If the VA is the best the US government can do, with some of the most sympathetic citizens, then it is incapable of doing better than our private system.
I literally could. The scandals you're referring to basically come down to them having been cooking books about care records. Bad, but not exactly in the realm of "literally nothing worse" hyperbole.
In fact the VA tends to produce health care outcomes that are well within the range of US citizens in the same income bracket (which is to say, not great relative to the rest of hte industrialized world, but not bad) at a cost that is much less than that of private insurance.
Really, you could do a lot worse. The criticism of the VA tends to be very similar to the criticism of the NHS in the UK. It's valid as far as it goes, but... neither UK citizens nor US vets are suffering serious catastrophes here. They're getting care and living decent, healthy lives by any reasonable standard.
Literally.
If a few motivated politicians can ruin the lives of millions those politicians shouldn't have that power in the first place.
Because America isn't the entire world and there are many places where socialized healthcare of various forms have been very successfully implemented for a long time. The idea peddled by conservatives in America that the only options for socialized healthcare are inevitable failure or tyranny is simply, demonstrably nonsense.
It's exactly this kind of parochial, limited mindset that needs to change.
> This is a principal reason why the US was crossed off my list of countries where I would work and live. I fight against the privatization that is occurring within healthcare in my native country, Iceland. We used to have the Scandinavian model but decades of attacks from the right-wing Independence Party has broken our healthcare system. The next phase described by Chomsky is handing it over to private capital since people are outraged that it doesn't work anymore. I'm sickened by the development and feel a little like an old man screaming at the desert wind.
It's exactly your kind of Utopian mindset that needs to change. Please read the news of countries other than the US. You might be surprised at the amount of controversy that surrounds universal healthcare systems.
"I am disappointed by my treatment in the system!"
"Do you want to privatise it?"
"Absolutely not."
If you do have that, then it is highly unlikely that your country will be able to implement a health care system that is competitive with Canada, Japan, Netherlands, etc.
But beyond that, it's very unlikely that your country will be able to implement other fundamentals, such as uncontaminated drinking water, safe schools, etc.
In other words, if your country has three branches of government, and the party that controls the executive, legislative, and judicial branches really is willing to fuck up any government in an effort to prove that government doesn't work... then, I'm afraid you are really pretty fucked.
Governments require somewhat good will from politicians and voters to do their job. Some news.
The only reason that system fails is because voters don't care about it. There's nothing exceptionally bad about the US that would not make it so.
> Until we change our collective view in what the purpose of a government and society is things won’t change significantly.
So yeah, if we don't change our collective view, then the republicans (or whomever) will continue to undercut these government run programs as much as possible for their broken ideology.
While it's tempting to blame any failure of national healthcare on Republicans, this is simply not factually accurate.
It's been at least two generations since the VA was anything resembling a good model for healthcare, and it's not simply the Republicans to blame for that, nor is it merely a problem of funding.
And sure, I blame the neoliberal third way Democrats as much as the Republicans. Their whole "let's move the party right and follow the Republicans" really muddies the waters here.
The problems with the VA date back to the 60s, although they've accelerated in the last couple of decades.
> And sure, I blame the neoliberal third way Democrats as much as the Republicans. Their whole "let's move the party right and follow the Republicans" really muddies the waters here.
It sounds like you're rather committed to the belief that right-wing ideology is responsible for destroying otherwise-viable public healthcare models. There are plenty of other places where the data might support that belief. The VA is not one of those cases; the VA has gone from bad to worse over the last 50 years, and it's not simply a partisan problem.
https://www.rand.org/news/press/2016/07/18.html
"Quality of Care in VA Health System Compares Well to Other Health Settings"
A lot of the bad press around it's deficiencies are because it, as a public institution, publishes a lot of information that the private healthcare system isn't required to publish.
And yes, having been from Newt Gingrich's district, and seeing the failed 1994 HEART act, that ended up being turned into Romneycare, and then morphed into the ACA (in order to steal the Republican's thunder in 2012), yes I do blame the right wing for the current state of healthcare.
