By Lambert Strether of Corrente.
Twenty-First Century America is so weirdly prodigal of resources, and yet so ancien regime with systems, that we have not one, not two, not three, not four, but five single payer systems, none of them integrated with each other, and directed at different siloed populations:
The truth is that the United States already uses single-payer systems to cover over 47% of all medical bills through Medicare, Medicaid, the Veterans Administration, the Department of Defense and the Bureau of Indian Affairs.
In this post, I want to look at the “Veterans Choice Card,” a partial privatization effort at the Department of Veterans Administration (VA) under the “Choice Program,” more formally the “The Veterans Access, Choice and Accountability Act,” introduced and rapidly passed in response to the 2014 patient wait time scandal, and brokered by Senators John McCain (R-AZ) and Bernie Sanders (I-VT). As a caveat, this is the first time I’ve looked at the VA, which is why I’m limiting the scope of this post to the Veterans Choice Card, instead of trying to understand the entire VA and all its problems. I’ll start by taking a high-level look at the VA, then look at the Choice Program and the Veterans Choice Card, and finally at privatization as in issue in the coming 2016 campaign.
The VA Is Big
Like, really big. (Like Britain’s NHS (at least before the Tories started gutting it) and as opposed to Canadian (or United States) Medicare, the VA actually delivers health care with its own personnel and in its own facilities). The GAO’s description (2010):
[The VA] is responsible for providing a variety of services to veterans, including medical care, disability compensation, and vocational rehabilitation. The Veterans Health Administration (VHA)—a component of VA—manages one of the largest health care systems in the United States, providing health care to more than 5 million patients in more than 1,500 facilities.
Except now it’s 6 million, not 5 million. CNN (2014):
The VA served over six million people in 2013.
There are approximately 21.4 million veterans in the United States.
President Barack Obama has requested an appropriation of $163.9 billion for the Department of Veterans Affairs in the 2015 Budget, a 6.5% increase over the 2014 Budget.
In 2013, the VA had 312,841 full-time equivalent employees.
Ranked by employees, the VA would be a top ten corporation in the United States. It’s big.
The VA Has Greatly Increased Its Patient Load
Big though it is, the VA, if measured by services delivered, only got bigger as the Choice Program expanded capacity:
Since the waiting-list scandal broke last year, the department has broadly expanded access to care. Its doctors and nurses have handled 2.7 million more appointments than in any previous year, while authorizing 900,000 additional patients to see outside physicians. In all, agency officials say, they have increased capacity by more than seven million patient visits per year — double what they originally thought they needed to fix shortcomings.
But what was not foreseen, department leaders say, was just how much physician workloads and demand from veterans would continue to soar — by one-fifth, in fact, at some major veterans hospitals over just the past year.
[The VA’s deputy secretary, Sloan D. Gibson] said in the interview that officials had been stunned by the number of new patients seeking treatment even as the V.A. had increased its capacity.
At this point, I can hear neo-liberal economists muttering about “too much care,” but that’s a discussion for another day; though I must confess that “Hmm, what shall I do today? Hit the golf course or go to the doctor’s office?” isn’t a conversation I often have with myself. So I would speculate that this increase in patient load is pent-up demand due to capacity problems.
The VA has Systems Problems
And in fact, the VA, for all its scale, does have systems problems. The two main blockages to care delivery seem to be personnel and eligibility determination. As far as personnel:
Half of critical positions open at some VA hospitals. Nationally, one in six positions — nearly 41,000 — for critical intake workers, doctors, nurses and assistants were unfilled as of mid July, in part due to complex hiring procedures and poor recruitment, according to critics of the nation’s network of 139 hospitals and clinics that treat veterans.
I don’t have figures on how many are turned away because of personnel shortages — and mandatory overtime for claims processors complicates the picture — but unfilled positions on this scale simply can’t be helping. (Ironically, at least one of the reforms in the “Choice Program” — making it easier to fire VA employees — makes the VA a less attractive place to work, and it’s not as if skilled health care workers can’t find jobs elsewhere.)
More centrally — and I believe this is the context of the 2014 “patient wait time” scandal — is the VA’s complex system of eligibility determination, in terms of intake, scheduling, and for various siloed programs. There seems to be a ginormous hairball of paper-based and electronic systems in varying states of repair, and I’ll just give a few examples.
First, means testing. From HuffPo:
Scott Davis, a program specialist at the VA’s Health Eligibility Center in Atlanta and a past whistleblower on VA mismanagement, provided HuffPost with a recent VA analysis of the number of combat vets, by city, who are listed as “pending” for health care enrollment because they didn’t complete a so-called means test, which assesses their household income. Many vets have to submit a means test to be enrolled, but it’s not required for combat vets, who are automatically eligible for five years of free care.
