Abolish the VA?

[wiggin]

Someone I know well just started a petition on the White House's website (linked here). She suggests that the bricks and mortar VA system should be scrapped in favor of a national insurance scheme like Medicare, where people can go to any doctor or hospital but be covered by the government. This is in contrast to now, where veterans must travel to often inconvenient VA facilities for treatment, and is particularly topical given several recent scandals in VA administration and waiting lists.

The wrinkle here is that the author is an attending physician at the ER of a major VA hospital, and has a front row seat to the disaster that is this system. She generally has positive things to say about the medical staff, but has frequently groused at the utterly broken bureaucracy in administering the system. As an aside, she's also a dyed in the wool Democrat with no particular antipathy to government largesse; she just can't stand the waste and nightmarish process of getting care through the VA.

What do you guys think? I can see some legitimate issues, but it seems like a pretty sensible position.

[GGT]

I think it's a good idea to move Veteran healthcare into the same facilities civilians use, and "abolish" most free-standing VA-dedicated hospitals/clinics. As I said in another thread, "traditional" VA hospitals were built to care for wounded soldiers returning home after warfare, mostly the WWII era, when hospitals weren't a routine presence in most places....and they couldn't handle patient loads that size anyway.

If a vet lives in a state with sparse hospital/clinic presence, the VA could provide transportation to the nearest existing facility, and everyone would come out ahead on all counts (quality of care, cost of care). I think a few facilities could remain VA-specific to care for the severely wounded, and get special funding for R & D and cutting edge medical technology from private sector universities at the same time.

We have all the 21st century "advancements" in medicine, technology, transportation (and even Warfare ) that make traditional VA Hospitals fairly obsolete. Their bureaucracy is outdated because it still uses a centralized, military-command structure, and military personnel as healthcare providers.

Since the nation subsidized their college educations, in exchange for enlisting in the military, and we expect them to "serve their duty" as providers within the VA system....that's another aspect we should re-evaluate. Good luck with that.

[wiggin]

I don't know of any healthcare providers in the VA system who are active duty members of the US military. I could be wrong, but the vast majority are civilians.

[Flixy]

To be honest I never really got why there was a separate system for veterans in the first place. Providing insurance for the regular system seems a lot more sensible, unless I'm missing some major advantage of the Va system.

[Spenni]

I don't know of any healthcare providers in the VA system who are active duty members of the US military. I could be wrong, but the vast majority are civilians.

They're all civilians... And don't have a military command structure....

[wiggin]

To be honest I never really got why there was a separate system for veterans in the first place. Providing insurance for the regular system seems a lot more sensible, unless I'm missing some major advantage of the Va system.

I think most of it is historical.

They're all civilians... And don't have a military command structure....

Spenni - I know you're probably covered under Tricare and thus don't interact much with the VA system, but what do you think? Do you think this shift will hurt provision of medical care to veterans, or improve it? Do you think other reforms are necessary as well (to, e.g., speed up approval of disability status)? I'd value your thoughts on this issue since you have more at stake than most.

[Loki]

The argument for the VA is that it has specialists that most private medical practices don't have. But that seems like a pretty damn stupid reason to have a massive (and massively ineffective) bureaucracy. I'm fairly sure the government can simply strike deals with practices in the same areas to have the exact same specialists in exchange for guaranteed income.

[wiggin]

I suspect that part of the reason these specialists aren't big in the private sector is because most of the demand is soaked up by the VA. Move those millions of patients into the general health system, and you'll get similar services available. To be honest, though, I don't think that any significant portion of VA services fits this category. The vast majority is routine stuff that is universally applicable.

[LittleFuzzy]

To be honest I never really got why there was a separate system for veterans in the first place. Providing insurance for the regular system seems a lot more sensible, unless I'm missing some major advantage of the Va system.

Because it predates widespread use of health insurance. By as much as 100 years, depending on what you choose as the starting point of each.

The first government-run/funded medical facility dedicated to veterans' service was authorized in 1811 (though it wasn't actually built until 1834). The VA system as currently implemented didn't start until 1930, when the various services provided during/after WWI were consolidated under one departmental roof in the beginnings of the Great Depression.

