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Depending on the poll question and sample size, single-payer has received on average about 30% — 60% U.S. support…Kaiser Family Foundation (5/13–5/18): 57% favorBusiness Insider (3/13–3/14): 49% favorQuinnipiac (11/21–11/25): 36% favorThe Economist/YouGov (9/14–9/17): 45% favorCBS News (8/28–9/4): 57% favorRealClearOpinion (4/30–5/5): 55% favorAnd according to the Washington Post, a majority of House Democrats now support Medicare for All.No matter how we slice it there’s a sizable chunk of the American electorate, especially among Democrats, who support single-payer healthcare.And so if this policy is so popular among Democrats then why hasn’t it been implemented by at least one Democrat-majority state, such as California, New York, Massachusetts, or Vermont?For one, the problem with state-based single-payer healthcare is the federal government already plays a major role in providing and regulating the industry. About 17% of Americans are on Medicare, which is a federal health insurance program, but a state can work around that by filling the gap, i.e. people under 65 who aren’t disabled would be put into the state-based version.We also know a state-based single-payer can be done because it has already been done!In 2011, Vermont signed into law the first state-based single-payer healthcare system. The signing of H. 202 led to the creation of Green Mountain Care, which was described by Kaiser Health News as “a state-funded-and-managed insurance pool that would provide near-universal coverage to residents with the expectation that it would reduce health care spending.” Vermont Governor Shumlin described the plan as “a single-payer system” that he believed “will control health care costs, not just by cutting fees to doctors and hospitals, but by fundamentally changing the state’s health care system.” Vermont Representative Larson described Green Mountain Care’s provisions as “as close as we can get [to single-payer] at the state level.”But in 2014 with all the roadwork laid, the governor saw what was up ahead and decided to turn back…“Calling it the biggest disappointment of his career, Gov. Peter Shumlin said Wednesday he was abandoning plans to make Vermont the first state in the country with a universal, publicly funded health care system.Going forward with a project four years in the making would require tax increases too big for the state to absorb, Shumlin said. The measure had been the centerpiece of the Democratic governor’s agenda and was watched and rooted for by single-payer health care supporters around the country.”According to Shumlin, the plan would have required an 11.5% payroll tax and a 9.5% income tax increase. Shumlin was particularly concerned about Vermont’s small businesses going bankrupt.Putting economics aside, it’s also understandable from a political perspective why governor Shumlin threw in the surgical mask because, despite the fact Vermont consistently ranks in the top 10 most-Democratic states, Shumlin almost lost reelection to a Republican mainly on the basis of his support for single-payer in what turned out to be the closest gubernatorial election in modern Vermont history with Shumlin getting 46.4% to Milne’s 45.1%. Governor Shumlin abandoned single-payer a month later.Other states have also come close to single-payer.California passed “The California Universal Healthcare Act” in 2006 and in 2008. Both times, Governor Arnold Schwarzenegger vetoed the bill (or should I say terminated ;). In 2019, Governor Gavin Newsom appointed a commission to study the feasibility of adopting a single-payer system in the state.Colorado through a citizen-initiated constitutional amendment proposal put a state-based single-payer proposal directly on the ballot, but it was rejected by 79% of voters.Hawaii got close to a state-based single-payer healthcare system. In 2009, its legislature passed a single-payer bill, which was vetoed by Republican Governor Linda Lingle. Lawmakers overrode the veto, but Lindle refused to appoint members or release funds. She was succeeded by a Democrat who then appointed members, but ultimately decided to abandon single-payer when talks turned toward dumping private insurance.The New York State Assembly passed a state-based single-payer health plan four times: 1992, 2015, 2016, and 2017, but it has never advanced through the New York State Senate.Ultimately, state-based single-payer hasn’t been implemented because voters haven’t been enthusiastic enough about it, the business community adamantly opposes it, and politicians are risk-adverse so when Democrats don’t have the power to implement it they are more likely to vote for it, i.e. U.S. House of Representatives, California, Hawaii, New York, because their vote will play well with their base, but then when they finally do have the power to implement it, .i.e. California, Hawaii, New