Veterans Health Administration
VA Secretary Denis McDonough released a controversial plan to restructure veterans’ health care services throughout the country and rely more heavily on outside providers.
At 2 a.m. on February 16, 2022, Joseph Riotta, an account manager in telecommunications, was awoken from a sound sleep at his home in Amityville, New York. The call came from nearby Huntington Hospital informing him that his 30-year-old son Joseph Matthew, who lives in a group home, had been admitted to its psychiatric ward. Since 2015, when Riotta’s son served in the Air Force and was diagnosed with schizophrenia, he has had periodic schizophrenic episodes that required emergency in-patient care.
On some of those occasions, the younger Riotta was transported to the nearest medical center operated by the Department of Veterans Affairs (VA), the option preferred by both the patient and his family. About five times in the last six years, the ambulance took Joseph Matthew to a private facility instead. That’s how he ended up in the psych ward at Huntington, an affiliate of Northwell Health, which serves two million New Yorkers in 23 hospitals and is now, outside of the VA, the largest health care provider for veterans in the state. From its websites, it appears that Northwell is trying to supplant the VA in New York as both a provider of veteran health care and also an employer of veterans who work in health care.
Joseph Riotta assumed he would see his son the next day. Instead, Northwell’s Huntington staff would not recognize the veteran’s father as his legal guardian, blocking Riotta from visiting Joseph Matthew for four days. He couldn’t even deliver the change of clothes that he knew his son would need. When Riotta vigorously protested this treatment, something that never occurred at the VA or any other hospital, Huntington denied him any access whatsoever. Eventually, his wife was allowed to visit their son until arrangements were made to transfer him to the VA Medical Center in Northport, Long Island.
On a scale of one to ten, Riotta gives most of the private-sector institutions that cared for his son a five. When asked how he would rate Northwell Health, after his experience at Huntington, Riotta pauses. “I give it a negative number.”
That’s why Riotta was astonished to learn that—one month after his son’s Northwell saga—VA Secretary Denis McDonough released a controversial plan to restructure veterans’ health care services throughout the country and rely more heavily on outside providers like Northwell. Included among McDonough’s recommendations to a congressionally mandated VA Asset and Infrastructure Review (AIR) Commission was a proposal to close the emergency room at Northport and rely far more on inpatient and outpatient mental health services at private-sector hospitals in the area. The secretary also proposes closing VA hospitals in Brooklyn, Manhattan, and Albany.
President Joe Biden’s pick to head the nine-member AIR Commission, which has yet to be confirmed by the Senate, is former Philadelphia-area congressman and undersecretary for the Army Patrick Murphy. Since his government service, Murphy has, according to his website, committed himself to securing “quality healthcare and mental health services” for his fellow veterans. He’s done that, quite lucratively, by building a career as a consultant and adviser to health care industry firms, including Northwell and the Cerner Corporation, which already has a controversial contract to overhaul VA health care information technology. Responding to the Prospect’s questions about his financial relationship to Northwell, Murphy’s chief of staff said that “he is not able to comment on anything relating to the VA Air Commission until after the Senate confirmation hearings.”
If, as Secretary McDonough recommends, more New York state VA hospitals are closed, Northwell will benefit significantly. That’s why the Riotta family’s experience goes beyond just another tragic mental health horror story. It could be a preview of coming attractions for millions of America’s veterans, should the AIR process proceed.
A Military Family’s Distress
Joseph Riotta’s difficulties with Northwell began when he called Huntington Hospital back on February 16 to check on his son’s condition and find out when he could visit. “I talked to someone on the phone and told them I was Joseph Matthew’s legal guardian,” Riotta said. “I was told that my guardianship didn’t apply at Huntington Hospital and that to discuss my son’s condition would be a violation of his HIPAA privacy rights. When I repeated that I was my son’s legal guardian, they hung up on me.”
Multiple hospitals have recognized Riotta’s legal status as his son’s guardian during the past six years. But Riotta was repeatedly told by Huntington staffers “that doesn’t apply here.” Riotta refused to take no for an answer, and finally reached a hospital representative who said that he and his wife could visit.
They arrived on the psych unit with a brown paper bag filled with clean clothes. “I know the drill,” Riotta explains. “I make sure to put in a couple of pairs of socks and underwear and some sweatpants without a drawstring … nothing dangerous, nothing he could use to hurt himself.”
When the Riottas saw their son, it was clear that Joseph Matthew not only needed a change of clothes, but a shower as well. His father recalls that “he just reeked, which really embarrassed him because he always likes to look his best around his mother.” Nevertheless, no one working on the ward seemed in any hurry to inspect and accept the bag of clothes or take his son for a shower. When Riotta asked about the bag, two nurses started quibbling with one another over whose responsibility it was.
At that point, Riotta says, “I admit it, I lost it. I began to scream at them.” Riotta suddenly found himself surrounded by hospital security guards. “I calmed down and said, ‘Look, you can call the police, do whatever you have to do. I just want to make sure my son gets a shower and new clothes.’” A hospital staffer finally escorted their son to the shower.
