not access health care in a timely manner. This is similarly outrageous.

I long for the day when we Americans are smart enough to elect leaders who can translate outrage into action. The action that we need is improved Medicare for all. Everybody in, nobody out.

Dr. G. Richard Dundas resides in Bennington.

http://www.benningtonbanner.com/opinion/ci_25891663/letters-we-need-i

*****

Addressing the problems at the VA

By Philip R. Lee, M.D., and Philip Caper, M.D.
The New York Times, Letters, June 2, 2014

Part of the cause of the long waiting times in the V.A. system is surely a combination of the V.A.’s difficulties in recruiting doctors (especially primary care doctors) and the surge in demand in recent years due to our military interventions in Iraq and Afghanistan. Neither of these causes of the current backlog will be fixed quickly.

If Congress is serious about helping to alleviate the problem and showing our gratitude to and support for our veterans, it will expand Medicare coverage to include all veterans. If that is done, our veterans could choose between the V.A. system and any doctor who participates in Medicare.

Medicare is approaching its 50th anniversary as one of the most durable, successful and popular federal programs ever created. Do our veterans deserve any less?

Dr. Lee, a Korea veteran, was an assistant secretary for health in the Johnson and Clinton administrations. Dr. Caper was a senior health care adviser to Senator Edward M. Kennedy; he resides in Brooklin, Maine.

*****

Single-payer would fix health care

By Bob Fischer
Register Guard (Eugene, Ore.), Letters, June 2, 2014

In his May 24 letter Roger Russell said the serious problems at Veterans Affairs hospitals have to do with allegations of veterans waiting weeks or months to see a doctor, malpractice, fraud and even unnecessary deaths.

Those are symptoms of serious problems related to the VA’s size and financing. It’s too small to handle the enormous need, and it doesn’t receive the resources it needs to do the job.

Russell said having a single-payer system would mean the federal government would take over and control the nation’s health care system. That’s wrong, too, with the error due to confusing health care financing with health care delivery.

Single-payer is about financing health care. It’s like Medicare. Under a single-payer system, the government pays the bills and health care delivery is left in the hands of doctors, nurses and other health care professionals, a matter between patients and their doctors. Unlike private insurance companies, the government doesn’t intrude or interfere.

Single-payer means the for-profit insurance industry is taken out of the health care equation. Private insurance companies are the reason Americans pay twice as much for health care as people of other industrialized nations, and they’re the reason we get worse health care outcomes.

If we want to fix our health care system, single-payer is the only way to do it.

Bob Fischer resides in Bandon, Ore.

http://registerguard.com/rg/opinion/31640663-78/care-health-eugene-system-payer.html.csp

Physicians: Independent professional practitioners or employees controlled by health care’s big players?

By Edgar A. Lopez, M.D., F.A.C.S.
Louisville Medicine, Letters, June 2014 

In the New York Times issue of February 14, 2014, an article written by Elisabeth Rosenthal and titled, “Apprehensive, many doctors shift to jobs with salaries,” the following information caught my attention:

Today, accordingly to the AMA statistics, in the USA:

  • 60 percent of family doctors and pediatricians are employees 
  • 50 percent of general surgeons are employees
  • 25 percent of surgical specialists including ENT, ophthalmologists and others are employees

In 2007, 24 percent of cardiologists were employed; it jumped to 35 percent in 2012.

Local hospitals in the state of New Jersey bought, just recently, 22 private cardiology practices.

These statistics reflect the rapid demise of the concept of the private delivery of medical care that has fallen in this country into the tentacles of the private health insurance companies that continue to siphon off, in a macabre way, the tax money that is supposed to be used for health care. Instead the funding of private health care in the USA, the richest industrialized country in the world, is all about profiteering and the Wall Street dance of the stock market as it relates to escalating health care costs for everybody.

In the meantime, the Affordable Care Act has only brought more sophistication to the profiteering process of the private health insurance companies while still more than 45,000 citizens a year die because of lack of health insurance. Believe you me these victims are hard-working middle-class citizens; they are not the immigrants (documented or otherwise), they are not the veterans of war, they are not from the top 1 percent, they are not from below the poverty line, they are hard-working individuals, low-level executives and college graduates, adjunct professors, low-level employees of the same private health insurance companies, etc., who carry exorbitant deductibles in the newly baptized Platinum, Gold, Silver, Bronze plans that, in my opinion, rather than precious metals’ names, should be called “chatarra” (which in Spanish means: scrap metal).

The concept of incremental health care reform sponsored traditionally and continuously by serious institutions like the AMA and the American College of Surgeons is another clear manifestation of a non-viable, non-sustainable system for funding and delivery of health care. It just doesn’t work, and the price for the ones left behind the affordability wagon is: death, debt, despair and mental illness plaguing the streets.

When you have an acute catastrophic illness and you are, for whatever reason, underinsured or even worse uninsured (don’t know which one is worse) there is absolutely no time to wait for incremental shenanigans.

My dear colleagues, the only viable solution to save the private practice of medical care (funding and delivery) in this country, and at the same time serve Everybody In and Nobody Out, is a single-payer system based on the bill introduced in the U.S. Congress on repeated occasions through the years by Rep. John Conyers: H.R. 676. We can call it also: Improved-Expanded Medicare for All, from birth to death and without the participation of the private health insurance industry. That bill will save at least $400 billion a year, to begin with. H.R. 676 is properly explained on the Web. Just google H.R. 676 and read the bill. Everybody’s back is covered, including the low-level employees of the private health insurance companies.

I want to respectfully invite the current president of the GLMS [Greater Louisville Medical Society] and the president-elect to a public conversation including members of GLMS to discuss why H.R. 676 doesn’t have the support of certain medical organizations. It is not even discussed. You bring your team of experts and I will bring mine.

