This article appears in the Fall 2015 issue of The American Prospect magazine. Subscribe here.
The other day, as part of my current research on patient care at the Veterans Health Administration (VHA), I tagged along with an occupational therapist named Heather Freitag. She works for the VHA's Home Based Primary Care Program (HBPC) in San Francisco, and was making her first visit to a 79-year-old Korean War veteran suffering from dementia.
The man's wife, only five years younger, was clearly overwhelmed by the burden of caring for him by herself while dealing with her own mounting health problems. For more than an hour, Freitag scrutinized every niche and cranny of their tidy bungalow in the Excelsior district of the city.
The VHA caregiver quickly discovered that her patient's narrow, sagging bed made it too difficult for his wife to turn him. In his frail condition, the two-inch lip around their shower stall had also become an insurmountable obstacle to daily bathing. The veteran's lack of mobility had already resulted in two small bedsores that could-if not properly treated-lead to serious infection and costly hospitalization.
The goal of Freitag's primary-care team is to prevent such problems from occurring. They try to keep patients comfortable and where most would like to remain-in their own home for as long as possible. After returning to her office, Freitag put in an order for a special bariatric hospital bed complete with a state-of-the-art air mattress. She also began designing a plastic chair that would ease the man's difficulty with home shower access.
In caring for this veteran, the HBPC would dispatch to the same San Francisco address a physician, a nurse practitioner, a nutritionist, a geriatric psychologist, and a physical therapist. And, of course, they would be supplemented by home health-care aides (who will be the only providers I can ever expect to see, under similar circumstances, when utilizing my own, privately funded, long-term care insurance sometime in the future). Indeed, for most elderly shut-ins, home-care workers are the main caregivers who render heroic critical services that help people function in daily life.
Such carefully coordinated, high-quality care may be unusual elsewhere, but it is not a rarity at the VHA. In the year I've spent visiting VHA hospitals and clinics all over the country, I've found it to be the norm. While observing primary-care providers and geriatricians, palliative care and hospice specialists, mental-health practitioners, designers of prosthetic devices, medical and nursing researchers, as well as experts in team training and patient safety, I've also interviewed veterans of all ages as well and their family members. Every health-care system has its critics and complainers. But, in 30 years of writing about the interaction between patients and providers, I've never seen better institutional support for the latter caring for the former.
This is all the more remarkable because the VHA's patient population is far older and sicker than the national average. A large fraction of the vets who are cared for by the VHA have disabilities stemming from combat. Yet the VHA delivers care to this challenging population more compassionately and more cost-effectively than other segments of our health system.
Right-Wing Wreckage and Pack Journalism
In 2007, journalist Phillip Longman wrote a book on the VHA entitled Best Care Anywhere. In it, he demonstrated that our health-care delivery system for veterans (at least those who qualify for VHA services) is far better than Medicare and way better than private insurance-and a better, more-comprehensive model for broader health-care reform than even a single-payer system. But most readers of the daily press would find Longman's picture at odds with the story of the VHA recently depicted in the media.
That's because of one recent overblown scandal combined with the Republican scapegoating of a fine public system that they underfund-and would love to privatize.
In February 2014, a VHA doctor in Phoenix, Arizona, blew the whistle on his own facility where administrators had been falsifying records about the time it took for patients to see a doctor. These revelations about appointment delays, as reported in The New York Times and other media outlets, led to the resignation of then–Secretary of Veterans Affairs Eric Shinseki. President Barack Obama quickly appointed a replacement for him from the private sector, Robert A. McDonald, former CEO of Procter & Gamble.
In February 2014, Vermont Senator Bernie Sanders, then chairman of the Senate Committee on Veterans' Affairs, had asked for a $24 billion appropriation for the Department of Veterans Affairs (mostly for health care), which Senate Republicans blocked. After the Phoenix wait-time scandal broke, Sanders brokered a deal with Republican Senator John McCain, and Congress grudgingly gave the Department $16 billion-$8 billion less than requested. This kind of under-funding was guaranteed to lead to problems, not only because the VHA, in correcting its wait-time issues, has attracted many new enrollees, but also because of the nature of the veteran population the VHA serves. Nonetheless, McDonald changed VHA managerial practices, fired some administrators responsible for the Phoenix "scandal," and, most important of all, began recruiting much-needed new staff-particularly primary-care providers.