So, two classes of veteran with a time-limit for one, and no closed loop to make sure that veterans are actually placed in one class or the other. No scope for problems here!
Second, enrollments (which is the current scandal). From Military.com:
The Veterans Affairs Department is rejecting reports that 300,000 veterans likely died while awaiting care, even though the figure came from its own inspector general.
The number reflects the number of veterans with pending enrollment applications that the Social Security Administration reports as deceased — but nothing indicates they went without medical care or died while actively seeking enrollment into the VA system, according to a senior official with the department’s Veterans Health Administration.
“[The IG] could not determine specifically how many pending records represent veterans who applied for health care benefits or when they may have applied,” Acting Deputy Under Secretary for Health for Operations and Management Janet Murphy said in an official VA blog post on Thursday. Some of the veterans could have applied for health care years ago and gone on to get care outside the VA. Murphy said the department does not have the authority to remove a claim from pending status even if they attempt, but fail, to contact the veteran.
So, an enrollment queue that never gets purged (“Some of the veterans could have applied for health care years ago”). No scope for problems here! (I’m skeptical of the topline, 300,000 number because McCain immediately picked up that stick and began to beat the VA with it in favor of privatization. More on McCain in a bit.)
Finally, I should point out that in processing disability claims, the VA won a rare IT victory, combined with the “brute force” approach of hiring more claims adjudicators, and mandatory overtime for them.
Stepping back, however, we can see how the VA is a “mirror world” of the civilian health care system, for one simple reason that single payer advocates will see at once: The principle of “everybody in, nobody out” is not accepted, and hence there are numerous systems for eligibility determination, program by program and system by system. These systems are one an all cumbersome, prone to error, enormous resource sinks, and opportunity costs for the delivery of actual care.
Reform: The “Veterans Choice Card”
Here’s a summary of the The Veterans Access, Choice and Accountability Act of 2014; note that it expands (!) government spending with $5 billion for new hiring, and 27 major medical facility lease. For our purposes, the important item is “The Veterans Choice Card,” because that permits veterans, for the first time, to seek care outside the VA system. Senator Bernie Sander’s website explains the program:
The legislation would allow veterans who have had to wait more than 30 days for an appointment with the VA to
seek care from a private physician, a community health center, a Department of Defense health care facility or an Indian Health Center. Veterans who live more than 40 miles from a VA facility also would be eligible for this program.
Just to foreshadow, followers of our series on ObamaCare’s launch (1,2,3,4,5, and 6) will recognize — besides yet another system for eligibility determination, this time for the Card — an attempt to even out random variations between jurisdictions (the “40 miles” test) and networks with low capacity (the “30 days” test).
So we’ve now had a year to look at the Choice Card. How’s it working out? We don’t have a GAO study, at this point, but we do have anecdotal reports. Here’s a list of the problems that are cropping up:
- Jurisdictional Issues: “One of the witnesses, Carlos Chacha–a veteran who lives in his district–had been unable to schedule an appointment under the Veterans Administration’s Choice program because of questions about his eligibility. [Asked why, the VA answers: “Because the contract requires us to wait for that eligibility file. We are not allowed by contract to act based on a VA medical center telling us that a patient is eligible” (Georgia)
- Narrow Networks: “When Hopkins tore his bicep tendon, the VA sent him to Albuquerque to get an X-ray, an MRI, and consultations with an orthopedic specialist. The veteran could not get that care in Durango because the VA clinic offers only primary care, mental health services and lab testing” (Colorado)
- Billing Issues: “”I had surgery on March 23. I had a bill sitting on my desk for 90 grand up until August. You tell me what hospital is going to sit and wait for their money to be paid when services have been rendered?” he said” (Alaska)
- Confusing Support: “They described unexplained denials of service, months of waiting for the VA to pay claims and confusing telephone conversations with automated phone systems in the Lower 48. According to an account from a previous hearing, there are 900 1-800 numbers and 14 websites that require their own login information associated with the new program” (Alaska)
Readers will recognize all these as problems
consumers citizens have under ObamaCare. In other words, the problems of the privatized VA reform are — as they must be — the problems of our privatized systems as such.
The VA and Privatization
Evidently, privatization is not a panacea. That will not, of course, prevent the neo-liberal mainstream from pushing it because markets. Take Ben Carson — please!
Carson said he wants to provide all veterans with health savings accounts to pay for private-sector medical care and reserve defense-run veterans clinics for highly specialized care, like traumatic brain injury treatment and limb replacements.