[Aimless]

In principle I believe it may be a good idea, and from what I can tell at least two separate bills with similar ideas have already passed major hurdles and are waiting to be reconciled with one another before approval.

In practice I think this may be an unmitigated disaster in the short term. My concern arises from doubts about whether or not there is enough slack in the rest of the US healthcare system to soak up the sudden influx of veterans (9 million people annually, "57,000 veteran patients have been waiting at least 90 days for their first VA medical appointment, and an additional 64,000 veterans appear to have been denied appointments after requesting them.").

I do not think that this in itself is a solution unless it means injecting more money into the system, although perhaps you can get some of that extra money from firing the administrators the VA has long had the authority and ability (in theory) to offer healthcare outside of the VA system, but have obviously not used that power to a sufficiently great extent. When you have a situation like that I think it may be fair to ask what it is that makes them so unwilling to do so. In addition to cultural problems, malice and repeated head-injuries among administrators, I think it may be a signal that the system is chronically underfunded and the administrators are therefore "discouraged" from referring veterans to any facility or specialist outside the VA system.

If that is the case, then I don't think this alone will solve the problem. Instead it may shaft everyone else. If that is not the case, and the VA is both adequately funded and administrators not discouraged, then maybe you can begin by making sure that the referral system works better and is actually used. If the administrators are the problem, then you can place more authority in the hands of the doctors who are better equipped to decide which patients would be better served by coming to the VA facilities and which ones could just as easily go to any other facility.

I don't doubt that the majority of medical issues regarding veterans can in general be handled outside the VA system but I don't think it's a good idea to dismiss the the added value of the psychological and social insights an experienced VA doctor may have into the situation of many veterans. That experience is of course useless if the patients never even get to see their doctors, but...

[Loki]

The VA doctors would still be doctors, so I'm not sure why there would be any short-term pain.

[wiggin]

In principle I believe it may be a good idea, and from what I can tell at least two separate bills with similar ideas have already passed major hurdles and are waiting to be reconciled with one another before approval.

In practice I think this may be an unmitigated disaster in the short term. My concern arises from doubts about whether or not there is enough slack in the rest of the US healthcare system to soak up the sudden influx of veterans (9 million people annually, "57,000 veteran patients have been waiting at least 90 days for their first VA medical appointment, and an additional 64,000 veterans appear to have been denied appointments after requesting them.").

I do not think that this in itself is a solution unless it means injecting more money into the system, although perhaps you can get some of that extra money from firing the administrators the VA has long had the authority and ability (in theory) to offer healthcare outside of the VA system, but have obviously not used that power to a sufficiently great extent. When you have a situation like that I think it may be fair to ask what it is that makes them so unwilling to do so. In addition to cultural problems, malice and repeated head-injuries among administrators, I think it may be a signal that the system is chronically underfunded and the administrators are therefore "discouraged" from referring veterans to any facility or specialist outside the VA system.

If that is the case, then I don't think this alone will solve the problem. Instead it may shaft everyone else. If that is not the case, and the VA is both adequately funded and administrators not discouraged, then maybe you can begin by making sure that the referral system works better and is actually used. If the administrators are the problem, then you can place more authority in the hands of the doctors who are better equipped to decide which patients would be better served by coming to the VA facilities and which ones could just as easily go to any other facility.

I don't doubt that the majority of medical issues regarding veterans can in general be handled outside the VA system but I don't think it's a good idea to dismiss the the added value of the psychological and social insights an experienced VA doctor may have into the situation of many veterans. That experience is of course useless if the patients never even get to see their doctors, but...

Minx, echoing Loki I think that since all of the hospitals, doctors, nurses, et al in the VA system would get subsumed in the broader healthcare system I don't think there is likely to be a significant capability gap during the shift. In fact, the US could plow more money into the system by selling or leasing VA assets (of which there are many) to the private sector. Furthermore, I would imagine that a lot of the current backlog and poor outcomes has more to do with bureaucratic waste; if it could be run better, there would be more resources available for care.

I honestly don't think there's some magical VA doctor who's uniquely suited to treating patients, outside of psychiatrists treating combat-related PTSD and the like. I suspect the switch could happen relatively painlessly and would have better long term outcomes in terms of administrative efficacy and cost.

