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Looking Ahead to Veterans’ Health Care in 2020

VHPI’S ANALYSIS OF CURRENT EVENTS AND PREDICTIONS OF WHAT WILL HAPPEN THIS YEAR.


By Suzanne Gordon, VHPI Senior Policy Analyst & Jasper Craven, VHPI Policy Fellow


Veterans’ health care is unique to American health care: it is the largest and only publicly-funded, fully integrated health care system in the country. Because of its size, structure, and unique model of care, it has the power to improve health care for all Americans. It’s also a research powerhouse and has tremendous purchasing power, for example, in lowering the price of prescription drugs. As you can read in our 2019 Year in Review blog, it may soon look like the rest of America’s broken and fragmented private health care system. Here are the things VHPI will be tracking in 2020.


Will privatization politics drive suicide prevention efforts?


Increased polarization in Congress impacts effective care for veterans when politics overpowers proven health care practices.


The House and Senate Veterans Affairs Committees have been historically marked by productive policy work in the service of former military members. The committees were motivated by a desire to help veterans and overseen by the once-powerful membership-based veterans’ organizations. The two committees pumped out some of the most progressive federal policies of the 20th century, from the G.I. Bill to a pioneering nationwide health care system.


Yet since a 2014 wait time scandal at Veterans Health Administration (VHA) hospital in Phoenix, this bipartisanship has largely evaporated for numerous reasons. The most pernicious factors include the proliferation of corporate donations to committee members, an intense increase in corporate lobbying on veterans’ issues, and the influence of right-wing groups like the Koch -funded Concerned Veterans for America (CVA).


The most recent example of this breakdown came in the debate over the Improve Well-Being for Veterans Act, which would have, in the name of suicide prevention, funneled millions of taxpayer dollars to private sector entities of varying qualities.


The bill faced significant concerns from Mark Takano, the Chairman of the House VA Committee, as well as a plethora of advocacy organizations including Disabled American Veterans (DAV), American Legion, American Psychological Association (APA) (VHPI also took part in an analysis).


Some lawmakers, and even Veterans Affairs Secretary Robert Wilkie, peddled misleading information about the bill. Furthermore, Wilkie refused to engage with Takano on his concerns and instead oversaw a lobbying blitz in support of the bill, a move that may violate the Hatch Act. This tension came to a head in a largely unproductive House hearing on the matter in which Wilkie questioned Takano’s commitment to veterans’ issues. “Don’t imply, Mr. Secretary, that I care any less about the veterans who are committing suicide,” Takano shot back. “We want to get it right. There are high stakes in terms of getting it right, and there are high stakes in terms of getting it wrong.” The future of the Improve Act remains uncertain.


The likelihood of this political fever breaking in the House is nil. The forecast in the Senate is similarly dire, as the long-time, well-liked committee chairman Johnny Isakson, has retired. He is to be replaced by Jerry Moran, a hardliner on veterans’ health care privatization who introduced the most conservative drafting of the VA MISSION Act. (Moran is a top recipient of cash from the Koch network, which supports privatization through work through the CVA.) VHPI analyzed the legislation, sent in testimony about it, and we wrote about it in The American Prospect.


VHPI is cautiously optimistic there may be room for innovation and improvement around veteran suicide prevention down the street from Congress at 1600 Pennsylvania Avenue. In 2019, a group of subject matter experts gathered at the White House to generate PREVENTS proposals. Some of the people in the room (like VHPI’s Russell Lemle) are leaders in veterans’ mental health. Additionally, by having an open discussion about the role firearms play in suicide that’s directed by firearm industry professionals and lethal means safety experts, there is the potential to make real headway. But as always, it depends on who has the final say in the matter.


If ideologues like CVA ultimately have the last word, PREVENTS will turn out to be just another initiative that fails turn make a dent in the high number of suicides among veterans that have no contact with the VHA.


VA facility closures coming soon?


VA facility closures could have a massive impact on veterans and the communities in which they live.


Last March, U.S. Sens. Joe Manchin and Mike Rounds introduced bipartisan legislation to block the establishment of a nine-person commission charged with considering the VA’s infrastructure needs for the future.


The Asset and Infrastructure Review (AIR) Commission was mandated in the VA MISSION Act and is now set to begin its work in 2022. It will make recommendations of facility closures based on utilization. The upshot is that if the push to shift veterans into private sector care continues, the corresponding decline in utilization of VA facilities could be used to justify closing those facilities permanently – regardless of who’s providing the highest-quality care. Manchin and Rounds teamed up to oppose this work because, in their eyes, the Commission will likely decimate rural VA hospitals in their communities.


“Although I am very supportive of reducing waste and other inefficiencies in the VA system, I am against bureaucrats in Washington cutting vital healthcare access to Veterans in rural areas of West Virginia,” Manchin said. “These veterans have put their lives on the line to protect this country and should all have easy access to the healthcare they have earned.”

Their proposal hasn’t racked up any additional co-sponsors, suggesting that the Commission will indeed be created. If a proposal from retiring U.S. Rep. Phil Roe is adopted, the Commission may even be created earlier than 2022.


Lawmakers have little oversight over the commission and no opportunity for direct input into its individual recommendations. The list of final recommendations will be voted up or down. The commission will be composed of various stakeholders, including a few veterans service organizations and potentially a lot of healthcare industry advocates. It could lead to the shuttering of VA hospitals – department officials have already zeroed in on facilities they claim are underused.


