Waldmann V Waldman

I was reluctant to read this post by Paul Waldman Obama must fix VA scandal to redeem liberal vision of government. In general, I think very highly of him and think he does our [n]name proud. The post is OK, but I will criticize it.

My reaction to the Veterans’ Administration scandal was first to recall the claim that the VA provides better care than other US systems and second to suspect that the scandal doesn’t prove this claim false. I was pleased that my fellow Waldman[n] noted the claim (which was based on solid evidence) here

In 2007, Phillip Longman wrote a widely-praised article, later expanded into a book, documenting how the VA health care system had transformed itself into a model of excellent care, using creative problem-solving and early adoption of electronic records.

Exactly. But then the next sentence is

So what happened since then?

This assumes that something has changed. But the scandal doesn’t prove that the VA care is worse than any other care in the USA. Longman’s article compared the VA to the rest of the US health care non system. The fact that VA care is scandalously bad and a violation of our contractual obligation to our veterans does not mean that it isn’t much better than the rest of the US health care system. The post contains a catagory error (or maybe Longman’s article did) contrasting relative evaluation of VA vs non VA with relative evaluation of actual VA vs promised VA.

Waldman’s hypothesis is that something has changed since 2007 (sic) (or rather since the data Longman discussed in 2005 were collected). I think he is wrong. Steve Benen noted “In 2012, RAND Corp. found in nearly every category, “VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.” ” Benen linked to this post by Jon Perr which is extremely convincing (just click there it’s too good to excerpt)

I didn’t know that, but I know the scandal doesn’t tell us two things. First it doesn’t tell us how the VA performs on average. Second it doesn’t tell us anything about the VA vs anything else in the world.

I think there are four problems here (and I don’t mean to pick on Waldman).

The first is that the data based response that things are worse in the rest of the US healthcare non system is not considered acceptable, because it suggests a lack of outrage or respect for the victimized veterans. I think in a discussion of horrible consequences of misconduct, reporting the fact that worse things have happened is not accepted. This means that there are facts which must not be mentioned. This is always a problem.

The second is a strong tendency to discount the not so distant past. Waldman should have looked for solid relevant evidence before guessing that something changed dramatically in the past decade. In fact, more recent studies comparable to the New England Journal of Medicine study which he indirectly cites reach the same conclusion.

A third is that there is (and must be) a legal and is (but shouldn’t be) a pragmatic distinction between making a promise and breaking it and not making the promise. The veterans were not given the care to which they were contractually entitled. Non veterans are not contractually entitled to (non emergency) care. At most, you are insured which means that you don’t have to pay for the care. There is no scandal related to secret waiting lists kept separate from the official public waiting lists by doctors with office practices. They don’t have official public waiting lists and you might be told to go elsewhere and not put on a waiting list at all. If there are no rules, there are no broken rules. A bureaucratic system will have scandals, because there are ruled to break and written records which can contain proof that they were broken.

The fourth is that in politics perceptions are reality and it is very hard to keep discussions of politics and policy separate. The public won’t be convinced by Rand studies. Stories beat statistics. A vigorous and severe response to the VA scandal isn’t needed just to make the VA as good as it must be, but also to refute the argument that the private sector works better, which is appealing to normal people outraged by the scandal even though the scandal provides almost no relevant evidence.

Waldman’s main argument is based on the fourth issue. His post explicitly focuses on the politics. I actually agree with his conclusion. But the post included the bolded sentence which is not supported by any evidence he presented and is contradicted by available evidence (which I didn’t personally find either).

update: back to the source. Ezra Klein interviews Phillip Longman here. He stands by his story.

the big question with these stories about the VA is, “compared to what?” This scandal wouldn’t exist if the VA didn’t have performance metrics on its employees. If it didn’t measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that’s far better than what goes on in the rest of the health-care system where no one is accountable for this at all.


PL: The metric here is they tried to get vets in for non-urgent appointments for care within 14 days. Compare that to a survey done in 2009 on average wait times outside the VA to see a family physician. [skip] The average wait time in major metropolitan areas is about 20 days.

Oh just click the link and read the interview.