York they don’t put it up for a vote.For example, as soon as Democrats took the New York State Senate in 2018, The Nation wrote,“A number of new or re-elected state senators, faced with the fresh possibility that single-payer might actually become a reality, have walked back their formerly full-throated support.”Much like Governor Newsom, Governor Cuomo has proposed a commission to “look into it,” but perhaps someone should have looked into it before it was passed in the state assembly with broad Democrat support in the previous four legislative sessions.Many Democratic politicians want to be seen as progressive fighters by doing everything up until implementation, i.e. passing a bill out of committee or chamber, forming a commission to look into it, and even signing it into law. But then when it requires some unpopular moves such as eliminating private insurance or raising taxes they have thus far always backed down because they’re afraid of a repeat of 2010 when Democrats lost power after the passage of Obamacare.Overall, dark blue states' inability to implement single-payer should give Medicare-for-All’s supporters pause because, for example, if such a homogenous, Democratic, and small state as Vermont can’t implement a functional single-payer system then what hope is there for the much larger and more ideologically divided federal government to do so efficiently? As Scott Adams said, “Ideas are worthless, execution is everything.”Since Vermont’s near-miss at single-payer, the country has become much more polarized on the issue where Republicans support it less and less and Democrats support it more and more. The silver lining to this polarization is maybe Democrats and Republicans could agree to let the other be. You do you!And then if single-payer health insurance does as its supporters contend, i.e. lower costs and increase quality, in states like Vermont, New York, and California then other states would choose to follow suit. Over time, this enthusiasm could spill over into a louder, bipartisan demand for a national single-payer system, but then at that point, many Americans may prefer to “keep their plan.”

Q. What is the particular line of study for a psychiatrist?A.Psychiatrist Education Requirements, Prerequisites and Career InfoCombined Residency ProgramsInternal Medicine/PsychiatryFamily Medicine/PsychiatryPediatric/Psychiatry/Child PsychiatryNeurology/PsychiatryPsychiatrist Education Requirements, Prerequisites and Career InfoA career as a psychiatrist can be highly rewarding; however, an extensive educational background will first be required. Once you have graduated from medical school, internships and residency training must be completed and board exams passed before one can be licensed as a board-certified psychiatrist.Essential InformationPsychiatrists are doctors who address their patients' mental and emotional health care needs. They may work in a hospital setting or private practice. Practicing psychiatrists have completed medical school as well as a supervised internship and residency. They must also be licensed and certified in order to practice their work.Required EducationMD or DO degree; internship; residency in psychiatryAdditional RequirementsState medical license; ABPN certificationProjected Job Growth* (2014-2024)15% for psychiatristsMedian Salary* (2014)$245,673 annual salary for psychiatristsSource: *U.S. Bureau of Labor Statistics (BLS)Education Requirements for a PsychiatristAs undergraduate students, many future psychiatrists earn a bachelor's degree in biology or psychology. These 4-year degree programs provide the basis for future studies in medical areas. Students planning to enter graduate medical programs should strive for a high GPA. Common courses include:BiologyPhysicsChemistryAdvanced mathematicsThe Medical College Admission TestAll students who seek to enter medical school must pass the Medical College Admission Test (MCAT). The Association of American Medical Colleges puts together this standardized test for potential medical school applicants. The test provides four separate scores for the various reading, writing and multiple-choice questions. Scoring well on the MCAT is helpful in determining a student's potential entry into the best programs.Doctor of Medicine and Medical ResidencyAspiring psychiatrists must complete four years of medical school where they take classes on histology, human anatomy, immunology and pharmacology. After medical school, graduates complete a residency program, in which they receive training in mental health care by working directly with patients in clinics and hospitals. Under the supervision of licensed doctors, residents diagnose patient illnesses and create treatment plans.LicensurePsychiatrists must hold medical licenses from the state in which they practice. To become licensed, students must pass a multi-step exam that begins during medical school. People