Suzanne Gordon

Suzanne Gordon is a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. Her latest book is The Battle for Veterans' Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care. She has won a Special Recognition Award from Disabled American Veterans for her writing on veterans' health issues, much of which has appeared in The American Prospect. Her website is www.suzannegordon.com.

Recent Articles

The Hidden Irony of GOP Outrage over the VA Secretary’s Disney Comparison

Poor VA Secretary Bob McDonald. Neither he nor the Veterans Health Administration he oversees can ever catch a break.

On May 23, a reporter questioned McDonald about the VHA’s tracking of patient appointment times around the country. McDonald’s predecessor was forced to quit over allegations of appointment delays and a cover-up at a Phoenix VHA hospital, and McDonald has often been on the defensive about the issue as the agency tries to hire the additional caregivers needed for the influx of Iraq and Afghanistan veterans.

In his response to the reporter, McDonald suggested that in the meantime, the VHA’s performance should be judged by a broader set of metrics. “What really counts is how does the veteran feel about their encounter with the VA?” McDonald said. “When you go to Disney, do they measure the number of hours you wait in line? What is important is your satisfaction with the experience.”

Unfortunately for the secretary, his invocation of the Magic Kingdom triggered a pack-journalism social-media response. The Koch-funded Concerned Veterans for America (CVA), a leading advocate of VHA privatization, immediately denounced McDonald on its website. According to CVA, McDonald showed disrespect for all VHA patients: “The sacrifice that accompanies earning that care is not the same as the sacrifice of taking a road trip to Florida,” the CVA declared. “Shame on Bob McDonald for trivializing veteran wait times this way.”  

American Legion National Commander Dale Barnett was similarly offended. House Speaker Paul Ryan called the remark “disgusting” and “beyond the pale,” a sentiment shared by House Veterans Affairs Committee Chair Jeff Miller, a frequent critic of McDonald and ally of CVA in seeking to dismantle and privatize the VHA. There was even talk of calling for McDonald’s resignation.

After two days of negative news coverage, McDonald, a veteran himself, issued a clarification and apology to any veteran who felt his comments trivialized the VHA’s “noble mission.”

But lost in the Republican baying for more blood was a great political irony: Throughout private-sector health care, Disney’s corporate model for gauging customer satisfaction is now widely used to determine patient satisfaction and to regulate the patient “experience.”

Quality patient care requires an application of skills, experience, and teamwork quite different from the prerequisites for good “customer service” in the hospitality or entertainment industries. Yet treating sick people as “customers” has become part of mainstream management thinking.

The Disneyfication trend took off ten years ago after consultant Fred Lee published the bestselling If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently. Patient surveys using methods and metrics from resort hotels and amusement parks are now the norm in U.S. health care. A hospital’s results on the Hospital Consumer Assessment of Healthcare Providers and Systems standardized survey even determine, in part, its reimbursement rate for federally subsidized patients.

Disneyfication has spawned a huge crowd of high-priced consultants, like Lee, or Quint Studer of the Studer Group, who teach hospitals how to improve their patient-qua-customer experience to score well on questionnaires. As Studer puts it in his HCAHPS Handbook, hospital administrators need to “manage the patient’s expectations” to succeed, by convincing patients they are receiving good personal care—even if the hospital has poor nurse-patient ratios or lousy patient safety records.

In some hospitals, nursing staff trained and managed under this model have been forced to use scripts when interacting with patients and families. They are coached to smile and repeat words and phrases (such as “excellent care”) that administrators want to see echoed in patient surveys.

Some hospitals now designate an employee to be “chief patient experience officer” (CXO), a position enjoying executive status. As CEO of the Cleveland Clinic, Delos “Toby” Cosgrove, now vice-chairman of the VA Commission on Care, has overseen annual patient-experience conferences for the past seven years. Despite having both a CXO and a patient experience office, the Cleveland Clinic has been investigated for patient-safety lapses that almost resulted in the hospital’s suspension from the Medicare program. Some suspect Cosgrove withdrew his name for consideration as VA secretary because confirmation hearings would have led to negative publicity for the clinic.

Inappropriately treating—and, in fact, trivializing—sick patients as customers is a central feature of health-care corporatization, and represents everything the VHA has never been and should not become. If it’s not good for veterans, it shouldn’t be good for any of us. But that would mean Republican critics would apply the same standard to the VHA as they do to private-sector health care. Dream on.

