In the Bay Area, public meetings critical of conservatives are not hard to find. But when about 200 San Francisco military veterans jammed into an auditorium in their city’s Veterans War Memorial Building in mid-April, they added diversity to the local “resistance.” Those in attendance—representatives of veterans-service organizations, patients of the Veterans Health Administration, health-policy experts, and local Congresswoman Nancy Pelosi—were trying to educate veterans and the public about proposals that could destroy a single-payer plan for 9 million Americans whose past military service, in combat and noncombat jobs, makes them eligible for VHA coverage.
The threat—faced by VHA users and staff (one-third of whom are veterans themselves)—is privatization. The Trump administration has no trouble boosting an already swollen Pentagon budget. But it favors only a modest increase in VHA funding, most of which would be spent on steering veterans’ care toward non-VHA doctors and hospitals and to for-profit companies for services like audiology and optometry. As part of their ever-expanding outsourcing strategy, Trump’s Republican allies—and even some Democrats—have demonized VHA employees and attacked their workplace rights and union protections. Meanwhile, according to a number of VHA clinicians I have recently spoken with, VHA leadership is making it difficult for facilities to hire needed staff. An in-house electronic medical-records system that’s one of the best in the country is slated to be replaced by one produced by a private vendor. More importantly, Congress is considering legislation that could pave the way for agency dismantling.
Such steps will dramatically increase costs to the US taxpayer—and strike a collateral blow against efforts by labor and the left to defend federally funded medical coverage in any form, whether through the Affordable Care Act (ACA), Medicaid, or Medicare.
The current VHA privatization push first gained traction in 2014, when staff whistle-blowing drew public attention to appointment delays at some overwhelmed VHA facilities, like the Phoenix VA Health Care System. Serious problems existed at the Phoenix VA and other VHA medical centers, where administrators, since fired or disciplined, were caught gaming performance measures that mandated that veterans be seen within 14 days of requesting an appointment (a performance standard many criticize as unrealistic and unattainable). A subsequent inspector general’s report identified “patterns of obstacles to care” in the Phoenix VA Health Care System, including a faulty appointment-making system and limited access to psychotherapy and mental-health services. The inspector general’s report found that 40 VHA patients had died while on treatment wait lists—a number that was widely reported in the mainstream media—but the report went on to say that only six of those deceased patients had experienced “clinically significant delays,” and concluded that it could not “conclusively assert that the absence of timely quality care caused the deaths of these [six] veterans.”
The Concerned Veterans for America (CVA), a Koch brothers–financed Astroturf group that provides no services and has few actual members, quickly exploited this situation and helped foster a wave of highly misleading reporting about the VHA. Although average wait times at the VHA are comparable to wait times in the private sector (a recent estimate reported average wait times of 24 days), the CVA and its allies continue to argue that the VHA is broken beyond repair. Coverage in mainstream media, like The New York Times, reflects this narrative consistently, describing the VA as “beleaguered,” a “stumbling bureaucracy,” or a “troubled health system.”
Republicans seized on the trumped-up scandals, despite having blocked the effort of Senator Bernie Sanders, then chair of the Senate Veterans Affairs Committee, to provide the needed level of funding and support the VHA earlier in the year. In response to the Phoenix scandal, Congress passed the hastily and ill-crafted Veterans Access, Choice, and Accountability Act of 2014, brokered by Sanders and Arizona Senator John McCain. Through the Choice program, vets faced with appointment delays of more than 30 days or more than 40 miles of travel to the nearest VHA facility could use private health-care providers instead.
The Choice program, which was originally scheduled to sunset in August, has already been extended until Choice money runs out. Now Republicans are seeking a wholesale expansion of the outside-the-VHA option, creating a gold mine for the health-care industry. At the San Francisco forum, speakers opposed to such privatization, like Michael Blecker, a Vietnam War veteran and leader of Swords to Plowshares, warned of its budgetary impact on successful VHA programs to reduce veteran homelessness in the Bay Area. House minority leader Pelosi argued that the Republican goal is not improving the quality of veterans’ care or reducing the cost of it. “The people who want to privatize the VA don’t want to make it better,” she said. “They want to make a buck.”
