Thursday, April 22, 2010

Health Care Inquiry

There is not a more unhappy being
than a superannuated idol
--Joseph Addison

Each organism raises its head

over a field of corpses, smiles into the sun,

and declares life good

--Elias Canetti


Obama's new health care initiatives have Ranger questioning the continued existence of the Department of Veterans Affairs health care system.

If health care is really reformed, why not treat veterans like every other citizen? Universal access to health care should obviate the need for a separate veterans system, which would then seem superfluous.

The counter argument is that veteran's health needs require special treatment -- issues like atomic and chemical exposure (depleted uranium, for example), post traumatic stress and traumatic brain injury are but a few of these. Another key DVA issue is disability determination, to include service-connected compensation, but this issue could stand apart from its health care function.

Ranger requests input from those familiar with how other nations handle veterans health care issues. How are they funded, and is their treatment apart from that of the general populace? How are veterans treated specially, if at all?

Do veterans receive health care beyond that received by non-military citizens? Is the level of treatment received by veterans abroad sufficient? Does it exceed that received in the U.S. in any way?

Input is appreciated to help Ranger put this issue in a global perspective.

I'll take my answers off the air.

[Cross-posted @


  1. The only two countries I am somewhat familiar with are the UK and Greece. Both have national Health Care, and both have a Veterans' Hospital System.

    The newly established Health Care law does not provide "universal access". It only increases access to insurance.

  2. Aviator,
    I'm taking about down the road a bit.I know it's not feasible now, but eventually when we socialize the health care system, then my comment will be something to discuss.

  3. jim-

    Are you talking about National Health Care (e.g. the UK) or National Health Insurance (e.g. - Canada, which is actually provincial insurance)?

    They are two different creatures. If it's "care" then the providers are government employees in government owned facilities. If it's "insurance" it's just a government operated single payer insurance system with both public and private private providers.

    The system in the US has so far to go before it approaches either of these models, that I can't quite figure out what you are asking. Nothing in a single payer insurance system would rule out veteran's hospitals, as they do provide a unique mix of services, and are capable of responding to the aftermath of war more readily than the other elements of the system. (When I say "capable", I don't mean every administration has or will be effective in using such capability). And, as note for Canada, a single payer insurance system easily allows for both public and private providers.

    Similarly, a national health care system regularly and routinely has facilities for specialized purposes. Again, veteran's facilities fit into this model quite well.

    National Health Care or its insurance correlary are social services, not necessary "socialism". While they would definitely be the manner of providing health care in a socialist state, they can, and are being well provided in capitalist countries. 87% of Canadians are satisfied with their country's single payer government health insurance program. Similar results are found in countries with national health care.

    Lastly, many recipients of care at the VA go there because they have no affordable access anywhere else. If health care becomes "universal" wouldn't that be just as good as turning to the VA as the provider of last resort, especially for care that is not uniquely associated with battle related type of illness or injury?

    What's the perceived problem? Are you asking for comment on the possible ramifications of an undefined future system? If so, I'd say 1.5 standard deviations.

  4. Ranger: Do veterans receive health care beyond that received by non-military citizens? Is the level of treatment received by veterans abroad sufficient? Does it exceed that received in the U.S. in any way?

    As to this specific question, my limited exposure is that where there is national health care or insurance, the veteran is provided the veteran's hospital/clinic benefits in addition to full access to the "mainstream" facilities. It's not a mutually exclusive choice.

    I'm a funny duck. I put health care in the same category as pregnancy. You are either pregnant or you are not. There is no such thing as "almost pregnant", "partially pregnant", or "over pregnant". Similarly, for health care, you either receive the full range of proper, comprehensive care or you don't. If you don't, to me, it's not acceptable health care. But then, my minimum standard for the level and quality of health care that our society should provide each of us is probably in the "gold plated" category. You know, that no one should have to go bankrupt as a result of medical issues.

    In a system where every citizen has full access to all necessary care, what is "health care beyond that received by non-military citizens"? You either get the full range preventative/well care or you don't. You either get full treatment for disease or injury or you don't.