Logistics and details can be properly planned.

Dr. Edgar Lopez is a member of Physicians for a National Health Program (PNHP) and a founding member of the Kentucky chapter of PNHP.

https://www.glms.org/Content/User/Documents/Publications/LouisvilleMedicineJune2014.pdf

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of the health care delivery system reform.

I don’t mean just the fulminations of the right-wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly. This article, the first of a series, appeared at the Washington Monthly’s “Political Animal” blog.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_still_the_best_care_an050598.php

*****

Veterans aren’t the only ones waiting for health care

By Ezra Klein
Vox, May 23, 2014

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 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.

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.

http://www.vox.com/2014/5/23/5745356/veterans-aren-t-the-only-ones-waiting-for-health-care

We need improved Medicare for all

By G. Richard Dundas, M.D.
Bennington (Vt.) Banner, Letters, June 4, 2014

We read in the Banner that as many as 40 veterans may have died in Phoenix because they could not get needed care at the VA hospital. This is truly outrageous (surely an overused adjective but probably better than disgraceful). We must do better for our veterans.

Here is another statistic that you may or may not want to know depending on your political mindset. It is estimated that in 2013 there were over 40,000 Americans (not a misprint) who died because they had no health insurance and could not access health care in a timely manner. This is similarly outrageous.

I long for the day when we Americans are smart enough to elect leaders who can translate outrage into action. The action that we need is improved Medicare for all. Everybody in, nobody out.

Dr. G. Richard Dundas resides in Bennington.

http://www.benningtonbanner.com/opinion/ci_25891663/letters-we-need-improved-medicare-all

Phillip Longman: VA health care is still the best

Poll: Confidence in veterans’ care plummets to new low

By Susan Page
USA TODAY, June 2, 2014

Americans’ confidence in the medical care provided for soldiers returning from Iraq and Afghanistan has plummeted to new lows in the wake of the VA scandal, a USA TODAY Poll finds. Most people see the problem as widespread and systemic.

Just one in five rate the job the government does in providing veterans with medical care as excellent or good, about half the percentage who said that in a Pew Research Center survey in 2011. Then, half rated the care as “only fair” or poor; now seven in 10 do.

42% have little or no confidence that the problems can be fixed.

Eight in 10 worry that the issue is turning into a political battle in which Democrats and Republicans are more interested in scoring points than solving the issue. On that question, there is almost no difference by party affiliation.

http://www.usatoday.com/story/news/politics/2014/06/02/poll-americans-view-of-va-health-care-scandal/9863621/

****

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title Best Care Anywhere, Why VA Health Care would be Better for Everyone, it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of health care delivery system reform.

I don’t mean just the fulminations of the right wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as, Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_still_the_best_care_an050598.php

****

Comment:

By Don McCanne, MD

Phillip Longman, as the author of “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” is a person to whom we can turn to get the full story on the VA health care “scandal” and how representative it is of the system at large. According to him it is not only the right wing attacks claiming that this is proof of the case against socialized medicine, but it is also “hard-working and earnest reporters” who “wind up giving the public a fundamentally false idea of how well the VA is performing as an institution.”

The new USA Today poll confirms that the reporting has caused Americans’ confidence in the VA health system to plummet, with the perception that the problem is widespread and systemic. Americans do recognize that the politicians are more interested in scoring points than they are in solving the issues (Sen. Bernie Sanders being a notable exception). Nevertheless, the poll indicates that they now believe that the government is doing a poor job and 42% have little or no confidence that they can fix the problems.

Longman states, “it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.” When individuals make the claim that the VA “scandal” proves that single payer would not work in the United States, refer them to this series being written by Phillip Longman where they can learn the truth.

Phillip Longman: VA health care is still the best

Poll: Confidence in veterans’ care plummets to new low

By Susan Page
USA TODAY, June 2, 2014

Americans’ confidence in the medical care provided for soldiers returning from Iraq and Afghanistan has plummeted to new lows in the wake of the VA scandal, a USA TODAY Poll finds. Most people see the problem as widespread and systemic.

Just one in five rate the job the government does in providing veterans with medical care as excellent or good, about half the percentage who said that in a Pew Research Center survey in 2011. Then, half rated the care as “only fair” or poor; now seven in 10 do.

42% have little or no confidence that the problems can be fixed.

Eight in 10 worry that the issue is turning into a political battle in which Democrats and Republicans are more interested in scoring points than solving the issue. On that question, there is almost no difference by party affiliation.

http://www.usatoday.com/story/news/politics/2014/06/02/poll-americans-vi…

****

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title Best Care Anywhere, Why VA Health Care would be Better for Everyone, it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of health care delivery system reform.

I don’t mean just the fulminations of the right wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as, Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_stil…

Phillip Longman, as the author of “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” is a person to whom we can turn to get the full story on the VA health care “scandal” and how representative it is of the system at large. According to him it is not only the right wing attacks claiming that this is proof of the case against socialized medicine, but it is also “hard-working and earnest reporters” who “wind up giving the public a fundamentally false idea of how well the VA is performing as an institution.”

The new USA Today poll confirms that the reporting has caused Americans’ confidence in the VA health system to plummet, with the perception that the problem is widespread and systemic. Americans do recognize that the politicians are more interested in scoring points than they are in solving the issues (Sen. Bernie Sanders being a notable exception). Nevertheless, the poll indicates that they now believe that the government is doing a poor job and 42% have little or no confidence that they can fix the problems.

Longman states, “it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.” When individuals make the claim that the VA “scandal” proves that single payer would not work in the United States, refer them to this series being written by Phillip Longman where they can learn the truth.