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Remaking the Politics of Veterans' Healthcare


Source: Facebook.com/VetAffairsDems

Part II of VHPI’s Conversation with Stephen Trynosky In part I of this conversation with Stephen Trynosky, VHPI discussed how the House Committee on Veterans’ Affairs (HVAC) was traditionally viewed as a backwater in Congress. Lawmakers on the HVAC quickly left it for more prestigious positions. The interview also examined how former Chairman Jeff Miller dragged the HVAC into the total war of modern partisan politics. Read it here.

In part II, below, VHPI discusses how Congress and the VA could mend its relationship to the benefit of veterans and the larger American healthcare ecosystem.

The conversation has been lightly edited for length and clarity.

Spreading VA Innovation and Influence

VHPI Senior Policy Analyst Suzanne Gordon: What can you learn from the way that Jeff Miller used his position to promote a negative message about the VA so that a more positive and accurate message can be promoted? What is extraordinary today is that the committee and the media and the Veteran Service Organizations (VSOs) focus almost exclusively on the negative, leaving out all the positive things the VA does. If the HVAC’s job is oversight, shouldn’t oversight also include a serious consideration of the value and contributions of the department you are overseeing? HVAC is effectively managing the largest health system in the United States. We know that good managers look at how well things work not just how poorly. In fact, as politicians who are supposed to serve not only veterans but a broader public, shouldn’t they also be considering how to get VA best practices out to the private sector to improve healthcare for all?

Stephen Trynosky: I agree with you in principle. This has just unfortunately been the way Congress has been since about 1995. As I wrote in my monograph, the VA committee was this kind of quaint, genteel oasis insulated from many of the partisan trends that were ushered in 1995 with the Gingrich Speakership – which persisted through Hastert and when the Democrats took the House in ‘06 and ’08. It eventually caught up with the HVAC almost two decades later, but it finally did catch up with Veterans issues and Miller exploited that. Weaponized it.

“The true experts on healthcare policy and financing in Congress, the Energy & Commerce and Ways and Means Committee staff, are not involved in oversight of the veterans’ healthcare system at all – and that’s a problem. ” — Stephen Trynosky

The thing is, the HVAC could be a platform for positive messaging and showcasing things, but it goes to the fracturing of veterans healthcare jurisdictionally in the House of Representatives. It has been ghettoized. It is overseen separately from the larger American healthcare system. The true experts on healthcare policy and financing in Congress, the Energy & Commerce and Ways and Means Committee staff, are not involved in oversight of the veterans’ healthcare system at all – and that’s a problem.

This is the result of the historical iron triangle, the closed system between the VSOs, the VA, and the Veterans committees. That world doesn’t communicate much with the larger health policy community – certainly in Washington and I would say even nationwide. Recognizing that disconnect and trying to fix it should be a high priority for any leadership team of either party in either house of Congress.

Gordon: One of the things that has struck me in my work in healthcare, is that the VA is not considered part of the ecosystem of the American healthcare system. It’s the nation’s invisible healthcare system. It’s doing all these amazing things. Ironically, its very isolation from market driven healthcare and the fee-for-service imperatives may have allowed it to develop better models of care. The problem is that you have the largest healthcare system in the country and nobody knows about what they are.

The VA is really the only population health system in the country. The innovations it makes are available to everyone. You can see that in the COVID-19 crisis. But you see it in everything – in end-of-life care and homelessness, primary care – everything the American healthcare system does not do well the VA does well, and yet no one knows about it.

Trynosky: Historically, that’s the nature of the Iron Triangle. The durability of the VA in the post WWII era meant that it never had to aggressively advocate for itself in that way. Broad bipartisan support was assumed and the imprimatur of the “Big 3” (VFW, DAV, and American Legion) was often enough to assure passage of sweeping legislation. In the middle of the Clinton impeachment when things were aflame in Washington, the Millennium bill – which was transformative for VA healthcare, was passed by unanimous consent in the Senate and was almost unanimous, if not unanimous, in the House. Massive bills have been passed with that kind of bipartisan durability.

So VA never had to build an infrastructure or a culture of having to assess and justify, not only just requests for funding, but its continued existence. We’ve seen that need since the beginning of the 1980s in virtually all other Federal agencies with incredible scrutiny and advancement of privatization and outsourcing. So generations of bureaucrats (using that term in the best sense) at DOE, EPA, HHS, have grown up in their jobs having to constantly justify and put forth a compelling rationale to Congress and the American public for their continued existence. VA never had to do that.

