The Republican War on the VA

The New York Times reports today that the Department of Veterans Affairs plans to transfer billions of dollars from veterans’ hospitals to private health care providers, initiating “the biggest transformation of the veterans’ medical system in a generation.”  

The NY Times piece goes on: “If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the billionaire industrialists Charles G. and David H. Koch and their network of donors, which has long championed increasing the use of private sector health care for veterans.”

Below is an edited version of my Op-Ed piece for the Washington Post, published last May:

“It’s a reflection of the fact that the VA is a government-run, single payer, bureaucratic health care system that doesn’t work.”

-Senator Ron Johnson (R, Wisconsin) on Meet the Press, April 1, 2018,

Republicans in Congress have made no secret of their intention to privatize the Veterans Health Administration, as indicated by Senator Johnson’s recent remarks. President Trump’s firing of Veterans Administration Secretary David J. Shulkin constitutes the latest Republican assault on the agency.  Dr. Shulkin’s poor judgment regarding his well-publicized European trip would not have provided sufficient cause for firing, were it not for his well-known views about limiting privatization of VA services.  (Remember Treasury Secretary Mnuchin’s use of government aircraft, or EPA Secretary Scott Pruitt’s need to fly first class?).  What is clear is that the dismantling of the VA is desirable to Republicans because of what it represents:  a successful, publicly-funded integrated health care system.

Yes, I said successful.

Sure, the VA suffers from a bloated bureaucracy.  Delays in getting appointments with primary care providers have been subjected to considerable scrutiny.  However, doctor shortages plague US healthcare as a whole; just ask anyone who is seeking a new primary care physician.  The VA succeeds in providing much-needed care to a complex, chronically-ill and largely elderly population.  The abundance of published, peer-reviewed data indicates that VA care is comparable, or in many cases superior to that in the private sector.  As an example, an independent assessment of the VA by the consulting firms of Grant Thornton and McKinsey and Company along with the RAND and MITRE Corporations found that, compared with private sector care:

  • VA post-operative complications were lower.
  • VA inpatient care was more or as effective.
  • VA hospitals were more likely to follow best practices for prevention of catheter-related infections.
  • VA mortality rates decline more rapidly for some conditions.
  • Veterans in nursing homes were less likely to develop pressure sores.
  • VA outpatients received better follow-up care, better mental health and obesity counseling, and blood pressure control.
  • Elderly VA patients were less likely to receive medications that can make them sicker.

For the purpose of full disclosure, I am VA-employed physician, but don’t speak for the agency. For more than 40 years I have practiced as a kidney specialist, largely in the world of private insurance and Medicare. Ten years ago, as part of my employment in a Brown University Medical School-affiliated practice, I became Section Chief of Nephrology at the Providence VA Medical Center.   Having worked in both worlds, I can say with full confidence, the care of veterans with complex medical conditions, such as chronic kidney disease, is generally far superior to private health care.  The reason for this:  the VA coordinates care among many needed providers via its system-wide electronic medical record, and at a lower cost.  Collaborative care, coupled with lower drug costs (unlike Medicare, VA negotiates drug prices with pharmaceutical companies) makes the VA highly cost-effective.

And the VA circumvents profit-driven decision making which permeates American health care.   This notion has recently been confirmed by a study in April’s Journal of the American Medical Association by Kumura and colleagues.  More than eleven thousand veterans with kidney failure, age 67 or older, getting kidney care by either VA or Medicare providers, were studied.  While those treated by Medicare physicians were more likely to be started on dialysis, regardless of co-existing conditions such as dementia or metastatic cancer, 2-year mortality was substantially lower in those treated in the VA, despite an equivalent severity of illness.

This study confirms my personal observations over many years.  In the private sector, kidney specialists are more likely to expedite dialysis in sick, elderly patients despite the absence of clear benefit.  This is because, as one of my nephrology colleagues remarked, “Not only is transferring patients to dialysis easier, it is also tremendously more lucrative.  Reimbursement to nephrologists for supervising chronic dialysis is much, much better than for monthly or bimonthly patient visits to the office.”   Hence, the Kumura study demonstrates what many fighting for “right care” – avoidance of potentially toxic drugs, and unnecessary tests and procedures – have long understood: that contrary to unsubstantiated claims, the VA provides clinically appropriate and often superior care.

Republicans don’t want you to know about the success of a publicly funded fully integrated single payer system. It’s called the Veterans Health Administration.