earning the M.D. degree (Doctor of Medicine) take the U.S. Medical Licensing Examination, or USMLE. Students earning the D.O. degree (Doctor of Osteopathic Medicine) take the COMLEX (Comprehensive Osteopathic Medical Licensing Examination), a similar multi-part test. Either type of medical degree may lead to a career as a psychiatrist.Licensed psychiatrists are periodically required to renew their licenses by their state board of medicine. Requirements for renewal may include completing continuing medical education coursework. Psychiatrists may check with their state board for more specific information.CertificationPsychiatrists must obtain certification from the American Board of Psychiatry and Neurology (ABPN) in order to legally practice. All psychiatry certification candidates need a medical license. Board certification shows patients and employers that the psychiatrist has appropriate knowledge from their completed specialty-specific training. The certification verifies this competence. The ABPN also offers subspecialty certifications in:Addiction psychiatryAdolescent and child psychiatryPain medicineSleep medicineForensic psychiatryCareer InformationOf the more than 28,200 psychiatrists employed in 2014, most worked in a doctor's office, psychiatric care hospital or substance abuse hospital, according to the U.S. Bureau of Labor Statistics (BLS). In the same year, the BLS reported that psychiatrists averaged $245,673 annually. Aside from outpatient care, some psychiatrists conduct research and publish their findings in medical journals. Psychiatrists may also give lectures at national psychiatry and medical conferences or go into academia where they conduct research and teach. The BLS predicts 15% growth in employment opportunities for psychiatrists between 2014 and 2024, which is faster than the national average for all occupations.Psychiatrists are required to complete four years of undergraduate school, four years of medical school, and a further three to seven years of internship and specialized residency training. Once complete, many psychiatrists open private practices and work to help people in emotional or mental crisis.Internal Medicine / Psychiatry PoliciesThe Association of Medicine and PsychiatryResidency ProgramsPsychiatry Combined Training PoliciesInternal Medicine / Psychiatry Policy OverviewThe American Board of Internal Medicine and the American Board of Psychiatry and Neurology offer dual certification in internal medicine and psychiatry. A combined residency must include at least five years of coherent education integral to residencies in the two disciplines. Participating residencies must be in the same institution.To meet eligibility requirements for dual certification, the resident must satisfactorily complete 60 months of combined education, which must be verified by the directors of both programs. The written certifying examinations cannot be taken until all required years in both specialties are satisfactorily completed.Charleston Area Medical Center/West Virginia Universityhttp://camc.wvu.edu/internal/psychiatry/index.htmProgram Director: James Griffith, MDEmail: [email protected] MacCorkle Ave, SECharleston, WV 25304Phone: 304-388-1000Fax: 304-388-1021Coordinator: Misty Hodel, [email protected] University Medical Centerhttp://education.psychiatry.duke.edu/training-programs/combinedProgram Director: Sarah Rivelli, MDEmail: [email protected] 3182Durham, NC 27710Phone: 919-684-2258Fax: 919-681-6448Coordinator: Lynsey Michnowicz, [email protected] Universityhttp://www.psychiatry.emory.edu/education/combined_residency/index.htmlProgram Director: Kellie, Clearo, MD and Ray Young, MDEmail: [email protected]; [email protected] Jesse Hill Jr Drive SEFaculty Office Building, 4th FloorAtlanta, GA 30303Phone: 404-778-1624Fax: 404-525-2957Coordinator: Danielle Terrell, [email protected] University of South Carolinahttp://academicdepartments.musc.edu/psychiatry/education/res_fell/psy_med/psy_med.htmProgram Director: Kelly Barth, MD67 President St, MSC 861Charleston, SC 29425Phone: 843-792-0192Fax: 843-792-6894Program Manager: Liz Puca, [email protected] Capital Consortium ProgramWalter Reed National Military Medical CenterThis residency program is only offered to Army applicantshttp://www.wrnmmc.capmed.mil/ResearchEducation/GME/SitePages/InternalMedicine/Psychiatry/Residency.aspxProgram Director: Vincent Capaldi, II, MDEmail: [email protected] Wisconsin AveBethesda, MD 20889-5000Phone: 301-400-1924Fax: 301-400-2150Coordinator: John Obie, [email protected] Illinois Universityhttp://www.siumed.edu/medpsy/Program Director: Andrew Varney, MDEmail: [email protected] N 1st StreetPO Box 19636Springfield, IL 62794Phone: 217-545-0193Fax: 217-545-8156Coordinator: Catherine Brower, [email protected] Tech Universityhttp://elpaso.ttuhsc.edu/som/im-psych/Program Director: Aghaegbulam Uga, MD, FWACPEmail: [email protected] El