Suzanne Gordon is the Senior Policy Fellow at the Veterans' Health Care Policy Institute, as well as 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.
By Suzanne Gordon | Jun 27, 2018
Under the guise of reducing veteran suicides, the Trump administration has released a plan that could radically reshape veteran care in the United States. The stated goal is to expand mental health services for newly transitioned veterans, the proposal, which administration officials approved on May 31, contains provisions that could starve the Veterans Health Administration of needed resources, add impossible burdens to already struggling VHA staff, and privatize veteran mental health care by outsourcing it to non-VA providers. As studies have consistently shown, such private-sector providers are ill equipped to address veterans’ complex needs.
Released on May 3, the Joint Action Plan represents an outline of how the Departments of Veterans Affairs, Defense, and Homeland Security propose to implement an executive order President Donald J. Trump signed in January. The order called for providing all service-members transitioning out of the military—about 245,000 a year—with 12 months of free mental health care. The impetus behind the plan—preventing veteran suicides—and a number of things in it are praiseworthy, even essential. But according to a careful analysis by the Veterans Healthcare Policy Institute, the plan could actually jeopardize the stellar suicide prevention and mental health programs that the VA has long pioneered.
The action plan stipulates that transitioning service-members will have access to 12 months of mental health benefits. Service-members must also be informed that they don’t have to seek help from the VHA and are free to go to private-sector mental health providers, if they are, for any reason, not interested in VHA care. The plan calls for some VHA oversight of these private-sector providers, but provides no funding for staff needed to monitor their care.
The danger is that VHA veterans could be cared for by providers who may not understand their specific problems or provide evidence-based treatment for them. As studies have documented, private-sector care falls well short of the public sector in treating veterans. Unlike the care delivered at the VHA, which is well-coordinated, veteran care in the private sector would be uncoordinated and their providers largely unaccountable. Even worse, the funds to pay for expensive care in the private sector will come directly from the VHA budget. Without new congressionally approved allocations, the VHA will be forced to cannibalize existing programs to pay for the mandates.
Such threats come at a time when the VA system is already plagued by underfunding and understaffing. On June 14, 2018, the VA Office of the Inspector General (OIG) issued a report that once again highlights the problems created by Congress’s long-standing failure to fully fund and staff the Veterans Health Administration. Its detailed, facility-by-facility list of staff vacancies includes the mental health professionals needed to serve a growing number of veterans with serious mental health and substance abuse problems. (Seventy percent of facilities had shortages of psychiatrists and 40 percent of psychologists.)
The Joint Action Plan does not require that the Defense Department or others provide transitioning service-members with information about the high quality of programs the VHA has developed to deal with complex mental health problems. This kind of education is essential because any current or future problems the VHA faces provide fodder for right-wing critics—like Fox and Friends—as they churn out a steady stream of anti-VHA stories designed to convince veterans that the VHA can never serve their needs. Neither conservative nor liberal media do much reporting on the many innovations the VHA has pioneered in the delivery of integrated primary care, mental health care, or suicide prevention. Yet as studies have shown, the VHA has a far better track record on these issues than the private sector.
The Joint Action Plan doesn’t even call for measuring whether newly discharged service-members receive such information. It does, however, recommend measuring how quickly department personnel are trained on the referral process to community-based support resources.
The plan’s defects don’t end there. Without offering additional funding, the plan requires the VA to train outreach workers and peer support staff, who then must repeatedly contact all 245,000 transitioning veterans. Staff will also have to provide care for an estimated 32,000 veterans each year. Finally, the VA will have to evaluate the success of all these and other programs.
Yet the plan does not suggest conducting an assessment of how many new VHA staff would need to be added, and thus funded, to accommodate these new caregiving and outreach responsibilities. Because twice as many veterans receive mental health treatment compared with ten years ago, VA mental health staff are already overwhelmed by their high caseloads. A recent report on VA mental health care from the National Academies of Science, Engineering, and Medicine said that the VHA’s mental health-care system could be a model for the nation but that it was plagued by shortages of staff and clinical and exam space, which had created high staff burnout and turnover. Trying to accommodate thousands of new patients will lead to increased burnout and delays, which, absent attention to increased staffing, will fuel demands to outsource more and more care.