That’s a lesson that Vietnam War vet Bob Rowen learned the hard way when his wife, suffering from terminal brain tumor, ran up large doctor and hospital bills. His family almost went bankrupt over her medical expenses, Rowen reported at the San Francisco meeting. In contrast, his own coverage is fully paid, without copays or premiums. His salaried VHA caregivers can coordinate treatment, in cost-effective fashion, for his multiple conditions, which include heart trouble, high blood pressure, high cholesterol levels, and post-traumatic stress disorder (PTSD), an area of unrivaled VHA expertise.
“How will veterans with serious mental and physical conditions be able to navigate the maze that is private-sector health care?” Rowen asked. “My wife and I couldn’t. We simply could not overcome the obstacles the system placed in our way.”
As the San Francisco speak-out demonstrated, grassroots organizing against VHA privatization is growing among veterans, their advocacy groups, and the American Federation of Government Employees union (which has more than 100,000 VA dues payers). But many progressives currently fighting ACA repeal or Medicaid cuts are only dimly aware of the parallel threats to the VHA. Some health-care reformers erroneously assume that veterans can easily fend off these attacks because of the lobbying clout and patriotic cachet derived from their membership in veterans-service organizations like the American Legion or Disabled American Veterans, which oppose privatization. Others, in left and liberal circles, have been adversely influenced by negative coverage of the VHA.
“When it comes to fighting to save America’s only single-payer system, even dedicated single-payer activists aren’t giving the issue much thought,” says VHA physician and “Medicare for all” advocate Jason Kelley. “Most health-care activists don’t know much about the VHA, and have no idea about the high-quality of care it delivers. Their views on what’s going on in the Canadian or European health-care systems are very up-to-date but, when it comes to the VA, they are closer to the public’s outdated attitudes.”
As Kelley points out, the VHA is the nation’s largest publicly funded, fully integrated health-care system. And the VHA is not just an insurer—reimbursing private providers like Canada or our federal government does, in more limited fashion, to provide Medicare for seniors. Like the British National Health Service, the VHA not only pays for but also provides services to veterans. It is, as Kelley suggests, a workable model for those fighting for single-payer health care in the United States, which should be promoted more effectively. The agency employs 300,000 people (a third are veterans) many of them functioning like direct-care providers in the UK’s national health service.
These VHA employees don’t serve all US veterans. Congressionally mandated eligibility requirements limit VHA access to about nine out of America’s 21 million veterans. To qualify, you must be either low-income or have service-connected disabilities. (As a result, VHA’s patient population is generally older, sicker, and poorer than in the private sector. There is, currently, no effort to expand benefits to veterans who are healthier and more affluent. In fact, current efforts to channel more veterans into private-sector care may lead to further restrictions in eligibility, cuts in services, or increased out-of-pocket payments.)
Because of the totality of veterans’ physical, mental, and economic problems, “the VHA endeavors to be a leader in health equity,” as the American Journal of Public Health has reported. Unlike its private-sector counterparts, the VHA operates extensive programs to reduce homelessness and help veterans find employment and adjust to civilian life when they leave active duty. The VHA also anchors a national system of Veterans Treatment Courts, helping veterans faced with minor criminal charges avoid jail time if they accept counseling help.
The VHA has developed what is, arguably, the only functional mental and behavioral health-care system in the United States. The veterans served by it have far more mental-health problems—including PTSD, depression, anxiety, schizophrenia, and other conditions—than the average private-sector patient. The VHA is one of the only health-care systems in the country that has integrated mental-health care into all of its primary-care settings. When patients raise a mental-health issue, their primary-care physician doesn’t just provide a specialist referral and leave it to them to follow up. A primary-care doctor can walk a patient down the hall and personally introduce them to a psychologist or psychiatric nurse practitioner at the same clinic location. Vietnam War veteran Denny Riley, for example, went to his primary-care physician in Martinez, California, to talk about the fact that he was having trouble sleeping. “She then immediately introduced me to a psychologist,” he said. “In the course of being treated for my sleep problems, I showed the psychologist a poem I’d written about tinnitus and she immediately sent me to a hearing specialist for hearing aides to help with that.”
