The Veterans Health Administration (VHA) has long been the subject of aggressive privatization efforts. However, veteran organizers say the fate of the program, drowning in fresh scandals under embattled Veteran Affairs (VA) Secretary David Shulkin, has never been in more danger than it is now.
The efforts to outsource veterans care are waged by the Koch brothers and their front group Concerned Veterans for America (CVA), among other advocates of privatization. The group held a press conference to discuss its privatization efforts -- which they like to call "choice" -- on Friday in DC. Should they succeed in their goals, it will have consequences not only for veterans, but also for the broader movement for a public system like Medicare for All. The VHA is the only truly public, fully integrated health system in the US. The attacks against it aim to undermine public support for government-run care.
In recent weeks, two critical VA Inspector General (IG) reports were released: one about Shulkin's excess spending during travel, the other about bad conditions in a VHA hospital in DC. Reports say the scandals could cost him his job. A Washington Post investigation described Shulkin's efforts to save his job "amid a mutiny," and relayed a surreal anecdote about the secretary working with an armed guard outside his door. His own aide was trying to push him out, according to several media reports.
The VHA is the only truly public, fully integrated health system in the US. The attacks against it aim to undermine public support for government-run care.
This chaos and negativity around the VA is in line with the sorts of circumstances that the Kochs have thrived on in the past, notably when they "exploited the Veterans Affairs crisis," as a 2014 Nation article observed, to further attack the "the idea of government-provided healthcare." Many veterans and organizers say Shulkin's troubles have little to do with traveling expenses and are more about an effort to push a militant ideologue in power to privatize the VHA.
"Veterans groups are worried that privatization advocates are using the [Inspector General reports] to get their way," according to James Clark at Task and Purpose, a news outlet devoted to veterans issues.
This sentiment was evident from public statements from veterans service organizations (VSOs) about the possibility of Shulkin being replaced.
"Their goal is to have somebody in place who, a couple days after they are confirmed, will go about bulldozing VA facilities," said Will Fischer, the director of government relations at VoteVets, a progressive veterans organization.
Trump's Ominous Phone Call to Koch Associate
Rumors of threats to Shulkin's job security come amid a flurry of changes in major positions in the Trump White House, including at the head of the State Department and the CIA. While initially Trump supported his VA chief enthusiastically, he recently scolded Shulkin at a meeting, Axios reported on March 11.
During the meeting he took the unusual step of calling former Koch associate Peter Hegseth (now a Fox News pundit) to discuss how best to privatize the agency. Hegseth, former CEO of CVA, was strongly considered for the post during the transition -- an ominous sign for Shulkin, who is seen as too moderate by many conservatives in the White House.
These ideological factors, and not merely the ethical issues raised in the IG report, help explain why right-wing commentators are so loudly calling for Shulkin's ouster, while VSOs, which largely oppose privatization, are still mostly supportive of Shulkin, despite his political liabilities.
"We don't want to see someone come in and start over. I think we will see the VSOs remain supportive of Shulkin," said William Attig, executive director of the Union Veterans Council, AFL-CIO, in an interview with Truthout. "There is a lot of money for some to make by farming out services to the private sector, but what the VHA needs is to be fully funded, not privatized."
Even if Shulkin manages to keep his job -- he is not likely to go down without a fight -- he will be in a weakened state at an agency where Trump's conservative "staffers are advancing health policy at odds with his own," according to a ProPublica/Politico report from February, which said war was "raging between the White House and veterans' groups, with Shulkin caught in the middle."
It's possible that Shulkin could accelerate privatization efforts to appease Trump or deflect the news away from his personal scandals. Meanwhile, whatever becomes of Shulkin, the Koch war on the VHA is clearly reaching a boiling point.
A Mixed Record on Privatization
Shulkin is not a progressive icon by any means. His appointment, however, did bring about relief for many veterans and Democrats. He was appointed by President Obama to be the VA's undersecretary of health, and wrote a book praising the VHA. During his confirmation hearings for his position under Trump, where he was unanimously supported, he said the privatization of the VA "will not happen on my watch." He won the support of key VSOs who "had fended off far worse candidates."
