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Hugh Hewitt Book Club

Reforming The VA (And The ACA)

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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 [ @LongmanPhil], 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 [ @TeviTroy], 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 [@MarkFlatten], 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 [@asymmetricinfo], 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 [@Spike72AFA], 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 [@lcbrown] 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.

— – – –

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.

HH: Interesting.

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.

— – – —

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?

— – – – –

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.

— – — –

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.

— – – —

HH: I begin with this Tweet, gentlemen and lady – so far, depressing panel tonight, tweeted Sean Ward. I see no one trying to solve the problem, a lot of talk, but no action. And are any of your folks, another tweet, on the panel actually using or used VA health care? General Rodgers, this brings to your overarching view, and maybe we set it up now. What is the fundamental problem, and you illustrated it to me in a triangle.

LR: Health care is bound by what we call the Iron Triangle. And each of the ordinal points are quality, which is most important, cost, which you have to deal with, and then access, which is the problem that the VA has had at this point. You can push on any of those. You can push on one, you can push on two. But if you push on any of those, it causes the other one to go contrary to the direction you want to. So if you want to increase quality, and you want to increase access, you have to spend more money. If you want to increase access and you don’t want to change the cost, then your quality is going to go down. They’re linked together, and you can’t get away from that.

HH: Phillip Longman, do you agree with that?

PL: In general, yeah.

HH: Megan McArdle, do you agree with that?

MM: You know, it’s always true that occasionally, you’ll find some amazing thing that’s a win-win. It cost less and it’s better. But no, in general, the reason that health care costs so much, or one big reason, is that if you want to get quality, you’ve got to spend to get it. We have a great health care system in a lot of ways, but it’s a very expensive system.

HH: Tevi Troy, do you agree with that?

TT: Not only do I agree with it, but we’re seeing it with the Affordable Care Act, where the push was to increase access, and you’re seeing huge increases in cost, and likely decreases in quality.

HH: Lowell Brown, do you agree with General Rodgers?

LB: I agree. Tevi was right.

HH: And Mark Flatten, do you agree with this?

MF: Well, access is clearly the problem at VA right now.

HH: All right, so…

PL: Wait, so can I amend my answer?

HH: Go ahead, Phillip. And rats, I had unanimity that the General had laid it out there.

PL: Yeah, yeah, right. So let’s define access, though, because that’s important, right? So there’s two kinds of access issues that we’ve been talking about and kind of conflating the two. One is the access issue of how long once you’re in the VA do you have to wait to see a doctor, right? Now the latest numbers coming out say that 96% of all people in the VA can see a doctor within 30 days. So it’s worse in some places, it’s better in others. That’s one issue that we can talk about. Then there’s this other issue that’s really unique to the VA, and that is who gets to get into the VA in the first place? We have these tremendous eligibility rules where we basically say to vets you prove to us that you are deserving of health care at our expense. So Congress, speaking for the American people presumably, you know, has set out all these incredible rules that the VA has to administer, and that vets have to jump through. For example, you’re a 67 year old veteran, you’re losing your hearing. You would like maybe to have some, a hearing aid. You think it’s because of that summer you spent on the highlands of Vietnam, a fire base, and all the exposure to artillery you had during that year. We don’t know that, though. Maybe it’s because it’s all the Who concerts you went to in 1968, right? So you prove to us that it’s the artillery fire on the Vietnam highlands, not the Who concerts. And we spend an incredible amount of effort litigating questions like that.

HH: But if my understanding is correct, most of the scandal that you, Mark Flatten, have been reporting on is not about not getting in. It’s about waiting once you’re in. Mark, is that your impression?

MF: Partly, but part of the other problem is they don’t really know what their access problems are now, and that’s one of the things the VA is finally, just within the last week or so, admitting to, is with all of the falsified records, a good example is what was going on in Phoenix. They had a 14 day goal to meet for primary care appointments. They were showing they were meeting that goal. The way they were doing that is you walk into your VA, said you needed to see a doctor. They put you this basically a secret list, a false list. And you might have to wait six months to get, to see a doctor. But you wouldn’t be put on the official list until your appointment was two weeks away. So on paper, you saw the doctor within two weeks. In reality, it may have taken you six months.

