Americans have been hearing for years that the health-care system run by the Department of Veterans Affairs is in crisis. In 2014 came charges that officials at the Phoenix VA and other facilities had altered or destroyed records to hide evidence of lengthy wait times for appointments. Most recently, David Shulkin, the former VA secretary who left amid a scandal over luxury travel expenses charged to taxpayers, contended that the president fired him for not moving quickly enough to privatize the system. In truth, misconceptions mar the debate about how veterans’ health care actually works.
Citing “bureaucracy run amok,” Rep. Jackie Walorksi (R-Ind.) sponsored a bill in 2014 to empower the VA secretary to, as she put it, “fire senior officials who aren’t up to the job” of reducing the department’s backlog of disability claims. Discussing his articles about the backlog for the Center for Investigative Reporting, Aaron Glantz concluded that “the problem is that the VA bureaucracy at the highest levels is so dysfunctional that they’ve been having difficulties staffing up to meet these needs even when Congress gives them the resources.”
Politicians and journalists are not alone in blaming VA bureaucrats for the long delays many veterans face in establishing eligibility for health care — veterans also point to the bureaucracy. The latest department data shows that as of the end of last year, more than 75,000 veterans were waiting for VA to decide whether they qualified for health care and other benefits based on a service-related disability.
Yet while VA has streamlined its claims process — the backlog is down from more than 600,000 five years ago — the fundamental reason for these delays isn’t bureaucratic inefficiency. The process certainly could be more administratively efficient, but it is ultimately Congress that makes it so difficult for many veterans to get VA care. Because of laws that strictly limit eligibility, veterans must show that they are either poor or suffer from some specific degree of disability related to their military service to qualify for many health-care services as well as pension benefits. The requirement to litigate different health conditions — such as, say, whether a veteran’s hearing loss is a result of artillery fire or exposure to rock-and-roll — is the ultimate reason the VA claims process is prolonged and often humiliating to vets.
Much attention has focused on how long veterans enrolled in VA must wait to see a doctor or receive a treatment, and on instances when VA employees altered the numbers to make wait times look shorter. “The VA, it’s a disaster,” Donald Trump told a veterans group during the 2016 presidential campaign. “. . . To see a doctor, sometimes it takes six and seven days, and then you finally get there and the doctor is gone on vacation.” “NBC Nightly News” reported in January that “VA hospitals face renewed scrutiny over lengthy wait times.”
Yet the coverage of this scandal has been deeply misleading. The key question that often goes unanswered is: compared with what? A 2015 study by the Rand Corp. concluded that, in general, “wait times at the VA for new patient primary and specialty care are shorter than wait times reported in focused studies of the private sector.” In a 2013 survey by the Commonwealth Fund, a foundation that supports independent research on health-care issues, 1 in 4 Americans reported that they had to wait six or more days for an appointment with their primary-care physician, even when they were “sick or needed care.” Most major VA medical centers, by contrast, now offer same-day urgent primary-care and mental-health-care appointments. Current enrollees seeking nonurgent primary care can typically get an appointment in three to seven days.
It’s not hard to find instancesof outrageous deficiencies in the system. A 2014 Fox News op-ed by Marc Siegel, a doctor, held that its hospitals “are fallback places, providing second tier medical care.” Individual VA hospitals have in recent years made headlines for allegedly keeping secret an outbreak of Legionnaires’ disease , exposing patients to hepatitis and HIV and failing to protect patients from inept doctors .
But compared with the rest of the U.S. health-care system, VA’s performance is pretty impressive. As a Rand review of the literature concluded, study after study has found that the “quality of care delivered by VA is generally equal to or better than care delivered in the private sector.” This has been true since VA underwent a structural transformation in the mid-1990s. Since then, health-care researchers, as well as mainline veterans’ service organizations, have consistently hailed its pioneering use of electronic medical records , adherence to evidence-based medicine, patient safety measures, and high levels of care coordination and scientific research.
The bipartisan Commission on Care , of which I was a member, found the quality of VA’s behavioral health programs “largely unrivalled.” In many areas, VA offers specialized polytrauma and rehabilitative care for veterans that cannot be obtained at any price elsewhere. Part of the reason you hear so many negative stories about VA health care is that it receives far more scrutiny than the rest of the health-care system, including from two standing committees in Congress, an inspector general, veterans service organizations and a highly engaged press.
“Veterans should be guaranteed the right to choose their doctor and clinics, whether at a VA facility or at a private medical center,” Trump said in 2016. Advocates from the president to Bernie Sanders, John McCain and the Koch brothers salute the idea that veterans should have more “choice” in the health care they receive. In a rare act of bipartisanship, Congress recently passed and Trump signed into law the Veterans Choice Improvement Act, which allows VA patients to continue to seek care from private doctors, subject to certain conditions.
But choice comes at the cost of other important values, such as providing coordinated, high-quality, cost-effective care. The Commission on Care found that giving VA enrollees the ability to choose any private doctor for any treatment (which the recent legislation does not do) would be fantastically expensive to taxpayers unless it involved all sorts of bureaucratic cost controls. Sending veterans to other providers could also threaten the viability of VA hospitals and clinics, many of which already face rapid shrinking in their patient populations, owing to the passing of the World War II generation. If VA hospitals wind up closing, that would leave veterans with less, not more, choice in doctors.
Many conservatives want to see VA outsource most of its care to the private sector. One example is Concerned Veterans for America, an organization supported by the Koch brothers, that is ideologically hostile to government-provided health care and has a great deal of influence within the Trump administration. Some large, integrated, private health systems, such as the Cleveland Clinic and the University of Pittsburgh Medical Center, advocate for at least partial privatization of VA, presumably because it would bring more business their way.
Sensitive to this debate, VA supporters bristle: “I work very closely with the major veterans organizations,” Sanders said on the CBS program “Face the Nation” two weeks ago. “. . . And what they say is they want to strengthen the VA, not dismember it, not privatize it.” Shulkin, the recently dismissed VA chief, along with many veterans service organizations, has warned of creeping privatization.
Yet not all calls for VA to make better use of private providers amount to “privatization,” as some liberals and public employee unions claim. VA has a long history of partnering with private medical schools and purchasing care in the community. Especially in rural areas, VA often lacks the facilities and personnel to offer vets timely, convenient, high-quality care. In such circumstances, joining with local private providers to create integrated networks of care makes both clinical and fiscal sense.