Suzanne Gordon

Suzanne Gordon is a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. One of her latest books is Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Her website is

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Hill Hearing Spells Bad News for Veterans

Not a single veterans service organization was asked to speak last week at the House Veterans Affairs Committee’s hearing on the final recommendations of the VA Commission on Care, though such groups represent millions of former military personnel.

Also noticeably absent from the witness list was Vietnam veteran Michael Blecker, executive director of the San Francisco veterans group Swords to Plowshares, who served on the Commission on Care, and who dissented from its final report. Blecker objected that the commission’s leading recommendation—the creation of a so-called VHA Health System network of private-sector care providers—could fatally weaken veterans’ health care.

Instead, Committee Chair Jeff Miller, a Florida Republican, invited only two people to testify before the panel: Delos “Toby” Cosgrove, vice chair of the commission and CEO of the Cleveland Clinic, and Commission Chair Nancy Schlicting, who is CEO of the Henry Ford Health System. Miller happens to be a faithful supporter of Donald Trump, who has touted the VA committee’s chairman as his top pick as secretary of veterans affairs in any Trump administration.

While Schlicting has expressed support for the VHA, Cosgrove was one of the leaders of a commission faction—what some have dubbed the “Strawman” group—that favored the complete elimination of the VHA.

At the hearing, which took place on September 7, Cosgrove and Schlicting both expressed enthusiasm for creating a VHA Care System that ostensibly would create a network of private-sector providers to deliver health care to veterans while also somehow integrating them into the VHA. The report estimates that this system would eventually channel up to 60 percent of veterans into private-sector health care, and even acknowledges that the new setup would potentially weaken the VHA itself.

Alarmingly, all the Democrats on the committee—with one notable exception—voiced support for this general policy direction, albeit with less ideological fervor than Miller and his GOP colleagues. The one committee member who spoke out against the plan—fortunately for veterans—was ranking Democrat James Takano, of California, who expressed serious reservations about the proposed VHA Care System, and echoed concerns about it that have already been raised by President Barack Obama and by VA Secretary Robert MacDonald.

The other panel Democrats came across as shockingly misinformed, and offered such VHA fixes as Texas Representative Beto O’Rourke’s argument that the VHA should only concentrate on service-related mental and physical health conditions, rather than routine primary care. If treatment of veterans were limited in this fashion, many service-related conditions that experienced VHA providers now identify in primary care visits would go undetected. Such conditions would be far less likely to be diagnosed by private-sector providers, who often have little knowledge of military/veteran problems. As Blecker has pointed out, if Vietnam veterans were dependent on the private sector, PTSD and problems related to Agent Orange, which the VA itself took too long to identify, may never have been recognized and researched at all. (Having learned from its Vietnam experience, the VHA has been quick to identify and act to treat traumatic brain injuries, the signature injury of the wars in Iraq and Afghanistan.)

Also alarming was Veterans Affairs Committee members’ bipartisan embrace of the recommendations by Cosgrove and Schlicting that the VHA abandon its highly successful in-house system of electronic medical record-keeping (which it is working to improve) and replace it instead with commercial products. Lobbyists for companies that produce these systems have spent millions urging hospitals to purchase their wares—despite the fact that, as a large body of research has documented and as a recent JAMA editorial underscored, they have largely failed to fulfill their promise of creating safer and more efficient health care. 

“The systems being proposed for purchase at the VHA have been widely disparaged by medical professionals and patient safety advocates for their lack of user friendliness, failure to consider clinical workflow and [prioritization] of billing information over care,” Ross Koppel, an expert in health-care information technology at the University of Pennsylvania, told The American Prospect.

During the hearing, no member of Miller’s committee expressed concern about the estimated 300,000 veterans whose military discharges—sometimes due to service-related mental health problems—leave them barred from the VHA. The Commission on Care recommended that some veterans with other than honorable discharge receive tentative eligibility for health-care services.

All in all, it was disappointing day for vets on Capitol Hill. It was also a warning of what’s in store for veterans if Trump, who has not only floated Miller as VA secretary but has revealed his own ignorance of veterans’ health-care issues, becomes commander-in-chief on Election Day.

