John C. Goodman

Did you know that one in every five suicides in the U.S. last year was a veteran? Last May, the 9th U.S. Circuit Court of Appeals in San Francisco said that with an average of 18 veterans killing themselves each day, “the VA’s unchecked incompetence has gone on long enough; no more veterans should be compelled to agonize or perish while the government fails to perform its obligations.”

A Miami Herald investigation (using the Freedom of Information Act) discovered that:  

  • Despite a decade-long effort to treat veterans at all V.H.A. locations, nearly 100 local V.H.A. clinics provided virtually no mental health care in 2005; the average veteran with psychiatric troubles gets almost one-third fewer visits with specialists than he would have received a decade ago.
  • Mental health care is wildly inconsistent from state to state; in some places, veterans get individual psychotherapy sessions while in others, they meet mostly for group therapy.
  • In some of its medical centers, the V.H.A. spends as much as $2,000 for outpatient psychiatric treatment for each veteran; in others, the outlay is only $500.

As for efficiency, the V.H.A. fails that test as well. According to a recent study in the Journal of Health Care Finance, "V.H.A. health care costs 33 percent more than it would if purchased in the private sector… [and] inpatient care costs were 56 percent higher."

To the V.H.A.’s credit, a RAND study concluded that overall the V.H.A. is providing higher quality care than other patients receive, although it also noted that the system does best on the quality metrics it measures than on the ones that go unmeasured. Unfortunately, these quality metrics tend to be inputs (was a certain test ordered?) rather than outputs (did the patient get well?). On the most important quality measure of all — did the patient survive? — V.H.A. patients appear to do no better than other patients.

A Kaiser Health News analysis revealed that surgical patients in V.H.A. hospitals are just as likely to be readmitted for post-surgical complications as patients at non-V.H.A. hospitals.

And let's not forget about amenities, including basic cleanliness. As health economist Linda Gorman writes:

Private hospitals tend to have private rooms and lots and lots of plumbing. These features help control infections and make hospitals safer for patients. Because governments can shut down private hospitals that fail cleanliness standards, private hospitals also spend a lot on maintenance and housekeeping. Government hospitals tend to do things differently.

An investigation of the Kansas City VA Medical Center revealed that things were so bad that clinicians felt compelled to clean their own areas. Management embarked on a hand washing campaign, but with limited success. The review found that many soap dispensers were empty and noted one clinician's hope that one day "sinks should actually work."

 An investigation of a V.H.A. system in Dallas reported that "Most patient rooms and bathrooms we inspected were unclean…the rooms had foul odors, suggesting that they had not been thoroughly cleaned over a significant period."

Outside commentators consistently praise the V.H.A. for keeping patient records electronically. In principle, all the doctors in the system should be able to access the same records and practice "integrated care," rather than the piecemeal approach that often characterizes health care generally. Also, the system is doing something else rarely seen: it is publishing outcomes data (mortality rates, infection rates and readmission-after-initial-surgery rates) on procedures at its 152 hospitals so vets will have information about the quality of care to expect. But because rationing-by-waiting is endemic throughout the system, it's not clear what patients can do with this knowledge.

Here is the bottom line: The V.H.A. may be good at some things and not at others. Quality and service levels apparently vary around the country. So, let the V.H.A. compete in the marketplace against private doctors, private hospitals and private insurance, instead of trapping veterans in a system that may or may not meet their needs.


John C. Goodman

John C. Goodman is Senior Fellow at The Independent Institute and author of the widely acclaimed book, Priceless: Curing the Healthcare Crisis. The Wall Street Journal and National Journal, among other media, have called him the "Father of Health Savings Accounts."