“The Larger Answers Must Come From Within”: The VA Reform Legislation Is A “Trojan Horse” For Privatization
In the aftermath of the Veterans Affairs scandal, Democrats and Republicans are moving swiftly to pass legislation to fix the problems at the department. In their haste, though, policymakers have crafted a bill that would do more harm than good—and it comes with a hefty price tag.
On Tuesday and Wednesday respectively, the House and Senate each passed a bill to reform the VA. The bills, would both create a two-year pilot program to allow veterans who do not live within 40 miles of a VA facility, or face a long wait time, to seek care at a non-VA facility. The Senate bill also includes funding for the VA to lease 26 new facilities and hire more medical staff. Now, the two houses will head to conference over the bills to try to agree on a final version.
The bills have not received much attention this week, but that could change: the Congressional Budget Office reported that allowing certain veterans to seek care at non-VA facilities would cost $35 billion over the two-year program, as The New Republic’s Brian Beutler predicted. If made permanent, CBO estimates it could cost $50 billion a year. For comparison, the VA currently spends $44 billion a year on its health care system. CBO notes that its estimate is preliminary, but it still is much higher than the expected cost. And this is only for the partial privatization part of the bill.
While the potential for a new $50 billion a year program is worrisome, the bill would not even address the underlying problems at the VA.
The fundamental problem with the VA scandal is not about long wait times or a shortage of physicians. Those problems exist in the private sector as well. Often, they are even worse there. It’s also not about quality of care either. Veterans routinely rate their VA experience above average. That advantage may have diminished in recent years, but it still exists. At its heart, the scandal revolves around poor financial incentives and fraudulent behavior by VA employees. These problems are systemic and reforms are needed. But many of the problems veterans face are not isolated to VA hospitals. They are larger problems of the American health care system.
The reason that clinics and hospitals—at both VA and non-VA facilities—have such long wait-times is a shortage of primary care doctors. This shortage has happened for a number of reasons: Medical students face financial incentives to choose a specialty field instead of becoming a primary care doctor. State occupational licensing laws prevent nurse practitioners from performing many straightforward medical tasks. Medical schools receive billions in federal funding with little oversight for how may primary care doctors they produce. The bills’ partial privatization scheme does nothing to ease these problems.
It’s a common misconception that the VA does not contract with private sector providers. As recently as 2012 the VA was fending off attacks that they outsourced care too much. And veterans who have been waiting for a long time for care, or those who are dealing with life-threatening situations, certainly deserve the ability to seek care at non-VA facilities. In fact, President Barack Obama has already ordered the VA to do so.
Republicans have long wanted to privatize the VA, but have never had the political power to do so, owing to veterans groups’ opposition. This recent scandal, though, has changed that: Veterans groups support the bills. While the partial privatization is only a two-year pilot program, Republicans will likely push to make it permanent in 2016, potentially undermining the entire VA health care system and leading to the total privatization that Republicans covet.
“You’re already in the situation where we’re having to close really excellent VA hospitals for a lack of patients,” Phillip Longman, a senior editor at the Washington Monthly and author of a book on the VA, said. “And now you’re going to say, ‘OK, anybody who lives 40 miles from a hospital can get free health care wherever they want.’ Now, you’re going to take revenue out of those hospitals and patients out of those hospitals. If they can’t maintain a certain volume, they can’t be safe. You wouldn’t want to be treated by a heart surgeon who only performs three operations a year.
“[The partial privatization plan] really is a Trojan horse,” Longman added. “It’s a really dangerous provision.”
Even if the legislation doesn’t cause VA hospitals to close, it could undermine the quality of care the VA provides. The VA is specifically designed to treat veterans and has vast experience doing so. Since most of its medical visits and procedures happen at its own hospitals and clinics, it coordinates care better than private sector providers do.
“The VA can treat the whole patient as opposed to one body part at a time,” Longman writes at the Washington Monthly. “And due to its near lifelong relationship with its patients, which often extends to long-term nursing home care at the end of life, the VA also has incentives for investing in prevention and patient wellness that are largely absent elsewhere in U.S. medicine.”
Beyond that, the legislation includes very little to address the management issues within the VA. That’s not Congress’s fault, per se, because those fixes must come from within the department. But government officials have the chance to use this renewed focus on the VA to improve the care it provides. By passing a bill that does not address the underlying problems, Congress might waste this opportunity.
