Hugh gave the background earlier about who was involved in the discussion about the pending legislation in Congress to reform the VA. What follows is the audio of the two hour conversation and the transcript.
HH: The Veterans Administration in freefall and in meltdown. And Congress is rushing through bills to fix what has become an appalling scandal across the United States. But are they going too quickly? One of the bills in front of the United States Senate, for example, proposes the VA be allowed to sign 26 major medical facility leases in 18 states and Puerto Rico, and use a half billion dollars in new spending on new doctors and nurses. Other bills propose different things. They’re all moving at the speed of sound in D.C. terms, so I’ve brought together six people to talk for the next two hours about what is wrong and what ought to be done. And I start with Phillip Longman, who is the author of Best Care Anywhere: Why VA Health Care Would Work Better For Everyone. Phillip has been a guest on the program before. He’s here in studio with me, as is Tevi Troy, senior fellow at the Hudson Institute, author of What Jefferson Read, Eisenhower Watched, and Obama Tweeted. He’s also the former deputy secretary of the Department of Health and Human Services. Also in studio with me in D.C., Mark Flatten, senior investigative reporter for the Washington Examiner, who has been all over this story, joined by phone from Seattle this afternoon will be Megan McArdle, who is the author of The Up Side Of Down, one of the remarkable people who study failure that we need more of, not less of, also joined on the phone by Major General Lee Rodgers, retired from the United States Air Force. He is currently the CMO of two hospitals, served for 31 years in the United States Air Force in the medical corps, ran a number of major medical facilities in that capacity, and my colleague from Arent Fox, my law partner, Lowell Brown is one of the super lawyers of health care in America representing some of the largest hospital and medical system providers across the United States. Between all of these perspectives, I hope we can tease out an idea of what Congress ought to do and ought not to do right away, because they’re going to try and do something within the next two weeks. Phillip Longman, I’m going to start with you. You are the biggest fan of the VA among our six, so what do you think is wrong, and what do you think the Congress ought to do or not do immediately?
PL: Well, it’s been frustrating to try and get some sense of context for this story. There are clearly problems at the VA, including criminal problems. But if we put this in context, I think we’ll find that the VA is still offering, as a whole, better care than can be found in the rest of the health care system generally, even with regards to wait times. That’s not to say that horrible things haven’t happened, and they need to be fixed. And I’m very disappointed in some of the things that have come to light. But it’s certainly no occasion to privatize the VA, or to even partially privatize the VA as this current legislation you’re talking about would do. The VA is a model for health care delivery reform, and we actually, the rest of the health care system has more to learn from the VA than the other way around.
HH: I will go back and forth between people on the guests in the studio and on the phone. Megan McArdle out in Seattle, what is your reaction to the question what Congress ought to do and when ought they to do it?
MM: Well, I mean, I think the first thing that Congress ought to do is slow down. This is a common thing that you see, especially with issues in government. But more generally, when there’s a crisis, there’s this urge to do something immediately to show that you’re really serious about dealing with the problem. And the problem is that we’re still learning about what has happened at the VA. We’re still learning about where these problems existed, why they came up. And in rushing to try to get something done so that we can put a public face on it and say that we’re getting, we’re going to change this, fix the problem, make it go away, we’re very likely to do what we did the last time around, which is add yet another layer of bureaucracy, and more layers of shake the system up, let’s change it up. And you know, hastily-enacted legislation generally, it’ll come back in four months and turn out to be completely unworkable. And then bureaucrats who aren’t accountable at all will end up implementing the things that Congress did just so that they could show that they were really, you know, they really cared about the problem. What we need to do is stop, figure out what happened, and then once we have figured out what happened, we should go forward. In the meantime, if we have a problem with wait lists, if people really aren’t getting access to care, there are temporary things that you can do in terms of voucherizing people out, regardless of whether you think the system should be privatized or not. But temporarily giving people, if we really can’t care for them in the system right this second, get the people off the wait lists by moving them into the private system, paying for that through the VA, and then go forward with more consistent reform rather than these kind of piecemeal layers that we’ve gotten that have largely created the problem that we have now.
HH: Mark Flatten, you’ve been covering the scandals for the Washington Examiner. What would be your advice to Congress at this point?
