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“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 goodand 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 hospitalsat both VA and non-VA facilitieshave 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

June 15, 2014 Posted by | Veterans, Veterans Administration | , , , , , , , | Leave a comment

“Will Congress Be As Brave As Shinseki?”: Will The Honorable Politicians Please Stand Up?

If you want a prime example of what’s wrong with our politics, study the response to the veterans’ health-care scandal. You would think from the coverage that the only issue that mattered to politicians was whether Gen. Eric Shinseki should be fired.

Shinseki is a true patriot, and his resignation as Veterans Affairs secretary on Friday calls Congress’s bluff. He played his part in a Washington sacrificial ritual. Will the politicians now be honorable enough to account for their own mistakes?

Thanks to Shinseki’s latest selfless act for his country, you can at least hope that we will move on to the underlying questions here, to wit: Why was the shortage of primary care doctors in the VA system not highlighted much earlier? Why did it take a scandal to make us face up to the vast increase in the number of veterans who need medical attention? And why don’t we think enough about how abstract budget numbers connect to the missions we’re asking government agencies to carry out?

It’s an election year, so it’s not surprising that the Republicans are using the scandal against President Obama and the Democrats, though there is a certain shamelessness about the ads they’ve been running, given the failures of the previous administration.

Shinseki and Obama might have averted this by pushing Congress much harder, much earlier to give the agency the tools it needed to do right by vets. And as a general matter, I wish Obama spent more time than he has on fixing government and improving administration. Progressives rightly assert that active, competent government can make things better — which means they need to place a high priority on making it work better. This would include, as The Post editorialized, a serious engagement with civil service reform.

It’s also fair to ask why Shinseki did not move faster elsewhere, notably on what the Iraq and Afghanistan Veterans of America called the department’s “egregious failure to process the claims of our veterans” in a timely and effective way. (For what it’s worth, I raised this concern in a column in November 2012.)

But this is where the story gets more complicated. Shinseki eventually made real progress on the claims issue and other inherited messes. He got little public credit, though many friends of veterans saw him as a reformer and refused to join the resignation chorus. Both House Speaker John Boehner and Minority Leader Nancy Pelosi deserve praise for insisting to the end that Shinseki’s departure wouldn’t solve the system’s problems.

The most important of these is not that VA employees falsified data about the excessive waiting times for veterans seeking appointments with doctors, as outrageous as this was. It is, as the New York Times reported last week, “an acute shortage of doctors, particularly primary care ones, to handle a patient population swelled both by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan.” Dealing with this isn’t sexy, just essential.

Sen. Bernie Sanders (I-Vt.), the chairman of the Senate Veterans’ Affairs Committee who wanted Shinseki to stay, is trying to push the discussion in the right direction. A Sanders bill to expand VA funding across a wide range of areas went down in a Republican filibuster in February. The new bill he hopes will come up for a vote this week focuses specifically on the health system.

It would authorize private care for veterans facing emergencies, which is similar to a House Republican idea. But Sanders would also broaden veterans’ access to other forms of government health care, fund 27 new VA facilities, and use scholarships or loan forgiveness to entice medical students to serve in the VA program.

Shinseki himself proposed other reforms in a speech he gave just before he quit, among them an end to incentives that have encouraged agency supervisors to produce fake information on waiting times.

If there is any cause that should be bipartisan, it’s care for our veterans. But too often, what passes for bipartisanship is the cheap and easy stuff. It tells you how political this process has been so far that so many of the Democrats who joined Republicans in asking for Shinseki to go are in tough election races this fall.

Now that Shinseki is gone, there are no excuses for avoiding the administrative challenges that Obama needs to confront and the policy errors for which Congress must also take responsibility.

 

By: E. J. Dionne, Jr., Opinion Writer, The Washington Post, June 1, 2014

June 2, 2014 Posted by | Congress, Politics, Veterans Administration | , , , , , , , , | Leave a comment

“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

June 2, 2014 Posted by | Veterans, Veterans Administration | , , , , , , | Leave a comment

“What Does Shinseki’s Resignation Change?”: Disappointing Republican Leaders With Big Plans For This Scandal

One of the more common developments inside the Beltway in recent years is seeing congressional Republicans call for various members of President Obama’s cabinet to resign. It’s become so routine, it’s almost as if GOP lawmakers consider it part of their daily routine: wake up, have breakfast, get dressed, and call for the Secretary of Whatever to step down immediately.

But as the tide turned quickly against Eric Shinseki at the Department of Veterans Affairs, House Republican leaders bit their tongues this week, refusing to call for his ouster. It became pretty odd – many of Obama’s close Democratic allies demanded the secretary’s resignation, even as John Boehner and Eric Cantor did not.

Was this because GOP leaders wanted to give the White House a break? Um, no. Was it the result of Republicans’ deep respect and admiration for Shinseki, a true patriot? That’s a nice thought, but that’s not what happened, either.

Instead, consider the response to Shinseki’s resignation.

House Speaker John Boehner said Friday that the resignation of Veterans Affairs Secretary Eric Shinseki “really changes nothing” to fix systemic problems at the department, calling on President Barack Obama to take further action to address system-wide mismanagement.

“One personnel change cannot be used as an excuse to paper over” problems at the VA, he told reporters after President Barack Obama accepted Shinseki’s resignation Friday morning.

As recently as yesterday, the Ohio Republican told reporters, “The question I ask myself: Is him resigning going to get us to the bottom of the problem? Is it going to help us find out what’s really going on? The answer I keep getting is no.”

It’s important to understand Boehner’s likely motivations here.

What Republicans leaders want is to blame President Obama for the controversy. Substantively, that’s not an easy sell – as Mariah Blake makes clear today, much of what plagues the VA started under the Bush/Cheney administration – but there’s an election coming up, and none of the issues GOP officials hoped to run on are going the way Republicans hoped.

What does this have to do with Shinseki’s ouster? Probably everything.

Inside the Beltway, there was an overwhelming demand that Obama “do something” and not let this story linger any longer. Boehner, however, likely wanted the opposite: White House inaction, more delays, and a controversy that lingers indefinitely.

Many on the right may have cheered today’s announcement, but in no way does this advance a partisan goal. The VA system hasn’t been working, so the president is replacing the head of the VA system with someone who’ll hopefully do a better job. This doesn’t help Boehner at all, which is why he was so quick to say the news “really changes nothing” – the Speaker is probably concerned attention will now shift now that the embattled Shinseki is leaving the stage.

And even putting partisan motivations aside, substantively, Boehner arguably has a credible point. The VA mess will be no better this evening than it was this morning. A cabinet secretary is gone, but the problem that forced him out remains.

If the political world decides to move on, it will disappoint Republican leaders with big plans for this scandal, but it will also do a disservice to veterans who continue to wait for a solution.

 

By: Steve Benen, The Maddow Blog, May 30, 2014

June 1, 2014 Posted by | John Boehner, Veterans Administration | , , , , , | Leave a comment

“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

May 27, 2014 Posted by | Veterans, Veterans Administration | , , , , , , , | 5 Comments

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