Donald Trump considers moving VA toward privatization (The Wall Street Journal)
President-elect Donald Trump is considering moving the Department of Veterans Affairs toward privatization, a transition team official said Wednesday, a policy decision major veterans’ groups have said they would oppose. Mr. Trump is considering changing the department to allow some veterans to bypass the VA heath-care system completely and get care exclusively from private-sector hospitals and clinics, the official said. It is an option that could give veterans full choice over their health care, but which many veterans groups argue is the first step toward privatization and one that will reduce the quality of health care over the long term. “It’s one of the options on the table,” the transition official said Wednesday. ”Definitely an option on the table to have a system where potentially vets can choose either or, or all private.” The possible reform plan was floated after Mr. Trump pulled aside a pool of reporters and instructed the official to give some details about changes he is considering at the VA, and that were apparently discussed during private meetings in Florida on Wednesday. Mr. Trump has met with a handful of people familiar with the VA, the official said, and discussed the possibility of coming up with an advisory council to assist in making changes at the department. “How would you implement a program that could get vets the ability to go to any hospital that they wanted to go to,” said the transition official, outlining conversations that have taken place. “If you were in the VA or out of the VA, how would you set it up?” Veterans groups, and the department itself, say a private-sector care program without adequate VA oversight or coordination leaves former members of the military navigating a private system that isn’t necessarily equipped to handle the unique problems veterans face, including post-traumatic stress and injuries sustained on the battlefield. “Veterans suffer very specific illnesses and injuries that come from the battlefield and that come from service and they tend to be multiple in nature,” VA Secretary Bob McDonald said in an interview on Dec. 13, when asked why the VA needs to remain the coordinating hub of care for veterans. “Veterans want a doctor, or want a provider, who understands these illnesses and these injuries and knows how to deal with them and deals with them every day.” Earlier this month, a group of advocates, including the American Legion, Vietnam Veterans of America and Paralyzed Veterans of America, said at a press conference they would oppose moves to privatize the department.
Commentary: The one problem that will make or break Trump’s pick for VA secretary (Task & Purpose)
Under ordinary circumstances, an enemy’s basic intentions are clear: kill or be killed, whether on the front lines of battle or in the red waters of the free market. Far from easy to execute, but fairly easy to understand. But what’s a strategist to do when his own forces become so wedded to mediocrity and self preservation that they become cultural norms? When accountability itself becomes the enemy to progress? Where any steps taken to bolster accountability are institutionally thwarted, with a little help from labor unions and pro-employee federal policies? With these challenges in mind, the Department of Veterans Affairs’ problems don’t start at the top with the secretary. Nor do the problems begin with the frontline clinical and administrative staff. They start with “the Middle” and propagate upward and downward along the lines of accountability that are to be shared at all levels. For that reason, the Middle is not just a problem, but will perhaps be the most serious problem that awaits the Trump administration’s pick for VA secretary. The Middle, a reference to the mid-level management tiers of VA, best demonstrates what happens when authority and accountability diverge, thus fostering an environment ripe for plausible deniability when things go wrong. Most of the public and too many in our government don’t understand how the VA healthcare structure is set up and how this structure has essentially abetted plausible deniability at certain levels. All 1,233 VA healthcare facilities, including 168 medical centers and 1,053 outpatient sites of care, according to VA, fall within the jurisdiction of a Veteran Integrated System Network, or VISN, of which there are 21. Those VISNs are managed by directors and other senior managers who control the funding and are supposed to oversee the performance for the VA facilities and providers under their respective auspices. This structure was intended to decentralize decision-making authority and integrate the facilities to develop an interdependent system of care. Over-decentralization occurred over time though, spurring rapid growth in the total number VISN staff nationwide, which only called for 220 in 1995. In fiscal year 2011, the combined total number of VISN employees had climbed to 1,340, a 509% increase, while bedside clinician and nurse staffing in specialized VA services eventually plateaued then fell behind demand. The VA failed to adjust by not appealing for more resources from Congress that would have enabled the department to scale its critical healthcare operations to actual demand, particularly in specialized services such as spinal cord injury and disorder care and inpatient mental health. The results now speak for themselves. Consequently, VA is left schlepping an overpaid, overstaffed, and underworked layer of middle-level management that has