Neoliberalism’s Assault on the Veteran’s Administration Continues

By Lambert Strether of Corrente.

Before they sink beneath the waves of the latest moral panic or election horse-race hot take, I want to draw your attention to two stories that are presented as separate but are in fact intertwined. Both concern the Veterans Administration (VA), one of America’s several eligibility-determined single payer systems. (Like Britain’s NHS, but unlike Canadian or American Medicare, the VA owns its facilities and employs its own medical personnel. That makes it a target-rich environment for neoliberals.)

1) A newly-signed contract with Cerner Corporation for a new VA Electronic Health Record (EHR), the same as the Defense Department’s

2) The VA Mission Act, now on President Trump’s desk

The stories intertwine because they look like they’re part of the neoliberal privatization playbook, here described in a post about America’s universities:

It’s almost like there’s a neo-liberal playbook, isn’t there? No underpants gnomes, they! [1] Defund [or sabotage], [2] claim crisis, [3] call for privatization… [4] Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama’s first response is send patients to the private system. Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it’s gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I’ve helpfully numbered the steps, and added “sabotage” alongside defunding, although defunding is neoliberalism’s main play, based on the ideology of austerity.) We can see this process play out not only in public universities, public schools, the Post Office, and the TSA, but in Britain’s NHS, a national treasure that the Tories are systematically and brutally dismantling.)

I’ll begin by looking at the VA’s EHR project, and then move on to the VA Mission Act.

A New EHR for the Veterans Administration

After a year or so of deliberation, the VA finally signed off with Cerner on an EHR “modernization” project in mid-May:

According to the announcement — and a budget forecast — the Cerner EHR at the VA will be identical to the one currently in the pilot phase at the Department of Defense. Currently, officials at both agencies are working together to impart lessons learned into the VA project. ‘We expect this program to be a positive catalyst for interoperability across the public and private healthcare sectors,’ said Cerner President Zane Burke in a statement. ‘We look forward to moving quickly with organizations across the industry to deliver on the promise of this Mission.’

(“positive catalyst.” Hoo boy). It does seem reasonable that DoD and the VA should both use the same EHR, but there’s… a snag: The DoD EHR project (“MHS Genesis”) is a debacle. HealthCare IT News, also mid-May:

The Department of Defense, along with EHR vendor Cerner and contractor Leidos, held a call with reporters late Friday in response to a report finding that MHS Genesis implementation is not effective and slamming the massive modernization work’s survivability as well as recommending DoD delay the project.

MHS Genesis “is not operationally suitable because of poor system usability, insufficient training and help desk support,” according to the Initial Operational Test and Evaluation.

Behler pointed to a lack of workplace functionality needed to document and manage patient care as examples, and noted that clinicians using MHS Genesis only completed 56 percent of the 197 tasks used to measure performance.

“Poorly designed user roles and workflows resulted in an increase in the time required for healthcare providers to complete daily tasks,” according to the report.

In some instances, EHR issues caused providers to work overtime or see fewer patients. In other cases, users actually questioned that accuracy of the data exchanged between external systems and MHS Genesis — which could have put patient lives at risk.

“Users generated 22 high severity incident reports that the testers attributed to inoperability, including interoperability of medical and peripheral devices,” according to the report. Users ranked usability at 37 out of 100 on the system usability scale.

More from Politico:

The first stage of the Pentagon’s $4.3 billion MHS Genesis project has been plagued with severe usability and interoperability problems, according to an April 30 report obtained by POLITICO. Pentagon inspectors who visited three of the four Pacific Northwest treatment centers in the rollout found 156 “critical” or “severe” incident reports — i.e. flaws typically serious enough to result in patient deaths. They canceled the fourth visit until problems could be resolved at the first three centers.The report concluded that MHS Genesis, is “neither operationally effective, nor operationally suitable” — and recommended freezing the rollout indefinitely. That, in effect, is what the MHS Genesis project management office has done, though leader Stacy Cummings says it’s still on track to finish on time in 2022.

