Walter Reed is an army hospital, not a veteran's hospital. The two systems have nothing to do with one another. That's why the problems at Walter Reed led to the resignation of the Secretary of the Army and not the Secretary of Veterans Affairs.
Ezra wins on points. But here's the thing: Army hospitals have all the advantages that single-payer advocates love about the VA. They're unified. There's no profit incentive--indeed, the doctors are on quite low salaries. They have great incentives for preventive care. They certainly don't have any profit motive to provide bad care. So why did Walter Reed suck? And what guarantees that the VA is the system we'll follow, rather than the multiple other dysfunctional government systems everyone hates?
Has Ezra responded about that rogue cancer fiasco at the VA?
And what guarantees that the VA is the system we'll follow, rather than the multiple other dysfunctional government systems everyone hates?
Because none of the plans on offer would have us "follow" the model whereby the federal government owns and operates the facilities. Even if the public option is enacted and promptly leads to the collapse of private health insurance, at "worst" we're talking French or Canada-care, here. The NHS is simply not in the cards.
One disadvantage Army hospitals suffer from ... They compete for funding with the rest of the Military which happens to be stretched to the limit fighting two wars. A second disadvantage are social norms in the military subculture that discourage the voicing of complaints or assertive pursuit of reform. Another obvious disadvantage is the fact that servicemembers don't have a private alternative.
I'd say you're down for the count.
Pardon my faulty English ("... are social norms"). I went to private schoolz.
You don't think, maybe, suddenly being inundated with thousands more patients with blown off limbs and a responsibility to treat all of them might strain their funding? I find it hard to believe that it would be difficult to see that funding might lag behind demand.
Depends. How quickly would a person in that condition be declared unfit for service, given an honorable discharge, and then transferred over to VA?
It depends, but you have to look at the type of problems uncovered at Walter Reid. A shortage of physicians, nurses, or other care professionals would be completely understandable. These people, after all, take time to hire. However, much of the problems were uncovered in living quarters. Paint doesn't peel faster, pipes don't rust faster, and mold doesn't grow faster simply because you have more patients passing through.
That was probably a good excuse in FY2003-2004, and maybe even 2004-2005, but the wars have been going better than expected for the past few years, and I suspect the funding has caught up to that by now, especially since I don't recall any stories about Army hospitals being overwhelmed by casualties of the wars.
"social norms in the military subculture that discourage the voicing of complaints"
hah! you've obviously never been in the military. one of the many things military people excel at is complaining.
I'm not clear on why you think these things describe the army, but not the VA or a putative single payer system.
The VA has a different funding stream, a much broader constituency, and its "customers" are civilians and therefore have some alternatives that active duty personnel don't have. Active duty personnel are often pressured to settle for what they're given and the time-frame for receiving care from the military is much shorter than it is for people who get their healthcare from the VA (which is for life). The military often does a great job but the mechanisms for correcting problems are much weaker for Army hospitals than for VA facilities.
These differences have less to do with organization (as you point out, there are similarities like: "[t]hey're unified. There's no profit incentive--indeed, the doctors are on quite low salaries. They have great incentives for preventive care. They certainly don't have any profit motive to provide bad care" and more to do with supply (VA's mission vs. DoD's) and demand (retired/disabled vets vs. active duty).
So while Army hospitals have some of the advantages, they also have some disadvantages.
Well here's a "the VA sucks" story for Ezra Klien. The Philadelphia Inquirer had a great article this week on the ordinary-course malpractice engaged in by the VA: http://www.philly.com/philly/news/homepage/48695417.html.
Sorry - Here's the link: http://meganmcardle.theatlantic.com/archives/2009/06/the_magic_of_the_va.php
Is this the article you're referring to:
http://www.philly.com/philly/news/homepage/48757382.html
That was it, Thorley. I seem to recall a supplementary article in the Philly Inquirer describing how one patient (now a minister) had bowel movement problems while preaching.
Well, clearly I can't cut and paste a web link. But here's the story: over a 6 year period, the Philadelphia VA committed acts of malpractice with respect to 92 veterans who suffered from prostate cancer.
And I seem to remember a much more recent story about an epidemic of VA malpractice concerning use of unclean medical equipment on veterans. Some veterans contracted HIV, thanks to the VA.
One disadvantage Army hospitals suffer from ... They compete for funding with the rest of the Military which happens to be stretched to the limit fighting two wars.
Yes, and we all know that non-military government health-care systems in other countries have plenty of money and are never stretched to the limit. Which is why it's almost unheard of for them to ration care or impose long wait times on patients...