enjoyed relative anonymity whenever scandals hit the headlines. These offices’ limited capacity to provide close managerial oversight means that the VA medical centers in their networks are free to undertake activities, such as deviation from policies, without the approval or even knowledge in some cases of the VISN offices and Veterans Health Administration central office. To make matters worse, VHA central office suffers its own issues as a result of the yawning chasm lying between its policy and operation functions, an extension of the Middle in terms of diffused accountability. So when the scandals at the Phoenix, Tomah, and other VA facilities had hit the news, it reportedly “surprised” VA senior leadership. The public channeled its outrage toward the facilities involved and the VA secretary, and rightfully so. We know the names of former Phoenix VA director Sharon Helman, who eventually pled guilty to unethical practices. We’re also well familiar with the illegal pharmaceutical practices of Dr. David Houlihan, Tomah VA’s so-called “Candy Man.” But the public and media don’t know the VISN directors or the lower-level VHA central office officials involved at the secondary and tertiary levels of responsibility, who collected paychecks, and probably bonuses, despite their highly publicized failures of leadership in those cases. What VA needs is a leader who either comes from within its own ranks or at least has worked with VA long and close enough to know where the bones are buried. One who will have the insight and confidence to make badly needed, likely unpopular changes, starting with drastically downsizing the VISNs, consolidating policy and operation functions at VA central office, and converting as many administrative functions to clinical positions as possible in understaffed VA hospitals. More importantly, VA needs a leader who won’t have to rely on the counsel of career bureaucrats who are content to simply wait out another wave of congressional scrutiny and public backlash; bureaucrats who are willing to suffer yet another new secretary’s short-term, superficial solutions to fixing VA until the next election. Hopefully, that someone will understand that the problems VA suffers are not sitting out in the open, where it’s been easy for the public, media, and politicians to whack it like a piñata with every new headline. The problems comfortably lie in the interstices of a huge bureaucracy, where moral hazard and complacency fester, hiding in blind spots and behind the good works of the thousands of federal employees who work hard and are fed up with those who hardly work. Whether this leader exists remains to be seen.
5 things about veterans and opioid addiction (The Wall Street Journal)
The U.S. Department of Veterans Affairs helped create a large population of opioid-addicted veterans by overprescribing painkillers for injuries. Now, the agency is struggling to get them the treatment they need. Here are some things to know about the issue:
- How the Problem Began
Increased prescribing of opioids by the VA mirrored that of the medical establishment generally. As doctors in the 1990s embraced the notion of pain as a “fifth vital sign” and focused more intently on managing it, the VA followed suit. After 9/11, the U.S. became embroiled in two wars, in Afghanistan and Iraq, swelling the ranks of VA patients at the same time that pain management became a priority for doctors. “It was a perfect storm,” says Rep. Phil Roe (R., Tenn.), Chairman of the House committee on veterans affairs and a physician.
- Tomah Was a Turning Point
Jason Simcakoski, a 35-year-old U.S. Marine Corps veteran, died in August 2014 with a dozen drugs in his system at the VA Medical Center in Tomah, Wis. Mr. Simcakoski and other whistleblowers for years had tried to warn the federal government of overprescribing of opioids at the Tomah facility, often called “Candyland.” But a congressional investigation, culminating in a 359-page report released in May, found the warnings were ignored or buried. The investigation prompted widespread changes in prescribing and monitoring of drugs at Tomah and throughout the VA system.
- What the VA Is Doing
Nationally, the VA is trying to rein in prescribing of opioids, recruit more addiction specialists and add new types of chronic-pain treatment, like acupuncture and yoga. In Fayetteville, N.C., VA director Elizabeth Goolsby co-chaired with the mayor this year an opioid task force comprised of police, counselors and church leaders to figure out ways to reduce overdoses and improve recovery services. The VA also works closely with two veterans treatment courts, allowing low-level offenders to avoid jail by completing programs that address their underlying conditions. On Veterans Day this year, a charity founded by hedge-fund manager Steven Cohen announced it would build a no-cost treatment center for veterans in Fayetteville next year.
- What Congress Is Doing
A bill signed into law by President Barack Obama in July included a section named after Mr. Simcakoski, with provisions aimed at addressing the opioid problem among veterans. Among other things, the act beefs up training on opioid prescribing among VA employees, expands research on alternative pain-management approaches for veterans and requires the department to focus on better identifying and treating patients with substance-use disorders. Critics said the bill didn’t provide sufficient funding. Still, “there is big change being made,” said Marv Simcakoski, Jason’s father, at a November roundtable with congressional and VA leaders.
