Health Care at the Veterans Administration and the “Choice Card,” One Year Later

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[1], 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.[2] 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

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[3] 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.[4] 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?[5] After all, those socialist Veterans love their single payer system, so why shouldn’t all citizens have the same right to health care?


[1] 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.

[2]  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.

[3] Oddly, the “consumers” locution is not used by “reformers” for veterans.

[4] 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.

[5] 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.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Clive

    [1] 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…

    Yes, you’re right Lambert. MUMPS was used many, many moons ago for coding up niche — but often critical — systems running on (the then) mid-range platforms. The sort of stuff that needed to be smaller and nimbler — and usually cheaper — than something which would justify sharing the corporate O/S390 (maybe more likely MVS at the time) host but needed more than the cheapest mini computer setup would allow.

    My TBTF runs a MUMPS system and sincerely wishes it didn’t. It pee’d middle single digit millions against a wall trying to migrate away from it and it is still in the process of giving it another try. Like all migrations, it’s fraught with risks of every conceivable permutation plus some which aren’t. But it has no choice. It once asked offshorer extrodinairre Wipro to body-shop MUMPS skilled people when it outsourced application development and support. Apparently (so the sales pitch from Wipro went), they had a labour force of 100,000 from which their lucky clients could trawl for specific skill sets. When requested to create a pool of staff to fulfil maintenance and development projects for the MUMPS-based system, the resulting number of people with MUMPS experience was, in a round figure, zero. Yes, precisely 0.

    So, good luck VA with “transforming”, “modernising” or “reforming” anything with a MUMPS back end.

      1. m

        You are right VA system based on MUMPS, but so are the new designer EHRs everyone is paying through the nose to get. DoD just purchased Cerner or EPIC, don’t recall. They (congressman from Wisconsin) trying to force VA to buy overpriced EPIC. All are equally junky, so why waste all our tax dollars, when systems are so similar.

      2. Clive

        “Actively developing” might == “trying to drag a legacy back end from out of the 1980’s without re-writing the whole thing from scratch and breaking backwards compatibility in the process”. Wiki isn’t unfortunely infallible and as far as my experience goes it’s flat out wrong here. No one in their right mind would do any new development in MUMPS. Legacy maintenance and slapping new front ends on old systems, possibly. New development would be just crazy.

        There is though a lot of legacy MUMPS creepy crawlies lurking under finance and healthcare rocks so Wiki is sort-a kind-a not dishonest in its summary but I think needs to be taken with a large dose of salt here.

    1. rfdawn

      MUMPS is the only language so simple that I can still remember it almost-perfectly after 20 years of not using it. The real cost of – shock! horror! – *training* a brain-equipped IT person to use it would be tiny.

  2. cwaltz

    Spouse and I are both veterans. Oddly enough the fact we are enrolled in the VA system is enough for us to call ourselves Obamacare enrollees. The VA system is fairly good if you are rated 30% or higher or if you are poor(when we first came out here I would have died had it not been for the VA and my treatment for a stone blockage would have been way more expensive the year later), however if you happen to have a median range income and not have that 30% threshold then it is more expensive because outside insurers bill you for their services as OUT OF NETWORK. The electronic health record system is fairly new but neat because it allows you to communicate with your primary care without having to make a visit(although you are supposed to get seen annually to stay in a clinic).

    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.

    This part kind of sounds like CHAMPUS/TRICARE and how the military treats it’s retirees. It’s interesting to note that fairly regularly that there are murmuring that the retirees should have to pay more for their coverage. I’d expect the same thing from VA CHOICE. The funny thing for me is how my insurance company treats the VA is a large impediment to me choosing them for my care. My spouse with his rating uses them and sees no reason not to. The system right no requires him to pay nothing for his care and since the federal government is the biller of last choice his PRIVATE INSURANCE actually is billed for his care. It must be torqueing them off that private money is funding a public system instead of the other way around.

      1. cwaltz

        Yep. Pretty much. You do have less choice though. If your doctor leaves the health care system you can end up with another doctor who may be less than wonderful. You kind of need to be your own advocate when that happens. We ended up in the patient advocate office and in a different primary care clinic when my husband was getting the run around. He’d go to the ER in pain and they’d tell him they couldn’t give pain meds to make an appointment with primary care. He’d make the appointment and by the time they’d see him he wasn’t actively in pain so they’d deny him something to control pain(for periods where he was actively in pain and ended up in the ER.) Lather, rinse and repeat. Essentially he was being penalized because other veterans had issues with pain meds so the VA adopted an ignorant policy of essentially not dispensing at all. He’s in a better clinic now. The PA we deal with now is definitely better with dealing with frustration(and occasionally shares his vents with the system from his end.)

