Single Payer? Try the Veterans Affairs System

By | May 1, 2017 | 0 Comments


As Einstein remarked, the only way to predict the future is to study the past. Many people yearn for single payer ‒ that is, government-run health care. But how is that going now? How good is the Veterans Affairs health-care system?


The defects in the medical care of military personnel returning from Iraq and Afghanistan, as well as older veterans, have been widely discussed. The military medical system made insufficient preparations for the influx of casualties, and the system of Veterans’ Affairs hospitals compounded these errors.

Possible reasons for this intolerable situation include:

● Assuming that the war would be short and the casualties few.

● Assuming that the military cutbacks and hospital closures of the Clinton era did not need to be reversed.

●Using available military funds for weapons and troop training, so as to minimize future casualties, rather than on care of current casualties – a regrettable but perhaps understandable choice.

● Bureaucratic reluctance to challenge the status quo.

● Fear of contradicting politicians by asking for bigger budgets.

● Fear of contradicting superiors.

● Fear of endangering one’s career.

● Fear of pointing out problems, because of “kill the messenger.”

All of these may be explanations, but they are not excuses. The young (and some not-so-young) men and women who volunteer to risk death or disability to defend our freedom are America’s finest. They deserve our very best care when they return from overseas wounded.

I spent three and one-half years in the Army Reserve before going on active duty with the U.S. Public Health Service. I was assigned to a general hospital unit, where we attended and taught classes on medical topics. I attended three 15-day sessions of annual active duty for training.

Two of these were at the station hospital at Fort Ord, which was a large post with perhaps 15,000 troops. Mornings I worked in a dispensary, seeing outpatients. Afternoons I worked in the hospital, helping care for inpatients. In general, the care I saw was comparable to the care I had seen in university and private hospitals, and superior to that I had seen at a large county hospital.

But there was one episode that reveals the defects in government medicine. I was completing my two weeks’ duty and preparing to return to civilian life. The lieutenant colonel who was chief of internal medicine called me into his office. I was a lowly first lieutenant, so I was a bit worried, but he asked a favor. He was on call that Saturday night as internal medicine consultant, but he wanted to go to a party for a colleague. He asked me to take call for him from 5 p.m. Saturday to 8 a.m. Sunday. I was going to explain that as of midnight Saturday, I was no longer on active duty. But to the man three pay grades above mine, I merely replied, “I’d be glad to, sir.”

Most of that evening, I sat around the emergency room, helping with minor injuries and illnesses. Just about midnight, when I should no longer be there, the phone rang. A medic spoke briefly, then turned to me and said, “They’re sending an ambulance to the Officers Club – some retired rear admiral is having chest pain.” The night went downhill from there.

The elderly gentleman was having a major heart attack. I did my best to stabilize him, without success, then phoned the chief of medicine, whose shift I was taking. I told him the problem, expecting him to come right in to care for the high-ranking officer. Instead, he merely told me to carry on. He barely knew me, and I was a first-year resident. He had no idea of my competence. But he left things in my hands. I wondered whether he had been drinking and could not come in.

As I hung up the phone, my worries increased. A distinguished, gray-haired man in civilian clothes was talking to the admiral’s wife. A nurse nudged me and whispered, “That’s the commanding general of Fort Ord.” The general spoke to me, assured his friend’s wife that everything was being done, and left – to my considerable relief. Soon after, my patient died. I had the sad duty of informing his widow, and the uncomfortable duty of signing the death certificate, though by that time I was officially a civilian and shouldn’t have been there.

Even a retired rear admiral, a personal friend of the commanding general, was cared for by a very junior doctor, without help or supervision. What should enlisted personnel expect?

Another year, I spent two weeks doing draft physicals in Los Angeles, then drove home to San Francisco, having received orders to use my own car. Just outside Paso Robles, an elderly couple got on the freeway – but they used an off-ramp. Our cars hit head-on at speeds estimated by the Highway Patrol at 50 miles per hour. Both cars were destroyed, the elderly driver killed, his wife seriously injured, and I got out of the small local hospital after an overnight stay. Every day from then on was a gift.

Still, I had a head injury with loss of consciousness, a lacerated eyebrow and arm, three broken ribs, and a swollen knee. The local doctor called for an Army ambulance, which took me to the nearby Camp Roberts dispensary. A bored Army doctor glanced at my records and asked what I wanted. I said I wanted to go home, which was quite understandable but quite unwise. Not wanting to be bothered by the paperwork of transferring me to the hospital at Fort Ord, he gave me a few pills for pain and nausea, then told the medics to drive me to the bus station in the ambulance.

Leaving the dispensary, I stumbled and nearly fell. The medics were worried about leaving me at the bus station, but I got home to San Francisco, carrying my suitcase in one hand and my uniform in the other – no mean feat with three broken ribs. You’d be surprised what you can do when you have to. The local doctor put 14 stitches in my eyebrow, but the arm laceration was too deep for him, so he simply covered it with a dressing. In short, I was released from active duty with an open wound.

My care was continued by the private hospital where I was a resident. An officer from Sixth Army Headquarters had me sign seven copies of an account of the accident, to document that I was not to blame. None of the copies found their way into my personnel file. I had to obtain a copy of my medical records and insert them into my file. Otherwise my Army records would not reflect this serious occurrence. No one from the Army followed up by asking whether I had recovered. In fact, my knee still bothers me.

From my experience and that of others, I conclude that:

● Acute care in combat zones is the best in the world, but those who concentrate on acute care tend to neglect chronic care.

● In a large bureaucracy, paper shufflers are often promoted over those who actually do the work.

● The further care givers are removed from patients, financially and emotionally, the worse things are likely to get.

● The more that bureaucrats are in charge, the worse things are likely to get.

● When inpatients become outpatients, records may be lost, and the ball may be dropped.

● When reservists go off active duty, the ball is often dropped – everyone thinks it’s someone else’s responsibility. The service thinks it’s Veterans Affairs responsibility, the V.A. thinks it’s the private sector’s responsibility, and the private sector thinks it’s the service’s responsibility.

Patients with serious injuries or illnesses, and their families, may be too distressed to know what is best for them. They need informed, concerned advocates to assist them.

If the federal government mishandles a relatively small group of high-profile patients, how do we expect it to handle the health care of all 324 million Americans? This notion gives new meaning to the word illogical.

Some time ago, a dirty, unshaven man appeared in the emergency room of a large county hospital. It was Sunday, and he had a cut hand. He sat for hours, while the staff joked and discussed personal matters. The following day, they discovered that he was the new chief of emergency medicine. He had cut his hand working in the garden in his old clothes. Needless to say, changes were made in that department.

That’s what we need. We need agents from the office of the Secretary of Veterans Affairs disguised as patients, especially outpatients, reporting back on how they are treated at V.A. hospitals and clinics. We need Inspectors General who actually inspect.

Our best young people gave us their best. Now we owe them our best. Nothing less must be tolerated. And the next time people advocate single payer, ask them how that is working out right now.

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