A Modest Proposal: Shut Down the V.A. Hospitals

[A quick disclaimer: Although I write a lot about the ACA, my professional expertise is in the funding of healthcare, primarily through insurance scemes.  So my usual “trust me, I know what I’m talking about” approach I normally take does not apply here.  Anyone who knows a wee bit about Veterans Affairs knows more than I do, and should speak up in the threads.]

 

I want to make a pitch for closing down our country’s Veterans Affairs hospitals (VAH) as soon as possible.

My experience with VAHs is both tenuous and indirect at best, and is actually a function of my depositing checks. I’ve have been a member of my credit union since I was first out of college and my customer loyalty to them is fierce, but they do have one flaw: They don’t have that many locations.  Since we moved a few years ago, the closest location is located in Portland’s VAH.  Almost all of our banking is done electronically these days, so it’s not that big a deal.  Still, every now and then someone gives us a check for something.  We let these pile up until there are enough to justify a bank run, and then we deposit them — usually at the VAH.

Every time I go to the VAH, I get angry.  Everything about it seems to ooze an FU to the men and women who have served our country.

First off, our VAH is located in the center of Portland’s West Hills, where the Rose City’s wealthiest citizens live in the region’s most expensive homes.  The VAH, on the other hand, caters to those on the lower end of the income spectrum.  What’s more, it isn’t near any high-traffic commuter roads.  So although public transportation does go to the VAH, those most likely to need to use it have to use multiple buses to get from where they live to get care.  A trip to the doctors can literally take three hours of accumulative transportation time for some.

Those who can drive themselves don’t fare that much better.  The VAH has a parking garage, but it’s not nearly big enough to accommodate the number of patients it sees on a daily basis.  And in that kind of platypus-by-committee thinking that so often plagues large bureaucracies, the VAH administration’s attempt to address this issue has actually made the problem worse: They repainted the parking lines to fit more spaces in, and to maximize the number of spaces they’ve drawn them to be just slightly bigger than the width of a compact car.

Here’s what that looks like:

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Keep in mind that the average VAH patient tends to be at least one of three things (and often all three): elderly, overweight, and lacking full mobility.  Watching them attempt to park, try open their door enough get out, and then try to squeeze their way out of spaces that are difficult enough to navigate if you’re young, spry, and don’t need a cane makes you want to go find an admin guy to punch in the face. Worse, VAH patients tend to own older cars that have larger bodies, and they skew heavily towards blue-collar vehicles such as GMC trucks and circa-90s Chevy SUVs.  Sometimes after a patient has parked, a new car replaces the one they were parked next to and parks so close that they can’t even open their doors, forcing them to wait until the new driver comes back and moves their car.

And that can take a while.

I tried taking pictures in the waiting rooms but was quickly told by security that I was not allowed, so you’ll have to take my word on this: The waiting room is packed, and a number of those with walkers and canes are forced to stand for long periods of time, because there are only so many chair to go around.  The hallway that leads to my credit union’s branch passes an office that deals with some kind of patient paperwork, though I don’t know what kind.  What I do know is that line of patients holding paperwork often goes right out that office’s door, and snakes throughout the hallways.  God (and hundreds of VAH patients every day) knows how long it takes to go through it.

It’s worse than awful; it’s a slap in the face to those we promised to take care of in exchange for putting their lives on the line to take care of us.  And I know that the response from the VA folks would be, hey, we only have so much money to work with.

Today, however, it hit me: With the ACA, why do we need to have VAHs at all?  Why don’t we just do away with them forever?

Lower income veterans could begin to go to hospitals and clinics closer to where they lived that wouldn’t treat them the way industrial farms treat livestock.  Other aspects of V.A. services wouldn’t need the kind of infrastructure a hospital needs, so those services could be severed from the healthcare component and moved to places more convenient to those who utilize them.  We can even have the government lease the buildings and equipment to other government or non-profit healthcare organizations.

