Phillip Longman is “a Senior Research Fellow with the New America, where he works on health care delivery system reform and issues related to market concentration. He is also the senior editor of Washington Monthly and a lecturer at Johns Hopkins, where he teaches health care policy.”
“His work on health care includes Best Care Anywhere: Why VA Health Care Would Work Better For Everyone, Third Edition, recently updated with a third edition,” continues his bio at the New America Foundation. “The book chronicles the quality transformation of the Veterans Health Administration and applies its lessons for reforming the U.S. health care system as a whole.”
Longman is an engaging, indeed inspiring speaker who has been a guest on this program as well as at the Fowler School of Law at Chapman University where I attended his lecture extolling the VA as a model for the future of American healthcare.
So he is in a tight spot. As are all of the reviewers of his book and sharers of his point of view. The VA, it turns out, is a disaster, a deeply corrupt and dangerous institution with what appears to be institutionalized criminality and widespread indifference to actual as opposed to bonus-eligible performance. To his credit, Longman joined me int he first hour of my program today to tell us his reaction to an IG report that essentially calls into question the central premise his work and all but guarantees that there won’t be a fourth edition of Best Care Anywhere.
My key question to him: Will he be willing to live with the data as it is, not as he wishes it would be? The left often accuses the right of “epistemic closure,” which accusation more often than not is a beautiful example of projection, but the future writing of Philip Longman is going to be a case study of what do public intellectuals do when their world view comes under assault from incontrovertible data that shatters their previously held positions.
HH: I’m joined now by Philip Longman. He’s a senior research fellow with New America Foundation, where he works on health care delivery system reform and issues of market concentration. He’s also a senior editor of the Washington Monthly. He’s a lecturer at Johns Hopkins where he teaches health care policy. And his work includes a book, Best Care Anywhere: Why VA Health Care Would Work Better For Everyone, third edition. Mr. Longman was a guest at the Fowler School of Law, Chapman University School of Law last year. He’s been a guest on my show before. When I heard his presentation, I thought wow, maybe there’s something to this single payer thing. Philip, welcome, what do you do when your book is sort of instantly discredited?
PL: Well, good to be with you, Hugh.
HH: Welcome back. I’m glad you came on, but you knew that was the question, right?
PL: Yeah, yeah, yeah. Well, look, this is a very serious scandal. Obviously, it’s approached, or exceeded a textual note of obvious criminality involved in the Phoenix VA system. But let’s put together exactly what we know for sure. So today, we have, or yesterday, we got this new preliminary report from the inspector general, and it makes it very clear that certain employees at the Phoenix VA health care system were gaming a performance metric in order to disguise how long waiting lists were for people newly enrolled in that system to get their first primary care doc visit. So the people in that facility reported to the VA central head office in D.C. that is was taking an average of 24 days for vets to get that kind of access. That’s pretty much in line with what it takes Americans outside the VA to find a new primary care doc. We have a survey just out of Boston showing people there have to wait about 29 days to get a primary care doc.
HH: But it was actually 115 days. It was 115 days in reality.
PL: Well, that’s right. That’s what I was getting to. So as far as, as they were reporting it to Shinseki and others, it was 24, which is in bounds. It turns out it’s 115, which is way out of bounds. So what do we make of that? Is that a sign that VA health care just stinks? Or is it an isolated incident? What are we supposed to make? Well, here’s some other things we know. We know that all of the major veterans service organizations, including American Legion, Vietnam Veterans for America, they all testified in front of the Senate Veterans Affairs Committee a week and a half ago, that they found VA quality of health care excellent. Just to reinforce this, those service organizations probably are speaking for the majority of veterans who actually get care from the VA. We have a brand new survey brought to us by the University of Michigan of consumer satisfaction, which shows VA patients showing higher than industry average satisfaction with the care that they’re getting at the VA. So if there’s a pandemic problem of excessive wait times throughout the system, it has to be squared with these other points of information that we have.