  5. Here's an anecdotal illustration of the irrationality of our system, and how the VA came to the rescue - quite by accident:

    A friend is celibate priest in the Orthodox Church. He is provided, as it is his desire to live a monastic-like life, room and board, and a modest stipend (pocket money for incidentals and a few of life's niceties). Several years ago he had a serious medical problem which was identified as a "pre-existing condition" for medical insurance purposes. Thus the insurance coverage he had from the parish was worthless. So he went to an emergency room, where he was admitted and given the minimum surgery to address the immediate situation, as he was the equivalent of "indigent" due to his manner of compensation. However, since the emergency room did not provide follow up care and rehabilitation services, he was on his own for the costs of that, which was way beyond his means and not covered by his insurance. Thus, he would receive no treatment until the problem once again reached the "emergency" level, which was guaranteed to happen. This would be the pattern for his remaining years.

    While the above was going on, I happened to be having lunch with a friend, who was the chief administrator of a major VA medical center. I dawned upon me that the priest's two years of draftee service in the early 60's might allow him to receive some kind of VA care, and so I explained the situation and asked. The answer was that if he faced another "emergency", which was inevitable based upon the nature of the minimal treatment given at the civilian hospital to meet their minimum legal requirements, he could be admitted to the VA hospital, which would entitle him to the proper and full regimen of treatment, follow up and rehab, even though the problem was not service related. His lack of insurance coverage and technical "indigent" status would bring him into the system. And, once in the VA system as an "indigent veteran", he would remain in the VA system for full medical care until he was no longer "indigent", which, by the nature of his monastic like life, wasn't going to happen. Since that day, he has been a client of the VA for all his routine and non-routine medical care, and it has been excellent and comprehensive.

    Now, if that had happened to a person in similar circumstances, but who had not been drafted, they would be up Sh*t's Creek. So, yes, in the US, "veterans can receive health care beyond that received by non-military citizens", if they meet the technical requirements, only because many citizens do not have access to baseline care. If this "veteran", however, did not live in the parish rectory, and received a salary just large enough to pay his rent and utilities out of his own pocket plus his "stipend", he would not have met the requirements for being "indigent" and would have only received the same emergency room treatment from the VA as he would receive from a civilian facility, if the VA were to treat him at all, rather than send him to the nearby civilian hospital.

    While that's just one person and one set of circumstances, it is an example of how irrational our non-system has become. We reward one citizen on the basis of having been drafted and his method of compensation over another citizen who might have been 4-F and received the value of his food and board in cash. If it takes "socialism" to cure this, then sign me up.

  6. Aviator,
    I'll start with your celibate priest example.
    From the input i assume he met the DVA means testing ergo he got treatment, but from your cmts i also surmise that he should've been eligible for Medicaid also due to income status. Isn't that how medicaid works?
    As for my article. I don't know where i'm going , and i'm trying to get a feel for the foreign systems for veterans.
    I've got a gut feeling that VA systems will change when we reform or evolve our health care system. In fact i'm amazed that we allocate as much as we do to the VA, b/c it's the natural place to look for budget cuts,especially after the shooting stops and money issues hit the fan.
    This i suspect will happen.
    It doesn't look like i'm gonna get any input from my inquiry.
    Oh well, tomorrows another day.
    Thanks for your cmt, as always they were thoughtful.

  7. Jim,

    I'd like to give you some input, but my knowledge of veteran-specific health care in other countries is very limited.

  8. To all,
    Yesterdays NYT had a front page article that Tricare is going to add costs to retired soldiers benefits , which exactly points to verifying my position. If it starts while we're still fighting then it'll steamroll when the wars tank out.

  9. jim-

    Yes, the priest was eligible for Medicaid, but that did not provide full, comprehensive health care, to include the proper level physical rehab (and, with spinal chord injury, he needed a lot). It would have been just a step above, "When you are seriously ill or injured, just come to the emergency room."

    As to raising our costs as TRICARE beneficiaries, that has been on the agenda since the Rumsfeld years. It's not the start of a "slippery slope", but just a regularly delayed reality.