Veterans’ Groups: Don’t Scrap the VA’s Health Care System

As they meet again in Washington, D.C., this week, the congressionally mandated Commission on Care, tasked with determining a 20-year strategic plan for the Veterans Health Administration, would do well to heed the voices of veterans and veterans service organizations that it has too often sidelined from its deliberations.

In its April meeting, the commission heard from leaders of the largest veterans service organizations (VSOs)—Veterans of Foreign Wars, the American Legion, Disabled American Veterans, Iraq and Afghanistan Veterans of American, Vietnam Veterans of America, Vietnam Veterans of America, Paralyzed Veterans of America, Got Your Six, and Military Officers Association of America. All of them adamantly rejected the dismantling of the VHA, which had been recommended by seven of the commission members in their so-called Strawman Document. 

What the VSO representatives argued for was a program like the one VA Undersecretary for Health David Shulkin has proposed. Within limits, veterans would be able see private-sector providers who have been vetted by the VHA. The VHA would still coordinate the care they receive, thus attempting to integrate private-sector providers into a larger VHA network.

What these VSOs do not want is the kind expansion of the current Choice program envisioned in new legislation proposed by Senator John McCain and sponsored by seven other Republicans. The Permanent Choice Card Act would eliminate current restrictions that limit the program to veterans who cannot get a VHA appointment within 30 days, or who live more than 40 miles from a VHA facility. Under this bill, any eligible veteran can go anywhere, to any private-sector provider, for any condition. This would lead to higher costs and, the VSOs fear, to even more limitations on access to services. Veterans with complex physical and mental conditions would receive no care coordination from the VHA which, given the reality of private-sector health care, would mean no care coordination at all.   

As Rick Weidman, executive director for government and policy affairs at Vietnam Veterans of America, explained at the hearing, care coordination is critical because veterans have far more complex problems than the average private-sector patient. Which is why Weidman also urged commissioners to move beyond anonymous data when estimating future VHA use. Yes, the number of veterans the VHA serves will diminish as World War II, Korean, and Vietnam War veterans die.  The veterans who still use the VHA, however, will be sicker than the average private-sector patient. Most older adults, for example, have three or more problems, while the average Vietnam veteran, Weidman reminded the commission, has nine to twelve, which are both military- and age-related. Iraq and Afghanistan veterans have even more complex conditions.

While some commissioners seemed to be listening, VSO leaders remain concerned about those who persisted in “misunderstanding” their positions, by insisting that VSOs favored removing the current 40-mile or 30-day restrictions on the use of Choice. On April 29, seven of the VSO leaders wrote a follow-up letter to the commission, making it completely clear what they and their members want: “the development of local integrated community networks in which VA serves as the coordinator and primary provider of health care to veterans; non-VA community care would be integrated into this network to fill gaps and expand access.”

In a letter to sent to the commission, a veteran of the Iraq war put it even more eloquently: “Your solution of sending us to private healthcare providers is the wrong direction. … There is no private health care provider office that can offer me this type of care. So just fix our VA because it belongs to us not to the private sector.”

Group Drafts Secret Proposal to End Taxpayer-Funded Veteran Care

Deliberations by the Department of Veterans Affairs Commission on Care, the congressionally mandated group planning the future of the Veterans Health Administration, have, as The American Prospect has reported, become increasingly marred by controversy. When the 15-member commission met in Washington in mid-March, another furor erupted. A recently uncovered proposal to privatize the VHA set off a firestorm of protest within the veterans community.

Several members of the commission learned that seven of their colleagues had been secretly meeting to draft a proposal to totally eliminate the Veterans Health Administration by 2035 and turn its taxpayer-funded functions over to the private sector. Those commissioners dubbed the plan “The Strawman Document.”

The authors of the Strawman Document insist that the VHA is so “seriously broken” that “there is no efficient path to repair it.” Although the commission’s work is supposed to be data-driven and done by the all the commissioners together, the faction meeting independently of the full commission has ignored many of the studies that indicated that treatment at the VHA is often better and more cost-effective than the care available in the private sector.

It is not surprising that the Strawman group has chosen to ignore this research—its members have a vested interest in dismantling the VHA. The Strawman authors include Darin S. Selnick, a part-time employee of the Koch-funded group Concerned Veterans for America, as well as Stewart M. Hickey, a former leader of Amvets, a group that broke away from a coalition of large veterans service organizations because of its support for Concerned Veterans’  interest in dismantling  the VHA.

The Strawman authors acknowledge that private-sector health-care systems do not provide integrated care, high-quality mental-health treatment, or many other specialized services that the VHA currently delivers. But if the VHA became an insurer—paying the bills instead of providing direct care—it could spend more money trying to “incentivize” providers to give better care in these areas.

