Journalist Phil Longman at the New American Foundation recently updated his book "Best Care Anywhere," which documents the 1990s rejuvenation of the Veterans Administration's health care system. Between editions, the wars in Iraq and Afghanistan placed strains on the VA not seen since Vietnam. Here's his thoughts on the current state of the system, and the lessons its transformation holds for other delivery systems in the U.S.

How does contact with the VA healthcare system compare in terms of
medical outcomes for its patients? How about in other measures of
quality?

In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the
leading edge of medical research, due to its close affiliation with the nation's
leading medical schools, where many VA doctors have faculty positions. The VA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers "Best Care Anywhere."

How has the VA managed to create such a successful model when government bureaucracy, political pressures and limited funding would seem to make it impossible?

During the 1990s, VA health care underwent a quality revolution. It was started by frontline doctors and nurses who simply wanted to do right by America's veterans. It was later propelled by the enlightened and
charismatic leadership of Dr. Ken Kizer, who took control of the Veterans
Health Administration under President Clinton. The key to making it all
work was the VA's near life‐long relationship with its patients, which means
it has incentives as an institution for investing in prevention, disease
management, and other protocols that keep patients well-incentives that
are sadly lacking elsewhere in the U.S. health care system.

The VA's medical records are entirely computerized. Why hasn't the
private sector been able to do the same? What are the effects?

As the VA has shown, digital medicine, when properly implemented, vastly
improves the quality of medicine. That's great for the VA, whose institutional
incentives are aligned with those of its patients. But elsewhere in the U.S.
health care system, the business case for quality is weak or doesn't exist.
Improved quality means that fewer patients get sick, and that when they do
they experience fewer complications. This is very costly to hospitals and
doctors who earn their money by performing procedures, as opposed to
keeping people well. Why invest it electronic medical records if its means
that ultimately you'll have fewer heart attack patients to bill, or will earn less
from treating diabetic patients because you have properly managed their
disease?

Health care reform passed without creating a public care option, a loss
many progressives feel dooms the bill to failure. Is that the case?

The Bill does concern itself primarily with expanding insurance coverage,
and not directly with reform of the actual practice of medicine. But it also
contains provisions, which few people know about, that could provide the
ground work for something like a civilian VA health system. Whether this
actually happens depends heavily on people at the local and state level taking advantage of the opportunity the bill gives them. It's kind of like getting just the toy you want for Christmas, only it says on the box "some assembly required."

What are the prospects for that happening, and is the funding
adequate?

There is at least $12 billion available for anyone who wants to set up what
the bill calls an "Accountable Health Care Organization." That means an
organization that is willing to accept getting paid for keeping its patients
well, and that is willing to adapt and integrate health care information
technologies of the kind the VA has pioneered. The barriers to entry are
remarkably low. The VA's software, for example, is free to any health care
provider who wants to use it, because was written by VA doctors on
government time. It's also "open source," which means that health care
providers outside the VA can modify it to meet their particular needs.

Would a civilian VA mean more and bigger government?

For those who are concerned about the growth of government, and I am one, the most important single objective is to control the cost of health care,
which is driving up spending at all levels of government. The more
Americans have access to the VA model of care, the lower health care costs
will be, while at the same time health care quality will improve. Done right,
the widespread adoption of the VA model of care could free up enough
resources to pay for tax cuts, or to start making serious down payments on
our national debt.

What effect would such a system have on health insurance costs for
American businesses and families?

It's estimated that one‐third of all health care spending outside VA goes for
over‐treatment, such as redundant testing and unnecessary surgery. Because the VA model gives doctors no financial incentive to perform operations people don't need, and empowers them with the information technology to keep track of test results and coordinate care, it's widespread adoption could well cut health care spending by a third. Insurance premiums would fall commensurately.

Would such a healthcare system mean that doctors and patients would
lose the freedom to decide which treatments and medications they
wanted to use?

Most Americans have very little choice of doctors right now. Just try finding
a primary care physician who is still taking patients. Every VA patient has a
primary care physician who coordinates their care among specialists. Unlike
most other health care providers, the VA does extensive research on what
works and doesn't in medicine, including by using the outcomes data
available from its own electronic medical records. This, ironically, provides
its patients with insurance against one of the leading health hazards in the
United States, which is being subjected to unnecessary treatment. Of course, no one is compelled to receive their care from the VA, nor would anyone be compelled to join a health care plan that adopted its model if it didn't fit their preferences.

What can the average citizen do to make VA quality medical care available for themselves and their communities?

Start by talking to veterans about the care they receive from the VA. It's rare
to fine a vet who has been treated there recently who isn't a big fan. Then
start questioning your health care providers about why they can't deliver the
same quality of care. People all over the world, including the people in
Uganda, enjoy the benefits of electronic medical records, but few in the U.S.
do. Demand to know why your doc is still using 19th century information
technology. Finally, be open to the many people both in and outside U.S.
medicine who are calling for wholesale reform of the delivery system, even if
what they say at first seems counterintuitive or contrary to conventional
wisdom.

How did you get interested in the VA and what did you think you would
find out when you began your research?

Several years ago, Fortune magazine asked me find out who was providing
the most innovative and effective health care in the U.S. Having lost my first
wife, Robin, to breast cancer, and having seen much of the dysfunction of the U.S. health care system up close during that ordeal, I was eager to take the assignment. No one was ever more surprised than me to find that that the long troubled VA had become the bright star of American Medicine.
What would you like to see the American health care system look like in
20 years?

If all goes right, we will have a health care system in which the interests of
patients and providers and aligned, as they are in the VA. Both individuals
and policy makers will pay much more attention to prevention, and to the
environmental and behavioral factors that play by far the greatest role in
determining our health and longevity. We will also come to understand that
many of the procedures performed by today's profit‐maximizing surgeons and other specialists have no scientific basis and, worse, cause much
needless death and suffering. And we will wonder why it took us so long to
open minds to these truths.