I'm a bit tired of the smearing of Walter Reed. The vast majority of the hospital runs extremely well, and is at the cutting edge of ambutee and robotic medicine. ONE Dept. in Walter Reed was ignored and horribly mis-served the veterans there.
My husband is a Marine, and thus gets all his medical care (including several expensive surgeries) through naval hospitals. They have served us incredibly well. As a military spouse, I have both government medical insurance, AND the ability to get care at any military hospital free of charge. While my TriCare insurance certainly underpays the doctors for their services compared to private insurance, as the consumer I get excellent private care, and quick and efficient care at all of the naval hospitals I've been to.
Perhaps knowing more about military health care than "years ago there was a scandal at Walter Reed" would help your argument.
As a military brat, I grew up going to military hospitals, and was always impressed by them, as was my family. If the opponents of socialized health care are trying to hold the military's hospitals as a scare tactic, it's going to backfire on them horribly.
I always thought it somewhat ironic that the conservative military lifestyle was probably the most socialistic sector of American society, and ran rather well, all things considered. No one I know who had military health coverage was relieved to be back in the private system.
I always thought it somewhat ironic that the conservative military lifestyle was probably the most socialistic sector of American society
I don't see anything ironic about that. Its not like the military is overwhelming libertarian or anything like that. Also the military is something that would be a government function even in a minimal state. It might have a smaller military but it would be run by the government not the market in most cases, and even if you do rely on mercenaries (and its often a dangerous idea to be totally dependent on mercenaries, even if using them as a supplement can be ok), the mercs would be paid for by the government.
Yeah, that's why I brought it up. I didn't want to imply that I thought TriCare would work perfectly if we just extended it to everyone. But the idea that TriCare or active duty medical care is poor is patently false, and saying "Walter Reed" repeatedly doesn't make it true. I have no idea how a country-wide insurance plan like TriCare would work, but to say that TriCare isn't working NOW is unfair and incorrect.
Fair enough.
Thank you! I've long said to people agitating for a universal health care plan that I've got Tricare, people complain about it constantly, and I don't see why it'll be different if it's expanded to cover everybody.
And the military system is covering people who are required to exercise and keep their weight under control or they'll be fired.
Sorry for the 2x comment...
And regarding your comment about having incentives for preventative care: they not only have a plan in place, they enforce it ruthlessly. I'm in a leadership position in charge of 15 people, and I get yelled at every week during the operations meeting because someone hasn't had their yearly dental or vision checkup. Then I go back to my office and yell at them for not checking their status on MEDPROS (the central system that tracks who's due vision, dental, hearing, HIV checks, etc.)
Yeah, I might side with Mrs. Teufelshunde. Does 'Walter Reed suck?
I don't see alot of Congressman or Senators heading over to D.C. General or Fairfax Inova when they need medical care not that I think Fairfax Inova sucks just that our leaders head to Walter Reed or Bethesda Naval Hospital or at least they used to.
I note Ruth Bader Ginsburg's latest cancer was found during a 'routine' examination at the National Institute of Health. I don't many people get 'routine' examinations at the National Institute of Health but maybe I'm wrong. If so I might be tempted to go outside my
healhcare plans guidelines and drive up from Richmond should I think I have a medical problem.
So,IMO, the issue is not that the government CANNOT provide quality care it is more a matter of who will get it. I just be Admirals and Generals at Walter Reed or Bethesda get more senior medical personel
than do sailors and privates.
The VA has had its share of scandals over the years. It's not a system to which we should aspire as a nation.
"The two systems have nothing to do with one another."
How can two parts of the federal government have nothing to do with one another? It's like saying the Senate and the House have nothing to do with one another. Or Medicare and Social Security have nothing to do with one another.
Why did WR suck? Let's see....
- Massive requirements for funding, materials, personnel due to the war in Afghanistan and the optional war in Iraq pulled needed resources from WR.
- Incompetence starting with the Commander in Chief and going down to the hospital administrators. The CiC, well, sucked at just about everything. The administrators failed to push back at their "superiors" when things started breaking down. Everybody in between, including Reps and Senators of both parties responsible for oversight who FAILED HORRIBLY TO DO THEIR JOBS.
GWMustGo,
all of those things are reasons why we should NEVER have government-run health care. Despite your hallucinations, GWB was not a singularly incompetent, malevolent dementor who caused everyone below him, at every level, to become incompetent. They already were. I'll bet you that even under Obama, may He be blessed, we will have incompetent career bureaucrats, self-serving politicians who ignore their responsibilities, and incompetency at every level. The difference is that we won't have anywhere else to go.
The CiC? Are we talking about Obama here? Because that's the CiC now.