MF: Well, at this point, there are some things that are simply no-brainers. If you are falsifying records, committing crimes, hiding backlogs to get five figure performance bonuses, you should have some sort of accountability measures. Maybe you should even be fired. That’s a big provision in both the House bill and the Senate bill. Now there are some significant differences between those, but that is a no-brainer. There is no reason that you should have to really question that there should be some accountability for ineffective managers, ineffective hospital administrators who have committed, potentially, criminal violations to hide long backlogs. One provision of the Senate bill that is almost laughable, although I guess it’s needed, is it requires the secretary of Veterans Affairs to come up with procedures for disciplining workers who deliberately falsify medical records to hide backlogs. That seems like a no-brainer that could be handled fairly quickly.
HH: General Rodgers down in San Antonio, what’s your reaction to the question of what Congress ought to do now, if anything, and what it ought to be?
LR: Well, let me first preface by saying I agree that the VA system is an outstanding system, and you can get wonderful care there once you get through the door. And the problem remains that there’s not enough resources for what they’re committed to do. The concern I would have is, like the others, is if we create a set of measures that are not completely thought through, we’re going to see untoward results, because people will always figure out a way around the system. What I see in the proposed legislation is sort of a Tri-Care lite. If you can get into the system, great, if you can’t, you’re going to have your care paid for. But that in itself has some challenge that they will have to think about hard before they implement.
HH: And so not rushing, though, General?
LR: Yes, sir.
HH: All right, how about you, Tevi Troy. You were the number two at HHS, senior domestic policy advisor to President Bush as well. You’ve seen emergency legislation come and go before. What’s your advice?
TT: I also would urge not rushing, and I’d also remind people that there are recurrent problems at the VA. In ’03, when I was in the Bush administration, there was a scandal of 236,000 people waiting. And then in ’07, we had to create the Wounded Warrior Commission, because there were some problems of neglect at Walter Reed. So there, these problems keep coming back, and I think there are some endemic problems in the system. I agree we need more accountability. If there is somebody who is lying or not telling the truth, or not doing their job, they should be able to be fired. I saw the Senate bill has a passage where you have to go through a mediation board. What I saw in the Bush administration is you can try and discipline people, but once they go to these mediation boards, they often get sent back into the workplace, which demoralizes the people who are trying to fix the system.
HH: So I’ve got a technical issue with Lowell Brown, so I’m going to go back to you, Mark Flatten. You’ve got the actual legislation here until we can hook up Lowell Brown. What does it, how long is it? Is it complicated to read? And is it widely available to the public?
MF: The bill is about 100 pages long, and it’s written in legislative language. There is a fact sheet, which is somewhat simpler. It misses a lot of nuance. For instance, when you talk about accountability, in the Senate bill, there is sort of broad brush language that is a manger is ineffective or incompetent, that the Secretary of Veterans Affairs can fire them. But again, that raises a question then what? In the House bill that’s already been passed, I think, 390-33 in the House, it says if you’re a top level manager and you are incompetent, or if you’re caught falsifying records or something like that, you can be fired immediately, end of story. The Senate bill has a lot of appeals procedures built in, although expedited, that makes it much harder to fire somebody. So there are a lot of nuances that are buried in those 100 pages.
HH: Phillip Longman, have you had a chance to grapple with the 100 pages, yet?
PL: Yeah, I’ve had that pleasure.
HH: What do you think?
PL: Well, the thing that worries me the most is this provision in it that basically says if you live more than 40 miles away from a VA hospital, then you can just go and find any doctor you want and present him, and that doctor can just present the VA with a bill, sort of like a Medicare system. And that, on its face, sounds completely reasonable given that we are under the impression that we have this tremendous waiting times problem, and we do in certain parts of the country. The first thing to say about that is the VA already does a lot of outsourcing of that kind. The contract with Humana, for example, to provide vets with health care in rural areas where access is difficult, it may be appropriate to do some more of that in specific cases. But if you go very far down that road, you miss the very thing that makes the VA so good, which is the integration of care that it offers.
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HH: Megan McArdle, I’m going to go out to Seattle and ask you this. We’ve got big, long lines of veterans, now 57,000 reported. Would you think it wise to pass the immediate ‘give them the voucher’ fix, and come back later, but make sure that that’s timed so that it doesn’t become the voucher that ate the VA?
