The V.A., Trump & Healthcare Reform: A View from (Almost) Inside

2020.09.07 Wilkie image
V.A. Secretary Robert Wilkie appears on CNN State of the Union, September 6, 2020

Summary

  • The media can be nit-picky and sophomoric, as with the CNN segment featured here
  • Veteran’s Choice and MISSION Act, if implemented properly, could be a good thing for veterans’ healthcare
  • As a general point (to fit in with the theme of this blog), the V.A. could be a model for healthcare reform, namely a “hybrid” that draws on what’s best from the private (for-profit), non-profit, and public spheres.

On CNN’s Sunday news show, State of the Union, on September 6, Host Dana Bash heralded “Trump has falsely claimed 150+ times that he passed veterans choice.”

Her guest, V.A. Secretary Robert Wilkie, retorted, “This Trump initiative, which is the MISSION Act, actually expands choice to all veterans… You’re talking about semantics… His actions have been beneficial to veterans across this country in ways that have not been seen since World War II.”

Is Secretary Wilkie right, that President Trump expanded veterans’ choice (with a small c)?  And right that it was a mere semantic quibble for Dana Bash’s to object that President Obama, not President Trump, signed the Veterans Choice Act of 2014 (with a capital C)? And is Secretary Wilkie also right to agree with Trump’s claim that “nobody’s done for the vets what I have”?

Let’s look at these claims. First, some background.

Background:  The Phoenix V.A. Wait List Scandal

To give context, the initiative to reform and improve V.A. began after the 2014 waiting list scandal. A whistleblower from the Phoenix V.A. Medical Center reported two parallel waiting lists, one kept in the official electronic record and a second one off-the-books. The official list rewarded managers with bonuses for timely care. The off-the-books did track needed services for veterans, but concealed unjustifiably lengthy waits, in some cases for cancer care. Some veterans on the off-the-books lists died while awaiting care.

Existence of these parallel “secret” lists first surfaced in Phoenix and then, upon system-wide investigation, to a greater or lesser degree in a large number of other VA centers.  A 2014 White House report cited on-going Inspector General investigations at 77 VA medical centers over scheduling practices. I could find no final summary of confirmed waiting list wrongdoing, but I did find in that same White House report the conclusion of a “corrosive culture” centering around how administrator bonuses were tied to waiting list metrics, leading to falsifications and in some cases these tragic delays of care.

President Obama pushed out General Eric Shinseki and replaced him with former Proctor & Gamble CEO Robert MacDonald in 2014. Secretary MacDonald launched a system-wide culture change initiative throughout the V.A. He also helped expedite the Veterans Choice Act that very same year.

Who’s Right, Dana Bash or Secretary Wilkie?

Thus, Dana Bash was technically correct that it was President Obama who signed the first Veterans Choice Act in 2014.

The first iteration of that Veterans Choice program was hastily and clumsily implemented. The program was marred by the outsourcing of its management to two ineffectual commercial vendors, Health Net and TriWest. Under Choice, wait times were actually longer and taxpayer costs higher, according to a ProPublica exposé.

“The Choice program has been a wreck, okay?” Sen. Jon Tester (Mont.), the Senate Veterans’ Affairs Committee’s top Democrat, said to the Washington Post.

After the 2016 election, the Senate Veterans Affairs Committee worked with veterans’ groups and both political parties to craft the new MISSION Act (Maintaining Internal Systems and Strengthening Integrated Outside Networks). The new program was passed by Congress later in 2018. To give credit where due, the President cooperated with the bipartisan process and thus merits plaudits for facilitating the politics of it.

The linchpin of this legislation was expanding veterans’ ability to choose non-V.A. providers.

Thus, Secretary Wilkie was accurate on both counts:  Dana Bash’s quibble about small-c or capital-C “choice” was purely semantic and sophomoric.  And “[Trump’s] actions have been beneficial to veterans in ways not seen since World War II.” But this is so only if one parses both Wilkie’s statement and Trump’s literally – “nobody’s done for vets what I have” — and ignores the implied grandiosity. One need only review the records of Presidents Lincoln, Grant, and Eisenhower or look at the success of the G.I. Bill after World War II to challenge President Trump’s boast.

How Beneficial Has the MISSION Act Been?

Not very beneficial, so far. 

But, in fairness, the program took effect only in June 2019. Thus, the extensive changes called for throughout the V.A. by the MISSION Act have only just begun to be implemented. Full implementation will be no mean feat, since the Veterans Health Administration is the largest integrated health care system in the United States, providing care at 1,243 health care facilities, including 170 VA Medical Centers and 1,063 outpatient sites, serving more than 9 million enrolled Veterans yearly, and employing more than 332,000.

