• 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citing a “corrosive culture that has led to poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors, nurses and physical space to treat its patients”), is a system morphing toward “Medicare for veterans” the answer?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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    Posted in Other Ideas, Trump

    Veterans’ Administration Secretary Straight-Up Lies

    February 25, 2015 // 3 Comments »

    va


    Veterans Affairs (VA) Secretary Robert McDonald apologized Monday for “misstating” that he served in the military’s special forces. McDonald made the “erroneous” claim while speaking to a homeless veteran during a segment that aired last month on the CBS Evening News.


    In a statement released Monday by the VA, McDonald said: “While I was in Los Angeles, engaging a homeless individual to determine his veteran status, I asked the man where he had served in the military. He responded that he had served in special forces. I ‘incorrectly stated’ that I had been in special forces. That was inaccurate and I apologize to anyone that was offended by my misstatement.”

    Stolen Valor

    Lying or exaggerating military service is known as “stolen valor.” There are entire organizations devoted to calling out fake claims to special forces service. In the specops community, this is a big deal.

    The VA website says McDonald is an Army veteran who served with the 82nd Airborne Division. Anyone who has been in the Army knows the 82nd is not a special forces unit. That term is reserved primarily in the Army world for Green Berets. You cannot be mistaken about whether or not you have undergone special forces training and deployment.

    The White House issued a statement saying, “We take him at his word and expect that this will not impact the important work he’s doing to promote the health and well-being of our nation’s veterans.”

    President Barack Obama chose the former Procter and Gamble CEO to take over the scandal-plagued VA last year. The questions about McDonald’s service come as TV newsmen Brian Williams and Bill O’Reilly have had their claims about covering foreign wars called into question.

    Thought Experiments

    So, some things to ponder.

    — Let’s try a thought experiment. Imagine you have a child. She is standing in the living room. A broken lamp is on the floor. She is holding a baseball bat with pieces of the lamp embedded in the wood. She has written on a large piece of poster board “I broke the lamp.” Would you, as the media has done in McDonald’s case, use the words “misstate,” “erroneous,” and “inaccurate” to describe her oral admonition that she did not break the lamp?

    — OK, another one. You know from my online biography that I have not served in special forces. If I write an article saying “I served in special forces,” would that be a misstatement? If, only after I have been caught dead to rights lying, I apologize to anyone “who might have been offended,” say persons who underwent the tough selection and life-threatening work of real special forces folks, or maybe a homeless veteran, does that make it OK?

    — If I worked for you and got caught lying in connection to my work and embarrassed the organization I lead, would you as my boss make a public statement of support for me?

    — But that said, let’s try it anyway. My name is not Peter. It is Rambo. Even as I type this, I am an active duty special forces operator. Please buy me drinks.

    BONUS: This is not McDonald’s first work-related lie. Obama named the clown to run the VA after veterans died awaiting care. McDonald said on NBC 60 people had been fired for their part in the misconduct, but the fact-checking website PolitiFact.com rated his statement as false, saying that fewer than 20 had been dismissed.




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    Posted in Other Ideas, Trump

    Government Demands Whistleblower Organization’s Encrypted Files

    June 11, 2014 // 4 Comments »




    For those people who still do not believe we have crossed a terrible line into a Post-Constitutional state, here’s another chance to repent before we all go to hell.

    The Department of Veterans Affairs’ (VA) in-house watchdog has demanded that the Project On Government Oversight (POGO) turn over all information it has collected related to abuses and mismanagement at VA medical facilities, according to a subpoena delivered to POGO May 30.

    The VA is part of the federal government. POGO is a private non-profit group.

    The subpoena from the VA Office of Inspector General demands all records POGO has received from current or former VA employees, as well as any other individuals, including veterans. The subpoena asks for records related to “wait times, access to care, and/or patient scheduling issues at the Phoenix, Arizona VA Healthcare System and any other VA medical facility.”

    POGO refused to provide the records, most of which have come from confidential tips submitted through VAOversight.org.

    Background

    The Project On Government Oversight has for 33 years helped government whistleblowers. They are scrupulously non-partisan and very dedicated to exposing waste, fraud and mismanagement in Washington. They’re part of the reason we know that the Department of Defense wasted billions on things like a $7,600 coffee maker and a $436 hammer. They are very active in trying to bring some modicum of transparency to what the NSA is doing.

