Friday, May 23, 2014

Veterans Administration Problems: Root Cause

The impeachment discussion brought up these interesting and timely comments.
"Obama has combined foreign and domestic disasters, scandals and failures in an entirely unique, unprecedentedly awful, comprehensive and kaleidoscopic fashion." Jerry

"Apart from the VA, I don't see any scandals. There have been some political disputes, however. I will be looking forward into the Congressional investigations in Congress' failure to adequately fund the VA. I expect they will be really hard on themselves." Hiram
Fox News: Obama Promises to Fix VA
Kaiser: VA Controversy Showcases Problems With Government Health Care
LA Times VA Problems Systemic
WP: Obama Defends Veteran Policies

So what do you think?

Is this just what happens when you try to "socialize and cost control health care"?
Is it a good reason to avoid single payer and/or single provider?
Or is it something else?

64 comments:

Laurie said...

my views are shaped by my favorite news interpreter, Kevin Drum who concludes his blog post with this:


"...None of this is really meant to exonerate the Obama administration from whatever faults the VHA still has. He's been president for more than five years, after all. At the same time, the VHA has had a lot of problems for a long time, and their origins span parties, administrations and branches of government. Obama may deserve to get knocked around for not doing more to fix them, but he also deserves credit for finally making significant progress on issues that have festered for decades."

Here's Why It's a Mistake to Foxify the VA Story

John said...

So Obama promised to fix the system and then I don't here him talking about it for 5 years until something bad happens. Maybe there weren't enough votes there.

I hear him talking about wealth distribution and pardoning illegal immigrants often... But nothing about the VA... Interesting.

Anonymous said...

I think what we see here is a systems failure. A lot of the visible problem, are just symptoms of that failure, concealment of wait lists, as opposed to the existence of wait lists. And the larger problem stems from the feudalistic state of health care; with each sector supreme in it's own domain, unable, and sometimes unwilling, to communicate with other sectors. It's a pattern I have seen before, in the public sector, in the private sector, and in the area where the public and private sectors interact.

The difficulties in addressing these problems are immense. For one thing, there is no central authority, no iron fist that can rectify the situation through fiat. To make it work, or at least work better, you have to get the support of people whom you don't have power over, who have their own turf to protect, who might indeed have very good reasons for doing what you don't want them to do. I can tell you from a lot of experience both personal and impersonal that any attempt to get a grip on this situation will yield a harvest of anecdotes, about how things went wrong or might have gone better.

In other words, it's a mess, and one that requires a massive and coordinated effort not to correct but just to make a little bit less of a mess.

--Hiram

Laurie said...

John, its funny how your responses to most issues include the words "wealth distribution." If you want to become a more popular blogger like Kevin Drum, I suggest more balance, objective, or nuanced opinions.

Also,perhaps the VA could be functioning better if congress had distribute more wealth by funding more VA care facilities.

jerrye92002 said...

First, Obama knew about this for years, and now says he knew nothing about it. Second, his administration may have officially created the rules that resulted in this chicanery and the death and unnecessary suffering. Like so many other scandals-- Obamacare, the IRS, Benghazi-- he claims he knew nothing, demands it be fixed, and goes back to his golf game.

Despite the constant increase in the VA budget and the decrease in the number of veterans, the system's inherent inefficiency made these failures inevitable. The root cause, in other words, is the fact that this is a government program. There is no competition, and no accountability. Those delivering the service do not depend on the customer's patronage or customer satisfaction to be paid. They get the same (or more) whether the vets live or die, are cured or go on suffering. Any private enterprise would have gone out of business long ago, and rightly so.

Anonymous said...

We all knew about it for years. The question is, do we have the political will to do something about it?

--Hiram

John said...

Sorry Laurie,
Economist Inequality

I didn't pick the DFL or Obama's 2014 platform... Two key legs of it are wealth inequality and immigration pardons. I am sure we will hear a lot about both of these before November.

And now that there is a problem, we may even hear about the VA system that he promised to fix.

Laurie said...

actions speak louder than words and it looks to me that overall Obama has done pretty well keeping

Promises about Veterans (on The Obameter)

Sean said...

Since when is the number of veterans decreasing? The VA is serving 1 million more people today than when President Obama took office.

jerrye92002 said...

They may be serving (or not serving, apparently) more people, but they aren't veterans.

http://www.va.gov/vetdata/docs/quickfacts/Population_slideshow.pdf

Sean said...

The total veteran population is different from the number of people served by the VA for health services.

http://www.va.gov/vetdata/docs/Utilization/VHAStats.xls

John said...