MM: Yes, I think that you can do some sort of very temporary program, a voucher that allows them to get Medicare-style care as Phillip Longman said, just to deal with this backlog right now. I mean, I think Mr. Longman has written that look, some of these are capacity problems in places where you have a lot of World War II and Korea era retirees. The VA doesn’t necessarily have the capacity there to deal with them, so we’re going to have to do something with them anyway, unless we’re going to pick them up and move them to Minnesota, which means that we need a fix that allows these people to get the care they’ve been promised. It’s complicated because of the way the VA handles care. They don’t do the majority of anyone’s health care, really, and depending on your level of disability and so forth, they provide varying levels and amounts of care for different people. But at least say, you know, there’s probably going to be a little extra spending. Sunset it after some time, but yeah, buy time to deal with the problem rather than feeling like immediately in crisis, you have to go and do wide-scale reform.
HH: General Rodgers, should anything be done until there’s new VA leadership? We were talking in the studio during the break. It’s hard to find people to run the Department of Veterans Affairs. Do you think that any massive overhaul ought to be taken before the new leadership there who’s going to be called upon to implement it?
LR: Well, the problem with doing that is that then, you have a leader who is not responsible for what’s already been implemented, and then you’re going to try to hold him or her responsible for the failures that happened. If I could just add a comment about the voucher system, as I’ve said before, this is like Tri-Care. And one of the things that we have seen in the military health system is that Tri-Care was provided for care when you couldn’t get into the military facilities. And that’s based on a discount off of Medicare. And we’re finding many places or many specialists who just say we’re not going to take that. We don’t need to take that. And that is a concern I would have with creating some sort of a voucher system in the veterans system, that if you don’t have buy in, you don’t get commitment from the medical communities, you really haven’t fixed it.
HH: Phillip Longman, about finding new leadership, the head of the Cleveland Clinic turned this down, very, in the public reporting in the Cleveland Plain Dealer, said it’s because he couldn’t fire anyone. You have a different take on why he didn’t take it? And what does that tell us about who ought to be there?
PL: Well, you know, it’s kind of revealing. I think one of the things we always have to bear in mind is the incredible extra level of scrutiny that the VA gets as compared to other health care providers, right? It’s got two standing committees in Congress, it’s got an inspector general, it’s got the General Accounting Office. And all of that asymmetry is nicely revealed by this Cleveland Clinic episode. So when General Shinseki had to leave town, and step down from the VA, the White House scratched its head and said well, who should we get in? Well, let’s get in the, what’s the most prestigious health care provider we can think of? Oh, that might be the Cleveland Clinic, right? How about we get the CEO of the Cleveland Clinic to come in?
HH: Who’s a Vietnam vet.
PL: Who’s a Vietnam vet, right? So it all sounds great on paper, right? But you know what? The Cleveland Clinic is a good provider. I don’t want to be taken wrong. But it doesn’t have anywhere near the scrutiny involved that the VA does, and all it took was for him to be mentioned as somebody that might be heading the VA, to have that scrutiny come down. So for example, two, three days ago, Modern Health Care Magazine, you know, just reported, matter of factly, right, that the Cleveland Clinic’s been in danger of losing its qualification to accept Medicare reimbursements because CMS has received so many complaints about patient safety at CMS, right? And within seven hours of that report coming out, Mr. Cosgrove, the CEO, withdrew his name.
PL: Yeah. So just bear in mind, like whenever you hear something back about the VA, compared to what, right? We have a health care system that kills 250,000 people a year, according to the Institute of Medicine and other credible sources, right? That’s more people than die from cancer or heart attacks in the United States. It goes in, year in and year out, and it’s not news unless, it’s a little exaggeration, but by and large, it’s not news unless it happens at the VA.
HH: Interesting perspective. Tevi Troy, who ought you to look for? You’ve helped to staff, you’ve been the deputy secretary of one of these massive octopus agencies. What skill set do you need to fix something in crisis like this?
TT: Yeah, it’s very difficult, especially because of what Phillip said, that you go under scrutiny if you’re in the private sector, and a lot people just don’t want to deal with it. And it’s not just how your institution dealt with it, but did you pay your nanny taxes, have you had any personal tax problems, did you ever had a divorce and a wife who’s going to say bad things about you? So a lot of people just don’t want to deal with that kind of scrutiny that Congress imposes on people. And what happens is you do go for retired generals, because they’ve been through vetting, and they’ve got the medals. And so they seem like the right people. But they don’t necessarily have experience running a health care system.
HH: General Rodgers, do you think that you ought to have military experience to run the Department of Veterans Affairs, which is more than just the hospitals, again?
