This piece is part of Fighting for Our Lives: The Movement for Medicare for All, a Truthout original series.
As Senate Republicans' Affordable Care Act repeal bill threatens more than 441,300 veterans' Medicaid coverage by 2026, new proposals by the Trump administration and Department of Veterans Affairs (VA) Secretary David Shulkin also threaten the nation's largest, integrated, government-run health care system: the Veterans Health Administration (VHA).
Secretary Shulkin unveiled a proposal before the Senate Committee on Veterans Affairs on June 7 for the creation of a "Veterans Coordinated Access Rewarding Experience" program to replace the unpopular 2014 Veterans Choice Program, which will sunset in August.
The new proposal eliminates mandates that were originally required under the Choice program. Under that program, veterans could only select a private-sector doctor if they had to wait 30 days or more for care from the VA, or had to drive more than 40 miles to a VHA facility.
"Under the new proposal, veterans and VHA providers will discuss every decision about care, and decide, on a case-by-case basis, whether care at the VHA would be better than the private sector. The plan, combined with President Trump's overall VA budget, would ultimately push more veterans into the private sector as the VHA is stripped of needed resources. If the trend continues, it could eventually lead to the dismantling of the VHA system entirely," says Suzanne Gordon, author of The Battle for Veterans' Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care in The Hill.
The proposal comes as legislation to overhaul the VA appeals process unanimously passed the Senate Committee on Veterans' Affairs last week and heads to the full Senate for a vote. It also comes as President Trump signed the Accountability and Whistleblower Protection Act into law in June that will make it easier for the VA to fire problematic employees and promote whistle-blowing in the aftermath of the 2014 national scandal over manipulative record keeping that obscurred lengthy amounts of time for care at VHA facilities. While veterans died while waiting for care in some places, there is no known link between the deaths and delays, according to The Washington Post.
Still, an increasing body of research shows that the VHA delivers care that is equal or superior to that provided in the private sector, with studies confirming its quality of care even after it was revealed that faulty record keeping concealed lengthy wait times at some VHA facilities in 2014.
Meanwhile, President Trump's VA budget would impose drastic cuts to much-needed resources -- sparking fierce criticism from both Sen. Bernie Sanders and Sen. Jon Tester.
"Our job is to improve to what already works reasonably well and not to dismember it," Senator Sanders said of Secretary Shulkin's Choice replacement proposal. "That is a fear that many veterans service organizations have, and it is a fear that I share."
Trump's VA budget is 6 percent larger than last year's, but the increases are funneled toward privatization. According to Senator Tester, 33 percent of the increases in the proposed VA budget go to private-sector care, while only 1.3 percent go to VA care. Trump's plans for a $186.5 billion VA budget for fiscal year 2018 include $13.2 billion in mandatory funding for outside-care programs.
"By making [private-sector care programs] mandatory, [VA officials] will be then pulling money out of other VA programs to fulfill the obligation of [private-sector care programs] being mandatory -- thus turning the VA into a slush fund for hospital executives and privatized care," said Will Fischer, a Marine Corp veteran who deployed to Iraq in 2004, and who is director of government relations for Vote Vets.
Moreover, Secretary Shulkin's plan to fund the Choice replacement program would cut disability compensation paid through the Individual Unemployability program to 208,000 severely disabled veterans, while the Trump budget proposes to scrap the Individual Unemployability program entirely.
The new plan also includes proposed pilot projects that reflect those previously offered in the 2016 "Strawman document" to the VA Commission on Care. The Strawman document's authors included members of the Koch brothers-funded Concerned Veterans for America and hospital executives who stand to profit from privatization. The document pushed for the dismantling of the VHA, using the 2014 scandals as a justification. Congress established the commission as an oversight group in the wake of the scandals to evaluate veterans' access to health care and recommend proposals for how to reshape the VHA over the next 20 years.
The proposals could spell the end of the VHA as we know it -- something veterans groups like Fischer's are pushing back against. They say single-payer advocates should be opposing these dangerous proposals more visibly.
Diane Reppun is a member of Fighting for Veterans Healthcare (FFVHC), a veteran-centered organization working to fight privatization efforts and improve the VHA. She deployed to Iraq in 2009, and has been getting her care from the VHA since 2010. She works as a supervisory program analyst in the office of education at the VA, managing graduate medical education for University of California medical residents and fellows on rotation at VHA facilities.
Truthout spoke with her as she was driving to Los Angeles for a Reserve Officers Association event, at which she planned to pass out information warning about ongoing privatization efforts.
"[Politicians'] all say 'Oh no, we're not going to privatize,' but then they turn around, and they do things that will eventually make the VA so withered that people will say, 'Well, I have to go to the private sector now.' It's basically stealth-privatization," she said. "It produces an incentive for the people who want you to go to the private sector to not fund the VA and keep the VA strong."
