SAFETY NET LESSONS FROM THE VETERANS HEALTH ADMINISTRATION

I read with interest Long et al.’s new analysis of outpatient trends at the Veterans Health Administration (VHA) in the December 2005 issue.1 A reinvigorated political interest in health care reform, with a push for consumer choice and responsibility, compels our profession to consider the role of social safety net systems (of which, Long et al. note, the VHA is a part).

This analysis should make us reconsider how far up the economic ladder our public health safety net now reaches. Long’s group found that many veterans now use the VHA in concert with other providers, especially to alleviate rising medication costs. Although Long et al. recognize the increasing frequency with which poor, old, and minority patients access VHA outpatient care, many VHA patients fall outside these categories. The VHA is a mechanism for health relief used by many insured, pensioned, and middle-class persons as well—patients not often perceived as requiring a safety net. The increasing use of the VHA suggests that more than just the neediest Americans are living, at least in part, off public health resources. This receipt of care through the VHA may represent augmentation—receipt of additional care that might otherwise have been unattainable—for some, but it also suggests that our notion of medical assistance is no longer restricted to the lowest socioeconomic strata. Further studies should explore the extent to which those with more resources than the most traditionally vulnerable persons use the safety net.

Additionally, the increase in numbers of “dual-use” patients, as Long et al. call them, exemplifies the potential for success of a social health system in the medical marketplace. Even when patients are not obliged to use VHA care, they choose to seek care there because of lower costs and better quality. Many market proponents may be surprised that a bureaucracy like the VHA can deliver such results, winning customers in the process. Yet market critics should also take heart—future market-oriented reforms may give social systems their best chance to shine.

The issues that Long et al. raise are ones that should not be neglected as health care reform once again creeps into the political arena.