Sorry Dr. Stewart: The Public Option is Still a Quacked One

William Kristol was recently taken to task by that well known health care economist, Jon Stewart, regarding an example of successful government run health care- military medicine. Stewart insisted that this example of government run medicine proves the validity of the proposed “public option” or other government run aspects of the hotly debated healthcare (health insurance?) reform debate now underway.

Military medicine is of course composed of two very different entities: the Veterans Administration (VA) and true military installations and programs like Walter Reed Hospital in Washington. The latter is successful, in fact wildly successful, in treating severe injuries sustained by military personnel. However, it caters to a very narrow patient group with a generally limited range of services although a few key centers like Bethesda Naval Hospital have a wide range of clinical services. How costly or inexpensive these institutions are would be very hard to assess. How effective they are would require some ability to compare them to civilian practice. This is not easily assessed in the U.S. The recent tragic experience of care of brain injured Iraq war personnel at Walter Reed Army Hospital may or may not be representative of chronic care at military facilities. Military hospitals are so different in scope from acute care hospitals in the civilian sector that the comparison is really impossible.

The VA is a different story and there is lots of data about the comparison to private healthcare. The VA can only manage the full range of healthcare needs of American veterans by being embedded in a private healthcare system. For example, while the kidney transplant programs and other surgical programs offered in the VA system are generally of high quality as documented in the surgical literature, the number of programs is very limited. The VA maintains only 4 kidney transplant programs in the country. If a veteran lives in Iowa City, Pittsburgh, Portland, or Nashville he or she has easy access to a facility and once a kidney is available to them, the procedure can be performed. But if you live in North Dakota, you will need to get your transplant locally through some arrangement with a local hospital that performs transplants. It is the limitation in access for veterans that has led to the need for increasing amounts of outsourcing in the VA system. The VA system strongly relies on a referral center system and the liberal use of local facilities to fill in the gaps in service that are inherent in its organization. While it does a good job of caring for the primary care needs and many of the more complex needs of veterans, it relies heavily on such outsourcing for as much as 30% of the care delivered. The only way the VA system avoids the sort of delays in care seen in other government run healthcare systems around the world is to rely on the non-government run healthcare system in the U.S.

I routinely care for veterans transferred to our hospital for specialized treatments not available at the local VA Medical Center. While this is a rational and, in fact, laudatory approach for the VA to achieve efficiency, it surely shows that when the government needs to provide a service, you may get what you need but perhaps not what you want. Patients generally do not like to be transferred from one hospital to another to access a needed service.

So Jon Stewart is right. There is nothing wrong with government run medicine such as military medicine. But military hospitals do not deal with chronic conditions, for the most part, and the VA system could not work if it did not rely on private hospitals and practitioners with whom it contracts to provide the care it cannot provide. Also, if Mr. Stewart was similar to the other veterans who are dually eligible for VA care and for Medicare provided by the private system, he would be much more likely to choose the private system as has been well documented to be the case for such dual eligible veterans. While he might say that is a good argument for Medicare, it would be, if that government run health insurance plan were not to be in deficit by $37 trillion in the coming years.