VA Gov Population Slideshow

VA Gov VHA Stats

John said...

I added an image of the VHA Stats to the post.

John said...

Politifact Obama VHA

So Obama intentionally overloaded the system by adding people who could afford healthcare elsewhere and had no military related health conditions?

I can understand providing long term on going healthcare for those that were negatively impacted by their time in the military, however are we really giving career military personnel free healthcare after they retire?

What am I missing here? That is quite a benefit...

Sean said...

The current priority 8 income threshold is $31,000 for a single person, which would qualify for an ACA subsidy.

Priority 8 veterans do not receive free healthcare from the VA -- the VA essentially functions as their insurance company, and they pay co-pays and deductibles.

John said...

If they pay co-pays and deductibles, who pays their premium?

jerrye92002 said...

How about going back to the original question? Why are some 40 of our nation's heroes dead by neglect of the VA bureaucracy? I contend it is an inevitable result of government-run healthcare.

John said...

WE Story
WP Story

Anonymous said...

Why are some 40 of our nation's heroes dead by neglect of the VA bureaucracy?

Inefficient allocation of inadequate resources.

--Hiram

John said...

The problem when one thinks they can price control something through single payer...

jerrye92002 said...

"Inefficient allocation of inadequate resources."

If the allocation is inefficient (and by one story it is less than 10% as efficient as private medicine), then the resources are not inadequate, they are excessive. And the reason is because there is no cost control due to competition, and imposing external (i.e., not driven by "customers") cost controls only makes matters worse.

Sean said...

So you guys think we should dismantle the VA, then? What next?

jerrye92002 said...

I would suggest that the VA follow its own rules, and send vets to private hospitals if they cannot treat the vets in a proper and timely fashion. It's a short step from there to providing "premium support" for veteran's care, with the VA hospitals becoming optional "charity hospitals" for vets, with an emphasis on their unique sorts of injuries. The good ones would continue to be patronized and the bad ones would go out of business. What's wrong with that?

John said...

Sean,
I think the VHA maybe be beneficial for people injured in action. Many similar injuries and disorders that are rare in the typical public. However it definitely provides a good example of the problems with single payer/provider and price fixing.

John said...

Jerry,
Source for your 10% comment?

Hopefully apples to apples. (Ie many severe injuries with long term impact)

Anonymous said...

"If the allocation is inefficient (and by one story it is less than 10% as efficient as private medicine), then the resources are not inadequate,"

I am not sure where that comes from, If I have four bananas to feed five people, I might divide them up in ways that are most efficient, the hungry person might get more than the person who isn't hungry. But that doesn't mean I have an adequate number of bananas.

For various reasons we have to few doctors and too few nurses in this country. That just doesn't mean they can't be deployed efficiently. what it means in fact is that efficiency in the deployment of their services is at a premium.

--Hiram

Sean said...

"However it definitely provides a good example of the problems with single payer/provider and price fixing."

I don't agree, because the VHA doesn't work like a single-payer system would work in the U.S.

Besides, you're all ignoring how the VHA produces better health outcomes than the health care system for the rest of us.

jerrye92002 said...

"For various reasons we have to few doctors and too few nurses in this country."

Yes, and the reasons all have to do with government interference in the free market. Right now you have many doctors planning to retire, or to not accept Obamacare plans, or Medicaid or Medicare patients. And fewer people want to become doctors because they won't be given the freedom to practice in their patients' best interests because of government interference. Prime example may be the VA, but as we learned yesterday the problem is "systemic."

jerrye92002 said...

better outcomes? You mean like death? It may be true overall, for those who actually get treatment, but when you ration care you do not produce a better outcome than when you don't.

Sean said...

"when you ration care you do not produce a better outcome than when you don't."

OK, but every health care system in the world rations. The question is how do you ration care -- or is it possible to provide the resources to prevent rationing altogether?

John said...

"every health care system in the world rations"

"rations
: food or supplies
: a particular amount of something (such as gasoline or food) that the government allows you to have when there is not enough of it" Merriam Webster

I guess I disagree. Please explain your rationale.

John said...

Since I can not afford to buy an incredible cabin on a beautiful lake, does that mean cabins are being "rationed"???

Personally I have never experienced any significant delay in getting healthcare or counseling... So I don't think we have a scarcity of healthcare resources.

Sean said...

You took the noun definition. I was using it as a verb:

"to supply, apportion, or distribute"

There is not a health care system in the world where everyone gets all the health care they need. As such, health care is rationed. If you want to debate semantics, feel free to substitute your own term for the process I just described.