Studies Show Veterans Health Care Improving

When the House Veterans Affairs Committee holds a hearing on September 7 to assess the future of the Veterans Health Administration, federal lawmakers would do well to consider recent reports that challenge the continual drumbeat of negative and often unfair coverage and congressional criticism of the VHA.

One report, from the RAND Corporation, said that while there were differences in care and leadership culture across the system, researchers “did not find evidence of a system-wide crisis in access to VA care.” In fact, the report identified congressional policies as one of the main barriers to VHA improvements (despite the Veteran Affairs Committee Chairman Jeff Miller’s apparent belief that firing VHA leaders is the solution to any access problems). The report noted that “inflexibility in budgeting stem[med] from the congressional appropriation processes,” and concluded that the hastily designed and implemented Veterans Choice Program, “further complicated the situation and resulted in confusion among veterans, VA employees, and non-VA providers.”

Though it received no media attention, another positive report on the VHA came this month from the Joint Commission, the independent nonprofit that accredits U.S. hospitals and health-care organizations. After surveying the VHA between 2014 and 2015, the commission found improvements in access, timeliness, and coordination of care, as well as in leadership, safety, staffing, and competency.

Finally, the Association of VA Psychology Leaders, the Association of VA Social Workers, and unions representing VA employees issued a policy brief opposing the Commission on Care’s proposal to create a new VHA Care System, which would ultimately channel up to 60 percent of eligible veterans into private-sector health care. Two independent national groups, the American Psychological Association (APA) and the National Association of Social Workers, also signed the policy paper.

In an email, Heather O’Beirne Kelly, the APA’s lead psychologist on military and veterans policy, told The American Prospect that the APA “is opposed to the primary recommendation of the Commission on Care’s report, which we feel would in effect disassemble one of the most successful, innovative features of current VA care: the primary care/mental health integrated approach.”

Every report on the VHA over the past two years has documented that the system provides care equal to or superior to private-sector care, and have spotlighted significant improvements in problematic practices that led to two years of scandal-mongering on Capital Hill and in the national media. But instead of lauding the VHA for its progress and working to sustain the system, federal lawmakers and critics are quick to jump on any hint of a glitch and lambast the VHA for not changing more rapidly, steadfastly ignoring the fact that changing the culture of any institution, particularly that of America’s largest health-care system, must take years.

Sustained improvement will also require transformations in the congressional budgeting process and dramatic shifts in health-care policy. As The New York Times reported in 2014, shortages in the physician workforce have made lengthy waits to get an appointment “the norm in many parts of American medicine.” If Congress is serious about protecting veterans, it must immediately appropriate more money so that VHA can offer salaries competitive with those in the private sector, as even the Commission on Care recommends, and allocate more medical residency training slots to primary, geriatric, and palliative care. 

The narrative of a VHA that is broken beyond repair that the news media and some federal lawmakers insist on does not acknowledge that the VHA is a national or global leader in fields like telemedicine, mental health, primary and geriatric care, and reducing opioid use. Why would anyone want to work in a system depicted as broken beyond repair, doomed to disappear, and filled with demoralized staff? That overwrought story discourages nurse practitioners, social workers, psychologists, and other professionals from working at the VHA.

Report: VHA Care Commission Recommends Private-Sector Options

As conservatives and congressional Republicans seek to dismantle the Veterans Health Administration, members of the commission called for giving veterans more private-sector options.

(Photo: AP/Mark Thiessen)
(Photo: AP/Mark Thiessen) The Veterans Administration Outpatient Clinic in Anchorage, Alaska A fter almost a year of meetings and hearings, the Commission on Care has finally issued its report on the future of the Veterans Health Administration. “Care delivered by the VA,” the congressionally mandated report states, “is in many ways comparable or better in clinical quality to that generally available in the private sector.” But with problems in accessing services, in variations in care, and in the managerial culture at various facilities, the commission believes that the major remedy lies not in outright privatization but in giving veterans more private-sector options, a finding that veterans groups fear may also weaken the decades-old system. One of the commission’s most complex and potentially problematic recommendations involves the creation of a “VHA Care System,” that would integrate private-sector providers into a VHA-supervised network. The network would service only those...

