This was just posted on the BMJ blog.  

Hope people will read and pass it on.

By the end of this year, the US will have a new president as well some new members of Congress. The results of the 2016 election will not only effect the further implementation of the Affordable Care Act (Obamacare), but the future of the country’s largest healthcare system—the Veteran’s Health Administration. That’s because most of the Conservative Republicans running for President—as well as many of those running for or already serving in Congress—are not only determined to repeal Obamacare. They are also committed to dismantling the largest and only publicly funded, fully integrated healthcare system in the US—the Veterans Health Administration (VHA). Even many Democrats are not fully supportive of the VHA. While Hilary Clinton says she does not support privatization of the VHA, only Bernie Sanders (D. VT) has demonstrated a deep understanding of what the VHA does and how it actually works.

The Veterans Health Administration grew out of Abraham Lincoln’s Civil War pledge “To care for him who shall have borne the battle and for his widow, and his orphan.” Since World War Two, the VHA has become the largest and only fully integrated, publicly funded healthcare system in the United States. Its 1700 sites of care include more than 150 medical centers, 1000 community based outpatient clinics (CBOCs), and other mental health, nursing home facilities, and in and outpatient facilities.

The VHA has over 260,000 employees, over a third of whom are veterans. Its tripartite mission includes the delivery of clinical care, research, and teaching. Since 1946, the VHA has affiliated with major academic teaching hospitals and now trains over 70% of American physicians as well as students and trainees in 40 other healthcare professions. It’s vast research arm has produced innovations that have improved the health of veterans suffering from illnesses like Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), as well as spinal cord injury. VHA research has also produced innovations that help all patients. To name only a few, the VHA developed the first implantable cardiac pacemaker, performed the first successful liver transplant, helped to test the Shingles vaccine and develop the nicotine patch.

Republicans have consistently refused to adequately fund the VHA and have resisted expanding its services to all veterans. The VHA only serves veterans who have some form of honorable discharge and who have service related disabilities and/or low incomes. The result is that the system takes care of the oldest, sickest, and poorest veterans. The average VHA patient is 62 years old, has multiple physical co-morbidities and a higher percentage of mental health problems than the average patient in the private sector. In spite of this significant challenge, an Independent Assessment of the VHA’s record on care delivery, mandated by the 2014 Choice Act, documents that the VHA outperforms the private sector on many measures, is equivalent on some, and marginally worse on only a few. Despite variability in the VHA system, the Independent Assessment repeatedly reports that the private sector healthcare system provides care with even more variability than the VHA. The Association of VA Psychologist Leaders recently posted yet another review of the scientific studies on VHA care which document similar outcomes.

Ignoring the VHA’s record of care delivery, congressional conservatives are exploiting the wait time problems and delays uncovered in 2014 in Phoenix and some other VHA facilities to argue that the entire VHA system is broken and that the VHA should no longer pay for and provide healthcare services. They want to eliminate the VHA and transfer veterans to the private sector healthcare system, with the government serving as payer, rather than also the provider of care.

Needless to say, this would be a huge boon to private sector hospitals, which is why many support this plan. It is also favored by large pharmaceutical and medical equipment companies. Big Pharma has long chafed at the fact that the VHA—unlike say Medicare or other US health plans—negotiates lower pharmaceutical prices through its drug formularies. Since VHA physicians and other staff are on salary, they have little financial incentive to either over or undertreat their patients and thus use medical equipment and treatments much more judiciously than their counterparts in the private sector. They have also developed more integrated mental health, primary care, geriatric and palliative care services than other US health plans.

Finally, the VHA has long been anathema to conservatives. As Alicia Mundy has recently reported in an article in The Washington Monthly, the Koch brothers have funded a group called the Concerned Veterans of America—a veterans’ service organization that has no veteran members and provides no veteran services.

The CVA has been lobbying for partial and ultimately full privatization of the VHA. The mainstream media have been filled with stories about VHA dysfunction. Media outlets have promoted this narrative and ignored continuing evidence that the VHA—in spite of wait time delays and top heavy management—continues to deliver high quality care to veterans.

As a result Congress is now considering two bills that could pave the way for the privatization of the VHA. At the same time, a congressionally mandated Commission on Care tasked with strategizing about the future of the VHA, is also dominated by discussions of VHA privatization.

Seven of the commission’s members have written a proposal entitled “The Strawman Document” recommending the total elimination of the VHA. The Strawman document has produced an outcry from veterans’ service organizations (VSOs). Eight of the nation’s largest veterans services organizations—including the American Legion, Disabled American Veterans, and Paralyzed Veterans of America, have written a formal letter to the commission to express their concern about the report. These groups support proposals, like that put forth by VA Undersecretary of Health David Shulkin, that would strengthen the VHA, give veterans the choice to see outside providers if necessary, but maintain the VHA as provider and coordinator of healthcare services.

The fate of VHA will affect more than America’s 24 million veterans and their families. With its research, teaching, and innovative models of team-based integrated care, the VHA serves as a model for quality healthcare delivery that should be emulated rather than dismantled.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Competing interests: SG is currently writing a book about the VHA.