Despite the VHA's vigorous efforts to root out a localized management scam and, with far greater difficulty, to remedy a shortage of primary-care providers that is nationwide in scope, congressional Republicans and many in the mainstream media continue to depict the VHA as being in a state of ongoing, almost terminal crisis. The Times, for example, has published article after article depicting the VHA as a "troubled health system, especially in rural or out-of-the-way posts." According to the publication's multiple reports, sources are quoted over and over again attesting to the VHA's "corrosive culture," and the fact that it has lost the "trust" and "confidence" of its patients, and has been rendered a "demoralized and dysfunctional agency."
The resulting pack journalism has had its negative effect. Even though one of its major stories challenged the contention that veterans had died because of wait times, the headline broadcast precisely the opposite: "V.A. Official Acknowledges Link Between Delays and Patient Deaths."
Getting the Story Right
The real VHA story is ideological opposition by the right-and clinical excellence despite chronic under-funding. The main opponents of the Veterans Health Administration are congressional Republicans. This Republican opposition is odd, since Republicans go to great lengths to demonstrate their support for Americans in uniform. But when vets return home and are hidden from view, the right short-changes their care and then blames the VHA. During the Senate debate about the $24 billion Department of Veterans Affairs allocation, for example, Alabama Senator Jeff Sessions echoed the sentiments of his fellow Republicans, insisting, "I don't think our veterans want their programs to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America." Has he asked any vets about that?
The long-term Republican goal is to privatize the VHA, a policy that would cap costs, increase middleman profits, reduce the efficiencies of a fully integrated system, and drastically cut care. Only six months after Congress allocated funds devoted to increasing access to VHA services, the results of its own $8 billion shortfall were clear. Because of its successful efforts to provide more services to more veterans, the VHA was facing a budget gap and asking for another $2.5 billion. As Deputy Secretary of Veterans Affairs Sloan Gibson tried valiantly to explain at a June 25 hearing of the House Committee on Veterans' Affairs, the VHA has so successfully addressed wait-time problems that it has now added 7 million more patient appointments and increased the number of patients receiving treatment, in some places by almost 20 percent. That success, obviously, increases costs.
But within the Republican caucus on both sides of Capitol Hill, this rise in costs was more proof of the VHA's dysfunction. House Speaker John Boehner of Ohio fulminated: "The VA's problem isn't funding-it's outright failure. Absolute failure to take care of our veterans." No injection of funds, he opined, can fix the department because it is just "a mess."
(Photo: AP/Cliff Owen)
Meanwhile, Florida Republican Jeff Miller, new chair of the House Veterans' Affairs Committee, accused the VHA of "a startling lack of transparency and accountability." On July 21, 2015, in an op-ed in the Pittsburgh Post-Gazette, Miller went even further, accusing the Department of Veterans Affairs of "years of mismanagement and a blatant lack of transparency and accountability. The department can't seem to meet any of its vital responsibilities-providing health care, approving disability benefits and constructing hospitals-without going billions over budget and falling years behind schedule."
On July 22, McDonald appeared at another hearing before the House committee. He explained why the shortfall had reached $3 billion and suggested various ways to sort out some irrational practices that Congress had built into the Veterans Affairs budgeting practice, which gave Miller another opportunity to attack the veterans' health system.
