Graeme Sloan/Sipa USA via AP Images
DC: Inauguration Construction, File Photos
The Department of Veterans Affairs in Washington, D.C. in December 2020.
Assuring that the nation’s military veterans have ready access to quality health care is one of the federal government’s most important obligations. As President Abraham Lincoln eloquently stated in his second inaugural address at the close of the Civil War, the nation must care “for him who shall have borne the battle and for his widow and his orphan.” Lincoln made no distinction between those who had borne the battle or the widows and orphans the nation would care for. This is why fairness and impartiality, known as equity of care, has long been a cornerstone of the Veterans Affairs (VA) Health System.
Recently, however, directed changes to VA hospital medical staff bylaws have caused concern that a crack might be forming in the foundation of equity that undergirds veterans’ health care. Attention was called to these changes last week in an article in The Guardian.
The article reported that VA headquarters directed changes to hospital medical staff bylaws, deleting language stating that clinicians shall not discriminate based on national origin, marital status, politics, disability, membership in a labor organization, or other criteria unrelated to professional qualifications. These changes were ordered despite established processes that require proposed bylaw changes be reviewed and approved by the hospital’s medical staff before being adopted.
The report quickly ignited a firestorm of concern and confusion among veterans, VA staff, veterans service organizations, and lawmakers. The matter quickly escalated and risked tarnishing the VA Health System’s reputation as the most equitable health system in the United States.
Why did this become such a big deal? What do the bylaw changes mean? In fact, what are medical staff bylaws in the first place, and why should this matter to anyone other than a coterie of medical administrators?
As a veteran, physician, and former leader of the VA Health System, and a staunch supporter of VA health care, I found the response unsurprising. Indeed, the furor over the bylaw changes was quite predictable. Anything hinting at a loss of equity in veterans’ health care is guaranteed to raise broad concern.
Staff bylaws are the operating rules that provide a framework for making decisions about patient care and the qualifications and performance standards of the hospital’s medical staff. They are essential to ensuring patient access and care quality. Insofar as the VA manages one of the largest health systems in the nation, serving more than 9 million eligible veterans and having facilities located in every state, the District of Columbia, and five U.S. territories, any changes to the bylaws that govern how physicians and other clinicians practice could have widespread consequences.
The bylaws tell doctors and other clinicians that they can’t refuse to care for a veteran because he or she is divorced or has children out of wedlock, even though such things might offend the treating physician’s religious or other personal convictions, or because the veteran voted for a Democratic—or Republican—candidate when the doctor is an ardent supporter of the other party. Bylaws also govern hiring decisions and prohibit the health system from not hiring a qualified doctor because they have a disability (that doesn’t prevent them from doing their job) or hiring one who belongs to a political party their future bosses don’t like or because they are a member (or not) of a labor union.
Discrimination, no matter what the reason, has not been and never should be allowed in veterans’ health care, so it’s understandable why frontline VA clinicians, veterans’ advocates, and legislators have expressed fears about the intent and possible downstream consequences of deleting nondiscrimination provisions from the bylaws. Even the American Medical Association (AMA) voiced concern. At its recent meeting, the AMA approved a resolution affirming the need for any changes to staff bylaws at VA hospitals and elsewhere to be reviewed and approved by medical staff before being adopted, consistent with longstanding traditions of professional independence and self-governance. Like others, the AMA is concerned about the possibility of ideological or political considerations influencing the doctor-patient relationship.
Since The Guardian’s article appeared, VA Secretary Doug Collins has affirmed VA policy supporting equity in veteran’s health care. In addition to legally protected individual attributes such as race, religion, and sex, Secretary Collins has assured veterans and the public that the VA will never discriminate based on politics, marital status, or other reasons. These statements are to be applauded.
Given the predictable response to the bylaw changes and the secretary’s subsequent affirmations of equity in veterans’ health care, why was the nondiscrimination language deleted?
VA spokespersons have explained that the bylaw changes were necessary to bring them into conformity with President Donald Trump’s Executive Order (EO) #14168, “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government.” In brief, this EO directs what language federal agencies can use when referring to a person’s sex and addresses other issues related to transgender people.
This explanation is confusing, though, because the bylaw changes go well beyond what is in this EO. Discrimination based on politics, marital status, or other reasons is not the subject of or even mentioned in that document.
Secretary Collins’s insistence that VA will not tolerate discrimination for any reason is reassuring, but it leaves unanswered many questions that need to be addressed to assuage the angst and fear that the changes have precipitated among veterans and VA employees.
For example, if the changes to the bylaws are a mere formality, as has been stated, then why the heavy-handed directive that they must be made? If a formality, then what difference would it make if it takes a little longer to follow the usual and customary processes and get pre-adoption medical staff review and approval? If the changes are of no consequence, as has been asserted, then what happens if a hospital’s medical staff does not make the changes? And if they are of no consequence, why even delete the nondiscrimination provisions at all?
Until these and other questions are satisfactorily answered, perhaps the original language whose deletion has caused so much concern should be restored. This would make clear that discrimination for any reason never will be tolerated in the VA Health System and would tangibly affirm VA’s continued commitment to health care equity.
