The VA Scandal: How About a Reality Check?

Recent reports from VA medical centers about their long waiting lists and subsequent efforts to hide those lists reminded me of a course I used to teach, misleadingly titled, “Introduction to the US Healthcare System.” No, I was not luring in students with the promise of an introductory course and then requiring them to become proficient in advanced statistical methods. The bait and switch was far more subtle: there is no US healthcare system. “System” denotes an overarching set of principles, practices, procedures and organizational structures. I later changed the name of the course to “Introduction to the US Healthcare Landscape” (still a bit deceptive in that one might assume that a landscape is attractively cultivated). A better title would be “Introduction to the US Healthcare Mess.”

Our so-called healthcare system is made up of an incoherent multitude of financing and delivery mechanisms with identities that are far from transparent. We have for-profit and not-for-profit hospitals both of which rely heavily on government funding. We have hospitals owned by religious organizations and hospitals that used to be owned by religious organizations that are now owned by for-profit chains, although they keep their religious names, like St. Elizabeth or St. Jude. We have physician practices that are situated in hospitals and look like they are hospital clinics but are actually just renting space from the hospital. We have insurance companies and hospitals competing for “good” (that is, well-paying and relatively healthy) patients and customers. We have ambulance services that are run by municipalities or counties; private ambulance services run by for-profit companies; volunteer ambulance companies – call an ambulance and you have no idea what kind of bill you’ll be paying or to whom. We have copious amounts of medical records that are rarely transferred from one institution to another, and we have medical errors accounting for an alarming percentage of American deaths. We believe that emergency rooms serve as a safety net, but by federal law emergency rooms are only required to assess and stabilize patients (and are allowed to charge a whole lot to do so), not to cure them. And I haven’t even touched on the anarchy of services for the elderly or the rapidly growing prison healthcare industry.

“System” is not the only misleading word in my old course title. “US” is nearly as deceptive. Health care services, regulations and financing vary enormously from state to state. Each state sets its own threshold for eligibility for Medicaid; in the stingiest states any income at all precludes Medicaid eligibility – essentially forcing individuals to choose between healthcare and food. In other states (such as my home state of Massachusetts) one can earn a fair amount above the federal poverty level and qualify for government-subsidized health care.

The consequences are frightening. Just this morning I spoke with Junie, a fifty-five year old woman whom I’ve known for the past six years. Abused as a child, Junie ran away from home and lived on the streets for many years. In her forties she found out that she was HIV positive. In Massachusetts she received excellent medical attention – the supervised use of retroviral medication kept her numbers well under control and she remained healthy. However, housing in Massachusetts is expensive (the wait list for low income housing can be as long as ten years), and Junie knew she had to get out of the shelters and into a stable apartment in order to stay off drugs and out of trouble. She moved to another state where living costs are lower, and a family friend helped her get into low income housing. However, in that state she was not eligible for medical care. Within a year or so the HIV turned into full blown AIDS with an array of awful symptoms. Her kidneys failing she came back to Massachusetts where she now is sick enough to be eligible for temporary respite housing.

We might be tempted to see Junie as a poor unfortunate who fell through the cracks of a healthcare finance system mostly made up of employment-based health insurance augmented by a safety net for that minority of Americans who are not covered through their employers. That view is simply not correct. In the state of Arizona (the epicenter of the current VA scandal) for instance, the numbers break down like this: 45% of the population is covered by employer insurance (either a the primary insured or as a dependent), 4% have other private insurance, 18% are covered by Medicaid, 13% are covered by Medicare, 2% have other public insurance, and 18% are uninsured. Arizona is among the ten worst states in regard to percent of uninsured residents. The worst states are Texas and Nevada (27% uninsured) and Florida (25% uninsured).

While the full list of VA centers under investigation for fraudulent waiting lists has not been released, the five states that so far are reported to be involved (Texas, Arizona, Colorado, Florida and Mississippi) are all states with bad track records of healthcare coverage overall: tightfisted Medicaid eligibility thresholds and large numbers of uninsured residents.

The VA as the National Safety Net

In much of the country – and especially in the states with high rates of uninsured residents – the VA functions as the de facto safety-net. Approximately one quarter of the nation’s population, about 70 million people, are potentially eligible for VA benefits and services. In any given year approximately 75 percent of all disabled and low-income veterans use the VA system for some service.

I will never forget Yolanda, a school teacher I met in southern Texas a number of years ago. Here is a letter she wrote to me:

In 1998, one of my younger brothers at age 39 took ill. Seizures that he had were mistaken for a heart attack. A CAT scan showed he had a shaded area in his head. “Possibly a blood clot.” said his doctor. It turned out to be a malignant brain tumor rated #5. The worst a person can get. Further testing needed to be done to determine the proper treatment. All of these were very costly and his medical bills had already started to pile. Even then, the doctor said that with the proper treatment and starting immediately with chemotherapy, my brother could live at least 4 more years. We acted quickly to get him on disability and Medicaid. Without Medicaid, my brother could not afford any testing or treatment. None of us siblings were in the position to help out financially. We couldn’t understand the denial of Medicaid since my brother would no longer be able to work. How would he or his wife pay for all his medical needs? The doctor wrote letters for them to present to the Texas Department of Human Resources but they didn’t help in making the decision to approve it. …