“The access issue, which is where everyone has focused, is one important, but ultimately narrow slice of the bigger problem,” Ashish K. Jha, a professor of public health at the Harvard School of Public Health and practicing internist at the VA, said. “What I worry about is because it has gotten all the attention, if we work on fixing this we’re not going to use this opportunity to have the broader conversation is that veterans don’t just want access to care, they want access to good care.”
In an article for the New England Journal of Medicine, Jha writes with Dr. Kenneth W. Kizer, the undersecretary for health during the Clinton administration, that the VA must change its performance management, reassess the VA’s use of technology to provide even better caregiver-patient connectivity, and increase its transparency so the public can evaluate its performance. The VA has already eliminated the 14-day average-wait rule that led to the rampant fraud, acknowledging that the incentive backfired, but much work remains.
What happened at VA facilities across the country was a tragedy. Former VA Secretary Eric Shinseki deserved to be fired. So do other senior VA officials. Policymakers naturally want to pass a big piece of legislation in response to the scandal. But like the American health care system, the VA system has no simple solutions. Congress can help on the margins, but the larger answers must come from within.
By: By: Dany Vinik, The New Republic, June 13, 2014
“Ignoring The Bigger Picture”: Shinseki’s Resignation Doesn’t Change The VA’s Daunting Problems
The resignation of Veterans Affairs Secretary Eric Shinseki was a foregone conclusion by the time it happened on Friday morning. After shocking problems at a VA hospital were revealed in an election year (in Arizona, no less, represented by Senator John McCain, one of the administration’s most powerful foils inside the Beltway) and the heavy suggestion that more mismanagement across the country will soon be made public, Democrats in what promise to be razor-thin House and Senate races had virtually no choice but to call for his resignation as a tide of desperate, angry veterans flooded cable news airwaves and local newspapers.
There was then no way Shinseki could have stayed on in the face of these calls from the very party to whom he owed his nomination; his resignation was the only way to simmer down the scandal that filled up most of the news hole over the past few weeks. (Note that the two most powerful people in Washington not calling on Shinseki to resign were John Boehner and Eric Cantor. They knew that every day he stayed was a good one for Republicans.)
It doesn’t mean his resignation was the right thing to do in practice—in fact, it very well may delay implementation of solutions and make the VA’s problems worse—but it was simply a fact of nature in the political ecosystem.
Now the VA will be set on a new course, and it’s crucial that attention is paid to the true scandal: the overwhelming medical and mental burden suffered by thousands of young men and women returning from largely elective wars in Iraq and Afghanistan, and our continuing inability to fully care for them.
Last year, the Institute of Medicine released a Congressionally-mandated 794-page study outlining the challenges facing these veterans. Though the findings didn’t result in the same media firestorm, they should have:
More than 16,000 troops were wounded in Afghanistan and 32,000 in Iraq.
In contrast with virtually every previous American conflict, “the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments.”
Scientific literature shows as many as 22.8 percent of these returning vets—nearly a quarter—suffer from mild traumatic brain injuries, while as many as 20 percent suffer with post-traumatic stress disorder. Up to 37 percent struggle with combat-related depression, and 39 percent for problematic alcohol use.
For many recent years, the unemployment rate for returning vets was nearly double that of the civilian population, which of course isn’t particularly low. (It has been coming down some recently).
As many as 45 percent of female troops experienced sexual trauma in the military, which is driving quite a bit of PTSD in those troops above and beyond what they would have experienced because of combat.
The unfolding VA scandal involves unacceptable cover-ups of coverage problems at VA hospitals, but that is not mutually exclusive with a system that is fundamentally unable to deal with the problems at hand. In fact, the latter may have fostered the former. We don’t fully know yet, and the upcoming investigations should shed light on these issues.
But over the coming weeks, the politicians that have been rushing to appear on camera along with the outlets eager to cover this story should focus on the bigger picture: the crisis facing returning veterans and the current inability of the federal government to help them. There are many reasons why this has happened. And at the heart of all this is yet another scandal, one that continues to echo through American politics over a decade after it began: the decision to commit, and keep, American troops involved in two messy ground wars with unclear goals and uncertain, at best, benefits.
