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Driving the Week: The VHPI Newsletter Logo Image
Last week, VHPI's policy analysts gathered via Zoom to discuss the potential progress and challenges in veterans' policymaking under a divided Congress and Democratic White House. 
The day after Veterans Day, on November 12, VHPI held a zoom forum on the future of healthcare for those who’ve served. The panelists included VHPI senior policy analysts Suzanne Gordon and Russell Lemle, VHPI fellow and interim Executive Director Jasper Craven, and VHPI steering committee member Paul Sullivan.  Commentators during the seminar included leaders inside the American Federation of Government Employees as well as Michael Blecker, executive director of Swords to Plowshares. Collectively, these experts offered proposals and potential concerns for a new Congress and the Biden administration as Washington enters a new era. They also dug into a number of topics VHPI’s three-pronged agenda for the next four years:
 
  1. Reverse the damage that’s been done to the VA healthcare system as the Trump administration pushed an aggressive privatization agenda.  
 
  1. Strengthen and improve veterans’ health services both inside and outside of the VA. 
 
  1. Address long-standing VA staffing and funding problems.
 
The realization of this work requires, among other things, education to ensure that Congress, the Executive Branch, the media, and the public are aware of the many benefits inside the veterans’ healthcare system. This knowledge will not only make it easier to improve conditions for veterans but can also help inform civilians as they work create a more equitable and effective healthcare system.
 
During this global pandemic, new leadership must solve a wide range of festering problems. This work will almost certainly come up against tough opposition from spending hawks. This means that the administration and Congress will have to exercise enhanced oversight – and great wisdom – about how scarce federal dollars are to be spent. While there is rigorous oversight of how funds are allocated inside the VA, there is almost no effort to ascertain – both on a micro and macro level – how dollars are spent in the private sector. 
 
In the webinar, Jasper Craven spoke of the need to improve VA accountability and transparency for the media and members of Congress. This can be attained in large part by speeding up the processing of public records requests and depoliticizing the VA’s press shop and its Office of Congressional and Legislative Affairs. Finally, the VA should open up its Office of Community Care to ensure that the public knows how many of their taxpayer dollars are going to private care under the MISSION Act. The VA must also mandate that any private providers publicly post wait-time and quality data so that veteran patients can compare these metrics with available VA statistics when deciding where to be treated.
 
As Suzanne Gordon explained, the VA is now being held hostage to massive private corporations that are seeing untold numbers of VA patients for unnecessary reasons, then charging the department an arm and a leg.
 
Veterans, for instance, are now being permitted to go to private sector emergency rooms when a VA facility is only a mile away. The VA is also expected to pay full price for an air ambulance and no longer allowed to negotiate discounts. As clinical vacancies in critical positions remain, the department is hiring hundreds if not thousands of staff to manage private sector care. This in spite of the fact that the VA is spending millions to third party administrators like TriWest and Optum. As one VA clinical leader told VHPI, “money we would use to hire additional staff is now going to the private sector.” 
 
A recent order from VA leadership similarly encourages outsourcing of VA care when veterans reschedule an appointment canceled because of the coronavirus pandemic. Gordon said that these orders are only the tip of a very large policy iceberg that Congress and the new administration must expose and reverse.
 
The new administration must also ensure that the VA has the required funds to accommodate an increase in veterans seeking benefits from the VA due to the COVID-19 pandemic.  In the first surge of the novel virus, veteran unemployment skyrocketed from three to 12 percent. As veterans and their spouses lose their jobs and thus health insurance (if they were lucky enough to have any) many will likely turn to the VA for healthcare.  This will mean a significant new surge of patients into the system.  In order to care for those patients, VA will not only need more money to hire more staff but will have to improve infrastructure to accommodate these new patients.
 
In his remarks, Russell Lemle noted that the VA is not allowed to count the availability of telehealth services as meeting its 20/28-day access standard. As a result, veterans are being channeled to private sector providers who give them telehealth rather than in-person appointments, when the VA could have provided the same telehealth services quicker, less expensively, and more effectively. 
 
Veterans are also being sent to private sector mental health providers who are not required to meet minimum competency standards when it comes to treating posttraumatic stress disorder (PTSD), traumatic brain injury (TBI) and military sexual trauma (MST). A license is all they need.  This must be corrected.
 
“A first step would be for the new administration to support and Congress to immediately pass, the VA Clinical TEAM Culture Act, which requires that private sector mental health providers complete a basic four-module course about military culture and core competencies for PTSD, TBI and MST. That would give the right message that quality standards are as imperative in the community as they are in the VA.”
Paul Sullivan, a Gulf War veteran and former Veterans Benefit Administration analyst, observed, “War is very expensive.  The numbers crunchers in a variety of government offices know that if they want to control VA spending increases, the way to do that is to slowly reduce or close the door on veterans applying for any type of benefits.  In most cases, a veteran has to win VBA service connection in order to receive free VHA care.”
 
Sullivan noted that, due to new hiring, new computers, and The Appeals Modernization Act (AMA) passed in 2017, VBA's claim inventory was coming down from almost a million in 2012, to 300,000 in 2019.  That’s good news.  However, because of COVID-19, the economic crisis, and Trump administration policies, the VBA claim inventory is now pushing up near half a million in late 2020. “VBA knows that when the economy goes down, claims go up,” Sullivan said.
 