      2. andyb

        I’ve used the Miami VA system now for 15 years after qualifying for 100% disability (took 10 months for approval but you get paid for all months after application date). The care is excellent and the wait times are less than my wife has experienced with private doctors. My only bitch is the parking which was sufficient until all the vets from the latest mideast wars began care.

  3. Oregoncharles

    To Be Clear: these are socialized medicine, but NOT “single payer” systems. Which is obvious, since there are 5, and they coexist with the private insurance model. No wonder it’s such a mess.

    That means they avoid the central advantage of a single-payer system, which is its ability to direct and remodel health care itself, as well as to have the largest possible insurance pool and set a national budget for health care,

    The last is both an opportunity and a problem: as Canada and Britain are finding, it offers an opportunity for a hostile government to cut the budget and crapify the system.

    The only counter to this that I know of is to put the budget in the constitution, as a percentage of the national budget. It would be affected by austerity, of course, but at least the effect would be limited.

    Better ideas solicited.

  4. bh2

    FWIW, a couple of medically retired 100% disabled vets I knew in Portland, Oregon, a decade ago found delivery of care was (at best) inadequate and endlessly tangled in hopeless bureacracy a mile deep. In a private office conversation, an administrator told one of them “frankly, the entire system is simply imploding”.

    While anecdotes don’t necessarily reflect general conditions, caution may be warranted in celebration that “those socialist Veterans love their single payer system.” Both of the ones I knew personally surely did not.

      1. bh2

        Could be. Don’t know. I was a VA adjudicator for a couple of years but that gave me no particular insight into day-to-day hospital operations. All we saw was the case load of claims incoming and outgoing.

        A senior manager once said to me “You can learn by heart every law and every regulation affecting the VA and you still will have no idea how the VA actually works.” The only way to discover that was to endure there for years and steadily accumulate a desk drawer full of “bulletins” once you entered the lower management level. These were literally paper flyers which described actual VA policy on different, specific policy topics.

        These were stand-alone documents not organized in any systematic way and there was no master list for reference to look them up. Indeed, there was no official reference to their existence. I don’t believe they were even numbered. They were just literally sheets of paper on topical subjects, sometimes covering several unrelated subjects in a single bulletin.

        These gems of occult wisdom were passed down from the gods on high only to management level people. Drones (journeyman adjudicators and education specialists) who worked cases full time never (or very rarely) saw them and therefore had to rely on mostly verbal guidance from managers privy to these keys to the kingdom.

        Whether similar management methods also prevailed in VA medical operations, I have no idea. If so, it would have produced a similarly bullet-proof bureaucracy absolutely immune to any possibility of “hope and change”.

        What this experience did make clear to me is that bringing in a new administration to “fix” the government is an entirely political exercise in pure fantasy.

          1. bh2

            You cannot organize material which you cannot access. That’s the point, actually.

            The VA is by no means the only agency relying on privileged distribution of eyes-only “guidance” which only the loyal annointed are permitted to see. (Cf. the IRS agents’ manual).

            These walled gardens are empires unto themselves. They are creatures of central government but by no means its captives. If anything, it’s the other way ’round. Presidents (and their political appointees) come and go in endless cyclical waves. But bureaucracies endure like granite against these passing changes in the electoral tide.

            1. Lambert Strether Post author

              Well, in a way that’s what you want bureaucracies to do, is it not? Otherwise “it’s political appointees all the way down.”

              I agree that the solving the IT problem for the circulars is necessary, but not sufficient, to solve access problems for the citizen. (Again, it’s a mirror world of ObamaCare, where nobody can figure out a consistent ruleset either, but stemming from different systemic causes.)

              1. JTMcPhee

                One tip the Reaganauts took from the Heritage Foundation’s 1980 “Mandate for Leadership” handbook (it’s also old wisdom, of course) was to grab the nodes of hiring and retention operations in HR to pack the bureaucracy, top to bottom (especially mid to bottom, looking to the Long Game with fellow travelers. They have had generations, now, to do that. As with the judiciary. Using the theater of “elections, the people have spoken, suck it up, losers”.