Union Conducts Nationwide Anti-VHA Privatization Protests

The American Federation of Government Employees (AFGE), the largest labor union representing federal and District of Columbia government workers, announced Tuesday that about 40 anti-VHA privatization rallies will be held nationwide. The move comes as the VA Commission on Care, the congressionally-mandated body tasked with making recommendations about the future of Veterans Health Administration, closes in on an early July release date for a report on the agency’s future.

The Veterans Council of the AFL-CIO and the Roosevelt Institute, a New York-based think tank, held a conference, “Keeping the Promise: What’s Next for the VA” in Washington last week. National health-care experts, VHA officials, and the directors of five veterans service organizations (VSOs), outlined what veterans stand to lose, if the VHA is privatized, which is precisely what one group of commission members (the so-called Strawmen), who represent the hospital industry and the Koch Brothers-funded Concerned Veterans for America, has proposed.

VA Undersecretary for Health David Shulkin and top VHA research, teaching, and clinical services officials described the VHA’s progress in improving access to VHA services. The VHA’s Million Veteran Program, which amasses health care and genetic information on hundreds of thousands of veterans, will be making significant contributions in efforts to individualize treatments for a variety of medical problems facing Americans. The VHA is a global leader in telehealth services, which allow providers to connect with patients who live miles away from a clinic or hospital. This type of care brings much-needed services to underserved areas, particularly in the 55 percent of rural counties that lack a single psychiatrist, psychologist, or social worker, according a recent HRSA report.

Terri Tanielian, a senior social research analyst who served as director of the RAND Center for Military Health Policy Research for more than a decade, delivered a key message. She debunked the idea that private sector mental health providers can adequately care for the nation’s veterans.  

Tanielian explained that a recent RAND study, “Ready to Serve,” found that only 13 percent of the nation’s mental health providers have an understanding of military culture or an awareness of the appropriate kinds therapies for civilian patients with specific mental health concerns. If mental health providers cannot provide suitable therapy regimes for civilians, how can they care for veterans with complex, military-related problems?

The VHA’s Marsden McGuire, the VA’s deputy chief consultant for mental health care, explained that the agency provides “wraparound services that other health care systems cannot.” In 2014, The American Journal of Public Health devoted an entire issue to VA programs like the national system of Veterans Courts that help veterans avoid or shorten jail or prison terms through housing, employment, and substance abuse programs. These measures go a long way to explain why, when surveyed, veterans overwhelmingly support the VHA, according to Joshua E. Ulibarri of Lake Research Partners Veterans.

According to Garry Augustine of the Disabled Veterans of America and other groups, veterans fear that a fragmented private-sector system will deliver inadequate care. They believe that private-sector providers have little or no understanding of their specific problems and are too often motivated by profit rather than interest in individual veterans.

Sherman G. Gillums, executive director of the Paralyzed Veterans of America and Marine Corp veteran who was paralyzed when a vehicle rolled on top of him, told The American Prospect that many of the VHA’s current problems stem from congressional underfunding and inaction. “It is Congress’s job to fund the VA and provide oversight of its functions,” he said. “The Independent Budget [a group of VSOs that submit recommended funding levels for and policy recommendations about the VA to Congress every year] have lamented the shortfalls in VA construction, information technology, staffing budgets year after year.” 

Capitol Hill also came in for criticism from Kenneth W. Kizer, a former Clinton administration VA undersecretary, who warned that relentless attacks on the VHA over the past decade have exacerbated the agency’s insularity. “You don’t create organizational excellence by focusing on how many people you’ve fired, which [is] driven by Congress, and is too much of a focus of current VA leadership,” he said.

Representative Tom MacArthur, a New Jersey Republican, has sponsored a bill that could eventually privatize VHA mental health; Senator John McCain, the Arizona Republican, supports a bill that would make the Choice Act permanent and eliminate its restrictions; and new legislation from Representative Cathy McMorris Rogers, a Washington state Republican, who chairs the House Republican Conference would also speed up privatization of VHA services. Twenty-six VSOs sent a letter Tuesday to McMorris Rodgers protesting her proposal.