Perhaps GWMustGo meant the Commanding Officer of WR? But then again, given the name perhaps s/he really did mean our former commander in chief.
Yes indeed. We had a group of politicians and "health economists" in the 90's that decided there were too many doctors. Cut training budgets. Brilliant idea. Oh yeah, come to think of it, there were too many nurses too.
It has taken quite a few years to fix that one. You know how they 'fixed' it? Closed hospitals. Not enough doctors and specialists or nurses to staff them, so closed them.
If you think that the US medical system sucks right now, just wait till you have a bunch of slimy policians running it.
Derek
Nice reasoning by anecdote.
I don't think the VA proves anything except "government health services don't have to suck."
Moving on to gov't health insurance, because that's what's actually being discussed in Washington:
If you knew that government health insurance didn't have to suck, then the other arm of the proof you need is that for-profit health insurance more or less DOES have to suck.
I would say it's logical that for-profit health insurance does have to suck, because it's in their profit interest to spend as much money as needed (up to the cost of the actual care) to DENY people health care.
Another reason is that the insurance company gets the money FIRST and then (usually long afterwards) is supposed to pay for your care. Why would they want to pay for your care if they already have your money?
Another reason is that insurance companies have a strong motivation to avoid actually PROVIDING care, because it's a COST. Thus, sick people go uninsured, people who get sick are dropped, the aforementioned claims are denied, etc.
Now why doesn't market feedback take care of these things?
Maybe there isn't good information about how much different insurance companies suck, and in any case, the feedback is very much damped because YOU don't make the choice, your employer does (usually.)
In this case government inefficiency actually could be a great BENEFIT for your insurance needs, because they're so cost-inefficient they don't even WANT to screw you over. They can just dumbly pay for ACTUAL HEALTH CARE.
They don't have to pay for marketing, seminars, and lawyers and bureaucrats whose job it is to aggressively deny you care.
How big is that portion? 20% 40%?
http://www.sciencedaily.com/releases/2005/11/051110215547.htm
"Another reason is that the insurance company gets the money FIRST and then (usually long afterwards) is supposed to pay for your care."
Every insurance company, not just health insurance companies, gets its money (i.e., premiums) "FIRST". They then invest this money (their float) and use it to pay claims later. For that matter, Medicare does this too (although it only invests its funds in the same sense Social Security does). If an insurance company didn't collect premiums first and just paid out claims, its business model would be -- how do the kids put it? -- Epic Fail.
"Why would they want to pay for your care if they already have your money?"
Why do any insurance companies pay out their claims? Because they are legally obligated to do so, according to their insurance contracts, and because if word got out that an insurance company wasn't paying its claims, it would lose its customers.
"They don't have to pay for marketing, seminars, and lawyers and bureaucrats whose job it is to aggressively deny you care."
Neither does Medicare, and yet its costs keep rising fast. That suggests that it isn't the marketing and other for-profit aspects of for private health insurance that are driving health care costs. It's the reimbursements to health care providers.
"in any case, the feedback is very much damped because YOU don't make the choice, your employer does (usually.)"
I've found that this is a strength of the current system. My son needed occupational and language therapy for many years, and each year I'd have a horrible, painful time trying to get the therapy provider (a hospital) and insurer to talk to each other and work out coverage. The hospital knew that it could collect from me if the insurer didn't pay, and the insurer preferred not to pay.
So, I reported my repeated problems to the human resource people of my employer, and based largely on my problems (plus others, I'm sure), they switched coverage for more than 10,000 employees to a new insurer who did a better job. In other words, competition meant that the insurer that didn't take care of its customers lost business.
With a government bureaucracy, maybe at first they'll "just dumbly pay for ACTUAL HEALTH CARE", or maybe not. What difference will it make to them either way, since they won't have one of those nasty profit motives which might give them an incentive to attract future business? And eventually, there will be pressures to cut the rising costs of health care, and then they'll have a strong incentive to just dumbly NOT pay for health care. And what alternative will people have?
Maybe there isn't good information about how much different insurance companies suck, and in any case, the feedback is very much damped because YOU don't make the choice, your employer does (usually.)
While this is *partly* true for the small business (
oops - forgot about the magic of angle-brackets....
While this is partly true for the small business (less than 20 covered employees) I work for, I still have the choice between Kaiser and BlueSomething, and can change at least once a year. Many larger employers have cafeteria plans which allow employees to allocate their benefits more flexibly, and most such plans have more than two companies' offerings available.
People *do* talk about their health coverage at work; insurance companies which are more aggressive about denying coverage *will* lose customers at open-enrollment time.
Out of curiosity, who on this thread has lived in another country with another system and what were your experiences?