The report confirms and deepens findings from our March investigation, in which doctors and IT specialists expressed alarm about the software system, describing how clinicians at one of four pilot centers, Naval Station Bremerton, quit because they were terrified they might hurt or even kill patients

Of the 7,000 trouble tickets submitted, 1000 have been resolved. Here is the DOD’s response. Federal Times:

As for negative reports, ‘we’re disappointed stakeholder feedback continues to be taken out of context to present an incomplete, inaccurate and misleading narrative about the successful completion of the MHS GENESIS initial operating capability phase,’ the spokesman continued. ‘MHS GENESIS is already achieving meaningful improvements related to quality, efficiency and safety in the initial deployment sites. We are confident MHS GENESIS remains on track for full deployment.’

Which totally explains why clinicians decided to enter today’s labor market because “they were terrified they might hurt or even kill patients.” You have to wonder why MHS Genesis project was initiated at all. NextGov:

DoD responds to report calling Cerner EHR ‘not operationally suitable’

The VA’s electronic health system was rated the best for overall user satisfaction in a survey of more than 15,000 physicians, while the Pentagon’s current platform–the Armed Forces Health Longitudinal Technology Application–scored dead last.

So, call me crazy, but why not give consideration to making the VA system the standard for the DoD?

“It’s no surprise that a program as big as MHS Genesis…is going to have problems like this—according to all the metrics, most large federal IT programs aren’t successful,” said [former VA chief information officer Roger Baker], who held the department’s top tech job from 2009 to 2013. “[VA] need[s] to remember that the probability they’re flushing that $16 billion down the toilet is actually greater than 50 percent.”For one, most VA doctors don’t mind the current platform.

So, replacing a system that works with a new system is a $4 billion coin-flip. Perhaps Roger Baker asks a question that answers itself:

‘What’s it going to look like when VA is trying to replace the most liked [platform] out there?’ Baker said, especially when the military is having trouble convincing doctors to quit one of the least liked.

To a cynic, it might look like Step One of the neoliberal privatization playbook: Sabotage. Especially because the first time the VA and the DoD tried this, it failed.

The VA Mission Act

And now for the VA Mission Act, passed in a thoroughly bipartisan fashionMR SUBLIMINAL Count the spoons when they leave the house! with support from the Koch Brothers (fascists, we are told, but apparently fascists with friends).

This Act may be cited as the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 or the VA MISSION Act of 2018.

(That acronym is almost as clever as “USA PATRIOT Act.”) If you’ve been looking for an honor roll of Democrat Senators who will defend a single payer system that actually exists, here it is:

The Senate easily cleared legislation on Wednesday overhauling medical care options for veterans, sending the bill to President Trump’s desk.

Senators voted 92-5 on the proposal, called the VA Mission Act, with only a simple majority needed to pass the bill. Sens. Bernie Sanders (I-Vt.), Brian Schatz (D-Hawaii), Jeff Merkley (D-Ore.), Mike Rounds (R-S.D.) and Bob Corker (R-Tenn.) voted against the legislation.

Here is a refreshingly open headline from the Washington Post:

Congress sends massive veterans bill to Trump, opening door to more private health care

Here is a one-liner from the Metal Trades Union, in a failed attempt to halt the bill:

Congress should be investing more in the VA, not privatizing and downsizing it.

In other words, another version of Step One from the neoliberal playbook: Not sabotage, but defunding.

Here is Sanders’ reaction, in Common Dreams:

I am concerned, however, that despite some very good provisions in this bill, it continues a trend toward the slow, steady privatization of the VA. No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has. This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong. My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

Step One, defunding, again. And surprisngly good coverage, well worth a read, from Mother Jones:

Congress Is Poised to Push Veterans’ Health Care Closer to Privatization

The first strike in this war over privatization occurred in 2014, when Republicans blocked a bill introduced by Bernie Sanders that would have provided the VA with much-needed funds and expanded services to veterans. A compromise measure, the 2014 VA Choice Act, gave the VA a fraction of the funds it needed while allocating $10 billion for care in the private sector. (More than one-third of all VA-funded medical appointments last year took place in the private sector.)