In fact, the more I’ve thought about this today, they more I think there has to be something I don’t understand about VAHs that has prevented this from already happening.

Can anyone here tell who knows more about this kind of thing tell me why this is a bad idea?  If not, why don’t we do this?

 

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40 thoughts on “A Modest Proposal: Shut Down the V.A. Hospitals

  1. Well other then snarky comments about how the VA is for honored Vets not just “free givaways” to lazy people by Obama i can think of one decent reason for VA hospitals. Vets will often have specialized needs for treatment of battle injuries or things like PTSD. It does make some sense to have a place that focuses more on the specific needs and problems of vets. Of course that could be done in a wing of a hospital or smaller focused clinics just as well. I’d also guess lots of Vets like having a place that is focused on them not civilians, which is not a good reason for VA hospitals. .

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  2. Sorry Tod, as much as I like your stuff I’m not following the logic here. The waiting rooms in these specialized hospitals are crammed with people so let’s shut them down so they can go to waiting rooms in bigger hospitals that will become just as crammed if they’re not already so. Hospitals that are non-specialist because they serve the whole community and therefore the specialized treatment vets might need will devolve on fewer specialists in each location.

    And then there’s this sentence: Other aspects of V.A. services wouldn’t need the kind of infrastructure a hospital needs, so those services could be severed from the healthcare component and moved to places more convenient to those who utilize them.

    Aren’t those “places” the existing vets’ hospitals? Why reinvent the wheelchair?

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    • “The waiting rooms in these specialized hospitals are crammed with people so let’s shut them down so they can go to waiting rooms in bigger hospitals that will become just as crammed if they’re not already so.”

      I’m not sure where you live, DRS, but what you describe isn’t the case with hospitals here.

      Emergency rooms can, at times, be over crowded, because it’s hard to predict exactly how to staff for what you don’t know — and even then, sometimes there are more bodies needing beds than there are beds.

      But the VA isn’t a place that caters to emergency care. In Portland, other hospitals are nowhere near capacity — they all engage in big, expensive ad campaigns to compete for more patients. The Portland VA is clearly over capacity — and my understanding is that that’s the case with most VAs throughout the country.

      “Aren’t those “places” the existing vets’ hospitals? Why reinvent the wheelchair?”

      Because in most places (Portland included), the infrastructure needs of a hospital require that it be in a place that’s not convenient for those that need VA services. Having VA services nearby where you live doesn’t sound that big of a deal for someone like you or me, but a huge number of people who depend on these services are elderly and/or have mobility issues.

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      • Okay but it still seems to me that this sentence: Other aspects of V.A. services wouldn’t need the kind of infrastructure a hospital needs, so those services could be severed from the healthcare component and moved to places more convenient to those who utilize them. is pulling a lot of freight since you don’t explain what you have in mind or how that would work or who would make the decisions about the “severing” and the “moving”. It’s just another glib “someone should do something” statement.

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    • Thing is, instead of the VA ghetto, these patients could use their “insurance” (or whatever we choose to call the instrument) to make smart choices about the closest hospitals/clinics/private providers based on things like wait time, access, quality of care, etc.

      Choice! It should make the libertarians around here giddy!

      (Actually, I’m not kidding. I think it should.)

      And yes, there may be certain specific conditions that warrant specialized care by a provider experienced with combat wounds. But who says that person has to be employed by the VA?

      (Again, another one of these wacky moments when we liberals might totally agree with the libertarian sorts.)

      (Although I would not entirely trust the market to provide this. If it were observed that some region was lacking in such care, I think the government should ensure that it is provided.)

      Speaking for myself, while in no way a combat veteran, I need very specific medical care. So I frequently make a special trip to a clinic that focuses on people like me. So, yeah, I make that choice. But I could go to a “normal” endocrinologist, if it was easier or cheaper or whatever. I like having that choice.

      Tod, this sounds like a entirely plausible idea.

      (Funny thing, many years ago I did computer work for a credit union that had a location in an enormous VA hospital. Like you describe, it was depressing.)