Afterward, Riotta met with Huntington’s security manager and apologized for his behavior. “He told me he understood and would probably have responded the same way if it was his son,” Riotta said, adding that the security manager told him he could visit the next day, as did his son’s attending physician.
But when Riotta did as he was told and arrived with his wife the next day, both of them were barred from the unit. Riotta was finally able to convince hospital security to admit his wife. Meanwhile, he got busy arranging his son’s transfer to the Northport VA. There, according to his family, Joseph Matthew was cared for without conflict, confusion, or contention about legal guardianship.
“The VA is incomparable to Huntington Hospital,” Joseph Matthew comments of his stay at the latter. “At Huntington Hospital my needs were not met. My back was hurting, the bed was awful, the shower overfilled, there weren’t enough staff to take care of the patients.” At the VA, he says, services are readily available. Joseph Matthew was aghast to learn of the proposal to eliminate services at the VA and send even more patients to Northwell facilities.
A Call to Action?
Riotta shared with the Prospect two detailed letters of complaint he wrote to Northwell CEO Michael Dowling, one of the nation’s highly paid hospital executives. Northwell’s 2019 financial filings show that he made over $4 million and was the recipient of a $96 million loan from the company. Among other things, Riotta informed Dowling about “nasty, hurried, non-caring people telling me that they could not tell me if my son was there AND that court orders of guardianship … did not apply.”
Dowling never replied to Riotta directly. On April 2nd, Riotta got a short note from Nick Fitterman, executive director of Huntington Hospital, saying the matter was being “reviewed.” A few weeks later, Riotta received a longer and more responsive message from Huntington’s medical director, Jean M. Cacciabaudo. After interviewing staff members and viewing relevant security camera footage, Cacciabaudo admitted that the Riotta family “did not encounter our best.”
She reported, however, that the Riottas’ sharing of “concerns regarding the care of your son … have become a call to action.” She acknowledged problems with the “handling of your guardianship document” and promised to hold a “Town Hall” meeting with the hospital’s legal counsel, to “educate the entire staff including the physicians on the definition of guardianship, competency, and capacity.” Cacciabaudo also concluded that critical communication between hospital staff and the patient’s parents “was devoid of compassion and failed to recognize the concern you had for your son’s well-being.” To prevent that in the future, she reported the hospital’s behavioral health inpatient unit was “being re-trained on Northwell Health’s Culture of Care curriculum as well as Humanism training.” The Prospect has emailed Northwell for comment, and has yet to receive a response.
Joseph Matthew Riotta is lucky to have a forceful and articulate father whose personal advocacy led to a belated recognition of the importance of patient care standards, staff training, and accountability. As the VA over the past decade has outsourced more and more service provision to private hospital networks like Northwell, the job of ensuring the quality of their care becomes a bigger institutional burden every year, falling on individual veterans whose collective voice is strong within the VA, but far weaker and more fragmented outside it.
If the staff and infrastructure of the VA itself are downsized in many places—as McDonough has proposed—not only will the agency’s direct-care capacity be reduced but its role as a monitor and coordinator of outside contractor performance will also suffer, since there will be fewer local staff to engage in oversight of private-sector behavior.
Just this month, for example, the prestigious Journal of the American Medical Association (JAMA) published a case study of veterans with advanced kidney disease who were treated outside the VA after referrals mandated by the VA MISSION Act of 2018, as implemented by the pro-privatization Trump administration.
The authors document how much time and effort VA staff must devote to what they call the “invisible work” of “cross-system care” (JAMA’s euphemism for outsourcing, a term it would not allow the authors of the study to actually use). This critical work consists of everything from helping patients secure an initial non-VA appointment to ensuring that there is subsequent sharing of medical records and proper reimbursement of non-VA providers. Yet, as the study suggests, the resulting costs have not been adequately “considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.”
Congressional Action—or Inaction—Needed
Over the next several months, Congress can choose one of two routes to stop the AIR process. The Senate can refuse to hold confirmation hearings on Biden’s AIR Commission nominees, thereby ending the AIR process. Congress could also pass a bipartisan bill, the Elimination of the VA AIR Commission Act, that was introduced last week by Sens. Joe Manchin and Mike Rounds.
The bill was floated in 2019, but gained no traction because of lack of support from veterans service organizations and other members of Congress. Today, VSOs would be far less likely to oppose it. As one VSO representative told the Prospect, “this bill is symbolic of the discontent over AIR. There is really no one that is supportive of either the AIR process or the secretary’s recommendations.”
Manchin and Rounds have also been far more active in promoting the bill this time around. Last Thursday, Manchin held a town hall on the AIR process in West Virginia. The last surviving World War II Medal of Honor recipient, Hershel “Woody” Williams, spoke out against AIR. Williams discussed a recent experience at the VA, where he said, “I certainly couldn’t have received more perfect care.”
Of proposals to eliminate services at the VA in Huntington, West Virginia, that bears his name, Williams was adamant. “We have got to kill this thing somehow,” he said.
Joseph Riotta and his son could not agree more.
