New legislation threatens to dismantle the most successful American experiment in government-delivered health care.
By Suzanne Gordon and Jasper Craven for The American Prospect
Last June, President Trump signed the VA Mission Act, commonly considered the biggest overhaul of veterans’ health care in a generation. Mission was designed to replace the hastily enacted Veterans Choice Program of 2014, which has made it easier for veterans to get care in the private sector if they lack fast or easy access to care inside the Veterans Health Administration (VHA).
Choice was a temporary program, one that would offer supplementary private care to veterans while Congress bolstered the VA’s capacity. Yet this work has not happened. Instead, Mission is making permanent the privatizing principles set forth in Choice.
The logical conclusion from the Mission is not as its boosters claim, to shore up the VA for the future and create a system that would be “veteran centric,” but to tear down the agency, brick by brick, visit by visit. This strategy will not only erase what has been the most successful American experiment in government-delivered health care, but will also send veterans out into a private system that is more expensive, less accountable, and unable to meet their particular needs.
The key notion underpinning the Mission Act, that the private sector can offer comparable care to the VHA, is deeply flawed. Study after study (after study) has found that the VHA generally outperforms the private sector on key quality metrics, and that private providers are woefully unprepared to treat the often unique and difficult veteran patient population. The most recent evidence came in a Dartmouth College study published in December, which compared performance between VHA and private hospitals in 121 regions across the country. The results: In 14 out of 15 measures, government care fared “significantly better” than private hospitals.
Yet these statistics were all but ignored as the Mission Act moved forward. The legislation saw intense and effective lobbying from private health-care interests eager to peel of VA patients, from the American Health Care Association to Ascension Health, the largest nonprofit health system in the country.
This lobbying continued into the rulemaking process. Last July, during the first public hearing on the implementation of Mission, last July, Joanne Frederick, Wellpoint Military Care’s vice president for strategy and innovation. Wellpoint, a subsidiary of the second largest health-care company in America, said “providers across the Anthem network would be honored to deliver high-quality care to veterans” before calling for private health-care interests to be deputized with new referral authority over veterans’ appointments and rejecting VA efforts to conduct quality oversight of private health-care contractors.
Health care companies have found allies in Trump advisers who are similarly hellbent on dismantling the agency for ideological reasons. They include a cadre of shadow advisers including current and former officials at the Koch-funded group Concerned Veterans for America (CVA) and a trio of billionaire members of Mar-a-Lago. (Senator Jerry Moran, a Kansas Republican and a key congressional architect of the Mission Act, hails from the Koch’s home state and is one of the top recipients of Koch family cash.)
Many Democrats, and virtually every veterans service organization, also supported Mission. As the bill made its way through Congress, these more moderate forces were able to strip out a number of onerous provisions. They were also promised that the law would not open the floodgates to private care. Yet the details of the outsourcing rules are now being written by the devils, like former CVA staffer Darin Selnick, who helped write Mission and is now working at the VA on its implementation.
Meanwhile, top veterans advocates and Democratic lawmakers say they are being frozen out of key discussions, and that the spirit of the law is not being followed.
“There’s been lots of conflicting information over Mission’s statutes, and no transparency about the process since the bill was signed into law,” a senior legislative staffer at a major veterans’ organization told the Prospect. “We have some concerns that whoever they are collaborating with might be running this thing off the tracks, and pushing for privatization. It appears that we’re going to have to force our way into the door.”
Rick Weidman, executive director of the Vietnam Veterans of America, offered similar frustrations with Secretary Robert Wilkie’s VA. “These guys are incredible,” he said. “They summon you to a meeting with less than 24 hours notice and then if you can’t come they say you’re not interested. Nevertheless, we are going to go after them and continue to exert pressure to make sure veterans get the highest quality care.”
During a December hearing with Wilkie, Democratic Senator Jon Tester of Montana, who championed the Mission Act, said he was “increasingly concerned with the department’s planned implementation” of the law, and that it was “moving away from the direction it was headed just six months ago, make no mistake about that.”
A senior staffer in the agency’s central Washington office observed that “under the Trump administration, political appointees seem to have far more influence in policy making than agency policy experts.”
Tester and other members of the House and Senate Veterans Affairs Committees repeatedly asked Wilkie for details about the access and quality measures he is considering, but got no concrete replies. Wilkie said simply that that he would notify committee members after briefing President Trump, who has ultimate authority over how the rules are written. (Trump is expected to broadly announce his decision over Mission rules in his State of the Union addresses next month.)
The text of The Mission Act mandates that private care only be offered under a narrow set of circumstances, including when the VA can’t offer a specific service, a veteran faces an excessive wait or drive time, or when private care “would be in the best medical interest of the covered veteran based upon criteria developed by the [VA Secretary].” Yet Tester said in December that rules in the works could essentially create “automatic eligibility for community care.” Advertisement
No new rules will be finalized until the summer, and VA sources are confused about exactly what the new standards may be. What’s clear, however, is that the new standards will almost certainly make it easier for private health care companies to capture more patients. The exact price tag for this increased level of private care is unclear, and Tester told Wilkie in December that it “concerns me that each time we’ve discussed this issue in the last two months, VA officials have given us wildly different estimates of how much this will cost.”