The AFGE and veterans groups are counting on the organized protests to force Congress and the commission to reassess its positions. If efforts to privatize the VHA persist, protests will likely continue throughout the summer. 

McCain Pulls a Bait-and-Switch on Vets

Almost as soon as Senator John McCain had finished working with Senator Bernie Sanders to craft the veterans’ health-care bill now known as the Choice Act in 2014, the Arizona Republican set out to renege on his promise that Choice would be temporary, and began floating plans to make it permanent. 

Part of the Choice Act was the establishment of the Commission on Care, whose deliberations the Prospect has covered extensively. This week that Commission is meeting to hammer out its final report, which will include recommendations about what the VHA should look like in 20 years. Instead of waiting to see what the Commission mandated by his own bill recommends, McCain has once again jumped the gun. He is lobbying hard for a bill that would not only make the Choice program permanent, but would eliminate any restrictions on veterans’ access to private-sector health care.

McCain’s gift to veterans is a bill misleadingly labeled The Care They Deserve Act. The subject of hearings on Capitol Hill the week of June 23, the bill would make the Choice Act—a three-year experiment enacted following revelations of delays in care at VHA facilities in Phoenix and elsewhere—permanent. Choice allows veterans to seek care from private-sector health-care providers if they face more than a 30-day wait for an appointment, or trips of 40 miles or more to the nearest VHA facility.

Under McCain’s new plan, the nine million veterans eligible for VHA care would be free to use any private health-care facility or provider, for any form of service, with the federal government paying the tab—no questions asked. McCain has gathered seven other Republican sponsors for his bill, all of them pushing the new conservative narrative that the VHA is broken beyond repair. This, of course, ignores reports by a Choice Act-mandated Independent Assessment of the VHA, which documents that its veteran/patients actually receive better care, at lower cost, than millions of Americans who rely on private sector health care.  

What’s wrong with The Care They Deserve Act? Just about everything, which is why many veterans service organizations like the Disabled American Veterans (DAV) and Vietnam Veterans of America oppose the plan, and why the VHA’s own undersecretary for health, David Shulkin, has proposed a more sensible alternative. 

Economists advising the Commission on Care estimate that McCain-style privatization could triple the cost of veterans’ care to almost  $450 billion a year—money that would not be well spent. The VHA’s clinicians and other staff specialize in the complex health problems related to military service, and deal with patients who are older, sicker, and poorer, with more mental health problems that those cared for in the private sector. The average elderly patient in the private sector shows up presenting between three to five physical problems. The “co-morbidities” of a Vietnam vet, for example, can number from nine to 12. That’s why VHA primary care providers spend at least 30 minutes with their patients per visit, compared to the ten or 15 minutes allotted to patients in the private sector. Will private sector providers want to take the time to care for aging, sometimes homeless, often mentally ill, veterans? Even if they do, will they be able to detect the difference between ordinary type 2 and Agent Orange-related diabetes, or be equipped to parse the myriad symptoms of PTSD?

McCain’s bill promises veterans a choice between VHA and private sector care. In reality, it would ultimately erode choice by weakening the VHA option, putting the entire veterans’ health system at risk. The VHA’s current budget is determined by how many veterans use the system and for what services. If far more eligible veterans start using private sector health care, there will be less funding available for VHA services that are unavailable elsewhere, and for maintaining the agency’s highly specialized research and clinical expertise in military-related health problems. As funding for costly private sector care eats up more of the VHA’s annual budget, there will be hospital and clinic closings, along with VHA staff layoffs. To reduce expenditures on veteran health care, Congress may also be tempted to make eligibility for veterans’ health-care benefits even more restrictive than it is today.

If Congress wants to improve the VHA, it should embrace the reform proposals of Shulkin and those Commission on Care members who want to allow veterans access to private sector providers in networks coordinated by the VHA. With luck, this recommendation will appear in the Commission’s June report. Strengthening the VHA, and giving veterans the choice to see outside providers if necessary, would really give veterans the care they deserve.