[Aimless]

Unless the burden on VA facilities is comparable to that on all other providers then I'm not sure how you could offload a large portion of the patients in the VA system without creating more pressure on the rest of the system.

As for whether or not experience of that sort may be valuable in the interactions with veterans, I don't think we'll come to any sort of agreement. I can only speak from my experiences and observations which has to be translated to the uniquely American context and which may also differ from that of your friend for other reasons. In short it has to do with the fuzzier interpersonal aspects of medicine and we can leave it at that.

[Aimless]

And, just so we're clear, we are in this thread implying that modeling something after Medicare may be a good thing

[wiggin]

Unless the burden on VA facilities is comparable to that on all other providers then I'm not sure how you could offload a large portion of the patients in the VA system without creating more pressure on the rest of the system.

As for whether or not experience of that sort may be valuable in the interactions with veterans, I don't think we'll come to any sort of agreement. I can only speak from my experiences and observations which has to be translated to the uniquely American context and which may also differ from that of your friend for other reasons. In short it has to do with the fuzzier interpersonal aspects of medicine and we can leave it at that.

Distributing another ~10 million patients over a system that handles 300 million (when you're simultaneously adding pre-existing capacity) isn't really a bit problem; even if that 10 million is currently underserved. In fact, I think in most areas care provision would only get better, though I could imagine some cases where it would get worse.

Re: the rest, I can't really speak with any authority. I know my friend (and others I know working either for the military healthcare system or the VA) generally treat it like any other medical job, but I certainly can imagine there may be some subtleties that aren't apparent to the outside observer.

And, just so we're clear, we are in this thread implying that modeling something after Medicare may be a good thing

*shrugs* A pseudo single payer system is better than a single provider system IMO. Medicare has relatively low running costs (esp. compared to private insurers) and could probably just fold VA patients into a new arm of their system without too much trouble. There are all sorts of issues with CMS - don't get me wrong, I have friends who work there too - but I think it's miles better than the VA. And an advantage to combining the systems is that Medicare reform (e.g. allowing bargaining for drugs and devices, changing cost structures to improve incentives, ACOs, etc.) could also help fix issues with veteran's healthcare simultaneously. (Medicaid, being largely run by states, does not benefit from the same scale.)

[Loki]

http://www.nytimes.com/2014/07/26/wo...-missteps.html Another great US government-operated healthcare system.

[Lewkowski]

Someone I know well just started a petition on the White House's website (linked here). She suggests that the bricks and mortar VA system should be scrapped in favor of a national insurance scheme like Medicare, where people can go to any doctor or hospital but be covered by the government. This is in contrast to now, where veterans must travel to often inconvenient VA facilities for treatment, and is particularly topical given several recent scandals in VA administration and waiting lists.

The wrinkle here is that the author is an attending physician at the ER of a major VA hospital, and has a front row seat to the disaster that is this system. She generally has positive things to say about the medical staff, but has frequently groused at the utterly broken bureaucracy in administering the system. As an aside, she's also a dyed in the wool Democrat with no particular antipathy to government largesse; she just can't stand the waste and nightmarish process of getting care through the VA.

What do you guys think? I can see some legitimate issues, but it seems like a pretty sensible position.

The VA is an example of government ineptitude. I'd say give veterans a choice to stay in the system or have their treatment paid for through outside doctors.

[Spenni]

The VA is an example of government ineptitude. I'd say give veterans a choice to stay in the system or have their treatment paid for through outside doctors.

You already have the choice you don't have to go to V.A. But its a nice option to only have to pay 15 dollars for a medical check up..

[Loki]

The co-payment for most decent insurances is about the same. The difference being that I could see a doctor within a day, not a month.

[Aimless]

I've always wondered one thing btw: what would regular insurance cost a vet anyway? Taking into consideration things like pre-existing conditions etc.

[Loki]

Insurance can't discriminate based on that anymore.

[GGT]

I don't know of any healthcare providers in the VA system who are active duty members of the US military. I could be wrong, but the vast majority are civilians.

They're all civilians... And don't have a military command structure....

