VHPI’s Conversation with Dr. David Shulkin
Part 1 of VHPI’s conversation with Dr. David Shulkin, the 9th Secretary of the Department of Veterans Affairs.
Former VA Secretary Dr. David Shulkin joined VHPI Executive Director Brett W. Copeland and VHPI Senior Policy Analyst Suzanne Gordon for a discussion about his new book It Shouldn’t Be This Hard to Serve your Country: Our Broken Government and the Plight of Veterans. The book presents a detailed account of Shulkin’s interactions with President Donald J. Trump and the ‘politicals’ who dominate his administration. VHPI’s discussion with Dr. Shulkin dives into the implications of The VA MISSION Act of 2018 for the future of veterans’ health care. Shulkin also talks about the political forces – like the Koch brothers and their representatives – who have pushed so hard for VA privatization.
This is part one of a two-part interview. The transcript has been lightly edited for clarity.
Suzanne Gordon: We’re just going to plunge right in...How important do you feel the Caregiver Support Program was in getting the support of the Veteran Service Organizations for the MISSION Act?
David Shulkin, M.D.: Well, you know, the Caregiver Support Program... was one of the most important things that was done as part of the MISSION Act. Obviously, it ended up being somewhat controversial in terms of whether it could be included or not because whenever you have a policy, it’s really sort of dual decision-making. It is the right policy? Does it work toward achieving the objectives you want?
And clearly, I think Caregiver Support did...The big issue with the Caregiver Support and getting it as part of the legislation was finding a way to pay for it. The argument that I had made was that the current, the old model the VA had for caregivers, which was, as you know to provide caregiver support to the younger veterans – it was only post-9/11 veterans – was probably the least cost-effective policy that you could have. The veterans that needed caregiver support the most and that would show cost savings would be the oldest veterans to allow them to remain and age at home as opposed to seeking institutional care which was very expensive.
So I think it took a long time to come to grips with how to pay for it but fortunately, I think it ultimately worked out and I think it’s a very important part of the legislation.
Brett W. Copeland: In Chapter 52, you describe the MISSION Act as a ‘major reform’ but warn that the access standards adopted by the current secretary will lead to ‘fragmented care’ and ‘the rapid dismantling of the VA system.’ But the MISSION Act gave the secretary enormous latitude to set those standards. So how can you ensure that the standards are implemented as you intended, especially since it seems that Congress’ control is limited?
Shulkin: I mean this is a little bit nuanced and technical but I think your question is really one of the most important questions facing VA.
First of all, I am a strong supporter of the MISSION Act. As I always tell people, if you wait for the perfect legislation in Washington, you’re almost assured to never get anything done. So I think 95% of the MISSION Act got it right and if I were a voting member of Congress I certainly would have supported it and I’m glad the president signed it.
But the one area that I believe has been a significant mistake has been in the development and the publishing of the access standards.
And because I knew when I was secretary, that it was essential we get the MISSION Act legislation through because...the Choice legislation had expired. It was a three-year program implemented in 2014. It actually had expired and we were doing temporary reauthorizations so it was important we get a permanent program in place.
But I knew that the development of the access standards was so important and so essential to get right that I asked Congress for a year beyond the legislation to be able to work on that, develop it, and then publish what those access standards are. Because I knew if we got them wrong it would have long-lasting implications and maybe unintended consequences.
So, the fortunate part is, as you say, that these access standards are actually really not legislatively [enacted]. To change them you don’t have to change the law. They are at the discretion of the secretary. I think this is the good news.
The difference in opinion that I have versus what the VA went forward with on the exact nature of the access standards are that I felt strongly that the access standards should be clinical in nature.
In other words, every health system that I know, including everybody outside the VA who has private insurance, has a system that is based on the clinical needs of the patient. When I’m a doctor and I take care of a patient who has insurance, I’m evaluating them to determine where the best place for them to get the care is and what that care would be.
The access standards that were adopted by the VA are not the clinical access standards. They continued with the administrative roles and so it’s based on drive time in minutes and based on wait time in days.
