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

    April 15, 2018 // 28 Comments »

    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citing a “corrosive culture that has led to poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors, nurses and physical space to treat its patients”), is a system morphing toward “Medicare for veterans” the answer?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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    Moving Forward to 2018? The Danger of Undead Hillary

    May 10, 2017 // 23 Comments »




    I’m wondering how successful the Democratic meme of “Trump voters, now you’ll get what you deserve” will be.

    Media regularly now run stories “telling” Trump voters how bad their decision was. Many outlets unlikely to be read by Trump voters produce elaborate charts and expert commentary about how whatever Trump is doing with taxes or the economy will negatively affect voters in Red states the most. The implication is hah, hah, suckers, you voted for more jobs and you’ll get nothing! Tag-on articles also include dubious surveys showing vast numbers of Trump voters agree with statements like “Even though Trump policies will definitely kill my mother in front of my eyes, I’d still vote for him.” That’s a two-fer: you were dumb to vote for him once, Cletus, and you still won’t admit how freaking dumb you are.

    The highbrow version of those nasty little stories is the literal glee of too many progressives over how poorly Republican health care plans will work out. Following their defeat in the House over so-called “Trumpcare,” Democrats as one pivoted to saying their loss was their gain, as Americans will suffer and maybe even die as a result of the new rules, and finally realize how wrong they were to vote Republican.

    So a serious question: do party leaders really think this will translate into votes for Democratic candidates in a few years? That badgering people to admit they were wrong is a good tactic (we all know how much anyone likes to admit they were wrong)? That mocking voters for their 2016 choice will bring them to your side in 2018? That hoping enough suffer under even worse health care policy to vote for the party that stood by chortling and watched it happen?


    Alongside this very odd strategy of gain through others’ pain is the issue of Undead Hillary. The two are connected.

    The standard for a losing candidate is to quietly go away. Mike Dukakis (Remember him? No? That’s my point) is the perfect example. For those losers who don’t want to simply write a memoir and fade away playing golf, they can also respectfully reemerge after some time has passed as an elder statesman (Walter Mondale) or as a specific issue spokesperson quietly tolerated at the sidelines of the moving-on-now party (Al Gore and climate change.)

    The problem for Democrats is that Hillary Clinton is not yet convinced, nor are many of her supporters, that she really lost the election. They act in some ways as if the campaign is still ongoing.

    By basically continuing to run a version of the same full-on negative strategy they did in 2016 (Trump is dangerous, evil, stupid, a threat, Putin c*ck holster), there seems to be this poorly-formed notion that somehow Trump will disappear (Emoluments Clause, impeachment for something, whatever) and that it will then be Clinton, not Pence, waking up the next morning in the White House.



    In other words, until the Democrats can stand up as a party and say “We lost. There were a variety of factors but at least some sizable part of the electorate wanted what Trump offered and did not want what we offered” they will continue to push Undead Hillary forward as if she and her negative campaign still represent a hope back into power.

    Until then, no alternatives. No new ideas. No positivity. Indeed, a near-ghoulish sense of “Well, America, you didn’t chose our Clinton so enjoy life in hell as a penalty” pervades. It seems a very unconvincing way forward for a party that currently controls no part of government.




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    Won’t Paying for Bernie’s Healthcare Make Us Pay Higher Taxes Like in Europe?

    April 22, 2016 // 8 Comments »



    Won’t paying for Bernie’s healthcare make us pay higher taxes like in Europe?

    Not likely. Here’s what Hillary doesn’t want to tell you.


    Free or very low-cost universal health care is available to citizens of all the countries marked in green, below, as well as China, North Korea, Thailand and Vietnam, left off for some reason:


    You’ll see the U.S. stands alone. Somehow our nation, alone among industrialized nations and some not so industrialized, has yet to figure out how to find a why to provide affordable healthcare for all of its citizens.

    One of the arguments posited is that the U.S. is too big for some poncy European system to work, but of course China and Russia are bigger. Another is that quality of care suffers, but people in Japan have some of the longest life spans in the world, and things are pretty good across Europe.

    But the argument that seems to stick best in America is that such “utopian” healthcare schemes are simply too expensive, that taxes over there are so much higher than in America.

    So keeping in mind that most of the places that offer free or very low-cost universal health care also offer free or very low-cost college (how’s it feel that a degree at Podunk State U costs more than Oxford University — about $12,000 a year for UK and EU students?),

    And, most of those other countries have dollar-adjusted higher minimum wages. And they save extraordinary amounts of money that in the U.S. end up being spent on social welfare and public health for people who are unhealthy because they can’t afford to see a doctor.



    But let’s look at some tax figures:

    Oops. The average U.S. income tax rate is actually higher than some of those places.


    And of course in the U.S., in addition to federal income tax, we also pay state and sometimes city tax. And Social Security/Medicare tax of 7.65% And property tax, sales tax and taxes/surcharges on cell phones, airports, hotels, restaurant meals and on and on. And of course other countries also have other taxes; the point is Americans are already paying a lot of taxes and getting damn little in return.

    And on top of that, we also pay (those who can afford it…) for health insurance. For 2012, the annual premiums for employer-sponsored family health coverage averaged $15,745, up 4% from 2010, with workers on average paying $4,316 toward the cost of their coverage. And of course those premiums paid do not include deductibles and co-pays.

    And prescription medicine costs. Americans pay more for drugs than anyone in the world. Drug prices in the United States are often up to 10 times more expensive than in almost all other developed countries.


    And that is how Bernie Sanders comes to the conclusion that even if taxes rise, the single-payer health care system he proposes would save an average American family of four almost $6,000 per year.

    Think about it. Doctor’s orders!




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