Letters

The Art of Budgeting

You simply cannot feed performance or any other data into a formula and get good budget decisions. Budgeting-allocating scarce resources-is, at its most fundamental, a political exercise. Budgeting is an art, not a science.

The leading academics in this area, such as Phil Joyce and Joe Wholey, would be the first to tell you that performance data should "inform" budget decisions, not make them.

The grail that Tom Shoop is looking for remains far out of reach because it doesn't exist.

Thad Juszczak
Office of Budget
Health and Human Services

Empty Bed Syndrome

In earlier years, the VA received its operating budget based on the costs of operating its facilities and providing care to veterans. Then, in the late 1980s, the budgetary process changed to more of an HMO mode, in which the VA's funding was to be based on a per-capita amount for each patient being treated. The amount was relatively low and thus required the VA to hold many health fairs to recruit healthy veterans or those who had health insurance onto the department's rolls, while discharging inpatients who had been receiving long-term care at a far greater expense than funds allotted. These long-term patients were discharged to the community to be cared for under private health plans or Medicaid.

In other words, the reduction of inpatients, closed wards and increase in outpatient visits was not related to changes in medical care required by veterans, but rather by the change in the VA's budgetary process. Just look at the budgets for the VA's long-term care facilities for the last quarter of the 20th century.

As noted in the article, the recommended changes submitted by the CARES program office were not initiated by the commission, but rather were provided by the VA's network directors. Since they were not required to achieve cost efficiencies, they could use their own criteria, allowing favoritism or politics to enter into their decision-making.

Perhaps if the VA's focus had remained on providing needed medical care-inpatient, outpatient and long-term-to veterans who had little other access to health care and left the healthier veterans and those with good insurance coverage to receive their care from the private sector, there would be fewer empty buildings and more patients in the system.

Robert Mandelstam
Former Chief of Medical
Administration Service,
Canandaigua, N.Y.,
VA Medical Center

Corrections/Clarifications

The April 15 feature "Changing of the Guard" incorrectly stated the percentage of troops in Iraq that are Army National Guard members. The figure is nearly 40 percent.

The April 15 cover image for "NASA's Next Step" was a photo illustration by Corbis.