- What the Trump Administration Plans to Do
During the presidential campaign, President-elect Donald Trump singled out the VA for criticism. He said too many veterans had been prescribed opioids and vowed to hold the VA accountable. He laid out a four-point plan to address the opioid crisis generally, including expanding access to treatment and providing more incentives for states and localities to set up drug courts. Mr. Trump has faced pressure from national veterans groups to retain VA Secretary Robert McDonald, who has been a vocal advocate for veterans with opioid-addiction problems. But he is also considering moving the VA toward privatization, a policy decision major veterans’ groups have said they would oppose.
VA has long list of Agent Orange decisions to make in 2017 (The Virginian-Pilot)
With 2016 drawing to a close and a new presidential administration poised to take over, the U.S. Department of Veterans Affairs faces an array of decisions related to the herbicide Agent Orange, which contained the toxic chemical dioxin and was used to kill vegetation during the Vietnam War. Among them:
- Whether to expand the list of diseases that are presumed to be linked to Agent Orange.
The VA so far has found enough evidence to link 14 health conditions, including various cancers, to Agent Orange exposure. In March, a federal panel of scientific experts said there is evidence to suggest that Agent Orange exposure may be linked to bladder cancer and hypothyroidism. It also confirmed, as previous experts have said, that there is some evidence of an association with hypertension, stroke and various neurological ailments similar to Parkinson’s Disease. Since then, a VA-led study has found stronger evidence to link hypertension, more commonly known as high blood pressure, to Agent Orange exposure. But high blood pressure is common as people age, so compensating veterans for the condition could be expensive. If the VA adds those conditions to its list of diseases connected to Agent Orange, anyone who has them and stepped foot in Vietnam – even for a day – could be eligible for disability payments from the VA. ProPublica and The Virginian-Pilot have profiled the efforts of vets with bladder cancer to secure benefits.
- Whether to make Navy veterans who served off the coast of Vietnam eligible for benefits.
Though most didn’t step foot in Vietnam, some 90,000 Navy vets who served offshore may have been exposed to Agent Orange and are seeking benefits. Advocates for the so-called Blue Water Navy veterans have been asking the VA for more than a decade to broaden the policy to include them. They say that they were exposed to Agent Orange because their ships sucked in water that was potentially contaminated and distilled it for showering, drinking, laundry and cooking. Experts have said the distillation process could have actually concentrated the Agent Orange. The U.S. Court of Appeals for Veterans Claims in April 2015 struck down VA rules that denied compensation for sailors whose ships docked at certain harbors in South Vietnam, including Da Nang. Those ports, the court determined, may have been in the Agent Orange spraying area. The court ordered the VA to review its policy. But in February, the VA largely stood by its old policy and once again asserted that there’s no scientific justification or legal requirement for covering veterans who served off the coast. A bill in Congress to change that had 336 sponsors in the House and 47 in the Senate. But it did not become law. Advocates have said they will try again.
- Whether to extend coverage to service members who served along the Korean demilitarized zone during the Vietnam War and who say they were exposed, as well.
Herbicides were not used exclusively in Vietnam. The VA provides benefits for Agent Orange-related diseases to veterans who served in or near the Korean DMZ between April 1, 1968 and Aug. 31, 1971. Some veterans, backed by several senators and members of Congress, say the start date should be earlier. They cite a declassified January 1969 document that cited use of herbicides in the DMZ for tests that began on Oct. 9, 1967. “We’re not victims, we’re not heroes,” said Eugene Clarke, the Connecticut veteran pushing for the change. “But we want what we deserve.” In a letter this month to Rep. Thomas MacArthur, R-New Jersey, a VA official said the matter was being reviewed. “We take our obligation to research these matters very seriously and will provide you with a more comprehensive response as quickly as we can,” Principal Deputy Under Secretary for Benefits Thomas Murphy wrote.
- Whether veterans’ exposure to Agent Orange can affect their descendants.