Because the Joint Action Plan claims that its provisions will advance the laudable mission of preventing veteran suicide, it may receive support from Congress and some Veterans Service Organizations. Like the recently passed VA Mission Act, the VA Accountability Act, and many other recent measures, it is rife with intended consequences. As advocated by representatives of the Concerned Veterans for America—a Koch brothers’-backed group whose representatives now advise the VA and White House—it is, in fact, just another step down the slippery slope of VHA privatization.
Trump's new appointee to head the Department of Veterans Affairs will likely do little to oppose the privatization of veterans' health care.Suzanne GordonMar 30, 2018
By Suzanne Gordon | Mar 06, 2018
As Congress moves ahead with plans to outsource more and more veteran health care to the private sector, three high-profile studies should urge lawmakers to pump the brakes. The studies, published in recent weeks by RAND Corporation, Federal Practitioner, and the National Academies of Science, Engineering and Medicine, spotlight serious flaws in private-sector veterans’ care compared with the VHA, from suicide prevention to overall health care. In so doing, the reports underscore a critical fact: Despite their best intentions, few private-sector physicians, hospitals, mental health, and other health-care professionals have the knowledge, experience, and skill to provide the level of care veterans need and deserve.
Perhaps the most damning of those studies comes from the RAND Corporation. In a report entitled “Ready or Not?” researchers examined whether private-sector health professionals in New York state had the “capacity” and “readiness” to deal with that state’s 800,000 veterans in need of care. Such patients, the study noted, are on average older, sicker, poorer, and far more complex than the ordinary civilian-sector patient.
The conclusion? Only 2 percent of New York state providers met RAND’s “final definition as ready to provide timely and quality care to veterans in the community.”
While the majority of providers said they had room for new patients, less than 20 percent of them ever asked their patients if they were veterans. Fewer than half used appropriate clinical practice guidelines to treat their patients, and 75 percent didn’t use the kind of screening tools commonly deployed in the VHA to detect critical problems like PTSD, depression, and risk of suicide.
Most providers had no understanding of military culture and less than one-half said they were interested in filling such knowledge gaps. Mirroring a similar study conducted by the VA and Medical University of South Carolina in 2011, RAND found that New York state providers had little understanding of the high quality of VHA care. Informed by media reports rather than medical journals, they had a negative view of the VHA and would be unlikely to refer eligible veterans to the VHA for needed care in programs in which the VHA actually excels.
Echoing the RAND study, another report by VA psychologist Russell Lemle in the Federal Practitioner warns that in the private sector, the quality of integrated mental health care for veterans lags significantly behind the VHA. Every VHA medical center, Lemle reports, has at least one trained suicide prevention coordinator who directs care for veterans at high risk for suicide. The VHA has also developed an algorithm to identify the veterans who are at the very highest risk of suicide and notifies their provider of the risk assessment, enabling preemptive intervention and expansion of services to the veteran. This and other programs explains why the rate of suicide of veterans not using the VHA increased by 38 percent between 2001 and 2014 while only 5 percent for those using the VHA. For veterans who had a “mental health or substance use diagnosis, the rate decreased by 25 percent.”
Finally, for veterans returning from the Iraq and Afghanistan conflicts, a prestigious National Academies of Science, Engineering and Medicine report released just four weeks ago found VHA mental health care to be “comparable or superior to that in the private sector.” The majority of veterans who accessed the system had “positive experiences” and appreciated VHA staff’s “respect toward patients.” This was despite serious shortages of mental health staff, as well as clinical and exam space, and confusion about how to access care—all of which could, and should, be improved. When veterans were asked whether needed services were provided in the VHA, 64 percent said they were. When they were asked about services they’d received in the private sector, only 20 percent said they got needed services.
These studies should be a wake-up call to Congress. Countless reports have documented that there is little excess capacity—and a huge shortfall of knowledge—in the private sector when it comes to veteran health care. Until studies document the opposite—that the private sector’s doctors, nurses, hospitals and other health-care providers can match what the VHA does routinely—lawmakers should hold off on privatization efforts. Rather than spending money for more expensive private-sector care of lower quality, Congress should instead be working to strengthen the excellent care the VHA gives by providing funding to remedy any staff and resource deficiencies as well as to address management problems at the top.
By Suzanne Gordon | Nov 22, 2017
In a now familiar pattern, leading veterans organizations are up in arms again over the latest revelations about White House plans for the Veterans Health Administration (VHA)—plans that were concocted behind closed doors.