    The Veteran’s Affairs disaster is well-known. In short, the VA, which should be helping returning service members with their health problems, instead has been hiding their impossible wait times for appointments. They got caught for some of what they did already, but to ferret out more, POGO set up an online drop-box where people could submit tips and blow the whistle anonymously. Much of the information POGO received– which could very likely help veterans– has been submitted by persons from inside the VA. After all, who knows more about what the government is really doing (or not doing) than those who work inside? Sadly, those same workers also know that today, blowing the whistle is considered a Crime Against the State, and they do not wish to go to prison simply for informing the American people what the People’s Government is up to.

    Drop Box

    As a way of helping those who wish to pass on information that may help our veterans, POGO created an online drop box. This is the equivalent of an email Inbox, except it is secure. POGO advises “To maximize your security and anonymity, you should consider using the Tor Browser Bundle for all of your electronic correspondence with POGO. You should never use a government or contractor phone, fax, or computer to contact POGO. The information you submit from this page will be sent to POGO in an encrypted message.”

    Some VA employees who contacted POGO and requested confidentiality said they feared retaliation if their names were divulged. Some of the employees told POGO that they had already filed reports with the VA. You know, through channels.

    Encryption still pretty much works. And the government knows that. That’s why, instead of trying to decrypt the VA whistleblowers’ messages to POGO, the VA has simply demanded them from POGO, unencrypted, via subpoena.

    Subpoena

    A subpoena is an order to do something, most typically to produce a document or appear in court.

    Wait a second. How can the Veteran’s Administration be able to “legally” demand documents from a private, non-governmental entity like POGO anyway? The VA’s Inspector General, whose real job is supposedly to inspect the VA and root out waste, fraud and mismanagement, has subpoena powers that are supposed to be used for that purpose.

    All other federal Inspectors General have the same power. So does Congress. These subpoenas have the titular power of law. They have the same power that a real court has to demand documents be produced. These sorts of subpoenas are authorized within the agency itself, and do not require probable cause or a court’s approval. They are considered administrative acts and occur with no outside oversight.

    That said, subpoena power was never intended as a blunt tool to chase down whistleblowers even as the organization they’re blowing the whistle on fails in its mission. You’d think that the VA Inspector General has gone rogue here. But that’s not true. This is 2014 and we’re in Post-Constitutional America.

    Subpoenas and the Old Fourth Amendment

    The Department of Justice created a novel interpretation of the Fourth Amendment that currently allows it to access millions of records on Americans without search warrants. To clarify, a warrant is court permission to search and seize something. A warrant must be specific– enter Mr. Anderson’s home and look for drugs. Warrants are not free-hunting licenses (with exceptions) and cannot be general in nature, such as search everyone around 93rd Street for whatever illegal things they might have laying around.

    DOJ has turned all that around. It claims now that under the Fourth Amendment, it can subpoena an Internet company such as Facebook and demand they look for and turn over all the records they have about Mr. Anderson. DOJ isn’t searching, per se– they are demanding Facebook do that for them, so no warrant is needed. Worse yet, DOJ believes it can subpoena multiple records, maybe all the records something like Facebook has, with one piece of paper. The same thing applies, DOJ claims, to email. If they came to someone’s home and demanded access to that person’s emails, it would require a specific search warrant. Instead, if DOJ issues a subpoena to say Google, they can potentially vacuum up every Gmail message ever sent.

    The Department has continued this practice even after a federal appeals court in 2010 ruled that warrantless access to e-mail violates the Fourth Amendment. An FBI field manual released under the Freedom of Information Act also makes clear agents do not need warrants to access email in bulk when pulled directly from Google, Yahoo, Microsoft and others.

    Snowden was Wrong

    Edward Snowden, along with many others, has said that the best tool right now to defeat the NSA and other government spying is the use of encryption. It is possible that some forms of encryption are not breakable by the NSA. It is likely that breaking other forms of encryption is slow and/or expensive to do on a world wide web-scale. It is a race of course, between how many supercomputing algorithms the NSA can throw at the problem and the cleverness of the people creating new forms of better encryption.

    If the government can access documents and information with a simple piece of paper– a subpoena– then all the encryption in the world is pointless.

    POGO says they’ll fight, and that their people are willing to go to jail instead of releasing any documents. Let’s believe them. But the possibility of the government getting the documents is likely enough to scare off would-be whistleblowers from submitting anything new. And not every whistleblower organization has the guts and the resources of POGO to fight back.

    The race for privacy may now be over, and the government is laughing at you still running around the track while they cut across the grass to the finish line. Suckers.



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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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