My career took me to Canada for 2 years and for all the talk about how horrible it is that one hears here in the US, I had a great experience. I paid a one-time fee to buy into it as a foreigner (which was WAY less than what I pay now than I'm back in the US), and it was pretty much hassle free. I saw two friends get quick and excellent treatment for breast cancer and I was quite impressed (compared to how my step-mother was treated here).
Right before I moved there, I had a giant 6 month nightmare of a battle with my insurance company (who doesn't have a nightmare insurance story?), and being in that system was quite a relief for me personally. It was just never anything I had to worry about.
I've only been back for a few months and already I have a huge file of about 10 letters concerning one sole doctor's visit and I've already paid more because of that one visit (not to mention all the time wasted on the phone with claims departments, etc.) than what it cost me to buy my way into OHIP for an entire year.
And please don't confuse my positive experience in Ontario with an endorsement for the idea that the US should become a single-payer or state run system. I'm just sharing my experiences.
I do feel though that its worth looking at the systems in places like Japan, Germany, Australia, France, etc. and seeing if maybe there aren't lessons to be learned.
If anyone has some first hand foreign experiences, I'd like to hear your thoughts on your experiences abroad.
"I saw two friends get quick and excellent treatment for breast cancer and I was quite impressed (compared to how my step-mother was treated here)."
This is rather interesting (or else shows how people's personal discussions of medical experiences are almost entirely anecdotal) because David Leonhardt's article comparing American care with other countries suggested that US care of breast cancer is far more effective than other countries.
I'll be happy to.
I spent 8 years training in Canada, first as a medical student, then as a resident.
The fundamental problem even then (15 years ago) was that the infrastructure was outdated. The hospital was 100 years old (and looked it), the radiology equipment was outdated, and the hospital was running at close to 100% capacity, which meant that any uptick in admissions (a flu outbreak, polytrauma, the like) could not be accomodated.
The hospitals were paid a set amount by the provincial government to cover expenses for the year. The result was that by November, resources were stretched thin, and by Christmas, no elective surgery was scheduled. Since OR access was limited at the best of times, this meant a significant waiting period for elective cases. Elective cases, by the way, include cataracts, joint replacement, sports medicine, thyroids, and so forth - the delay doesn't cause mortality, but it sure causes morbidity.
This was compounded by the government's decision to pay older doctors to retire early, thus creating a shortage, and to limit medical school admissions, thus compounding future shortages because no new doctors were in the pipeline.
None of these issues have improved. In fact, they have worsened substantially, to the point where it is essentially impossible to find even open primary care appointments. This is in Montreal, one of the biggest cities in Canada. Forget specialist appointments - they're booked into infinity.
The lesson is that politicians and bureaucrats respond to immediate pressure, but have no interest in what occurs 15 years down the road. By the time the US system implodes because of the current quest for free universal coverage, Obama and his ilk will be writing their memoirs, and remarking with sorrow on how we screwed up his perfect health care plan.
As a lifelong Canadian I'm rather worried about the U.S. driving out private health care, for my countrymen's own selfish reasons. Experimental or cutting-edge treatments are as a rule unavailable here, typically for budgetary reasons; even MRIs are still in short supply. If you can show you require treatment (to the system's satisfaction; Google the name "Lindsay McCreith" for a troubling story) they'll pay to send you to places like the Mayo Clinic. But any Canuck can see that the U.S. is the world's new-drug and experimental-medicine leader because there are large profits to be had there. If the United States moves to erode that motive, that kind of medical progress will slow or stop, and it won't just be foreigners who lose out as a result.
I've experienced health care and health insurance in Hong Kong. Probably because of the tradition of herbal medicine, medication is typically covered as part of the visit. If you have a cold, they'll load you down with big bottles of the nastiest-tasting cough medicine, baggies full of aspirin, etc.
If you need antibiotics, they don't give you the full course because that would be too expensive - they just give you a few day's worth of the antibiotics and tell you to come back for another visit. Of course many people feel better after a few days and don't come back, thus helping to spread resistance to antibiotics. At least, though, they have an incentive to give everyone the oldest, cheapest antibiotic, so they're not destroying the effectiveness of the latest ones (unlike in Japan, where the doctors sell you the drugs and get a markup, so they have an incentive to go directly to the newest, most expensive drug even when a cheaper generic would work).
Anyone with a Hong Kong ID number can get care in any public hospital for something ridiculously cheap like $10 a day. If you're 'lucky' enough to be in intensive care, you get top of the line care for very little money. If you're not as sick, you're put in a ward room, jammed into a bed as close as possible to other patients (if the room is half empty, everyone will be close together in one half rather than spread out, so that the nurse doesn't have to turn her head). You often come out sicker than when you went in (although since SARS, that might have finally been fixed). And of course in a ward room, you'd better have family to feed you, wash you and take you to to the bathroom, because that's not considered part of nursing care.
