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The Agenda

NRO’s domestic-policy blog, by Reihan Salam.

Vox-splaining the VA



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Vox, the media venture started this spring by the Washington Post’s Ezra Klein to add context to news and explain breaking stories, hasn’t exactly been falling over itself to cover one of the major news events of the past couple weeks, the cascade of scandals from the Veterans Affairs administration. So far, they’ve run three posts: One reported the resignation of a VA undersecretary, which was only later updated to include context (the undersecretary was already scheduled to retire this year) that rendered it utterly meaningless and a face-saving gesture that deserved no attention. One featured a Jon Stewart clip and little context.

The third, an “explainer,” is entitled, “What the hell is happening at the VA?,” and you’re not going to find a complete or penetrating answer. It was last updated on Wednesday, May 14, but that still doesn’t really explain the fact that it basically suggests there is one VA scandal — the creation of a secret waiting list in the Phoenix health system on which 40 veterans may have died waiting for care. It doesn’t tell you that VA whistleblowers have been coming out of the woodwork recently to document these practices and other delaying tactics all across the system; it just notes that “there’s also been issues with scheduling practices in at least three other locations.” This understates the problem considerably.

But more important, there’s no mention at all of the important context that these kinds of problems — gaming statistics, secret waiting lists, long wait times for serious procedures — seem to be endemic to single-payer health systems and especially fully socialized ones (as in ones where the government employs the doctors and runs the hospitals, too, like the VA, Britain’s, and Spain’s). Public-choice economics teaches us that systems run by the government are inherently unaccountable to their customers. When the system being run is health care, that means sick and dying people’s needs aren’t met.

It’s an unfortunate and uncomfortable truth for people who believe public bureaucracy deserves a bigger role in our health care and our lives. There are certain truths that liberals will admit about statist policies (rent control is a bad idea, at some point the minimum wage will kill jobs, etc.). This isn’t one of them.

Now, it’s important not to overstate what this means: Most countries’ single-payer health systems, though it’s very hard to measure this, don’t have substantially worse mortality rates than the U.S. does, and fully socialized systems, while they appear to get slightly worse outcomes, don’t manage terribly. Such is the case at the VA — it accomplishes fairly good outcomes and has high rates of satisfaction at relatively low cost.


The Veterans Affairs Medical Center in Phoenix (Corbis)

That said, most vets go outside the VA for care, too, so the system’s outcomes are probably not as good as it gets credit for. And it ignores the needs of vets all the time, and has remarkably long wait times — which is something that plagues most single-payer systems, but especially the rich world’s other most-socialized systems. In a fully socialized system like the VA, payments, hospitals, and doctors are all managed by the government. How to address the lack of incentives and accountability in such a system?

Mandates and regulations, of course. In Britain and in the Veterans Affairs system, hospitals are incentivized or required to meet certain metrics — primary-care appointments have to be available within 14 days, say, or cancer diagnostics have to be offered within a month. The VA has also implemented a bonus system to reward administrators for hitting these metrics. Often they get a funding boost, as well, as Britain’s NHS did under Tony Blair, but it doesn’t seem to get allocated in a way that actually increases quality or access. When the system can’t meet the requirements or incentive goals, officials are often tempted just to lie — that is the crux of the principal-agent problem here, and it’s exactly what happened with the Phoenix VA. As Charlie Cooke has noted, almost literally the exact same thing has plagued the Britain’s health system. Officials’ primary incentive isn’t to save customers’ lives, since their customers don’t really have a choice; it’s to serve their own interests.

Of course, resources are limited in any health-care system — people die in America waiting for treatment, too, sometimes when they have crappy coverage (hi Medicaid) or sometimes because they have no coverage at all. But in a fully socialized system, the only incentives influencing the ultimate allocation of those resources are the private incentives of bureaucrats and the oversight of politicians. Vox doesn’t explain the significance of this, but it does admit that politicians don’t care enough to hold the system’s feet to the fire and get it to work. To some extent, other countries do manage to keep their systems from getting so deeply corrupt, since all their citizens — not just a small minority, veterans — have to put up with the level of care provided.

Which brings us back to why Vox looks to be whistling past the context: Its editor-in-chief (Klein) is something of a fan of a more-socialized health system (and has praised the VA, though I’m not sure how far he’d want to imitate it) and the site has an odd obsession with Vermont’s quixotic and unaffordable attempt to set up a single-payer system in Vermont. (Such is their commitment to the idea of single-payer that they ignore that most of its cost-savings won’t be feasible in a state-level system.)

Vox has provided plenty of useful insights on a range of topics so far; maybe this is just that their health-care team is busy with reporting on Obamacare. But there’s another reason why they’d be loath to communicate the key lesson of the VA scandal: They’re understandably uncomfortable acknowledging that a bureaucratized health-care system that they and their ideological compatriots have been touting for years leaves life-or-death decisions to authorities with special interests. This may not mean dramatically worse outcomes, but it does mean that Americans are automatically, and rightly, wary of such a system (for rational and irrational reasons). Once you note that public bureaucracies are in some sense inherently unaccountable, you start looking to avoid them rather than expand them.

(All of these issues is why veterans’ groups have called for Congress to pass a bill giving the secretary of Veterans Affairs extra power to dismiss senior officials — enabling him to enforce accountability more efficiently than anywhere else in the federal government, though no more harshly than congressmen can call their own staff to account. Some have also called to give vets more flexibility in where they can use VA coverage — if they live far away from a VA hospital but near an excellent private or public one, they should get coverage there, too. Neither of these ideas, to my knowledge, has received any attention from the Obama White House. Or Vox.)



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