                The EPA, in a small way before I started there and accelerating through the Reagan and later regimes, grew large volumes of what the silk-stocking lobbyist-lawyers called, in selling their ” access and “representation,” as the “secret law,” to which they, as former EPAers or Justice Dept. skulch, and therefore cognoscenti, had double-secret access. Complex regulations, written sometimes by people like my friend Joe Boyle, a classically trained philosophy Ph.D and environmental scientist who reveled in the complexities and cross-connects and minutiae of definitions and scopes and actually, as a most knowledgeable person, became a kind of walking talking oracle for “the law,” under the Resource Conservation and Recovery Act governing hazardous waste generation, storage, and disposal, and a host of reviewers and commented and secret inputters, like Dow and Monsanto operatives, needed “regulatory interpretive memoranda” and a bunch of guidance documents and letter opinions and other stuff to turn the gears. And DOJ had their own sets of guidances and policies, no deference to agency expertise there, because Qui pro domina justitia sequitur, OK?

                There is a thing called the Administrative Procedures Act, but you would hardly know it from the Real World… hahahahaha…

                That kind of structure may be inevitable, because greedy, mean-spirited people congregate around wealth and power like blowflies on dog sh_t. And interesting policy challenge: “we” want and need rules, and some consistency in their administration and hahaha enforcement. Ask about the Clean Water Act’s former Spill Prevention, Control and Countermeasures program some time…

                But while it would be nice to be able to dump reactionary bureaucrats who add energy to the looting, there are reasons for civil service protections. But then making it easier to fire the parasites makes it easier for the parasites to outplace the good people (my preferences, of course, in defining “good.”)

                It’s hard to find people dedicated to the other play of the Long Game, looking to decency and sustainability and the building of a meta-stability into governance that would operate like the homeostatic systems that keep our puny bodies breathing and more or less healthy. Way too many people happy to participate actively and gleefully and with career satisfaction in the looting. Dam’ limbic system…

          2. bh2

            It isn’t primarily a programming challenge. It’s an access challenge.

            These bulletins were (are?) apparently issued ad-hoc in hard copy only and with no permanent records of their existence centrally retained. (E.g. laws and regulations are required to be published in the Federal Register to take effect.) It was my impression that different regulatory specialists could issue bulletins at will (though likely only with higher level endorsement).

            It might be possible, of course, to fetch these notes retained over the years by managers directly from their desk drawers. Then the question is who would do the physical invading of their “private” work space? Higher level members of the VA bureaucracy? The White House? Congress? Good luck with that.

            The recent pursuit of the Lerner emails demonstrates how an entrenched bureaucracy can passively resist intrusion on its privileges, prerogatives, and internal decision making processes. And email documents already exist in electronic form (except, of course, those mysteriously “lost” or “destroyed”).

            Indeed, there’s a specific law requiring archived backups of official emails at the IRS and other agencies. You may notice this long-standing law was willfully disregarded and nobody went to jail — and never will. Responsibility is inherently diffused across a vast number of people, none of whom can be individually held to account for anything “bad” happening. And if called to task, suspect employees can simply deflect any potential legal threat by pleading the 5th.

            This is precisely why public employees, IMO, should be required by law to explicitly waive their constitutional immunity against self-incrimination or else seek other employment; but I digress…

            VA “bulletins”, unlike email messages, were literally published only in hardcopy and distributed within the tons of other office mail.

            No doubt any attempt to round these up into a single large pile would meet the usual wall of passive resistance. There would also have to be an authority with strong incentive to round them up. And who, exactly, would that be?


  5. Jacob

    “. . . there are numerous systems for eligibility determination, program by program and system by system.”

    To qualify for 100 percent unlimited access to VA healthcare, a veteran has to have a 100% VA disability rating. It’s likely that the veterans who are reported to have died while awaiting VA care either didn’t have a VA disability rating or were rated significantly lower than 100%. Getting a VA disability rating is a major hurdle for most veterans who seek VA benefits. Service organizations such as DAV and AMVETS provide highly trained veterans’ advocates who help many vets win disability claims. Only about 3-5 percent of disabled veterans have the VA’s highest disability rating of “100 percent permanent and total” (note: this rating becomes permanent only after 20 continuous years). None of the VA’s disability ratings are permanent, however, and the VA can rescind a veterans’ disability rating at any time as a result of periodic VA medical re-examinations. Winning a VA disability claim is somewhat similar to fighting for a Social Security or Worker’s Compensation disability claim.