After these show-trial hearings, Congress did give the VHA a temporary budgetary reprieve, by funding the shortfall. Even so, the new anti-VHA narrative, so popular with would-be GOP privatizers of the VHA, now dominates the public imagination. When I tell my liberal and progressive friends that I am writing about VHA health care, I invariably get some version of "Oh, that must be so depressing." Can you blame them? While the media and congressional Republicans gleefully jump on any hint of problems at the VHA, news about its innovations in care rarely makes the headlines. Like many members of the media, most people don't understand how difficult it is to care for the very particular population of veterans the VHA actually serves. Moreover, few politicians and pundits understand or acknowledge that many of the problems the VHA faces reflect the skewed priorities of both our broader health-care system and the institutions that educate its future professionals.
In fact, confusion about veterans' health care is so profound that many veterans themselves don't understand which branch of the Department of Veterans Affairs, or of the government, is responsible for either their good or bad experiences.
Many think that the Department of Veterans Affairs, commonly known as the VA, is actually one unified agency, when in fact it is comprised of three different branches. There's the VHA, which is the health-care system. Then there's the Veterans Benefits Administration (VBA), which determines who is eligible for what benefits, which include the Medical Benefits Package, disability compensation, pensions, the GI Bill, survivor benefits, and home loans, among other things. Then there's the National Cemetery Administration, which is in charge of burials and cemeteries. Another central player in VHA health care is the Department of Defense, which issues discharges from the military and determines the five discharge categories that underpin eligibility for VHA health care. In many instances, veterans attribute delays in getting health care to the VHA, when the hold-up may be with the VBA or the Defense Department's determination of a veteran's discharge status.
A Research Powerhouse
With its salaried staff of about 250,000, the Veterans Health Administration is the nation's largest and only publicly funded, fully integrated health-care system. Its 150 hospitals, 819 clinics, 300 mental-health centers, and other facilities-many located in rural areas that the private sector ignores-care for more than 230,000 people a day. As Longman describes in his book, the VHA was the first health-care system to develop, implement, and embrace the kind of health-care information technology that other hospitals and health systems are now trying-with far less success-to utilize.
One of the VHA's primary missions is research, and with its high number of enrollees it has become a research powerhouse that produces scientific advances that benefit all Americans, not just veterans. To cite just two examples, the VHA, in partnership with the National Institutes of Health, conducted the studies to prove that the shingles vaccine-which millions of senior citizens now take-was indeed safe for all Americans. VHA researchers also did pioneering work documenting that post-surgical mortality was reduced when patients with known cardiac risks were given beta-blockers before surgery. Now this is standard practice not only for veterans, but for all patients who undergo surgery. The VHA recently launched the Million Veteran Program to study how genes impact health. Needless to say, findings will not be limited to the use of veterans alone.
Long before the cost-effectiveness of palliative and hospice care was better recognized elsewhere, the VHA was providing some of the best services in the country to people with advanced and terminal illnesses. Although it took the federal government far too long to officially recognize post-traumatic stress disorder (PTSD), VHA psychologists, psychiatrists, and social workers have developed pioneering treatments that are the gold standard for anyone suffering from PTSD today. The VHA is also the pace-setter in diagnosing and developing new understanding of traumatic brain injury (TBI) and chronic traumatic encephalopathy; its institutional research and knowledge is now benefitting victims of pro-football head-banging that occurs far from any foreign battlefields. Its Polytrauma System of Care is also pioneering new methods of rehabilitation for TBI.
The VHA is a leader in the use of telemedicine for patients suffering from both mental and physical illness-a development recently featured on the front page of The New York Times (without, of course, mentioning any VHA role in it).
Health Care For the Old
With the exception of Medicare or Medicaid (which are not integrated delivery systems), no other health-care system cares for as many older and poorer patients as the VHA. Because of the pattern of America's participation in various wars, most of the veterans the VHA serves are far older (the average age in 2012 was 62) than the typical patient. Older people, of course, are more challenging to treat, and vets have more medical conditions than most. Go into a waiting room at a VHA hospital or clinic anywhere in the country, and you will not see a mix of older and younger patients. You'll see a bunch of guys proudly wearing baseball caps that say "Vietnam Veteran," or "Korean War Veteran." There will even be the occasional octogenarian or even nonagenarian, but you will see very few people under 40-and of course there will be hardly any women. (This is not only because fewer women serve in the military, but also because female veterans now benefit from a new push to serve women more effectively through a system of women's clinics, which have their own separate spaces within larger facilities.)