As for medical insurance, they like to exclude those most likely to need it. When my newborn son needed brain surgery shortly after birth because of a subdural hematoma (the doctor got a bit careless with the forceps and cracked his skull, cutting a major vein), the surgery and intensive care were not covered, because they specifically excluded newborns from coverage. After all, they explained, it might be expensive to cover newborns.
We're working on a lawsuit that might eventually cover our medical costs (apparently you're not supposed to put the forceps on the back of a baby's skull, because it can lead to fractures, and apparently it's not all that hard to check the placement of forceps before you start yanking; there was no particular hurry). But even if we win the malpractice lawsuit, it will cover only direct medical costs, legal costs (no contingency fees; you pay upfront and hope to recover costs if you win) plus possibly, if we can show lifelong injury, something along the lines of $10,000 or maybe $15,000 compensation. Our medical expert said that he had already testified several times against our doctor and was convinced that she was incompetent, but I think she's still practicing, since losing several malpractice cases isn't all that costly.
Ok, Why did Walter Reed Suck?
To the Hostess:
A few years ago before Walter Reed sucked the Military realized that it had several large scale military facilities around DC. One for the Air Force, Navy, and Army. One day somebody at the Pentagon or Congress came up with a good idea: collecting all the services under one roof. This is what they're building at Bethesda Maryland as we speak. The U.S. military after that time started the B.R.A.C. (Base Realignment And Closure committee)realizing that Walter Reed was going to be redundant they advocated the closure.
Now here is where Walter Reed starts to suck. In order to close down a facility your going to see a shift in funds. More temporary solutions less big fixes, closing down buildings, minimal repair, etc.
In peacetime the following would never have happened, but it wasn't peaceful. The war in Iraq drags on and gets worse. Putting more and more stress on a facility that should be on its way out, not operating at peak. Thats where building 18 (or whichever) comes from, thats how soldiers are neglected, the people above them who are supposed to keep things together fail. They failed because they were focused on other issues Inpatient care, moving, about to retire and were eyeing the future.
The inpatient care at Walter Reed has always been some of the best anywhere. That didn't change, but whereas most people could do outpatient care from home, soldiers were put up in miserable conditions, and in a culture that doesn't do well with disabilities they were abused because of them. Walking out into the wet field at 6:30am is a daily ritual in the army at every installation. So naturally even though it seems obvious to all "why change?" at Walter Reed.
To close saying that Walter Reed sucked because it provided poor medical care is to not understand the causes. The causes were bureaucratic and cultural. The health care provided was top notch. But we don't consider housing individuals, who anywhere else would be at their own home, a part of health care do we? I went there 3 times during my Army career: once for shoulder surgery and twice for follow-up. The medical care was top notch, much better than I'd find at any local clinic.
What guarantees that the next post in this blog will one of the ones that is intelligent and thought provoking, rather than one of the ones that is off-base and uninformed ones that everyone hates?
I think this is another embarrassing comment from Megan on healthcare. Very similar to the one earlier this week using an incident suggesting that the VA cancer unit story in the NYTimes, tragic as it is, outweighs the years and years of data showing that the VA destroys other healthcare in the US. It's very like the "it's snowing so there is not such thing as global warming" crowd.
Megan, i ignored the disaster that was your performance on bloggingheads about healthcare last week, i pretended that you didn't write the VA cancer comment but this post is idiotic. I want to believe that you care about data and evidence but you are teetering on the edge at the moment, and if you are honest with yourself you'll agree.
Please point us to this "years and years of data." Thanks.
happy to help... there might be a useful start.
http://www.washingtonmonthly.com/features/2005/0501.longman.html
http://www.amazon.com/dp/0977825302/?tag=googhydr-20&hvadid=3325975191&ref=pd_sl_9scbgi6t2_e
Need I remind Megan that the plural of anecdote is not data. Hospitals have fraud and sometimes mistreat their patients. Sometimes the hospital is run by the government, sometimes it's run by private individuals. If you want to prove that the ones run by the military are worse you are going to have to provide data.
What are you arguing for Megan? It's either adopting Canada/UK/France care or go broke. I know private insurers and doc's hate this but there's just no other choice.