I was talking about http://en.wikipedia.org/wiki/Categor...cal_facilities that still have large military medical staff.

wiggin is right -- there's a lot of historical relevance. There used to be tons of Army and Naval bases throughout the US, and each one had its own hospital that could be used by active-duty *or veterans* because it was organized under one huge bureaucracy. That changed during "peace time" restructuring when many Bases were closed. WWII, Korean and Viet Nam war combat vets were transitioned to private long-term care "Nursing Homes", or got money to pay for Home Health Care assistance.

Remember -- all these changes were happening at the same time private healthcare was changing, too. It was no longer necessary to admit a patient for a week to do a complete "Cardiac work-up", or a day or two before major surgery (once commonly referred to as "pre-op days"), or be an Inpatient to get comprehensive physical therapy and rehab.

The military was slow to "evolve" at the same speed, but it's not just because it moves like a snail under the weight of large governmental bureaucracy. No, it's actually complex and difficult to care for several generations of veterans, from very different wars, all at the same time. Particularly since we now know that war wounds can take years, even decades, to fulminate.

[LittleFuzzy]

I was talking about http://en.wikipedia.org/wiki/Categor...cal_facilities that still have large military medical staff.

But none of those are part of the VA, I don't think. I know that Walter Reed specifically is not part of the VA though it does, of course, have liasons with the administration. They do treat family and "military retirees" through the Tricare program (and its something-CHAMPS predecessor) and I will readily acknowledge that I don't understand the difference between discharged vets and the VA, on one hand, and Tricare and "military retirees" on the other. All I know is that there is one and it is apparently important. What I do know is that the permanent military hospitals do not give primary care to vets except for procedures and some therapeutic treatment proximate to their active service, or as it relates to their function as adjuncts to general community health services in their area (for instance, San Antonio provides care as called for as a teaching hospital with a relation to several medical schools in Texas)

[GGT]

But none of those are part of the VA, I don't think. I know that Walter Reed specifically is not part of the VA though it does, of course, have liasons with the administration. They do treat family and "military retirees" through the Tricare program (and its something-CHAMPS predecessor) and I will readily acknowledge that I don't understand the difference between discharged vets and the VA, on one hand, and Tricare and "military retirees" on the other. All I know is that there is one and it is apparently important. What I do know is that the permanent military hospitals do not give primary care to vets except for procedures and some therapeutic treatment proximate to their active service, or as it relates to their function as adjuncts to general community health services in their area (for instance, San Antonio provides care as called for as a teaching hospital with a relation to several medical schools in Texas)

An important point worth making....is that many military veterans don't have any better idea about their care than you do, as a civilian. And you're probably more informed than many modern vets. They enlisted based on all sorts of expectations.....including total healthcare for themselves, and their immediate family by proxy.

That's one predominant reason behind our "voluntary" military.

For the most part, Americans don't enlist in the military for purely patriotic reasons. If they did, we'd have more than 1% of the population serving in armed forces.

[Spenni]

I think people are getting the VA and the military healthcare system confused. They are two separate entities entirely. And again GGT no military doctors work at the V.A. because it is not a Military institution.
The VA is more than health insurance guys, it handles everything from education benefits to healthcare to business grants to disability claims, in fact the disability claims are what is kicking their ass. Terrible foresight by the way. I mean if your in two long terms wars claims are going to spike, and if the V.A. had spent the money on extra doctors and staffing to meet those needs from the get go probably wouldn't of have had the backlog..


Wiggin asked for my views on the matter, I gave him a half ass answer via pm while i was on road trip, but in all honesty I still haven't wrapped my head around yet. V.A. does do a lot of good outside the medical portion of it. However the medical portion of the is the biggest part, and its a fucking nightmare. At the very least it needs to be reformed and streamlined but thats been needed since Vietnam. Every administration since then has kicked the can. Something I find insulting really, my brother fight our country's wars and the government can't get their shit together on something that we are in dire need of.


Back to the medical/claims portion. No I don't think it should be abolished because there is a system in place for claims and the medical portion in neccesary for that. However I am not above outsourcing if the doctors are overwhelmed. That I think it can easily be arranged and with the huge backlog still there just as easily justified. It's a bandaid but while but it nee done to relieve the stress on the system. once that stress is relieved and will take a couple of years for it to even out again. then direct reform should be looked at. It won't because the politicians don't know their head from their asses anymore but thats what should be done.


