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‘Veterans are losing 6 different ways right now’

Many VA defenders believe, encouraging veterans to seek treatment outside its walls — and paying for them out of the VA budget — will take away the cash needed to hire doctors and other staff and to improve aging facilities in some parts of the country. | Wakil Kohsar/Getty Images

The implosion of Ronny Jackson’s nomination to lead the Veterans Affairs Department may look like the Trump administration’s drama of the moment, but it carries big consequences for 9 million veterans in a sprawling health care system with uneven results and a precarious future.

Not only does the VA have no leader, the veteran health care community is divided between conservatives inclined to privatize much of veterans’ care and those who want to invest more in fixing the current system. The impact can be seen across 170 medical centers and hundreds of clinics of varying quality that treat veterans who served in the U.S. military in every conflict since World War II.

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Political conservatives at the agency contend last month’s sacking of Secretary David Shulkin put the VA back on track to support the president’s goals of greater accountability and more veteran choice. But where the Trump supporters see unity, members of Congress and veterans groups see chaos and danger.

“VA’s reputation is damaged, staff is demoralized, momentum is stalled, and the future is shockingly unclear,” said P.J. Rieckhoff, head of Iraq and Afghanistan Veterans of America.

“Veterans are losing six different ways right now, from all directions, and it’s discouragingly unclear why this keeps happening or what might make it stop,” said Joe Chenelly, national executive director for AMVETS, the nation’s fourth-largest veterans group. He and other vets groups say that while VA care is generally good when veterans get into the system, obtaining appointments can be difficult.

The 2014 Veterans Choice program, which made it easier for veterans to get care from private doctors, helped in some areas of the country but has been a disappointment in others. Congress will have to pass a new version of Choice before it runs out of money in June, but Democrats and the administration disagree on how much of the VA’s budget should be spent outside the agency’s facilities.

All the big veterans organizations, representing about 10 million members, rue last month’s firing of Shulkin. They think he and his predecessor, former Procter & Gamble CEO Bob McDonald, were carrying out reforms that made the VA better without risking its dissolution. They aren’t confident that will continue.

“The American Legion is very concerned about the current lack of permanent leadership,” said National Commander Denise Rohan. “The VA has made significant improvements in modernizing and realigning the department since 2014 and was headed in the right direction under the past two incumbents. Our nation’s veterans deserve a strong, competent and experienced secretary.”

The VA is the nation’s second-largest bureaucracy, with a budget of $ 200 billion and more than 350,000 employees. Reforms begun by Shulkin and McDonald disrupted the agency — with some positive effects — but remain unfinished.

With no secretary and many other top jobs unfilled, the current emphasis within the agency is on loyalty to President Donald Trump, rather than expertise, said one official who left recently.

“Under McDonald and Shulkin, everyone was always asking each other, ‘Is this good for veterans?’” said the official. “Now all anyone asks is, ‘Does this further the president’s agenda?’ And no one knows what that is. I haven’t got a clue myself.”

“Choice” for veterans was a buzzword of Trump’s campaign, and it remains central to debate over the agency’s future. The 2014 “Choice” bill, responding to a wait-times scandal, allowed veterans to seek care at private clinics and hospitals, but quickly burned through all its allotted cash and needs to be revised.

The wait scandal also led to an accountability law, signed by Trump last year. It was designed to cull bad apples from management, but of the 1,850 people fired under the law so far, all but 20 were low-level employees, according to Ashley De Smeth, spokeswoman for the American Federation of Government Employees. The most recent batch of firings involved nurses and food service workers.

“Most of our employees feel like they’re in a daily pressure cooker,” said De Smeth. “They’re afraid of being fired, there’s a continued hostile work environment because of ever-changing work evaluation standards, and impossible workloads due to policies and staffing shortages.”

But Darin Selnick, senior White House veterans adviser until last month, said Shulkin hadn’t gone far enough, and that the new powers at the VA would push for more change. The White House wanted Shulkin to give more power to a central office to fire managers, but he delegated most of that authority to field leadership, Selnick said.

“In a few cases, employees who were wedded to the status quo and not on board with this administration’s policies or pace of change have now departed VA,” spokesman Curt Cashour said Wednesday in a news release. “[S]enior VA officials are now on the same page, speaking with one voice to Veterans, employees and outside stakeholders.”

Shulkin blamed the Trump appointees who helped push him out last month for conspiring to slowly privatize the VA. Selnick calls that a myth. He says the other Trump-appointed VA officials just wanted to give veterans more power to choose whether to get care outside the VA.

“There’s never been an intent” to get rid of foundational VA services, such as treatment for spinal cord injuries and post-traumatic stress disorder, he said. However, “no health care system can do everything for everyone. And if VA can’t meet certain standards, vets should have the choice to go elsewhere.”

To be sure, while the VA is the only large, federal single-payer health system in the United States, it’s not entirely public even now. Veterans seen at the VA get only a third of their health care in its facilities, on average.

But at some point, many VA defenders believe, encouraging veterans to seek treatment outside its walls — and paying for them out of the VA budget — will take away the cash needed to hire doctors and other staff and to improve aging facilities in some parts of the country. VA officials also say they have 35,000 unfilled vacancies in the health system.

Although the biggest public group calling for VA reforms is the Koch brothers-supported Concerned Veterans for America, every study that’s ever been done of the Choice proposals shows they will be hugely expensive, apparently undercutting calls for fiscal restraint.

“It’s [a] fantastic, liberal, big-spenderish thing to say, ‘All vets have free choice to choose their health care, just send the bills to the taxpayers,’” says Phillip Longman, a policy analyst who served on the Commission on Care, a massive 2016 study of the VA. “The Koch movement is libertarian. Can they really be for this?”

Longman said the true advocates of privatization are more likely large academic medical centers and other health care systems that want as much of the VA’s business as they can get. Health networks such as the Cleveland Clinic, TriWest Healthcare Alliance and Ascension Health have spent hundreds of thousands of dollars lobbying on VA issues in recent years.

The power vacuum at the VA is partly due to the decay of the agency’s decades-old support structure, which some called the Iron Triangle — referring to the agency, VA congressional committees and veterans organizations such as the American Legion.

As the number of veterans shrinks and surviving vets increasingly cluster in a smaller percentage of congressional districts, veterans’ issues have become more provincial and also more subject to partisan politicking, as the centrist veterans groups lose clout.

The shrinking veteran population in some areas also puts the agency into a chicken-and-egg quandary about how to assure care for veterans without wasting resources. Some little-used clinics clearly need to be sold or closed. Others may be the only resource for veterans in a large geographical areas. If care is consolidated, veterans may abandon the VA, leading to more privatization.

Ronny Jackson is pictured. | AP Photo

“Nobody is actively lobbying to privatize the Veterans Health Administration,” said a Democratic staffer. “But under the guidance of providing more choice, these organizations are working to take money that otherwise would be used for care at VA and move it to [the] private sector. The more you refuse to invest in VA, the more private care is necessary to fill those gaps.”

A former senior official who had dealings with Trump on veterans‘ affairs said he wasn’t sure whether the president understood the fine line between veterans’ choice and allowing the VA to bleed out.

When Trump stayed out of the details and let Shulkin drive policy, things went well, the official contended. But sometimes “someone was whispering in his ear to do things differently.”

Without more investment, the official said, the VA in many cases won’t be able to provide the kind of services that veterans want to keep.

“The real issue is, are they willing to invest in making VA a stronger, more competitive place?” the official said. “Or are they not willing to do that? And if so, the answer is care in the private sector.”

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