Ben--
Good point. I forgot what drives bad infrastructure almost anywhere in the Army: "We don't need to maintain this building because we're replacing it in 2 years"
This gets repeated every year for 15 years, but the new structure never seems to arrive because funding priorities always seem to change, and the plan (generally made with the best of intentions) falls aside. Soldiers during basic training during Vietnam lived in ratty barracks buildings that were built during WWII with the intention of being used for only 3-5 years. The military is constantly using structures well beyond their design lifespan.
Here's a link to the story about a number of clinics and hospitals around the VA botching colonoscopies.
http://www.cbsnews.com/video/watch/?id=5092544n
Yes, the VA put 3200 veterans at risk of HIV and hepatitis due to incompetence.
Honestly, the spectacle is amazing... we have the very same bunch of socialists who were complaining that the last Administration 'gutted' or 'slashed' the VA are now saying the VA is a model of efficiency and quality.
Must be all those unicorn droppings being drop-shipped to VA clinics nationwide courtesy of the White House.
At any rate, most veterans are excluded from the VA system, unless they have service-related medical issues, thanks to the strict income limits placed on VA eligibility.
Here are the income limits:
http://www.va.gov/healtheligibility/Library/pubs/VAIncomeThresholds/VAIncomeThresholds.pdf
This exclusion helps preserve available dollars for veterans with service-related medical issues - many of whom are uninsurable, and the poor.
The reason the VA can do this? We have a robust private system of medical care and insurance. The very same system now under assault by the Obama administration, congressional Democrats, and their lackies in the media.
The VA system isn't even universal within the veterans population. Priority 8 veterans cannot enroll. If you try to make VA care universal for veterans, the quality of care and availability of specialists and special equipment will decline substantially.
Walter Reed DID NOT SUCK!!!!
I was a patient at WRAMC during the so-called "suckage". The problem was not with patient treatment, but with billeting of outpatients.
Patient treatment at WR was, and remains, first-rate! I am really tired of hearing the lies about this.
I spent 29 years in various capacities in the military, a customer of the military medical system. At no time have I ever felt that the care I or my dependants received was anything less than the best available.
Now, I am retired, and am a customer of TriCare. This is a completely different matter. TriCare is the governement run insurance program that handles ilitary retirees. If this is an example of what is to come, there are many challenges to meet.
Eh, if you avoid any critical assessment of the current system, especially in how it deals with the lower 50% (or whatever) of Americans, you're always going to find fault with the alternatives. It's a ridiculous style of argument, and it puts you on rhetorial a par with, say, the Chinese government when they argue that pluralist democracy would bring chaos, or with Islamic theocrats who argue that the emancipation of women would produce libertinism and prostitution.
I used the military system for years and I would never go back. If you are healthy it's great, except for the long wait time for basic appointments. Want a yearly pap test? Start booking the appointment 4 months out. I think the system uses personnel more efficiently also, as you often don't see a doctor, but most times a tech or nurse will do. Of course, if you need to see a doctor get in line. Active duty have priority of course, so if you are a dependent, hope you don't need to see anyone that is in shortage, like say a dermatologist. In the states you can see a 'regular' doctor, but overseas you are stuck. I lived overseas many years, both in europe and asia, and their systems are nothing to emulate. Most Americans would never put up with them anyway, we all want 'cadillac' coverage. For another useless anecdote, I had three kids in military hospitals and never got any anesthesia, because every time the one anesthesiologist was needed some where else. The last labor I had a german doctor deliver because the other army docs were with more difficult deliveries. We're lucky my son is alive today. Perhaps the australian system is worth looking into, but I would never go for the military or german system. Sorry for the rant, but most people never have used any kind of socialize medicine and really know nothing about it. Drives me nuts!
Well, I'll admit I don't know much about medical care overseas, but my anecdotal experience is the exact opposite of yours. I moved to California and had to change to TriWest, changing all of my doctors and all else. I had a physical (with a pap) within a week of calling the doctor. When I was on private health care, it took me months to get a gyno to see me, because they "weren't taking new patients". My PCM referred me to a dermatologist, who yes, she had to get clearance from TriCare to send me to, but they called with the referral within 15 minutes of me leaving the office. The dermatologist? Saw me twice in one week, the week after I called with the referral.
When my husband had surgery, he had three navy doctors hovering over him the whole time. I showed up at the walk in clinic at the hospital with an eye infection, they saw me within a half hour.
Maybe it's connected to the area you live in, or maybe I've just been lucky, but I would NEVER go back to paying private health insurance premiums if I could help it.
They compete for funding with the rest of the Military which happens to be stretched to the limit fighting two wars.
So what happens when government-subsidized insurance has to compete for funding with the everything else in the federal budget? You don't think that'll provide a powerful incentive to cut corners?