From your own link, which is a press release by the firm which sponsored the research:
> Researchers say there were few studies [included in this meta-analyis] to evaluate equity, efficiency and patient-centeredness, and that the quality of the available studies vary.
Incidentally, those are three of the four main issues for which people typically criticize the VA.
In other words, that meta-analysis more or less confirms that the VA probably does well at the things people already knew it was good at doing, without looking into any of the areas where it's known to have problems.
I mean, it's the Rand Corporation. It's not like it's some fly by night 'you pay us and we'll say whatever you want' firm. The link to the real study is right there.
> Incidentally, those are three of the four main issues for which people typically criticize the VA.
That statement was for the whole study, including the private side. Once again, the VA publishes quite a bit of this information, when was the last time you saw average wait times for the private side?
...okay? The point is that the primary reference itself shows that the study isn't relevant to this conversation at all: by its own account, it doesn't attempt to investigate the issues that we're talking about. It doesn't attempt to study the issues that make the VA a bad model for healthcare (and have since the 60s).
IN most nations with a VA-style (Beveridge) setup, there is great media interest in the least failing or hint of scandal. And they mean politicians lose a lot of votes. The VA hasn't enjoyed that feedback system until recently.
It's not perfect, by any means, and struggles with cost constraints (veterans are sympathetic, but sympathetic doesn't mean well supported), but many of its quality outcomes are superior.
See, for example, https://jamanetwork.com/journals/jamainternalmedicine/articl...
Have other folks actually stepped inside a VA facility? Many of them are old/outdated/underfunded it's true. But some of them truly do offer superior care to a typical private hospital (in staff, facilities, and outcomes). The VA system could use significant improvement, absolutely. But if the fear-mongering 'worst case scenario' is that everyone gets VA levels of healthcare, that's still a huge win for all of America. That's a great baseline standard to start with, that no one should ever fear falling below.
If an uninsured American is critically injured, the options today are "A: Die" or "B: Bankruptcy". Having a new option "C: Universal VA-levels of healthcare" would be a win for literally every American, even for Americans who are lucky enough to already have great private insurance and who would never need/use this option themselves.
Which ones? Because that has not been my experience at the hawaii facility. From my appointment time being written down on a piece of paper then they send me my actual appointment date a few months later to the doctor being an hour+ late, my personal experiences have been subpar.
Add in how doctors/nurses at multiple hospitals do comically incompetent things like reusing insulin pens/colonoscopy bags/not washing equipment, the general sense of incompetence when they lose my records every few years, or talking to my buddies who got out and ended up working at the VA and have told me that they'll never get treated there, and I do not have the same sense of "superior care" that you're talking about.
If I want hep C, I'll go to the VA. If I want medical care, I'll go anywhere else or just not go to a doctor.
I work in hospital infection control research - if you think your private hospital isn't making many of those same mistakes, I have some very bad news for you...
His first experiences weren't that great, but you could easily tell it was because they were understaffed and underfunded.
Once they got to the point where he could start seeing specialists and whatnot, everything since then was a breeze.
He had a surgery on his stomach. It wasn't life threatening, but he was in some pain. The VA was able to get him an appointment with a Dr. and schedule the surgery within a few days to a week or so.
He also needed eye surgery. This one he had to wait for his eye to get to a certain point before surgery. The VA was able to get him to see an eye Dr the same day he went in for something else. Then less than a month later he was going to go in for surgery but something came up so he had to have it rescheduled. They were able to reschedule the surgery for the following week.
I would consider this a success story. He was hesitant on getting the eye surgery because of costs that were told to him by the previous company, but the VA told him he would not be paying anything, and he didn't.
Congress has underfunded our troops for decades, related to healthcare and not. Something as simple as body armor is often purchased with personal money. A woman that works for me is high up in the Marines and I hear stories that disgust me. I do not know how Congress gets away with this. The stories are out there, but the American people seem to not give a you know what.