Because Congress has not allocated sufficient funds to provide health care to all 22 million American veterans, the VHA also has had to institute an overly complex system of eligibility requirements that assure that the system cares for the sickest and poorest-and actually excludes some of the healthiest and wealthiest-veterans. To be one of the estimated nine million veterans who currently have the highest priority of eligibility for the VHA's full Medical Benefits Package, veterans must have an honorable discharge. Not all eligible veterans have to have been in combat, but all of them-if they served after 1980-must provide evidence that they have some health problem related to their service-known as a "service-connected disability." The level of service connection-the scale goes from 10 to 100 percent-covers a spectrum that goes from, say, back strain or knee injuries caused by carrying 60-to-100-pound packs during basic training or combat, to more serious, chronic conditions like diabetes, heart disease, multiple myeloma, and amyotrophic lateral sclerosis (ALS, or Lou Gehrig's Disease) from which Vietnam vets exposed to Agent Orange now suffer, or the traumatic brain injuries or amputations suffered by those who served in Iraq or Afghanistan. Many combat veterans may have physical and mental illnesses for which they need treatment-in fact, veterans suffer from mental illness at a higher rate than the general population, and also have a higher toll of chronic illness. An estimated 16 percent to 30 percent of combat veterans, for example, have PTSD, as do many female veterans who have been victims of military sexual trauma.
Apart from Medicaid, no other health-care system in the U.S. treats as many poor and low-income patients-many of whom are unemployed and homeless, not to mention mentally and physically ill, or abusing drugs, alcohol, and other substances.
The Department of Veterans Affairs doesn't only provide health-care services to these low-income or homeless veterans; it also provides them with social and legal support. In 2012, the department launched its Housing First program to assure that even veterans who were abusing alcohol or drugs or had other unaddressed health-care needs could find shelter, which will hopefully make it possible for them to address other serious health problems.
It is ironic that the VHA has gotten a reputation for failing to reach out to and welcome new veterans as patients. The real culprit is Congress, which keeps narrowing eligibility. While some outreach efforts may have lagged in some specific places, I have been repeatedly impressed by the amount of outreach that is done on a daily basis to recruit new veterans and make sure those already enrolled have access to services. For example, I followed a VHA social worker who spends her days patrolling the streets of San Francisco trying to find homeless veterans who were not connected to the VA. She and other social workers all over the country also make sure that veterans in board-and-care homes, shelters, and transitional housing facilities are not being exploited by the kind of unscrupulous "entrepreneurs" who prey on the poor, mentally ill, and homeless.
In West Haven, Connecticut, I recently visited a remarkable program called the Errera Community Care Center, which provides intensive services for mentally ill and homeless veterans, including not only finding them permanent shelter but also landing vets jobs and getting them connected to primary-care medical providers. Over and over again, in VHA hospitals and clinics all over the country, I have watched clerks, nurses, and primary-care providers practically walk veterans to appointments, call them to remind them about this or that service, and even visit their homes to make sure they are safe.
(Photo: Toby Talbot)
A Veterans Administration psychiatrist looks at a monitor showing his image, part of a 2010 pilot project in which psychiatrists and psychologists at the VA Medical Center in White River Junction, Vermont, counsel patients remotely via webcams. The VHA has been a leader in the use of telemedicine to reach distant patients.
At the West Haven VA, I spent a day at one of the system's 13 Blind Rehabilitation Centers. These residential facilities serve some of the 157,000 veterans who are legally blind or the one million who suffer from the kind of low vision that makes it difficult for them to navigate daily life. Here, veterans whose private-sector ophthalmologists or optometrists may have dismissed their particular ocular disease by saying, "There is nothing further to be done," spend multiple weeks in an inpatient residential program learning how to function in daily life. Therapists-who have themselves spent hours wearing goggles or glasses that simulate the vision problems of their patients-teach them how to walk with a cane, cook, do leather or woodwork, or use computer programs that are specially designed to allow them to recover daily function. When they return home, they take special microwaves, iPads, iPhones, computers, or other equipment with them, courtesy of the VHA. The private sector does not offer any similar inpatient residential program with such extensive benefits.
