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We've Had a Single-Payer Health Care System All Along

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The Veterans Health Administration (VHA) is one of the largest integrated health care systems in the U.S. It takes care of over 9 million patients in 170 hospitals in nearly every state. Its patients are, on average, older, sicker, and more disadvantaged than the rest of the American population. 

Unfortunately, public perception of the VHA has soured over the past decade. Some of our political leaders have denigrated the establishment, stating that VHA hospitals, “provide substandard care” and, “if you’re a real doctor, you’re probably not working at the VHA.” This is more striking when considering that the VHA has, in many cases, historically outperformed commercially managed hospital systems. The sentiment against the VHA has led many politicians to consider privatizing its services, mainly arguing that doing so would lead to greater market competition and improvements in the quality of its medical services. 

Well, I’m here to tell you that these assumptions may be misguided. Unlike most hospitals in the country, the VHA wasn’t built to satisfy insurance corporations, extract the highest profit margins, or provide the highest returns for investors. Rather, its sole purpose is to help veterans, full stop. This notion has systematically transformed the VHA into a one-of-a-kind organization that treats the illnesses that most affect our veterans: substance abuse, homelessness, and chronic medical conditions. Remarkably, it provides these services through a unique single-payer model. In turn, as the U.S. continues its slow trek toward a more universal form of health care, the VHA has much to teach us about the power of a centralized single-payer system to integrate EHRs, treat chronic medical conditions, and respond to public health emergencies. 

I was introduced to the VHA as a first-year resident in Baltimore. As a novice to its model of care, I was pleasantly surprised by the internal consistency of the system. Many patients came to our hospital from associated long-term care facilities or nursing homes. These facilities ran on the same electronic platform as our hospital. This meant that any documented care they received at their nursing homes, rehabilitation facilities, outpatient clinics, or other VHA hospitals was easily accessed through an all-in-one EHR system. Even information on a patient’s social situation was readily available. I didn’t have to hunt down outside records, call family, or spend valuable time trying to extract information from a patient who may be altered. This is the holy grail for private EHR systems that are struggling to emulate the VHA’s level of integration. In turn, it should come as no surprise that many of our country’s most important population-based public health studies have come from data collected through the VHA’s EHR. 

In addition, the VHA has developed into a health care system that can rapidly adapt to public health emergencies. Its strong federal oversight provides a central decision-making authority that allows for newly formed policies to rapidly disseminate through its satellite hospitals. Its response to the COVID-19 pandemic has been a powerful example. In the early days of the pandemic, the VHA implemented a strategy to provide outpatient surveillance for anyone who tested positive for the coronavirus. This meant that every nonhospitalized patient was sent home with a pulse oximeter, thermometer, and home telehealth follow-up. Once they returned home, they were instructed to measure their vitals daily and relay them to a nurse who would then monitor their clinical status. If they were deteriorating, the nurse would prompt the veteran to return to the hospital for admission. This simple strategy was designed to reduce unnecessary hospital admissions while still facilitating close surveillance of infected patients in the outpatient setting.

Now this is where the power of the VHA comes in. Due to its centralized decision-making, the VHA was able to rapidly scale these interventions to all its other satellite hospitals. It was able to bargain and buy thermometers and oximeters in bulk and deliver them across the country through existing supply chains. This also held true for vaccine delivery, as the VHA was able to identify vaccine allocation guidelines, proactively prepare mass vaccination facilities, and mobilize early to vaccinate staff and veterans.

As with any large bureaucracy, the VHA has its share of problems: long ER wait times, aging infrastructure, funding issues. And yet, even with all the bureaucratic inefficiencies and negative public optics, the VHA has continually innovated in arenas that have come to define modern health care in the U.S. This is likely a result of its integrated EHR, focus on chronic conditions, and central decision-making authority. Its ability to provide these services ultimately flows from its single-payer system. The VHA receives funding from the Department of Veterans Affairs, which is allocated funds by the federal government. Its funding structure — split into mandatory and discretionary spending — is hugely cost-saving, since the VHA is able to bargain and choose its health services, unlike Medicare. 

As we can now appreciate, the VHA model of care looks strikingly similar to current models of a public single-payer health care system. The COVID-19 pandemic has shown that health care in the U.S. needs to be more equipped to handle a rapidly changing medical landscape. The VHA has been structured to do just that, while still providing exemplary care for chronic medical conditions. To skeptics of a single-payer health care system in the U.S., I’d say we’ve had one in the VHA all along, and it’s doing just fine.

Have you worked or considered working for the Veterans Health Administration? Share your experiences in the comment section.

Naveen Reddy is a neurology resident at the University of California, San Diego.

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