HH: Lowell Brown, this is the government system, and right now, the culture of disbelief is deep. No one’s going to believe the VA for many years to come about any of their statistics. If you, you know, you’re the general counsel for a health care system. How do you institute self-policing such that that culture can be turned over in a short period of time?

LB: Well, in every hospital in the United States now, there exists, or should exist, a compliance program. This is because of the enforcement efforts of the inspector general and the Department of Justice to root out fraud and abuse. This is a whole different subject from what we’re talking about right now. So every provider in the country that participates in the Medicare program, which means all of them, already has in place a pretty sophisticated, or should have, a sophisticated program for dealing with, with being in compliance. I’m not sure if that answers your question or not.

HH: Well, I’m wondering why that can’t be imposed, and I’ll ask General Rodgers, since he’s been on both sides of that. Why can’t that system be imposed on the VA so that the problem here is who believes anybody in the VA right now?

LB: Well, it can be imposed, and the way it’s been imposed in the private sector is interesting. It’s been imposed by incentives, and the threat of enforcement. Basically, the OIG, for example, in HHS, says you need to have a compliance program. It should include these elements. And when problems arise, if you have a program and it meets these standards, then we’re going to go easier on you than if you don’t have such a program.

HH: A safe harbor.

LB: Right.

HH: And General Rodgers, would that work for the VA?

LR: Well, it depends on who’s looking over your shoulder. If you had somebody as the oversight, but there is no, there are no teeth, I don’t think it’ll make any difference.

HH: Megan McArdle, how do you end a culture? I was telling these folks in your book, The Up Side Of Down, the horrific story of the care your mother got, which was miscommunication, no accountability, don’t go into a hospital on a Saturday, etc. How do you take, that system’s not so great, either. So what do you impose on the VA if the private sector system isn’t so well, either?

MM: Well, this is one of the most amazing things. You know, the CEO of the Cleveland Clinic, who I actually interviewed, they’ve got an amazing corporate culture, and they seem to do a very good job with it. But replicating a corporate culture, much less changing it, is incredibly difficult. It’s probably the most difficult task that turnaround people undertake. And one of the issues with government is that you can’t do what a lot of them often end up doing, which is they fire people. So how do you get around that? That is going to be an enormous challenge. And I don’t think there are any easy answers. The fact is you have to go in and say well, the answer that we’ve had in the past is oh, we’re going to make different rules, we’re going to make new rules. But as we’re seeing now, that has not been a successful answer for the VA or really for almost any government agency.

HH: Let the record show I did not lead Megan to that, but it’s exactly what I hoped she was going to say. Tevi Troy, I was the general counsel of OPM, deputy director. We couldn’t fire anyone, anyone, ever. It took forever to fire. You could discipline occasionally. You couldn’t fire. Isn’t the fundamental reform the ability to walk around and fire people even if some injustice occurs? That’s the tradeoff, is that some people will be wrongly fired. But isn’t that a good thing to have empowered in VA administrators?

TT: I think that’s a good thing not just in the VA, but in other arms of the federal government. That’s something I saw throughout my tenure in government, that there would be people who didn’t do what they were supposed to do, and there was really no sanction upon them, that if they, most people who work for the federal government are good, solid employees and doing hard work. But if there’s someone who’s not doing the job, there’s nothing you can do about it.

HH: Mark Flatten, go ahead.

MF: One thing to bear in mind is through all of these scandals we’ve seen over the last two years, including the current one, no top official has been fired.

HH: Phillip Longman, does this help?

PL: I’m a little conflicted about this. I mean, let’s remember how come we know any of this, is because front line employees came forward as whistleblowers, right?

HH: But give me a proportion of those who knew and didn’t come forward versus those who did. I don’t think you want to go down that road.