I again I stress the V.A. is not just medical. It handles all of our veterans benefits. Federally. So abolishing it would be a terrible idea.

[Loki]

If the VA does the non-medial parts well, why can't it just do those non-medical things?

[wiggin]

I think people are getting the VA and the military healthcare system confused. They are two separate entities entirely. And again GGT no military doctors work at the V.A. because it is not a Military institution.
The VA is more than health insurance guys, it handles everything from education benefits to healthcare to business grants to disability claims, in fact the disability claims are what is kicking their ass. Terrible foresight by the way. I mean if your in two long terms wars claims are going to spike, and if the V.A. had spent the money on extra doctors and staffing to meet those needs from the get go probably wouldn't of have had the backlog..


Wiggin asked for my views on the matter, I gave him a half ass answer via pm while i was on road trip, but in all honesty I still haven't wrapped my head around yet. V.A. does do a lot of good outside the medical portion of it. However the medical portion of the is the biggest part, and its a fucking nightmare. At the very least it needs to be reformed and streamlined but thats been needed since Vietnam. Every administration since then has kicked the can. Something I find insulting really, my brother fight our country's wars and the government can't get their shit together on something that we are in dire need of.


Back to the medical/claims portion. No I don't think it should be abolished because there is a system in place for claims and the medical portion in neccesary for that. However I am not above outsourcing if the doctors are overwhelmed. That I think it can easily be arranged and with the huge backlog still there just as easily justified. It's a bandaid but while but it nee done to relieve the stress on the system. once that stress is relieved and will take a couple of years for it to even out again. then direct reform should be looked at. It won't because the politicians don't know their head from their asses anymore but thats what should be done.


I again I stress the V.A. is not just medical. It handles all of our veterans benefits. Federally. So abolishing it would be a terrible idea.

Spenni - thanks for your more detailed answer. I want to clarify right up front - my thread title was hyperbolic. Of course I don't want to abolish the institution of providing benefits for veterans. I certainly believe that many of the services that VA provides should continue to be provided; since most of them are largely administrative, I don't see why they couldn't continue to be done by the VA (or a reorganized successor agency with fewer nincompoops running it). I certainly agree that much of its non-medical services should be kept under the aegis of a government agency.

That being said, I think we all know that a huge portion of the VA budget and administration goes to providing healthcare to veterans. It's also a big chunk of their assets - hospitals, clinics, equipment, etc. - and leaves a big logistical train with employee pensions et al. The suggestion, as I understand it, is to keep the VA administering claims and payments just like it currently does - but divest it entirely of the big bureaucracy involved with running a nationwide network of healthcare providers. For your average veteran, I doubt they would see a difference (other than, hopefully, shorter wait times and a larger selection of physicians to choose from). The out of pocket costs would be set by the VA, not the private physicians, and stripped over government shenanigans one can hope that a privately run hospital would work more efficiently. The real difference would be in the administrative overhead at the VA - they could focus instead on benefits eligibility and claims payment, rather than also trying to run a massive network of hospitals and clinics - and also in cost. This would help the taxpayer (and indirectly, veterans), and would hopefully be a better solution for all.

I'm not sure I understand your objection to the theory, but I'd love to hear more when you get a chance. Thanks!



(As for GGT - everyone else has already handled you, it appears, but there's a clear distinction between VA healthcare and healthcare given to active duty servicemembers and their families, which is administered through Tricare and run very differently.)

[Spenni]

Spenni - thanks for your more detailed answer. I want to clarify right up front - my thread title was hyperbolic. Of course I don't want to abolish the institution of providing benefits for veterans. I certainly believe that many of the services that VA provides should continue to be provided; since most of them are largely administrative, I don't see why they couldn't continue to be done by the VA (or a reorganized successor agency with fewer nincompoops running it). I certainly agree that much of its non-medical services should be kept under the aegis of a government agency.