And so, what I argue is...if you’re a veteran who happens to live next door to a VA Medical Center, I believe you should sustain the ability to access care in the private sector or at the VA [just as] a veteran who happens to live 70 minutes drive time from a VA Medical Center. And therefore I would have not used these administrative rules in drive time minutes and wait time days. I would have put in a clinical system of care around access standards.
That would have allowed the VA to continue to develop and focus on programs of considerable strength that, I believe, the VA does uniquely and does best. And it would’ve allowed the VA then to assign clinical services that the private sector does better...You make these decisions based on the clinical needs of the patient rather than administrative standards.
Now – I’m sorry I’m rambling on about this, but I think this is one of the essential policy cruxes – when you open up the system based upon 30-minute drive time for primary care and 60-minute drive time for specialty care, you’ve opened up the aperture for private sector care so wide that if this policy is implemented and should the veterans take advantage of it, you may see a rapid shift in resources from internal VA to the private sector in a way that could really threaten the sustainability of the VA.
...This is where my experience in running health care a long time lets me understand what usually happens when you have a system like this. Since most veterans get part of their care in the VA, and part of their care in the private sector currently – so that they use VA healthcare for certain services and they use a Medicare benefit or a commercial insurance benefit in other cases – once that veteran is now eligible for VA care for all their services, because they live 35 minutes away or 65 minutes away, instead of having a 20% copay in Medicare, they now will no longer have a copay.
So they’ll start using their VA benefits more and that will considerably drive up the cost of care. That additional cost is going to have to come from somewhere. And when you look at what VA put as an assumption with the CBO when the MISSION Act was passed, they assumed no shift in resources. I just think that’s unrealistic.
Gordon: I want to follow up with this because there is no health care system, there is no health insurance system that lets a patient go anywhere they want. I’m limited by my insurance. In an OpEd in the New York Times, Avik Roy said, “veterans should enjoy the same health care options as all most Americans are in narrow networks and don’t have a lot of options
Shulkin: Right, but for example in the Medicare program...you can only go to people that are participating in Medicare. But it’s a pretty broad network. Most hospitals, many physicians participate.
Gordon: One of the problems is that there’s a double standard applied to the VA than is applied to the private sector. Now, if you live in a rural area, for surgery or specialty care, the contracts allow Optum and TriWest, to send veterans to specialists up to 180 minutes away while the VA is held to a 60 minute drive time standard. They also don’t apply the same quality standards to the private sector as they do to the VA. If you had been the secretary, would you have insisted that the private sector reach the same rigorous quality standards as the VA?
Shulkin: I think the VA needs to develop its own quality standards. VA has a robust quality measurement system. Part of that system that we had developed when I was secretary was comparing VA to private sector hospitals. That was a major change.
VA’s quality system had always compared one VA to another VA. It’s a five-star system. My belief is that if you live in Detroit and you’re a veteran, you’re looking at whether you want to get your care at the Detroit VA or Henry Ford Health System or University of Michigan – not whether you’re going to get your care at the Detroit VA or the Miami VA or the San Diego VA.
So I think the quality standards are becoming ubiquitous and standardized across the industry and I think they should be the same standards. But VA has to make sure that it’s measuring its care the same way that the private sector is.
Copeland: Before when you were talking about more and more veterans going out to private sector care, at what point does outsourcing veterans to those private sector care providers, what is the tipping point to where you can no longer have a robust Veterans Health Administration (VHA)? Is it 50%, 20% of veterans that are outsourced? At what point is the VHA diminished by the number of patients it’s losing?
Shulkin: I don’t think it happens that way. I don’t think it’s a number where it becomes an unsustainable system. Like everything else in healthcare, it’s by the geography, by the location of where the facility is.
So what you’ll begin to start seeing is places having the toughest time hiring healthcare professionals – rather than focusing on recruitment efforts and getting those services and healthcare professionals back – they simply say ‘we don’t need to do that, we can get these patients to the private sector.’
And slowly you’ll start seeing, by location, a decline in services to the point that...an institution becomes unsustainable. So once you start closing your ICU, once you start closing your emergency room...ambulatory surgery facilities, or your surgical services, pretty soon you have an outpatient clinic.
I think that we’re in a situation where there are going to be shortages of healthcare professionals. There are very capital-intensive requirements to keep your institutions modernized and without the focus and investment on sustaining the VA, you’ll just see a wiggling-away of these capabilities and ultimately, my concern is, a decision that it’s not just possible to catch up when you start having large vacancies and capital deficits and everything else.
