Last year, several scandals unfolded involving the Veterans Health Administration. Close to home, the Fort Collins VA hospital falsified its wait times for clinic appointments. To meet the VA goal of clinic appointments within 14 days, the hospital instructed its clerks to “cook the books,” falsifying appointment records to give the illusion that the vets were being seen in a timely manner.

Farther away in Phoenix, the local VA hospital had two separate wait lists for clinic appointments and surgeries. One was the public wait list where everyone received timely appointments. The other was a secret wait list where veterans would wait a year or longer for treatment and where at least 40 veterans died waiting for appointments.

The VA system is the largest integrated health care system in the United States. It consists of 150 medical centers, 1,400 outpatient clinics, and 53,000 health care providers. This is a model of “one stop shopping” health care delivery where all providers are employed by the VA and all care is integrated under one umbrella, all at no cost to the patient.

This also represents the “holy grail” of single-payer universal health care championed by presidential candidate Bernie Sanders and President Obama. Are the high costs, confusion, and chaos of Obamacare paving the way for a VA-like system for the entire country?

If so, how are such systems working out elsewhere in the world? First let’s look at the British National Health Service where the government promises specialty care “within a maximum of 18 weeks from referral unless it’s clinically appropriate that you wait longer.” Suppose your headache or double vision is due to a brain tumor rather than a migraine? Or your belly pain is due to cancer rather than acid reflux? That four and a half month delay might mean the difference between life and death. It might be “clinically appropriate” to wait a year or longer for a hip or knee replacement since it’s not a life threatening condition, merely painful and inconvenient.

What happens when the wait list becomes too long? The VA approach is to simply hide the longer wait list and pretend it doesn’t exist. New Zealand took a more direct approach. Their government promised its residents elective surgery within six months of referral. When the wait list grew too long, they simply removed 35,000 patients from the wait list, sending them back to their GP. If the GP could have solved their patient’s problem, they would not have referred them for specialist care at the public hospital. Instead the patient must begin the referral process all over again.

Not mentioned is the obvious alternative, paying out of pocket for care in the parallel private system that exists in both countries. For those with the means to purchase private health insurance or simply write a check, high-quality care is available immediately. But this is not the “universal coverage” that Bernie Sanders is talking about.

The reality is that health care has a finite supply and infinite demand, meaning that some form of rationing will be needed. This is worthy of a societal debate. However care is rationed, there will be winners and losers, some getting all that they need and others being shortchanged.

The question is whether consumers of health care will self-ration based on cost and other market forces or whether our all knowing and benevolent government will decide for us. If the government is the arbiter of who gets what, expect the VA stories to become commonplace.

Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor. This article originally appeared in the Villager.

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