Private hospitals would also get federal funding to run what are now VHA Centers of Excellence, which treat epilepsy, Parkinson’s disease, and other conditions veterans face.

Representatives of veterans service organizations (VSOs) believe the secret meetings of the Strawman group may violate the Sunshine and Federal Advisory Committee Acts, as well as the commission’s agreed-upon processes. The commission had set up working groups to consider key VHA issues. Unlike the secret Strawman meetings, the subcommittee members were well known by all members and the public. Meeting times were posted, and discussion minutes were recorded. 

The Strawman faction engaged in another end run around their colleagues when they met with Republican Representative Jeff Miller, chair of the House Veterans’ Affairs Committee, and Speaker Paul Ryan. One representative of a major VSO, who asked not to be identified, observes: “If the authors requested the meeting with the House leadership, that constitutes lobbying. If they were invited by the House leadership, that constitutes more interference into the commission’s deliberations. Either way, this meeting, funded by the U.S. taxpayer, was totally inappropriate.”

“The plan does represent a complete deflection of responsibility to subject these men and women to an alternative ‘payer-only’ system of care that not only is ill-equipped to absorb the demand but is also, at best, minimally equipped in terms of expertise and the ability to coordinate such complex care over a veteran's lifetime,” says Sherman Gillums Jr., acting executive director of Paralyzed Veterans of America.

Before the Strawman proposal became public, Disabled American Veterans (DAV) launched Setting the Record Straight—a social media campaign against proposals that would privatize some or all of the VHA. Garry Augustine, DAV’s Washington executive director told the Prospect, “Although we have voiced our views about VA health care for the future, it seems many on the commission are committed to [doing] away with the VA health-care system and turn veterans over to private health care, which we believe would result in uncoordinated and fragmented care for veterans.”

The commission would do far better to consider the views of VA Undersecretary of Health David Shulkin and commission member Phillip Longman. Shulkin has argued for strengthening the VHA and giving it a more active role in directing and coordinating any care veterans receive in the private-sector system. Longman believes that the VHA should serve all veterans—not just those with service-related conditions or those who are low-income veterans.

House Veterans Affairs Chairman Blasts Health-Care Commission Member

The VA Commission on Care, the 15-member bipartisan body created by Congress to make recommendations about the future of the Veterans Health Administration (VHA), has been meeting for months and plans to publish its findings in June. Until this week, Congress had not interfered with the commission’s supposedly independent deliberations.

That all changed on March 14 when Republican Congressman Jeff Miller, the House Veterans’ Affairs Committee chairman and a staunch advocate of privatizing the Veterans Health Administration, wrote an angry letter to the commission chairwoman Nancy Schlichting. In this unprecedented missive, Miller personally attacked Phillip Longman, a commission member who has advocated not only preserving but strengthening the veterans’ health-care agency in part by eliminating its cumbersome eligibility requirements, and expanding health-care services to veterans’ families. 

Miller accused Longman, a Washington Monthly senior editor and author of a sympathetic appraisal of the VHA, Best Care Anywhere: Why VA Health Care is Better than Yours, of personally editing a recent article by former Wall Street Journal reporter Alicia Mundy. Mundy criticized Miller for his singular focus on VHA wait times and his insistence that 40 veterans had died because they were waiting for care. She also detailed the role that Miller and other congressional conservatives have played in the Koch brothers’ campaign to privatize veterans’ health care. Mundy warned that private hospital systems, which have representatives on the commission, are “circling like vultures over the idea of dividing up the VA’s multibillion-dollar budget.”

Miller said Longman helped spread “blatantly false propaganda in an attempt to minimize the wait-times scandal at the Department of Veterans Affairs” through the Mundy magazine article. Longman “either believes the article’s false claims or he—as an editor of the piece—signed off on them knowing they were untrue,” Miller wrote. He warned the commissioners “to take anything Longman says with an extremely large grain of salt.”

A subsequent Washington Monthly blog post by Paul Glastris, who actually edited Mundy’s article, rebutted Miller’s claims about patient deaths and other issues.  Longman, who is a part-time staff member at the magazine, also reviewed Mundy’s piece but did not edit it. (However, members on the commission, which includes health-care industry executives, veterans’ advocates, and a representative of the Koch brothers-backed Concerned Veterans for America, can continue to perform their professional duties as long as they do not claim to be acting on behalf of or speaking for the commission.)

Veterans advocates say that Miller’s tirade was the first time any of them could remember a congressman attacking a commission member.

