• Trump, Privatization, and the Passion of Veterans Affairs Secretary David Shulkin

    April 15, 2018

    Tags: , , ,
    Posted in: Other Ideas, Trump

    As some seek to further privatize veterans health care, with hundreds of billions of dollars at stake, sacrifices will have to be made. Let’s hope few fall on the veterans themselves.


    Former Veterans Affairs Secretary Dr. David Shulkin once held the title of least controversial Cabinet secretary in the Trump Administration. He was confirmed in the Senate by a vote of 100-0, and for most of his time in office enjoyed broad bipartisan support as he sought to reform veterans’ health care.

    That all changed for the lone Obama Cabinet holdover when Donald Trump sacrificed Shulkin on March 28 in favor of White House physician Rear Admiral Dr. Ronny Jackson. Though pushed out ostensibly over a damning ethics report, Shulkin’s story is really one of whether or not further privatizing health care for veterans is the right way to fix a damaged institution. Shulkin being pushed out is a big story that has been both understated and oversimplified in the press as mostly just another episode of the Trump chaos soap opera.

    Shulkin himself pulls no punches. “I believe differences in philosophy deserve robust debate, and solutions should be determined based on the merits of the arguments. The advocates within the administration for privatizing VA health services, however, reject this approach,” wrote Shulkin after his dismissal. “They saw me as an obstacle to privatization who had to be removed. That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”

    Despite the quick-fix appeal of privatization in the face of a VA clearly not meeting fully the needs of its population (Shulkin took over the VA in the wake of a report citing a “corrosive culture that has led to poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors, nurses and physical space to treat its patients”), is a system morphing toward “Medicare for veterans” the answer?

    In its simplest form, privatization means that instead of seeking care at a VA facility at little-to-no charge, veterans would be free to visit any health care provider in the private sector, with Uncle Sam picking up most of the tab. The VA would shift from directly providing care in its own facilities to become the insurance company of dreams. In many cases long waits to access a VA facility would diminish, veterans in rural areas would most likely have less of a travel burden, and patients could better match their needs to a provider. The latter could be especially important to LGBTQ veterans. It’s hard to argue against choice.


    The issue is money. According to one report, moving vets to private providers would double spending in the immediate term. By 2034, the cost of VA health care could be as high as $450 billion, compared to a baseline of less than $100 billion. And even those numbers may be too low; as Vietnam-era vets require more expensive end-of-life care, and as waves of veterans from the past 17 years of the War on Terror enter the system, costs will rise. The challenge is clear; between 2002 and 2013, the number of annual VA outpatient visits nearly doubled to 86.4 million. Hospital admissions — the biggest driver of costs — rose 23%.

    Under any calculus veterans health care is big money and proponents of privatization want to pull as much of it as possible into the commercial sector. But where would the money come from? Major veterans’ organizations opposing additional privatization worry disability benefits and other core VA programs such as education would be cut back. Others speculate a privatized VA system would quickly go the way of civilian insurance, with limited networks, increased co-pays, and complex referral systems, all as a way of passing increasing costs on to the patient. As for many under Obamacare, vets would be caught in the gap between being able to have insurance, and being able to afford health care. Choice can come at a price.


    The specialized needs of many veterans are part of the reason for the specialized veterans’ health care system. Despite much justified criticism, the VA serves the needs of many of its patients well. In the critical area of psychology, VA performance was rated superior to the private sector by more than 30%. Compared with individuals in private plans, veterans with schizophrenia or major depression were more than twice as likely to receive appropriate initial medication treatment. RAND concluded separately “the quality of care provided by the VA health system generally was as good as or better than other health systems on most quality measures.”

    The VA also has expertise in prosthetics, burns, polytrauma, and spinal injuries rare in civilian life. The VA has a lifetime relationship with its patients, leading to broader implementation of preventive care and better integration of records. These advantages could be lost as more choice under a largely privatized system could result in significantly less choice at the VA in areas where it matters most.

    The risk is throwing out the baby with the bathwater, as increased privatization will inevitably mean shuttering some VA facilities. The solution lies in a system which pairs the best of privatization with a reformed government-run veterans health care system. Paring off some services into the private sector while retaining those unique to the VA, all to the satisfaction of Congress, demands an administrator with extraordinary bureaucratic skills. The Trump administration was very likely wrong when it decided Shulkin was not that man.

