You don’t often see Donald Trump pull a punch, but he did it last week. Trump spent his entire campaign deeply angered by how the government treats veterans, particularly regarding their medical care. He promised to overhaul the Veterans Administration (VA) health care system and “take care” of the vets. Everyone has interpreted this as code for privatizing the VA, a long-awaited conservative goal.
But last week at Mar-a-Lago, after a meeting with health care executives about his VA plans, Trump told reporters this: “We think we have to have kind of a public-private option, because some vets love the VA. Definitely an option on the table to have a system where potentially vets can choose either/or or all private.”
If the current VA system is so reviled, so horrific, so offensive in its unfair treatment of veterans, why do “some vets” love it? Why must it be preserved as a choice?
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Trump appears to be running up against a typical problem for those favoring total overhaul to tweaks along the edges, especially in health care: People fear change over what they have. In the case of the VA, that’s certainly true for veterans, who like the current arrangement. And it’s also true of the privatization-friendly group of experts who looked at the VA just last year.
Let’s back up: The VA is a unique feature of the U.S. health care system, more reminiscent of Britain’s National Health Service. Doctors and medical personnel work directly for the VA, and it owns the facilities where they operate. The rationale is that veterans experience several common combat ailments, from traumatic brain injuries to PTSD to amputations requiring prosthetics. Centralizing care at the VA allows for specialization on the unique needs of veterans, which private hospitals lack. The VA serves more than 8.9 million veterans a year at 1,233 facilities.
Trump bases his stance on the VA mostly on a 2014 scandal about backlogs for patient care and falsifications of waiting periods, which led to the dismissal of several top officials. But as The Fiscal Times’ Rob Garver explained, the VA’s new leadership has already acted to reform the system and change the agency’s culture. Pending claims are way down, virtually all VA facilities extend same-day access to care and performance exceeds the private sector by nearly every measure.
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On top of that, Trump’s preferred option of giving veterans the choice of VA or private care has already been implemented, with interesting lessons. After the backlog scandal, Congress passed a reform bill co-authored by Bernie Sanders, and as part of it, a pilot program gave veterans a Choice Card to use at private facilities if their local VA hospital is more than 40 miles away, or if the wait time is over 30 days. This theoretically ensures that no veteran has to wait for or be inconvenienced by seeking medical care.
The rollout has been shaky, mainly because the 90-day deadline Congress demanded for setting up the system meant that the VA had to turn to private contractors with a history of botching health care management. This has led to a secondary waitlist for those seeking difficult-to-access private care, along with numerous billing errors and questions of eligibility. There was also no setup for integrating care between VA and non-VA providers, which meant veterans skipping between the two could get duplicative or substandard care. While some have predictably used this to label the VA as incompetent, it says more about the hurdles to delivering a public/private hybrid.
Republicans have responded by advocating for a permanent Choice Card, allowing veterans to go to anywhere they want (oddly, they haven’t offered the same kind of single-payer card for the nation’s other 300 million-odd citizens to present at any medical facility). That mirrors the Trump plan of a “public/private option.” But that would further strain a hobbled scheme private contractors couldn’t figure out for a much smaller universe of patients. It would also double the costs of the current VA.
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It’s clear that conservatives expect the private market to deliver better service than any public agency. The VA, they expect, would obviously wither on the vine if challenged by the free market. These true believers have perhaps never had to navigate the private health care system and its even longer wait times; comparatively the VA looks like a dream.
Republicans tried to lay the groundwork for back-door privatization. The 2014 VA reform legislation mandated a report from a bipartisan Commisson on Care on how to best redesign the VA. This was a stacked deck, widely expected to give Republicans a blue-ribbon pro-privatization report to “prove” their case. Three of the 15 commissioners were CEOs of health care companies that would financially benefit from breaking up VA hospitals; two others had ties to the Koch Brothers, who have bankrolled the privatization front group Concerned Veterans for America for years.
But a funny thing happened. The final report of the Commission on Care did not endorse privatization. It recommended enlisting credentialed community provider networks to increase capacity for veterans care, integrated with the VA’s electronic medical records system. The 18 recommendations largely tracked with what VA Secretary Robert McDonald has already been implementing.
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When considering privatization, the commission sought feedback from the veterans themselves. Consistent with recent polling, the vets didn’t want the VA privatized. They preferred the quality of care at the VA and had problems with outsourcing treatment to non-VA providers. Veterans groups also prefer the current system. Transition officials reportedly met with 30 organizations last month, finding that they held near-unanimous opposition to privatization. American Legion Executive Director Verna Jones said of the VA recently, “there is no better care or value available anywhere in the United States — period.”
So like Trump, the Commission on Care pulled its punch. When you can’t even get a commission seeded with conservative ideologues to sign off on VA privatization, it shows the formidable nature of the task.
The VA continues to be demonized and maligned in conservative media, for the reading benefit of the large numbers of Americans who have no military experience. (Blaming the VA for over-prescription of opioids rather than the drug companies who relentlessly pushed them on patients as a miracle cure is just one example). But those who know and study the system find it indispensable. Maybe when Donald Trump names a VA secretary, they’ll figure that out too.