The VA’s senior executives grew up in the 80’s, 90’s and 00’s in a world apart from their peers in the rest of the Federal government. That’s why 2013 through 2014 were so disorienting and so traumatic. Suddenly, in Congressional oversight and the media, what had been happening in other areas of government since the 1990’s, at least, had finally caught up to VA. But VA was uniquely unprepared to deal with those challenges and crises. It was such a sudden change from the way the VA and its senior leaders had historically interacted with members of Congress and the media. It found itself on the backfoot, and it was having to justify its existence very quickly. I think that created some challenges to rapidly and nimbly adjust to that changed environment.

Transparency and an Long-Term Engagement Plan

Gordon: You argue in your monograph that it essentially didn’t adjust that it just clamped down.

Trynosky: That’s exactly right. If you look at complexity theory, where a system comes under stress – opening the aperture that you want to do. The VA had actually taken the opposite approach, certainly in the year leading up to Phoenix with this drip, drip, drip of investigations.

It tightened control of what information left and that obviously had a second or third order effect on timeliness of that information. It created an environment where there was a tremendous amount of mistrust toward the VA and responses to the most basic and nonpolitical inquiries took weeks. Rick Weidman from Vietnam Veterans of America who had observed veterans healthcare issues since the 1970s. He observed that the culture of information sharing in the Obama VA around the 2013, 2014 at least up until that point, was the most non-transparent that he had seen.

So even natural allies in Congress and advocacy groups felt like they weren’t getting the access or information they needed. That level of frustration fed into the platform that Chairman Miller was able to build - where he was becoming a counter source of information from the VA public affairs and Congressional affairs structure which had been increasingly seen as slow, lumbering, and not forthright.

Gordon: If you take this as a lesson, the Administration wouldn’t want to cut down but instead encourage a radical opening up.

Trynosky: Yes, but in the nature of a federal bureaucracy, that requires having a robust cadre of vetted, trusted staff throughout the organization. That’s another thing that makes the VA unique - but not in a good way.

When VA became a cabinet-level department in 1989, Sen. John Glenn, who was the chairman of the Senate Committee that oversaw that bill, was insistent that the VA not have the complement of political or presidentially appointed personnel that other federal agencies had. It was 1989, things were very different in Congress. Certainly, the 24/7 media cycle didn’t exist. Congress was much more bipartisan, and veterans’ issues certainly were. There may have been some wisdom to Sen. Glenn being so adamant about not wanting presidentially appointed personnel in great numbers in a VA cabinet level department. The problem is that whatever rationale made sense in 1989 may no longer be operative. What you have now is the second largest federal department by employee headcount with a fraction of the authorized presidentially-appointed personnel than any other cabinet level department.

There are like a 160 at HHS and Education has over a 140 – these are much smaller departments in terms of headcount. VA has a cap of about 40 - and that includes the secretary himself. There is this very small group of individuals that the secretary is able to pick as his team.

And so when you have such a small number of people, the human response in an adversarial situation is to close things, have those trusted people who have your back to review things for you, clear things, make sure they’re consistent. A tremendous amount of things at VA have been forced up for the secretary’s office for clearance. That is not the case at other departments.

Obviously when you have a small number of people to quarterback all those things, the bandwidth and flow they can process is smaller. So, you have that situation. One of the things that has to happen is for VHA to have presidentially appointed positions, which they currently do not.

That would enable direct, vetted, trusted oversight of what’s going out, what’s leaving the building in a way you don’t currently have. The VHA is essentially a turnkey operation. No matter who gets elected President, no matter who becomes the secretary, this 300,000 plus employee organization is basically a turnkey body of career staff. There’s very limited ability, whatever their intention or goals are, for a President or VA Secretary to install their team to drive change, provide a feedback loop, and reinforce what the other priorities are. At this point it is hampering the department’s ability to react to external forces and seize opportunities. The VA Secretary is limited in a way that none of his Cabinet peers are.

Legacy VSOs, Education Institutes, and Corporate America

Gordon: You also argue that the VA needs to build relationships outside of HVAC and SVAC with other actors in Congress.

Trynosky: Yes, all facets of the Iron Triangle need to go to these other committees, too. The VA needs to seriously engage the other actors in Congress who oversee healthcare. They were in a terrible situation in 2014 because when something bad happens in healthcare, there’s a limited number of people who the Speaker and House leadership will confer with. The rank and file members of the veterans’ committees or their staff are not it. You have this situation where this VA access crisis percolated to the top. but there were very few people on the Hill who were able to make the connection that this was an access problem writ large in all of healthcare.

The access situation at VA is probably better than most places. But VHA’s jurisdictional ghettoization on the HVAC and lack of outreach to other panels within Congress inhibited this dialogue. You can’t pick up the phone in the middle of a crisis and build a relationship on the fly and this is doubly true when your reputation is in tatters. I think the VA should certainly be more intentioned in engaging the people in the Congressional realm who are healthcare advocates and experts - not necessarily veterans’ healthcare experts.

