ImageI’ve been on my Internal Medicine rotation at the local Veterans Association (VA) hospital. I’ve really enjoyed it – the Veterans are almost all super appreciative, friendly people and make great patients to learn from. They’re used to medical students and mostly don’t mind our repetitive and lengthy interviews and exams. In fact, many seem to enjoy being part of future doctors’ educations and often wish me good luck after I see them. Maybe it’s the culture of service and commitment to their country that the Veterans really seem to take to heart (despite the shady deeds of the US military in the name of “protecting” Americans but in reality pushing imperialism and exploiting other less powerful countries – but that’s way beyond the scope of this post!) One Veteran told me the other day, “The VA is a great place to learn! You’re going to see some really sick patients!” As morbid as that sounds, it’s true. The patients at the VA seem to have a disproportionate amount of medical complications and coexisting conditions that are generally highly predominant in the working class (and, well, all of the developed world)– COPD, heart failure, obesity, diabetes, often all at the same time. I’ve found them to be extremely trusting of and grateful to physicians and even medical students. Like many patients with complicated medical conditions affecting multiple organs, they can be shuffled from specialist to specialist. They sometimes will start explaining a medical problem only to be told by that particular doctor that they are there to manage only a certain organ system. I’ve seen them often leave appearing pretty frustrated and confused.

I feel compassion for all patients I see, but I find myself feeling extra protective towards the VA patients. They require much care and coordination and it’s no surprise the VA is an expensive system. It highlights the importance of a large, motivated, talented primary care workforce and having a single competent person overseeing the care and referral to specialists. Yet, our American healthcare system rewards specialists with more money and prestige.

Often, I’ve heard residents and fellows talk about how inefficient the VA is and how much better private hospitals are. I’m not exactly sure what experience they have with those hospitals as the other training hospital for the program is a large public tertiary care center, taking on a ton of disproportionately uninsured patients. If you qualify for the VA and choose to use this service (as I understand it, Veterans can also choose to be privately insured through a job or otherwise), you have to use only VA facilities and doctors unless the technology isn’t available at the VA, in which case they will refer you to a place that has the appropriate services. Some of the patients end up traveling hours to get to the clinic. I can’t help but think this problem would be solved if the veterans’ care extended to any hospital or doctor. If we had single payer, national health insurance.

This past Friday, the day I leave for the Students for a National Health Program summit, we had a Grand Rounds presentation from a senior staff attending about the ACA and Medicaid in Virginia! For the most part, the presentation was mostly numbers about how coverage in Virginia would change if Medicaid expansion was implemented and the state of Medicaid in Virginia. It seemed pretty nonpartisan until he began to use buzz words like “large government program” and it started to become clearer which team he was batting for. When he mentioned Delegate John O’Bannon’s position on the panel involved in deciding whether and under what conditions Medicaid expansion will occur in Virginia, it seemed pretty apparent. He said that Virginia was set to become one of the states that did not accept Medicaid expansion until “the Left” colluded to put the transportation bill in jeopardy. He did not mention how an independent economic study determined that Medicaid expansion would cost less than not expanding it, which I’ve written about in previous posts. He also didn’t mention the terms of the Medicaid expansion. I was feeling pretty irritated. I’m in a pretty vulnerable position though, since I’m interested in going into general Internal Medicine, it’s to my advantage to not do anything that would negatively stand out and might result in a bad evaluation. No one wants to hear a med student get ornery during Grand Rounds when people by and large just want to get on with their day.

But the temptation was too much. After the presentation, I couldn’t pass up the opportunity to ask a single question which I attempted to frame as diplomatically and non-confrontationally as possible. “One of the criticisms I’ve heard about Medicare and Medicaid is that as soon as they are contracted out to private insurance companies, they become more expensive. What’s going to happen with the Virginia Medicaid expansion – will it get contracted to private companies and will it become more costly then too?” He replied that whether it was more expensive was a matter of some debate (it’s not), and that the commission was trying to make certain that every person’s Medicaid was contracted out to private insurance, and that would be a very good thing. He did not elaborate why, and I didn’t think it wise to keep pressing him.


a sampling of privatized Medicare logos

 A few minutes later, as I was reviewing charts for the morning, one of the attendings in the presenter’s own department (and an attending that I had worked with!) came to the exam room I was working in and told me he thought the presenter should have included some information about Medicare Advantage (the version of Medicare that’s contracted to private insurance companies) to the presentation. He said it was proven that Medicare Advantage cost more than traditional Medicare and didn’t have any proven better outcomes, which is true. He then gestured around and said “For all the imperfections of a single payer system, it’s what we need.” Comrades! Sometimes taking a tiny risk and speaking out helps people reach out to you. I just wish he had given the Grand Rounds.

It bears mentioning how harmful it is to present biased and only partially accurate but incomplete information to groups of physicians. A senior attending is a trusted source of material, and doctors are often too busy to do primary research about every issue. Grand Rounds exists to educate with facts, not half-truths. It was an informative and well-researched presentation in many ways that happened to conveniently neglect some key data.

 When reading info about the superiority of single payer over existing systems, I am often struck by how obvious of a solution it becomes from all angles – reduction in bureaucracy, centralization of records, marketing power to bring down pharmaceutical and medical device costs, thus providing incentive for pharmaceutical companies to develop truly innovative drugs instead of  “me-too” substitutions that are guaranteed to make money, just to name a few. And when one simply steps back, how much sense could it ever make to rely on companies whose main goal is to produce profit for shareholders to reduce healthcare costs? It’s a fundamental conflict of interest. Yet, in the face of presentations like today which I’m sure are a common occurrence, physicians are given biased views and told about the bloated, complicated Medicaid system that covers millions of US citizens and costs taxpayers billions of dollars (with a special emphasis on the low provider reimbursement rates) without explaining how much more inefficient and wasteful private insurance is.

We have much work ahead of us and much misinformation to put to rest, but every day the road becomes a little clearer and the facts speak more loudly for themselves.