For decades, the Department of Veterans Affairs has collected – and ignored – reams of information that could have helped answer that question, an investigation by ProPublica and The Virginian-Pilot has found. Its medical staff has physically examined more than 668,000 Vietnam veterans possibly exposed to Agent Orange, documenting health conditions and noting when and where they served. For at least 34 years, the agency also has asked questions about their children’s birth defects, before and after the war. A recent ProPublica analysis found that the odds of having a child born with birth defects during or after the war were more than a third higher for veterans who say they handled, sprayed or were directly sprayed with Agent Orange than for veterans who say they weren’t exposed or weren’t sure. Experts said more research is needed and that the VA should be taking it on. This month, Congress passed a bill that requires, among other things, that the VA pay for an analysis of all research done thus far on the descendants of veterans with toxic exposure. It also requires the agency to determine the feasibility of future research and, if such studies are possible, to pursue them. The VA said it recently asked the National Academies of Sciences, Engineering and Medicine to look into whether exposure to Agent Orange could have effects in vets’ offspring. It could be a couple years before any report is issued with recommendations for future research.
Learn more about Agent Orange
Music project helps veterans coping with war memories (The Baxter Bulletin)
With every strum of the guitar, the pain of war fades for veterans participating in a program run through a local not-for-profit organization. Playing their guitars, about a dozen veterans inside a large room at Truman Memorial Veterans’ Hospital concentrated on learning the Christmas tune “Silver Bells.” They tapped their feet to the beat of the music, and some closed their eyes while singing. The veterans were led by Dave Dunklee, who has played guitar for 55 years and runs The Healing Box Project with his wife, CJ. The couple helps put guitars in the hands of veterans and Dave Dunklee shows them what to do next. The Gravois Mills couple travels to Columbia every Tuesday so he can provide hours of free lessons to veterans. The Dunklees started The Healing Box Project at the Warrior Transition Unit in Fort Leonard Wood a few years ago, serving soldiers Dunklee described as “fresh off the battlefield.” Trying to cope with the wounds of war, music became part of their recovery process. The transition units were meant to serve severely wounded soldiers returning from tours of duty but they began to close as wars in Iraq and Afghanistan wound down. When the Dunklees learned that the Warrior Transition Unit was closing, they knew they wanted to continue their mission. They didn’t have to wait long before a peer specialist contacted them about bringing the program to Columbia. Though not associated with the VA, the Dunklees have offered guitar lessons at the hospital for one year and taught 48 veterans to play the guitar. Decades have passed since most of the veterans in the program served in war, but Dunklee said the pain for many never has fully subsided. The thoughts and memories of war and pain are replaced when they start playing the guitar, he said. “We had a veteran tell us not too long ago that every time he comes to class, he sees a chalkboard of things that happened to him in battle and when he starts to play the guitar, he starts seeing somebody erase the list from the top down,” Dunklee said. Earlier this year, Vietnam War veteran Joe Finnell, 68, of Centralia, came to the hospital for an appointment and noticed someone carrying a guitar. After his appointment, he said he spotted another person carrying one and stopped the man to ask about it. That’s when he first learned about The Healing Box Project. Finnell is considered an intermediate player, and he said he enjoys helping fellow veterans learn to play during group lessons if Dunklee is busy with someone else. Reflecting on his time serving in the Vietnam War, Finnell said he was a boots-on-the-ground Army soldier, carrying a rifle, machine gun and M79 grenade launcher at age 19. No matter what he’s feeling when he walks into a lesson, Finnell said, he always feels better once he leaves. “The thing that’s amazing with it is that it can transfer you into a little bit of a different world,” Finnell said. “You can be having troubles, a headache, a heartache and you can pick up the guitar, and all you’re thinking about is what you’re playing and getting into the beat.” For 65-year-old Kelly Johnson — who served in the U.S. Navy from 1969 to 1974 during the Vietnam War — playing guitar alongside fellow veterans brings back the camaraderie he experienced while at war. He said that feeling has attracted veterans to the program and contributed to the increased participation the past year. No one is able to understand a veteran like another veteran, Johnson said. This year, The Healing Box Project has spent $17,500 on guitars for veterans, Dunklee said. The organization covers the expense through fundraising events and sales of Dunklee’s music and his comprehensive guitar method book. Dunklee said all proceeds from those sales go to The Healing Box Project. Guitars are always new and brand name. When a veteran receives a guitar, he said, the reaction is always the same. “Maybe they haven’t smiled for a long, long time, but there’s always a smile,” he said. “And sometimes it’s like disbelief.”