This is not to say everyone is pleased with his performance. Some argue he has not followed through on this promise and has been complicit in Trump's ongoing efforts to privatize the system. "He is an unreliable advocate for the VA health system," said Suzanne Gordon, author of The Battle for Veterans Healthcare, in an interview with Truthout. "He sometimes doesn't call it privatization, but that is what he is doing. He has also been using the same conservative rhetoric about the VA being broken."
Six months into the Trump administration, Shulkin wrote a USA Today op-ed that insisted, once again, that he would not privatize the VHA, saying "nothing could be further from the truth." But in the same article he added that veterans should get the best care possible, "whether it comes from the VA or the private sector." Shulkin put forth these contradictory arguments while lobbying for $2 billion to extend the controversial VA Choice program for another six months through a variety of cuts and fees that were opposed by VSOs. Shulkin also suggested farming out the VHA's optometry services because "there is a LensCrafters in every corner."
None of this has stopped VSOs from standing with Shulkin, if only to avoid his replacement. As Clark wrote (emphasis in original): "the rallying cry for Shulkin amounts to: Better the VA chief we know."
Now there is a struggle between the VSOs and conservative power brokers within the Trump administration. Although the attempted VA "coup" on Shulkin, to use The Washington Post's phrase, is "popular in the White House, the effort is viewed skeptically by the American Legion and other veterans groups that fear it will lead to VA's downsizing."
Louis Celli, national director for veterans affairs for the American Legion -- the largest VSO in the country -- called the attack on Shulkin a "salacious conspiracy," and "treason." VoteVets filed a Freedom of Information (FOIA) request for documents about replacing Shulkin.
Meanwhile conservative lawmakers and media called for Shulkin's ouster. "His main agenda is to block any real reforms for veterans, which includes expanding their ability to obtain care from private doctors and hospitals," said syndicated columnist Michelle Malkin. "He needs to hear those famous words from [Trump]: 'You're fired.'"
On February 15, a day after the first IG report was released, The New York Times reported that critics within the Trump administration wanted to "knock Shulkin down a peg or two" for "not pushing harder for privatization." Some conservative/Koch-funded attacks on Shulkin predate not only the IG report, but the Trump presidency. In 2016, when Shulkin was under secretary for health at the VA during the Obama presidency, Concerned Vets for America criticized Shulkin for embarrassing the VA. "The American people were treated to a show of incompetence and shifting of responsibility by Dr. David Shulkin," a story on their website said of a congressional hearing.
The Veterans' Health Administration: Myth vs. Reality
Negative press on the Veterans Health Administration is not new. In many ways it mirrors the US media's treatment of foreign health systems, such as Canada, which get similar treatment in the national debate. (This is improving since awareness of single-payer has grown, due in part to the Bernie Sanders campaign in 2016.)
The popular narrative of the VA as a frightening case study in the horrors of "socialized medicine" is largely the result of an effective Koch-fueled messaging campaign. The Kochs make it easy to attack the VHA, amplifying any bad news they can find from around the country on their front group's website and on social media using the hashtag #VAFail:
Rarely, however, do the pundits who mock the VHA compare it to private insurance using metrics like cost, quality and patient satisfaction. The VHA, studies show, is superior to private health options, is more cost efficient and has happier patients. The VHA has, according to numerous reports, been found to "compare favorably" to our private system: Better surgical conditions, higher vaccination rates, better outcomes with stroke treatment and controlling blood pressure are just a few of the areas where VHA care was superior. This helps us understand why the VHA scores high on satisfaction surveys among its patients. One Gallup poll from 2015 showed veterans as the most satisfied group of patients in the country, followed by Medicaid and Medicare recipients, with private care being last.
In the New England Journal of Medicine, Shulkin himself boasted that the VA outperforms private industry in "lower risk-adjusted mortality rates, better patient-safety statistics, and better performance on a number of other accepted process measures."
It also ranks especially well in mental health services. As a 2016 report from Psychiatric Services, a peer-reviewed journal of the American Psychiatric Association, concluded: "We found that the quality of care provided by the VA to veterans with mental and substance use disorders consistently exceeded the quality of care provided by the private sector for the performance indicators examined, sometimes by large margins."