Last week, the Associated Press reported that Secretary of Veterans Affairs David Shulkin and other Trump officials have been quietly discussing ways to shift veterans, now eligible for VHA care, into Tricare, the private insurance program for active duty military personnel and their families. The administration’s Tricare discussions have been conducted without input from members of Congress or veterans groups.
In recent months, Amvets, Disabled American Veterans, the American Legion, and other veteran service organizations have become increasingly worried about the Trump administration’s moves to out-source more VHA services through expanding a program called “Choice,” which reimburses non-VHA doctors and hospitals that treat veterans.
Veterans’ advocacy groups have reacted with shock and anger about the prospect of a VHA merger with Tricare, which pays for private-sector health-care services. Such a move could ultimately lead to the dismantling of the VHA, which provides integrated, direct care for nine million patients at 1,700 facilities nationwide.
As Louis Celli, a top staffer for the American Legion, told the Associate Press, a merger would siphon off funds from VHA hospitals and clinics and eventually shift costs directly to veterans, through co-pay and other possible fee increases. (Tricare patients have recently started paying higher co-pays.)
Curt Cashour, a Veterans Affairs Department spokesman, called the concept a possible “game-changer” that would save taxpayers money because it is based on “the type of businesslike, common-sense approach that rarely exists in Washington.”
Recently, congressional Republicans have tried to convince veterans that the troubled Choice program should be renewed with even fewer restrictions on veterans who want to use private-sector providers—even though the program has been rocked by $2 billion in cost over-runs. (The VA Inspector General released a report in September that also revealed that the third-party contractors responsible for the Choice program had overbilled the federal government by almost $90 billion in 2017.)
The author of one such proposal is Representative Phil Roe, the Tennessee Republican who chairs the House Committee on Veterans Affairs. He has insisted that his bill, the VA Care in the Community Act, would actually strengthen veterans’ health services. Some Democrats on the House Veterans Affairs Committee, like Tim Walz of Minnesota, even co-sponsored Roe’s bill, despite the VHA privatization threats. But others, including California Democrat Mark Takano, a staunch supporter of the VHA and ally of veterans group, sought major changes in the legislation that would ensure the VHA maintains a critical role in providing direct care to veterans and coordinating any care veterans receive in the private sector with services provided by the VHA.
But with the revelations about secret meetings, Walz now believes that the real White House goal is “to force unprecedented numbers of veterans into the private sector for their care.” In response to the AP story, Walz demanded that the administration release “unredacted copies of any and all documents, records, memoranda, [and] correspondence” related to the private insurance scheme.
This latest development in the long-running Koch brothers–backed campaign to turn veterans into private-sector health-care customers should not come as a surprise. As The American Prospect has previously reported, when the Choice program was initially created in 2014 to deal with VHA appointment delays, Congress and the Obama administration also formed a VA Commission on Care to make recommendations to improve the health-care system. But health-care industry executives and allies of the Koch brothers who favored VHA privatization influenced the commission’s findings. Darin Selnick, a top official of the Koch brothers–funded Concerned Veterans for America (CVA), served on the commission and later became a senior adviser to Shulkin.
The Prospect also reported that a conservative faction on the commission known as the “Strawman group” short-circuited public deliberations about the future of the VHA by meeting in secret. Their “minority report” called for replacing the VHA with an insurance scheme like Tricare. One Strawman group member, Obama appointee Joyce Johnson, is a top Coast Guard official who helped to move the Coast Guard into Tricare.
Secretary Shulkin’s secretive approach raises new questions about how he intends to run the agency. Last winter, the VHA’s defenders breathed a collective sigh of relief when Trump decided to keep Shulkin (who served as the VHA undersecretary for health under former President Obama) in his cabinet. (The other leading contenders for the job, Pete Hegseth, former CEO of the CVA, and Florida Republican Jeff Miller, the former chairman of the House Committee on Veterans Affairs, had both publicly supported VHA privatization.) His credibility among veterans may take a big hit if he continues to speak out against privatization while working behind the scenes to steer the VHA in that very direction.
