Fix the VA's problems, don't exploit them

June 3, 2014

Instapundit’s op-ed on the problems at Veterans Affairs hospitals reads like a plug-and-play template for libertarian commentary: “The cleanup will be, basically, impossible. That’s because the VA is government health care.” He goes on to argue that the unacceptably long wait times, deceptive record keeping, and undeserved executive bonuses at VA facilities are due to a lack of free-market competition: there’s no bottom-line issue, so managers mismanage with impunity.

This would be a more compelling argument if the free-market alternative—the real-world one, not the theoretical one used so often to bash (real-world) government work—actually performed consistently better, and actually had a better system for accountability. But as Philip Longman tells Ezra Klein, neither of these things is quite true:

If [the VA] didn't measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that's far better than what goes on in the rest of the health-care system where no one is accountable for this at all....

They tried to get vets in for non-urgent appointments for care within 14 days. Compare that to a survey done in 2009 on average wait times outside the VA to see a family physician. In Los Angeles, people waited an average of 59 days. In Boston, they waited an average of 63 days. In Washington DC, they waited an average of 30 days. The average wait time in major metropolitan areas is about 20 days. The VA is attempting to create a performance metric by which it would be substantially superior to the rest of the health-care system.

To be clear, the VA facilities in question failed to meet this two-week wait-time standard and then tried to cover this up. That’s no small problem. Still, Longman’s points here are crucial: it’s a stringent standard, and the incentive to cover up the failure came from not just a desire to be paid well but also the fact that oversight exists to try to evade in the first place. If I lead cops on a high-speed chase and manage to do some damage before they finally catch me, this isn’t a reason to stop having cops.

The problems at the VA are real, serious, and systemic. This graphic from the American Legion—a VA reformer but no antigovernment crusader—offers a quick look at the scope of the problem. I’m glad to see the secretary dismissed and Congress working on reforms. Taking the problem seriously means fixing it, not concluding that nothing will ever work because the government is bad at things. It also means diagnosing the problem correctly: the VA has a problem of access to care, caused by not just malpractice or incompetence but also complicated realities rooted in politics and the particulars of veterans’ needs. Longman explains

On the one hand there's a [national] consensus that any vet hurt in the line of duty should be put back together by the VA for free. But we're conflicted about whether everyone in the military should get health care for free. So the way it stands now is most veterans have to prove that the health-care complaints they have are the direct result of military service. And so if you look at what the bureaucracy at the VA is doing most of the time, it is trying to adjudicate questions like whether someone who's 58 years old is losing their hearing because of the artillery fire they heard while deployed in Vietnam or because of all the Who concerts they went to in 1968. That's a real example, by the way.

Almost a decade ago, Longman wrote an important article about how VA hospitals had effected a massive turnaround in care quality in the decade before that. When I first read this article, I told a lot of people about it. Some were pretty skeptical. These days, news about major issues with access to care (though hardly the biggest such issue in American health care) will make people even less willing to believe that the VA’s care itself, once a vet’s actually getting it, is quite good. Yet the two are different things.

The VA system is socialized medicine, and people’s opinions about it tend to reflect their overall politics. But in reality, the VA is doing some things well and some things poorly. The same, of course, is true of private health care, that impressive innovation machine that's bankrupting families that need affordable basic care, not innovation. To fix either system, we need to focus on actually fixing it—not on why its problems vindicate our way of seeing the world.