Here is an excerpt from the Independent Budget report on the MISSION Act implementation issued June 2020. This is an assessment done jointly by the Disabled American Veterans (DAV), Veterans of Foreign Wars (VFW) and Paralyzed Veterans of America (PVA), the three most prominent veterans advocacy groups, whose love is not lost on either the V.A., President Trump, or Secretary Wilkie:

…[O]f the 26 recommendations made in [our] 2019 report, only one has been fulfilled, 11 have not been fulfilled, and 14 are considered “to be determined,” which indicates partial or no fulfillment, with aspects that cannot be fully evaluated at this time…

Among those recommendations that the [report] rates as not fulfilled are conducting an open, transparent process for developing market-area assessments and strategic plans that actively engage veterans service organization and veteran stakeholders; the equal application of quality and competency standards across both VA and non-VA providers to ensure the highest level of care possible for veterans; and the creation of a tiered integrated network that places VA providers first and the Department of Defense, federal partners and academic affiliates second when VA care is not accessible.

“DAV, in particular, is disappointed in the VA’s failure to expand the comprehensive caregiver assistance program to support veterans injured prior to 9/11,” said Reese. “That portion of the VA MISSION Act is something our organization fought very hard for, and the continued delays are just unacceptable.”

The ”fulfilled” recommendation is noteworthy.

VA must not use the new Innovation Center to propose pilot programs based on proposals that were previously rejected by the Commission on Care, VA, or Congress, or that contradict the underlying consensus upon which the VA MISSION Act was approved.

Veterans groups feared that the Choice Act and MISSION Act would become a pretext for slowly dismantling the entire V.A. system. And they especially feared that President Trump’s cronies would siphon off taxpayer dollars for lucrative services to be provided by themselves instead of by the V.A. This same fear was widely shared within the ranks of the V.A. The DAV, VFW and PVA judge that this travesty has not happened — so far. This is to the immense credit of Secretary Wilkie, who is threading the needle between humoring the President’s kleptocratic tendencies while defending the V.A.’s mission, “to care for him [and her] who shall have borne the battle,” first articulated by President Lincoln.

The complete “Critical Issue Update” from February 2020 can be accessed at:  http://www.independentbudget.org/pdf/IB-Critical-Issue-Update-VA-MISSION-ACT-Implementation-Feb-2020.pdf

Conclusions

In summary, President Trump can claim credit for the MISSION Act, giving veterans improved options and choices under their V.A. benefits. But implementation is slow and still a work in progress. Secretary Wilkie has succeeded for the moment in keeping the V.A. and the Choice programs within its guardrails, and protecting it from designing outside raiders.

On the other hand, this post would not be complete without acknowledging recent claims by two admittedly “never-Trump” writers that call into question President Trump’s true motives.

  • John Bolton, Trump’s former National Security Adviser, has written in his recent book, The Room Where It Happened, that in every one of Trump’s decisions, Bolton didn’t “see anything where [reelection] wasn’t the major factor.” Trump might support veterans’ interests solely to help his reelection.
  • Jeffrey Goldberg, writing in The Atlantic, quotes the President as disparaging fallen soldiers in private conversations as “suckers” and “losers.“ This would give the appearance that he does not comprehend military sacrifice, duty, honor nor to care about those who have borne the battle.

These two facts may cancel each other out with the veteran voting bloc on November 3. Time will tell.

In addition, some less partisan V.A. employees, veterans themselves, and others outside the V.A. system defend President Trump’s good intentions, but acknowledge that the V.A. — awash with cash and power — can be a magnet for greed or political intrigue despite any President’s best efforts.

And even those who impugn President Trump’s motives must consider that if a leader does the right thing for the wrong reasons, wouldn’t it still be the right thing? This appears to be what Secretary Wilkie is banking on.

Additional Comments from Inside the V.A. and Implications for Healthcare Reform

Fixing U.S. Healthcare blog favors moving U.S. healthcare toward some of the beneficial aspects of the Veterans Health Administration. Those include the ability to leverage the V.A.’s massive purchasing power and market power to overcome anti-competitive pricing and service cartels. The V.A. can also leverage its position to hybridize private commercial “choice” services with non-profit-driven public services to achieve optimal results for its veteran beneficiaries. Lastly, the V.A. embraces health-driven rather than profit-driven care. It achieves efficiencies through service integration and its large interoperable electronic record system. It also provides a full continuum of services, including long-term care, mental health care, wellness counseling, caregiver support, as well as attention to social determinants of health such as housing, vocational rehabilitation, addiction services, and post-offense reentry support. And perhaps most importantly, the V.A. strives to be patient-centered and customer-responsive. This can be a model for reform in the wider health system.

At the same time, problems such as the waiting list scandal also teach us a valuable object lesson about the potential for malfeasance within any public system and thus the necessity of building in monitoring systems, reporting systems, and a culture of integrity. Here again the V.A. can serve as a model for effective public administration, continuous quality improvement, and transparency. In this regard, V.A. insiders are the first to acknowledge that a number of V.A. Medical Centers perform poorly. They will need more than an Executive Order or even an act of Congress to fix them.

Finally, on a personal note, after having myself worked within V.A. for 11 years, I can truly validate the V.A.’s raison d’être (“to care for him who shall have borne the battle”) and the uniqueness of its veteran patient population. Veterans’ special needs would require and justify continuing the V.A.’s unique focus within a reformed national healthcare system.

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Image Credit

Title:  Screenshot, State of the Union, CNN, September 6, 2020

URL:  https://www.cnn.com/videos/politics/2020/09/06/sotu-wilkie-full.cnn

Copyright 2020, Cable News Network – Used with permission.

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