LR: I think the great advantage of having a military person is that they’re used to the culture of the people that they’re taking care of. But there is a difference between the culture, between the military and the Veterans Affairs, because in health care, for example, the Department of Defense is focuses on acute health care, and mostly a young, mostly a healthy community plus the retirees, whereas the Veterans is mostly chronic diseases and significant problems and an elderly population. There’s a few generals who I know would just be great to do it, but whether or not they’d be willing to do it under the current environment of scrutiny, I agree with Mr. Longman, it may be tough.
HH: One last, before the break, and I understand we’ll get Mr. Brown fixed after the break. Let me ask you, Mark Flatten, does anyone on the Hill have any idea, you know, it’s dangerous to fix the system without the input of the person who’s going to have to administer it, because the assumptions that go into the law will not be commonly understood. Is that slowing them down at all?
MF: No, most of what we’re finding out now, that’s the national scandal now, is really not new. Back in 2010, an internal email went out at VA warning hospital administrators here are some of the scams that are being used to hide backlogs, quit using them. There have been 18 different inspector general reports since 2005 identifying the very practices that are going on now. Nothing has been fixed. One of the challenges, one of the dangers is to try and focus on the micro of how do we fix the health care system without looking at the macro of what’s wrong with this agency.
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HH: And my law partner, one of the super lawyers in American health care, Arent Fox’ own Lowell Brown joins us now, and we’ve got our technical issues resolved. Lowell, since you haven’t had a chance to speak up, yet, I’m going to start with you here. There’s a hundred page bill that very few people have seen, I know you tried to read it. What is your experience with the American Affordable Care Act, and the consequences of hastily-written, not widely distributed legislation?
LB: Well, Hugh, hi. I’m holding a copy of that 100 page bill in my hand right now. I was able to get my hands on it first thing this morning, and as was said earlier, it is written in legislative language, and very difficult to break down, especially for a radio audience. But I guess it is 1/30th the size of the Affordable Care Act at a hundred pages. All I can say is that as somebody who spends most of my life these days trying to help health care providers unravel the statute of the Affordable Care Act, and Nancy Pelosi was right, we’re finding more and more things in it now that it has been passed. The last thing we want to do is rush into another comprehensive revision of an existing system that has been around for decades, which is what the Sanders bill proposes to do, and even the McCain bill is, that one is 60 pages long, or maybe only 25 pages long, small by comparison. Anyway, the last thing we want to do is rush into something like that. I agree with what everyone else has said.
HH: Megan McArdle, you are a student not only of failure in The Up Side Of Down, but also on Obamacare. You come on this program and talk about it a lot. What’s your law of unintended consequences from hastily-written, poorly-understood legislation?
MM: Well, I mean, I think we have seen it over the past six months as we have been implementing it, really, the past almost a year now of, for example, people who, there are all sorts of little drafting holes that left open, for example, there wasn’t any place to put a budget in the law for the federal government to develop exchanges. They had just assumed that the states would. No one really worked it through. And so when it turned out that most of the states didn’t want to develop their own exchange, the federal government had to kluge together budgets out of stuff that was already in CMS, which ran the program, and also runs Medicare/Medicaid. And because of that, they had this bizarre byzantine architecture of who was doing what, three different offices, each responsible for a different part of the design, not working together very well. And that is one of the big reasons that we saw the giant exchange failure that we did. You know, the best laws are laws that are carefully thought through. You take some time, you think about it, especially now, because when you look at the laws that, say, architected the New Deal, what’s amazing to a modern person is how short they are. They’re very simple. They do a simple thing, and then they move on, because there’s already so much law on the books. The legislative language is impossible to parse, because it all says, you know, amend sub-section A of this law that you’ve never heard of, and then sub-section B of this section of a different law, that incredible complexity means that it’s more imperative than ever that you take time and think about it, and don’t rush through with hastily-drafted things. But it looks like we may go the opposite direction on this, as we often do in crises.
HH: The Homestead Act was ten pages, settled a quarter of the United States. Tevi Troy, you had your hand in a few of these bills. Why does it have to be that way, because legislative language, to which Mark and Phil and Megan and Lowell have referred, is always impossible for even an interested discerning public to decipher?
TT: It’s absolutely true. Once lawyers get involved, when I worked on the Hill, we knew that we would come up with proposals for legislation, and we would give it to this group called LegCounsel, and these are these gnostics, I guess. They would take what you had written in English, and they would translate it into something that you could not comprehend. So there’s a consciousness, or an intentionality to this, people know on the Hill that when you write a proposal, what ends up is going to be something that’s illegible and not understandable to the American people.