PL: I don’t, we have a civil service for a reason. If you want to make it so it’s even easier for Congress or certain elements of Congress to reach into the VA and pluck and punish people they don’t like, I’m not sure that’s the way, that’s the lesson of this scandal.

HH: Good redefinition of what I want. I want to give administrators at the SES level who are permanent service people, I hear you, we’ve got to go to break, give them the authority to fire, not Congress.

— – – —

HH: Lowell, when we went to break, you were saying CEO set culture. If you want to reform, make it possible to change the CEO of VA facilities. Did I hear you right about that?

LB: That’s right. The average tenure of a hospital CEO in the United States is about three and a half years or less, and so there’s enormous pressure on those folks to be responsible for what goes on. By the way, our friend, Kimberly Cripe, has been in her job as CEO for 17 years. So the really good hospitals, I can walk into any hospital and talk to the mid-level managers for ten minutes, and I can understand the culture of that hospital.

HH: Kimberly Cripe, whom Lowell refers to, is the CEO of the Children’s Hospital of Orange County, one of the country’s great pediatric critical care facilities. General Rodgers, do you feel in the civilian side, you’re one of the few people who can answer this, that you were under as much scrutiny and responsibility as you were when you were commanding army medical facilities, Air Force medical facilities?

LR: Well, I had more surveys, more visits by oversight while I was in the military. The other thing that I’d say that’s different between the military and the Veterans system is that we had turnover of all of our staff every two or three or four years, and so the problems where you see something going on wrong that nobody notices for ten years didn’t happen, because the new guy would come in, he’d say why are we doing this, and then he’d turn over the rocks. And the problem, one of the problems I see with what we’re seeing in the VA system is because of the fact that people have been in place for a long, long time, you don’t see the rocks.

HH: Interesting. Now Phillip, you were saying during the break we’ve got to insulate VA administrators from Congressional interference, which is a little contrary to both what the General and Lowell Brown just said.

PL: Right. Well, one way to think about what the VA is, is think of the VA as a gigantic staff model HMO. That’s what it is, right? It’s managed care, right, just like people are familiar with what an HMO is, right? But it’s got a specialty population of veterans. People have looked at this carefully, including the service organizations convened committees to think about the long term future of the VA, believe that if you allowed veterans to bring their Medicare entitlement, and remember, most veterans these days are elderly, if veterans could bring their Medicare entitlement to the VA to get treatment, which they can’t today, the VA would probably break even or maybe even make money as an institution, which makes, you ask the question well, why don’t we do that? Why can’t we create some kind of quasi-public/private partnership that insulates the top of VA from this Congressional micromanagement that has been so unhelpful, and let the VA, and all of its component regional parts, do their thing.

HH: Tevi Troy, how do you react to that idea? You’re a health policy intellectual as well as a government administrator, and a political person. So what do you think of that?

TT: Well, what makes me a little nervous about it is perhaps VA breaks even, but we’re still spending the money from Medicare, so it’s government putting the money from one pot into another pot. In general, and this is in response a little bit to your friend, Sean, the tweeter, I’m in favor of modesty in public policy changes. I don’t think we should do massive, quick policy changes. The ACA, Affordable Care Act, obviously fits in that not modest category. So I’d be wary of going overly hubristic in making big changes at this point.

HH: Megan, what do you think, and I’m going to stick on this now for a second. They want to, in the bill, the Senator Sanders bill at least, wants to authorize the leasing of scores of new facilities, and to do so in rapid time, and to hose down the VA with a half billion dollars. What do you think of that?

MM: I think that money is sometimes a good way to solve problems. I mean, you know, you look at something like the FDIC. We had bank runs. We created the FDIC. We don’t. We throw money at the problem. That said, it’s not clear to me that the problem at the VA is money, per se. It’s kind of the whole structure of the system, and the way that we have to have facilities everywhere. We can’t match them easily to populations. We handle part of care arguably very well, but then we don’t do other parts. And a Medicare patient may not be getting coordinated care, but at least they’re in one payment system, not going back and forth between two systems. And so I think overall, what I would really like to see is deep structural reform that looks at hey, is this the right way to do this, and can we break this down, and can we kind of figure out what the core functions are, rather than trying to do a little bit of everything for everyone everywhere.

