the Rx for American health care

After making an exhaustive case for the argument that the problem with American healthcare is not a lack of money, but a system whereby doctors are incentivised to overtreat patients rather than manage their long term health care, Philip Longman of the Washington Monthly reveals a solution that lies right under our noses. A solution that no one on the Democratic Presidential stump seems to be talking about.

The cure to America’s health care crisis is a system that’s already up and running right here in the United States, with facilities in every state, plus the District of Columbia and Puerto Rico. It is, in fact, the largest integrated health care system in the United States, and it points the way to the future.

Most of its doctors have faculty appointments with academic hospitals—over the years, two have won the Nobel Prize for medicine. The system’s innovations have included the development of the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, and the nicotine patch, plus many advanced prosthetic devices, including hydraulic knees and robotic arms.

More impressively, health care quality experts also hail it for its exceptional safety record, its use of evidence-based medicine, its health-promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, it’s the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.

Though comparatively few Americans, especially among coastal elites, have any contact with this system these days, and even fewer qualify for its services, its example shows that it is possible to make vast improvements in the quality, safety, and effectiveness of the health care all Americans receive, and to do so for a fraction of what an unreformed health care system would cost.

I’m talking about the Veterans Administration, which over the course of the last decade or so has undergone a remarkable transformation. Even with its problems, the VA’s model of care turns out, in study after study, to be the best the American health care system has to offer. As Harvard’s John F. Kennedy School of Government gushed, in awarding the VA a top prize in 2006 for innovation in government: “While the costs of health care continue to soar for most Americans, the VA is reducing costs, reducing errors, and becoming the model for what modern health care management and delivery should look like.”

This is another inconvenient fact absent from the health care debate. What can you say about it? The VA is an example of the government running a health care system, not just writing checks to cover other people’s medical bills, which is all that Medicare does. The VA also has a near-lifetime relationship with its patients and therefore has an incentive to invest in prevention, disease management, and protocols of care that demonstrably work—incentives that are weak or absent throughout the rest of America’s fragmented health care system. Medicare for everyone, or some similar scheme for universal coverage, just doesn’t address the root cause of America’s health care crisis, which is poor-quality, uncoordinated care. The VA model of health care does.
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Upon hearing some anecdote about the VA, we should always ask, “Compared to what?” As a system, the VA outperforms the rest of the health care sector by every conceivable metric, including wait times and, of course, protection from catastrophic medical bills. And it is more cost-effective: for every patient who switched from Medicare to the VA, the taxpayers would save about one-half to two-thirds in medical costs, while the patients themselves would receive demonstrably higher-quality care. Step one on the road to true health reform should be to allow all veterans on Medicare to use their entitlement for VA care, and then gradually expand access to the VA model of care for all Americans.

Adopting the VA model, with its salaried doctors and its extensive use of electronic information technology and evidence-based medicine, would cure the American health care crisis. Throwing more money into the current, fragmented, profit-driven system without changing the actual practice of American medicine might ease the problems of the uninsured temporarily, but would also give us more inappropriate, sometimes dangerous, and ever-more-expensive care.

The bottom line is that if any Democratic candidate is serious about health care as an issue - yes, even Obama or Edwards, our putative "transformational" and "progressive" champions - then why aren't they talking about the VA? Why haven't they invoked it?

Maybe it is up to us, the netroots, to educate our erstwhile champions about this.

As far as I am concerned, Hillary's proposal (re-elect me in 2012 and I'll have healthcare solutions by the end of my second term) is a nonstarter. Obama and Edwards have complicated plans on the table that try to address speccific shortcomings that they perceive to be important. Fair enough. But in the case of health care, true transformational change is what is needed to really change the fundamental financial dynamic of the business of medicine. I don't think that either Edwards or Obama have really made the case that their untested ands complex proposals really fix the basic problem, which is as Longman points out,

Remember first what American doctors and hospitals get paid to do. Outside the Veterans Administration and a few staff­‑model HMOs, they don’t get paid to keep and make patients well. They get paid to provide treatments—and that’s a big difference. It means that most American doctors and hospitals have no economic interest in your long-term well-being, while they also have an enormous economic incentive to perform operations and procedures for which Medicare and private insurance pay well. The result is a systematic bias toward the overtreatment of patients—and particularly of those who are well insured—and a simultaneous neglect of prevention and well-being.

HillaryCare, HillaryCareLite or HillaryCareNuevo just aren't going to address this fundamental problem. The first candidate to step to the plate and say, "let's start over - and extend the VA system to all Americans, effective immediately." will send a shock wave through the system. Coupled with a trebling of the VA budget, to be used to simply epxand facilities across the country to handle increased capacity so that any American can walk in the door, we might well see the problem of healthcare in America and the plague of murder by spreadsheet vanish in a generation.

THAT's transformational, progressive reform of American medicine. Obama, Edwards, are you listening?