Because no supplementary funding has been earmarked for private sector care through Mission, every dollar spent on private sector care will most likely be siphoned off from the VA budget, starving the agency of needed resources and making it virtually impossible to fill the 45,000-pus staffing vacancies that plague agency facilities all over the country. To make matters worse, staff may be moved from providing hands-on care to patients to coordinating care with the private sector.
“If care in the private sector is more expensive than at the VHA and staff have to be allocated to coordinate care and get records back from the private sector, then less money and staff will be available for patients cared for directly by the VHA,” a VA medical center director told the Prospect.
Over the past several months the Prospect has spoken with regional Veterans Integrated Service Network (VISN) and medical center staff directors who have either attended meetings with Wilkie or are familiar with his deliberations. These directors, who requested anonymity to avoid retaliation, have become increasingly alarmed that access standards under consideration are indeed so broad as to give automatic eligibility to private sector care.
One medical director told the Prospect that one standard Wilkie is mulling over would send a veteran into the private sector after just ten days of waiting for a primary care appointment and 14 days for a specialty appointment. Directors worried that the VA could also potentially interpret any follow-up appointments, whether in six weeks or a year, as overshooting acceptable wait times and thereby qualifying virtually every vet as eligible for private care.
“Everybody is of the same belief that what is going on with the VHA is death by a thousands cuts,” one VA VISN director told us. Another said “this is privatization pure and simple,” while a hospital chief of staff said bluntly that broad Mission’s rules would be “kaboom for the VA.”
According to a senior VA official, Wilkie is also considering moving veterans who have to wait longer than 20 days for a mental health appointment into the private sector. Within a relatively short period of time, (no one knows quite how long) the standard would change to 14 days and then, potentially, seven days, which almost exactly mirrors the wait time standards of the military’s health care program, TriCare. (Wilkie is a former Defense Department undersecretary for personnel and readiness.)
Several VHA directors also told the Prospect that Wilkie is considering making veterans who must drive more than 30 minutes for a primary care or behavioral health appointment or 60 minutes for a specialty care appointment eligible for private sector care, a move that would further open the floodgates.
These standards could so substantially drain veteran patients from the VA system that it could collapse entirely. One chief of staff at a major VA facility told us, “these standards would bring about the end of our centers of excellence since they would no longer have the patient volume necessary to deliver quality patient care or conduct research.”
The same would be true of VA transplant centers, surgical suites, and rehabilitation centers, which are scattered across the nation and inevitably require that patients travel some distance—travel paid for by the VA, but which deliver far more affordable and higher quality care than what’s offered in the private sector.
The media and Congress are ignoring an even greater threat to the VHA, a provision in Mission, which kicks in 2020, that could spur closures of VHA facilities and programs across the nation. During that year the president is mandated, after consulting with Congress, to appoint a nine-member Asset and Infrastructure Realignment Commission, whose chief task will be to consider whether underutilized facilities should be shuttered. Creating underutilization will guarantee that the next logical step is shutting programs and closing facilities.
The legislation stipulates that three members of the commission must be from veterans service organizations and other interests, including the private health care sector, also must get seats. As soon as he signed the law, however, Trump announced that he was not mandated to consult Congress or to set aside seats for veterans advocates on the commission.
Only two of the 42 members on the House and Senate Veterans Affairs Committee opposed Mission last year, when it came up for a vote. One of those lawmakers, Bernie Sanders, the Vermont Democrat, reiterated his opposition to Mission in December.
“This is nothing short of a steady march toward the privatization of the VA,” Sanders said. “It’s going to happen piece by piece by piece until over a period of time there’s not much in the VA to provide the quality care that our veterans deserve.”
The question now is what newly empowered Democrats in the House and frustrated veterans advocates on the Hill do to halt this overreach. Sources inside the VA opposed to Trump’s agenda have suggested to the Prospectthat the House Committee on Veterans Affairs should file subpoenas and hold hearings to uncover the influence health care executives, the Mar-a-Lago group and Koch brothers have had on the implementation of MISSION. Yet the new committee chairman, Representative Mark Takano of California recently told the Military Times that he remains committed to bipartisanship and won’t “be issuing subpoenas or demanding witnesses without the backing of his Republican counterparts on the committee.”
While work on veterans’ affairs legislation has historically been a cordial, bipartisan effort, the agency will quickly be privatized if veterans organizations and Democratic legislators don’t wake up to the fact that the Trump administration and congressional Republicans have blatantly politicized veterans issues for corporate and ideological gains.