By: George Zornick, The Nation, May 30, 2014
“Vets To Burr–You Clearly Represent The Worst Of Politics”: Quite Frankly Senator, You Should Be Ashamed
For Republicans, the politics of the VA scandal were pretty straightforward. All GOP officials had to do was express outrage – an emotion that spanned the partisan and ideological spectrum – and demand that the White House improve the system through which veterans receive care.
But Sen. Richard Burr (R-N.C.), the ranking Republican on the Senate Veterans Affairs Committee, apparently couldn’t leave well enough alone.
The conservative Republican, who never served a day in the military, decided it’d be a good idea to start condemning veterans’ groups that had not yet called for VA Secretary Eric Shinseki to resign. In an “open letter,” Burr argued that leading veterans’ organizations are less interested in helping those who served and “more interested in defending the status quo within V.A., protecting their relationships within the agency, and securing their access to the secretary and his inner circle.”
It’s hard to know what Burr was thinking. Perhaps the senator assumed he could pressure the veterans’ groups, bullying them into calling for Gen. Shinseki’s ouster. But if that was the Republican’s strategy, it became clear over the weekend that Burr’s gambit did not go according to plan.
The Veterans of Foreign Wars, the Disabled American Veterans and the Paralyzed Veterans of America hit back hard. […]
The responses were unusually personal. Bill Lawson, the national president of the paralyzed veterans group, and Homer S. Townsend Jr., the executive director, criticized Mr. Burr for supporting the filibuster of the veterans bill in February, and said, “You clearly represent the worst of politics in this country.”
William A. Thien, the commander in chief of the V.F.W., and John E. Hamilton, the adjutant general, pointed to a staff with more than 47 combat deployments in Vietnam, Somalia, Iraq and Afghanistan and four Purple Hearts, 16 Air Medals, Bronze Stars and other honors.
Responding to Burr’s attacks on its motives, the VFW added, “Senator, this is clearly one of the most dishonorable and grossly inappropriate acts that we’ve witnessed in more than forty years of involvement with the veteran community and breaches the standards of the United States Senate. Your allegations are ugly and mean-spirited in every sense of the words and are profoundly wrong, both logically and morally. Quite frankly Senator, you should be ashamed.”
One of the more striking aspects of Burr’s offensive is that it was entirely unprovoked. The Veterans of Foreign Wars, the Disabled American Veterans, and the Paralyzed Veterans of America have expressed ample criticism of the VA scandal, but because they hadn’t called for the resignation from Shinseki – himself a retired four-star general – the North Carolina Republican decided he was justified in publicly questioning their commitment to veterans’ issues.
And Burr did this, for reasons that make sense only to him, on Memorial Day weekend.
Look, I don’t imagine Republican senators are looking for my guidance, but here’s a tip: if you never served a day in the military and you recently filibustered a bill to expand VA health care access, tuition assistance, and job training, maybe you shouldn’t question the motivations of those who’ve devoted their careers to looking out of veterans.
Just throwing that out there.
As for Burr, instead of walking back his shots at the veterans’ groups and recognizing the fact that he went too far, the senator told the New York Times yesterday, “Clearly I hit a nerve. I think they’ve shown more outrage toward my open letter than outrage toward the current crisis at the V.A.”
In other words, the North Carolina Republican has decided he was right all along. We’ll see what happens, but I have a hunch he’s picking a fight against some men and women who don’t back down easily.
By:Steve Benen, The Maddow Blog, May 27, 2014
“If It’s Too Expensive, Don’t Send Them Off To War”: Instead Of Austerity And Slogans, VA Needs Full Funding And Accountability
The troubles at the Veterans Administration are not just a serious issue for veterans. They are a serious issue for every American who believes the federal government can and must meet the basic commitments necessary to maintain a civil society.
Unfortunately, that seriousness is not reflected in the frenzy of fingerpointing that has developed as a response to “the public’s outrage over excessive wait times and rigged recordkeeping at Veterans Affairs hospitals” — an outrage that the president of the American Federation of Government Employees (AFGE), the union that represents caregivers for vets refers to as “more than justified.”
There is no question that the VA has a problem that must be addressed.
The question is whether the politicians in Washington are ready to address it.
