American health care is remarkably diverse. In terms of how care is paid
 for and delivered, many of us effectively live in Canada, some live in 
Switzerland, some live in Britain, and some live in the unregulated 
market of conservative dreams. One result of this diversity is that we 
have plenty of home-grown evidence about what works and what doesn’t. 
  
     
Naturally, then, politicians — Republicans in particular — are 
determined to scrap what works and promote what doesn’t. And that brings
 me to Mitt Romney’s latest really bad idea, unveiled on Veterans Day: 
to partially privatize the Veterans Health Administration (V.H.A.). 
What Mr. Romney and everyone else should know is that the V.H.A. is a 
huge policy success story, which offers important lessons for future 
health reform. 
Many people still have an image of veterans’ health care based on the 
terrible state of the system two decades ago. Under the Clinton 
administration, however, the V.H.A. was overhauled, and achieved a 
remarkable combination of rising quality and successful cost control. 
Multiple surveys have found the V.H.A. providing better care than most 
Americans receive, even as the agency has held cost increases well below
 those facing Medicare and private insurers. Furthermore, the V.H.A. has
 led the way in cost-saving innovation, especially the use of electronic
 medical records.  
What’s behind this success? Crucially, the V.H.A. is an integrated 
system, which provides health care as well as paying for it. So it’s 
free from the perverse incentives created when doctors and hospitals 
profit from expensive tests and procedures, whether or not those 
procedures actually make medical sense. And because V.H.A. patients are 
in it for the long term, the agency has a stronger incentive to invest 
in prevention than private insurers, many of whose customers move on 
after a few years.
        
And yes, this is “socialized medicine” — although some private systems, 
like Kaiser Permanente, share many of the V.H.A.’s virtues. But it works
 — and suggests what it will take to solve the troubles of U.S. health 
care more broadly.        
Yet Mr. Romney believes that giving veterans vouchers to spend on 
private insurance would somehow yield better results. Why?        
Well, Republicans have a thing about vouchers. Earlier this year 
Representative Paul Ryan famously introduced a plan to convert Medicare 
into a voucher system; Mr. Romney’s Medicare proposal follows similar 
lines. The claim, always, is the one Mr. Romney made last week, that 
“private sector competition” would lower costs. 
But we have a lot of evidence about how private-sector competition in 
health insurance works, and it’s not favorable. The individual insurance
 market, which comes closest to the conservative ideal of free 
competition, has huge administrative costs and has no demonstrated 
ability to reduce other costs. Medicare Advantage, which allows Medicare
 beneficiaries to buy private insurance instead of having Medicare pay 
bills directly, has consistently had higher costs than the traditional 
program.        
And the international evidence accords with U.S. experience. The most 
efficient health care systems are integrated systems like the V.H.A.; 
next best are single-payer systems like Medicare; the more privatized 
the system, the worse it performs. 
To be fair to Mr. Romney, he takes a somewhat softer line than others in
 his party, suggesting that the existing V.H.A. system would remain 
available and that traditional Medicare would remain an option. In 
practice, however, partial privatization would almost surely undermine 
the public side of these programs. For example, one problem with the 
V.H.A. is that its hospitals are spread too thinly across the nation; 
this problem would become worse if a substantial number of veterans were
 encouraged to opt out of the system. 
So what lies behind the Republican obsession with privatization and 
voucherization? Ideology, of course. It’s literally a fundamental 
article of faith in the G.O.P. that the private sector is always better 
than the government, and no amount of evidence can shake that credo. 
In fact, it’s hard to avoid the sense that Republicans are especially 
eager to dismantle government programs that act as living demonstrations
 that their ideology is wrong. Bloated military budgets don’t bother 
them much — Mr. Romney has pledged to reverse President Obama’s defense 
cuts, despite the fact that no such cuts have actually taken place. But 
successful programs like veterans’ health, Social Security and Medicare 
are in the crosshairs. 
 
Which brings me to a final thought: maybe all this amounts to a case for
 Rick Perry. Any Republican would, if elected president, set out to 
undermine precisely those government programs that work best. But Mr. 
Perry might not remember which programs he was supposed to destroy. 
~~~~~~~~~~~~~~~~~~
 
After posting this I checked my e-mail and found this entry from Rob Zerban, running for Congress in Wisconsin.  
He quoted Paul Krugman from another article.  It fits this post so I am adding it.
~~~~~~~~~~~~~~~~~~~~ 
Paul  Krugman made a
 great point recently about politicians like Paul Ryan. Whether it is 
trickle down economics or Bush tax  cuts, they think their theories are 
the same as facts.
 
[Paul
 Krugman said: "Criticism of policy proposals is not the same  thing as 
an ad hominem attack. If I say Paul Ryan's mother was a hamster  and his
 father smelt of elderberries, that's ad hominem. If I say that  his 
plan would hurt millions of people and that he's not being honest  about
 the numbers, that's harsh, but it's not ad hominem."
What he is talking about is why we have such gridlock in Washington. We cannot reach any agreements by debating anymore because Republicans refuse to accept any facts.
~~~~~~~~~~~~~~~~~~~~~