By Suzanne Gordon | Oct 16, 2017
In September, The American Prospect reported that budget cuts at the Veterans Health Administration would have eliminated the system’s ten Patient Safety Centers of Inquiry. After protests from leading patient safety experts and members of Congress, the centers were saved. But late last month, brand new threats emerged that could jeopardize the VHA’s ability to serve mentally ill, homeless, and female veterans; prevent veteran suicide; and increase access to needed services.
An internal VHA memo signed by Poonam Alaigh, then acting under secretary for veterans affairs for health, informed VHA deputy under secretaries, chiefs of staff, and network directors that they are free to shift almost $1 billion in funds allocated to specific VHA programs either to their general operating budgets or to finance Veterans Affairs Secretary David Shulkin’s five new VHA priorities. Shulkin’s priorities include outsourcing more care from the VHA to private-sector hospitals and doctors as well as creating more suicide prevention programs.
The memo obtained by the Prospect has caused a stir at the agency’s downtown Washington headquarters and the funding transfers were temporarily put on hold. But after agency officials conduct a detailed review, some cuts may still go forward.
Homeless veterans advocates are deeply disturbed that the list of targeted programs includes more than $265 million in spending for the Housing and Urban Development’s VA Supportive Housing (HUD/VASH) program’s social workers who work with homeless veterans. The HUD/VASH program “is the chief strategy to reduce veteran homelessness,” says Randy Shaw, who directs the Tenderloin Housing Clinic in San Francisco.
“The HUD/VASH program has allowed VHA case managers to work in partnership with local and municipal homeless programs to reach chronically homeless vets,” says Michael Blecker, the executive director of Swords to Plowshares, a San Francisco veteran service organization. “Allowing the program to literally be zeroed-out sends the worst message to all the VHA partners who have helped make the program so successful.” Anything that jeopardizes HUD/VASH social workers or vouchers, Shaw agrees, would be “disastrous.”
Other programs on the chopping block include $30 million in additional mental health initiatives and $21 million for coordinators who help Iraq and Afghanistan veterans transition to civilian life. Potential downsizing or elimination of the delivery of mental health and rehabilitation services, suicide research, and myriad of other programs jeopardize the secretary’s stated commitment to preventing veteran suicide among veterans.
The new shifts in funding also target funding for spinal cord injury programs, rehabilitation programs, and amputation care for those who have suffered disabling injuries on and off the battlefield. The plan also includes trimming almost $26 million allocated to Mental Illness Research Education and Clinic Centers. These Centers do pioneering research on the causes and treatments of mental disorders and translate this new knowledge into routine clinical practice with veterans.
Almost $23 million in funding for occupational health and safety programs could be eliminated and some training programs for VHA staff have already been canceled. These programs teach staff how to safely lift and handle vulnerable veterans in VHA hospitals and nursing homes as well as how to deal with “disruptive” veterans who are a danger to themselves as well as those who care for them. Programs to prevent workplace violence have also been targeted. After much prodding from women veterans and groups like the Iraq and Afghanistan Veterans of America (IAVA) the VHA initiated many programs to better serve women veterans. Potential cuts, however, include $6 million devoted to women’s health.
Although the secretary insists he wants to increase veterans’ access to needed services and recruit staff to fill the VHA’s 34,000 vacancies, potential shifts in funding away from primary and geriatric care, and telehealth, will also affect access. If the secretary is really committed to expanding access to VHA services, why is the VHA’s “Educational Debt Reduction” program, used to provide incentives to recruitment in rural areas, on the list?
The memo tries to soften the blow of these proposed cuts by suggesting that giving medical and regional directors the flexibility to use funds allocated for specific programs as they see fit won’t “completely eliminate” specific programs. This optimistic assessment ignores current fiscal reality at the VHA. The cost of outsourcing VHA care to the private sector, has, according to another internal VA memo been a “major driver, in budget shortfalls for VHA facilities across the country.”
Medical centers and regional offices have been strapped for cash to fund operating expenses. Without additional infusions of funding, directors will be very tempted to use these newly available funds to pay for day-to-day operations.
VHA officials would not have to resort to the types of choices that could inflict more pain on the men and women who have fought in the country’s wars, if President Trump backed adequate funding levels for the agency. Ken Watterson, president Dallas Veterans Resource Center and founder of Homeless Veteran Services of Dallas, says Washington needs start listening: “It’s time for veteran service organizations— and veterans—to make it clear that balancing the budget on the backs of veterans is not the choice they want.”