The most predictable of the political careerists, Republicans and Democrats, seem to think that firing VA Secretary Eric Shinseki will somehow “fix” things, or that the removal of a few failed managers will suddenly create a functional VA. But that is an absurdly insufficient response.
Depending on what reports regarding the agency reveal, there may well be a place for new leadership and a management shakeup. And those changes might briefly produce a fantasy of action and improvement. But that is all it could be: a fantasy. And a cruel fantasy at that.
Neither the immediate crisis, nor serious issues relating to the long-term future of the VA, will be settled with a mere reorganization of upper management. The real issues are closer to the ground. The VA needs to have enough doctors, nurses and aides to provide the care that is needed – and the doctors, nurses and aides who are now on duty must have the resources and the flexibility to assure that this care is delivered in a timely and responsible manner.
That is not now the case.
“When we look deeper into this issue of extended wait times for veterans to receive an appointment, we have to recognize that understaffing is a major culprit,” explains AFGE president J. David Cox Sr. “All around the country, medical facilities are understaffed, with numerous frontline care positions going unfilled. How can the VA expect to keep up with the growing needs of our nation’s heroes if it doesn’t properly staff its facilities?”
AFGE notes that, “According to the Independent Budget for the Department of Veterans Affairs, developed each year by leading veterans groups, funding levels will remain an estimated $2 billion short in FY 2015 and approximately $500 million short for FY 2016.”
Members of Congress – at least those who pay minimal attention to veterans issues – have for some time been aware of the funding shortfall. Yet, too many of them have resisted calls for action.
The reason is that the current Congress is packed with partisans who are more concerned with maintaining an austerity agenda than with caring for Americans who are in need.
Too many members of Congress continue to prattle on about how government is the problem, about how spending must be cut to meet their imagined bottom lines, about how the resources are not there to keep promises to vulnerable Americans – even if the resources are always there for wars of whim and a military-industrial complex that provides daily evidence of the extremes to which waste, fraud and abuse can be taken.
The current Congress includes a striking number of members who express open antipathy to meeting the guarantees that have been made to all Americans, including veterans. These members of Congress are so unthinking in their approach, so cruel in their budgetary calculus, that they casually, in some cases gleefully, presided over a government shutdown last fall.
Republicans get blamed for advancing the austerity agenda, but it is important to remember that more than a few Democrats have compromised with it. And the difference between those who promote austerity and those who make the compromises that allow for austerity means very little to Americans who are stuck on the waiting lists that are created by budgeting that owes more to Ayn Rand tomes than accounting textbooks.
The VA crisis is a wake-up call.
It is time to get serious. It is time to abandon austerity, and to recognize that core commitments cannot be compromised in order to maintain ideological fantasies.
Senate Veteran Affairs Committee chairman Bernie Sanders, I-Vermont, tried to get ahead of a host of issues concerning veterans in February, when he proposed comprehensive legislation to improve VA health care, education and job-training. Though it was strongly backed by the American Legion, Veterans of Foreign Wars, Disabled American Veterans, Iraq and Afghanistan Veterans of America and other organizations representing vets, the measure was blocked when most Senate Republicans opposed it. To Republicans who suggested the measure was too expensive, Sanders said, “”If you think it’s too expensive (to fund veterans programs), then don’t send them off to war.”
Last week, Sanders announced that he would reintroduce his plan to allocate $21 billion more for veterans initiatives over the coming decade. He is, as well, proposing a new VA accountability measure. The latter legislation removes bureaucratic barriers and makes it easier for the Secretary of Veterans Affairs to make management changes that are necessary to protect those who have served in the military.
The Sanders approach recognizes the need to move beyond the failed responses of America’s austerity-minded politicians while at the same time increasing accountability. It’s a smart long-term fix that eschews the easy sloganeering and empty promises of those who would politicize the VA crisis.
Conscious of the urgency of that crisis, the senator plans to move quickly to get both measures to the Senate floor. “In recent years, as a result of the wars in Iraq and Afghanistan, 1.5 million more veterans have entered the VA health care system,” says Sanders. “Congress must do everything possible to make certain that the VA has the financial resources and administrative accountability to provide the high-quality health care and timely access to care that our veterans earned and deserve.”