Paso DriveEl Paso, TX 79905Phone: 915-215-5880Fax: 915-545-6442Tulane Universityhttp://tulane.edu/som/departments/psychiatry/education/CombinedMedPsyc/combined-med-psychiatry.cfmProgram Director: Mary Beth Alvarez, MDEmail: [email protected] Canal StreetNew Orleans, LA 70112Phone: 504-988-5246Fax: 504-988-4270Coordinator: Latonya Guice, [email protected] of California Davishttp://www.ucdmc.ucdavis.edu/psychiatry/residency/medpsych/Program Director: Robert McCarron, DOEmail: [email protected] Stockton BoulevardSacramento, CA 95817Phone: 916-734-2733Fax: 916-734-3384Coordinator: Morgan Luthi, [email protected] of Iowahttps://www.uihealthcare.org/medpsychresidency/Program Director: Vicki Kijewski, MDEmail: [email protected] Hawkins Dr E330-2 GHIowa City, IA 52242Phone: 319-356-1373Fax: 319-356-2587Coordinator: Stephanie Wainwright, [email protected] of Kansashttp://www.kumc.edu/school-of-medicine/psychiatry-and-behavioral-sciences/residency-training-programs/internal-medicinepsychiatry.htmlProgram Director: Teresa Long, MDEmail: [email protected] Rainbow Blvd, MS 4015Kansas City, KS 66160Phone: 913-588-6412Fax: 913-588-6414Coordinator: Stacy Buckley, [email protected] Medical Center/East Carolina University at the Brody School of Medicinehttp://www.ecu.edu/cs-dhs/psychiatry/combinedRes.cfm?modProgram Director: Michael Lang, MDEmail: [email protected] Johns Hopkins DrGreenville, NC 27834Phone: 252-744-1406Fax: 252-744-2419Coordinator: Scarlette Stovall, [email protected] Medicine/PsychiatryUniversity of California Davishttp://www.ucdmc.ucdavis.edu/psychiatry/residency/combfam/Program Director: Jaesu Han, MDEmail: [email protected] Stockton BoulevardSacramento, CA 95817Phone: 916-734-2614Fax: 916-734-3384University of California San Diegohttp://www.combinedresidency.org/Program Director: Kurt Lindeman, MD200 West Arbor Drive, Mail code 8809San Diego, CA 92103-8809Phone: 619-233-8500, ext 1402Fax: 619-687-1067Coordinator: Ruben Figueroa, [email protected] of Cincinnati Medical Centerhttp://www.psychiatry.uc.edu/Education/residency/about/about.aspxProgram Director: Lawson Wulsin, MDPO Box 670559Cincinnati, OH 45267-0559Phone: 513-558-5190Fax: 513-558-3477Coordinator: Susan Scholl, [email protected] of Iowahttp://www.uihealthcare.org/fampsychresidency/Program Director: Alison Lynch, MDEmail: [email protected] Hawkins DrIowa City, IA 52242Phone: 319-356-1373Fax: 319-356-2587Coordinator: Stephanie Wainwright, [email protected] of Pittsburgh (UPMC)http://www.psychiatry.pitt.edu/node/1365Program Director: Michael Travis, MD3811 O’Hara StPittsburgh, PA 15213Phone: 412-246-5320Fax: 412-246-5335Coordinator: Kimberly Kirchner, [email protected]/Psychiatry/Child PsychiatryBrown UniversityRhode Island Hospitalhttp://www.brown.edu/academics/medical/about/departments/psychiatry-and-human-behavior/training/child/triple-board-residencyProgram Director: Jeffrey Hunt, MDEmail: [email protected] Eddy StProvidence, RI 02903Phone: 401-444-3762Fax: 401-444-8879Coordinator: Marsha Spirito, [email protected] Children’s Hospital/University of Cincinnatihttp://www.cincinnatichildrens.org/education/clinical/specialty/triple/default/Program Director: Carol Engel, MDEmail: [email protected] Burnet AvenueCincinnati, OH 45229Phone: 513-636-1837Fax: 513-803-0571Coordinator: Kristin Holhubner, [email protected] School of Medicine at Mount Sinaihttp://icahn.mssm.edu/departments-and-institutes/psychiatry/educational-programs/triple-board-residencyProgram Director: Barbara Coffey, MD; John O’Brien, MDEmail: [email protected]; john.o’[email protected] 1230, One Gustave L Levy PlNew York, NY 10029Phone: 212-659-8838Fax: 212-996-8931Coordinator: Rebecca Segal, [email protected] University School of Medicinehttp://psychiatry.medicine.iu.edu/education-residency-programs/triple-board-residency/Program Director: David Dunn, MD702 Barnhill Dr, Suite 4300Indianapolis, IN 46202Phone: 317-963-7307Fax: 317-963-7325Coordinator: Jeanette Souder, [email protected] Medical Centerhttps://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Psychiatry/Training-Education/Triple-Board-Training.aspxProgram Director: John Sargent, MDEmail: [email protected] Washington StreetBoston, MA 02111Phone: 617-636-1636Fax: 617-636-1277Coordinator: Mikayla Gregorio, [email protected] Universityhttp://tulane.edu/som/departments/pediatrics/residency-program/triple-board/triple-index.cfmProgram Director: Myo Thwin Myint, MDEmail: [email protected] Tulane Avenue #8055New Orleans, LA 70112Phone: 504-988-7829Fax: 504-988-4264Coordinator: Linzi Conners, [email protected] of Hawaiihttp://www.hawaiiresidency.org/psychiatry-residency/about-the-triple-board-programProgram Director: Anthony Guerrero, MDEmail: [email protected] Lusitana StHonolulu, HI 96813Phone: 808-586-7445Fax: 808-586-2940Coordinator: Dana Iida, [email protected] of Kentuckyhttp://psychiatry.med.uky.edu/triple-board-residencyProgram Director: Robert Simon, MD245 Fountain CourtLexington, KY 40509Phone: 859-323-6866Fax: 859-323-4927Coordinator: Crystal Stover, [email protected] of Pittsburgh (UPMC)http://www.psychiatry.pitt.edu/node/294Program Director: Sansea Jacobson, MDEmail: [email protected] O’Hara StPittsburgh, PA 15213Phone: 412-246-5320University of Utahhttp://medicine.utah.edu/psychiatry/triple-board-program/Program Director: Douglas Gray, MDEmail: [email protected] S Komas DrSalt Lake City, UT 84108Phone: 801-581-3936Fax: 801-585-9096Coordinator: Glenda Evans, [email protected]/PsychiatryBrown Universityhttp://med.brown.edu/neurology/neuropsychiatry-residencyProgram Director: W. Curt LaFrance, MDEmail: [email protected] Blackstone BlvdProvidence, RI 02906Phone: 401-444-6183Fax: 401-444-3298Coordinator: Neelum Wong, [email protected] University of South Carolinahttp://academicdepartments.musc.edu/psychiatry/education/res_fell/psy_neur/psy_neur.htmProgram Director: Edward Kantor, MDEmail: [email protected] President St, MSC 861Charleston, SC 29425Phone: 843-792-0192Fax: 843-792-6894Program Manager: Liz Puca, [email protected] York University School of Medicinehttp://www.med.nyu.edu/psych/education/residency-training/combined-psychiatryneurology-programProgram Director: Siddhartha Nadkarni, MDEmail: [email protected] Park AveNew York, NY 10016Phone: 646-754-4838Fax: 646-754-5431Coordinator: Barbara Dartley, [email protected] of Massachusettshttp://www.umassmed.edu/neuropsychiatry/programs/residency/Program Director: Sheldon Benjamin, MDEmail: [email protected] Lake Ave NWorcester, MA 01655Phone: 508-856-4087Fax: 508-856-5000Coordinator: Vickie White, [email protected]

There are so many roads to go down in answering this question, none of them satisfactory. But, let’s follow two or three to see if something of value can be found. There is a qualifier here, and that is we have to understand the “they” in your question. “They” is not the White House. “They” is Congress, the ultimate board of directors for all things federal. The White House may lobby aggressively for privatization (though the Trump White House is backing off on that pledge), but in the end, dumping a Cabinet department—one of the very largest, with 150+ hospitals, hundreds of clinics, mobile clinics, VetCenters, and specialty care centers vital to the treatment and rehabilitation of wounded warriors—would come with massive congressional input and pushback, given that every state, and probably every voting district in the U.S. is linked in some way to veterans.Former Congressman John Linder (R-GA), a Vietnam-era veteran writing for The Hill this past January, made an oft-repeated, and undeniably passionate, personal, and compelling case for privatizing VA: “The VA should first commit to shortening the long lines waiting for the determination of eligibility for VA medical care. The government’s role in veterans’ care should then be focused entirely on matters that are the result of war. Traumatic brain injury, amputations, post-traumatic stress and the rehabilitation from those injuries are unique and special, and we should dedicate the entire medical resources of our government toward improving the lives of the wounded and their families.“Medicare needs reform as to reimbursement formulas and regulatory burdens,” Linder continued, “but it is the most patient-centric of all of our government healthcare programs. VA eligible vets should be enrolled in Medicare and allowed to make their own healthcare decisions. If that is privatizing VA healthcare, this old vet is for it.”Linder’s argument has a populist foundation—and, frankly, a pretty reasonable one if you’re the veteran or veteran family member in this situation—and that is there are many aging veterans (WW II are dying at the rate of 400 per day), and Cold War and Vietnam vets who aren’t far behind them who don’t enjoy urban or even suburban access to a VA hospital or clinic. There are many younger veterans suffering from traumatic brain injuries (TBI) or amputations or who are para- or quadriplegics for whom local access to VA specialized care is simply not an option—they have to look locally for care.Privatizing advocates in Congress, with Senator Bernie Sanders leading the way, pushed through legislation in 2014 allowing veterans to seek care from a private medical facility using the Choice Card, with reimbursement from the government if the nearest VA hospital is more than 40 miles away or the wait time for a closer VA hospital is over 30 days. In 2015, Senator John McCain (R-AZ) called for a permanent Choice Card that would have opened health care access anywhere, anytime, to all veterans. While that legislation languished, Donald Trump was elected and, just a few days ago, the President signed a bill to extend the current Choice program, closing financially-burdensome loopholes for veterans, but not fully implementing the McCain vision for