Our current policy, if not monitored closely, is not a binary decision. Nobody is going to come out and say that they’re in favor of privatization...that would be just too politically unpopular. But I fear that the unintended, or maybe by some, the intended consequences of our current policy is just going to lead by a drip-by-drip, slow dismantling the system.
Gordon: We're getting reports of that already. The current secretary has said he’s not interested in filling vacancies. He’s said that several times, which is a disturbing comment. Do you have anything to say about that?
Shulkin: I do, which is why I always look at this issue through my lens as a doctor, through a clinical lens. I don’t think it’s a matter of – and this is probably the problem that I had politically, I tend not to be a person who is on either end of the extreme of political ideology – I don’t think you necessarily need to fill every vacancy in every area and I certainly don't agree with not filling vacancies in every area. How you make these decisions has to be principle-based.
The principle that I have is, you do it by clinical decision-making on what’s right for veterans. So what I’ve said is, look: the reason we need a VA, and a strong VA, is the private sector cannot replicate and reproduce the services that the VA provides today that veterans need.
And one of those areas is clearly behavioral health. But that's not the only area. It’s traumatic brain injury, post-traumatic stress, orthotics and prosthetics, rehabilitation. It’s the system that we have of a strong integrated primary care model. It’s women’s health care for veterans.
I’ve labeled these services as foundational, which means VA should double down and invest in strengthening those services to make them world-class and continue to build them. But in other areas, where the private sector has plenty of supply and is really good quality I don’t believe the VA needs to or should replicate or necessarily always provide those services.
...VA often provides eyeglasses that require three visits to the VA. You end up getting a choice of black rims that take three weeks to deliver and yet in every shopping mall in America you can get a wide supply and get your glasses and in an hour. So I’m not sure why we need to be in the eyeglass business.
And the same idea applies to some super tertiary care services that, frankly, the VA may not be doing at the same quality level as some of the places that are leading edge on that. So I would take that question...and I would really break it down and I wouldn’t let anyone get away with generalizations.
I would say, ‘well look, what are you trying to strengthen and support and where do you think we should be recruiting?’ If the answer is simply ‘we don’t need to fill any vacancies anywhere,’ then, frankly, I don’t know what your vision for the system is.
Gordon: ...We’re learning there are a lot of primary care vacancies, a lot of mental health vacancies.
Shulkin: ...Those are foundational to me. Behavioral health, primary care…there is a lot of data out there suggesting that when we send veterans out into the private sector for those services, they do not perform at the level that VA does. So I’d be hiring and making extra efforts to recruiting all the primary care, all the behavioral health that we could.
Copeland: This all circles back to the access standards. What I’m understanding from folks across the country – supply and quality...are critical things that need to be looked at before a veteran is sent out [to the private sector]. But those steps aren’t happening. How do you ensure the supply and quality of care is available in the community...?
Shulkin: Because of the way those services are delivered. A behavioral healthcare practitioner or primary care practitioner in the VA isn’t performing the same exact services as a private sector person. In fact, I was at a New York State Health Foundation event last night where they surveyed [private sector providers in the state]…They found that less than two percent of providers in the private sectors met all the criteria to take care of military and veteran patients.
And how do I know this? Because I’ve spent my life practicing as a doctor in the private sector. And then I was VA Undersecretary of Health, I would put on my white coat and I would see patients in the VA and it was a very different experience. I had to relearn what medicine was about when I went to the VA. It was a much more holistic approach. It dealt with all sorts of different issues. As I talk about in my book, patients who come in that are homeless and knowing that it’s part of the VA’s mission to find these people places to live because how do you deliver medications to a patient who is living in Central Park like the patient I took care of?
And in the private sector, I wouldn’t have seen that as part of my responsibility. Of course I have empathy, but I wouldn’t have seen that as a key issue.
Gordon: One of the things that we’re concerned about is the Asset and Infrastructure Review (AIR) Commission. You mentioned they want to push up the start date...even if private sector capacity isn’t there. Plus, under the current legislation, if Congress were to pass a resolution not accepting the recommendations of the commission and the president, the president could veto that.
