Veterans Affairs to the forefront
July 23 marked a rare event in the politically and ideologically lacerated chambers of Congress. President Donald Trump’s nominee for veterans affairs secretary, Robert Wilkie, won Senate confirmation by a strikingly bipartisan vote of 86 to 9.
Wilkie’s task ahead is daunting.
The VA borrows its mission statement from the penultimate phrase of one of the American history’s loftiest documents, Abraham Lincoln’s Second Inaugural Address: “To care for him who shall have borne the battle, and for his widow, and his orphan.” In so many ways, the VA has fallen short on that mission.
Over the years, my graduate students have included numerous doctors, nurses, and administrators from VA hospitals, and they always struck me as people I would easily entrust with my life, health and safety. But as an institution, the VA fails to live up to the brilliance and devotion of its employees. The whole, it seems, is considerably less than the sum of its parts. (There are exceptions to this rule, of course. For example, the VA has been rather innovative and successful in enabling patients to access telemedicine.)
The VA can be mind-numbingly bureaucratic, with months-long waiting lines, shocking mismanagement, regiments dying in the queues while waiting for help, and pricy electronic health records that can’t adequately track patients’ progress. The Veterans Choice Program, designed to ease overflow demand by giving veterans access to out-ofnetwork providers, has long waits and heavy cost overruns. This year, Congress passed, and Trump signed, the VA Mission Act—aimed at meeting Lincoln’s plea by, among other things, bolstering funding, reorganizing institutional structures, streamlining access to nonVA care, and establishing walk-in clinics.
Wilkie’s predecessor as secretary, David Shulkin, reportedly left office in a dispute over “privatizing” the VA. Appointed by both Presidents Barack Obama and Trump, Shulkin steadfastly opposed privatization, though no one seems to agree on exactly what that term means with respect to the VA. In his confirmation hearing, Wilkie said he did not aim to “privatize” the VA, though the fogginess of the term leaves the substance of that promise rather vague.
Clearly, the Choice Program and the Mission Act both contained elements of privatization—at least as release valves. News accounts regularly described the Mission Act as a partial privatization. For what it’s worth, support for the bill was overwhelming among both parties in both houses of Congress—perhaps, again, because privatization is in the eye of the beholder.
Wilkie’s successes and failures will be closely watched. (Whether purposefully or by coincidence, a majority of the nine senators voting against his confirmation are potential 2020 presidential candidates.) What happens at the VA especially matters because single-payer health care—whatever that means—has become one of the two or three hottest hot-button issues for the 2018 and 2020 election campaigns.
The VA will likely be, and ought to be, a topic of discussion in that context, as it is the closest thing America has to a full-blown, government-run, centrally planned health care system. The VA’s pathologies closely resemble those of fullblown single-payer systems, such as Britain’s National Health Service or Canada’s Medicare.
Can the right manager fine-tune the organization to deliver quality care at a reasonable price? Or is the government-funded, government-operated system the intrinsic problem?
For what it’s worth, among the system’s patient base, the VA remains quite popular. But then, patients in other countries are often devoted to government-run health systems. I would interpret this as a devil-you-know versus devil-you-don’t-know situation, but that’s just me.
Whatever the explanation, Wilkie has likely signed on for the bright lights over the next few years. Expect to hear the word “privatization” a lot over the next two election cycles.