The uproar over the manipulation of wait times at the Phoenix VA hospital and other VA sites has tended to overshadow the larger issue of whether U.S. veterans have sufficient, unimpeded access to care. The short answer is they don’t, due to the inherent limitations of the VA program and the fragmented nature of our current health system. Among other problems, many veterans don’t even qualify for VA care and are completely uninsured.

There are 22 million veterans in the U.S. today. They are mostly poor, and the Vietnam-era veterans are getting to an age where they need more health care.

Over the years there have been long waits for different kinds of care at the VA, even as the overall population of veterans is declining. As we now know, some VA administrators have gamed the scheduling system to make their wait times appear shorter, the result of a “pay for performance” scheme that financially rewarded managers if they kept waits to under two weeks – even if that goal was unattainable at their facilities due to doctor shortages, a rapid influx of veterans due to retirement nearby or eligibility changes, or other factors.

But the longest and most onerous waits are associated with the time it takes to determine if veterans are eligible to receive care at the VA, and at what level. This determination is done precisely because the VA is not a single-payer system. It doesn’t cover everyone; it’s not accessible to every veteran; it is just one payer among many in our fragmented system. Currently about 2.3 million veterans and their family members are completely uninsured.

In contrast, a single-payer national health program would cover everyone and allow them to choose any provider and source of care in the U.S.

The VA has pioneered quality initiatives, delivery system changes and an electronic medical record that is far ahead of the private sector. Veterans’ service organizations praise the VA, even as they complain about waits, precisely because of its high quality.

But any health care program that benefits low-income individuals and families (including the VA, because today the poor are more likely to join the military) is politically vulnerable to budget cuts or calls for privatization, and is likely to suffer from more problems than a health system that benefits everyone — rich and poor, young and old, soldiers and civilians, i.e. the entire population. Otherwise there will be pressure to underfund it.

Single-payer national health insurance, an improved Medicare for All, will offer a single tier of high-quality care to everyone. It would address wait times in an organized way, be transparent and accountable, and allocate medical resources based on need, not ability to pay.

For more resources on the ongoing issues at the VA: