For example, Longman says:
So what's left? Consider why, ultimately, the veterans health system
is such an outlier in its commitment to quality. Partly it's because of
timely, charismatic leadership. A quasi-military culture may also
facilitate acceptance of new technologies and protocols. But there are
also other important, underlying factors.
First, unlike virtually all other health-care systems in the
United States, VHA has a near lifetime relationship with its patients.
Its customers don't jump from one health plan to the next every few
years. They start a relationship with the VHA as early as their teens,
and it endures. That means that the VHA actually has an incentive to
invest in prevention and more effective disease management. When it
does so, it isn't just saving money for somebody else. It's maximizing
its own resources.
The system's doctors are salaried, which also makes a
difference. Most could make more money doing something else, so their
commitment to their profession most often derives from a
higher-than-usual dose of idealism. Moreover, because they are not
profit maximizers, they have no need to be fearful of new technologies
or new protocols that keep people well. Nor do they have an incentive
to clamor for high-tech devices that don't improve the system's quality
or effectiveness of care.
And, because it is a well-defined system, the VHA can act like
one. It can systematically attack patient safety issues. It can
systematically manage information using standard platforms and
interfaces. It can systematically develop and implement evidence-based
standards of care. It can systematically discover where its care needs
improvement and take corrective measures. In short, it can do what the
rest of the health-care sector can't seem to, which is to pursue
quality systematically without threatening its own financial viability.
The analysis is theoretically appealing, but there are a couple of problems for it. First, on the theory side: it's not clear what incentives the VA has to become more cost efficient. Finding ways to save money in a government bureaucracy is not generally rewarded. Finding ways to save money usually means you get your budget cut, while cost growth can provide an argument for a bigger appropriation. And when the VA runs out of money, it can reallocate services between priority levels, cutting some of its customers off in order to cover higher priority patients.
Which brings me to the empirics: the VA does not, in fact, provide lifetime care for its patients practically from kribbe to grav. The VHA works on Priority Groups, which categorizes who is eligible for what treatments. Some of the categories are rather fun:
Veterans in priority group 6 served in World War I or the Mexican Border War, are seeking care solely for disorders associated with exposure in the line of duty to chemical, nuclear, or biological agents (including, for example, Agent Orange), have compensable SCDs [Service Connected Disabilities] rated zero percent disabling1, or are within a five-year period of special eligibility for recent combat veterans.
The footnote goes on to explain that this covers a handful of vets receiving payments for tuberculosis, "special monthly compensation under 38 U.S.C. 1114(k)" or other disabilities. And here is 38 USC. 1114(k):
if the veteran, as the result of
service-connected disability, has suffered the anatomical loss or loss
of use of one or more creative organs, or one foot, or one hand, or
both buttocks, or blindness of one eye, having only light perception,
has suffered complete organic aphonia with constant inability to
communicate by speech, or deafness of both ears, having absence of air
and bone conduction, or, in the case of a woman veteran, has suffered
the anatomical loss of 25 percent or more of tissue from a single
breast or both breasts in combination (including loss by mastectomy or
partial mastectomy) or has received radiation treatment of breast
tissue, the rate of compensation therefor shall be $89 per month for
each such loss or loss of use independent of any other compensation
provided in subsections (a) through (j) or subsection (s) of this
section but in no event to exceed $3,075 per month; and in the event
the veteran has suffered one or more of the disabilities heretofore
specified in this subsection, in addition to the requirement for any of
the rates specified in subsections (l) through (n) of this section, the
rate of compensation shall be increased by $89 per month for each such
loss or loss of use, but in no event to exceed $4,313 per month;
Pardon me for a moment while I meditate on the notion that we must have more government involvement in our health care in order to bring some rational, efficient order to our broken system.