There is an elderly veteran somewhere in the country with a crackling cough who needs an x-ray to rule out pneumonia. There is a female veteran who needs diagnostic testing to ensure her blurry vision and lower leg numbness is not an early manifestation of multiple sclerosis. More alarmingly, there is a combat veteran contemplating suicide who would be perhaps best served by VA mental health services but will be referred to care in the community because the waitlist is too long. None of these veterans care about ideology or to be the political pawns of pro- or anti-privatization proponents. They simply want to seek treatment for what ails them in a fair, predictable, and trustworthy system.
In recent testimony on the future of veteran healthcare before the Senate Veterans Affairs Committee, VA Secretary David Shulkin may have provided more questions than answers for these veterans.
Shulkin offered the first glimpse of his plan to redesign the current Veterans Choice Program, called the Veterans’ Coordinated Access Rewarding Experience, or CARE, Program. Under the new initiative, veterans would no longer access community providers based on a set of arbitrary, administrative rules, which mandated authorization for community care for veterans who live more than 40 miles away from a VA medical facility or if the wait time for care is 30 days or longer. It also includes a number of pilot proposals that will test new ways to generate revenue and manage the healthcare system. They also leave many believing those pilot proposals are precursors to privatizing a healthcare system that veterans will end up paying for out of pocket.
Will veterans be hurt or helped by the new plan? The answer doesn’t lend itself well to the oversimplified, headline-expedient explanations the public has become accustomed to. For one, many service-disabled, retired veterans enrolled in VA opt to pay through the Department of Defense’s payer-only insurance, Tricare, to access care in the community. Other veterans use Medicare. Still others use private insurance that also bears costs.
Additionally, many factors influence the decision on how Joe or Jane Veteran choose to access care. Distance. Wait time. State of health. Urgency of need for care. Complexity of care needed. Prior experience with VA. Then consider that any number of these factors could influence the choice of 9 million veterans who are eligible for VA care, and one can see how truly complicated the problem is when taken out of the abstract.
Previous arguments for privatization have not exactly helped the situation or the dialogue in media and on Capitol Hill. It did not take a genius to figure out that some of the proposals outlined in the VA Secretary’s plan mirrored the VA Commission on Care’s 2016 “strawman” document, which was widely criticized as a feeler to test reaction to proposals to privatize VA. Trying to sell veterans, Congress, and the public on the idea that a longstanding government agency should abrogate its sacred obligation to care for veterans to the private sector in the name of small government — and the cowboy capitalism that has increasingly characterized the healthcare industry — was not exactly a sound strategy, at least not in the short term.
But the opposite extreme is just as unpalatable, if the country and Congress are serious about giving veterans timely access to the best healthcare possible that our country can afford. The private and community sectors, notwithstanding their limitations and lack of sensitivity to veteran-specific issues, already incur the burden of providing care to many who have worn the uniform. Even with the new measures that will implemented by the passage of the accountability and whistleblower protection law if passed, it will take some time to purge VA of unethical and underperforming employees and transform the culture. It will also take time to adjust staff levels and establish metrics that will allow veterans to measure the quality of VA care against community care.
Should veterans have to pay out of pocket when they seek care for a service-related condition? Probably not. But those military retirees who use Tricare opt to do so. Should VA recoup payment from insurers, like Tricare, Medicare, and Medicaid for treating veterans who are covered by those entities? Current law does not allow it. But failing to do so obscures the true cost of providing care for veterans, which arguably explains why VA budgets have fallen woefully short for decades. And finally, can VA afford to maintain parallel VA and non-VA healthcare frameworks in the long run? The answer is likely no. And it is on this question that the future of VA, as we now know it, presently hinges.
Outsourced federal and state functions such as prisons, law enforcement, firefighting, trash collection, waste water treatment, railroads, airports, energy companies, postal services — even warfighting through the use of private contractors — presents a litany of lessons and cautionary tales on both sides of the debate. But advancing slippery slope arguments in support of the status quo or mere incremental improvements to the system will not make life better for veterans who have suffered enough and await major changes in VA.
Somewhere in between lies uncharted territory, where expanded care into the community and the private sector makes sense and, if resources are redistributed more efficiently, increased investment in the foundational VA services that non-VA providers cannot deliver makes sense as well. But allowing a fear of privatization to quash innovation, suppress the exploration of untested practices, and impede breaking with convention will be a disservice to those who defended our country and now await meaningful change to a system that just about all involved say is badly needed.
Albert Einstein said of risk and the status quo, “A ship is always safe at the shore—but that is not what it is built for.” In the case of VA healthcare, whatever the best option ultimately happens to be, it is the one that positions our government to best fulfill its obligation to our nation’s veterans without scandal, disappointment, or political ideology. It is also likely to be the one approach that has not yet been tried.
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