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    • I could well be reading the link wrong, but it looks like RAND found that VAs performance was due to those patients being more likely to receive care (including preventative care) than non-VA hospitals:

      “How does performance measurement affect actual performance in health care delivery? To answer this question, the researchers conducted another analysis focused solely on the health indicators that matched the performance measures used by the VA. They found that VA patients had a substantially greater chance of receiving the indicated care for these health conditions than did patients in the national sample. They also observed that performance measurement has a “spillover effect” that influences care: VA patients were more likely than patients in the national sample to receive recommended care for conditions related to those on which performance is measured. For example, VA outperformed the national sample on administering influenza vaccinations, a process on which the system tracks performance. However, it also outpaced the national sample on other, related immunization and preventive care processes that are not measured. This provides strong evidence that, if one tracks quality, it will improve not only in the area tracked but overall as well.”

      The ACA should even that playing field, should it not?

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      • I read it as indicating VA patients were more likely to receive standard of care treatment than were others (who are more likely to get treatment that is all over the map).

        The ACA should even that playing field, should it not?

        To the extent it succeeds in encouraging “evidence-based medicine,” which is one of its goals.

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      • Our VA Hospitals (we have several) are on high traffic bus lines. And we do some pretty damn fine research at the VA hospitals, some of it utterly groundbreaking.
        There seemed to be plenty of space there.

        I doubt we’d be looking at Motion Capture Research for people with disabilities without a VA, honestly.

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  3. Well, we could start with this

    I go back and forth on what we should do with health care, but national clinics of the sort of available in VA (which I know little about, but which a lot of people do like) and the IHS (where my wife worked, for a time) enter and go periodically. It has its problems, but it’s generally a low-cost mechanism for delivering care. As the lower of a two-tier system, I could imagine it working quite well. (The biggest problem would be staffing them. One of the two reasons we didn’t consider IHS when things fell apart in Arapaho was that we have student loans to pay off and are way behind on retirement for us and college for our future children. Of course, I have been duly informed by folks here that compensation plays absolutely no role in where doctors choose to practice, and who am I to disagree?)

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  4. As an occasional patient of the VA system (I’m US Navy, Ret. – Medically Retired), I can tell you that Tod is right in that VA hospitals are not always nice places. They tend to be old, poorly staffed, and poorly funded. The rules governing VA facilities can be a pain (if you live with 50 miles of a VA or military hospital, you have to use it unless the hospital decides it can not help you, or you have private insurance that will cover you, at least partly). It’s not always a good system.

    However, I would not shut them down. They provide a needed service, as well as medical training.

    What I would do is ask private, or even other public hospitals, to partner with the VA. For example, in Madison, the UW Hospital is physically connected to the VA hospital, and if the VA is swamped & the UW is not, the UW sends over staff. It also helps if the VA is unable to provide a service, they can just walk the patient next door & get him/her help straight away.

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  5. Belive it or not, for a period between, say, 1998 and 2005, the VA was widely regarded as the most effective healthcare organization on earth. National health care systems would study it as a model.

    Mr. Bush started pulling funding from the VA as the bills from our Iraq venture mounted, and it started to regress back to its former, 70s, reputation, as an underfunded last resort for the homeless and alcoholic.

    Here’s a link to an old Washington Monthly article about the VA at its peak:

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  6. For years I’ve gone one step farther — why does the federal government insist on using so many programs to buy health care? VA, Tri-Care, Medicare, Medicaid, SCHP, federal employee benefits, less directly state employee benefits (eg, benefits for state employees handling food stamps are largely paid for with federal dollars), and private company benefits (eg, workers on Lockheed-Martin’s F-35 production line). Just buy good health care, and how it gets paid for is accounting. Cost control: we’re buying health care for 35% of Americans and we pay the bills promptly; we get 10% off the best price you give anyone else, or you don’t get any of our clients.

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    • This is a great point that, as a supporter of UNI HC in general, I endorse. But one caveat: I believe that care for strictly combat-related injuries/conditions should come from the defense budget for purposes of proper accountability.