HH: So Phillip, do you understand what’s in these 100 pages? Do you really think you’ve got a grip on what they’re proposing to do?
PL: I think so. I mean, it’s fairly straight forward, what’s being proposed here. It’s not anywhere near as complex as Obamacare, right? But that doesn’t stop it from being really dangerous, and largely because you’ve got to diagnose the problem, or the disease correctly before you can have the right prescription here. But one thing, problem is, that it pervades the whole conversation, is you’ve got two different wait times that get conflated, right? The wait time to get in the VA, and the wait time once you get in, right?
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HH: When we went to break, Lowell, you said this is an opportunity to actually do reform the right way, make it an experiment in reform. What do you mean by that?
LB: Well, the VA is a well-established, well-developed system, and it’s sort of a bit of a hothouse we can observe as we try to do some reform. In my law practice, one of the areas I spend most of my time in is helping providers and hospitals to deal with the compliance with the quality mandates that come down from the federal government, and from accreditation agencies. General Rodgers will know about those. So the University of Utah, for example, has a partnership with the VA hospital in Salt Lake City where the veterans who are getting care there have access to the world-class physicians that work at the medical center, that world-class medical center. And so that’s an example of a place where things are going well, and there are other such partnerships. Why don’t we look at that and see if we can emulate that and encourage that in overhaul of the overall system? Another thing, I think, that we can learn from this system is how in a huge government system, and there are things that happen that maybe we don’t want to emulate. There’s the two week rule for scheduling, for example. Everybody’s heard about that in the news. Once you have a rule like that, and people’s compensation and the performance evaluations are tied to it, inevitably, there’s gaming, which is what happened. People start to manipulate the statistics and the records so that they’re complying with and meeting that standard. It leads to fraud, abuse and so forth. So why don’t we learn from this rather than rush through a couple of bills to reform a well-establishes system? Let’s learn from it, do something deliberate, and come out with some ideas that can help not only the VA, but the overall system as well.
HH: General Rodgers, your reaction to that?
LR: Well, the first thing I want to do is correct the host and say that I don’t run any hospitals. I’m a chief medical officer. I’m responsible for quality, but I’m not responsible for the margin.
HH: Okay, got it.
LR: Now that being said, a key precept in disaster care is triage, and I would argue that this is a disaster. And in triage, what you do is you sort out what’s going to kill you right now, what do you need to do a little bit later, and what things shouldn’t you do at all. And I think that that’s really what we should be doing before we write legislation. What is the most critical thing to get this back on track, and then work on the long term fixes. If we try to fix everything all in one step, it’s going to be a disaster.
HH: Megan McArdle?
MM: You know, this is not just a problem that the government faces. I remember Jim Manzi, who’s a great CEO, telling me you know, as soon as you try to change the compensation scehem for your sales people, these people who couldn’t pass high school math, they’re suddenly like Aristotle telling you everything that’s wrong with their scheme, and they game, and they will come up with ways to jam products on customers that gets returned the next quarter. Whatever metric you set up, people are going to try to game it. That’s why you need less in the way of these hard and fast rules, and more in the way of accountability. And that, I think, is something that’s really been missing from the VA system, is that instead of sort of putting this in the hands of local people, which is why I think a lot of people are looking at things like vouchers, that you know, you keep layering more rules on the system, and then people keep finding new ways to game the rules.
HH: Phillip Longman, you noted that that 14 day metric was absurd to begin with.
PL: Yeah, it is, and I mean, it’s always good to try and inspire your employees with difficult to achieve goals. But that one was just a bridge too far. I think in general, the VA, in the 90s, when it went through this renaissance, went through a period where it pushed power out of Washington into the field. It decentralized under the charismatic leader of Ken Kizer, who ran the VA in that era. And that’s when the VA had its golden age. And since then, bad things have happened from time to time, and the response of everybody is to say oh, my God, we need more control on people, right? So like 2006, an employee lost a laptop, and people got so freaked out by the idea that somebody lost a laptop that they shut down all innovation in the field in health IT, right? And that’s the kind of recentralization that’s been going on at the VA for the last eight or nine years, and it’s the root cause of what this problem is.
HH: Mark Flatten, do you agree? Is that the root cause?
