A Veterans Administration hospital in Fort Collins Colorado, it was recently revealed, falsified its wait times for outpatient clinic appointments. In order to appear to meet the goal of clinic appointments within 14 days, the hospital taught its clerks how to falsify the appointment records to create the illusion that the appointment goals were being met. Many of the 6,300 veterans treated at this clinic actually waited months for their appointments. Yet the clinic clerks were required to “cook the books” else they were punished by being placed on a “bad boy list.” Aside from the moral outrage of treating our veterans in such a callous manner, this episode provides a glimpse of coming attractions for health care delivery in the US.

The Veterans Health Administration is the largest integrated health care system in the United States with 150 medical centers, 1400 hundred outpatient clinics, and 53,000 health care providers. Such systems are, “Poised to play a pivotal role in reform efforts,” according to health care academics. This is the “one stop shopping” model of health care delivery, with all services under one structural umbrella, all providers employed by the system, providing integration and continuity of care. It’s also the progressive holy grail of single payer universal health care. The president is a proponent of such a system, as is his former Medicare chief Donald Berwick. The U.S. health care system is sliding toward single payer, so it would be instructive to consider how the VA news foreshadows the future.

The first place to look would be at the British National Health Service. The aforementioned Donald Berwick told us, “I am a romantic about the NHS; I love it.” The NHS is famous for its wait lists. Their website reassures British residents, “You have the legal right to start your NHS consultant-led treatment within a maximum of 18 weeks from referral, unless you choose to wait longer or it is clinically appropriate that you wait longer.” Consultant means specialist. So that persistent headache, stomach ache, vision loss, or cough will be addressed promptly by an appropriate specialist within four and a half months. Hope the headache isn’t from a brain tumor and the belly pain isn’t from cancer because in 18 weeks, the concern may be moot. If “clinically appropriate,” you may wait longer, such as for a hip replacement. Not life threatening, only painful and inconvenient, so a 6-month wait in Wales is deemed reasonable.

What happens when the wait lists become too long? Several years ago the NHS had over 150 thousand people waiting longer than 18 weeks for their specialist care. New Zealand, with a health care system similar to the NHS, faced this problem in 2007. They promised patients treatment within six months. But when the wait list grew too long, they simply removed 35,000 people from the wait list, sending the patients back to their GP. If the GP could have solved the patient’s problem, they would have and not referred them to the specialist at the public hospital. So back to square one for the patient.

This sounds much like the VA hospital. If the wait list is too long, just remove everyone beyond the targeted wait and voila, the wait list is operating as promised. Don’t think this could happen in the U.S.? The VA hospital in Phoenix had two separate wait lists, “One of them secret, deliberately put in place to avoid the VA’s own internal rules.” That way no one finds out that veterans promised timely care get anything but, in a system, “Where wait times can last more than a year.”

Health care rationing is a subject that can discussed and debated. The reality is that some type of rationing is needed for any resource with a finite supply and an infinite demand, such as health care. But this is a societal debate because in any rationing scheme there are winners and losers. Oregon already rations care under Medicaid, serving as a pilot program that can be observed and monitored, then modified or scrapped by the residents of Oregon based on its performance.

Yet rationing is the dirty little secret that politicians won’t talk about. Obamacare already has a built in rationing provision called the Independent Payment Advisory Board that conveniently insulates elected officials from the difficult rationing decisions. So they can pretend that all is well, as Nancy Pelosi recently exclaimed about Obamacare, “It’s going to be a glorious thing.” It’s not glorious for the veterans told to shut up and wait. Expect similar stories about wait lists and delays as we slowly unveil the glories of Obamacare.

Brian C Joondeph, MD, MPS, a Denver based physician, is an advocate of smaller, more efficient government. Twitter @retinaldoctor.