The VA Health System: A National Alternative?

Abstract

In 2007, as in 1993, acknowledging the need for reforming U.S. medical care resembles breathing: No one can escape it. But now, as one or two or three decades before, the obvious question is not whether problems exist, but whether there is a politically acceptable, administratively workable, and economically affordable policy at hand. Phillip Longman’s book, with the foreword by his journalistic sidekick Timothy Noah, claims to have an answer, if not the answer. It is the Department of Veterans Affairs (VA) arrangements, through the Veterans Health Administration (VHA), for the financing, organizing, and delivering of medical care to its clientele. Longman first outlined this bold, unexpected argument in a 2005 Washington Monthly article with the same title as his book: “Best Care Anywhere.” “Ten years ago,” he then claimed, “veterans hospitals were dangerous, dirty, and scandal ridden. ...Now they’re producing the highest quality care in the country. Their turnaround points the way towards solv ing America’s healthcare cr isis .” Longman’s book indisputably documents the amazing improvement in the reality and imagery of the VA medical system. The book elaborates two separable themes. First, it is a fascinating case study of organizational change, the transformation noted above in the operation of the VA’s nationwide medical care system. As such, it shows what is organizationally possible when leaders have both workable reform ideas and the levers of power to put them into practice. In that sense, Longman’s work is a tribute to both the leaders and staff of the VA reform—Ken Kizer most prominently—and the VA’s various constituents in Congress and interest groups for permitting this transformation to take place. Second, he claims, the VA presents a model for U.S. medical care reform. But that is quite another, controversial matter. The central claims of the reform story are easy to state. With the help of electronic medical records across the VA system nationwide, it has been possible to greatly improve the quality of care. Whether the VA is better at that task than, say, Kaiser Permanente, will no doubt generate dispute in the medical journals. But that it does a better job than the disjoined care most Americans receive is not only plausible, but highly likely. Not only is the quality comparatively high, but the cost of the care given is modest by comparison with the rest of U.S. medicine. This is especially true for prescription drugs, where the VA uses its market muscle to purchase the products of Big Pharma at prices Medicare’s congressional masters would be delirious to pay. And, in addition, eligible veterans face medical ailments without a glimmer of financial fear, with a range of benefits (and trivial cost sharing) that makes the rest of U.S. health insurance seem terribly restrictive. Yet the obvious question is whether this remarkable reform story has all that much to offer our national debate over what to do about the cost, quality, and organizational complexity of medical care. Here one should acknowledge the moral zeal and the emotional intensity of the message Longman (and Noah) send. B o o k R e v i e w s