private-care-for-all-vets.But VA isn’t just medical facilities: VA is benefits—the Veterans Benefits Administration, VBA—covering home loans, student loans, employment and training, insurance programs; While not statutorily a part of VA, the U.S. Court of Appeals for Veterans Claims in inextricably linked to veterans’ claims processes. VA is also cemeteries—unlike Arlington National Cemetery, which is operated by the Department of the Army and the Military District of Washington, VA’s vast inventory of final resting places for the nation’s veterans come under the services and supervision of the National Cemetery Administration (NCA). The Department of Veterans Affairs also shares special interests like veterans homelessness programs with other Cabinet Departments. There is also an Office of Tribal Government Relations within VA.Do the privatization advocates want benefits and cemeteries in their operations portfolios? Maybe benefits…but cemeteries, not likely; homelessness programs? Probably pass on that, too. So, if the question is appended to include “…privatized the VA healthcare system,” there is some room for a more detailed reply.Does the Congress have the will to support dismantling a 100-year-old system, multi-pronged system, employing nearly 300,000 people (voters), on a multi-billion dollar budget that benefits Congressional districts from Florida to Hawaii, and from Maine to California? Doing away with something as sacred as VA, even though it has significant flaws in its health care and benefits services, is asking a lot of a Congress that is reluctant to do much of anything of merit in the past two or three decades.Partial-privatization advocates like Linder suggest VA retain its core medical competencies—trauma care, prosthetics, and rehabilitation, for example—and open up the private care market to the balance of the nation’s 22 million veterans. But polls and research don’t bear out the need for such cherry-picking care. Veterans on the whole are not dissatisfied with their VA care and many veterans recognize that the stories of wait lists so long that veterans die before they are seen don’t represent the average veteran’s experience.But more than that is the problem of what I call “Records re-absorption” once a move to privatize VA got underway. It’s one thing for a major health care consortium (and it would have to be a consortium—no one healthcare organization has the total scope of abilities and resources to take over VA) to build a non-federal management structure to operate the medical side of VA.The nation’s largest healthcare corporations are familiar enough with the brick and mortar and management of hospitals to figure out how to operate the medical structures—the basics—currently operated by the federal government. What I don’t believe they have any proven track record on is transitioning a two-headed (VA and DoD) federally-created health care records over to a private heath care records’ management system which has to incorporate a veteran’s military medical records history as well.Even VA and the the Department of Defense haven’t arrived at an efficient record’s transfer system that allows for the seamless shifting of active-duty medical records to VA’s medical records databases. If you need evidence of that, just look at this partial list of speakers at the most recent (April 20–21, 2017) Military Electronic Health Care Conference in Washington, D. C.I. Achieving an Interoperable Electronic Health Record – Government & Military Needs, Programs and Opportunities“Not Everything is Computable: Archiving and Sharing the DoD Health Record”■ COL JOHN S. SCOTT, USAInformatics Policy Director, Health Affairs, Department of Defense, Office of the Assistant Secretary of Defense, Health Affairs, Uniformed Services University of the Health Sciences“MHS GENESIS: Driving Successful Business Transformation”■ DR. PAUL CORDTS, M.D.Director, Functional Champion, Military Health System, Defense Health Agency“Achieving Interoperability Among DoD, VA and Private Sector Partners”■ MR. LANCE SCOTTDefense Medical Information Exchange (DMIX)“Advancements in Health Data Interoperability and the Impact on the Veterans Benefits Management System”■ MR. THOMAS MURPHYPrincipal Deputy Under Secretary for Benefits, Department of Veterans Affairs Benefits Administration (VBA) and■ MR. BRAD HOUSTONDirector, Office of Business and Process Integration (VBA)“Interoperability 2020- Why Data Exchange is Not Enough”■ MR. KEN RUBINDirector of Standards and Interoperability, Veterans Affairs Health AdministrationI know some of these speakers, and they’ve been doing hard work in the vineyards of progress toward a seamless VA-DOD health records interoperability for years! In the 1980s, when I was on the staff of the House Veterans Affairs Committee, an Army general, a well-respected military physician, came to us with his idea for a medical identification