Retired Army captain Steve Robertson, a former Senate Veterans’ Affairs Committee staff director, told The American Prospect that, in his 30 years working on veterans issues, he couldn’t “recall a member of Congress ever instructing members of a commission or advisory group to ignore one of their members.” Robertson said, “Miller is way out of line.” Another representative of a major veterans service organization who did not wish to be identified, called Miller’s letter an attempt to “intimidate an independent commission and politicize their recommendations”

One week later, Miller appeared before the commission and continued his critique of the agency. In his hour-long comments, Miller had nothing good to say about the VHA. He ignored the findings of an independent assessment commissioned by Congress that found that the VHA delivers care that is often superior to the private sector. When commission member Michael Blecker of San Francisco-based Swords to Plowshares tried to defend the VHA’s model of integrated care and worried that many veterans would fall through the cracks of a private health-care system, Miller barely let Blecker finish his comments. The congressman argued that the VHA is “holding veterans inside” the system and must allow them to move into private sector care. Miller concluded by encouraging the commission to offer “bold ideas” on overhauling the system in their upcoming report.

The congressman may want to “empower veterans,” as he terms it. But moving them into a private health-care sector that has primary care physician shortages, coordination of care difficulties, serious wait-time challenges, and hundreds of thousands of deaths due to preventable medical errors poses risks that the commission can ill-afford to ignore.

Congressional Commission Moves Toward Privatization of VA

The Commission on Care—a congressionally mandated federal body tasked with evaluating alleged shortcomings at the Veterans Health Administration (VHA)—is deliberating largely behind closed doors and, according to sources close to the deliberations, may have a heavy bias towards privatization. This is ironic because one of the critiques against the VHA has been its purported lack of transparency. The commission's pro-privatization tilt also worries veterans health advocates who point to research documenting that private health-care providers are not performing as well as the VHA on many measures critical to veterans.

Although some portions of the Commission’s meetings are open to the public, most of its internal deliberations are closed. The commission holds all of its meetings in Washington, D.C., making it impossible for veterans who don’t have the money to fly to the capital to be heard and to observe. Of course, veterans may send in comments to the Commission, but it’s impossible to know how much influence those will have.  This in spite of the fact that the VHA is the largest health-care system in the United States, serving eight million veterans—intensifying public interest in the commission’s deliberations.

The commission did release an interim report, as required by the 2014 law that mandated its creation. The Veterans Access, Choice and Accountability Act, passed in the wake of public concern over alleged treatment delays at VA hospitals around the country, charged the commission with examining how the VA should best locate, organize, and deliver its veterans health-care services.

Yet that report identified certain practices that are built in to any government program, such as the federal personnel system, as detrimental to the VA. Among other findings, the Interim Report concluded that one of the primary challenges facing the VHA is meeting the “standards governing health care in the private sector,” a critique with a distinctly conservative ring.

The commission’s explicit charge is “to examine strategically how best to organize the Veterans Health Administration (VHA), locate health resources, and deliver health care to veterans during the next 20 years.” Some veterans’ health-care advocates who have attended the commission’s open sessions say they see signs that influential commission members are pushing for privatization of at least some VHA services. “There seems to a consensus among most of the commission members that some privatization should occur with some members recommending total privatization. It’s clear that a number of the members of the commission—particularly those who come from private sector health-care institutions—have little experience with or knowledge of the unique problems of veterans,” commented one veterans’ health advocate who has attended most of the open sessions and has talked with commission members and staff. 

“The mind set seems to be that the Commission should ‘split the difference’ between those who are determined to hand over services to private sector providers and those who believe veterans are best served if the VA is strengthened and continues to deliver comprehensive services,” said another veterans’ advocate who also asked not to be identified. “Splitting the difference would compromise a high-quality integrated health-care model without saving any money.” 

The subtext of the commission’s interim report and of its open meetings appears to be that the VHA is fundamentally broken, and that private sector health-care is both superior to VHA care and can handle an influx of veterans with complex medical and psychological problems. Yet a 2014 Rand study of veterans’ mental health care explicitly tackled the question of whether the private sector healthcare system was “ready to serve” the needs of veterans. The answer was no.

The commission’s final recommendations are not due until later this year. The big question now is whether the commission will base its recommendations on empirical research, such as the findings of the Rand study, or on the talking points of the VA’s conservative critics on Capitol Hill.

And check out Suzanne Gordon's in-depth take on the Veterans Health Administration's strong performance in the face of right-wing attacks from our Fall 2015 issue. 

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