Please don't conflate the problems of the VA with Universal Healthcare.
https://www.military.com/daily-news/2016/02/26/lacking-basic...
Do a search for "us troops buying own". You'll find lots.
edit, If this is a benefits/paperwork thing, then shouldn't that be separate from the care provider network?
It's not the best Uncle Sam can do. It's the best it wants to do. It's the (minimal) "best" is has to do.
Sure there's plenty of verbal grandstanding - by both politicians, the public, and the private sector (e.g., NFL) - about supporting the vets and their families, but actions speak louder than words. (Verbally) supporting the vets is good branding. It's that simple. That's all it takes.
Put another way, if the US brought back the draft and the armed forces made up a wider cross-section of society (i.e. poor, rich and in between) priorities would change. Actions would speak louder than the words.
Do Medicare recipients seek to leave it? That’s a government run healthcare system.
Universal healthcare can be implemented poorly but it doesn’t have to be. It can be done right. There are lots of examples of this.
No, because it's free, but 1/3 of Medicare recipients opt to receive their coverage through private insurers that typically add on additional coverage, an indicator that Medicare alone is not enough for a large segment of the population, or that they prefer a private insurer even with government subsidization.
Perhaps the idea that everyone be covered in such a system is not so far fetched.
People literally are leaving it, to the fullest extent that they legally can.
It's not a small number, either. About 40% of Medicare patients aren't on the government-run system at all, and that number has consistently grown over the years.
No, this is wrong. Private Medicare plans fully replace Original Medicare. If you are on a privately-managed Medicare plan, you receive none of your benefits from Original Medicare (the government-run program).
Unfortunately, you're still subject to some of the care delivery restrictions that Medicare sets, which means people moving from privately-managed plans (without Medicare) to Medicare Advantage (privately-managed Medicare plans) will typically experience a drop in coverage, because private insurers tend to be more forgiving with these limits.
> they want to use a doctor that is not participating in the medicare program
I'm not sure what you're referring to here. Though yes, one of the big advantages of Medicare Advantage is that it's dramatically easier to find in-network providers, even for Medicare Advantage plans that don't cost anything out-of-pocket above what Original Medicare does.
I am talking about Medicare Advantage. Medigap is different.
What I am talking about isn't "universal", but it's what about 40% of Medicare patients use in 2018. It's not universal because people have to choose to opt into Medicare Advantage, but it's an option for everyone: everyone[0] who's eligible for Original Medicare is eligible for Medicare Advantage.
[0] well, there are a couple of small exceptions, but I'm 100% sure your mom doesn't fall into those categories, based on what you've already said
Uh, no. "Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans." [0] So although the Advantage plans are privately managed, the premiums are subsidized. I don't think this counts as "leaving" Medicare.
[0] https://www.medicare.gov/sign-up-change-plans/medicare-healt...
By that logic, there's no way to leave Medicare, because you can't stop paying taxes for it or "disable" your eligibility for it (and all of the restrictions that Medicare eligibility brings for people on private insurance).
People leave Medicare to the full extent allowed by law. Unless you want to claim that people using school vouchers for private schools is a demonstration of their satisfaction with the public school system in their area, you can't view their use of Medicare Advantage as a demonstration of their satisfaction with Original Medicare either.
It certainly doesn't indicate dissatisfaction with the fact that the money for those vouchers comes out of tax receipts! The primary education system is a single-payer system, and the use of vouchers doesn't change that.
You're basically arguing a tautology: Because there's no legal way to fully opt out of the system if they dislike it, people can't leave it (by your definition), and you're then saying that, because people don't fully leave the system, that means they don't dislike it.
40% of people choose not to use Medicare, to the extent that's legally possible. The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators. It takes some real contortions to look at that data and use it as evidence in favor of a single-payer system, or even evidence that patients like Medicare, but if you're fully committed to interpreting available data in a way that supports that end goal, I guess that's all we can really say.
> The program that they choose to use instead outperforms Medicare on every key performance indicator (medical outcomes, cost, patient satisfaction), while also underperforming the same private insurers on those same indicators.
