Health Care Strategies


Mark Kleiman observes that "since its reform under Bill Clinton" the Veterans' Administration health care system "now has the best medical-records system going and produces high-quality health care at a reasonable cost" and wonders if we couldn't "move a baby step toward national health insurance by allowing non-veterans to buy into the VA system at a price equal to whatever the VA figures is its marginal cost?"

The initial, emotional reaction from veterans' groups might be opposition, but surely having a bigger client base would strengthen the VA system politically, against the moment — coming soon — when we're no longer at war and when, accordingly, treating veterans well starts to lose political saliency saliency.

I'm sure this isn't a new idea. Is there a good article that canvasses the pros and cons?

Phillip Longman's 2005 Washington Monthly article "The Best Care Anywhere" laid out how the VA came to be such a solid system and considers a related idea: "What if we expanded the veterans health-care system and allowed anyone who is either already a vet or who agrees to perform two years of community service a chance to buy in? Indeed, what if we said to young and middle-aged people, if you serve your community and your country, you can make your parents or other loved ones eligible for care in an expanded VHA system?"

Why make public service a requirement for receiving VHA care? Because it's in the spirit of what the veterans health-care system is all about. It's not an entitlement; it's recognition for those who serve. America may not need as many soldiers as in the past, but it has more need than ever for people who will volunteer to better their communities.

Obviously, adding something like a community service requirement makes this somewhat less attractive as health care policy, but does have political benefits in terms of reducing the negative initial emotional response from veterans' groups that Mark worries about. I, however, worry that this is the kind of small-scale change that shrinks rather than grows the constituency for a more systemic reform over the long term. To me, it's always seemed that instituting universal health care for children, as Jonathan Zasloff proposes is a constituency-building small reform and thus, the sort of thing one should look at doing. Steve Teles, however, disagrees:

It gets over some political obstacles in the present (since kids are sympathetic and relatively cheap to cover) but it also gets rid of one of the most attractive public faces of the health care coverage issue. So far as I know, no country has ever moved toward universal coverage one demographic group at a time--arguably, that was THE great mistake the U.S. made by starting with coverage of the elderly (as opposed to Canada, which started by covering hospitalization and moved on from there).

I think the dynamics of health care for kids would be different from health care for old people. For one thing, the definition of "kids" has a natural sort of elasticity to it. So the program starts out covering everyone 18 and under. Then it starts covering you up to 25 if you're in school. But then maybe it just covers everyone up to 25 and so forth.

More to the point, since people are young before they get older, if everyone grew up being covered by a well-designed single-payer health care system then middle-aged voters would be much less inclined to believe insurance company scare stories about "socialized medicine" -- since socialized medicine would be something they'd all grown up experiencing.