HH: Mark Flatten, you mentioned whistleblower protection as a pathway to better accountability?

MF: One of the things we found consistently across the country is whistleblowers from inside the VA have come forward to report all kinds of wrongdoing that is negatively affecting patient care. Almost to a person, they are harassed, they are demoted, they are put on administrative leave. Some of them are fired. There is a clear pattern within the VA, or at least there has been, of shutting these people down, retaliating against whistleblowers. Now the VA insists that does not happen, but if you look at just about every single one of these whistleblowers who has come forward, just about every one of them describes almost exactly the same treatment after they did so.

HH: Quick question, we’ve got two minutes to the break for, and I’ll start with you, Tevi. I’m afraid that this is the future of American health care writ large, because if the VA is a foreshadowing of what happens when the government controls more, then we will get more of this. Do you share that concern?

TT: I am very concerned about growing government roles, whether it’s in the role of the ACA, or in the role of the VA. But I’m also encouraged a little bit by what Mark Flatten said. If they can go after whistleblowers, that means there are things that you can do within the bureaucracy to sanction people. So I’d like to follow up on that a little bit.

HH: Phillip, what do you think? You know, you must be viewing this completely differently than I am. I think this is a foreshadowing of a disaster in the health care system, but you like the VA.

PL: Yeah, and I think it’s essentially a conservative institution in that it’s fiscally responsible. It’s much more cost effective per patient when you do all the proper adjustments, and it’s difficult. But like I say, it’s a giant staff model HMO. It has the efficiency of an HMO.

HH: But I mean, our friend, Avik, said that they don’t actually get to spend, private sector doctors don’t get to spend anywhere near the kind of time that VA doctors get to spend with their patients, that it’s a factor of five and six hundred percent.

PL: The private doctors don’t.

HH: Yeah, they get to see 15 patients an hour, and the VA doctors see three.

PL: That’s right. And we haven’t really talked about what makes the VA care better. Megan alluded to it. It’s the coordination of care. It’s the fact that all the different specialists involved in a patient’s care are working from the same electronic medical record. They’re part of the same institution. They’re aware they’re not just treating one body part at a time, oblivious to what each other is doing.

HH: And that’s wildly expensive, though, isn’t it?

PL: That’s what the private health care sector is, and that’s why it’s so wildly expensive, and why VA is thrifty by comparison.

— – — –

HH: In the next segment, I’m going to each give you 90 seconds to go on the soapbox and say whatever you didn’t get a chance to say. But here, I want sort of a statement, yeah or nay and why, should the Congress pass anything in the next two weeks to four weeks, and I’m going to start with you, Megan, since you’re farthest away.

MM: I’m just going to say that we should have a temporary system to help out the people who can’t seem to get through these wait lists, but that we should really look for in the future, given after we’ve bought some time, look for a radical rethink of how we’re doing this. The VA was designed during a very different era in health care. It was designed during a very different era in government. And we might have better ways to do this with some sort of public-private partnership, or just by reforming the VA to do a job for the 21st Century, instead of the early 20th.

HH: Very…who would do the radical rethink, Megan? I mean, where would you even begin that?

MM: Well, I think I would look at something like a presidential commission. I am somewhat skeptical of them often, but in this case, it’s a good vehicle for getting serious recommendations. The problem, then, is actually following through on that. And in this, the veterans groups may sometimes actually be an obstacle, because they like having really detailed control of the VA. But unfortunately, that creates multiple constituencies in a time when you sort of have to go in and say okay, you know, is it the veterans groups that are important? Or do we put this back in the hands of the veterans themselves?

HH: Lowell Brown?

LB: I agree with Megan. I think that if people learned anything from the ACA, it’s that rushing into a big change for political reasons produces disasters.

HH: General Rodgers?