Our system is largely rationed on ability to pay. Other systems do the rationing on different criteria. Your personal experience means little in the larger scheme, where we know people die because they don't have reliable access to the health care system.

Anonymous said...


Yes, and the reasons all have to do with government interference in the free market.

If government got out of the business, do you think investing in medical schools would be a good business opportunity?

--Hiram

John said...

So someone is rationing those lake front cabins...

Sean said...

Sure, you could say the number of lakefront cabins are rationed. Are you done with this silly semantic argument now?

John said...

No. I think rationing is when some "person, organization or government" decides how to distribute a scarce resource.

I do not think health care is a scarce resource. And I don't think any "person, organization or government" is choosing how to distribute it.

I'll give some thought to a better word.

John said...

"Rationing: verb (used with object)
4. to supply, apportion, or distribute as rations (often followed by out ): to ration out food to an army.

5. to supply or provide with rations: to ration an army with food.

6. to restrict the consumption of (a commodity, food, etc.): to ration meat during war.

7. to restrict the consumption of (a consumer): The civilian population was rationed while the war lasted."

Sean said...

Well, then, by your logic, lakefront cabins are more rationed than health care because government regulations strongly control how much and where people are allowed to build on lakefront property.

But back to the original point. Do you disagree with my statement that "There is not a health care system in the world where everyone gets all the health care they need."

Sean said...

Here's a useful article.

http://www.vox.com/2014/5/29/5761482/what-the-va-scandal-tells-us-about-health-care-rationing

John said...

What VA Tells Us about Health Care Rationing

John said...

I am unsure...

"There is not a health care system in the world where everyone gets all the health care they need."

In the USA a very large number of us who can afford it get all the healthcare we need...

And those who can not afford it get as much healthcare as the government budgets for them or rations to them.

Sean said...

"In the USA a very large number of us who can afford it get all the healthcare we need...

And those who can not afford it get as much healthcare as the government budgets for them or rations to them."

That answer indicates that in our system not everyone gets all the healthcare they need.

John said...

However, many of us do get everything we need and more.

Is it better to "ration" everyone in the name of equality?

Rush Trees

Sean said...

"Is it better to "ration" everyone in the name of equality?"

That's the question, isn't it? Are we OK with people being left out of the system or not?

John said...

I guess my point is that they currently are not left out of the system. We have medicaid, medicare, VHA, etc to provide healthcare for the needy.

This cold hearted saying is pretty appropriate... "Beggars can't be choosers." Therefore if one is to "ration", it seems this is the place to do it.

Rationing services for those who are paying their own way seems distinctly un-American.

Sean said...

"I guess my point is that they currently are not left out of the system. We have medicaid, medicare, VHA, etc to provide healthcare for the needy."

These plans, while better than nothing, don't get it done. Health outcomes for the uninsured are significantly worse. See:

http://www.mathematica-mpr.com/publications/PDFs/health/reformhealthcare_IB1.pdf

http://www.iom.edu/~/media/Files/Report%20Files/2009/Americas-Uninsured-Crisis-Consequences-for-Health-and-Health-Care/Americas%20Uninsured%20Crisis%202009%20Report%20Brief.pdf

http://www.medscape.com/viewarticle/573877_4

http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

John said...

Health Reform Care
Uninsured Crisis
Medscape View Article
KFF Uninsured Facts

John said...

I'll look at them later.

John said...

Just curious... Do you think society is also responsible to pay so every person standing on American soil has food, housing, clothing, utilities, etc also?

Whether they strive to learn and work hard or not? No matter how many children they choose to have? Whether they gamble, smoke, drink, or spend their money in other unhealthy and somewhat wasteful ways?

Is providing low cost healthcare more or less important than the above in your opinion?

We already ensure they have access to a free education, and many squander that.

If we do provide free food, housing, clothing, utilities, healthcare and education, etc to every person standing on American soil, do you really see this incenting people to strive for more, better lives and a better America? Or will many happily live their minimalistic lives and go fishing, etc?

Sean said...

I think as a society we ought to be able to guarantee folks access to our health care system. That will actually make people MORE free, not less.

How many people do you know that have made job decision based solely or primarily on health benefits? That's incredibly distortive to labor markets, which should be about matching employee skills and experience to employer needs.

How great would it be for American competitiveness to have the cost of health care largely removed from the cost of producing a good or service?

You're complaining about the small number of people who might freeload -- while defending a system that in fact rewards freeloading (because that's what the pre-ACA world does).