The Choice Act, cast initially as a temporary measure, has been extended repeatedly. The Mission Act will make permanent its privatizing principles by allowing and even encouraging more veterans to seek care outside the VA. The Congressional Budget Office estimates that the act would result in 640,000 additional veterans seeking private care in the first few years after its passage, and that the agency’s current annual allocation of $9 billion for private care would increase substantially.

The bill is essentially a Trojan Horse, and the provisions tucked inside it will further usher in privatization without meaningfully addressing core agency challenges.

Sanders was too nice when he said “very good provisions.” He should have said “Trojan horse.” This sets up Step Two, crisis, and provides the “solution”: Step Three: Privatization.

According to a detailed analysis by the Veterans Healthcare Action Campaign, a veterans advocacy group that opposes the law, the bill imposes stringent new quality metrics that are untested and fail to consider key health outcomes such as symptom reduction. Moreover, if a VA hospital is found to be underperforming in a certain area, a huge swath of patients can be pushed into the private sector. The act loosens other restrictions that determine a veterans’ eligibility to seek care from a private doctor or hospital.

Without providing the funding to hire extra staff, the law also imposes new time-consuming bureaucratic challenges on the VA (or, potentially, a contractor), including setting up appointments with private providers, coordinating care, processing payments to private providers and making sure they provide documentation of the care delivered.

Sabotage, crisis.

The law would also require VA employees to develop and deliver training materials for the private sector.

The old “get them to train their replacements and fire them” ploy! It never gets old!

Finally, the bill would establish a nine-person commission, beginning in 2021, to assess the VA’s future infrastructure needs. The commission will make recommendations of facility closures based on utilization. The upshot is that if the push to shift veterans into private-sector care continues, the corresponding decline in utilization of VA facilities could be used to justify closing those facilities permanently—regardless of who’s providing the highest-quality care.

Step Four, profit. Let the looting begin!


It’s clear the VA is an institution to watch. Note that I’m by no means an expert on the VA — it’s seemed to work pretty well, so far, so there’s been little reason to pay attention to it, with so much else going on — and so I’d welcome reader comments from those who have availed themselves of its services, or work there.

APPENDIX I: Software

Remember when we could write software that worked? Good times:

APPENDIX II: Privatization

Here’s a nauseatingn instructive opinion piece from Anthony Tersigni, CEO of Ascension, the world’s largest Catholic health system and the largest non-profit (so-called) health system. You can read it if you don’t already have a sense of privatizer’s choice of tropes, but this caught my eye:

Ascension’s mission calls us to care for all, especially the poor and vulnerable. It’s for this reason that the VA Mission Act truly resonates with us, and we are humbled to serve this deserving population.

Well, fine, but Mattew 7:16: “Ye shall know them by their fruits. Do men gather grapes of thorns, or figs of thistles?” Some coverage on Ascension, from the St Louis Post-Dispatch, in 2014:

But under Tersigni’s leadership, Ascension has emerged in the past decade as the nation’s third-largest health care system — acquiring dozens of nonprofit hospitals and immersing itself in numerous for-profit ventures.

That dramatic growth culminates Tuesday with the grand opening in the Cayman Islands of the first phase of a $2 billion “health city” complex — a project that seems far removed from the nonprofit health system’s humble origins and its Catholic mission to serve the poor and vulnerable.

Ascension executives say they hope through this joint venture with a for-profit, India hospital chain to learn ways to reduce medical costs.

But the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities. Its health ministry [!!] has drawn criticism for risk-taking and its ties to Wall Street. And some critics have raised questions about its tax-exempt status.

By 2017, Ascension had backed out of this sketchy venture into greenfields medical tourism (and it certainly is odd, isn’t it, that the United States doesn’t have a thriving medical tourism system, and that in fact those who can flee from the United States for health care, do?) Apparently, the approach of Narayana Health’s Dr. Devi Shetty, Ascension’s partner in this venture, was to “standardize medical procedures to bring costs down.” One might wonder whether there was a reason Ascension did their experimentation offshore, and whether they plan to apply their lessons learned to veterans. Interestingly, Ascension’s Caymans project (“Health City”) is the subject of a Harvard Business School case study.