VHPI has studied the potential downstream impacts of facility closings. They would, among other things, increase wait times and costs through privatization and diminish veterans’ access to the highly specialized, comprehensive care unavailable in most private community practices. The shuttering of facilities could also negatively impact crucial fellowship, residency, and other programs that train thousands of health clinicians in America as the VA partners with research universities across the country. Veterans, who make up one-third of VA employees, would be disproportionately and negatively impacted by hospital closures – not to mention the devastating economic consequences closures would have on local and regional economies.


Moreover, the boosters of this commission have failed to acknowledge that, even if some hospitals may now be underutilized, the dynamics will almost certainly shift when America becomes ensnared in its next major military conflict – a prospect that increases by the hour.

The final threat from the AIR Commission? Congress will have to muster a veto-proof majority to reject any of the Commission’s recommended closures.


Technology and Veterans’ Health


The good and the bad of technology in veterans’ health care.


VHPI expects that VA’s history of technological innovation will continue in 2020 – particularly if facilities begin to face closure. The telehealth program is particularly important when reaching veterans in rural communities. The ATLAS program is also meeting older veterans where they congregate, like American Legion halls.


The new artificial intelligence program could assist with predicting which veterans are most at risk of developing chronic conditions or suffering from PTSD. It also has the potential to further help the VA improve on its record of accurately predicting which veterans have the highest risk of suicide. The data-sharing partnership between the Department of Defense and VA will be critical to the success of transitioning active military members back to civilian status. It increases the likelihood of a warm handoff between the military’s medical corps to the VA – an important step often missed in the past, as veterans are most at-risk in the first year after their separation from service. At the VA, 3D printing isn’t just a private sector fad to create fun, cute plastic collectibles. The VA has used it to tailor prosthetics for individual veterans.


But, be warned: the flip side of the technological coin comes with the increasing influence of tech giants like Apple, T-Mobile, and Cerner. Benjamin Krause has warned, in particular, that “surveillance capitalism” will soon be playing out with veterans’ personal health care data. Apple (as the Mar-a-Lago trio long-advocated) now has access to veterans’ data, which can be funneled through its health app.


Cerner, meanwhile, is doing its best to make as much money as possible, rebuilding the VA’s (admittedly aged, but) much-loved and ground-breaking electronic health record system. T-Mobile’s “free” service allowing veterans to access the VA app without hitting their data usage is nice, but when will it become unprofitable without some kind of bundled promotion? And how long before Walmart’s ATLAS kiosks are placed side-by-side with Walmart products promising equal effectiveness to that of a VA physicians’ advice?


The VA’s Chronic Staffing Crisis


Will unfilled positions lead to more outsourcing and less care at the VA?


It is estimated that there are are some 49,000 vacancies in the Department with the majority at the VHA. Secretary Wilkie has repeatedly made it clear that filling these vacancies is not a priority for him. Given his commitment to outsourcing veterans’ care to the private sector, this is hardly surprising. Unfilled vacancies mean more delays in care – which justify more outsourcing. It’s a self-fulfilling prophecy that could to program and facility closures. And we’re learning now that these closures are already emerging all over the country.

It’s unclear how this staffing crisis will be solved. Congress has exacerbated the problem of recruitment and retention by capping the amount of money that the VHA is able to offer qualified, talented candidates.


Policymakers, administration officials, and the media often fail to place the issue of vacancies and staffing problems in a broader historical context. When it competes with the private sector, the VHA is at a distinct disadvantage because it cannot offer competitive, market rate salaries. Even when a qualified candidates are willing to sacrifice higher private sector pay to work at the VHA, they confront discouraging HR protocols and VHA policies that we will explore in detail. Navigating through this maze is so time-consuming that some potential new recruits simply drop out and choose the private sector over the VHA.


When it comes to filling clinical positions, these problems are further aggravated by national shortages of healthcare providers like primary care physicians, mental health professionals, general surgeons and more. The VHA is dependent, for hiring, on the supply of healthcare professionals produced by the nation’s healthcare professional training programs.


Rather than addressing these long-standing problems, national provider shortages, and pay gaps between the VA and the private sector, Trump’s VA leadership, aided and abetted by Congress, focuses instead on outsourcing care.


The Administration has also implemented policies that discourage federal employment and created a hostile work environment for those who remain committed to working with veterans. All the parties involved have abandoned veterans and failed to uphold their statutory responsibility to fully staff and run the nation’s largest public healthcare system. If administrators, legislators, and policy makers were doctors and nurses, one could credibly assert that they were guilty of medical negligence and of violating their oaths to ‘first do no harm.’


Tracking the VA MISSION Act’s Implementation


The biggest budget in the VA’s history may not be spent on direct care for veterans.


VHPI’s investigative agenda for 2020 will also include tracking of how the VA MISSION Act is depleting VHA budgets in facilities across the nation. We will explain just how the devilish details of MISSION Act implementation is leading to dramatic cost overruns, as well as de facto hiring freezes. This means that even a large increase in the VHA budget is insufficient to cover the huge expense of caring for more and more veterans in the private sector.


President Trump and lawmakers constantly boast that, thanks to their efforts, the VHA now has a larger budget than ever before. Members of the media and Congress are blinded by the stats.


But here’s the stark reality: If you get a large budget increase which is then dedicated to increasing the profits of private sector health care providers and you deplete the budget for clinical care at the VHA, this is not progress – it’s privatization.


We rely on tips and insight from veteran advocates, Capitol Hill aides, and VA employees at all levels. Want to speak to a VHPI staffer about an issue you’d like highlighted? Contact us at suzanne.gordon@veteranspolicy.org or execdirector@veteranspolicy.org.

© 2020 Veterans Healthcare Policy Institute

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