Cost to whom? I don't see how Medicare Advantage can cost less to patients than Medicare; nor does it seem likely that the premiums for a private plan are less than the subsidized Medicare Advantage premiums. (Re the latter, I guess you didn't see my other reply to you: https://news.ycombinator.com/item?id=16979926)
How do you think Medicare works? Do you think that, once you're covered by Medicare, you just show up at a doctor or hospital, flash your government-issued Medicare card, and receive free treatment for any covered services, without having to pay anything out of pocket?
(For the record, that is not how it works. Medicare is not free for patients. Premiums are neither your only nor your largest expense.)
I’m glad your view does not prevail. I would hate to live in a country in which the majority shared this opinion.
It's unprofitable for an insurance company to insure someone near death and still provide a decent level of services. It's why there used to be pre-existing condition exclusions and why health insurance companies like Aetna went out of their way to try to deny claims.
Also, if the expense of coverage is greater than the amount of money a person has then it won't be profitable to treat them whilst still bankrupting the person.
They don't simply add on coverage; they replace it. Most people on Medicare Advantage don't opt for coverage above what Medicare itself can provide - they simply receive their benefits from a private entity instead of Medicare, because Medicare provides such a bad experience for patients.
How many of these people on private Medicare plans pay for Medigap? Everyone who get kicked off a private plan can go back to the original Medicare. Your point is disingenuous. Medicare is the universal insurer of last resort for elderly. Their lives would be much worse without this last resort insurer.
That's a far cry from "people don't seek to leave Medicare", which is literally the original claim. By and large, people do seek to leave it, to the extent that they can, both legally and financially.
Yes, for people who can't access anything better, having Medicare is better than literally nothing, but nobody's arguing that. That doesn't mean that Medicare provides a good model of what would best suit everyone else, and that's the relevant question when talking about a single-payer system.
If you want to talk about a single-payer system and use Medicare as an example in support of it, you have to address the fact that privately managed plans consistently outperform Medicare on the top three performance indicators, and that patients themselves prefer all the alternatives to Medicare except "no coverage at all".
While you may have a good argument against a "single-manager" health care system, this doesn't seem like an argument against a single-payer system. In fairness, I guess a lot of existing universal-coverage systems, such as the UK's NHS, are also single-manager (someone will correct me if I'm mistaken), but the very existence of Medicare Advantage shows an alternative possibility. I think that, far from being an argument against single-payer, it shows how single-payer can be made to work even better, through premium subsidies (and, I would guess, reinsurance for catastrophic losses) to private insurance companies, for those who are willing and able to pay additional premiums for better care.
I don't think you understand how Medicare Advantage works. There's really nothing about it that suggests a single-payer system would work. The premiums are not subsidized. (Reimbursements are, but that's a separate matter.)
Medicare is the fullest extent to which people can legally opt out of Medicare, short of claiming religious exemptions (rare), working for a foreign government while in the US (rarer and legally questionable for citizens), or surrendering US citizenship altogether (drastic). Medicare Advantage outperforms Original Medicare on the top performance indicators (medical outcomes, cost, patient satisfaction), though underperforms the same exact private insurers on those same metrics, despite the latttermost also being saddled with the burden of subsidizing Original Medicare reimbursements.
If you still want to advocate for single-payer healthcare on philosophical grounds, okay. But from an empirical standpoint, Medicare is not the place to look for data to support that stance.
How is that not a premium subsidy?
[0] https://www.medicare.gov/sign-up-change-plans/medicare-healt...
A competing setup is the Bismarck style of insurance company administered management, either for-profit or non-profit. Germany, the Nederland's, Switzerland, etc runs this sort of system. Always with a lot of legislation and safeguards to ensure that people do not fall outside the system. It is similar to the US employer-provided insurance setups.
Other systems are National Insurance, as used in Canada and Japan. Similar to Medicare. Canada is fairly unique in its hostility to private provision.