I'm worried about the large number of people who will gain security and the freedom to live life without worrying about how they would handle a medical crisis or a car accident or how they're going to fill that next refill on their expensive prescription.

Sean said...

And when I say "folks", I mean people who are here legally.

John said...

The Liberal folks on MinnPost want the free healthcare etc so people will be free to pursue their artistic or other passions... Is that what you want for American citizens?

"made job decision based solely or primarily on health benefits?"

Since I see health benefits as just a form of compensation, I disagree with you. People have been free to buy their own health insurance at any time. My Parents and farming/self employed friends have been doing it for decades.

By the way, you avoided my questions... To be "fair", do we need to provide free food, housing, clothing, utilities, healthcare, education, etc to every person "legally standing" on American soil?

I mean food seems just as important as healthcare... Many think housing is right up there also.

John said...

The commenters at MinnPost Resign have a lot to say about the cause...

John said...

I added my 2 cents.

"Metrics matter: Top level managers tend to rely heavily on metrics when turning the knobs on a large organization. I mean what else can they do...

So yes the misreporting was a huge problem. If you are in charge of the VHA and the reports continue to show excellent care, acceptable wait times, reasonable costs, etc. Why would you lobby hard for more resources or make big changes? What would you use as proof that change was required?

This is a key problem with single payer/ single provider systems. The customers aren't free to go elsewhere when they are dissatisfied. So the problem stays hidden..."

Sean said...

Not all people have been free to buy their own insurance. People with preexisting conditions didn't have that freedom.

As for your other question, no, I don't believe in an unlimited safety net. I would put health care, though, at the top of the list of things we should be providing. It's hard for people to be "productive" if they are in poor health.

Sean said...

I agree that metric matter. Unfortunately, the VA administrators were judged on wait times, so they were incentivized to fudge it.

John said...

NR Doomed to Failure
DB Scandal Hits New Hospital

I thought this was interesting. "For perspective, 60% of cardiologists reported seeing between 50 and 124 patients per week, according to a 2013 survey of medical professionals’ compensation conducted by Medscape. On the low end, the average single private practice cardiologist who participated in the study saw more patients in a week than the Albuquerque VA’s entire eight-person cardiology department."

jerrye92002 said...

"Our system is largely rationed on ability to pay." What keeps getting forgotten is that when prices rise, more suppliers enter the marketplace, and price comes down to minimize the rationing. That is, so long as someone wants to buy, someone may wish to sell.

The systems which do the most rationing are those in which prices are fixed, as by government. In such cases, suppliers desert the marketplace and more rationing-- denial of service-- occurs.

And let me disagree that "there is no health care system" that "gives people all the health care they need." There is no system which will give everybody all the health care they WANT, and when government provides it "free," the wants quickly outstrip the available providing resources. Rationing MUST take place by people being responsible for the cost of their purchasing decisions. The system in the USA, like it or not, USED TO come closest to providing all the health care people NEED.

jerrye92002 said...

"Not all people have been free to buy their own insurance. People with preexisting conditions didn't have that freedom."

Not true. Many states have "high risk pools" where people who want to buy insurance for not RISK, but certainty, can buy health insurance, paying what it reasonably costs. Obamacare basically wipes out that fairness and requires all of us to pay those extra costs.

Sean said...

"The system in the USA, like it or not, USED TO come closest to providing all the health care people NEED."

That's just not true. If we were getting the health care we needed, we wouldn't rank so poorly on so many health outcomes.

jerrye92002 said...

Yes, we would. For one example, we base infant mortality on every live birth, including radically premature babies. Other countries start counting an "infant" at age one. And few developed countries have the diverse population and violence of our society. More medical care, good bad or otherwise, isn't going to change those statistics much. And turning it over to a system in which the perverse incentives require rationing of care is exactly the wrong answer.

Sean said...

Stanford Medical School doesn't agree.

http://stanmed.stanford.edu/2013fall/article2.html

What can we do to reduce infant mortality: "eliminat[e] social disparities in medicine"

jerrye92002 said...

As usual, there are any number of ways to interpret the raw statistics. Certainly, one can expect young mothers without health insurance, absent any other factor, to have higher premature birth rates and infant mortality as a result. But finding a solution isn't nearly as simple and straightforward. The majority of these "poor" women were eligible for Medicaid and didn't apply for it. Regardless of the quality of care that would provide, one might assume it better than nothing, and the responsibility to obtain that care falls on that young mother. Now if she didn't know she needed prenatal care (which is likely) you might argue that "society" should have educated her. But she may have refused that as well. After all, she ignored society's advice about not getting pregnant in the first place.