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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. Jeremy Grimm

    We have a generation of young men and women who for various reasons join our armed services and end up in a meat grinder of endless foreign wars protecting the Homeland from ‘threats’ in places far far away. These veterans were trained to kill using the latest weapons. Some of them suffer from various forms of PTSD. We live in a country that glorifies killing and open possession of deadly weapons. Many of the veterans are preferentially selected to join the U.S. police forces keeping the Homeland safe at home. Now out fearless leaders want to screw with the VA?

    It’s not quite the same but the situation made me think of this quote from the “Dark Knight”:
    “Let me get this straight, you think that your client, one of the wealthiest and most powerful men in the world, is secretly a vigilante, who spends his nights beating criminals to a pulp with his bare hands, and your plan is to blackmail this person?”

  2. Daryl

    > The report confirms and deepens findings from our March investigation, in which doctors and IT specialists expressed alarm about the software system, describing how clinicians at one of four pilot centers, Naval Station Bremerton, quit because they were terrified they might hurt or even kill patients

    It’s great that IT specialists and doctors quit because they refused to put their stamp on something like this. If only there were a union that could apply pressure to the garbage organizations that end up with these types of contracts.

  3. Doug

    It took a while to find, but it seems that EHR stands for Electronic Health Record (?)

  4. Divadab

    Ya the corporatist creed is infecting and attempting to kill everything socialist and bad because it doesn’t produce profits for the few.

    And this includes Catholic healthcare- our local monopoly was originally run by the
    Sisters of St Joseph- and they’ve just kicked the sisters out of any role in managing the hospitals. In favor of corporatist functionaries making millions.

    There is still the feel of a place motivated by something other than greed because there are still nuns here and there but the corruption has taken hold.

  5. Jeremy Grimm

    Defense of the Homeland rests upon the Army’s fully collapsible Future Combat Systems (FCS), the F-35 pacifist fighter plane, and the Navy’s floating targets. But I guess even Lean Six Sigma (LSS) black belts were unable to to re-engineer business processes throughout DOD and attain DoD’s goal of auditable financial statements by FY2017. Maybe we can recover some savings by spending billions on a new DoD electronic health record (EHR) system. [I wonder how much Cerner Corporation and friends allegedly paid (ref. Lambert’s WIKI link) the Rand Corporation for the 2005 report predicting great efficiencies from electronic health records? That must be in the running in its class for the most bang-for-the-buck.]

    Isn’t there some new version of ninga-agile programming or some systems architecture tools with best of breed automatic programming apps to help the DoD in its time of need? Are there no mythical men to work the aggressively planned mythical man-months needed to birth some working software for DoD, on-budget and ahead-of-schedule? Is DoD running out of new software paradigms, are there no new software environments and programming languages with catchy jargon? Will software program managers have to admit defeat? These are dire times.

    Maybe it is time to double-back, to do no harm, and pay billions to Cerner Corporation NOT to change the VA’s existing EHR system.

    Although I never worked with them I heard the Army’s MC4 systems circa 2014 worked well in the field and interfaced well with the VA’s existing EHR system. A lot of the casualties so far have tended to be Army. I’m not sure how well the Marine Corps systems interface. The Marine Corps and Army have been playing nice for a number of years and might share the MC4 systems or some versions of them.

  6. Synoia

    But I guess even Lean Six Sigma (LSS) black belts were unable to to re-engineer business processes throughout DOD and attain DoD’s goal of auditable financial statements by FY2017.

    No DoD accountability? = Feature.

  7. sd

    It’s fascinating that today’s cheering neoliberals can not see where the path they tread is leading. Seriously, f*cking with veterans care is just idiocy. The whole point of social safety nets is to create a stable society. But no, they’ve got to get their greed on so that the nation can march straight into the jaws of a bloody revolution under a military coup.

    1. Norb

      This is social and moral blindness.