LR: I don’t think that you need to have the legislation done immediately. A lot can be changed just by policies that the interim leaders can do. But it’s going to take some major change. If you look in last week’s New England Journal of Medicine, Ken Kizer actually had an article on how to improve it. And one of the things he points out is that from the time in the late 90s, there were 800 people at the VA central office, and in 2012, there’s 11,000 staff. So you see the bloat there that has to be dealt with.

HH: General Rodgers, is that available publicly?

LR: Yes.

HH: If so, if you’ll tweet it, I’ll retweet it out to people.

LR: Yeah, I’ll send it to you.

HH: That’s a terrific…Mark Flatten, should they do anything in the next few weeks?

MF: Well, don’t get too focused on the Sanders-McCain bill. Just legislatively, a lot of this stuff, as I say, has been moving in the House. The Senate’s been sitting on it until it just became clear that this scandal was completely blowing up. Suddenly, Senator Sanders wanted to talk, and wanted to get something done. So some of these ideas have been floating around out there for a long time. Somebody mentioned earlier triage. Veterans are dying. Some things need to be done right now, and some veterans cannot wait for sort of long esoteric policy debates and discussions. There are some things that, at the agency that are broken, and short term measures need to be taken to make sure people don’t fall through the cracks. These bigger policy discussions, some of them can wait.

HH: Tevi Troy?

TT: I agree with Megan on a temporary fix legislatively, if anything, at this point. But when I was in the Bush administration, we came up with a bipartisan commission, the Dole-Shalala Commission, two honored, trusted public servants who really looked into this issues, came up with good ideas, good recommendations, and they took their time on it. And I think we are not yet at the point where Congress can just go off half-cocked and say we’re going to do this or do that.

HH: Phillip Longman, 45 seconds to the break?

PL: Well, I think the picture is we have some very, well, somewhat serious very local problems in Phoenix and a handful of other hospitals. We need to go in there and fix it. But by and large, the system enjoys the overwhelming support of all the veteran service organizations. It’s winning huge numbers on patient satisfaction. So no, there’s no incredible urgency to go blow the thing up in the next four weeks.

HH: When we come back from break, I call it my burning desire segment. Anything I have not given my six guests an opportunity to say that they wanted to say, they get an opportunity to say. But here’s mine. Whatever they do, if they come at a conference, they should put it out with a commitment that they’ll leave the conference report on the table for two weeks and then reconvene after people have had a chance to read it, and have input into it.

— – – –

HH: The 90 second soapbox segment of the Hugh Hewitt Show two hour special on the VA. My soapbox is very simply this. Nothing should happen at least until the beginning of September, and whatever comes out of the conference should not be acted on until experts have a chance to crowd source it. I’m going to go in reverse order. Mark Flatten, you get your 90 second soapbox from the Washington Examiner.

MF: I know there’s a lot of discussion about sort of the, is this a money problem, is this not a money problem. I guess that’s a policy debate that needs to be had. President Obama, the day he accepted Eric Shinseki’s resignation as secretary of Veterans Affairs, alluded to the fact, I don’t know if he came right out and said it, but he alluded to the fact that throwing money at VA alone will not solve the problem. He talked about a culture change that is needed there, where you’ve got top managers who see nothing wrong with not only falsifying records, but with ordering their subordinates to falsify records, things like that. Until you fix that culture, you’re not going to fix the VA. Right up until about three weeks ago, when Eric Shinseki appeared in front of a Senate committee, VA was still insisting there was nothing wrong, that there were no problems, there were a few isolated instances. These warnings have gone back for ten years. Exactly the stuff we’re seeing now, exactly the scandals now, that people are outraged about, have gone on for ten years, have been reported on for ten years. And yet three weeks ago, Eric Shinseki got up and said this the first I’m hearing of it.

HH: Phillip Longman, author of Best Care Anywhere?