Veterans who need help understanding how to take their medications or who have trouble adjusting their diet or obtaining housing get the same kind of “warm hand-off” to a pharmacist, dietician, or social worker who are part of primary-care teams. Care is also coordinated between, for example, a specialist in hearing loss—a widespread veteran problem—and a neurologist familiar with Agent Orange–related Parkinson’s disease, or a pulmonologist who can diagnose the respiratory damage done by exposure to military-base burn pits in Iraq or Afghanistan.
Myriad studies have found that treatment of veterans with diabetes, heart disease, and mental-health problems like PTSD is superior to private-sector care precisely because this VHA model of team-based integrated care stands in stark contrast to the fragmented, episodic nature of much patient care elsewhere. One RAND study on mental-health care documented that 70 percent of VHA mental-health providers understand military culture, while only 8 percent in the private sector had any familiarity with the kinds of specific military-related issues that effect veterans. A recent study on cancer care published in the Annals of Internal Medicine reported that older male veterans received care in the VHA that was often better than that in the private sector, because the VHA “is much better coordinated than in most other settings.”
The VHA is also able to deliver such high-quality care because its doctors, nurses, and other clinicians are salaried. They have no financial incentive to over-treat their patients, as so many private-sector physicians paid on a fee-for-service model do. Instead, the VHA encourages what’s known as “right care”—avoiding unnecessary tests, medications, and procedures that are sometimes harmful themselves, responsible for many patient injuries, and claim one-tenth of all US health-care spending.
Despite an aging US population, many private hospitals and health-care networks still have insufficient services for elderly patients. VHA hospitals are, in contrast, recognized leaders in the provision of geriatric and palliative and hospice care. As Dr. Diane Meier, a specialist in those fields, notes, “The VA was first out of the box on geriatrics,” starting fellowship programs throughout the country when few other hospital systems had them, and is a leader in delivering appropriate end-of-life care. The VHA trains a huge share of American physicians; 70 percent do their residency at the VHA. VHA clinicians also conduct research of great benefit to the broader US patient population; among their singular achievements are the shingles vaccine, the first implantable cardiac pacemaker, and the nicotine patch.
All of this and much more is in jeopardy. At a June 7 meeting of the Senate Committee on Veterans Affairs, VA Secretary David Shulkin unveiled a plan to outsource more VA services to the private sector and defended White House budget priorities. Shulkin is a medical doctor and former VHA undersecretary for health under President Obama; he is the only Trump cabinet pick both qualified for his position and publicly supportive of his agency’s mission. Now, in meetings at the White House, he must placate Trump’s son-in-law, Jared Kushner, who leads the administration’s Office of American Innovation, which includes VHA overhaul in its portfolio. In addition, Trump has saddled Shulkin with advisers like Darin S. Selnick, a former staffer for the Koch-funded CVA and leading conservative advocate of VHA privatization. Trump has also met with private-sector hospital CEOs who stand to gain from the outsourcing of VHA care to their institutions.
On Capitol Hill in June, Senator Jon Tester (D-MT) questioned the fact that 33 percent of the budget increase sought by Shulkin would be diverted to private-sector treatment, adding only 1.2 percent to support directly delivered care. “It doesn’t take very many budgets like that and…we’re privatizing the VA,” Tester warned. In its longer-range forecast, Fighting for Veterans Healthcare, a San Francisco–based VA advocacy group, predicts that, as budgets are shrunk to pay for outsourced care, more salaried caregivers, specialized programs, and clinics would be eliminated, and “the VA will become a shell of itself.” In early July, the chair of the Senate Committee on Veterans Affairs, Johnny Isakson (R-GA), went even further, introducing a draft of a bill that would pave the way for the total privatization of the VA health-care system.
Those on the left who oppose the Trump agenda and want to erode his working-class support—where it exists—have a golden opportunity in the fight to save the VHA. They can help promote the closest thing to a European-style national health service the United States has ever produced—a working example of single-payer financing that has broad popular support among the millions of patients covered. Without additional allies and public broader understanding of what’s at stake, national veterans’ organizations, plus affected VHA unions, could easily lose this crucial anti-privatization fight, making it even harder for health-care reformers to win Medicare for all.