      A bloody revolution in the service of the masses is inevitable. It is that or maybe a quiet revolution can proceed where people who reject the current system can begin creating parallel structures that will be resilient enough to survive the inevitable crash of the existing system.

      Either way, I think the violent opposition and peaceful creative solutions are two sides of the same coin. Maybe our smart Neoliberal rulers know this and preempted the movement by creating the Terrorist threat. It short circuits coordination of like minded people using different means to achieve their goals.

      It undermines any true account of history and perpetuates the ruling elite.

  8. Synoia

    You can count of the Americans do the right thing – after trying everything else.

  9. Tomonthebeach

    Public Law 110-181 (FY2008) – that is 10 years ago if you do the arithmetic – MANDATED an interoperable EHR for DOD and VA. Eventually they found a guy who had the savvy to create the system, Roger Baker, but Shinseki did not like the price tag and sent Baker packing only to see the replacement fail. It is unclear how many DOD and VA separate and joint contracts have been let and then scrapped since 2008, but I have read estimates run into the billions of dollars. 10 years folks, billions of tax dollars, and there still is no EHR system that allows both VA and DOD to access it.

    The problem, as I see it, is capricious and incompetent political-appointee leadership, and lack of accountability at the top for what should be by now a high-profile scandal where it not overshadowed by porn stars and corrupt agency heads. Lambert might be on to something. This latest neolib tactic may be a double-fronted attack that privatizes just enough health services to force privatizing the EHR system (after another failure, say at the 12-year point), and then the HMOs can move in more easily.

    Why is privatizing bad (except for the setback to neolibs)? Because battle-damaged warriors have unique needs, and VA has assembled expert knowledge and skills to address them which simply put is in short supply in the private sector – especially rural hospitals where these privatization bills are focused. On the plus side, VA will help keep Podunk General from closing next year.
    More corporate welfare at the expense of vets.

  10. VietnamVet

    I am still here. VA provides free medical care except for $8 per prescription copayment. I use it for primary care, urology and allergy shots. For my eyes, I go to private doctors. I will avoid elective surgery there after ending up in intensive care for three days which was one step away from hell. All in all, the VA is not great but a lot better than nothing at all. Simply put, the VA Mission Act is a way for financiers and the connected to tap into a steady stream of taxpayer money. The system will take the money and not provide any better or more comprehensive health care. The impact on the little people is of no concern. As shown by the disappearance of rural hospitals and the decreasing American life expectancy.

    This is no different than fighting forever wars. WP published today “Could the U.S. fight dual wars in North Korea and Iran? After diplomacy breaks down, questions loom” without mentioning that there will be no war unless the USA starts one or indicating that the wars will kill millions and the casualties will overwhelm national health systems; let alone, the VA with the surviving soldiers and sailors.

    1. Jen

      Questions loom, but oddly, or not, the only choices appear to be between either/or, and both/and. None of the above, anyone?

      I was talking with a veteran (didn’t ask which conflict, though he seemed on the young side for vietnam) in the waiting room of an animal hospital up in Burlington. He’d lived in Oregon for a while and said you sometimes got lost in the system. He could not say enough good things about the VA in White River Junction, VT. I have a couple of friends who are physicians there, and it’s obvious whenever you talk to them about there work, how much the love their patients.

    2. tegnost

      “Simply put, the VA Mission Act is a way for financiers and the connected to tap into a steady stream of taxpayer money.”

      our entire system in one sentence..

  11. Chauncey Gardiner

    Particularly appreciated Lambert’s insightful summary of the stages in their modus operandi that has been applied across so many government agencies and institutions, and to all levels of federal, state and local government from public education and sales and “leases” of our publicly owned lands and resources to public surveillance to health care to privately owned military service contractors to “privatization” of the VA, as described here and to list but a few. It has become almost impossible to keep up with all their rackets.

    1st Stage: Defund and/or sabotage the existing government services.

    2nd Stage: Claim there is a crisis in government providing the services. (“Never waste a good crisis.”)

    3rd Stage: Call for discontinuance or transfer of the services to privately owned entities, whether taxable or large tax exempt corporations.