Battle-Related Trauma
In most health-care systems, younger patients are usually the healthiest and least expensive. Not so in the VHA. Veterans from the recent wars in Iraq and Afghanistan suffer from battle-related trauma that may, in the years to come, dwarf the physical and mental-health problems of those who served in Vietnam. Because of the military's successful system of battlefield hospitals and triage, these young men and women have survived trauma and injury that would have quickly killed those in prior conflicts. And because of their combat experiences and multiple tours of duty, many also suffer from PTSD, traumatic brain injuries, and perhaps even amputations-in other words, polytrauma. One in six veterans who served in these conflicts also has a substance abuse problem.
The VHA has waived its standard eligibility requirements and is providing care to post–September 11 veterans for five years after they leave the military. After that, it will continue to provide care for any service-related conditions. Some of the veterans I have interviewed include men who have lost a leg or an arm and who are fitted with state-of-the-art prosthetics-usually unavailable in the private sector-not only for daily but also for athletic use as well. Others-like a 28-year-old who spends his nights at home on guard duty, patrolling the perimeter, by checking the locks on the doors to make sure no one can get in-may receive intensive, inpatient treatment for PTSD.
In 2010, the VHA launched a program to support caregivers who are tending to post-9/11 veterans with mental or chronic physical illnesses at home. In our larger health-care system, family caregivers are essentially on their own when they care for a loved one who has a major mental-health or physical disability. Many are rewarded for their service by loss of jobs or promotions, and may eventually sacrifice their own health because of the emotional and physical stress of their caregiving burden. The program provides these caregivers with training, supportive services-including mental-health counseling-and even financial stipends to help them shoulder their burdens. Why does the VHA take on this long-term commitment? Because the VHA has a lifelong commitment to its patients and their families, it recognizes that it is cost-effective to help keep the veteran in his or her home rather than paying for hospital or nursing-home care.
Despite the fact that the VHA has an expensive and challenging population to serve, it does so at a far lower cost than would be incurred if the private sector were to provide the same services.
Although it is difficult to compare VHA care to the private sector because so many veterans have so many more severe problems, a 2004 RAND study documented that, at least in 1999, the full range of services the VHA provided would have cost 21 percent more in the private sector.
Inpatient care in the private sector would have cost 16 percent more, outpatient care 11 percent more, and prescription drugs a whopping 70 percent more. These estimates were based on Medicare and Medicaid payment methods.
The VHA can produce these savings because the government negotiates lower prices with the pharmaceutical industry, physicians and other health-care providers are paid on salary and don't have an incentive to over-treat, and care is more focused on prevention, early treatment, and patient function, which saves money over the long term. And of course, there are no for-profit middlemen, as in the private, partly for-profit, insurance-based system.
There are no current studies comparing costs in the VHA with the private sector. It may, however, be safe to assume that if private-sector providers were to provide an equivalent level of service (and that is a very, very big "if") to aging veterans as well as those returning from America's current wars, the costs would be astronomical. Some critics of the VHA insist that it is too costly to provide the level of services I have described. In his Senate testimony on his February 2014 budget request, Bernie Sanders eloquently addressed this critique: "When our men and women come home from war, some wounded in body, some wounded in spirit, I don't want to hear people telling me it's too expensive to take care of those wounded veterans. I don't accept that. If you think it's too expensive to take care of veterans, don't send them to war."
A Primary-Care Shortage
To care for these veterans requires not only money and time, but people. And herein lies one of the VHA's most serious problems-one that helped produce the wait-time problem in 2014. To hire enough staff-particularly primary-care physicians (PCPs), nurse practitioners, and physician assistants-the VHA depends on the supply produced by medical schools and residency programs and other health-care professional schools. The ability to recruit also depends on health-practitioner choices.
