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.
Trump's pick to head the VA is actually someone who is both qualified and committed to the department's mission.Suzanne GordonJan 13, 2017
By Suzanne Gordon | Dec 20, 2016
The Veterans Health Administration has weighed in on a controversy that has embroiled medicine and nursing for the last 50 years: whether advanced practice registered nurses (APRNs) can operate without direct physician supervision. On December 14, the VHA amended its medical regulations to “permit full practice authority” to many of the system’s nurse practitioners, a move that immediately drew the ire of the medical community.
Since APRNs appeared on the health-care stage in 1965 with the enactment of Medicare and Medicaid, physicians have responded with deep ambivalence. Some have embraced them as full members of the health-care team, while others—particularly leaders of organizations like the American Medical Association—have argued that nurses should not function on their own and should always—no matter how much experience they have—work under the direction of doctors. APRNs have consistently argued that they should be allowed to make diagnoses and prescribe treatments without physician supervision.
The Institute of Medicine has recommended APRNs be granted what is known as “full practice authority,” and countless studies have documented that APRNs provide safe and effective care at lower costs than physicians. The fight has been waged in various states, 22 of which have granted full scope of practice to APRNs. But as a federal employer, the VHA’s own internal regulations can supersede state law on nursing practice when there is conflict between state law and federal law. The VHA’s new ruling, which will establish additional “professional qualifications an individual must possess to be appointed as an APRN within the VA,” might actually lead to requirements stricter than those of some states.
This is by no means an arcane, internecine fight. Advanced-practice nursing appeared in the 1960s because of the need to expand health-care access in a country that did not, and still does not, produce enough generalist physicians but overproduces medical specialists. Over the years, nurse practitioners and other APRNs have become increasingly critical in both pediatric and adult primary care, as well as in specialist clinics and acute-care settings where they work on medical teams.
Of the 93,500 registered nurses, licensed practical nurses, and nursing assistants employed by the VHA, more than 5,700 are advanced practical nurses (APRNs), hired to work on primary-care teams or in settings with provider shortages. In its deliberations on the future of the VHA, for example, the VA Commission on Care recommended that APRNs be allowed to practice to the full extent of their education, training, and certification, which means without direct physician supervision.
When the VHA’s regulation came out, medical leaders expressed their usual reservations about APRN practice. During the 60-day comment period for the proposed ruling, just the hint of liberating APRN practice unleashed an unprecedented torrent of comments from the American public (including many veterans and their families) and professional organizations. AMA President Andrew Gurman immediately denounced it, saying, “We are disappointed by the VA’s decision today to allow most advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law.”
Medical leaders must stop defending an outdated model in which physicians, some of whom may have no training in either leadership or teamwork, dominate the health-care team. It is time to follow the lead of the VHA and establish a model of care that helps not just veterans, but all Americans.
By Suzanne Gordon | Dec 12, 2016
In the debate over the future of the Veterans Health Administration (VHA), no concept has attracted more controversy than “privatization.” Since wholesale privatization of the VHA is deeply unpopular among veterans and their advocacy organizations, groups like the Koch brothers-funded Concerned Veterans for America (CVA) argue that they do not support “privatization” of the VHA. As the CVA’s “Fixing Veterans Health Care” report, published earlier this year explains, the group just wants to give veterans “the same degree of choice that is available to other Americans,” with the federal government paying the tab.
Last week, The Washington Post entered the fray. Writing for the paper’s “Fact Checker” column, reporter Michelle Ye Hee Lee gave Senator Jon Tester of Montana and Representative Mark Takano of California, both Democrats, three out of a possible four Pinocchios (signifying “significant factual error and/or obvious contradictions”) for suggesting that the CVA and Trump transition team members support VHA privatization. According to Lee, the CVA’s position does not constitute privatization because, the “CVA has not proposed a wholesale transfer of VHA’s services over to the private sector—which is what ‘privatization’ usually describes.”
Lee’s interpretation flies in the face of volumes of academic and policy research on the privatization movement that went mainstream in the 1980s, notably in the United States and Britain. As the Prospect’s Paul Starr wrote in a 1988 essay, privatization is “any shift of activities or functions from the state to the private sector; any shift of production of goods and services from public to private; including the wholesale of transfer of services from the public to the private sector or what Starr calls “privatization by attrition,” as furnishing costlier private-sector services lead to an underfunding of public ones.
Ironically, as Starr and other critics point out, the privatization movement decreases accountability and oversight of services currently delivered by the private sector by directing attention to poor government performance while deflecting attention from similar flaws in the private sector.