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      • 1) They don’t entirely come from the defense budget now. (split now between Tricare and VA depending on the service members status)

        2) A direct connection is not the easiest thing to evaluate. (hence, the – imo correct – trend for a more ‘permissive’ benefits eligibility regime)

        3) They’re actually a small portion of the overall defense-related health care budget. (Vietnam health related claims are peaking now as that generation is currently the elderly one and thus requires the most health care services and expenditures)

        (Notably, we’re still paying survivor benefits from the Civil War. So unless we re-link the VA and DOD budgets, it’s not really possible to get proper accountability in the way you’d like, I think.

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    • Mostly because we really don’t believe that health care is a human right. it’s a human right for deserving people, and all the slaves and non-taxpaying workers can go fuck themselves.
      I’m all for “cover the damn care, save us from the plague” [you’re from the Rockies, you’ll get the joke, I trust?]

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  7. In the VA’s defense, it does have health-care issue unique to the population it serves.

    My stepfather spent a year in a POW camp during WWII; and had all sorts of ‘ignored’ mental health issues as a result. In the early 1980’s, the VA had done enough research to recognize that men from different camps had different sorts of issues; and also that most were too proud to seek help for these problems. I know they brought him (and my mom, too) in for a ‘screening,’ and had him in a room with other people who’d been in the same camp; sort of tricking him into group therapy that he wouldn’t have participated in otherwise. After the first meeting, he willingly went to the others, these were his buddies. Meanwhile, the wives were given some education on what had happened to them (many never knew before) and suggestions on how to help.

    I realize there’s much bad about VA care, and that reflects poorly on all of us. But this kind of care could not have happened outside the VA system.

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  8. How about

    1. Increasing funding to improve VA facilities. (Part of a second stimulus package? No, that would be evil.)

    and

    2. Allowing some vets to get some smaller, cheaper-to-treat conditions treated at local facilities that would then bill the VA.

    No?

    Would solve many of the problems with crowding and having to go for regular procedures without reinventing the wheel.

    There is a logically possible way to get rid of the VA, sure, but it would be hard, not just politically, but practically.

    Right now the VA provides great health for fairly cheap prices. Under a system where private hospitals and providers bill the government, you have to give some though to cost controls, too, as Medicare has too, and as is done in Canada, etc. Not impossible, but needs be done if you are gonna move vets onto the exchange or Medicare.

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  9. In case anyone is wondering, this is precisely the sort of provision vs. production question that was discussing the other day. Veterans’ care is important, but need not be performed in specific, government-owned facilities.

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    • Although I take seriously the argument of some here that some elements of vets health care possibly are better handled through specialized facilities. But certainly there’s little clear reason why general medical care need be.

      Maybe we should just give them a vet’s medical card that every facility that accepts any public monies has to honor.

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      • First, a lot of veterans receive care outside the VA system due to their location or personal choice; not all veterans go to the VA. (Also, a lot of problems that probably should be covered by the VA aren’t, early PTSD, agent orange, as examples that have risen to general-public attention.)

        There have also been studies about the VA/non-VA system, which suggest VA health care is both generally better and more cost-effective. The VA has the right to negotiate price for pharma, etc., too. I’ve read/heard a lot of discussion that the VA system offers a lot of best practice examples for bringing down the overall cost of providing health care.

        Some of the research (there’s a lot saying similar things):
        http://www.ncbi.nlm.nih.gov/pubmed/20966778

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      • When I was reporting in he mid 2000’s, I talked to a lot of veterans, the VA, etc.; first it was pretty obvious that the war over-stretched the existing system, and money wasn’t really going to upgrade it (the whole Walter Reed fiasco, for instance). So yes, there was a definite stinging, there still is.

