3 Big Issues Facing Healthcare for Veterans

VA workers and patients at the 2016 Memorial Day parade in Chicago, Illinois.

Memorial Day is dedicated to those who died serving in the United States’ armed forces. The majority of American soldiers, however, survive their service—but many move on with a unique host of medical challenges that require detailed, personalized care. The agency meant to help them along the way, the Department of Veterans’ Affairs (VA), receives equal parts criticism and defense for its ability to provide that.

And the divisions over the VA’s role and its performance in recent years have started to spawn policy changes, and the process seems to be accelerating quickly. Let’s look at the major storylines that are unfolding as the United States decides how (and if) it will reshape the agency that cares for its service members.

The Leadership Question

VA Secretary has been a cabinet-level position for nearly 30 years. Since 1989, 16 men have held the position: 9 were confirmed by Senate while the other 7 held the seat in an Acting capacity. Prior to January 2017, no single presidential term had seen more than 3 men hold the title, and no VA Secretary had served less than 3 years of a President’s first term.

>>READ: The Chasm Between Public Perception and Clinical Reality at the VA

In less than half of the Administration’s first term, the agency has had 3 Secretaries—2 acting, 1 confirmed. David Shulkin, MD, concluded the shortest tenure of any confirmed VA Secretary to date when he was relieved of the position 13 months after his confirmation. Currently, Robert Wilkie, undersecretary of defense for personnel and readiness at the Department of Defense (DoD), is serving in the Acting capacity, but the President made the surprise decision to nominate him to serve the agency full-time in mid-May. His confirmation hearings are expected to be held in early June.

It isn’t just Secretaries who have seen turnover, however. In April, the agency’s Acting Chief Information Officer, Scott Blackburn, resigned. He was the 4^th high-ranking VA official to leave the agency in a span of less than 6 months, and the continual turnover has left the agency’s executive leadership page on its website looking dramatically different depending on the month.

The Privatization Battle

Shulkin himself alleges he was fired because he stood in the way of VA privatization. For years there has been suspicion on behalf of the political left that their counterparts on the right want to take the medical functions of the agency—which contains the largest integrated health network in the country—out of the government’s hands.

“They saw me as an obstacle to privatization who had to be removed,” Shulkin wrote in an op-ed. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”

For Shulkin and other opponents of VA privatization, the agency’s failures aren’t the driving factors: It’s the successes. When veterans can get access to care, they say the VA actually outperforms private care in some regions (consistency is an issue throughout the system).

“The dismantling of VA is desirable to Republicans because of what it represents: a successful, publicly funded, integrated health-care system,” VA physician and former administrator, Andrew Cohen, MD, wrote in a recent Washington Post op-ed.

Those who believe the government is on an inexorable drive towards privatization took note of the sweeping, recently-passed VA MISSION Act, a $55 billion piece of legislation meant to evaluate the agency’s infrastructure and realign how the agency reimburses veterans who opt for care outside of the VA. While it passed the Senate with more than 90 votes, it still drew cries from critics who saw its increased emphasis on private choice as an indicator that privatization could be on the horizon.

The Modernization Issue

Whether the VA health system remains government-run or goes private, its IT infrastructure is going to get a facelift. Its legacy electronic health records (EHR) system, Vista, was actually one of the first EHRs ever designed and implemented. Dated in appearances and capabilities, it still receives some affection for its ease-of-use.

But its days are numbered. After nearly a year of delays, the agency formally agreed with Cerner on a multi-year, $10 billion contract to use its MHS Genesis platform, a customization of the company’s off-the-shelf Millennium suite that was designed for DoD and VA. The massive implementation will begin as its progress at DoD has received heavy scorn, and as the agency was mandated to improve interoperability with the private sector by the VA MISSION Act. It will be the largest singular EHR transition ever attempted.

But it isn’t just EHRs that the agency will lean on. Short-staffing and the complexity of veterans’ health conditions have led the VA to become something of an industry leader in telehealth use, with special permissions to allow telehealth care across state lines. The agency has also embraced artificial intelligence and analytics techniques, including a relationship with Google-backed firm DeepMind to use its techniques to try to track patients whose health is deteriorating.

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