Lack of Funding Is the Real VA Scandal

As the firestorm about wait times at VA facilities continues, political representatives from both parties insist that waits must be eliminated for veterans seeking care. Now that Republicans have succeeded in forcing the resignation of Secretary of the Department of Veterans Affairs, Eric Shinseki, who resigned last week – the new focus is on seeking partial privatization of the system by allowing veterans to get care from private sector doctors – care that would be paid for by the government program. None of the current calls to action, however, –whether they include criminal prosecutions of those responsible for secret waiting lists, or channeling vets into the private sector – will fix the wait times at the VA that keep vets from getting needed care.There are two primary reasons for the problem of wait times. One has to do with Congress’ consistent failure to provide adequate funding so that the VA could hire more staff to care for an increasing number of veterans who live longer with complex service and age related health problems. The other – which may be the biggest and hardest to solve problem of them all – has to do with the US healthcare system’s persistent refusal to provide the number of physicians who deliver primary care services in this country.

Let’s look at the issue of funding. Over the course of the past ten years or more, the VA has been taxed with a population of veterans who have very particular problems. Many of those who survived the Vietnam and first Iraq war are often poor, sometimes homeless, have serious mental health problems and more than the usual share of age related health problems.

Added to this group are veterans who made it through the recent wars in Iraq and Afghanistan. They have survived long enough to be VA patients but with serious and equally special health problems. A not atypical VA patient might have a traumatic brain injury (TBI), plus an amputation, on top of Post Traumatic Stress disorder, combined with the normal problems of people who live longer in advanced industrialized societies – heart disease, diabetes, obesity, cancer, or asthma.

In spite of this increasing load of combat and age related problems, Congress has refused to allocate more funding to the VA.

In February of 2014, Independent Senator Bernie Sanders of Vermont proposed a bill that would have allocated $21 billion that would have improved access to healthcare, education, and other services for US veterans. Republicans – the same ones railing against Shinseki in particular and the VA in general – blocked killed that bill. Here is one typical comment that illustrates the tenor of the debate about adequately funding veterans’ care. “I don’t think our veterans want their program to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America,” said Senator Jeff Sessions, (R-Alabama). If you go to this website you’ll hear even more.
The same politicians who killed Sanders’ bill are trying to find out what and who is at the bottom of the VA wait list crisis. It is clearly in their interests to ignore any serious discussion of how precisely the VA supposed to care for all the veterans who depend on its services with the limited resources it has been allocated – resources which Republicans staunchly refuse to increase.

This, in turn, leads to the broader and far more stubborn problem of the persistent shortage of primary care providers in the US.

Consider the preliminary report just issued by the VA’s inspector general. It documents that many of the veterans on waiting lists – secret or otherwise – are those seeking a first appointment in the VA system. The VA has set an ambitious policy of seeing such patients within 14 days of receiving a call for a non-urgent appointment. It considers longer waits of 30 days or more unacceptable. But fulfilling this goal is a mission impossible in a country whose medical education and training system (over which the VA has no control) consistently fails to produce enough primary care providers to care for the needs of an aging population suffering from an increasing number of chronic conditions.

Unlike other healthcare systems in other industrialized countries, students graduating from US medical schools and choosing their area of practice overwhelmingly eschew primary care and are increasingly going into highly paid specialties like gastroenterology, radiology, or orthopedics. Only about 20% of current medical school graduates are entering primary care. (Nursing schools are trying to produce more Nurse Practitioners (NPs) to deal with the crisis in primary care, but have been consistently attacked by MDs who insist that NPs are not well enough educated to provide even routine primary care.)

Even if the VA received the funding it would need to hire more physicians and nurse practitioners, where would they find them? They are simply not there to be hired. Not now and not next year or the next. It takes an average of seven to 12 years to produce a Nurse Practitioner, or Primary Care Physician.

If the US healthcare system suddenly figured out that it needed to produce 30% more primary care physicians than it has (bringing the ratio of primary care physicians to specialists at 50/50, which is what most other industrialized nations achieve), the US healthcare system would have to adjust its skewed incentives and begin producing more primary care providers next year in order to produce enough to care for patients in 2021 or 2026. (This would involve a whole series of reforms that Congress is loath to consider – including making medical and other health professional education free so that people do not incur the kind of huge debts when leaving school that push them in the direction of lucrative specialization among many other things).

Since these kinds of reforms are not even on the radar, the system-wide shortage of primary care providers also makes another “fix” Republicans have proposed almost laughable. Republicans who have long wanted to privatize the VA see a way to begin that process by pushing for creeping privatization. They want the government to allow vets to see physicians in the private sector and pay the freight.

But patients who already have good private insurance have trouble scoring an appointment with a primary care physician. Which is why, as Philip Longman, who wrote a wonderful book about the VA called Best Care Anywhere,  points out in his great interview in the Washington Post, wait times for an appointment in Los Angeles are on average up to 59 days and in Boston up to 63. Newspaper reports like that in the New York Times spotlight vets who have been able to get immediate appointments in the private sector. Well I congratulate them.

Most other people I know, even those with good health insurance have a pretty hard time finding a PCP whose practice is even open to new patients and have to wait a good long time for specialist care as well. How will the nation’s overtaxed primary care doctors suddenly be able to accommodate millions of vets when they can’t handle the patients they already have, plus the influx of patients who will now be insured thanks to the Affordable Care Act?

Critics of the VA are studiously avoiding dealing with the only system-fixes that will solve the problem of wait times at the VA and elsewhere. It’s time for them to stop ranting about accountability and to take some real action to encourage medical students to go into primary care and allow more nurse practitioners to deliver the care our population so desperately needs. And it’s overtime for them to fund the VA at the levels necessary to serve the needs of America’s vets.