David Sandman

David Sandman

Just after Dr. David Shulkin was confirmed unanimously last year as Secretary of the U.S. Department of Veterans Affairs (VA), I shared my advice for reforming the VA.

Despite his accomplishments, Dr. Shulkin was fired via tweet in March 2018. Now we have a new VA Secretary, Robert Wilkie. The job has been a revolving door; Secretary Wilkie is the fourth person to hold this role in the last five years. After so much turnover and turmoil, the VA desperately needs stable, focused, veteran-centered leadership.

Much of the advice I had for Dr. Shulkin still holds true today for Secretary Wilkie: he should listen to veterans themselves, restore trust and credibility in the Department, ensure timely access to high-quality care, and be cognizant of the evolving needs of an increasingly diverse community of veterans. But there are a few other pieces of advice that are especially timely and pressing:

1. Don’t succumb to the false choice of VA privatization.
A battle is raging over whether to preserve the VA system largely as it is or to privatize even more VA health care. It’s a binary question that oversimplifies a complex topic, and it sets up a false choice. Veterans want and need options about where they get their care, and research backs this up: about half of veterans want to get their care at the VA, while half prefer community-based options.

The VA generally delivers care that is at least comparable to and often better than private care. Research from the RAND Corporation shows that private care is neither safer nor more efficient than VA care. VA health care, for example, outperforms private sector care on more than 95% of measures of outpatient treatment such as diabetes care and cancer screenings. But veterans also want community-based options. For some, the nearest VA facility is too far away from home. Others want to get their care in the same place as their spouses and children; they don’t want their family’s care to be fragmented. Still others worry that VA care, especially for mental health issues, is stigmatizing. And some prefer to use both VA and community options, depending on the type of care. These preferences are practical. Veterans should not be asked to sacrifice their health for an ideological agenda.

Rather than fighting about where veterans get their health care, the VA should focus on improving the quality of care for veterans, wherever they choose to get it. The VA and community-based providers shouldn’t exist in separate orbits that result in fragmented and uncoordinated care. Secretary Wilkie can best serve veterans by supporting a strong, accessible, and high-quality VA that works in tandem with community-based private care, ensuring that care is coordinated across providers of all types.

2. Avoid the pitfalls of the Choice program as you implement the Mission Act.
Faced with scandals over long wait times, Congress hastily established the 2014 Veterans Choice Program, which allowed veterans to use VA benefits with private providers in their community. The program was troubled from the start; wait times remained inexcusably long and approved provider networks were inadequate. Providers who did participate sometimes didn’t get paid.

This past May, Congress passed the VA Mission Act. The new law consolidates numerous duplicative community care programs at the VA (including the Veterans Choice Program) into one cohesive program, extends veteran caregivers’ stipends, and authorizes an asset review of VA facilities throughout the country. It changes the standards for when and how care can be accessed outside the VA. Overall, it has potential to make some important improvements.

But, as was the case with Choice, tremendous confusion surrounds the launch of the Mission program. Local VA directors have complained that there are few details available about the program just weeks before it is to be implemented, on October 1st.

The longer-term problem is how to pay for the Mission Act once funding runs out in the spring of 2019. The White House and Congress are at loggerheads about whether to lift the cap on discretionary funding to support the Mission Act or whether its funding must come through cuts to other programs. There is also uncertainty about how much funding is needed to support the program. The law won’t do much if it isn’t properly funded.

3. Ensure that civilian providers deliver high-quality care to veterans.
In New York State, only about 3% of civilian health care providers report being fully ready and prepared to provide timely, high-quality care to veterans in the community. Less than half of private providers report being familiar with military culture and most report that they do not regularly screen for conditions that are common among veterans. If we want to provide real options for veterans to get care in their communities, more needs to be done to equip civilian providers to address the unique needs of veteran patients. Beyond the basics, strengthening links between the VA and private providers and spurring the exchange of clinical information would help. If we don’t address the civilian workforce issue, failure is likely and it is veterans who will pay the price.

4. Fill critical vacancies in VA staff positions.
The VA currently lacks the human resources to carry out its mission effectively and has more than 45,000 vacancies — more than 1 in 10 department jobs. Three of the most senior positions — deputy secretary, undersecretary for health, and chief information officer — are vacant. Secretary Wilkie has noted that filling these staff positions is a top priority, and progress needs to happen quickly. A severely understaffed agency cannot fulfill its obligations.

The VA is an enormous, complex department, often surrounded by intense politics. Leading it effectively is a difficult task, and one man alone can’t give veterans everything they need. My most important piece of advice for Secretary Wilkie is to make the views of veterans themselves his North Star guiding his decisions in this critical role. Our veterans need and deserve a health care system that works for them, one that delivers timely, reliable, accessible, high-quality care. Given a fair chance, support, and the resources he needs, let’s help Secretary Wilkie do just that.

By David Sandman, President and CEO, New York State Health Foundation
Published in Medium on September 12, 2018

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