None of this is a credible comparative analysis. If we want to judge any health care delivery system based on whether there are unhappy customers, then they all stink. Everyone knows someone who has had an unsatisfactory/frightful/tragic medical experience. Trading anecdotes as a substitute for institutional analysis is pretty counterproductive.
There are 2 parts to the discussion: 1). the price of care, and 2). the rules of its delivery. Conflating the 2 parts only confuses the issue.
As far as Megan's specific post, it is pretty weak and only serves to stir anecdotal debate instead of providing sensible/realistic information (as journalists are *supposed* to do).
Yes, Walter Reed and the VA are affiliated with government institutions. However, to assume they have the same institutional mechanisms and the same strengths/weaknesses is disingenuous. To assume so ignores the very different principle/agent incentives inherent in each organization. The population they serve differs in both average health, age, and mission. The leadership structure and administration are entirely different.
Compare the health outcomes of a VA to a typical city hospital system, and you will most likely get similar results.
Additionally, governmental institutions have different rules regarding transparency than private ones. Of course you hear of horror stories coming from government-administered healthcare entities-- private entities are entitled to different privacy privileges. The assumption that they screw up any less is at best naive, and at worst, ignorantly biased.
There's a movement afoot from the left wing talking point crew to dismiss the real criticisms of the VA system as "anecdotal," in an attempt to dismiss them.
One botched colonoscopy is an anecdote.
3200 botched colonoscopies across several facilities is a systemic failure.
One botched prostate cancer treatment is an anecdote.
92 botched prostate cancer treatments out of a sample of 116 + a coverup attempt + the failure of the nuclear medicine safety board to enforce its own standards despit knowing a problem exists is a systemic failure.
Jason- I think the VA story from this week (which was really a story from a year or two ago, brought back to "illuminate" the current debate) is a very serious systemic failure, as you note. But it's not 92 out of a sample of 116; that "sample" is the total of prostate cancer treatments performed by a doctor already known to be incompetent and corrupt at the time the "sample" was drawn. 92/116 is an appropriate statistic in determining how incompetent and corrupt the doctor was, but it's not a meaningful statistic about the quality of prostate cancer treatments in VA facilities.
I'm willing to discount the anecdotal evidence of government-provided health care failure provided the advocates of further socializing health care discount anecdotal evidence of privately-funded health care failures.
Veterans are happy with care at VA hospitals because it was SO terrible before, their basis for comparison is skewed. They are also a group that is not entirely representative of society overall.
The VA healthcare system is already backsliding on its gains in the past decade (which were mostly due to technology). The influx of new patients is putting enormous pressure on the entire VA system.
VA is excellent at making numbers and surveys look good--you cannot entirely trust them. I would not dismiss the growing anecdotal evidence concerning problems at VAMCs lightly. And I would also not use the success of the VA health care system to support a position, as it is an example that will almost certainly be used against you in the next 2-5 years, as the current problems accelerate and become more apparent to the general public.
The VA is a single payor, but not a single source of care .... it outsources something like 55% of its services.
The argument is not apples and apples, because those institutions that are outsourced to from the VA's system have their own payor vehicles, which have to interact with the VA's.
"the doctors are on quite low salaries"
Doesn't this indicate a problem to anyone else?
Why are those doctors on "quite low salaries"? Are they planning on continuing with those salaries, or are they planning/hoping to change to higher salaries in the private sector at some point in the future? Even if they are happy with their salaries and have no plans to change, how many prospective doctors are going to share that attitude?
Patterning a country-wide plan on the VA network, or any other kind of government-run system which requires similar low salaries for doctors will quickly lead to the same types of shortages of medical personnel that other countries are now suffering under. Why the hell would you put in the extra years of hard work (and cost!, monetary and opportunity) of medical school when you will only end up making a "quite low salary"????
The VA's success in hiring doctors at low salaries hinges on 3 things:
1. You don't have to work very hard there. Therefore it appeals greatly to female physicians who want time off, easier hours, etc., to be with the kids.
2. There's always someone around to help out. The VA affiliates with residency programs (i.e., someone else does your paperwork) and is a large enough single employer that, if you're a timid physician, you're never really alone - everybody who does your specialty is, after all, a member of the same practice group as you.
3. Foreign-born physicians can get green cards by working in "underserved areas" or at a VA hospital (see here). Given the choice between working in a horribly rural area or being ill-paid at a VA that is, for all its faults, in a city, many choose the latter. My department (an academic anesthesiology department) has two members who came from the VA as soon as they got their green cards and is hoping to hire another.