(Photo: AP/Rich Pedroncelli)
The American health-care system has long had a primary-care crisis. Only about 20 percent of medical students choose to go into primary care, where salaries are lower. When the VHA tries to recruit new PCPs, it has only a very limited pool from which it can pull. For its primary-care providers, the VHA is also in competition with institutions that may offer higher salaries, and with market newcomers like doc-in-the-box shops such as CVS or Walmart, who lure nurse practitioners with the promise of salaries $30,000 or $40,000 higher than those paid by the VHA. Any problems the VHA has recruiting for "rural or out-of-the-way posts," as the Times described it, are not unique to the agency but reflect the broader health-care system's long-standing difficulty convincing physicians-and even nurse practitioners-to practice in rural settings. Specialists in the private sector also earn far more than they do at the VHA.
The negative media attention the VHA has received has not helped this or any other kind of recruitment. At the VHA, health-care professionals do not experience the kinds of insurance-company denials and hassles that plague those in the private sector. In VHA primary-care clinics, providers can actually spend more time with their patients: Patient panels in the VHA average 1,200 patients, compared to 2,000 to 3,000 in the private sector, which translates to half an hour per visit rather than 10 to 15 minutes. VHA physicians also save on malpractice since they do not have to pay for that kind of insurance coverage. These are not facts promoted by media outlets that have repeatedly portrayed demoralized and depressed department staff.
Far from being demoralized by their patients or their work at the VA, most of the staff I have talked to actually can't imagine working in the private, for-profit system.
Many have, in fact, fled that system because they could not stomach the restrictions imposed on their time with patients or the pressure to make choices dictated by institutional bottom line rather than needs of patient care. As one VHA physical and occupational therapist told me: "In the private sector, even with the best insurance, you get to give a patient either a walker or a wheelchair but not both. Here, I can give this veteran both, and I can design a shower chair especially for him."
Or as Andrew Budson, a neurologist who is a clinician, researcher, and the associate chief of staff for education at the VA Boston Healthcare System (truth in advertising, he's also my cousin) explains: "I don't have the same kind of minute-to-minute pressure that they have in the private sector in terms of generating Relative Value Units (otherwise known as patient visits). Obviously here, people have to be productively occupying their time. But if you need to spend ten more minutes with a patient, you may be able to prevent a hospitalization. There aren't the same pressures as I know my colleagues [have in the private sector], where they have to see patient after patient after patient."
Defending a Public Good
The failure of the media and politicians to present a balanced and accurate picture of our nation's only public, nationally integrated health-care system could not come at a worse time.
The Affordable Care Act has fallen far short of full coverage of the previously uninsured. The recent Supreme Court decision upholding the ACA could, under a very different Congress, lead to reform efforts to address the growing risk of cost-shifting to patients and the money wasted on insurance-industry middlemen and expensive fee-for-service, but often futile, care.
If, however, too many Americans have concluded, based on mixed ACA experiences and erroneous media reports about the VHA, that government is incompetent in matters of health-care reform and administration, that does not bode well for the systemic changes we still very much need. The fact that a federally run, direct-service program actually delivers cost-effective and appropriate care could help counter such damaging public perceptions. If we listen to them, one of the most respected parts of the population-vets-consistently attests to the positive experiences that most such patients and their families have had, over the years, with this remarkable system.
To find a better health-care model, we don't have to turn our gaze north, in the usual direction, to Canada, or across the pond to the UK and other European countries, or even limit ourselves to calling for "Medicare for all." Eight million of us already have something better than Medicare and more akin to the UK's National Health Service, right here, in America-with the private-insurance industry almost completely eliminated from the equation. The real question we need to ask was posed just last month by an obviously impressed UK physician, during an NHS study visit to the VHA in West Haven: "Why," he wondered out loud, "do you have to be a veteran to get this level of care in America? Why isn't it available to all Americans?" Why indeed.
