The Truth About the VA

Ronald Citkowski

Wounds of War:
How the VA Delivers Health, Healing and Hope to the Nation’s Veterans
By Suzanne Gordon
Cornell University Press 2018, 464 pages, $29.95 hardcover.

SUZANNE GORDON IS an author, journalist, speaker and patient advocate with a long and distinguished career in the field of health care systems. In 2014, a number of highly publicized media attacks on the U.S. Department of Veterans Affairs Health Administration system (VHA), characterizing it as inept, corrupt and incapable of delivering adequate health care to veterans, caught her attention.

Gordon decided to find out how well the VHA system, which operates as a European-type centrally administered, single payer system, actually compares to the U.S. market-driven, private-sector system. Gordon presents a thorough and very readable answer to the question in her latest book, Wounds of War: How the VA Delivers Health, Healing and Hope to the Nation’s Veterans.

I’ve heard a lot of blistering criticism of the VHA, going back to at least the George W. Bush years. Since I am a U.S. Army veteran who has had more than his fill of what we called “The Army Way,” I must admit, now with a bit of embarrassment, that I tended to believe at least the less lurid accounts of the shortcomings of the VHA.

I found I was not alone in falling for these stories. In an interview following the publication of her book, Gordon noted: “Many liberals and progressives who don’t buy the propaganda about climate, or about education, buy the propaganda about the VA.”

How the VHA System Operates

During the five years she spent investigating the VHA system, Gordon visited hospitals and clinics and sat in on patient visits. She also carried out interviews with patients, their families and health care providers, and found that the VHA does a better job of caring for patients than does the private-sector health care system.

The VHA operates as a single-payer, integrated care system in which the patients’ medical needs, which can include primary care, geriatric medicine, chronic pain treatment, mental health and rehabilitation, as well as their social issues such as drug abuse and homelessness, are all considered and treated together. As such, it is very similar to the integrated health care systems of many European countries.

The VHA uses a Patient-Aligned Care Team (PACT) approach in which the doctors, nurses, practitioners and office clerks have morning meetings each day to plan for the needs of the patients they will be seeing. Inclusion of the clerks into the planning process may seem to be unnecessary, but as Gordon found out, clerks are the portal to the system who can often provide very good insights to a particular patient’s issue — such as transportation and living conditions — which can influence their compliance with a treatment protocol.

If a patient needs to be referred for further care by a doctor, social worker, psychologist, dietician or other specialist, the primary care physician uses what is referred to as a “warm handoff” in which he or she introduces the patient to the specialist, in person if they are in the same complex, or by teleconference if not, and discusses the patient’s needs.

VHA pharmacists are also integrated into the care team. Patients have an office session where their pharmacist will go over the prescribed medications as well as over-the-counter medications a patient may be using and discuss possible side effects and interactions.

The VHA system is actually very successful in providing mental health care. Veterans suffering from PTSD and or chronic brain damage often have problems of depression, anger management and substance abuse, reflected in a high suicide rate.

Survey data show that suicide rates for Veterans not using the VHA system actually rose by 40% over the period of 2000-2010. Meanwhile the suicide rate for those using the VHA system declined by 20% over that same period. Further studies have confirmed that veterans with severe mental illnesses who receive VHA care live much longer on the average than their non-veteran counterparts.

Women veterans, in addition to issues of PTSD and combat-related injuries, often have to deal with problems resulting from sexual harassment. Since the number of women in the military is growing steadily, these problems are of increasing importance. Furthermore, many women veterans are reluctant to deal with the same military hierarchy that gave rise to their harassment.

The VHA has come to appreciate the significance of this problem and has established separate women’s primary care and mental health clinics in each of its centers, and gives women the choice of using these dedicated facilities or the general clinics.

In the VHA system, the average patient load for full-time primary-care physicians is 1200, while a private sector primary-care physician has a patient load in the range of 2100 to 3400. As a result, primary care physicians in the VHA system typically spend 30 minutes per visit with each patient.

Gordon includes a number of detailed personal accounts of patients in which they discuss their own experiences in and out of the VHA system. As she finds, patient satisfaction with the VHA integrated team-approach is very high, and a number of patients made a point of telling her that they turned to the VHA after disappointing experiences in the private sector.

Why the Criticism?

One criticism the VHA system we repeatedly hear is that patients experience long delays in obtaining services. Gordon addresses this point in detail and acknowledges that there were some real issues, particularly with regard to the Phoenix facility in 2014, primarily due to the inadequacy of that facility to accommodate a high winter-season influx of snowbird retirees.

She notes, however, that this problem has been addressed and goes on to cite a 2015 study by the Rand Corporation and a 2017 report done for the American Legion. Even though 16% of VHA facilities are operating at over 100% capacity, the average wait to see a primary care physician is five days; the average wait to see a mental health specialist is four days; and the average wait to see a specialist is nine days.

Overall, the wait times in the VHA system were found to be at least as good as those in private sector systems.

So, if the VHA has established a good track record of providing veterans with high-quality health and social services on a timely and cost-effective basis. Why does the general public perceive it to be a failing organization?

To answer this question, we need to ask: Who would like to see the VHA fail?

As Suzanne Gordon documents, wealth-backed conservative groups have been making a strong push to delegitimize, defund, and ultimately privatize the VHA. Sixteen conservative lobbying groups, most of which were funded by the Koch brothers, appealed to Senators and Congressional representatives in October of 2017 for the immediate privatization of the VHA.

The Koch brothers have also created and funded an AstroTurf group, “Concerned Veterans for America,” which is actively lobbying the Trump Administration to implement steps to weaken the VA. Hedge fund billionaire and major Trump donor Steven A. Cohen has established The Cohen Veterans’ Network as a private sector competitor of the VHA poised to take on outsourced mental health treatment.

The VHA represents a very good model of a single-payer health care system, and its success is a threat to the private-sector health care industry. The push against the VHA is just a part of the right wing’s opposition to all forms of nationalized health care.

Furthermore, the VHA has a patient base of nine million veterans, a budget of $200 billion, and currently sees 250,000 patients a day. That makes for a large chunk of income that the private sector would like to see directed its way.

Wounds of War is a valuable resource for veterans’ rights advocates as well as everyone concerned with the struggle for Medicare for all.

July-August 2019, ATC 201