Here's my take:
It's an interesting post and discussion. The VA has made significant strides in quality improvement and in deploying electronic patient records. They are currently working on the what will be their next generation of EPRs. But there's always room for improvement ...
In addition to having a longer time horizon for its improvement investments than many private health plans, the VA has another advantage: a hierarchical organizational structure in which the person at the top can issue commands and its more likely to be followed than in a private hospital (most of which do not employ their physicians).
The VA aside, the discussion of this case also shows us how much of the public-private debate is overwrought and oversimplified.
No system (whether public or private) is completely isolated. There is rarely a clear line between the two. For example, the VA case shows us some fuzzy boundaries when it uses private (non-employee) surgeons who practice at both private and VA hospitals in the same region. Much of the improvement in VA care also involved private physicians. Those who use this case to argue for government run healthcare need to be explicit about what they mean with respect to the core professionals. Do they intend that all physicians be public employees? The systems in Canada and the UK do not.
No system (whether public or private) is completely unique. The VA does offer medical privileges to private physicians and does not rely totally on employed physicians. There are a few private hospitals that also employ their physicians. Before the big managed care boom in the 1990s, there were a number of health maintenance organizations that also employed their physicians. Underlying organizational structures tend to drive system behavior regardless of whether public or private.
No system (whether public or private) is static. Before we use the VA experience to conclude that everyone should get care through a government run system we should ask how the VA would have known that it needed to make significant improvements without the contrast of an alternative system? We should acknowledge that for years, it did provide lousy care and, in some instances, still does today. And we should also acknowledge that there's tremendous variation in the use and quality of private medical care. Here too, there have been improvements, but some moved first and some still lag behind.
No system (whether public or private) is immune to variation. Even after major quality improvements, there will be some instances of the best, some instances of the worst and a lot in the middle. Our challenge is two-fold: to ensure that those which are the worst are at least minimally acceptable and, much like improved manufacturing processes, to move the entire system toward better (both squeezing the bell curve to reduce variation and moving it in its entirety in the preferred direction).
No system (whether public or private) that allows its members to operate in isolation is going to provide good care. Today's medicine is way too complex and involves too many people to be effective if they are not coordinated and kept up to speed on the patient status and care (through effective information systems).
No system (whether public or private) of significant size is immune to bureaucratic BS and political (small "p") infighting.
This debate would be more productive if we called a time-out on debating the public-private ideological divide and looked at what the two sides have in common that works and doesn't work and how they affect organizational dynamics and trajectories.