After 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 veterans eligible for VHA services. Currently, about nine million veterans have been able to establish VHA eligibility; that is, they have health problems connected to their military service or a low-enough income to qualify for enrollment.
The commission recommended that veterans who are VHA-eligible would choose a primary care provider who, in turn, would refer them to specialists. These primary care doctors or specialists could work within the VHA or go outside the VHA to be providers who contract with the agency.
The VHA would be required to create a network that includes all providers who take care of veterans. The agency would have to screen and then contract with community or private-sector providers and ensure that those providers use information-technology systems that are compatible with the VHA’s networks. The VHA would also have to make sure that those providers understand military culture, and would be responsible for coordinating the care veterans receive and helping them navigate the system.
Coordinating care will not be easy. The commission found that veterans who are treated in the VHA do receive coordinated care while those with private plans, Medicare, or TRICARE receive care that is of “lower quality, threatens patient safety, and shifts costs among payers.”
The commission also suggests revising the byzantine VA eligibility requirements that deny benefits to veterans who were “dismissed from military service with an other-than-honorable discharge because of actions that resulted from health conditions (such as traumatic brain injury, posttraumatic stress disorder, or substance use) caused by, or exacerbated by, their service.”
The VHA needs more funding for competitive salaries, which will help recruitment and retention of professional staff. Since there are nationwide shortages of certain health-care professionals, recruiting will not be easy.
The commission estimates that over the next few decades, about 40 percent to 60 percent of veterans will receive some, if not all, private-sector, health-care services. Treating fewer patients could significantly compromise VHA care if health-care providers cannot maintain their clinical skills.
Those developments could also discourage health-care professionals from working in or staying with the VHA, which could lead to closing some facilities. “Reductions in volume of care within VA facilities, and potentially adverse effects on quality” are not addressed, the report notes.
The commission’s recommendations are a product of a fractured political divide within the commission itself. Members who supported the VHA constantly fought with hospital-industry executives as well as representatives of the conservative Koch brothers–funded Concerned Veterans for America (CVA), the so-called Strawman group, which advocated dismantling VHA. Darin Selnick and Stewart Hickey, commissioners who were both connected to CVA, refused to sign the final report. They viewed it as weak on privatization.
Two other commissioners had differing views. Michael Blecker, a Vietnam veteran and executive director of Swords to Plowshares, a San Francisco–based veterans organization, refused to sign the document because of serious concerns that the proposed health-care system “would threaten the viability of VA care for millions of veterans who rely on it.” However, Philip Longman, author of Best Care Anywhere: Why VA Health Care Would Work Better For Everyone, one of the few studies of the veterans health-care system, supports the plan with some reservations. He believes it could bring more veterans into the VHA system and improve the quality of care.
To provide a stronger system, Congress would have to allocate more funds to allow the VHA to hire the necessary staff to provide direct care and handle all the demands of integrating private-sector contractors into the veterans health-care system. Without these resources, the integrity of the VHA will be compromised and the agency would face blame for poor care that veterans receive.
The pending VHA privatization bills proposed by Senator John McCain, an Arizona Republican, and Representative Cathy McMorris Rodgers, a Washington Republican (supported by Representative Jeff Miller, a Florida Republican and chair of the House Veterans Affairs Committee), obviously would not give the agency that leeway. Neither would Donald Trump’s plan to give all veterans vouchers for use in the private sector, which would effectively eliminate the VHA. Announced Tuesday, the plan has already sparked outrage from veterans groups and unions.
The news media will also influence future perceptions of the agency. Mainstream media outlets like CNN that use headlines like “Billions spent to fix VA didn't solve problems, made some issues worse” to describe the commission report help create a VHA-is-broken-beyond-repair narrative. Although The New York Times has been extremely critical of the VHA, its recent editorial opposing VHA privatization could turn what many veterans groups see as an anti-VHA bent in the national news media.
Finally, the commission report stresses that the VHA currently delivers some of the best care anywhere. Rather than just talking about teamwork, most VHA providers actually work in teams, communicate with one another on electronic medical records, and help patients avoid unnecessary and dangerous overtreatment. The VHA also provides some of the best services for mental health, rehabilitation, and homelessness in the country.
A plan that contributes to strengthening the VHA and improving the private-sector health-care system would be a positive development for veterans and all the rest of us. But if the deficiencies in the civilian health-care system begin to infect the VHA, millions of Americans will lose out.