And then there is out of pocket, like rural Africa does it. That's basically like being uninsured and not qualifying for Medicaid.
Thing is, the US accumulated massive bureaucracy and costs by h\trying to run every system at the same time with little attempt at standardization and lots of billing and gatekeeping. Everyone else picked one system and stuck with it, letting private providers fill in the gaps. (Except Canada for the last)
Since you asked - yes, yes they do. Medicare patients can opt to receive their inpatient/outpatient benefits from a private insurer in lieu of traditional Medicare benefits, and an increasing number of people do so.
Privately managed Medicare plans, incidentally, outperform Medicare on the three key performance indicators: medical outcomes, cost, and patient satisfaction.
If you want to convince people to support a single-payer system, this is quite possibly the worst argument you could use. Any veteran or anybody who has had any experience whatsoever with the VA will instantly assume you don't know what you're talking about.
The VA is, on the whole, atrocitous. There are a couple of regions which do relatively well, because the system is federated, but on the whole, it's almost universally considered to be a disaster, even by people who are supportive of the program's existence.
If you want to convince people that a single-payer system wouldn't end up like the VA, start by acknowledging the problems with the VA, not denying them.
Yeah, this is bullshit. The VA and its effectiveness has been studied quite a bit. Its quality has been found to generally exceed the quality of private hospitals. The media and conservatives paint this idea that the VA is "atrocious" but it has no basis in reality.
The scientific evidence for universal healthcare is overwhelming. The only "controversy" -- exactly like the "controversy" around climate change -- exists within people who have carefully decided to ignore the evidence and buy into the propaganda. The problem here is not the VA. The problem here is that many Americans have abandoned reality.
That's certainly one way to summarize the research around the VA, but it's a highly misleading one. It's easy to cherry-pick the metrics on which the VA performs well, but they're not representative of the big problems that the VA has: massive disparity between regions, accessibility of care, timeliness of interventions, adherence, and so forth. This is why VA hospitals have dramatically worse patient satisfaction rates than their non-VA counterparts. (They actually got in trouble a couple of years ago for misrepresenting and hiding the data around this for a while, until independent studies were done which forced them to admit that they'd redefined their internal metrics to make themselves look better).
As someone who has experience with Medicare and the VA, both on a personal level and on a professional level, nothing makes me more skeptical of arguments advocating single-payer healthcare than people willfully ignoring the vast documented problems that exist with both of those systems. That doesn't mean they're not fixable problems. If you want to advocate for single-payer healthcare and argue why these problems could be fixed in a single-payer system, fine. But don't go around pretending that they don't exist - you can't fix a problem by ignoring it and hoping it will go away.
I think this pretty much proves the point.
The point here by the way is not that the VA is perfect. Nobody has claimed that, though you seem to keep insisting that people must admit something they don't claim. The actual evidence we do have shows the VA has problems but still offers better care so I'm not sure how we're "ignoring" anything. It seems like you're the one ignoring the plain facts and have chosen to buy into a convenient falsehood. Until people like you are willing to even look at the evidence -- and the evidence for universal healthcare is overwhelming at this point -- real discussion is pointless.
To be entirely honest, you alluded to research around the VA (but did not offer up any studies or data of your own). I responded by alluding to research around the VA which provides a different conclusion (but did not offer up studies or data either, although I did at least state the actual metrics used to draw said conclusion).
> Until people like you are willing to even look at the evidence -- and the evidence for universal healthcare is overwhelming at this point -- real discussion is pointless.
We're not discussing scientific evidence here. At best we're discussing your interpretation of (possibly-scientific) research that you've seen in the past but haven't actually named.
There is one point on which we do agree, though: that it's pointless to continue. It's pointless for me to continue a discussion with someone who starts a thread with bold claims and no supporting data, and then criticizes someone who responds in kind for the exact same thing. To be honest, it's also pointless to continue discussions of healthcare policy on Hacker News beyond a certain point too, because of the inherent political makeup of the site. Even the most well-researched comments which reference primary sources alongside research published in peer-reviewed journals are routinely downvoted because they express skepticism of monopsonic healthcare models. Instead, the top comments are usually low-effort criticisms that contain no rigor, depth, research, or citations, but do contain witty, biting criticisms of US healthcare and political soapboxing. In that sort of environment, there's not much of an incentive for people with domain knowledge who've studied these issues to participate in earnest.