FFVHC does support the VA utilizing private-sector partners in some instances, to ensure veterans get timely care even during staff shortages or surges in veteran enrollment. But they argue this needs to be done using supplemental resources -- not at the expense of existing services.
"None of us are saying that there is never a situation in which the private sector can't help," Reppun said. "It's just that if your intention to start off with is to basically say, 'The VA sucks, and we're going to make sure that you can use something else,' it could be a self-fulfilling prophecy, and that's exactly what we believe most of the people who are appointees by Trump are trying to accomplish."
She and other veterans advocating on behalf of the VHA support single-payer as a way of expanding access to health care for all veterans, and want to see single-payer advocates take an active role in dispelling right-wing myths about the VA and VHA as a step toward accomplishing universal health care for all.
"You can look at the VA as an example of a fully integrated, single-payer system for certain veterans," Reppun says. "But very few people know what a good example the VA is because of this concerted, determined effort by the conservatives [to smear it]. It's a real threat to the whole concept of single-payer."
Progressive veterans organizations say that the problems exposed by the 2014 national scandals around waiting times at VHA facilities are a symptom of substantial increases in health care workloads, coupled with inadequate staffing and funding levels. On top of that, the Iraq and Afghanistan wars have increased demands on VHA resources. Many Iraq and Afghanistan veterans have come home with complex health challenges, such as traumatic brain injury, multiple amputations and post-traumatic stress disorder.
"[The VHA] is over-capacity because we have been at war over 16 years now, and turning out tons more disabled veterans. So, when the population served grows exponentially and the staff doesn't, there's no way to keep up," says Gina Bua, an Army veteran and former VA employee, who is on the board of directors of Iraq Veterans Against the War (IVAW). "We've grown the rest of [the] military budget exponentially, but we aren't willing to support the disabilities that come as a result of the wars. That's where there's a huge disconnect with our Congress."
In addition to campaigning against veterans' health care privatization and calling for increased VA funding, IVAW is also calling for a reprioritization of the national budget that would reduce military spending.
"We need to change our whole national budget to where we're not spending most of our money on a huge war machine and the military industrial complex," Bua says. "If we had those dollars not being spent on military hardware, upgrading the nuclear arsenal and those things, we would have money to provide health care for everyone."
Both Bua and Reppun said they have attended various VA-focused town halls and forums in which the problems with private-sector programs have been on full display, with veterans actively speaking out about the Choice program's lengthy wait times and other complications.
Wait times for new appointments and care are not much better in the private sector than at a VHA facility. Health care consulting firm Merritt Hawkins conducted a 2014 study of wait times in US hospitals, finding large disparities and lengthy waits depending on location. In an updated study this year, the firm found that wait times in 15 metropolitan areas had increased by 30 percent since 2014, with an average wait time for a new appointment lasting about 24 days.
Additionally, multiple polls have confirmed that a majority of veterans are satisfied with VA care. Most recently, about two-thirds of nearly 11,000 veterans polled by Veterans of Foreign Wars indicated that not only are they satisfied with VA services, but that they would prefer improving VHA medical services to establishing private-care programs.
Beyond health care, veteran-activists told Truthout that VA benefits have been essential in getting jobs, housing and education after returning home from deployment overseas. Fischer, for example, who also receives his health care from the VHA, bought a house and earned his degree via VA programs.
"The VA is popular among the people who use it," he said. "The VA works very well and the VA is a government-run, single-payer health care system. Those who are the enemy of universal health care know that if they can kill the VA, they can axe the hopes of there ever being single-payer," he says.
Despite the VA's overall popularity among veterans, advocates say it does not extend far enough. Not all veterans are eligible for full health care benefits from the VHA, including veterans who have less than an honorable discharge, who served less than 24 continuous months or who are less than indigent. Moreover, those who have less than a 50 percent disability rating based on their military experience do not typically receive full medical benefits, and only receive care for service-connected injuries and ailments. Those with disabilities that are deemed to be less serious also typically experience longer wait times for appointments.
That's why Reppun, Bua and Fischer all hope to eventually see a national health care program that would ensure every veteran -- and non-veteran -- is cared for.
"[The VA] is a great system, and I think that that level of care is something that everybody in this country deserves, which is why I support single-payer," Bua says. "I think we should just extend the amount of hospitals we have that are like the VA, and provide that kind of care for everybody."
The activists say coalitions between their organizations and single-payer advocates are steadily growing, but that their organizations are focused first and foremost on saving the VA and defeating Trumpcare. IVAW members are currently in talks about their ongoing campaign to save the VA being part of a larger call for universal health care, though that position is not yet official.
"First we have to fight the battle of what they're doing to the VA. As much as I agree with [single-payer], I have to put my energy into what I can actually accomplish," Reppun says. "If saving the VA helps [the push for single-payer], then that's a bonus."