        But just for some balance, I heard yesterday about a county in Oregon that had more people enroll in medicaid in the first two months of ACA signups than the expected in the first two years. Many haven’t seen a doctor in years, and have serious health problems. There is, of course, serious staffing and facility shortages. So it’s possible that the same problem exists throughout our health-care delivery system; we just rationed by insurance. Source: http://www.npr.org/blogs/health/2014/04/08/300248220/wave-of-newly-insured-patients-strains-oregon-health-plan

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  10. Credit Unions:
    Dude, mail you checks to be deposited. That’s what I do. My CU has ONE location. Everything I do is either online, by phone, or mail. Hell, I even get loan applications processed by Fedex. Never had an issue.

    VA: Heard the stories, heard about the nightmares and the bureaucracy. Every time I head some politician talking about vets and honoring their service, etc. it disgusts me. Stop funding wars and shorting the troops on the back end when they come home. I’m all for getting rid of the VA if these guys can get better care elsewhere.

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    • Also, many credit unions participate in branch sharing. This means you might be able to go to a different credit union to deposit checks in your account with your current credit union.

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  11. I’ve known people who go to the VA, and they’ve not had much complaints.

    Paperwork line is probably “prove you had a medical condition caused by the war” — that is backed up beyond belief.

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  12. If I was an adult vet in 1983 who had to go to the VA hospital that my grandfather used, I probably would have snapped and burned the place down to the ground.

    That was thirty years ago, though.

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  13. One of my practicum placements as an MSW student was at a VA hospital, and as a social worker I’ve had a fair amount of experience assisting clients in accessing health care at a VA hospital in a different city. I have a few thoughts about this topic.

    1) VA hospital placement is political. The hospitals are typically sited where a well-placed Representative and/or Senator lobbied to have one built. This means that if a hospital is geographically convenient for veterans to get to, it’s probably due to chance. In rural areas, veterans typically have to travel large distances for their health care. (This has improved a bit with the growth of VA outpatient clinics.)

    2) The second VA that I experienced had very full, fairly unpleasant waiting rooms. There was at least one occasion when the client I was accompanying was overlooked and the clinic almost closed before I was able to get someone’s attention so that he could be seen. Without someone to advocate for him, he likely never would have been seen that day. However, most of the other hospitals I have been in also have very full, slightly less unpleasant waiting rooms. I have had to advocate for clients in many outpatient clinics within hospitals (“We’ve been waiting for 90 minutes, do you know when she might be seen?” “Who?” “Mrs. X. See, she signed in right there.” “Oh my gosh, her doctor left, let me see if another physician can see her.”)

    3. At times, I have been able to get needed care for my clients that they never would have been able to receive in a non-VA setting. I once worked with a physically disabled client who had been drinking himself to death. I finally convinced him to go the VA ER. When we arrived, he was triaged in immediately (his smell probably helped move things along) and received attentive assessment. They admitted him, provided alcohol detox, and were able to place him in a VA-affiliated group home to continue his treatment with no break in care. I wish I could have accessed such care for all my clients.

    4. The lack of money-pressure meant that practitioners at the VA could try to focus on client care in a way that didn’t involve the perverse incentives that other health care providers face. A different non-profit hospital system I know tried really hard to change its focus from providing good general care to increasing the amount of surgeries performed. Why? Surgeries bring in far more money. I don’t think they were doing unnecessary surgeries, but they sure started putting their money on bringing in surgeons and advertising that service. This was because of the institutional need for income rather than an unmet medical need in the community.

    5. The fact that VA hospitals are a government institution was often very close to patients’ minds. “You think my procedure isn’t medically necessary? I’m going to call my senator!” is something I heard from patients at the VA more than once during my practicum. (They weren’t saying to me, of course. I was only a social work student.)

    6. The very first real-life libertarian I ever met was an employee of that VA hospital where I was a student. He’d been there for almost 20 years as a low-level administrative paper-shuffler. I don’t know how he reconciled that. (He was a caring and thoughtful guy btw.)

    Are VA hospitals something we would create today? Probably not. There are problems within any such system. But I’m not sure I’d get rid of them just yet.

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