Conversation with Philip Longman about the VHA
Two years ago, in the wake of a scandal involving long wait times at some VA hospitals, Congress called for the creation of a bipartisan Commission on Care to study the VA and recommend reforms. It was widely expected that the commission would recommend sweeping privatization of VA health care — two of the commission’s fifteen members were representatives of Koch brothers-allied pro-privatization groups and several others were executives from major medical centers that stand to profit from outsourcing VA care.
Earlier this month, the Commission on Care released its final report. While offering a series of recommendations on how to improve the quality of health care veterans receive, the Commission, surprisingly, took a strong stance against the privatization of the VA.
One member of the Commission on Care was Phil Longman, senior editor at the Washington Monthly and a program director at the New America Foundation. A few days after the report’s release, he sat with Suzanne Gordon, who is writing a book about veterans healthcare and the care the VA provides.
Both Gordon and Longman believe that the Veterans Health Administration (VHA) can serve as a valuable role model for America’s fragmented and dangerous healthcare system, but Gordon is also skeptical about some of the report’s recommendations. The following is an edited transcript of their conversation.
Gordon: Can you start by explaining how you came to be on the Commission on Care?
Longman :My main credential was being the author of the book, Best Care Anywhere: Why VA Care is Better than yours. In it, I described the quality transformation that the VA had undergone in the 1990s, and how study after study shows that it still delivers care that, for all its deficiencies, is generally superior to that rest of the U.S. health care system. Senator Bernie Sanders knew my work on the VA, and he and I talked several times about it in the context of dealing with the so-called VA “scandal” that broke in 2014. At his request, Harry Reid appointed me to the commission. I’d never been on a commission like this before and didn’t know what to expect.
Gordon: What most surprised you at the first meeting?
Longman: The commission consisted of six Republican appointees and six Democratic appointees chosen by the leadership of the House and Senate, as well as three appointees named by the White House. The Republican appointees were predictably hostile to the VA, but I was surprised to learn that so were several of the Democratic appointees. One even joined with many of Republicans in putting forward a plan that aligned perfectly with that of the Koch brothers, while others pushed agendas that would have effectively privatized the VA.
Gordon: Before we get to that, can you explain a bit about how VA health care currently works?
Longman: The VA has long been the only actual example of socialized medicine in the United States. Unlike Medicare and Medicaid, it owns and operates its own hospital clinics, and most of the doctors and other medical professional who work in these facilities are government employees with civil service protections. The VA serves patients with service-related disabilities and/or low incomes, as well as other honorably discharged veterans who meet its eligibility requirements, which change over time.
Gordon: What do you mean by “privatization” and who’s for it?
Longman: Over the decades, many conservatives have, for ideological reasons, sought to get the VA should get out the business of providing health care. According to their worldview, the VA must be broken, and must be shown to be broken. To them, it is axiomatic that government, and by extension, socialized medicine, is wasteful and inefficient. Facts showing the VA outperforming the private health care system and enjoying overwhelming support from veterans basically contradict their entire worldview, and so must be denied.
Most conservatives with this cast of mind propose abolishing the VA altogether and just giving vets vouchers they can use to purchase care from private providers. Sen. John McCain is a long-time proponent of this idea. Others, including the Koch brothers and the astro-turf veterans organization they support, Concerned Veterans for America (CVA), would let the VA survive as a vestigial institution but would divert most of its patients to competing networks of private sectors providers. Trump has recently come out with a proposal along these lines as well.
Many private sector providers, in turn, love the idea of privatization because it is means lot of new patients and lucrative government subsidies flowing their way, – particularly if there are few controls over expenditures. This is especially true these days, as American health care evolves into a system dominated by giant corporate hospital chains that would very much like to feed off the VA’s current patients.
Gordon: Such corporations were well represented on the commission.
Longman: Indeed they were. Three of the commissioners were CEOs of giant health care systems, and one was a high level executive. With one important exception, they pressed hard to get the VA substantially out the business of being a provider of health care. Instead of the VA continuing to compete with them for patients, they wanted the VA to send patients their way. The VA would thus cease to be a provider of health care, and become a mere payor of health care bills submitted by the corporations they represented. At the end of the day, however, all the commissioners affiliated with giant hospital chains overcame their built-in conflict of interest and signed off a proposal that, while it may incidentally bring some more business their way, does not privatize the VA. I applaud them for that.
Gordon: Are there other reasons people support privatizing the VA?
Longman: Well, some hope, reasonably enough, that allowing VA enrollees to see private sector doctors will ease the wait times that veterans experience in some facilities for some treatments. They also hope to give vets more choices. Though there are tradeoffs involved, under certain conditions, these are goals worth pursing.
Improved access and choice were the rationales for the so-called “Choice Act” that Congress passed with bipartisan support in 2014. That legislation commanded the VA to quickly set up networks of private providers who would be available to treat veterans living more than 40 miles from the nearest VA providers or who had to wait more than 30 days for an appointment.
