Secretary of the Department of Veterans' Affairs, David Shulkin, has pledged not to privatize the Veterans Health Administration (VHA). He understands, he says, that the VHA's ability to provide care that, as studies document, is superior to those in the private sector is because veterans are treated in an integrated system that meets all their health needs. In testimony to the House Committee on Appropriations Veterans Oversight Hearing on May 3, Shulkin argued that unlike the private sector, the VHA "defines health far more broadly as physical, psychological, social, and economic." Such a "unique national resource … often cannot be found in the private sector."
In spite of this some of Secretary Shulkin's recent decisions are very troubling. In March, Shulkin announced that the VHA would begin providing emergency mental health services to veterans previously ineligible for them. While that coverage is long overdue, the VA's budget will likely push some already enrolled patients out of the VHA system and onto private providers. At the same time, Shulkin has proposed outsourcing optometry and audiology care to the private sector. In both cases, the changes threaten to jeopardize the kind of integrated services the VHA provides.
For years, the VHA has not been able to provide care to an estimated 500,000 veterans who have what are known as "other than honorable" (OTH) discharges (as documented by the San Francisco-based veterans service organization Swords to Plowshares). This is because a veteran's eligibility for VA benefits is determined by the kind of discharge they receive when they leave the military. Only those with honorable, general, or medical discharges qualify. Those with "other than honorable discharges" or "dirty or bad papers" are disqualified because they committed acts that, while not worthy of a court marshal, led to their discharge. In reality, many of these vets went AWOL, got into fights, abused drugs or alcohol, or had discipline problems because they had PTSD, suffered from military sexual trauma, or other conditions arising from their military service.
Shulkin has announced that he wants to provide these veterans with emergency mental health services if they are in crisis, but his position on funding the coverage is worrisome. During his Appropriations Committee appearance, Shulkin was asked how he would pay for caring for hundreds of thousands of veterans who may not have had health-care services for years, even decades. "Maybe this doesn't fit into the budget," he replied. "But frankly I don't care … I don't want more money for this. We're going to figure out a way to help these people and then connect them to community resources and get them help because this is the right thing to do."
Serving these veterans is definitely the right thing to do. But creating what could be an unfunded mandate may be the wrong way to do it. As Shulkin admitted during his testimony, the VHA is already short 1,500 mental health professionals needed to serve its currently enrolled patients. It will need more staff, and more inpatient psychiatric beds, and outpatient services to care for hundreds of thousands more.
"By definition, the veterans with OTH discharges need intensive mental health treatment because they will enter our system only when they are in crisis," one VHA psychologist, who asked to remain anonymous, told the Prospect. "Many will have to be admitted to inpatient units and not every facility has enough beds. They will also need intensive treatment. We want to help them. But we need the staff and funds to do it well."
Veterans with OTH discharges are also, by definition, ineligible to be referred to Choice care in the private sector, the psychologist explained. If the VHA does not have sufficient mental health staff to care for them, currently eligible veterans with mental health problems will face longer wait times or be pushed into Choice. They will thus be referred to private sector providers, who as numerous studies document, may not be trained to treat their complex, military related conditions.
More recently, Shulkin has proposed yet another way he may seek to privatize VHA services. Shulkin has told VA health-care directors from around the country that he wants to stop providing audiology and optometry services. "There are LensCrafters on every corner," the secretary reportedly commented. Not only would this impact the optometry and audiology training the VHA provides to future clinicians, it would curtail two of the most popular and cost effective services the VHA delivers.
Hearing problems from toxic noise exposure are, in fact, a primary reason veterans seek VHA care. VHA optometrists do more than prescribe eyeglasses. Among other things, they evaluate whether patients with impaired vision are eligible for the impressive services offered through the VHA's national system of 13 Blind Rehabilitation Centers.
And like all VHA employees, VHA audiologists and optometrists are trained to recognize if patients are at high risk for suicide. Would a technician at LensCrafters recognize that a veteran is seriously depressed and contemplating suicide if the patient (now customer) makes a stray comment indicating that he may not be around to collect his glasses?
Outsourcing public sector services and starving a public institution of necessary funding is one of the facilitators of privatization. The challenge facing Shulkin is how to respond to real needs and problems without setting in motion what Garry Augustine, executive director of the Disabled American Veterans, has called the "withering on the vine" of the VHA.