HH: Now Philip, on the left, there’s been quite a lot of debate recently about the concept of epistemic closure, where the accusation leveled at the right, that the right is not open to new facts and new theories, and that they live in an echo chamber.
HH: What I’m curious about is are you prepared, upon the receipt, if the Phoenix facility is an isolated criminal syndicate, you know, anarchic archipelago of just, it’s random and everyone else is working, but if in fact, or a lot of the VA facilities have similar problems, and it’s a malignant situation, are you prepared to say gosh, I was wrong, VA and government health care doesn’t work?
PL: I don’t, well, let’s be clear. What apparently has happened, and let’s take your hypothesis. Let’s suppose that throughout the VA system, there are many, many examples of front line employees gaming a performance metric on wait times. That’s bad. That’s bad and it needs to be fixed. But you know, outside the VA, what’s the hot new idea that everybody that’s reforming health care has, whether they’re liberals or conservatives? It’s called pay for performance, whereby we put performance metrics on employees to actually deliver specific results in health care. The VA actually pioneered this back in the 90s, and guess what? Having set up these high goals for itself, it apparently has fallen short in some places, right?
HH: But now, wait a minute.
PL: But the rest of us…
HH: But what if the evidence…
PL: We have a serious problem, potentially. The thing that the rest of us ought to learn from this is that pay for performance metrics are subject to abuse, and no more or less…
HH: But we also have to learn from it, a much bigger issue, a much bigger issue, which is that government always fails to deliver in an efficient and effective manner that which the private sector typically does. And so the title of your books is Best Care Anywhere. That’s an absolute statement – best care anywhere. And I’m just curious, you are the go-to guy on single payer. This is really an argument about single payer. Are you prepared to say I was wrong about it, depending on what turns up. It could be just Phoenix, and there are a few other facilities we know are in trouble, or it could be absolutely systemic and malignant. And if it is systemic and malignant, is Philip Longman going to come out with Why I Was Wrong, because you’re the guy. If you would come out and diagnose the problem, that would be damning. I mean, it would be one of those things where, you know, Nixon to China moment, right, where Philip Longman was selling the VA long, and then he came back and said I’ve studied what happened here, and we’ve got to run away from single payer as quickly as possible. Is that within possibility? That’s what I’m wondering intellectually? Can you take the pain?
PL: Well, you know, I’m an evidence-based guy. When I set out to write this book, I didn’t have any ideas the VA had best care anywhere. I’d lost my wife to breast cancer. I’ve seen some really nasty parts of the U.S. health care system, and went out on a crusade to find out who had best care anywhere and was surprised to find out that it was the VA that was outperforming the rest of the health care system on all kinds of quality metrics. So if the evidence changed, I would change, too.
HH: You see, I’m going to get you and Megan McArdle, who I think are two, you’re both evidence driven, and you’re both very thorough and well-respected, to sit down and debate this, because she also had, she almost lost her mother to medical care fiasco, and I hear your talk about your wife, and I said okay, these are two people with emotional investment and scholarly chops. And if you turn on this, the game’s over. And so I’m really hoping that this, is there anyone else calling you about this and saying Philip, come tell us what’s going on here?
PL: Yeah, I’ve done a lot of speaking, and as we’re writing, I mean, as we’re speaking, I’m writing an op-ed piece trying to put all this in context. So I’m very much in play.
HH: It’s pretty bad, isn’t it?
PL: But just remember this, Hugh, I mean, what we know about quality of health care includes, you know, vast literature by now of peer-reviewed studies on who provides the most cost-effective health care with the highest rates of patient satisfaction. And it’s just a blunt fact that the VA consistently outperforms the rest of the health care systems on those kind of comparative measures.
HH: Oh, but it’s like the global warming hockey stick, Philip. If it was built on crap data, no one’s going to believe it. Well, we’re short on time today. I’m going to get you and Megan in for maybe an entire day next week to talk about this. I appreciate you coming into the front point, and we’ll talk next week, Philip Longman.
End of interview.