PL: Well you know, as you well know, it’s the VA’s own inspector general that developed a lot of these facts. So yeah, the VA’s been very aware of this. They’ve been trying to fix the problems. So…but for my soapbox, right? Here’s the piece that everybody’s missing. The population of veterans in the United States has dropped by 17% since 2000. It’s about to go into freefall. In most VA hospitals that I’ve been in around the country, they don’t lack for anything except enough patients. Palo Alto is a Class A medical facility that lacks for nothing except a sufficient number of patients. Where we have problems is in certain places like Phoenix, where a lot of retired veterans have moved to settle there, and people didn’t expect that to happen, and Congress didn’t allow for the growth of VA hospitals. In Orlando, we had to wait 35 years to get our VA hospital, even as all these people were moving there. So in Orlando, in some sunbelt retirement meccas, we’ve got wait times and other problems. Throughout most of the rest of the country, basically everything north of the Mason-Dixon line and all of California, we have already incredible disappearing veterans problem with VA. So if we’re going to get smart about thinking about the future, remember, right, we’re going from 25 million vets down to like 17 million by 2030, right? So if you want to keep the veterans system, what you have to do is open it up to larger categories of people, right?

HH: Interesting. All right, Tevi Troy from the American Health Policy Institute, your 90 second soapbox?

TT: Well, first of all, I agree with Phillip that the population of veterans is shrinking. We’re about 22 million, maybe getting under it now. And that could actually give us an opportunity after some careful thought to make some real changes to the system. It’s very hard to come up with improvements when the system is growing, but when you have a shrinking number, it can let you move around some resources. The other thing is, and this is unfortunate, I think there’s been a waste of time. There’s been, the Obama administration’s been around for about six years now, seems like 60, but six years, and they knew. They were told in the transition in 2008 that these wait time numbers were not accurate and they needed to look into that issue. And I wish they had looked into this earlier.

HH: General Rodgers, your 90 second soapbox?

LR: Several issues. One is the quality of care is good, you’ve got great medical professionals. But it’s an inherently slow and inefficient system. We had a neurologist at the local VA that wanted to moonlight, and we asked her how much, how many patients she saw in a day. And she said seven. And our neurologist said that doesn’t even pay the rent on my building. And so we have real problems there. The concern I have is that we have a system which does great care for the people that can get in, but it can’t do what it needs to. You know, when you fight a war, where you build a military, you should start with what are our threats, what are the things we’re concerned about, and then you build it up from the bottom to be able to deal with that instead of saying to the politicians, where would you like to have a veterans hospital. And that’s a problem. And to transfer that to Obamacare, or to the Affordable Care Act, we are going to probably have all the disadvantages of the VA without any of the advantages.

HH: Wow. Lowell Brown from Arent Fox, your 90 second soapbox?

LB: Well, you know, three comments. First of all, I think it’s important to recognize, as has been said several times today, that there’s a lot of good in the VA. Our family had an experience with them earlier this year when my father in law had his final illness there. I know my way around hospitals, and I was very impressed with the quality of care he received. On top of that, though, second, good policy really is possible. Most people don’t know about the Bennett-Wyden bill, the Healthy Americans Act. It was hated by people on both extremes of the political spectrum, bipartisan. It failed to get the White House’s support, because it wouldn’t include, they wouldn’t include the public option, if you remember that. Of course, that went by the wayside anyway, but that was a good bill, but it never went anywhere. You can have bipartisan approaches to these problems. Last of all, culture, we’ve talked a lot about culture, and I think that there’s a lot to learn about culture from the private health care sector. As is said often in that world, culture is everything. And so whistleblowers, we talked about that. Private hospitals fear whistleblowers, and set up systems to accommodate them and make sure that they are listened to, because the consequences of not listening to them are so extreme. Local hospital boards, we could emulate that in the veterans system. CEO’s are fired, because they don’t please their board. They must meet with them monthly and tell them what they’re doing. And there’s accountability right there. I think the VA could borrow that.

HH: Megan McArdle, I’m going to give you first 45 seconds, and then the start of the second, last segment, so go ahead.