Gordon: After Phoenix, Miller attacked Sec. Robert McDonald, because the Secretary had mentioned Disney in relation to veterans’ healthcare. He also attacked the VA for spending a pittance on care in its facilities. He was able to get away with these attacks because no one on either committee knows much about healthcare.

Trynosky: I will give you some personal examples – two members of Congress whom I was in meetings with while on the VHA Legislative Affairs team that really impressed me. One was Rep. John Sarbanes (MD-03). Incredibly thoughtful, what an advocate he could’ve been – he was enthusiastically telling us about the strengths of the VA system. And Rep. Joe Kennedy (MA-04). These two had the ability to be real VA advocates but they weren’t on HVAC and not seen as a priority for VA to engage. The irony is that both sit on the Energy & Commerce Health Subcommittee which essentially oversees the U.S. healthcare systems (less Medicare and Medicaid financing). I remember writing up my summary of the Sarbanes meeting and sending it up to the Under Secretary’s office - saying that he really needed to meet with him and cultivate Rep. Sarbanes as a surrogate on the Hill. That recommended meeting never happened. I witnessed a lot of missed opportunities with very influential Members and committee staff because they weren’t on the HVAC. It was a very un-sophisticated approach to outreach that we were going to shower all this attention and focus on these green, first term members of Congress who are going to leave the HVAC as soon as they can.

They’re not invested in healthcare and they’re not invested in the VA in the long term. And meanwhile, we have these people who are very young like Reps. Sarbanes and Kennedy - they’re going to be in Congress a long time. They’re focused on healthcare issues and they’re not going to lose that focus. The point was, the VA doesn’t play that long game. It was very transactional, very short term gain.

Is there a will to reform the Iron Triangle?

Gordon: How does one begin to change this?

Trynosky: This can happen on multiple levels. There’s no one answer. Part of the answer is Congressional leadership from both parties recognizing the importance of having more senior members and members with a focus on healthcare on the veterans’ committees. That can be done.

Energy & Commerce and Ways & Means, the two House committees which oversee most of the U.S. healthcare system are “exclusive” committees. If you’re on either one of those panels, it’s the only committee you’re on. But leadership can give a waiver allowing someone on the exclusive committee to also serve on the Veterans’ committee. Rep. Gus Bilirakis (FL-12) an HVAC Republican member is an example of this. That’s something that Speaker Pelosi or Leader McCarthy could do in the next Congress. Identifying four wonkish, healthcare focused members from Energy, Commerce, or even Armed Services and have them sit also on the VA committee and that would immediately inject the committee with seniority, gravitas and connect the larger discussion about healthcare policy in the U.S. with veterans’ healthcare.

The second thing that can be done is internal to the VA. Yes, it would require legislation to increase the number of appointees, but there is no prohibition on the VA for having a more sophisticated approach to members of Congress on both sides focused on healthcare. There’s an incredibly thoughtful number of members focused on healthcare but they don’t necessarily engage with the VA committee.

A few years ago I staffed then Under Secretary David Shulkin when he spoke to the GOP Doctor’s Caucus – the Republican House Members that are physicians. Only two of the 16 were on the VA committee, but the others included the then-Chairman of the Ways & Means Committee. It struck me that we didn’t interact with the non-HVAC Member in any meaningful way other than on narrow constituent issues in their district, despite their seniority and influence in the House. That’s one of many incredible opportunities the VA could take upon itself to talk about what it does and build relationships with thought leaders in healthcare in Congress beyond the four walls of the VA committee.

“...corporate interests now have a seat at the table in the veterans’ committees in a way they never did before. The VSOs don’t have the role they once had and it would behoove them to go beyond their traditional Congressional audiences and engage.” — Stephen Trynosky

One of the aftermaths of 2014 and the demise of the traditional iron triangle is that corporate interests now have a seat at the table in the veterans’ committees in a way they never did before. The VSOs don’t have the role they once had and it may behoove them to go beyond their traditional Congressional audiences and engage.

The National office staff in D.C. needs to engage other lawmakers in ways that they haven’t. They need to cultivate leaders of other committees as a champion for VHA healthcare as they would for a lawmaker on the Veterans Affairs Committees. The members most ideologically inclined to support an enlarged VHA system are not on HVAC.

VA’s academic affiliates are also important audiences the VA and VSOs need to engage. Members of Congress pick up the phone when these highly influential academic institutions call. It may be just another way to communicate the importance of the VA system. When the VA or the VSOs come calling, it's already stigmatized a little bit. But if these academic institutions come forward and talk as surrogates about the VA and its importance - that could be very powerful.

Read Part I: The Broken Politics of Veterans’ Healthcare

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