    Though painted as a solid opponent of privatization, as he was fired Shulkin was already pushing the VA to further privatize its audiology and optometry programs. He oversaw change that led to 36% of VA medical appointments being made in the private sector. Shulkin’s Veterans Choice Program (VCP) allowed access to private doctors where the VA couldn’t provide specialized care, when wait times exceeded standards, or when travel to a VA facility represented a hardship. Shulkin was advocating for the program’s expansion when both his funding and his tenure ran out.

    The VCP program was consistently underfunded, in part due to the unpredictability of month-to-month expenses that will plague any privatized system. However, some of the underfunding was political; one holdout was Senator Jerry Moran. Moran wanted the program tapered off in lieu of his own bill calling for the greater leaps into privatization Shulkin remained skeptical of.

    As Department of Veterans Affairs Secretary, Dr. David Shulkin was an experienced medical administrator who had specialized in health care management at some of the nation’s largest hospitals. The new secretary nominee, Dr. Ronny Jackson, is a fine Navy doctor who has served two presidents, but comes to the job with no experience with an organization the size and complexity of the VA, already the government’s second-largest agency.


    Questions will be asked at what will no doubt be contentious confirmation hearings about whether Jackson can rise to the challenge, or if privatization advocates will take advantage of him to rush ahead with their own preferred changes, to their own financial gain.

    Hanging in the balance? Nine million veterans who rely on the VA for life-sustaining care in return for the sacrifices they have made.




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    Copyright © 2018. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity. Follow me on Twitter!

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  • Recent Comments

    • John Poole said...

      1

      Trump’s agenda makes perfect sense. We’ve privatized war making so why not privatize the aftereffects? Shulkin just didn’t get that. His heart was in the wrong place for the heartless. As a taxpayer I’m going to be stuck with the bill regardless.

      04/15/18 9:55 AM | Comment Link

    • Rich Bauer said...

      2

      So the Repugnicans are so concerned about out of control rising medical costs in Medicaid and Medicare, and yet they see no problem with doubling the cost of Vet care by pharmaing it out to private providers. If the Repugnicans seriously were concerned with controlling costs to the taxpayer, which they aren’t, they would make it their agenda in the Dem controlled House is to go single payer for all medical care.

      04/15/18 11:46 AM | Comment Link

    • Rich Bauer said...

      3

      Time for a change

      The biggest problems are the longest waits associated with the time it takes to determine if veterans are eligible to receive care at the VA, and at what level. This determination is done precisely because the VA is not a single-payer system. It doesn’t cover everyone; it’s not accessible to every veteran; it is just one payer among many in our fragmented system. Currently about 2.3 million veterans and their family members are completely uninsured.

      In contrast, a single-payer national health program would cover everyone and allow them to choose any provider and source of care in the U.S.

      The VA has pioneered quality initiatives, delivery system changes and an electronic medical record that is far ahead of the private sector. Veterans’ service organizations praise the VA, even as they complain about waits, precisely because of its high quality.

      But any health care program that benefits low-income individuals and families (including the VA, because today the poor are more likely to join the military) is politically vulnerable to budget cuts or calls for privatization, and is likely to suffer from more problems than a health system that benefits everyone — rich and poor, young and old, soldiers and civilians, i.e. the entire population. Otherwise there will be pressure to underfund it.

      Single-payer national health insurance, an improved Medicare for All, will offer a single tier of high-quality care to everyone. It would address wait times in an organized way, be transparent and accountable, and allocate medical resources based on need, not ability to pay.

      04/15/18 11:52 AM | Comment Link

    • jim hruska said...

      4

      PVB,
      Medicare is a no go. most doctors will not accept such insured as patients.
      Why not put the DVA system under the cadillac health care enjoyed by our national leadership?
      why does the congress, senate,and potus get special treatment?
      the choice program has been a great disservice to me. my complaints are never addressed.
      pls remember that i am a PH recipient, 100% service connected and in pain every day of my life.
      as for j poole , you may get stuck with paying for the care, but isn’t that the price of citizenship?
      i surely paid the price in suffering.
      jim hruska

      04/15/18 1:25 PM | Comment Link

    • Rich Bauer said...