More seriously, McCain is already using the “Choice Card” as a wedge to privatize more VA heatlh care services:
Now, a leading Senate Republican who has consistently questioned how VA is utilizing the effort, is proposing legislation that could be a seismic change to the department’s healthcare system and allow any veteran enrolled in the agency’s insurance network to seek private care any time they’d like.
The proposal by Sen. John McCain (R-AZ), rolled out on Wednesday, would make permanent the “choice card” pilot program and lift the restrictions in the 2014 law, of which McCain was a key architect. Most notably it would get rid of criteria such as if a patient has faced a long wait time to get an appointment at their local facility or lives more than 40 miles from a VA facility.
That McCain wants to universalize the “Choice Card” after only a year of implementation — and in the face of the problems listed above — shows how tendentious the original proposal must have been. Which is what one might expect, given that reactionary oligarchs like the Kock Brothers are funding one of the privatization efforts, “Concerned Veterans for America” (and have you ever heard an organization’s scream Astroturf more loudly?)
Of course, privatizing a huge and complicated organization like the VA will not be easy. Via State of Reform, “Pros, cons of privatizing the VA health system”:
- The VA health system serves a unique population with common ailments: ncidences of traumatic brain injuries (TBI) among veterans are higher than the general population (especially veterans of the recent Afghanistan and Iraq conflicts).
- Shifting to private market more complicated than dual-eligibility: As one of the largest health systems in the US, the Veterans’ Administration could not privatize overnight (or overyear).
- Niche value will decrease with aging veteran population: While some service-connected injuries do correspond to ailments later in life, many conditions won’t relate to the niche benefits that the VA offers.
- Tighter government spending won’t sate increased demand for care: As privileged a status as veterans hold in society, the Veterans’ administration is not immune to charges of administrative fraud, waste, and abuse as evidenced by the recent scandals.
State of Reform regards the second “Con” bullet point — “Shifting to private market more complicated” — as dispositive, especially when considering cost, making VA privatization “a political non-starter.” Veterans agree:
Veterans groups already have cautioned that the issue of privatizing VA health care will be a major discussion point in the 2016 election campaign, and that they will oppose plans that seek to remove safety nets for veterans in need of health care and support services.
American Legion National Commander Michael Helm vowed his group “will not let someone step in and try to privatize health care for our veterans,” calling those plans “crazy ideas.”
Oh, if you look at the details of the “Concerned Veterans of America,” it’s clear that their objective is crapification of health care for veterans. Stars and Stripes:
The Veterans Health Administration would be split into two organizations, one that deals with health insurance and another — an independent nonprofit government corporation separate from Veterans Affairs — that oversees VA health facilities.
Veterans enrolled in the VA health-care system would still be eligible for free VA health care but would have the option of choosing private health care with co-pays and deductibles. Patients would be able to transfer federal funds spent on their care at the VA to help pay for private health care.
Future veterans would have to use the new system and be subject to cost-sharing depending on their level of disability or financial need. Lowest-need veterans would not be included in the program.
So all that the privatizers would need to do then — exactly as with charters — is gradually gut the VA, and force everybody into the private system. Ka-ching.
Maybe I didn’t get the memo, but is there some reason we couldn’t do away with all the complexity and give every American a “Choice Card” in a single payer system? After all, those socialist Veterans love their single payer system, so why shouldn’t all citizens have the same right to health care?
 Basically, all I know about the VA is that its back-end uses a really keen language called MUMPS, designed for the health care industry and also used in finance, which was a NoSQL database before NoSQL was a thing. I should really find out why MUMPS couldn’t have been used for a ObamaCare’s backend, given that MUMPS, well, actually works. Since MUMPS is also used for the Indian Health Service, it can clearly be used to implement additional systems. So far as I can tell, the VA’s scheduling system debacle — the IT aspect of the patient delay scandal — is down to incompatible Electronic Health Records formats, though I’d welcome comments from more knowledgeable readers.
 I also have priors, in that as an old hippie, I think that every citizen deserves equal access to health care, not just veterans, and that not all heroes are in uniform. That said, we as a country made a deal with our soldiers, part of which includes health care, and we should live up to it.
 Oddly, the “consumers” locution is not used by “reformers” for veterans.
 So what were you thinking, there, Senator Sanders? Hopefully, this is a clever maneuver to deke the Republicans into doing something Veterans will hate, and to allow you to pose, from your position on the Veterans Affairs Committee, as a defender of veterans (which has the great merit of being true). But I don’t trust 11-dimensional chess reasoning at all.
 To be fair, “The Episode of the Greek Drachma,” as Sir Arthur Conan-Doyle might call it, should remind us that things are desirable, or even necessary, are not always possible. IT and systems issues in a transition to single payer would need to be carefully thought through.