The VHA was recently praised for having a good record with transgender patients, compared with private insurers. "This is an optimistic and promising finding for VA and perhaps reflects the recent advances in transgender health in VA," concluded the Journal for Medical Care in September 2017.
The VHA, of course, has major flaws. While the Kochs often amplify bad stories, the VA has made their job too easy with public scandals. There were serious problems in the aforementioned 2014 incident involving falsified reports to hide long wait times, which still hamper the agency today. This was only six years after another high-ranking VA official, according to Veterans for Common Sense, "cooked the books" on suicide data, to make the crisis seem less severe.
The VHA compares favorably to private care, but it is still lacking in many ways. Many veterans with PTSD receive subpar care, in part due to a lack of mental health staff. The VA estimates that about 20 veterans a day commit suicide.
Underfunding is a major problem. "Congress left the VA woefully unprepared for all the problems that took place in two wars in Afghanistan and Iraq," Attig said. "My feeling is if you can afford to send people to war, waged for some questionable reasons, you should be able to afford to take care of them when they come back."
Private insurance providers, however, have major problems too, including wait times that are worse than the VHA, according to a September 2017 study commissioned from the American Legion. "Does anyone doubt that many Americans have died while waiting for approval from private insurers?" asked Paul Krugman of The New York Times in 2014.
Indeed, every health system has flaws. If the VHA were sufficiently funded, and there were more public investment in it, it could improve its care dramatically. Conservatives, however, have been effective at telling Americans that the problems are caused by government. The story of the VHA is one largely being told by its harshest critics.
Socialized Medicine Saves Lives
But there is another story to tell: about the VHA that saves lives. Samuel Jay Keyser, 82, is a professor emeritus of linguistics and philosophy at MIT. At 78, he went paralyzed from the chest down and was told by doctors he would never walk again. After spending months in the Intensive Care Unit, rehab and various other hospital beds, he was told he would no longer be able to have his treatment covered.
A nurse heard he served in the Air Force in the 1960s and suggested calling the VHA, he told Truthout. "This was my introduction to 'socialized medicine,' and the difference was palpable. I had been through virtually every part of the US health system, and the VHA was the only place where money didn't seem like a major priority," he said.
Now Keyser spends time talking about his story, and how the VHA was the only place that didn't give up on him until he was healthy enough to go home. "Everyone should be able to experience care like that," he said.
Save the VHA: An Election Issue?
The effort to stop the Koch/Trump attack on the VHA is a subject on which VSOs, progressive groups and single-payer advocates can find common cause. While single-payer advocates routinely defend systems in Canada, the United Kingdom or Taiwan, the VHA is far less frequently noted, though it is the only socialized health care system in the United States. It could be held as a model for the benefits of public health care.
VSOs have also taken similar positions as progressives on several contemporary health care issues. VoteVets has opposed Trump's latest attack on Medicaid via work requirements, saying Trump "has now officially declared war on veterans in need." For similar reasons, they were among the many veterans groups that opposed the Medicaid cuts in Trumpcare bills from 2017.
More than 30 percent of veterans make less than $30,000 annually, Attig maintains, and depend on these social programs. The VHA covers about 9 million veterans and has strict eligibility requirements that leave many former service members unable to use the service. "Cuts to Medicaid, Medicare, unemployment -- they are all cuts to veterans as well," he said.
If the Democrats chose to put a lot of political capital into protecting the VHA, they could rightly hit Republicans for cutting support for the troops. This priority could also appeal to single-payer advocates and the 80 percent of Democratic voters who support a public health system.
"I would like to see candidates put this issue at the center of their campaigns," Attig said.
So far, however, VSOs have mostly had to fend for themselves, with the media and the Democrats focused so strongly on other issues. If Democrats aren't interested in making the preservation of the VHA a priority, advocates say, organizers and veterans groups will have to continue to pressure them.
"Privatization is a very real issue right now," Verna Jones, executive director for the American Legion, recently told reporters at the National Press Club. "This isn't something we can sit idly by and hope that it doesn't happen."