Can VA’s struggles, successes help improve health care for us all?

Despite the barrage of terrible headlines about reported problems in its care, the VA, aka Veterans Affairs, “continues to perform as well as, and often better than, the rest of the U.S. health-care system on key quality measures [including] patient safety, patient satisfaction, care coordination, and adherence to evidence-based medical practices,” a new study of the embattled agency concludes.

The work, issued by the American Legion and conducted by health care journalists with affiliations including Johns Hopkins University and the University of California, San Francisco, is part of a growing, continuing, and urgently needed re-examination of one of the nation’s major medical providers.

The VA’s struggles, past, present, and into the future, are driven in part by its size and the scope of its mission and commitment, as a recent, detailed article in Foreign Affairs points out:

By law, nearly all of the country’s 21 million former service members are eligible for VA health care; of these, nine million have enrolled, and almost seven million used the system in 2016, at a cost of $63 billion. This system provides comprehensive coverage, not only for injuries and illnesses sustained in the line of duty but also for any other medical needs that may arise at any point. To do this, the VA runs 144 hospitals, 800 clinics, and 300 mental health Vet Centers and employs more than 300,000 people. In addition to treating veterans, the VA trains nearly half of U.S. doctors and two-thirds of U.S. nurses at some point in their careers and conducts more than $2 billion in research each year.

In the mammoth system, scandals have blown up, including regular, “scathing” assessments of the agency’s failings by its inspectors general or by journalists finding, as they did in 2014 in Phoenix, unacceptable lags in the delivery of quality care. The public and political outrage that ensues is understandable and likely justified.

But broader, deeper, evidence-based dissections of the VA, its mission, and performance inevitably raise hard questions not only about the agency, the nation’s commitment to its service personnel, and the rise and role of an all-volunteer force. A thoughtful discussion of veterans’ care also should prompt some tough consideration of the nation’s whole health care system, especially as some advocates push for vets to get more of their treatment integrated into it rather than through a separate agency like the VA.

Independent, nonpartisan, expert researchers at institutions like the RAND Corporation have concurred, based on meta-examinations of extensive earlier studies of the VA, that the agency’s care matches (is as good as) much of what is available in the private sector. But what does that comparison say about the hospitals and medical services available to non-military Americans?

As the Legion researchers point out, both vets and private patients experience challenging wait times for appointments, sometimes for weeks or months. The VA performs better on this score than what ordinary patients experience in many big cities like Boston. Vets also may be safer in agency care than patients in non-military hospitals: Medical error plagues the U.S. health care system, costing by some estimates 685 deaths a day and ranking as the third leading cause of preventable death behind only heart disease and cancer. Vets and non-military patients alike struggle to get mental health care, though, again, the VA outperforms its private sector peers in this area, too.

Meantime, all Americans—whether through the VA system or not—struggle with some significant banes that only appear to be bigger and tougher in the days ahead. Where will we get the doctors, nurses, and other medical staff we desperately will need in the future, as we’re already encountering shortfalls? How can we make technology, including electronic health records, function better in a sector as big and complex as health care? How will the VA or the health care system as a whole deal with the tsunami of older, sicker patients as the nation grays?

And, of course, how will we keep paying for medical care when its price keeps skyrocketing?

In my practice, I see not only the major harms that patients suffer while seeking medical services but also their wrenching struggles to afford medical care, treatments, like those that many veterans need, that are complex, costly, and will be needed for a lifetime. Americans spend more than $3 trillion a year in the health care sector. Some experts estimate that the nation is on the hook for as much as $4 trillion in the years ahead to fulfill our commitment to deserving military personnel from 9/11 forward.

The VA can be a messy, frustrating, and imperfect agency. It deserves criticism on occasion, especially if that leads to improvements. There’s also a case to be made not only that it is, as the Legion contends, a “system worth saving,” but maybe that it can provide lessons and ways forward to make health care for all Americans more affordable, efficient, accessible, safe, and excellent.