    I agree that it's hard to see what the future will bring. My take is that all we are doing it trying to "adjust" an irrational system to make it apply to more people. I don't see the irrationality being eliminated.

  10. Al,
    The only irrationality that i see is the belief that veterans won't get screwed.
    Both parties liberally enjoy this form of entertainment as the people cheer.
    Mark my words-we'll take it in the shorts if/when the health care system is actually reformed in any realistic manner.
    We will not be in the front of the line.

  11. Ranger, I haven't commented here primarily because I don't have much insight into veterans' care provided by other nations. I will say, however, that I doubt other industrialized nations do anywhere near what the U.S. does in the whole area of veterans/military medical care.

    Two reasons I see for that. First, every so-called advanced nation save the U.S. has pretty comprehensive medical care for all citizens. Al's priest buddy wouldn't have had to resort to using VA in any European nation. I suspect there are millions of US veterans who spent one hitch and got out without any disabilities now going to VA who might not be doing so if we were a civilized nation and had comprehensive medical care for all citizens.

    The two countries with which I have a lot of peacetime experience are South Korea and Germany. I first hit Korea in 1964 as a teenager. That now-advanced nation was very much a third-world country then. Limbless beggars on the streets were common; they were Korean War vets. But reality was that no Korean got a break in those days. You recall we saw that in Vietnam as well. Later, in the 70s and 80s, one didn't see nearly so much of it. I first hit West Germany in 1966 for what turned out to be a short tour in Berlin before going back to Vietnam. No beggars, lots of guys with obvious combat wounds, but all seemed reasonably healthy. Later, in the 70s and 80s, no signs of poor treatment of veterans. I speak German; I read the newspapers and watched the local news and never saw any sob stories about veterans.

    The second reason why I think veteran medical care might not be a front-burner item in other advanced nations is simple. None of those other countries likes to grind its youth up in "small wars" the way the U.S. does. Off the top of my head, I'd say our death toll since 1950 is approaching 120K. We all know the math when it comes to casualties vs KIAs, don't we? We need a comprehensive VA and military medical system simply because we like to play at war. This nasty little habit of ours means we bust our youth up with all kinds of trauma rarely seen in civilian land. And since it wouldn't be politic to have too many guys begging on the streets, we have to have a big VA.

    And, oh, yeah, vets and the military will pay for health care "reform." We always do, don't we?

  12. Pubilus: I will say, however, that I doubt other industrialized nations do anywhere near what the U.S. does in the whole area of veterans/military medical care.

    Two reasons I see for that. First, every so-called advanced nation save the U.S. has pretty comprehensive medical care for all citizens.

    I think that this is the heart of the problem. There is no way to predict what any given individual has in terms of access and coverage for their health care. Thus, for many folks, the VA is a safe harbor in a sea of turbulent waters riddled with sharks.

    In my priest friend's case, even of he were earning $50k cash per year, his condition was defined by several insurance carriers as "pre-existing" and therefore not covered. He had a parish provided policy, as they saw it as their obligation to him. They just never foresaw that it wouldn't cover something of which he wasn't even aware until it began to disable him. Thus, he had to "resort" to the VA, and ultimately they dropped the private insurance, as it was, in his situation, a waste of money.

    The "basic care" available to any and all residents of the US is simply "emergency room service". From there, what you can depend upon is a hodge podge of levels that only become increasingly predictable and comprehensive on the basis of any, a combination of or all for these factors:

    1) the luck of your employment benefits
    2) veteran's status
    3) state and local programs
    4) personal ability to pay
    5) existing or pre-existing conditions
    6) knowledge of "the system" or an advocate
    7) your age
    8) which way the wind is blowing or any of a dozen or more other factors

    With a "system" like that, of course special facilities for veterans is important, at least to veterans. It's the only way we can insure that their service is rewarded and/or appreciated, at least in terms of medical care. Especially if the need is service related, and thereby possibly "earned".