Unfortunately, the program was deeply flawed in design. Because of the very short timelines Congress imposed on its creation, the plan was even worse in execution. The 40-miles/30-days requirement is arbitrary. Most vets who try to use the program have trouble making it work for them because it is administered by private contractors who add an extra layer of bureaucracy. There was no provision for the integration of care between VA and non-VA providers, which creates all sorts of opportunities for medical errors and impacts the quality of care veterans receive.
Gordon: What did the commission propose instead and why?
Longman: We started with a number of observations, one of the most important being that, in reality, care outside the VA is often very dangerous, as you well know.
Gordon: In fact, preventable medical errors are the third leading cause of death in the United State. I’m also reminded of a story told in Walter Isaacson’s biography of Steve Jobs. When Jobs was dying of pancreatic cancer, his wife had to force the myriad specialists who were caring for him to talk to one another. So even a billionaire with the best insurance in the world and more money than God didn’t get coordinated care without his wife fighting for it.
Longman: Indeed. One of the things that is unfortunate about how this commission functioned is that we didn’t have people come in to testify about how fragmented and dangerous American health care system is. We had people on the commission who were simply unaware, or in denial about, how contact with the U.S. health care system kills a quarter of million Americans a year through a combination of overtreatment, under-treatment, and mistreatment.
Unless one is aware of this reality, one is unable to put the real deficiencies of the VA into context, or to think straight about the implications of privatization. When some other commissioners heard about, or experienced things that are wrong about the VA, they didn’t think to ask the all-important, “compared- to- what?” question. They failed to realize, for example, that though wait times are sometimes unacceptably long at the VA, they are on average even longer for most Americans outside the VA, including those who are fully insured.
I, and VA supporters on the Commission, such as Michael Blecker and David Gorman, and its masterful chairperson, Nancy Schlicting, wanted to preserve the best features of VA care. All VA doctors work off a common electronic medical record, which allows for extensive coordination of care between different specialists, as well as between primary care and mental health professionals. Unlike fee-for-service doctors in the private sector, VA doctors have no financial incentives tempting them to perform unnecessary surgery or redundant tests. VA clinicians are also typically highly competent when it comes to the physical and mental health issues – particularly those that affect people who have served in the military. These were a key value of VA care that I believe this proposal, if correctly implemented, preserves.
At the same time, however, we recognize that the VA does face capacity constraints in certain areas, and that it doesn’t always make economic or clinical sense for the VA to produce on its own every single health care service it provides. Some veterans live in areas where there are no nearby VA hospitals or clinics. Others may need rare and highly specialized treatment that the VA cannot efficiently provide on its own.
There is nothing really new or different about this. The VA is one of the world’s largest purchasers of drugs. It does not follow from this that the VA should run its own pill factories. It does much better for its patients by using its massive purchasing power and clinical expertise to extract value from private drug companies. Moreover, for years the VA has been contracting for care with providers in the community when that made sense.
Gordon: So what are you proposing that is new?
Longman: We are proposing giving the VA expanded powers and flexibility in contracting for auxiliary capacity. Specifically, we envision the VA setting up highly integrated networks of very well credentialed community providers in areas where it lacks the capacity to give timely, high quality care to veterans.
Importantly, these community providers will be chosen by the VA itself, will work off a common VA electronic medical record platform, and will be accountable for meeting VA clinical performance standards at a set price. They will work alongside VA employees as part of a coherent, integrated health care delivery system. They will effectively be contract employees, and as such, will give the VA managers far better ability to adjust capacity up or down quickly and as needed in different areas.
Importantly, these networks should increases the choices veterans have in health care. But it’s important to note that the proposal does not put choice above all other values. Offering unlimited, unmanaged choice of doctors and treatments would not only lead to dangerously fragmented care, it would also cost so much that in the real world, it would be a political non-starter and thus limit choice.
Two of our commissioners, who both have affiliations with the Koch Brothers, refused to sign the report because they said it did not provide veterans with sufficient choice. I interpret this to mean that the Kochs feel more threatened by the specter of socialized medicine succeeding in the United States than they are by the prospect of the government spending hundreds of billions of taxpayer dollars to subsidize the services of private sector health care providers. I guess this makes sense if you remember that their plan, though it may inflate government expenditures, essentially amounts to corporate welfare for hospital chains.
Gordon: Some critics, including your fellow commissioner Michael Blecker who also refused to sign the report, are concerned that these networks amount to privatization and that their cost will crowd out funding for traditional VA hospitals and services.
Longman: I understand and respect Michael’s concerns, but I believe strongly that the upsides, for both the vets and VA, are far greater than he realizes. Most veterans eligible for VA care do not use it or use it only sporadically. Three common reasons are that they do not live near a VA facility, or they need a specialty treatment the VA does not offer, or they cannot get an appointment as quickly as they would like.
This proposal addresses all those concerns and more. It makes the package of benefits the VA offers superior to what is available today, which means, and this is the key point, more veterans will sign up for VA care. We are not talking about a zero-sum game, we taking about growing the VA. And expanding the “customer base” for the VA expands the political support for the program, and by extension, for the VA’s model of socialized medicine.