MM: Well, you know, I think that we’ve heard a lot of different arguments about what could be done, but the thing that I think we need to remember is that these are characteristics of how the government works. When you talk about the incentives were wrong, you know, these are the sorts of incentives that the government is equipped to provide. Policy is a very blunt instrument. And so if we want to do deep reform, we may really need to think about going to a more market-oriented solution. And you know, some of the things that Phillip Longman talks about, like the coordination of care, that’s stuff that health systems are doing. I go to a medical practice that has all of my records. All of my doctors are in one building. And there’s a hospital attached. That’s stuff that the private sector can do. And what the private sector can do that the government as a provider can’t do is these sorts of accountability systems and the kind of feedback and control that we lack in the government.

HH: Final thoughts coming up after the break, America.

— – – –

HH: Without saying, it goes without saying that I think if you want information on the VA fixes underway, you would consult with the guests I’ve had on this hour, and I’ve got them all listed at, including their sources. But I’m going to ask them each where do they go? I think you ought to read Best Care Anywhere, you ought to read The Up Side Of Down, you ought to read Mark Flatten’s reporting, and you probably, I don’t know, Tevi, if your new health program thus far at the American Health Policy Institute is putting out anything yet in writing. Is it?

TT: We have not, yet, but we do have a study coming up about the cost per covered life. That is going to cover VA.

HH: All right, so just going around the horn, Megan, where do you send people if they want to get smart on this issue and associated issues?

MM: Oh, my gosh, there are so many great resources. There’s the Washington Monthly, which Phillip Longman has written for. There’s my publication, Bloomberg View. But of course, if you want the ultra-wonky sources, then you go to the Kizer newsletter and to Health Affairs, which are big subscriptions in my household.

HH: Interesting. Very interesting. What do you think, General Rodgers?

LR: I don’t think I have much to add to that. I go to a bunch of collector type blogs on the web that keeps me informed, and then they lead me off into the news.

HH: If you tweet them out, I will follow and let people know. How about you, Lowell Brown? What’s your source for hospital lawyers?

LB: Oh, apart from extremely nerdy health care lawyer publications like the BNA Health Care Affairs and so forth, I read Health Affairs like Megan said. I also read Modern Health Care, which is kind of the People Magazine of the medical/health care world. But it lets you know what people are talking about.

HH: I’ve never heard of that. I’ve never heard, what’s the name of it?

LB: It’s a trade press – Modern Health Care.

HH: Interesting. Phillip Longman?

PL: Yeah, Modern Health Care is doing good work. They’re out of Chicago, and you should be aware of that. They’re the ones that brought all the attention to the Cleveland Clinic’s deficiencies in patient safety.

HH: Oh, are they free to the public? Or can you go online and read it?

PL: You can, they’ve got a paywall, but you get 30 days free access if you give them your email number.

HH: Important 30 days coming up. How about you, Mark Flatten?

MF: Well, of course, everybody needs to be reading the Washington Examiner’s coverage. Aaron Glantz at Center For Investigative Reporting has done some outstanding work looking at the consequences of this. And then a lot of local papers throughout the country have done yeoman’s work exposing some of the scandals locally.

HH: And Tevi Troy, you mentioned, I mentioned your own American Health Policy Institute, But where else?

TT: Well, I would say there’s not enough conservatives writing about this, so there’s a dearth of sources on the conservative side. I am going to read Phillip’s book. It sounds fascinating, and I’ve not yet read it. For general health care, the first thing I read in the morning is Politico’s Pulse, which lists all the key stories of the day.

HH: Thank you all three, all six people, Phillip Longman, author of Best Care Anywhere, Megan McArdle, author of The Up Side Of Down, which is a remarkable book on subjects far and wide, Lowell Brown, my colleague from Arent Fox, Tevi Troy from the American Health Policy Institute, Mark Flatten, senior investigative reporter at the Washington Examiner, and General Lee Rodgers, thank you for your 31 years in the uniform, and for continuing to help us out here on the Hugh Hewitt Show.

End of interview.


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