So I guess that's one thing we can agree on: the futility of continuing this comment subthread.
Or you could actually read the linked Economist article
* The VA is very cost effective. It is much cheaper than any private sector health plan or Medicare. Instead of buying into the propaganda go straight to the source [1] and look at the actual facts.
* The VA enjoys very strong customer satisfaction. You wouldn't know this because the media and conservatives work together to denigrate the VA every chance they get but you should actually talk to people on the VA plan. Surveys of actual VA customers [2] indicates they're quite happy with their free, comprehensive government healthcare. (Shocker.)
* Study [3] after study [4] has shown that VA hospitals are better than private, profit-driven hospitals.
Most Americans would kill for VA coverage. It far exceeds anything they will ever receive unless they make it to the 1%. And this is why it's so very important to keep spreading this lie that the VA is this gross, evil system where all the patients are just waiting to die and ignored by incompetent and indifferent government bureaucrats.
And this is the real problem. You can't have real discussions about health care in America because, frankly, most Americans don't live in the real world. They've been led to believe objective nonsense and you simply can't build anything off such a foundation.
[1] https://www.cbo.gov/publication/49763
[2] https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2537
[3] https://link.springer.com/article/10.1007/s11606-016-3775-2
[4]https://jamanetwork.com/journals/jamainternalmedicine/articl...
Normal hospitals don't have multiple scandals of reusing insulin pens on different people, reusing colonoscopy bags, killing people, paralyzing people and periodically losing all of our records.
A lot of veterans who are covered by the VA are like me. Technically covered because of service connected disabilities, but I will never use it.
If you were told that you'd get an appointment some time in the future and they sent you a notice randomly in the mail a few months later, you probably wouldn't be happy with the service. If your doctor was over an hour late, you wouldn't be happy. If you had a friend that was paralyzed after a spinal tap (my dad's buddy) then you probably wouldn't hold the VA in high regard.
You are the first veteran I've ever met who had good experiences at the VA and who doesn't know anyone that has been crippled by the VA.
Doctors aren't on time in privatized offices either. It's always a long wait for me. But you're right about the not being happy about it.
>If you had a friend that was paralyzed after a spinal tap (my dad's buddy) then you probably wouldn't hold the VA in high regard.
Yes, but that happens in private hospitals as well. They aren't all that great in the US either.
>f you were told that you'd get an appointment some time in the future and they sent you a notice randomly in the mail a few months later, you probably wouldn't be happy with the service.
Ya that sucks. Private industry has solved the scheduling problem with DSS and template based schedules. My uncle didn't have a good experience with the VA either. He had dementia and the nurse questioned him about it and he said "I have diabetes," which he did, but he didn't know what was going on. The nurse of course said, "we don't treat diabetes," or something like that and sent him away. All the while his sister was telling her about the dementia, she just didn't want to hear it.
I could tell you horror stories about private hospitals too and how after being admitted, they shipped him to a nursing home an hour away wearing nothing but a gown in winter. No calls, no nothing.
I guess the bottom line is right now, the US sucks at healthcare, period. I'm sure being a highly politicized wedge issue doesn't help matters much. (The VA, universal healthcare, skyrocketing costs in the private industry, etc).
The VA is run in a federated fashion, so there is a massive variation in how well they operate.
The problem with the VA isn't that literally every hospital is terrible. The problem is that:
(1) a lot are bad
(2) the bad ones are really terrible
(3) the bad ones are consistently bad over time, with no success in improving them
Part (3) is the really damning one, because it's not like there haven't been efforts to fix the issues with the VA. But because the US is such a heterogeneous country, the successes of Portland don't translate well to Memphis.
Who said it was?