That being said, I think we all know that a huge portion of the VA budget and administration goes to providing healthcare to veterans. It's also a big chunk of their assets - hospitals, clinics, equipment, etc. - and leaves a big logistical train with employee pensions et al. The suggestion, as I understand it, is to keep the VA administering claims and payments just like it currently does - but divest it entirely of the big bureaucracy involved with running a nationwide network of healthcare providers. For your average veteran, I doubt they would see a difference (other than, hopefully, shorter wait times and a larger selection of physicians to choose from). The out of pocket costs would be set by the VA, not the private physicians, and stripped over government shenanigans one can hope that a privately run hospital would work more efficiently. The real difference would be in the administrative overhead at the VA - they could focus instead on benefits eligibility and claims payment, rather than also trying to run a massive network of hospitals and clinics - and also in cost. This would help the taxpayer (and indirectly, veterans), and would hopefully be a better solution for all.

I'm not sure I understand your objection to the theory, but I'd love to hear more when you get a chance. Thanks!



(As for GGT - everyone else has already handled you, it appears, but there's a clear distinction between VA healthcare and healthcare given to active duty servicemembers and their families, which is administered through Tricare and run very differently.)

In theory I agree with you, but its already been fucked with alot that last few years, and god damn it the last thing i need is some restructuring to fuck my education check X_X. Too much pain for gain right now...

[wiggin]

Fair enough; I'm sure the transition would be far from smooth.

[GGT]

I think people are getting the VA and the military healthcare system confused. They are two separate entities entirely. And again GGT no military doctors work at the V.A. because it is not a Military institution.

The VA is more than health insurance guys, it handles everything from education benefits to healthcare to business grants to disability claims, in fact the disability claims are what is kicking their ass. Terrible foresight by the way. I mean if your in two long terms wars claims are going to spike, and if the V.A. had spent the money on extra doctors and staffing to meet those needs from the get go probably wouldn't of have had the backlog..

Yes, the VA is more than just Veteran healthcare, an important distinction. But there are military doctors, nurses, technicians, medics etc. working within the VA healthcare system as part of fulfilling their military service (and re-paying educational loans).

It's rather like the GI Bill in reverse: people have 'enlisted' in the military to cover college costs, but they're required to 'work' for the Armed Services, in some capacity, for X amount of years, with that college degree. That might mean deployment to combat zones, but not always.

Timing is important, contextual, and relative. There are physicians whose medical educations/degrees were gotten during 'peace time', and they did a stint at military facilities OR Veteran's Hospitals/Clinics, then moved to private practice. Today, there are HS students going to college on ROTC/military "scholarships" paying 100% of their education. In exchange, they can be required to serve in any way the military/DoD chooses....including stints at military facilities OR private hospitals using federal funds.

Wiggin asked for my views on the matter, I gave him a half ass answer via pm while i was on road trip, but in all honesty I still haven't wrapped my head around yet. V.A. does do a lot of good outside the medical portion of it. However the medical portion of the is the biggest part, and its a fucking nightmare. At the very least it needs to be reformed and streamlined but thats been needed since Vietnam. Every administration since then has kicked the can. Something I find insulting really, my brother fight our country's wars and the government can't get their shit together on something that we are in dire need of.

Well, that's a symptom of US policies....where our "volunteer" army is conflated with, and dependent on employment, income, education, healthcare, retirement, and other debt incentives.

Back to the medical/claims portion. No I don't think it should be abolished because there is a system in place for claims and the medical portion in neccesary for that. However I am not above outsourcing if the doctors are overwhelmed. That I think it can easily be arranged and with the huge backlog still there just as easily justified. It's a bandaid but while but it nee done to relieve the stress on the system. once that stress is relieved and will take a couple of years for it to even out again. then direct reform should be looked at. It won't because the politicians don't know their head from their asses anymore but thats what should be done.

I again I stress the V.A. is not just medical. It handles all of our veterans benefits. Federally. So abolishing it would be a terrible idea.

I assumed wiggin didn't mean to abolish the entire VA, but re-structure how veteran healthcare was delivered and funded. "Administration" is involved in both, hence the confusion?

In theory I agree with you, but its already been fucked with alot that last few years, and god damn it the last thing i need is some restructuring to fuck my education check X_X. Too much pain for gain right now...

That's what we should be discussing in the first place, since it frames the debate. Incentives matter. Patriotism and Nationalism are worthy values.... but it's how we combine military service with other public values like education and healthcare (and taxation) where policy gets sticky and complicated.