card that would hold all a soldier’s (I’m using “soldier” to cover, generically and in a gender-neutral way, all branches of the military, rather than adding sailor, airman, marine, coastguardsman every time) active duty medical history. The card would stay with the soldier when he or she left the military and was eligible for VA care. The information on the card would then be “read” by the VA system, and all the appropriate boxes in the veteran’s VA medical history would be properly filled in with the previous active-duty history.A wonderful idea, and although it was about two decades ahead of its time in terms of chip storage and read/write capabilities, it should have been embraced and worked on. But neither our committee or the folks in the Pentagon could get enough energy behind the concept to really put the proper work into it. Despite come-to-God meetings in the Oval Office where more than one president has commanded the Secretaries of Defense and Veterans Affairs to get their act together and work together to come up with a joint-records-sharing plan, the real work has eluded both departments.The irony is that VA has a perfectly fine electronic records management system, one that is doctor-nurse-patient friendly, and completely transportable. During Hurricane Katrina, veterans who were evacuated from the New Orleans VA care area, had their health care records in place no matter where they went in escaping the storm’s path. That was 12 years ago. Even medical imaging records—X-Rays, CT scans, MRI’s—can be passed along to another VA Medical Center as needed.Look at the world of the private physician working through a private healthcare system. In all likelihood, they have a proprietary health records system that utilizes lap-tops, desktops, and a linked central server. My primary care physician and his practice are set up that way. If they are affiliated with a local hospital (and most are) or hospital system, they may have additional access protocols shared between their practice’s office and the hospital inpatient system’s. But that is not always the case.A doctor I spoke with in reference to this Quora answer, discussed the challenge of working with veterans’ health records.“I always look at hardcopies, paper printouts, of any records that they have brought with them,” he said, referring to new patients coming from the military. “If they have imaging,” he continued, “I look at the disks as well. There is absolutely no crossover between the military medical record system and ours. (my italics) Patients are often under the illusion that our system can directly access medical record systems at other practitioners offices, or even the hospital as well, but our systems have no such access.”With respect to the specialized coding system used by physicians—referred to as CPT and ICD 10—the physician I spoke with said, “As far as what coding system the military may use for their diagnoses and procedures, I would imagine that they use the same CPT terminology for procedures and ICD 10 as we do. But anything that came from anywhere else, military or otherwise, would have to be entered manually.” (my italics)Which should make anyone who supports privatizing VA healthcare think long and hard about re-absorbing veterans medical records into a privatized system when even VA and DoD haven’t been able to work out the transfer kinks. A lot of progress has been made, don’t get me wrong, but countless taxpayer dollars have been expended in the quest for records “jointness” and still more will be spent before anything approaching full transferability is achieved. Just because Amazon can deliver products to your doorstep by drone in under 30 minutes does not mean a similarly aggressive and consumer-savvy healthcare network will be able to deliver better healthcare to a veteran in anywhere near such a timely manner. The veteran healthcare learning curve will be exceedingly steep, and, I think, prohibitively expensive.A privatized VA healthcare system would, in my opinion, be a crippled and vision challenged beast from the very start. The private companies running it would not see anywhere near the profits they seek (or suggest to their stockholders); the veterans using it would, in all likelihood, have more, not fewer, time, records, and care obstacles placed in their way; veterans’ service organizations—like the VFW, the American Legion, the Disabled American Veterans and many other similarly chartered advocacy organizations—would lose much of their grip on VA; Congress would have to cede some authority (which it hates to do), and therefore would find new ways to meddle in the process; and non-veteran healthcare consumers would see their doctors’ offices filling up with veterans who, in all probability, would have “move-to-the-front-of-the-line privileges” as part of the privatization mandate, and that would never end well for either side.