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A friend reminded my brother that he was a veteran of the military service and should check out the VA clinic. My brother and we thought that the VA only helped war veterans and my brother never went to war during his 4 years of service. Mistaken we were. However, to receive medical services, we had to take him to San Antonio where VA Hospitals and more clinics are located. This is a 5-hour drive from our hometown. We took turns driving him to and from every weekend. It was hard for us but harder for him going to and from so many times in his weak state. Eventually he had surgery and was started on radiation. It didn’t help any and a second surgery was done. The second surgery left him paralyzed on the right side. I went from working full time to part time so I could help out more with his physical needs. Months passed and he kept getting worse. My sister in law again went to apply for Medicaid so he could get care locally. It was getting harder and harder to move him on the 5 hour drive to San Antonio. There was no success in getting Medicaid and months passed. The whole situation became hardship for his wife, children and all family members. My brother eventually stopped responding to anything and we were basically just waiting for his time to end. Two weeks before he died at age 41, my sister in law received a phone call to say that finally the Medicaid had been approved. She told them exactly what to do with it. From the day my brother was told he had a brain tumor, he only lived for 1 year and 10 months.”

Yolanda’s brother certainly would have been saved a great deal of suffering if the VA were to have allowed him to receive treatment closer to home. But let’s be clear about this: Yolanda’s brother did not die because of the VA. He did, however, die with more suffering and less dignity because we do not have a healthcare system in the United States.

The Call for Privatization

As soon as the Arizona VA scandal broke, House Speaker John Boehner and others could hardly contain their excitement. This was a golden opportunity for pushing the same old proposal for privatizing the Department of Veterans Affairs. Privatization is not a new idea. But it is a bad one. Who would take over the care of veterans? Halliburton? Corrections Corporation of America? United Health? Aetna? None of these companies have track records that suggest trustworthiness.

There is no doubt that the VA is riddled with problems including half-hearted recognition of the needs of women veterans and a long history of denying that lethal wartime practices such as the use of the defoliating Agent Orange made veterans sick. All of this is inexcusable and the VA must be held accountable. The VA also must be held accountable for hiding the lengths of waiting lists for care instead of screaming from every DC rooftop for adequate funding.

But framing the current unconscionable delays for care at the VA as an issue of government inefficiency is disingenuous. The VA is not responsible for the fiscal conservatism that drives politicians to vote against adequate budgets. (To paraphrase one of my favorite bumper stickers from the 1960s: Things would look a lot different if the VA were to get all the money it needs and the Air Force had to hold a bake sale to buy bombers.) The VA cannot make up for the lack of a national system of healthcare coverage for all Americans, especially when those who serve in the military disproportionately come from and return to communities with few economic resources and little political power.

In the short term (until the VA can hire sufficient numbers of providers) it certainly makes sense to allow veterans on waiting lists to receive treatment at non-VA facilities. In the long term, that is not a good solution. The VA as a national enterprise acknowledges the collective responsibility for our society to care for veterans, recognizes that veterans have unique health needs that are best met by providers with expertise in those needs and provides a level playing field in which all veterans have the right to receive equal treatment regardless of their personal finances or the willingness of private companies to take them on as customers. Permanently outsourcing veterans on the waiting list to non-VA facilities undermines these principles. In addition, the annual Independent Budget published by the nation’s leading veteran organizations reported that the VA is “the most efficient and cost-effective health-care system in the nation.” A 2005 survey from the RAND Corporation [link] similarly found that “VA patients were more likely to receive recommended care” and “received consistently better care across the board, including screening, diagnosis, treatment and follow up.” I recall a conversation with a physician who, splitting his time between the VA and one of the large, prestigious Harvard teaching hospitals, told me that, “At the [Harvard] hospital I need to get referrals and approvals for everything and the patient has to run all over the place to be treated. In the VA it’s more of an old-time G.P. practice – As the doctor I can get the care for my patients that they need all in one place.”

Good News: Embracing Health Care as a Right

Something fabulously exciting has emerged from the public mea culpa of the past two weeks. It turns out that Americans are not afraid to use the word “rights.” Again and again, I’ve heard liberal and conservative pundits say that our veterans have the “right” to healthcare. While national debates over Obamacare have backed away from declaring that access to adequate health care is a basic human right (instead, discussions have been framed in terms of cost and choice), the VA scandal has opened the door for us to think deeply about healthcare as a human right not just for military veterans but for all who serve as teachers, parents, growers of food, cleaners of streets, producers of the clothing we put on our backs, builders of the houses in which we live – that is, for all human beings in that we all, by virtue of being human, are depended upon and depend upon others for our very survival. To my mind, the real lesson we need to learn from the current scandal is quite the opposite of privatization which would further chop up and distribute responsibilities (and profits) for healthcare among more and more corporations. What we need to learn from this scandal is that the VA should become part of an integrated, rational, coherent national healthcare system.

For more on the VA follow these links: On Memorial Day: “Remember the Ladies” and An Open Letter to Robert McDonald