As a young military medical officer after medical school, I began my career when money flowed freely to the military health care system. The Viet Nam war was over for some time, but veterans were still plentiful from that conflict. There were many more bases open then since the downsizing movement had not started. We had very busy ward teams: three medicine teams of one resident and four interns, caring for about twenty to thirty patients each. Pathologies of all types were Medivac'd to our center all all hours of the day. The call team would see them and get each admitted, even late at night. Sleep came infrequently then. In short: it was hoppin'.
But over time, things changed.
It is interesting for me to recall my experience in the Navy as I ponder the implications of our push toward government-run health care. I mean, given my relatively positive experience with military health care, why would anyone want to leave such a system?
It certainly was not the people.
But after extensive years of training, it was clear that military doctors were significantly underpaid relative to our civilian counterparts. This is not to say that we did not fare well earlier in our training - we certainly did, making twice what the indentured servants of civilian residencies earn. But the lure of greener civilian medical pastures was a powerful incentive to leave the military, especially for specialists like myself.
Second, was what I called the Three O'clock Syndrome. Go to any military base in America and watch the stream of cars leave that base at 3PM every weekday. Three O'clock Syndrome. On military bases, most people are salaried. Overtime does not exist. People punched their ticket, did their job, then got the hell out of there. Best of luck to you if you needed something done after 3PM. Better to wait until the next morning.
Third, it was incredibly hard to remove non-military non-performers. The Human Resource rules regarding civil service employees were incredible. If you think unions are bad, think again. Civil service employees have even more safeguards to maintain their status quo. If you had a secretary that insisted that there were six digits in a phone number when you knew otherwise and wanted to fire him or her - best of luck. It wasn't going to happen. In the private sector - you don't perform, you're gone. With minor provisions, certainly. But gone.
Fourth, our entire military medical operation was beholden to Congress. If the money was too great, the system downsized. Considerably. That is how cost-savings occurs in the government. Witness the great military base/hospital shuttering that began in 1988 called the Base Realignment and Closure Act and was reinforced further in 2005. As would have it, military members (be they active duty or retired), often turned to civilian facilities for their care, and the inpatient military hospital patient census rapidly dwindled. ICU isolation rooms became nurses offices. As a doctor who knew things as they were, this was not a model that instilled a lot of confidence in the system of care for our military members and their retirees. Not that there aren't extremely capable people supporting our troops - there are - but the gradual deterioration of operations was obvious to those of us who had been there in more robust times. Finally, no matter how hard they tried to retain and recruit their doctors with "specialty bonuses" and "critical care bonuses," the military never seemed to be able to fill their demand for doctors.
I reflect on these experiences not to criticize the military health care system, but rather to offer a perspective of the real challenges we can expect as government bureaucracies take over the business of health care:
Outsourcing - this will occur when government facilities are filled to capacity. Look for private pay or secondary private insurers to pick up the slack - at considerable direct cost to the patient.Thankfully for me, I've been there before. For those not familiar with government bureaucracies to this magnitude, prepare to strap in. The adjustment will be harder for some than others. But one thing's for sure, it's coming. And if you would permit me one piece of advise I can impart that saved my butt more than once in the military, it would be this:
Shift work - Employees without economic incentives have little motivation to stay late, follow-through. Look for "hand-offs" of clinical care to accelerate. Continuity of care will occur by computer, rather than interpersonal connection.
Unionized workers - what other chance will workers have for bargaining against the government bureaucracy? Lone wolfs will simply not be heard.
Limitations to access - doctors will increasingly challenging to recruit. Facilities will be "reconfigured" and closed to save costs. As such, there will likely be increasingly long waits for care. But care will be available - really it will.
Equipment will still be state-of-the-art: after all, there will always be government contracts for which the private sector will continue to compete and schmooze members of Congress to fulfill. The equipment for the active duty military (though not always the VA hospitals I frequented), at least, was usually exceptional. It was finding the staff to run the equipment that was the problem. Look for this trend to continue.
Be sure to xerox everything you sign and keep a copy.
Because rest assured, the bureaucracy will lose it.