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Inside a Terrible House Hearing

The July 14th House Veterans Affairs Committee hearing on the private care program established through the VA MISSION Act was an occasion for more shots across the bow aimed at dismantling the VA.

The hearing started on a thoughtful note. In her opening remarks, Chairwoman Julia Brownley (D-CA), outlined serious problems with the outsourcing of care to the private sector. As she eloquently stated, spending on non-VA care has increased by 116 percent over five years while investments in care provided by VA medical facilities grew by only 32 percent. “Why,” Brownley asked, “are VA’s investments in community care so vastly outpacing investments in in-house care?” And “how,” she continued,” is VA coordinating care in the community and monitoring its quality?” Finally: “What oversight is VA conducting to assure its third-party administrators are delivering on their contractual requirements including building adequate networks of providers?”

But as the hearing proceeded, Brownley’s questions were completely ignored.

No one who tuned in after her initial remarks would think there were any problems with the cost, timeliness, or quality of care delivered in the private sector. That’s because the hearing was dominated by conservative ideologues who crafted a clear and misleading message designed to discredit the VA.

Without any pushback from Democrats, Republicans returned to what has become a familiar, deceitful trope: Delays in scheduling appointments for community care is the VA’s fault. In this false scenario, no failure is attached to third party administrator’s well-documented (and well-compensated) failures to assemble adequate provider networks, accept new patients and manage VA payment rates. Delays are solely the result of a burgeoning VA bureaucracy standing between the veteran and the perfect private sector. “Why does VA need to increase oversight over community care providers,” asked ranking subcommittee member Jack Bergman (R, MI), who led the anti-VA charge throughout the hearing.

He and other Republicans insisted that veterans should be able to go to any of the 1.2 million Veterans Community Care Program providers they choose, for any reason, and for as long a period of treatment as that private sector provider deems necessary. The only role the VA would play in this process is to pay the bills. In other words, Republicans want the VA to shift to being an insurer and payer of care, not a system that delivers care. Worse still, the VA would not engage in the kind of utilization review and oversight processes that other insurers routinely implement to ensure the quality, timeliness, efficacy, and cost of that care.

VA witnesses were largely unprepared to counter the sustained attacks that Republicans mounted. Unstated was that these very lawmakers had vigorously pushed that the MISSION Act include new eligibility determination hoops for veterans to jump through. Now they’re conveniently complaining that their own processes are barriers that need to be abolished.

They further claimed that the job of authorizing, monitoring, and coordinating care in the private sector is creating a giant new government bureaucracy (a myth designed to trigger ire in the Republican base). The implication was that veterans should simply have automatic eligibility for community care, i.e., replace the VA system.

To support that calamitous vision, conservative committee members invited the co-founders of Forge Health, CEO Eric Frieman and VP Eric Golnick, to testify. Forge, which entered the market in 2016 and today operates in six states on the East Coast, is a private, for-profit mental health and addiction treatment company. It has special programs for veterans, first responders and active-duty military servicemembers.

In his testimony, Frieman paid lip service to VA’s sterling record on mental health and suicide prevention services as some of the best in the land. “The individuals providing care at the VA are amazing,” Frieman said. “99.99 percent of the individuals, especially for the administration side, are fantastic. Point zero one is the hold up.”

Yet, as soon as Frieman offered this acknowledgment, he pivoted and advocated two overhauls to the veterans’ care eligibility and delivery system, both of which would cripple VA.

Forge specifically called for the elimination of VA’s role as the pre-authorizer of care, even though pre-authorization is the core foundation of the VA system (outside of Emergency Medical/ Psychiatric Care, and Urgent Care).

Frieman stated: “Over the past year one of our clinics has served 41 Veterans who each met the VA MISSION Act eligibility and access standard criteria. Of these 41 Veterans, we received zero community care referral authorizations from the VA.” Golnick added: “This is not ideal from our perspective.” They argued that Forge, and, by extension, any other provider, should be able to render treatment to veterans without approval to do so and then be paid by the VA anyway. (No integrated health care system or any insurance carrier in America allows patients to go out of network at will.)

Frieman and Golnick also called for eliminating VA as the decision maker for timing and intensity of mental health and substance use disorder care that a veteran needs. If a VA mental health evaluator makes the judgment, for example, that bi-weekly in-house care beginning in a week is the appropriate treatment plan, Forge’s model would allow the Forge to unilaterally overrule VA and commence higher intensity care.

Forge’s suggestions, in accord with Republican subcommittee members, would end VA oversight and allow veterans to obtain whatever care they want -- with VA footing the bill. That philosophy also aligns with private equity-funded companies whose business models, according to one recent report from UC Berkeley School of Public Health, are “fundamentally incompatible with sound healthcare that serves patients.” Forge Health has received millions from private equity investors and has a number of big players from this sector on their board.

Privatizers know that the VA’s community care program is already stressing the veteran healthcare system and that removing oversight and utilization review would all but bankrupt the VA. If this new agenda is implemented, it will inevitably lead to service cuts and higher veteran co-pays.

The framers of the VA MISSION Act were clear that VA be the initial point of contact and authorizer of care. This is the only way to protect veterans from unscrupulous private sector profiteers. The field of substance abuse treatment is rife with grifters and fraudstersand it is the VA’s charge to protect veterans from people who put profits before patients. Forge wasn’t asking for special consideration just for itself. It recommended that legislators remove the guardrails and protections across the board. That opens the door for unscrupulous providers to exploit veterans. This is hardly a way to thank the nation’s heroes and give back to those who have served.

Instead of eliminating VA oversight and monitoring, lawmakers should be addressing the VA’s ongoing mental health and substance abuse staffing shortages. The majority of facilities fail to meet the VA-required mental health staffing ratio of 7.72 clinical FTE per 1000 MH patients, a ratio that when attained, has been shown to prevent suicide.

Legislators should also be answering the questions that Chairwoman Brownley asked in her introduction. The answers to these questions, not arbitrary attacks on a model of healthcare that is still delivering the best care anywhere, should dictate future discussions about the future of private sector care.

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