Lack of progress after VA scandal provides important lessons for healthcare reform

The Associated Press recently reported​ that, despite the public outcry regarding the medical care our veterans have been receiving through the Veterans Administration (VA) and the resulting billions in additional funds, the number of patients encountering lengthy delays has not decreased.  

The VA scandal broke in April 2014 when Dr. Sam Foote, a physician in the VA system for 24 years, claimed that VA managers in Phoenix created a secret wait list to conceal that 1400 to 1600 veterans waited for months for an appointment and some waited for over a year. According to Dr. Foote, at least 40 veterans died while waiting to see a physician.  

{mosads}The VA Office of Inspector General (OIG) found​ there were over 3500 veterans waiting for appointments who were not on the official Phoenix VA wait list. According to the report, 28 delays were “clinically significant” and six people died. The VA OIG also acknowledged that it’s received 445 allegations of wait time manipulations at other VA facilities and is currently investigating 93 sites.  

The recent Associated Press report indicates that unfortunately the situation has not gotten much better for veterans dependent on the VA for care. According to the report, from August 1 to February 28, approximately 894,000 VA appointments failed to meet the VA’s goal of an appointment within 30 days while 232,000 appointments had delays of over 60 days. The number of veterans waiting over 30 or 60 days has been relatively stable since last summer and those waiting 90 days or more has actually doubled.  These problems have persisted in light of the allotment of billions of additional dollars for the VA.   

Money was never the issue at the VA. The problems were due to inefficiency and culture. In fact, these problems are not strictly limited to the VA, rather they are inherent in government bureaucracy—whether it is the U.S. Postal Service or the IRS or the DMV. 

The “corrosive culture” described by the White House report is also a dangerous side effect of bureaucracy. There are fundamental differences between a government bureaucracy and a business. Incentives push businesses to improve operations, grow, and strive to better serve the customer. They need to do this to survive. If not the customer will go elsewhere and the company will go out of business.  

A bureaucracy operates on a different playing field. It generally does not need to become more efficient or offer its customers a better product. It does not need to serve its customers, but rather it serves itself. Furthermore when bureaucracies fail they are typically rewarded with more money as the VA was in the recently passed legislation. Yet, more money cannot fix this culture and protect patients in government health systems. Only freedom and choice can.  

These lessons should not be heeded in isolation.  The Affordable Care Act brings the role of government healthcare to all new levels. It’s more than 2900 pages and establishes 159 committees, agencies, and programs. These committees have broad authority to transform healthcare as we know it and with time will likely get between patients and their doctors.  

This raises an important question. If you or loved one are sick, who do you want making, that life or death decision? Who do you trust more? Do you trust a doctor who has spent four years of his life in medical school and another three, four, five, six years of his life in training? Or do you trust an administrator in Washington, perhaps one who has recently transferred from the VA to make that decision? 

It’s a simple dichotomy. They are simple questions. Yet the answers take our healthcare system and our country in dramatically different directions.  

Perhaps Paul Krugman put it best when he wrote that the VA “offers important lessons for future health reform.”

Fodeman is an assistant professor of Medicine at the University of Arizona. He specializes in healthcare policy and is currently studying for his MBA.