Sullivan also pointed to problems at the Board of Veterans’ Appeals, where tens of thousands of veteran’s legacy claim appeals (from before AMA) have been languishing for years due insufficient staffing to hold in-person hearings. The new administration also has to rein in the power of for-profit colleges that target a veteran's GI Bill education benefits administered by VBA.
 
The new Biden administration must also look at a new and equally troubling phenomenon which is the for-profit claims representation industry.  Lots of businesses are springing up – multi-million-dollar enterprises, not Mom and Pop shops – that are charging veterans thousands of dollars in fees to offer dubious help obtaining the critical evidence needed to win VBA claims that open the door to free VHA care.
 
Finally, as Sullivan noted, Trump’s VA Secretary has ordered that all Compensation and Pension exams (C&P exams), are to be outsourced from trained and experienced VHA providers to private sector companies. C&P exams are part of the VBA claim process.  The medical exams done at VHA facilities determine if a Veteran has a medical condition, the severity of the condition, and if the condition is related to military service.  Having untrained, for-profit C&P examiners puts a bulls-eye target on the back of veterans.  Privatization and the profit motive push companies to conduct more exams faster.  This drives up costs and pushes down quality, as C&P exams related to conditions such as posttraumatic stress disorder require cultural competency and time to understand the underlying trauma and severity of the condition.  This VA decision must be reversed, and sufficient VHA staff should be hired and trained to conduct adequate C&P exams. 
 
Finally, Michael Blecker explained that, in 2015, the VA received a petition to change the rules making that determines how the VA assesses veterans who have unjustly received other than honorable discharges and are fighting to obtain a positive characterization of discharge review from the VA that would allow them access to VA healthcare. The VA has responded in a less positive way to this petition.  The new administration has an opportunity to act in a positive way to make it easier for veterans to obtain a positive response to the review process, as many received subpar charges due to PTSD, TBI or other conditions formed or exacerbated while in the military.
 
This collective backsliding in the veterans’ policy space is happening because major veterans’ groups are facing budget and staffing shortfalls and diminishing influence. With fewer genuine veterans’ advocates with great institutional knowledge and experience, this creates a perfect storm for privatization.
 
One of the major challenges for the new administration and a critical theme of this forum was the need to carefully study how taxpayer dollars are spent on private sector care so that precious public funds are not wasted on lower quality services in the private sector.  Congress and the new administration will need not only to reverse policies but create new ones that finally give veterans the care they deserve. A truly bold future would also include expanding the role of the VA’s Fourth Mission, which is playing a critical role during COVID-19 in helping struggling private hospitals, to assist the public when they face shortfalls in the private sector.
To wrap up the digest, VHPI asks: Why did the media again choose to use the 2020 National Veteran Suicide Prevention Annual Report to disparage the VA rather than praise department on its good work? 

On November 12th, the VA released its 2020 National Veteran Suicide Prevention Annual Report. It was an occasion to celebrate what were called “Anchors of Hope.” 
  • Between 2017 and 2018 (the most recent year of available data), there was a 2.5% increase in the number of suicide deaths in the general U.S. population, though the suicide rate of veterans increased only a fourth as much, a fractional 0.6%.
 
  • Better yet, between 2017 and 2018, for veterans who use VA for their care, suicide rates decreased by 2.4%, while rising 2.5% among other veterans. This was especially true for women veterans seeking VA care. 
Those manifest successes should have garnered praise for VA’s approach to this vexing problem, especially for concerted efforts within VA healthcare facilities. But headlines of the report by much of the media chose a very different – and negative -- line of emphasis.
 
The Military Times’ led with the headline “Suicide rate among veterans up again slightly, despite focus on prevention efforts.” Stars and Stripes: “Veteran suicides increased again in 2018.” “Veteran Suicide Rate Creeps Up as VA Makes New Investments in Prevention.” Connecting Vets: “Veteran deaths by suicide rose again in 2018, VA report shows.” American Military News: “New VA report shows vet suicides increased in 2018.”  However, Military.com highlighted the positive, “Suicides and Attempts Among Veterans (using VA) Dropped During Pandemic, VA Says,” and UPI’s headline was half affirming: “Veteran suicide rate rises, but is lower for those who recently accessed care.” 

Assailing the VA’s suicide prevention efforts continues to be the media’s narrative, despite VA’s sophisticated strategies (of flagging, extensive follow-up, analytic predicting and provider training) succeeding better than other health systems.
 
Yet, it goes without saying that much more is needed. VA’s suicide report revealed that access to firearms remains the overwhelmingly biggest threat to suicide, and any serious strategy to prevent suicide must include safe firearm storage during crises as a central component. That idea was proposed by Democrats (and opposed by Republicans) at a recent House Committee on Veterans’ Affairs hearing to require providers who treat veterans through the Community Care Network or VA grants to be trained how to counsel at-risk veterans with cultural competence about lethal means safety. A further call for lethal means safety by the press, and politicians, could strongly help to address suicides by the majority of veterans in the community who are outside of VA care.    
 
Lastly, VA facilities could achieve even more superior outcomes if its programs were provided resources to keep up with demand for mental health services. The workforce remains markedly understaffed. Most facilities fail to meet the VA-required mental health staffing ratio of 7.72 clinical full-time equivalent per 1000 MH patients, a ratio that, when attained, has been shown to prevent suicide.
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