    4th Stage: Complete the transfer and commence Looting. (With the “profits” flowing into the coffers of the privately owned entities for the benefit of the wealthiest individuals in our society.)

    The scheme also presents hidden impediments to the possibility of future reversion back to public provision of services or future initiatives to provide public services that cut out the privately owned profiteers. All is designed to enrich the few at great cost to the many.

    1. pretzelattack

      yes, that is a very helpful summary. and the democrats complicit in every stage in most of these scams (i assume there are some republican grifts they may have resisted because they didn’t have part of the action, or because there was a struggle between some specific donors, but i don’t have any immediate examples)>

  12. Edward E

    Still haven’t given my dad his aid and attendance approval. If there’s an award for stalling and making stuff up…

  13. RJ McElroy, MD

    Thank you Lambert for the update on the VA with the Cerner Corporation EHR contract and the VA Mission Act. It has been obvious for over a decade Congress deliberately underfunded the VA and failed to provide the support necessary to deal with the problems veterans of our most recent wars and non-wars have experienced. Even though time from injury in Vietnam to medical facility was relatively short, it has been further improved in the era of Afghanistan and Iraq. More have survived more complicated injuries requiring more complicated rehabilitation and long term followup that is not in the usual realm of treatment of a civilian doctor or facility.

    The MHS Genesis system report above indicates veterans will once again be put in “harms way” only in a hospital rather than a battlefield while soaking the taxpayer.
    Most of my clinical training in medicine including as a medical student, intern, resident and fellowship at the West 10th Street VA in Indianapolis and it was among the best available in the 1960’s and early 1970’s. The medical staff was outstanding and the standard of care was high. Throughout the country some of the very best in medical education occurred in university associated VA hospitals. Private practice does not provide the same quality of medical education. Privatization of the VA threatens the quality of medical education as well as the care of veterans.

    1. cnchal

      >. . . Privatization of the VA threatens the quality of medical education as well as the care of veterans. . .

      So what. The intelligent people in charge of complexity could not care less. Here is what it’s about.

      $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ for those at the top of the heap.

  14. The Rev Kev

    What really gripes me is how these neoliberals are so in-your-face about their schemes. Anybody remember the sale of the UK’s 500 year-old Royal Mail? How a deliberate low price was put on the price of it for privatization because the financial institutions that priced it were also the ones that brought it on the cheap, thus ripping off the British of over a billion pounds? The fix was in as they knew that they would never be brought to account.
    And this is what the Veterans Administration will be facing. How many of the V.A.’s facilities occupy prime real estate as an example. What is the real value of their many buildings. How can all the service it gives be monetized? Oh, and the Royal Mail I used as an example? How are they doing? Here is how-

    1. JBird

      There are plenty of people that want all the land that all those USPS office sites are on. Over two centuries of infrastructure and land to sell off.

    2. Lambert Strether Post author

      > How many of the V.A.’s facilities occupy prime real estate as an example. What is the real value of their many buildings.

      Ask DiFi’s husband, the guy selling off Post Offices. I’m sure he knows.

  15. Eustache De Saint Pierre

    Slightly off topic, but in the light of the celebrations in Ireland at the moment due to finally allowing women to have more control of their bodies, which Neoliberal Varadkar is milking for all it’s worth. I wonder how long it will be before abortions become for the many unaffordable .

    I do not know the details of how the Irish received the service by crossing the Irish Sea to avail of the NHS, but if the privatisation process continues on both sides, then perhaps at least for those at the bottom, the good news will prove to have been only symbolic & leave them in a worse state than they were actually already in.

    1. PlutoniumKun

      I seriously doubt there will be many abortions performed in Ireland, except for medical reasons. The religious groups (not just catholic) have always had a very strong grip of the ‘voluntary’ hospital sector and will not be willing to set up ‘on demand’ services and will struggle to find obstetricians and nurses willing to do it. Maybe some private hospitals will do it discreetly (as they always have done) for a stiff fee. Public hospitals I think will see it as a headache and will only set up clinics if there is strong government pressure, which I think is unlikely. Almost certainly, the majority of women who want one with no immediate medical requirement will find it much cheaper and simpler to go to Britain or eastern Europe.

