Yes, Trump is privatizing the VA

New proposals announced by the Trump Administration and Department of Veterans Affairs Secretary David Shulkin should dispel any doubt about the administration’s intentions to privatize the Veterans Health Administration. 

Although President Donald Trump and Shulkin have insisted they are opposed to privatization, the proposal the VA Secretary unveiled to the Senate Committee on Veterans Affairs on June 7 – coupled with Trump’s Veterans Health Administration budget – will end up pushing more veterans to private doctors and hospitals, and ultimately dismantle the VHA system.

In his testimony to the Senate Committee about a replacement for the Veterans Choice Program that sunsets this August, Shulkin said he wants to create the Veterans Coordinated Access Rewarding Experience program.

{mosads}Under this plan, veterans will be able to select any private sector physician or provider even if they do not have to wait 30 days for care at the VA or drive more than 40 miles to a VHA facility – restrictions embedded in the 2014 Choice Program.

In this new program, every decision about care will be preceded by a conversation between a veteran and VHA provider — via telephone, virtually, or in person — in which it will be decided, on a case by case basis, whether care at the VA is better than that in the private sector.

Shulkin insists all decisions made during these conversations will be dictated by clinical evidence about care quality and wait times in both the private sector and VA.

If a veteran decides to go to a private sector provider, it is their responsibility to find a physician, hospital or mental health practitioner or other service. The VA will provide outside providers with information about the veteran, and collect information about the course of treatment from that outside provider.

The only way the VHA can improve, Shulkin insisted, is by giving the “customer” (as he now defines veterans), needed  information and forcing the VA to compete with the private sector. This, in spite of the fact that reams of studies show that the VHA — without relying on market based incentives — already delivers care that is equal or superior to that provided in the private sector.

When skeptical senators questioned Shulkin about the availability of data upon which this new program would depend, he acknowledged that the VA only collects information on wait times. 

He said he hoped the private sector would follow the VA’s lead in this area. He also assured senators that the kind of robust, detailed data on quality that would help patient and provider make wise choices can be made readily available.

In fact, there is little or no detailed data to guide many of these decisions. Who knows whether a particular private sector mental health practitioner delivers evidence-based therapies to patients with PTSD? Or whether an individual endocrinologist has experience diagnosing Agent Orange related diabetes?

Even if such data existed, what busy clinician dealing with VA patients, who may have multiple health problems, has time to figure out if every therapy or treatment the VHA delivers is better or worse than that delivered in a private sector facility?

As one harried nurse practitioner told me, “ I don’t have time to figure out whether we do better colonoscopies than somewhere else. All I care about is that my patients get their colonoscopies. If they want to go to the private sector I don’t have time to deal with it.”

In Shulkin’s ideal world, decisions under this new program might be determined by robust clinical evidence. In the real world, they may be determined by customer inclination and provider fatigue – not by clinician expertise.

Also buried in this new plan are proposals for pilot projects that, as Senator Patty Murray (D-WA) warned, perfectly echo those proposed by the infamous Strawman group to the VA Commission on Care. The group of supporters who favored completely dismantling the VHA include the Koch Brothers funded Concerned Veterans for America and hospital executives who would benefit from VHA privatization.

Now these proposals have been resurrected as pilot programs to see whether the VHA could be turned into an insurance plan that no longer delivers services to veterans.

When Murray asked Shulkin why he included such “extreme” and “unacceptable” proposals to the committee, he answered, rather lamely, that it was done in the spirit of “innovation and testing.”

Finally there is the issue of the Trump budget, which both Senator Bernie Sanders (I-VT) and Senator Jon Tester (D-MT) argued starves the VA of needed resources. Tester pointed out that, of the increases in the proposed VHA budget, 33 percent of this goes to private sector care and only 1.3 percent to VA care.

Murray added that investing only in things like treatment of Traumatic Brain Injury, PTSD, polytrauma and prosthetics, which is also being proposed, would mean that VA hospitals can’t be “viable when you only invest in a small number of things.”

Murray’s concluding comments underlined the fundamental  problem with almost all the proposals coming from Republicans and the Trump administration.

“What’s missing from the conversation,” she said, is  “how you plan to actually build and strengthen the VA system for the long-term. There is no comprehensive plan to…get more frontline providers, increase appointments, expand services, build and upgrade facilities, and bring more veterans into the system.”

Shulkin’s plan, according to Murray, was moving completely in the “opposite direction.”

Suzanne Gordon is the author of the new book “The Battle for Veterans’ Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care.” Her work has appeared in the American Prospect. Follow her on Twitter @SuzanneGordon

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