MF: Well, the problem is you’ve got sort of the worst of all worlds here. You’ve got edicts coming down from Washington, you’ve got metrics coming down from Washington. You need to meet these backlog numbers. You need to meet these wait time numbers. But there’s a great deal of flexibility within the local offices, and very little oversight of the local offices as to how they meet it. So if you’re a hospital administrator looking to get your ten or fifteen or twenty thousand dollar bonus based on wait time performance, you can either get the patients the health care they need, which is the right thing to do, or you can find ways to cook the books and game the system. Unfortunately, not in every facility, but in many facilities, what we’re finding out is it was far easier for them to just game the system. The consequence of that is the patients did not get the care. We’ve heard of patients dying, for instance, in Columbia, South Carolina, six patients died because they could not get a colonoscopy. Patients were waiting a year to get a colonoscopy. If you or I walked into our doctor tomorrow, and they decided we needed that, I’ll guarantee you, we could walk in any hospital in the city and get one in a week.
HH: Tevi Troy, decentralization? How about, you know, there are circuit courts of appeals? How about circuit VA’s as opposed to one VA run from D.C?
TT: Well, I think there has been more control from Washington over the last decade or so, and that’s a problem. And I was actually at the White House during that laptop scandal when there were a lot of VA records that were vulnerable, because a guy had not followed procedures with the laptop. So I think the more you centralize it, the more problems you have. There are good people at the local levels, but you do also have to watch it. It’s a careful balance, because what’s going on in Phoenix is significantly problematic as well. So I think there needs to be more thought put into this, and I wouldn’t just put my thumb on the scale of centralization or decentralization.
HH: Well, right now, there’s this reform conservatism, right? And they’re popping out a thousand things to do. Why doesn’t AEI and Hudson and the American Health Policy Institute, why don’t you guys get together in a room and suggest what the Congress do, because I’m just not persuaded that the legislative staffs and the interest groups know what to do.
TT: It’s a great idea, and I think one of the problems on the conservative side of things is there’s not enough conservatives who follow this issue and have made good suggestions. And I think maybe this will wake people up and have them start doing it.
HH: Because it will become a model for what follows Obamacare, if in fact Republicans get control of the ability to repeal that. I’ll be right back on the VA special. This is really all about Obamacare, by the way, whether or not you know that.
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HH: In our short segment, takeaways from Hour One – don’t do anything in a hurry, don’t do anything in the dark, but now also a political question, and I’ll do a roundtable, 30 seconds each. Will this discussion have an impact on what follows Obamacare, and whether or not it ought to be repealed? Megan McArdle, you get to go first.
MM: Absolutely. You know, a lot of the promise of Obamacare was that the government could do a better job of handling your health care than the private sector. And the VA was exhibit A for a lot of writers and thinkers about this. So I think people are going to react by saying hey, wait a minute, I’m not sure I want the government to be doing my health care.
HH: Phillip Longman?
PL: Couldn’t disagree more. Obamacare is not about the government providing health care. Obamacare is about insurance issues surrounding health care. So I would hope that what comes out of this is people focus on what actual government provision of health care is like, good or bad, as opposed to this ancillary conversation we’ve been having for ten or fifteen years about health care insurance.
HH: Lowell Brown?
LB: Well, I think that we’re not going to return to a Dickensian world where there are charity hospitals, so the debate between private and government might be a false one. I think that we’ve decided there’s going to be some mixture between the two. So we have an opportunity to learn from this, and people will use this, as Megan said. You know, Obamacare was about access to health care. It didn’t deal with costs, didn’t deal with quality, which are the other two aspects of the system, and maybe we can work that into the discussion, too.
HH: That is definitely coming, especially General Rodgers leading off next hour. But Tevi Troy, what do you think? Does this impact the discussion on what follows Obamacare?
TT: Yes, and for two reasons. One is because of the skepticism that will increase now of government’s ability to work in the health care sphere, even though they’re different systems. Bu the second thing is there are going to be massive changes in health care as a result of Obamacare, specifically 170 million employees get their health care through their employers, and recent predictions suggest that might be going away.
HH: Mark Flatten, will that have an impact, do you think?
MF: Well, it has an impact on the discussion, because people are drawing the comparison. In terms of making a policy determination, that’s a little out of my wheelhouse.
HH: So there’s no way to avoid it. General Rodgers, we’re going to open next hour with your email to me about the Iron Triangle. But this iron triangle applies both in VA politics as well as Obamacare, correct?…Did we lose you, General Rodgers? We did lost him. All right, when we come back, we’ll reconnect with him, and we will bring back, he’s supposed to go off and find the Iron Triangle for me. He explained it beautifully in an email. We actually did a lot of preparation for this.
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