      5

      Where is the evidence to document your claim that the MAJORITY will not accept Medicare? Most reports I found indicated less than 20 percent would refuse Medicare patients. Specialists like dermatologists – not real doctors- refuse higher percent. So go fuck them.

      04/15/18 1:37 PM | Comment Link

    • John Poole said...

      6

      Jim: Our leaders are plutocrats and they deserve the best medical care that taxpayers can deliver! Now on to a subject you will find offensive. Trump’s latest salvo is the message of resolve and valor that America sends to its purported adversaries. We will hide safely in the dark hundreds of miles away and launch “fire and fury” into your camp. No more scaling the castle walls hoping a vat of oil isn’t directly above one’s head. The cowardice of the American fighting man and woman today is astounding. “Technology please spare me any harm or injury!”

      04/15/18 5:42 PM | Comment Link

    • John Poole said...

      7

      Jim- do they even teach hand to hand combat in basic anymore? I doubt it. Any guy or gal who is desperate for money and signs on to the American global hegemony platform of the military is hoping to be assured it won’t cost him or her their life. Lots of vets with catastrophic injuries may want to be there at recruiting centers. NO ONE wants to discuss the crucible of faux manhood for my age group of draftees during the Vietnam War.

      04/15/18 5:58 PM | Comment Link

    • Karl Kolchak said...

      8

      Funny how there is never any problem with coming up with the funding for the wars that makes veterans’ health care an issue in the first place. If America can afford 900 overseas military bases and hundreds of high tech warships and submarines in the oceans, it can afford health care for everybody, not just veterans.

      04/15/18 6:52 PM | Comment Link

    • Rich Bauer said...

      9

      KK,

      The reason is obvious: no one in Congress represents US, the taxpayers.

      04/17/18 12:12 PM | Comment Link

    • Rich Bauer said...

      10

      Grumpy Trumpie is feeling sick:

      As PA goes…The most recent Franklin & Marshal College Poll’s “generic ballot” reports that 53 percent of Pennsylvania voters “very interested” in the election plan to vote for a Democrat while only 30 percent of those “very interested” in the election will vote Republican — a yawning gap of 23 points favoring Democrats. At the same time, Trump’s approval rating is only 30 percent. suggesting that he may be dragging down the ticket.

      04/17/18 5:57 PM | Comment Link

    • Rich Bauer said...

      11

      Trumpie is a Veteran of Foreign Affairs

      While Trumpie paid his sex playmates to keep quiet, lest his evilgelicals feigned outrage about his adulterous behavior, in the end it is Putin Trumpie really wants to get in bed with, and expects to be paid well for his prostitution.

      04/18/18 11:01 AM | Comment Link

    • John Poole said...

      12

      Bauer: we have strayed way too far from PVB’s main point. In the meantime I found the MSM to be very biased. They always point out that Trump was married at the time of his tryst with Stormy making him a sleazy adulterer. Stormy-portrayed as sort of victi- was also married at the time and said she did not report the incident of being threatened in the parking lot to the police because she was embarrassed that her then husband would find out what she had been doing. Both were adulterers! Meant for each other! It is a perfect world.

      04/18/18 1:08 PM | Comment Link

    • Rich Bauer said...

      13

      The point about ALL of this is someone is always screwing US.

      there will always be some private concern that wants to feed at the taxpayer expense, and the pigs in Congress are at the head of the line.

      04/18/18 2:30 PM | Comment Link

    • Rich Bauer said...

      14

      Foreign Affairs can be fatal

      Trumpie’s fixer may need some medical attention IF he has info implicating Putin in the Big Fix. Stay away from balconies and wear gloves.

      04/19/18 10:35 AM | Comment Link

    • John Poole said...

      15

      Bauer: Comey was not going to indict Hillary because he felt she was destined by fate to become the first female POTUS. He wasn’t going to mess with fate! Mueller may be just as reluctant to bring charges against Trump perhaps believing an impeachment crisis would bring more harm than good to the country.