Gordon: What would have to happen to realize your vision? The creation of a high functioning network of outside providers who work in concert, not competition, with those in the VHA is an enormous job. To create an interoperable IT platform, teach outside providers how to do integrated care and talk to one another as well as VA providers, educate them in cultural and military competence – all of this will take a lot of time and money. Congress would, for example, have to allocate more money to the VHA to allow the hiring of staff to engage in the very large job of setting up these networks and would have to make sure that money for care within the VHA is not cannibalized for care outside of it? Is that not correct?
Longman: Yes, setting of these networks will take money, and it will take time. Our mandate was to come up with a 20-year plan for the VA, and that’s how long this plan might take to fully implement. In the report, we call on Congress to give VA managers more flexibility in deploying their budget. We also have many other proposals for improving the VA’s recruitment and training of managers. This should help prevent poor decision making in how the VA deploys its available resources. If, as I believe, improving the benefit package causes many more eligible veterans to enroll in the VA, then costs will increase commensurately, but there is plans for that as well that commission recommends be studied.
Gordon: Are you talking about the plan to expand access to VA care to currently ineligible veterans and family members of veterans who have not served in the military?
Longman: I am. The plan is to allow such folks to use their Medicare or private insurance to purchase care within the VA network where sufficient capacity exists or can be made to exist. The VA already has excess capacity in many regions. Moreover, with these new expanded community networks, we can adjust capacity upwards comparatively easily. Doing so allows the VA to increase its revenues by attracting paying customers, who eventually could include every American. The VA under this scenario becomes the means by which the U.S. finally achieves a true public option in health care—not just the option to purchase government health insurance, but true socialized medicine.
I could not get a full recommendation out of the commission for this proposal. Veterans groups such as the American Legion support it. But it ran into opposition from representatives of corporate medicine who concluded, correctly, that it would eventually mean serious competition for their largely monopolistic enterprises.
Nonetheless, I did get the commission to recommend setting up another commission to study the matter. A full description of the plan is also included in the appendix. Just maybe this could turn out to be a big deal in, say, five to ten years, when the American people finally rise up against the abject failures of the rest of the U.S. health care system.
Gordon: The VA would also have to do a tremendous amount of outreach to help veterans understand what kind of services the VHA provides, and how these services can help them. Right now, as we’ve seen, many eligible veterans don’t enroll in the VHA because of misperceptions about how it works, who is, in fact, eligible for services, and what kind of quality of care it delivers. Congress currently prohibits the VHA from advertising and marketing its services, and most VHA medical centers do not have enough public communication staff to get the message out. This significantly restricts its ability to reach veterans and the public. These communication obstacles need to be addressed if this plan is to work,
Longman: I agree that the VA needs to do a much better job of telling its own story. It would be great if it were allowed to advertise and if had a more effective communication strategy. Some of the governance changes we make in the report may help with that, particularly the creation of a board of directors that can concentrate on communicating the VA’s story to members of Congress and the public at large.
Gordon: This particular recommendation has been very contentious has it not?
Longman: Some folks have interpreted the language in the report to mean that this board would somehow usurp the power of Congress and the Executive branch over the VA—or that, in other words, it constitutes some kind of privatization. But read the substance of the proposal carefully and you’ll see that this is a misreading. The board would include people drawn from the private sector, but this in no way changes the VA’s legal status as a government agency accountable to Congress, the White House, and by extension, the public.
To the disappointment of some conservatives on the Commission, we did not recommend that the VA become even a government-sponsored organization like Amtrak or the Postal Service, let alone a private corporation. With the right members, the board we propose could serve a useful function in advising on strategy and could help insulate VA managers a bit from all the political interference they now get from grandstanding members of Congress. We certainly hope it does. But Congress would still control the VA’s budget and Congress and the White House would together select the members of this board, so strictly speaking, it would have no independent power.
Gordon: What role do you see veterans advocacy groups playing in the future of the VA?
Longman: Veterans groups have an obligation to draw attention to the deficiencies of the VA; that’s part of their mission. But it is equally important for them to make sure that the public and its representatives also recognize the excellent services the VA provides and realize that veterans will not stand for privatization of the VA. Disabled Americans Veterans is playing a particularly valuable role in informing veterans and other stakeholders about the dangers of privatization . They are doing a great job of rebutting the largely false narratives about the VA that are bundled up and promoted by privatizers and often mindlessly recirculated in the press. Since most members of the press, like most members of the public, have no contact with military life or with the VA, effective advocacy is becoming harder and harder to pull off, but also more and more essential.
Gordon: When many non-veterans, and people who don’t know any veterans read about the debates about the VHA, they may not consider the outcome to have any impact on them whatsoever. I know we both believe that what’s at stake in this debate isn’t just the quality and cost of healthcare services to veterans, but the future of American healthcare and – even more important – of American government. Can you comment on why you believe the fight for the VHA impacts all of us?
Longman: As I mentioned before, I believe the VA can become the mechanism by which universal, government-provided health care comes to the United States. The VA model of care, with its emphasis on integration, prevention, and evidence-based, cost-effective care, is also in the forefront of where the rest of the U.S. health care needs to go. If we lose the VA, the cause of real healthcare delivery system reform will be set back by at least another generation, with incalculably dire consequences health and finances of the American population.