    1. cwaltz

      Our experience has been different. My husband’s rating isn’t 100% but he’s had no problem being seen for his disabilities.

      I do wonder if these veterans who died before getting care actually went to the VA ER who has the ability to triage and can get you into a clinic faster than just going through a primary care. I also wonder what kind of experience these people would have had with the private sector where you ALSO often have to wait for some time to get appointments. It’s not like it’s always possible to call a specialist and get seen the same day. Some of the problems the VA has aren’t specific to the VA but to health care as a whole.

    2. Kris Alman MD

      I was a VA doctor in internal medicine from 1987-89 in Albuquerque (which came with the surprise that my employment data was part of the recent Office of Personnel Management breach). Just out of my residency then, I began to learn about pre-existing conditions. Many of the vets I saw (some even from WWI!) either could not access private insurance or were under-insured.

      Often, they came to the VA hospital in Albuquerque from all corners of New Mexico just to get their meds refilled from a private practice physician who they saw in their community. (There are far more clinics in communities to accommodate vets’ needs currently.) This posed problems if the med was not on the formulary. Moreover, I didn’t always agree with the management by their PCPs. Chronic pain management was always a problem–especially when narcotics were involved.

      VA heath care eligibility is not automatic after serving. Priority is given to vets who were diagnosed with medical conditions or disabled during service, who received medals, and who were prisoners of war.

      Insufficient service connection created barriers to care. I never understood how these determinations were made, but they could be appealed and reviewed. I remember many of the Vietnam vets of that era complained that agent orange was responsible for their medical conditions. They would go to a special agent orange clinic for evaluations. No doubt, soldiers continue to be exposed to chemicals that cause harm long after they are served. PTSD was and continues to be a challenge for vets. Unsurprisingly, PTSD and other mental health conditions may appear after discharge, when eligibility has already been determined.

      Regardless, many under-insured vets are likely seeking supplemental care at VA hospitals and clinics (further straining their resources) to mitigate out-of-pocket costs. Privatizing the VA won’t solve this problem.

  6. Bob Stapp

    As a non-combat, non-disability rated Vietnam vet who will turn 68 this year, I did not avail myself of VA health care until 2004 and only then with trepidation due to the many horror stories I’d heard about the VA. To my great surprise, I’ve found it to be some of the very best health care I’ve experienced which, due to my high mobility and serial employment, has been a lot and has varied from private practice to HMOs to German-run health care in Afghanistan to a private hospital in Delhi, India.

    I can’t speak to the Choice Card but I can say right now that I’m not at all interested. I’m very happy with my primary care doc and the service and responsiveness has been outstanding. I’m currently under referral to a VA specialty clinic and that has been very smooth, professional, and efficient as well.

    With that said, all of my experience with the VA health care system has been through the VA hospital in Reno, Nevada, which, I’m told, ranks very high among VA health care facilities. Also, in the interest of full disclosure, both my son and my daughter-in-law work for the Reno facility and, had it not been for my daughter-in-law kicking my butt back in 2004, I might never have enrolled, but it was one of the best moves I’ve ever made.

    Please, please, run a stake through the heart of the privatization monster. It would ruin a perfectly good health care system.

    1. cwaltz

      I’m sure the VA system, much like it’s military counterpart has problems with cost over runs. I used to work as a Navy corpsman in the pharmacy and the person who handled supply used to rant regularly about why bother having a formulary when each and every request to get a non formulary item was granted. It also never failed that come September we’d have to hand out IOUs because we ran out of money to buy medication. That isn’t so bad when it comes to handing out artificial tears but it’s less than ideal when you have to tell someone that you can’t give them their blood pressure medication refill and that they’ll have to see their doctor to get a prescription to cover the gap period(since you can’t exactly hand back a prescription you’ve already filled.) We tried hard to offer up substitutions but the truth is that there are hazards to switching someone who is on a maintenance drug to another drug that might not perform as well.

