What Hillary gets (I hope).

In 1994, the New Republic asked me to write an article about the Clinton administration's "reinventing government" (REGO) initiative. REGO, you may recall, was the campaign spearheaded by Vice President Al Gore to improve the performance of federal agencies by encouraging innovation within the bureaucracy. It was widely considered by the national press corps to be the world's second most boring story, right behind the trade dispute over Canadian softwood lumber. But I was actually excited about the assignment. As an alumnus of the Washington Monthly, I'd internalized Charlie Peters's neoliberal prime directive (see "A Neoliberal Education," page 30)--that a journalist who believes in a strong federal government should go to the front lines of that government and report back honestly on what he finds.

The department I decided to look at was Veterans Affairs. If REGO was the second most boring story in the world, then the VA had to be considered the second most boring federal agency, right behind the Office of Personnel Management. But it was also, with more than 200,000 employees, the largest nondefense department in government and hence an important one. At the time, the VA was known for vast inefficiency (scores of facilities across the country were sitting half empty) and poor service (a reputation captured in the 1989 Tom Cruise film Born on the Fourth of July, about a wounded Vietnam vet who receives nightmarish care at a veterans' hospital). If REGO could make a difference at the VA, I figured, there might really be something to it.

So on a cool fall day I made my way to what I'd heard was a promising REGO experiment: the Central Region Contract Service Center, located on the campus of the Clement J. Zablocki Veterans Administration Medical Center in Milwaukee. The center was housed in a converted Civil War-era domiciliary amid the rolling hills of a military cemetery. Inside, contract officers and a government attorney spent their days negotiating with private vendors for everything from bedsheets to ambulance services on behalf of eight VA hospitals in the upper Midwest. Previously, such work had been done by purchasing agents at each individual hospital, the documents often having to be sent to lawyers at VA headquarters in Washington for final approval. The idea of the service center was to centralize the contracting (buying in bulk to garner lower prices) and to decentralize the decision making (having the legal work done on-site to speed up the process).

After some days of reporting, I determined that the center seemed to be working. Vendors loved being able to deal with one purchasing office rather than eight. Hospital nurses loved the quicker and more predictable delivery, which meant they could spend less time hording supplies and more time caring for patients. And the VA was beginning to save money. Though the center had enemies within the bureaucracy--especially civil servants at headquarters whose authority had been usurped, and purchasing agents at the eight hospitals whose jobs were threatened--the bottom line, I wrote, was that this reinventing government experiment at the VA looked like a real success.

Turns out I didn't know the half of it. That same year, Clinton appointed Dr. Kenneth Kizer, a physician, public health expert, and registered Republican, to run the entire VA hospital system. Kizer was given free reign to make sweeping changes, and he did so, cleverly. To build political support for shuttering underutilized hospitals, he cut a special deal with the Office of Management and Budget, whereby the VA could keep a portion of the proceeds from the downsizing. He then promised veterans' groups that opposed dosing hospitals that he'd spend part of the money on projects their members wanted, like new ambulatory care facilities. He plowed the rest of the money into an innovative information system that could electronically keep track of every aspect of a patient's care and make those records available to any VA doctor or nurse anywhere in the country with the click of a mouse. He used that system to identify best practices, reduce medical errors, and generally reorganize the entire VA caregiving operation around better managing the chronic illnesses of the aging veterans who make up the bulk of the VA's patients.

Kizer's efforts are chronicled in a new book by Phillip Longman, Best Care Anywhere--a book that began as a cover story in the Washington Monthly (January/February 2005). Those efforts, Longman shows, so completely transformed the VA that it now outperforms every other sector of the American health care system. Elderly VA patients have longer life expectancies than Medicare patients who choose managed care. VA hospitals earn higher ratings from the National Committee for Quality Assurance than Massachusetts General Hospital and the Mayo Clinic. And the VA achieved all this while spending less per patient than the average American consumes in health care dollars per year, even though VA patients tend to be older and sicker.

Reading Longman's book left me with four strong reactions. The first is irritation at myself for not having stuck with the VA story, and hence missing its turnaround. (Had I known, I could have slipped stories of the VA's comeback into Clinton's speeches when I later worked for him.) The second is a rekindled fury that the Supreme Court chose George W. Bush, and not Al Gore, in 2000. Imagine if, over the past six years, we'd had someone in the Oval Office with the passion and know-how to improve the performance of government agencies by bringing out the best in career employees, rather than someone who has routinely put incompetent political cronies in top positions and treated career experts with contempt. (Given how many hospital beds his Iraq policies are filling, Bush is lucky that Clinton left him with a VA in such good shape.)

The third feeling is one of profound hope that in the VA we finally have the right model to achieve universal health care. As Longman argues elsewhere in this issue (see "Misdiagnosed," page 59), the private health care system is enormously expensive and not so great at keeping people healthy. Yet most universal health care proposals envision bringing the uninsured into that system. Why not instead create a new medical network, using existing public hospitals and clinics, let the VA or its managers run it, and give every uninsured American access to it? Such a solution would be cheaper for taxpayers and would likely provide the uninsured with better-quality health care, frankly, than those of us with private insurance have. Indeed, if it worked, any individual or company could be allowed to buy into the new network. Over time, you'd have an effective public-sector competitor to private-sector health care.

The fourth reaction I have is an intense curiosity about which of the presidential candidates, if any, would suggest such a solution. John Edwards has a detailed plan that basically builds on the current system. Barack Obama is now under pressure to put forth a plan of his own, but while he's a brilliant man, he's new to the whole health care debate and may gravitate toward a more conventional solution.

The one candidate who I suspect really "gets" the VA model is Hillary Clinton. She's cosponsored bills in the Senate on enhanced electronic medical records and dropped strong hints on the campaign trail that the universal health care plan she's working on will be very controversial. She'd be taking a political risk if she were to embrace the VA model: the GOP would surely accuse her of advocating creeping socialized medicine. But there would be political benefits, too, especially for her. Imagine the hawkish senator visiting vets at VA facilities in every swing state, telling the story of the agency's turnaround under the previous Democratic administration, and proclaiming the agency to be a homegrown, red-white-and-blue solution to America's most intractable care problem. While she's at it, she could propose that veterans on Medicare be allowed to use their entitlement for VA care. Such an idea would delight veterans' groups, and save the taxpayers money, too.

Al Gore would have won decisively in 2000, I think, had he run more on the record of the Clinton/Gore administration. I hope Hillary doesn't make the same mistake. With the current employer-based system unraveling and the number of uninsured growing, Americans may be ready to believe that the health of the nation requires real national health care.