LONG-TERM CARE AND THE VA....Kevin wonders why, in "Best Care Everywhere," I say that the VA's near lifetime relationship with its patients, which it has always had, is a key to its current success.
In part the answer is that the VA was never as bad as portrayed in movies such as Born on the 4th of July. As detailed in my book, Best Care Anywhere: Why VA Health Care is Better Than Yours (Polipoint 2007), activists long ago admitted to stage setting at least some of the outrageous conditions chronicled in the media during the post-Vietnam era. It's also true that as a very large, public institution the VA is routinely subject to high levels of scrutiny. Failings that go unreported elsewhere in the health system become instant headlines and the subject of congressional hearings when they occur at the VA. Opponents of "socialized medicine" also long have had a high stake in pointing to any shortcomings in its only actual example in the U.S. The VA thus has a built in PR problem, as do all government run health care systems around the world. Yet even when the VA's reputation was very low compared to today, veterans groups strongly resisted proposals to replace VA health care with vouchers. Most vets who use VA health care prefer it to private sector health care, and always have.
So the VA never was that bad. Still, why did it get so much better during the 90s, both compared to its past performance and to other providers? Partly it's a matter of inspired leadership. In larger measure, it's a matter of the changing nature of illness. The improvements the experts are talking about are largely in the realm of preventing and managing long-term chronic disease, which have become the leading causes of death in modern populations. This change is key to understanding the VA's superior performance. In the treatment of acute care injuries and infections like pneumonia, it doesn't matter much if there's a long-term relationship between patient and provider. You either get the right short-term treatment or you don't, then recover or die. But now that more and more of us are living long enough to die of heart disease, cancer, and especially diabetes, which by their nature require long-term, highly coordinated care to prevent and manage, it has come to matter a lot if we are treated by an institution that has a stake in our health five or twenty years down the road.