Whether you are a veteran of not, the recent report of waiting lists, and possibly preventable deaths of veterans, has implications for all citizens. There is no large health system which functions perfectly. But I would say that the efficiency of any given system is inversely related to its size. If this is true, then the VA health system is, and has always been, a bureaucratic and wasteful mess. Like most physicians trained in this country, I rotated through many VA hospitals, from Cleveland, to San Diego to Houston.

Many veterans receive important and good care at these facilities. However, many are shorted good care not for lack of funding, but due to layers upon layers of bureaucratic rules, regulations, and officials. Long before there were diagnostic-related groups, or DRGs, for private hospitals, the VA health system was famous for extraordinarily long lengths of stay. So long in fact, that when I was a house officer at the La Jolla VA outside San Diego, we had our own admitting diagnosis: IFTW, (in for the winter). Veterans got admitted for something, and stayed hospitalized for months.

Now the pendulum has swung to the other extreme and patients have a hard time getting admitted and staying long enough to be stabilized.  (This is not unique to the VA system and affects private medicine as well.) I have recent first-hand experience with this.  A friend of mine, who is a Vietnam War veteran, had to wait nine months for hernia surgery. Admittedly this is not a lethal condition but the story of my father-in-law was. A wounded WWII veteran, he was an insulin-dependent diabetic for over 30 years. He had already lost one leg due to the disease. In his eighties, his diabetes became increasingly brittle. It was not uncommon for the ambulance to appear several times a week at his assisted living facility, for symptomatic blood sugars of 50 to over 500. He was repeatedly “stabilized” in the local VA ER, and then sent home. Finally, I told my wife to tell the ER staff that she was not leaving the ER, unless her dad was admitted. That worked — at least for three days.

His blood sugar was no better after discharge and two days later EMS was again summoned to his residence for hypoglycemia and syncope. He was readmitted and at this point I intervened. I spent over 30 minutes on the phone arguing with a hospitalist about how he needed an endocrinology consult before discharge. Ultimately she relented. Later I found out that his clinic endocrinologist did not even see him, but only an endocrinology PA visited and did a consult prior to discharge.

I called his doctor and asked about an insulin pump. I was told he was too old. Later at a nursing home his other leg developed gangrene and he refused more surgery. He and the family chose hospice care, where he quickly died.  I have often wondered if his last few years would have been different in a private hospital.

I doubt that ACA will make this any better for non-veteran patients. Simply insuring millions of patients with a Medicaid-like product does not guarantee access to care. In fact, a recent survey of thousands of doctors estimates a least one-half will not accept patients in the future with Medicaid or ACA-related insurance. Wait times for potentially life saving care will become the norm and unnecessary deaths a reality.

Do I believe that there were secret wait-lists at VA hospitals? I’m not sure, but I wouldn’t be surprised. Surely Washington administrators and executives had to have known. And if they did not, then they should be fired. In fact, I have longed argued that the government could save billions, and veterans could receive better care, by simply giving health insurance vouchers for their care in the private system, instead of a VA hospital or clinic. Do I think this will ever happen? No.

It is unrealistic to expect a monumental bureaucracy like the VA to deliver timely and efficient medical care routinely. It is laden with career government employees who sadly care more about their jobs than good care for our veterans. At the bottom are wonderful and giving nurses and other staff, but at the top are people whose only goal is to preserve the status quo and keep their job until retirement and secure a government pension. Efficient care is an anathema to such a system.

I predict we are headed for a two-tiered system of health care in our country: those who wait for care, and those who don’t. And in this respect, what happens in the VA health system has implications for all of us.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.