      04/19/18 5:47 PM | Comment Link

    • Rich Bauer said...

      16

      The Repugnicans want Trumpie gone before he destroys them.

      04/19/18 7:23 PM | Comment Link

    • John Poole said...

      17

      Bauer- Trump may not need the Republicans if they continue their disloyalty to the party. A sitting POTUS has a lot of power to make himself look heroic and “leaderly”. An ineffectual Obama sat in the Oval office for EIGHT!!!!! years and then kicked the North Korean can of worms over to his successor. Trump may not be so inclined.

      04/20/18 8:53 AM | Comment Link

    • Rich Bauer said...

      18

      JP,

      There is only one party: the Wall Street War Party.

      The troops will stay in Korea, We will continue the Syrian Quagmire. Bolton wants to bomb Iran.

      So how is Trumpie any different?

      04/20/18 10:11 AM | Comment Link

    • Rich Bauer said...

      19

      Bring all the troops home if he wants to look heroic.

      Afghanistan, Yemen, Iraq….

      04/20/18 10:15 AM | Comment Link

    • John Poole said...

      20

      Bauer- And hundreds of thousands sitting around doing nothing in 800 bases around the world sucking on our tax tit. Where are all those “warriors” going to be redeployed in the Homeland? Alaskan and Texas border?

      04/20/18 11:11 AM | Comment Link

    • Rich Bauer said...

      21

      Trumpie is a veteran of foreign and domestic affairs

      While the sex molestation Trumpie admitted on tape didn’t get into the voters mind in 2016, bragging to Bush he grabbed them by the genitals, women in 2020 will have him by the balls. The pervert is losing the women vote by 50 percent.

      Hell hath no fury like a woman scorned.

      04/20/18 11:21 AM | Comment Link

    • Rich Bauer said...

      22

      Among women 50 years old and younger, Sanders leads Trump by 49 points.

      04/20/18 11:24 AM | Comment Link

    • John Poole said...

      23

      Breaking news: The Democrats are suing Trump, Russia and Wikileaks for their loss. They of course left out the real culprit- a despicable horrid female shaped object named Hillary.

      04/20/18 1:55 PM | Comment Link

    • Rich Bauer said...

      24

      One more time, there is only one party – the Wall Street War Party.

      Hillary and Trumpie serve the same master.

      04/20/18 3:09 PM | Comment Link

    • Rich Bauer said...

      25

      Now if Peter would run…

      04/20/18 3:09 PM | Comment Link

    • Rich Bauer said...

      26

      Peter’s People’s Platform:

      Bring home all troops

      Cut military budget to the combined Russian and Chinese budget

      Single payer health care for all

      Free community college

      15.00 minimum wage

      50 percent fed tax rate on income over $1 million

      04/20/18 3:16 PM | Comment Link

    • Rich Bauer said...

      27

      Trump says Cohen won’t flip.

      Nixon said he wasn’t a crook.

      There is another cancer in the White House.

      04/21/18 10:05 AM | Comment Link

    • Rich Bauer said...

      28

      Man, this be one stupid country

      Travis Reinking, a 29-year-old who police have named as the suspect, was arrested by Secret Service officers on July 7, 2017, when he refused to leave the White House grounds. As of Sunday afternoon, he remained at large.

      Todd Hudson, Special Agent in Charge, U.S. Secret Service, told reporters Sunday that to his knowledge Reinking was not armed at the time of the White House incident, but was arrested after he refused to leave the area near some bike racks. Hudson stressed that Reinking was only in the White House complex area and did not make it farther into the grounds.

      Hudson added that Reinking wanted a meeting with President Donald Trump.

      Tennessee and federal authorities said that the episode caused the FBI to ask for Illinois authorities in Tazewell County to revoke Reinking’s firearm license and to seize his four guns. Among the guns seized at the time, authorities said, was the AR-15 rifle used during Sunday’s shooting. According to Metro Nashville Police Department spokesman Don Aaron, Tazewell County authorities told Tennessee officers that the AR-15 was released to Reinking’s father, who has since told police that he returned the guns to his son. Aaron said two of the guns remained unaccounted for.

      04/22/18 5:35 PM | Comment Link

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