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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

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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

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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.

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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

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

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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

By Mike Dennison
Independent Record (Helena, Mont.), May 28, 2014

The parent firm of Blue Cross and Blue Shield of Montana has been sued by a benefits-administration group that says the Chicago-based insurance giant is hoarding excess profits and unduly enriching its executives.

The lawsuit, filed last week in federal court in Chicago, said Health Care Service Corp. is breaching its contract with customers by running up excess profits of nearly $5 billion.

The Chicago Tribune first reported on the lawsuit, which said that money should have been distributed to HCSC customers as a paid dividend, reduced prescription drugs costs or lower premiums. Instead, HCSC used some of the money to pay nearly $100 million in bonuses to its top executives from 2011-2013, the suit said.

The Lee Newspapers State Bureau reported last year that HCSC Chief Executive Patricia Hemingway Hall received $16 million in compensation in 2012, including a $14.9 million bonus.

In all, the company’s top 10 executives took home $53 million in bonuses for 2012, when the company reported $1 billion in net revenue.

Figures on HCSC’s executive pay for 2013 weren’t immediately available Wednesday.

HCSC, which has 8.5 million fully insured customers, owns Blue Cross plans in Montana, Texas, Illinois, New Mexico and Oklahoma.

The company bought Blue Cross and Blue Shield of Montana last year for $40 million. In Montana, HCSC has about 250,000 customers.

John Doran, a Blue Cross spokesman in Montana, said Wednesday that HCSC is “in the process of analyzing the pending litigation and will determine (its) next steps.”

The suit was filed by Babbit Municipalities Inc., a Chicago-based benefits administration company that does business as Group Benefits Associates, working primarily with labor unions. The company asked the court to certify the lawsuit as a class-action that would include all of HCSC’s fully insured business.

The Chicago law firm representing Babbit is one of the largest consumer class-action firms in the country, according to the Tribune, and has brought dozens of consumer lawsuits against large, prominent companies.

The lawsuit said HCSC had a $10.3 billion reserve at the end of last year when it needs only $5.4 billion in reserves.

Holding such a large reserve “obliterates (the company’s) purpose as a nonprofit mutual corporation and exceeds the bounds of proper business judgment,” the lawsuit said, and makes the company effectively a for-profit firm that provides “no substantial mutual benefit to its members.”

HCSC posted net income of $684 million last year and $1 billion a year in 2010, 2011 and 2012, the Tribune reported.

http://helenair.com/news/local/blue-cross-parent-firm-sued-over-big-profits-big-bonuses/article_fa4b9036-e6a9-11e3-8a18-0019bb2963f4.html

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2013 salaries for Blue Cross executives in Montana

By IR State Bureau
Independent Record (Helena, Mont.), May 29, 2014

While Blue Cross and Blue Shield of Montana’s parent company is being sued over allegedly excessive bonuses paid to its executives, its top executives in Montana actually saw a pay cut last year.

Mike Frank, who’s now president of the Montana Division of Health Care Service Corp., received about $228,000 in compensation last year, including a $224 bonus.

In 2012, the year before Montana Blue Cross was purchased by HCSC, Frank was paid $635,000 as president and CEO of the Montana health insurer, including a $213,000 bonus.

HCSC, based in Chicago, bought Blue Cross and Blue Shield of Montana last year. A lawsuit filed last week alleges that HCSC has made excessive profits and used some of that money to pay millions of dollars in bonuses to its executives.

Last year, after HCSC bought Montana Blue Cross, its highest-paid executive in Montana was Mark Burzynski, the vice president for provider services. He received $334,700 in compensation, including a $190,000 bonus. That amount is $14,000 less than he was paid the previous year by Blue Cross.

Other top HCSC Montana executives’ salaries last year were:

• Frank Cote, vice president of Montana sales, $184,000 – about $37,000 less than he received in 2012.
• Monica Berner, vice president and chief medical officer, $164,000, or $47,000 less than in 2012.
• James Spencer, chief actuary, $159,300 – about $121,000 less than in 2012.

http://helenair.com/news/local/salaries-for-blue-cross-executives-in-montana/article_2ac38e18-e6f4-11e3-ba31-0019bb2963f4.html