      1. makedoanmend

        Was speaking with a very liberal yesterday who had flown home to vote for repeal of the eighth. According to this person, the groups who supported repeal now have 2 goals: get an amendment for Universal Health Care in Ireland enacted and make abortion legal in the North. Can’t decide, myself, which one is more far fetched.

      2. Eustache De Saint Pierre

        PK – so basically business as usual ?

        Make……There does appear to be much in the way of pie in the sky out there.

        1. Eustache De Saint Pierre

          I have a memory sparked by all of this of visiting my Mother who had undergone a hysterectomy. This would be around forty years ago & was followed by her convalescence in a large ward that once formed part of the old workhouse.

          I was surprised to see that most of the around a hundred occupants were young women, some that could be described as girls. I was confused by this & sought an explanation from Mum as I was aware that hysterectomy’s were usually for older women. Her only answer was words to the effect of ” Poor girls & a good few of them are Irish ” – later my Dad put me straight on the why of the terrible atmosphere in that place.

          1. JBird

            There were reasons why often pro-life, and/or conservative American doctors and nurses before Roe v. Wade were still pro-choice; they had to treat the often fatal consequences of desperate people in a far more socially conservative time.

            It’s just great that some of the same conditions are back in parts of the United States. (Yes, it’s sarcasm)

  16. Otis B Driftwood

    Not sure if this was called out specifically, but Ascension also uses Cerner’s EHR. Part of the work I have done, in fact, was to provide an interoperability solution for Ascension as they have acquired other hospitals and clinics with different IT systems. It essence, an application that would allow a doctor using Cerner’s PowerChart (that’s the name of their EHR, btw) to see a patient’s clinical data coming from an Athena or Meditech EHR in one of those acquired hospitals. This is transitional as all those systems will be converted to Cerner eventually. I’m proud of that work.

    Also, that big VA contract came down to Cerner versus Epic, which are no. 2 and 1 in the EHR market, respectively. Believe it or not, Cerner was the better choice. Also, I know from experience that working with the VA and DoD is a nightmare – first and foremost, meeting their stringent security requirements.

    But yeah, the VA system was always regarded as one of the best and I don’t know why it had to be updated. Just like the Mayo Clinic had a state-of-the-art homegrown EHR that was replaced by Epic, a great private system was tossed out in favor of a commercial EHR.

    1. Lambert Strether Post author

      > Not sure if this was called out specifically, but Ascension also uses Cerner’s EHR.

      That’s a great piece of information! And if Cerner aren’t the usual collection of crooks, all the better. I still think success is a coin-flip, though. And while I notionally support interoperability, I’m not sure how replacing a top-ranking, working system to achieve it nets out.

      1. Otis B Driftwood

        Hey Lambert – the good case for interoperability is to have a system whereby people can visit healthcare providers anywhere in the world and have their medical history readily available to caregivers. The classic example is the snowbird who has a primary care physician in New England, but will have occasion to see a physician while they are wintering in Florida. Great if that Florida doctor can electronically access the records from the PCP’s system in Boston.

        The not-so-great case is supporting consolidation of healthcare providers in a given region. That’s what Ascension and other big health systems have been up to in recent years. Will this result in efficiencies or a lack of choice or access for patients? That’s what bothers me. And while helping make sure that patient data is accurately shared between those consolidating systems is a good thing as far as it goes, they could just as easily share their data as separate, independently operated organizations.

  17. Alex Cox

    It would be nice to heap all the blame for the ongoing privatization of the NHS on the Tories. But it was first and foremost a project of “New” Labour, courtesy of Tony Blair – who promised British patients a “choice” of doctors under a privatized regime – and Gordon Brown, the disastrous chancellor who saddled the NHS with billions of pounds worth of debt for “public-private” hospital building.

    The Tories, the LibDems and Labour (absent a few principled MPs such as Corbyn and Abbott) are essentially the same party: neocons abroad, neoliberals at home.

