Vet­er­ans Af­fairs to the fore­front

Calhoun Times - - OPINION & VOICES -

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-of-net­work 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 non-VA 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 hot­but­ton 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 full-blown 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, gov­ern­men­t­op­er­ated 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-youknow 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.

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