By: John Nichols, The Nation, May 25, 2014
“Truly Something To Behold”: Republicans War-Monger, Then Complain When We’re Overwhelmed By Sick Vets
It took very little time at all for reports of falsified records covering up delays at a Veterans Administration hospital in Phoenix to balloon into just another who’s up-who’s down Washington political story. From the New York Times’ front-page article today declaring in its headline that the “V.A. Accusations Aggravate Woes for White House”:
Republican lawmakers intensified their criticism of Mr. Obama, and some made it clear they intended to use the incidents at the hospitals as fodder for a broader political theme about incompetence in his administration.
“The election of President Obama ushered in a new era of big government and with it a renewed flurry of mismanagement,” Representative Kevin McCarthy of California, the House Republican whip, said in a statement. “If the president truly did not know about these scandals and mistakes, we should doubt his ability to properly manage the leviathan government that he helped create.”
Representative Eric Cantor of Virginia, the No. 2 Republican in the House, told reporters on Tuesday that Mr. Obama had not acted swiftly enough. He added that “it is time for our president to come forward and take responsibility for this and do the right thing by these veterans and begin to show that he actually cares about getting it straight.”
Meanwhile, after Obama addressed the Phoenix scandal at the White House this morning, Republican Senate leader Mitch McConnell huffed, “Unfortunately [we] have yet to hear” Obama treating the “VA crisis with the seriousness it deserves.”
The hypocrisy on view here is truly something to behold. If V.A. employees in Phoenix, or anywhere else, were engaged in fraud and cover-up of the sort that is being alleged, that is a travesty and heads will have to roll, as one already has. And it’s fair to ask, as we did with the bungled rollout of healthcare.gov, why the White House hasn’t paid more attention to the nuts and bolt functioning of the federal bureaucracy. But for Republicans to expand the scandal into a broader indictment of Obama’s overall handling of veterans affairs means overlooking some relevant context.
For starters, there is the matter of funding. If there’s been one side pushing for greater resources for the Veterans Administration in the age of austerity these past five years, it hasn’t been the Republicans. It was the much-maligned economic stimulus package of 2009 that included $1 billion for the V.A. While the V.A. itself was protected from the budget sequestration that Republicans fought to keep in place last year, many other veterans programs—providing mental health services and housing, among other things—were hit hard by the sequestration cuts. And when the Senate was poised to pass a $24 billion bill for federal healthcare an education programs for veterans three months ago, Senate Republicans, led by McConnell, blocked it in a filibuster, saying the bill would bust the budget and complaining that Senate Democrats had refused to allow an amendment on Iran sanctions to be attached to the bill.
But there is a whole other level of context to consider here as well. There is a pretty basic reason for backlogs at V.A. facilities and in the disability claims process, the other ongoing V.A. mess. Put simply: when you go to war, you get more wounded veterans, and in a country without a universal health care system, they are all funneled into this one agency with limited capacity. Every one of the Republican leaders quoted above attacking Obama for the V.A. backlogs strongly supported launching the wars in Iraq and Afghanistan that resulted in nearly 7,000 fatalities and a huge surge in medical needs and disability claims. Nearly one-half of veterans returning from Iraq and Afghanistan have filed claims for permanent disability compensation. These claims need to be assessed for their validity, just as we attempt to do with claims for other programs, such as Social Security disability, unless we want to simply throw open the doors on a compensation program that is already expected to cost close to a trillion dollars for Iraq and Afghanistan vets. Making the assessment all the more challenging is the nature of the disability claims being made. Awarding disability status for a missing limb is easy. Harder are the much larger numbers of claims for traumatic brain injury caused by the IED explosions that were the greatest threat to our service members in these two wars of occupation. Consider this graph:
Something, it appears, happened around 2003 that caused the rate of traumatic brain injuries in the U.S. military to spike. Now what could that have been? Whatever it was, it happened while Barack Obama was in the Illinois state Senate, giving an obscure speech against invading Iraq. He is now having to reckon with the fallout from that event, as is his responsibility to do as commander in chief. But you’d think that those who had actually played a part in bringing about that event would have enough self-awareness to resist scoring political points off of the years-later fallout. Apparently, though, even that is too much to ask.
By: Alec MacGinnis, The New Republic, May 21, 2014
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