    1. Eustache De Saint Pierre

      Yes you are correct & it was a betrayal – they turned out to be as awful as that pop song that rang out on that long ago day, when there was the appearance of a brief glimpse of hope.

      Much the same with Obama, although it was Clinton who really opened the financial Pandora’s box.

      Turncoats & traitors all, but at least we know what is on offer with the Right.

  18. Disturbed Voter

    The problem with the present VA or former Mayo Clinic computer systems are, they were not designed to be developed and maintained professionally. They were initially developed and maintained by clinicians. It is spaghetti code. Unfortunately doctors know the most about medicine, but the average computer jock doesn’t know a clavicle from a aorta. Finding doctors who can also program professionally, is impossible.

    Historically, the old DoD system (CHCS) was an implementation of the predecessor of Vista (the present VA program). But no effort was made by either department to further resolve differences or maintain compatibility. Bureaucratic inertia and career agendas rule. The mission of the two will always be different, however they are related. That is why they are separate departments in the first place.

    The best inside story of the VA system is …

    1. pretzelattack

      seemed to work pretty well, though, going by reports of the doctors/users. certainly better than this f-35 of a replacement system–well, except for extracting money from the taxpayers, the new system looks like it will do that.

  19. Lambert Strether Post author

    Here’s a quote on the MUMPS language in which VISTA is written:

    MUMPS was born in 1966 to solve the problem of massive data flowing into multi-user systems in the healthcare industry.

    It predates RDBMS but has all the features of NoSQL including (in its modern form) massive parallel processing, horizontal scaling, and runs on commodity hardware.

    It easily models all four types of NoSQL DBs (key-value, column, document, graph). In the 70s and 80s it was modified to model RDBMS and handle SQL queries.

    It shares features with NewSQL in that it is fully ACID compliant.

    It’s alive and well today used in a wide variety of healthcare patient information systems, banking, the European Stock Exchange, and the travel industry among others.

    Astonishing stuff. Astonishing. I really don’t think “spaghetti code” is fair.

    And from the Politico article, which is a must-read:

    You’d have to be a very brave VA administrator, and perhaps a foolhardy one, to keep VistA in 2017: The system’s homegrown structure* creates security and maintenance challenges; a huge amount of talent has fled the agency, and many Congress members are leery of it. Because it serves nearly 9 million veterans at 167 hospitals and 1,700 sites of care, however, the wrangling over VistA concerns much more than just another computer software system. The men and women who created and shaped VistA over the decades were pathfinders in efforts to use data to reshape the multi-trillion-dollar U.S. health care system. Much of what they’ve done continues to serve veterans well; it’s an open question whether the Beltway solution to replacing VistA, and the billions that will be spent pursuing it, will result in a system that serves the VA—and the nation—as well in the long run.

    Talent “fleeting” looks a lot like sabotage, to me (and the Politico article supplies many vivid examples of same).

    * The architecture is not homegrown at all!

    NOTE Downloadable version of ANSI Standard MUMPS. Only four months old, too, so the language is very much alive. I wonder what effect a distributed system of MUMPS databases managing content or messaging would have on the discourse. Beneficial, I would think. Plus, there’s be plenty of angry greybeards ready to translate the Great Runes.

    1. Otis B Driftwood

      MUMPS is the database used by Epic, the leading commercial EHR in the country. FWIW.

    2. Disturbed Voter

      Why Mumps? Two reasons, it is what the lab instruments talk in. Hence Cerner etc (they do lab instruments). Spaghetti code is how you code in it, not the language syntax. The architecture is advanced for its time but obtuse, because it has a built-in data store (but not SQL standard). The actual syntax is hard to read, because it is meant to talk to instruments … like printer-code is obtuse.

      From Wiki: MUMPS (Massachusetts General Hospital Utility Multi-Programming System), or M, is a general-purpose computer programming language that provides ACID (Atomic, Consistent, Isolated, and Durable) transaction processing.

      Both old systems, current systems, and Cerner, all use MUMPS. It isn’t the issue at all.

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