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Elliott S. Fisher, MD, MPH; H. Gilbert Welch, MD, MPH
VA Outcomes Group White River Junction, Vt Center for the Evaluative Clinical Sciences Dartmouth Medical School Hanover, NH

JAMA. 1995;274(14):1130-1131.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

In Reply.

—Although many options can be invented for the future of the VA, we chose to focus on four. They were not intended to be either comprehensive or exclusive. Furthermore, they were framed using a relatively constrained perspective: the choices that an individual VA medical center might face. Dr Moskowitz has invented another possible future, one that markedly expands the perspective by involving all federal health programs.

The reform that he proposes is huge. By including Medicare and Medicaid, it is a reform of similar magnitude to President Clinton's health care plan. And in the current climate it would likely face similar political obstacles. A major barrier to any reform is the uncertainty about the outcome. When proposing a reform of this order of magnitude, there is immediately a large constituency that shares the legitimate concern that the changes might be harmful. To overcome this barrier, we advocated inventing . . . [Full Text PDF of this Article]

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