Gordon: Given what you’ve said about the administration’s commitment to privatize, couldn’t this be a really significant problem, if not a disaster, for veterans?
Shulkin: I have a couple thoughts on this. It’s deeply concerning to me, the increasing partisanship that I see seeping into VA. This is something I’ve fought very, very hard to keep politics out of VA issues and to keep this a bipartisan policy-making group.
I was confirmed 100 to 0. We got eleven bills through Congress to the president for signature the first year I was there. And this was working very, very well. The day I left, I remember Senator Tester saying he’s worked with me for three years, he couldn’t tell if i was a Democrat or a Republican and I said ‘that’s perfect.’
And last week, we see the Republicans storm out of the committee meeting. There’s attacks on both sides and I worry are they really going to be able to get these issues looked at objectively or are we going to start seeing partisan views of efforts like this? If you are going to undertake this effort, it has to be done objectively.
I worry about a commission like this or an assessment of our facilities. If it’s simply going to take a look at what our current state is and then make decisions...it becomes self-fulfilling.
If a facility that, frankly, hasn’t been filling its vacancies, hasn’t been providing the right quality care, then you may jump to the conclusion that that’s a facility that should be shut. When, in fact...if you’re going to do this process you have to start by saying what your vision and your principles are in caring for veterans.
If your vision and your principles are put out there first, that’s a framework with which to evaluate and objectively look at data to make decisions whether a facility is meeting those principles and objectives.
So if the facility is serving a population that needs to be served...then when you evaluate it, you may say well we don’t want to close this, we actually need double down our efforts to recruit and to improve the services. On the other hand, if you have your principles and you come to a facility where, frankly, there aren’t many veterans and there is good access to private sector care and the quality is better in the private sector or it’s very good, you may actually decide that facility can be either downsized or eliminated giving those resources to places that are struggling.
We have had a demographic shift of veterans from the Rust Belt to the Sun Belt. Any organization or company needs to make adjustments to their plans based upon the needs of their customers.
What worries me though, is seeing a commission like this work in isolation of the strategic framework and principles that we’re trying to achieve.
Gordon: So there is a danger in this commission?
Shulkin: I think that what you find is a spectrum of thinking on this. You have the pure, political idealogues at one end of the spectrum. And then you have those that are looking at the situation and saying look, ‘I see all these problems in the VA. I see they are not meeting veterans' needs, I don’t like that so isn’t the solution just to privatize?’
And I will acknowledge that when I was in the private sector and I was called by the Obama Administration to come in I had a pretty open mind on this issue. I thought I might find that the VA is doing what the private sector is doing, they’re just not doing it as well. And the right answer might be, let’s get these people the care they need, let’s start shifting everything to the private sector.
It wasn’t until I really got there and I saw that what the VA was doing was very different than the private sector that I began to develop a different view of how you change the system.
And it’s not exclusively in the VA. I don’t think the VA can meet all veterans’ needs alone. So I think it has to be a system that works with the private sector but you design the system based on the strength of what the VA does extraordinarily well and can do even better if it’s given the right resources and...what the private sector is doing well and different than the VA.
And ultimately this is a plan that I published in the New England Journal of Medicine, that basically says you design this around the veteran. What’s the best for the veteran? You get them to the place where they can get the best care. And the irony is that when you talk to people who are so critical of the VA and say let’s close it, most of them are not veterans. Most have never been to a VA in their life and don’t really understand what the VA system is about or what it does.
Shulkin: That was not a strategy that I had which is to publish a book and then make it unavailable. I obviously felt that this was a really important book to get out to everyone in VA but also that the private sector could learn a lot in the VA.
I’ve since then published a paper that’s posted on LinkedIn called The Twelve Reasons for the Superpower of VA Healthcare which meant for private sector CEOs to look at what’s been working so well in the VA system so they can begin thinking about building it into their own health systems in the private sector.
When I came to VA I thought I would be bringing in all this great knowledge about how to change government by bringing in private sector best practices, and in fact I did that in some cases like helping with the waiting times. But actually I think I learned much learned much more from the VA that I would bring out into the private sector because the VA is doing so many phenomenal things.