As a life-long consumer of military health care in military facilities, with experience using US-based TriCare, and overseas health care, I'm grateful for what I've had, but I wouldn't want the entire system to be run like the military medical system. Here's why:
1. Military health-care is great if you're healthy, have no chronic conditions, and are not a dependent. If you have a chronic condition, you are in trouble because you never see the same medical caregiver twice. The next person you see has 20 minutes to "listen" to you, "read" your records and decide what to do. If that doesn't work, you start all over again with the next one. This is particularly bad if they can't figure out what you have. Not to mention that either you or the doctor will probably move in 6 months anyway.
If you are a dependent, you wait in line for all the active duty to be taken care of first (I'm not complaining, just stating a fact). If you're active duty, you cannot sue for malpractice. Also, there is a culture (at least among pilots) of never admitting to any health problems in order not to be taken off of flight status, mandatory annual physicals notwithstanding. Both the patient and the doctor conspire to brush off anything not imminently life-threatening in order to preserve the flight pay.
2. If you are savvy, and willing to pay for TriCare standard coverage, you can see some great civilian doctors in the US. However, you have to stay on top of it and be willing to wade through lots of paperwork and TriCare employees who don't give you the same answer twice to the same question. If you happen to reside in a location TriCare considers "remote" (like central Illinois) good luck finding anyone who will accept TriCare. There are only one or two.
3. I've lived in three European countries where there was no nearby military medical facility and our family saw local providers. It was very similar to the military medical system: great if you're basically healthy. But if you have to be hospitalized, you'd better have family to advocate for you and take care of your needs. And they have to be persistent, as some European providers feel no need to keep next-of-kin informed. Be prepared to pay up front in Britain. I once had an NHS doctor at an emergency room refuse to even take my temperature until my credit card had been charged.
I felt the level of care my family received was fine overseas (again, we were infrequently sick), but I knew I had the alternative of going to a military base or flying home if anything really bad happened. I wouldn't have wanted a major illness or surgery in one of the socialized countries we lived in because the treatment options are limited--not just by funding, but by the attitudes of the doctors, and even the patients themselves. Their expectations are lower. This is endemic in every aspect of a socialized system: lower pay = fewer people willing to go to med school = lower standards to increase the number who qualify; lower profit = less likelihood firms will invest in research for new treatments, drugs or diagnostic equipment; lower patient expectations = no malpractice suits or complaints = no real reason to improve anything. Eventually, a two-tier system evolves anyway, with those who can afford it either leaving the country for treatment in the US or subscribing to private networks (common in the UK today) so they don't have to wait in line.
One thing I've learned; good information is important in improving any system. It's hard to compare infant mortality across countries, for instance, because some countries in Europe count a baby that dies 8 hours after delivery as a 'stillbirth' and some count it as a person with an 8 hour lifespan. The second is more honest, but the first looks better on paper. I'd like a national _feedback_ system, maybe similar to that on eBay so that we could get a better idea of the quality of doctors and insurers up-front.
I'd like to see some healthcare reform without nationalization.
For instance, instead of caps on lawsuit settlements how about a system which encouraged doctors to disclose their mistakes and settle out of court in exchange for protection from legal liability. We could say that if a patient lost a hand that $100,000 (or whatever) was sufficient compensation according to some established paychart. If the doctor offered that money upfront and in a reasonable timeframe then they would be absolved of any future legal liability. If they didn't, well, sky's the limit. Failure to disclose information would also lead to an increased risk for punitive damages.
Reducing huge malpractice lawsuits would lower the cost of private healthcare. It would lower the need for expensive lawyers and the unevenly-distributed damage awards. (Since many people who have been mistreated aren't going to sue.) But we'd still have mechanisms in place to identify and eventually remove the worst doctors.
These are great suggestions. But those expensive lawyers, malpractice insurance companies, and bad doctors might have some economic concerns.
Yeah, true. And unfortunately the country is run by lawyers. Otherwise, we'd have a lot more outsourcing of legal and court work to India. (I know some occurs now)
And what guarantees that the VA is the system we'll follow, rather than the multiple other dysfunctional government systems everyone hates?
Because we have Hope! and Change! and the willingness to fire any inspector general who asks too many questions about why campaign contributors mysteriously get the best gov't care.
I'm mostly just excited to hear what wonderful euphemism our newest branch of government will be appellated with. Will it be the "Happy Fun Health Zone?" "Department of Goodfeeling?" "Ministry of Wellness?" Stay tuned!
To add to the point Pete P made above (and probably no one will read this given the date this item was originally posted), what actually sucked was the administrative system to deal with wounded soldiers and determine what should be done with them (discharge, retain, etc.). Problems in that led to a backlog of soldiers who had to be billeted in what turned out to be less than ideal conditions. So what actually sucked was the personnel system, not the medical system.