As a veteran who served in Vietnam and then has spent nearly 30 years as a psychologist at the Veterans Health Administration (VHA), I am heartened by President Donald Trump’s pick for Secretary of Veterans Affairs. Dr. David J. Shulkin, who served as undersecretary for health in the VA under Obama, is very different from Trump’s other cabinet picks. He supports the VHA’s mission and is opposed to privatizing VHA services. Although he believes veterans should be able to receive care from private sector providers, he wants that care to be integrated into the VHA system, which, as all evidence shows, delivers higher quality care to veterans at lower cost than the private sector ever could.
That said, there is still a lot to worry about as Congress, the media and the president continue to publish misleading articles about the VHA and propose legislation that will end up jeopardizing its quality and even its very existence.
Consider for example, how VA healthcare is portrayed in much of the media. The Wall Street Journal recently ran the headline: “The VA Hooked Veterans on Opioids, Then Failed Them Again.” But the article, which focuses on a VA facility in Fayetteville, North Carolina, goes on to reveal to those who read it closely that the VA treatment protocols include some of the most sophisticated tools available, including video Telehealth, extended hours appointments, community partnerships, and extraordinary recruitment efforts for staff.
This is not the first article to lambast the VHA for allegedly hooking veterans on opioids and then failing to wean them from dangerous narcotics. What these articles consistently leave out is the context. In many cases, veterans come to the VHA after leaving the military where they were prescribed opioids for pain and other complex conditions. In others, VHA clinicians prescribed opioids during a period when all American physicians were encouraged to treat pain more aggressively. The pendulum has swung in the opposite direction, and the VHA is trying valiantly to swing with it. It offers all sorts of programs to wean veterans from narcotics and help them manage their chronic pain through treatments such as acupuncture, meditation, and mental health counseling.
Articles like those in The Wall Street Journal also fail to mention that VHA facilities are facing an escalating demand for services. The Fayetteville VA serves the fastest-growing veteran population in the nation, with 70,000 patients last year, up from 42,000 in 2010. Beyond the headlines, embedded in the article is the admission that this VA is struggling to deal with a 60 percent increase in demand for healthcare services from veterans over a 50-mile radius from Fayetteville.
Could any other private healthcare system be expected to keep up with such an extraordinary demand for services? Why are so many veterans choosing the VHA when they could get care in the private sector?
This media narrative is having a very pernicious effect on recruitment and retention of VA employees.
A new Government Accountability Office report has noted that annual VHA outpatient medical appointments rose by 20 percent, or 17.1 million visits from fiscal year 2011 through 2015. During this period there was a troubling rise in the number of staffers in five critical occupations who left the agency. In 2011, 5,897 physicians, registered nurses, physician assistants, psychologists and physical therapists either retired or chose to leave VHA. By 2015, over 7,730 had left—an increase in the annual loss rate from 7.3 percent to 8.2 percent. In part this reflects competing private sector recruitment with salary enticements the VHA cannot meet. But it is also due to the relentless criticism of VHA employees. No matter how much harm they do, private sector healthcare providers are rarely subject to this level of scrutiny and censure.
The reality the media fails to capture is that most veterans who use the VHA love the services they receive—which is documented in yearly customer satisfaction surveys of both inpatient and outpatient services. Many studies have documented that the VHA is providing care that is at least as good and in many instances better than systems like the Cleveland Clinic – which Donald Trump praised so highly in his press conference announcing David Shulkin’s nomination as VA secretary.
I have worked in Cleveland for over 28 years and I know how different the Cleveland Clinic is from the VHA. The Cleveland Clinic, has enormous resources to pay for both capital expansion as well as to offer high salaries. It spends millions on advertising in an attempt to convince the public that it is number one in quality. More to the point, it can pick and choose which patients it serves and often prefers elite customers.
Plus, its top executives make millions. Highest among them is CEO Delos “Toby” Cosgrove, whose annual salary in 2014 was $4. million. The top executive at the Cleveland VA Medical Center, the third largest and most complex VA in the nation, makes about $200,000 year. And because Congress won’t allocate sufficient funds for VA Medical Centers to compete with market salaries for physician providers, and often prohibits the VHA from offering salaries that make it competitive with the private sector, it is difficult to recruit and retain providers, even in well-resourced urban areas where there are more providers available
Given Congress’s failure to allocate sufficient funding for veterans’ health care it is amazing that so many providers and VHA staff are willing to work for less to take care of patients that are among the sickest, oldest, and poorest patients in the nation.
The media consistently misses is that the VHA staff’s patriotism and caring for veterans is by far the VHA’s most important legacy. The VA is not just providing healthcare, it is providing a lifeline and safety net for services that veterans would never receive in any other healthcare system. As someone who has cared for my fellow veterans for decades, I know that they are extraordinarily proud of their service, have a strong allegiance with the military, and see the VA as a reward for their service and legacy for those who will serve their nation in the future. As David Shulkin, Congress, and the president move forward, we must focus on improving the VHA by helping it become more efficient and effective, providing the funding that will allow the VHA to offer market rate salaries, and developing stronger mechanisms of oversight for low producing facilities. While I don’t want to end on a cliché, the admonition to not throw the baby out with the bathwater has never been more apt than it is when considering the future of the veterans’ health care.