    If we had a decent system for everybody, as Publius notes, this thread wouldn't be in existence. So what is it we want? Preserve veterans care independent of the rest of the population, or an respectable level of comprehensive care for every swinging Richard, without regard to all the factors listed above, that might include specialty facilities for specific service related needs?

  13. Publius,
    I think that you are saying that the DVA is too big to fail.

  14. jim-

    The VA hospital/clinic system is said to be the most efficient/effective medical package in the country. It is said to get the job done (albeit with some warts in handling initial intake) at a much lower administrative and operating cost, without sacrificing quality.

    Now that's the healthcare delivery portion of the VA. Disability claims tend to be slow and backlogged, which does not necessarily mean that healthcare delivery also suffers long backlogs.

  15. Aviator.
    I've been thinking about your celibate priest buddy and a few little niggling points rattle around my brain.
    Since this guy has voluntarily eschewed society then why is society responsible for his health care?
    Why doesn't God thru his real estate rich church provide realistic health insurance? Surely god should carry the load for his faithful. The church ain't exactly running in the red.
    We all make our choices as individuals and society should not carry the load.
    I prayed on this before sending it.

  16. jim-

    I never said he eschewed society. He is a celibate Orthodox (not Roman Catholic or Episcopalian) priest because he chose celibacy. He chose a simple life style while serving as a parish priest. Parish "duty" is not eschewing society, but engaging it. The parish, in the Orthodox Church (which is not property rich) is responsible for his support. Along with his room, board and his requested stipend, they provided health insurance, as stated above. His malady was defined as "preexisting" by the insurance company, even though the first manifestation was a surprise to him. In his initial diagnosis, the attending mentioned or suspected a possible cause that might have been inherited. The insurer cried "pre-existing" and that was that, to include an appeal. Thus, he had, for treating a serious malady, no insurance, and no hospital would accept him unless it was cash up front or "indigent care" status. So he elected to have surgery as indigent, just to get any treatment. However, the problem would require follow up care subsequent surgery(s) for proper procedure, which he was not eligible for unless his situation became "emergency" again or came up with cash in advance. (We are talking big bucks) Thus, his health was actually forecast to worsen, as the care available was not sufficient to be curative. Fortunately, while this was going on, I had that lunch with my friend at the VA, and he entered the VA system, and over the next three years and four surgeries and attendant care, the problem was solved. His VA surgeon told him that with the sporatic and delayed care he would have received without insurance and through public assistance, he would have ended up permanently disabled, no less living a life of severe pain.

    I had offered that as an example of how irrational our "system" can be and where the VA is indeed a quality system, far more effective and comprehensive than Medicaid. If you have an ax to grind with a given church, be sure it is the one being discussed first. And, as I said above, and in the initial post, the parish did provide health insurance, to which I would add, was from a "name brand" company.

  17. Good job at filling in the blanks, Al. I think it's good that VA was there to help this fella, and of course the story of the insurance company only confirms our contempt for those dogs. I'm personally very wary of the new health care paradigm, but if it fixes this preexisting shit, that's good. And WRT to the VA, I had few if any complaints on the care and overall treatment I got in California. I'd still be with VA, in fact, but the nearest hospital or even clinic is in Charleston, which can take up to two hours to drive.

    BTW, something I'd frankly never thought about, and that's health insurance for priests. Good to know the orthodox folks—and as you note, they're not rich—provide it. How about those boys in Rome? And the fundies, the Baptists, all of the others? Anybody know?

  18. Publius: I'm personally very wary of the new health care paradigm, but if it fixes this preexisting shit, that's good.

    My view, exactly. What I suspect is that the bean counters in the insurance world and the provider world will simply look for new and creative ways to boost their P&L. It's been their primary goal for too long for a real "culture shift".

  19. Publius,
    I'm stretching here , but if this priest is Orthodox then he's Russian or Greek and neither organization is poor. They own real estate and are tax exempt , so how did they get poor?
    I'm OT but wtf?
    Your cmt about the distance to a DVA hospital is a great point to prove the system ineffective.I must drive 168 miles to the Gainesville Center.Not exactly a cheap go.
    I should bundle trips and go to church while i'm there.

    Thanks for your cmts.