      My own experience with the VA has been a mixed bag. I have found that much like my military experience that you’ve got good doctors and less than good doctors and you don’t have a lot of control over which ones you get. My first two urologists at the VA were awesome. They were diligent and very patient friendly. The second did everything they could to keep track of the stone I had that blocked off my right kidney after placing in a stent to the point where I joked that they had more pictures of my kidneys than I did of my kids) while I waited for lithotripsy. I daresay I would have had better care if I’d have searched for it outside. My third was a jerk. He informed me I had stones in both kidneys and pretty much shrugged at the problems and concerns that come with that(I have an enlarged kidney due to pyelonephritis in1999 after my 5th pregnancy as it is that no one can really explain.) He essentially handed me a hat and told me to use the ER rather than add to his workload. At that point luckily I had more options available to me.

  7. BEast

    The combat veterans/non-combat veterans split is news to me, and it’s particularly galling because of how service members are classed may have nothing to do with their experience. e.g., driving supply trucks in Iraq was non-combat… but that doesn’t mean those people couldn’t get blown up.

    I had a female acquaintance who served in Iraq who was in an explosion. The VA tried to say she couldn’t have combat PTSD because she hadn’t been in combat. Just one problem — she had the incident on video. They also tried to say she had already had another injury, so they wouldn’t have to cover that — even though there’s no way she would have been sent over if she already had that injury.

    This fictional discrimination between combat and non-combat forces in a war zone (there is no “line” or “behind the line” in modern warfare) affects both men and women but is particularly bad for women because the Army refused to admit any women were in combat back in c. 2003.

    1. cwaltz

      I personally feel anyone in the military should be classified as combatant(in terms of the ability to receive care) since bullets and bombs definitely do not discriminate.

      I found it interesting when I was trying to get my female care covered that the VA said my dysplasia was “just a lab result”(mind you it was a lab result that was so concerning that it required a biopsy) but you can get rated 0% for a scar. It definitely felt discriminatory. I hope your friend appeals and gets a congress person involved if she has to.

      1. BEast

        For those deployed to war zones, I agree with you. I think a distinction between those deployed to Iraq or Afghanistan or Vietnam and those who served during peacetime and/or never deployed to a combat zone would be valid.

  8. JGordon

    Funny thing is that whenever I go into the VA they’re running Fox News on the TV in the waiting rooms. That’s like, in every waiting room I’ve been in at the VA: primary care, bloodwork, radiology, etc.

    The irony struck me reading the post that those who most want to gut the VA system are seemingly viewed rather favorably by those within the VA system. Not to disparage Republicans in particular; I’m sure Hillary and her ilk are slavering to gut the VA system too.

    1. JTMcPhee

      Can you spell ” cognitive dissonance?” ”Keep your filthy gaddam guvermint hands off my Medicare and Social Security!!!!!!” If you unpack that a little bit, go behind the sneerable surface irony, its actually a bit of folk wisdom

    2. Jacob

      “Funny thing is that whenever I go into the VA they’re running Fox News on the TV in the waiting rooms.”

      VA employees are, to a surprisingly large extent, steadfast right-wing ideologues, quite a few of whom seem to view disabled veterans as moochers (relatedly, the American Legion, a service organization which claims to help veterans process disability claims, was founded by a group of right-wing businessmen and has a long history of right-wing activism). The irony is that the VA system is public-funded and exists to treat veterans who are disabled or otherwise qualify for VA benefits, but right-wingers are ideologically opposed to public benefits – “entitlements” – of any sort for veterans or for any other working-class people. Many veterans incorrectly believe that VA benefits are not entitlements, like Social Security and Medicare, but were earned by veterans rather than being a right granted by legal mandate.

  9. run75441

    I have had no problem with the VA and its care for me. I pay the deductibles ($15 for PC doctor and $50 for a specialist) and have no disability other than drinking the water at Camp Lejeune in the late sixties and early seventies whenever I was in-country. I get my meds there at a far lower cost than commercially. The waits to see the PC doctor is about the same as at a U of M clinic.

    Dealing with any government program officials is fraught with snafu. When I got out in 71, I would get angry at the VA rep for his answers till I saw him. He was in a wheel chair and a vet like I was. Except for the water issue, I am mobile. The VA is one of the few places you can go to for treatment resulting from exposure from depleted uranium shells (another agent orange issue). Veterans should have their own facilities to seek medical treatment. If the citizenry and politicians do not want to pay the cost of VA hospitals, doctors, homes, and other benefits; then quit going to war and spending $trillions financing it. The numbers of vets seeking care would decrease then.

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