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Ruser, Kravetz, and Federman's “great dismay” at my proposal to alternatively fund health care for veterans1Weeks W.B. An alternative way to provide healthcare for veterans.Am J Med. 2006; 129: 554-556Abstract Full Text Full Text PDF Scopus (3) Google Scholar is unjustified, particularly because they misrepresent my “central premise” as an apples-to-oranges comparison. In effect, the $6344 per Veterans Affairs (VA) enrollee is a premium because it insures access to VA health care even for the many enrollees who do not use that care. What is “specious” is their contention that if this premium was used to buy a Medicare premium instead, it would somehow increase average per-patient treatment costs from $10,000 to $16,000. That is a fallacious argument because most VA enrollees have other insurance coverage and use it to obtain care: the 2015 Veterans Health Administration (VHA)2Gasper J. Liu H. Kim S. May L. 2015 Survey of Veteran Enrollees Health and Use of Health Care.http://www.va.gov/healthpolicyplanning/SoE2015/2015_VHA_SoE_Full_Findings_Report.pdfGoogle Scholar survey of enrollees found that 80% of VA enrollees had at least one additional form of non-VA health insurance and that 52% of VA enrollees who obtained health care in Fiscal Year 2014 got none of their care through the VA. Other studies show that even VA users get most of their care outside of the VA.3Auerbach D.I. Weeks W.B. Brantley I. Health care spending and efficiency in the US Department of Veterans Affairs.http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR285/RAND_RR285.pdfGoogle Scholar Given the low reliance on VA for most VA enrollees, instead of adding to taxpayer costs, purchasing Medicare insurance instead would essentially eliminate veterans' out-of-pocket care costs while covering about 63% of average annual per-capita Medicare expenditures, considerably more than the “0% to 25%” that the authors suggest. Further, care coordination and elimination of redundant VA- and Medicare-funded care might reduce care costs. To counter my assertion that subsidizing Medicare for veterans might improve care quality, Ruser, Kravetz, and Federman cite a review article concluding that the VA “often […] performs better than or similarly to other systems of care.”4O'Hanlon C. Huang C. Sloss E. et al.Comparing VA and non-VA quality of care: a systematic review.J Gen Intern Med. 2016 Jul 15; ([e-pub ahead of print])https://doi.org/10.1007/211606-016-3775-2Crossref PubMed Google Scholar But over 40% of studies in that review were local in scope, and most national studies examined process measures that nonreciprocally inflate VA performance (for instance, in 2009, 66% of older, Medicare-enrolled VA primary care users got Medicare-funded colonoscopies outside the VA,5Malhotra A. Vaughan-Sarrazin M. Rosenthal G.E. Elderly veterans with dual eligibility for VA and Medicare services: where do they obtain a colonoscopy?.Am J Manag Care. 2015; 21: e264-e270PubMed Google Scholar thereby inflating VA colon cancer screening performance). Of the 6 nationally scoped articles that compared VA to non-VA risk-adjusted outcomes important to veterans (like survival, readmission, or morbidity), 5 found that VA care was worse or worsening and 1 found that VA care was “mixed” with regard to private-sector care in 2000-2001, but worse in 2003-2004. Those results hardly support that VA provides “better or similar performance.” The VA should focus its efforts on new ways to efficiently and effectively provide veterans access to high-quality care. My proposal suggests a relatively simple and cost-effective way to do that. A Case of Apples and OrangesThe American Journal of MedicineVol. 130Issue 3PreviewIt was with great dismay that we read a recent commentary by Weeks.1 He proposes that we use Veteran's Health Administration (VHA) funds to subsidize veterans' enrollment in Medicare. The central premise, comparing expenditures per capita for VHA users with the cost of Medicare premiums, is specious. Notwithstanding his arguments regarding true per annum costs of caring for VHA users, it is a scenario of apples and oranges to compare expenditures related to providing care with the costs of enrolling in a plan. Full-Text PDF