Privatization can erode public support for the belief that government plays a positive role in handling social needs. So CVA officials are keen to promote a counter-narrative: The VHA is broken. The group relies on stories from veterans who have had negative experiences at the VHA to support its claims. (One female veteran recently told me she’d sent in a story about her positive VHA experiences and never received any acknowledgment.) CVA allies like Florida’s Republican Representative Jeff Miller, the House Veterans Affairs Committee chairman and one of President-elect Donald Trump’s candidates for Veteran Affairs secretary, have also attacked agency employees and targeted the unions that represent them.
The CVA claims it wants to preserve the VHA, but its proposal would shift government funds to private-sector providers, depriving VHA doctors and other staff of the ability to maintain a high level of clinical and research expertise by treating the specific service-related problems of a large numbers of patients. Such a move would also drain resources for supporting current workers and recruiting new ones.
Moreover, the CVA promotes private-sector care even though such care would be more expensive. Like many proponents of privatization, the group supports shifting costs to veterans through out-of-pocket payments and mechanisms like interest-bearing health savings accounts. The CVA proposal would also limit eligibility for care in the private sector or in what remains of the VHA, to veterans with service-related conditions—a change that would hit low-income and indigent veterans the hardest.
CVA officials continue to claim that these moves do not constitute privatization. Some staff members like Darin Selnick, who was a member of the VA Commission on Care (and is now a member of Trump’s VA transition team), have supported eliminating the VHA as a care provider. Selnick was a coauthor of the Strawman Document that outlined a vision of a privatized VHA. In his dissent from the Commission’s final report, Selnick also proposed emulating military insurance programs like TRICARE, which would ultimately turn the VHA into just another insurer. So who really deserves the Pinocchios: two Democratic members of Congress, the CVA, or The Washington Post?
By Suzanne Gordon | Nov 14, 2016
On the campaign trail, President-elect Donald Trump repeated one key promise: to “Make America Great Again” by increasing the country’s military might and supporting its 24 million military veterans. After all, he promised to raise money for veterans and said he donated a million dollars out of his own pocket to veterans’ charities.
But Trump showed his true colors long before Election Day. He finally wrote a personal check to one veteran’s group but only after four months when reporters shamed him into doing so. Trump dissed mentally ill veterans for being weak. Most famously, he called Senator John McCain, who was a Navy pilot during the Vietnam War, a “loser” after being shot down in combat, badly injured, captured, and then abused as a prisoner of war. Nevertheless, many veterans voted for Trump by a large margin.
That’s no great start for “veterans affairs.” But the mistreatment of vets could go from rhetorical to real. That’s because Trump favors some form of privatization of all Veterans Health Administration services, a long sought-after goal of congressional Republicans. His allies on Capitol Hill and his appointees plan to take aim at taxpayer-supported health-care coverage for veterans that actually works better than the federally-subsidized, private health insurance system that was expanded under the Affordable Care Act, which Trump has promised to repeal.
The federal government currently provides veterans with comprehensive and highly specialized care as needed; outside the VHA, the same services would be far more costly and much harder to find. The VHA Commission on Care estimated that treating veterans in the private sector would be almost four times as high—a whopping $450 billion.
However, to the right-wing ideologues already shaping VHA policy under Trump, private health care is the best kind of care there is. Any public program that threatens that framework by being cost-effective, widely accessible, and popular with its patients needs to be curtailed, they believe, regardless of the outcome for millions of veterans.
Trump promised to make outgoing Congressman Jeff Miller, a Florida Republican who chairs the House Veterans Affairs Committee, his secretary of veterans affairs. (Miller did not run for re-election.) He has been hostile to the VHA and will certainly favor some form of VHA privatization. Also leading the Trump charge in the wrong direction is Darin Selnick, a Concerned Veterans for America (CVA) senior advisor and executive director of its “Fixing Veterans Health Care” taskforce. The CVA is an inside-the-Beltway creation of the billionaire Koch brothers rather than a “veterans service organization” with hundreds of thousands of members like the Disabled American Veterans, Veterans of Foreign Wars, or Vietnam Veterans of America, which all support the VHA. CVA may not have pumped big money into the Trump campaign but now they see a golden opportunity to downsize government by installing paid hirelings like Selnick in Trump’s VA transition team or in the executive branch.
Sally Pipes, president and CEO of the Pacific Research Institute, another conservative think tank funded in part by the Koch brothers, was one of Rudy Giuliani's top health-care advisers when he sought the 2008 Republican presidential nomination. She recently wrote a San Francisco Chronicle op-ed, which criticized the VHA as well as any other possible type of single-payer health care. She exaggerated and misrepresented recent problems at some VHA facilities, such as wait times, and accused the agency of “rationing care.”
Selnick and Pipes are previews of coming attractions in the top administrative ranks of the VHA, when heads start to roll and Koch brothers-minded managers replace them. As Trump’s plans for the VHA unfold, veterans and veterans service organizations must go on the offensive against behind-the-scenes power plays to protect a invaluable, specialized program that cannot be outsourced without compromising the quality of care.
Correction: This post has been corrected to reflect that Sally Pipes is the current (not former) president and CEO of the Pacific Research Institute, and does not hold a post on the Trump transition team nor does she advise them on VA or other health care issues.
By Suzanne Gordon | Sep 12, 2016
Not a single veterans service organization was asked to speak last week at the House Veterans Affairs Committee’s hearing on the final recommendations of the VA Commission on Care, though such groups represent millions of former military personnel.
Also noticeably absent from the witness list was Vietnam veteran Michael Blecker, executive director of the San Francisco veterans group Swords to Plowshares, who served on the Commission on Care, and who dissented from its final report. Blecker objected that the commission’s leading recommendation—the creation of a so-called VHA Health System network of private-sector care providers—could fatally weaken veterans’ health care.
Instead, Committee Chair Jeff Miller, a Florida Republican, invited only two people to testify before the panel: Delos “Toby” Cosgrove, vice chair of the commission and CEO of the Cleveland Clinic, and Commission Chair Nancy Schlicting, who is CEO of the Henry Ford Health System. Miller happens to be a faithful supporter of Donald Trump, who has touted the VA committee’s chairman as his top pick as secretary of veterans affairs in any Trump administration.
While Schlicting has expressed support for the VHA, Cosgrove was one of the leaders of a commission faction—what some have dubbed the “Strawman” group—that favored the complete elimination of the VHA.
At the hearing, which took place on September 7, Cosgrove and Schlicting both expressed enthusiasm for creating a VHA Care System that ostensibly would create a network of private-sector providers to deliver health care to veterans while also somehow integrating them into the VHA. The report estimates that this system would eventually channel up to 60 percent of veterans into private-sector health care, and even acknowledges that the new setup would potentially weaken the VHA itself.
Alarmingly, all the Democrats on the committee—with one notable exception—voiced support for this general policy direction, albeit with less ideological fervor than Miller and his GOP colleagues. The one committee member who spoke out against the plan—fortunately for veterans—was ranking Democrat James Takano, of California, who expressed serious reservations about the proposed VHA Care System, and echoed concerns about it that have already been raised by President Barack Obama and by VA Secretary Robert MacDonald.
The other panel Democrats came across as shockingly misinformed, and offered such VHA fixes as Texas Representative Beto O’Rourke’s argument that the VHA should only concentrate on service-related mental and physical health conditions, rather than routine primary care. If treatment of veterans were limited in this fashion, many service-related conditions that experienced VHA providers now identify in primary care visits would go undetected. Such conditions would be far less likely to be diagnosed by private-sector providers, who often have little knowledge of military/veteran problems. As Blecker has pointed out, if Vietnam veterans were dependent on the private sector, PTSD and problems related to Agent Orange, which the VA itself took too long to identify, may never have been recognized and researched at all. (Having learned from its Vietnam experience, the VHA has been quick to identify and act to treat traumatic brain injuries, the signature injury of the wars in Iraq and Afghanistan.)
Also alarming was Veterans Affairs Committee members’ bipartisan embrace of the recommendations by Cosgrove and Schlicting that the VHA abandon its highly successful in-house system of electronic medical record-keeping (which it is working to improve) and replace it instead with commercial products. Lobbyists for companies that produce these systems have spent millions urging hospitals to purchase their wares—despite the fact that, as a large body of research has documented and as a recent JAMA editorial underscored, they have largely failed to fulfill their promise of creating safer and more efficient health care.
“The systems being proposed for purchase at the VHA have been widely disparaged by medical professionals and patient safety advocates for their lack of user friendliness, failure to consider clinical workflow and [prioritization] of billing information over care,” Ross Koppel, an expert in health-care information technology at the University of Pennsylvania, told The American Prospect.
During the hearing, no member of Miller’s committee expressed concern about the estimated 300,000 veterans whose military discharges—sometimes due to service-related mental health problems—leave them barred from the VHA. The Commission on Care recommended that some veterans with other than honorable discharge receive tentative eligibility for health-care services.
All in all, it was disappointing day for vets on Capitol Hill. It was also a warning of what’s in store for veterans if Trump, who has not only floated Miller as VA secretary but has revealed his own ignorance of veterans’ health-care issues, becomes commander-in-chief on Election Day.