A Better Health Care System?

Above photo: Veterans Administration protest in Atlanta, Georgia from The Progressive.

Despite glitches during the pandemic, the VA provides a model for the nation.

The last Sheila Elliott heard, the health care workers at the Hampton VA Medical Center in Hampton, Virginia, were getting a batch of personal protective equipment (PPE), meaning they’d be able to use a new N95 mask each day.

“Although one per day was better and I was happy for that, it still didn’t meet the manufacturer’s requirements,” says Elliott, the president of American Federation of Government Employees Local 2328. Part of her role at the union is to ensure that staff at the center have what they need to fight the COVID-19 pandemic. But before that shipment in late April, she says, “I talked to a respiratory therapist. He told me he was wearing [his N95 masks] seven-plus days.”

Elliott has worked at the Hampton center, run by the Department of Veterans Affairs (VA), since 1989. She took the job over other options because “the private hospitals in the area did not provide a fertile ground for utilizing and growing clinical skills, whereas the VA did.”

Now Elliott oversees a bargaining unit of about 1,000 people and serves patients in a community with one of the fastest-growing veterans populations in the country. She still considers the VA program better than the private sector’s options.

“The VA is the place where you can go and you can get a heart stent or a liver transplant. But you can also get a mortgage, you can get a student loan, you can get family counseling. It is addressed to the socioeconomic determinants of health, not just stitching people up when they get busted up in a car accident.”

But in the face of the pandemic, Elliott’s sense of frustration is clear. It’s not just the lack of PPE—that would also be true in any number of private sector institutions. It’s what she sees as the refusal of management to collaborate with staff to ensure that the VA’s often vulnerable patients get the best possible care while workers are protected as much as possible from catching the virus themselves.

At the Central Arkansas VA hospital in Little Rock nurse Barbara Cassanova is also frustrated with the lack of PPE and the muddled guidelines for when and how to use it. “We shouldn’t have to bargain [for] PPE,” she says. “That should be a given.” She worries that the VA might not have enough gear as the COVID-19 crisis continues.

Elliott’s union, in late March, filed a lawsuit seeking hazard pay for frontline workers, and National Nurses United filed a grievance demanding more PPE. The workers find this particularly frustrating because, if the institution’s managers included them in planning, the VA would have been better prepared for this crisis—it should, in fact, be the best-prepared institution in America to deal with the COVID-19 pandemic. All around the country, health care workers are making demands for a public health care system to deal with this crisis, one that takes workers’ input seriously and puts patient outcomes before profits—a system like the VA at its best.

Suzanne Gordon, a longtime health care reporter and author of Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans, says the VA “outperforms the private sector with one hand tied behind its back.”

The VA delivers health care to around nine million veterans each year at more than 1,200 sites across the country. In Wounds of War, Gordon described the VA as resembling “the health care systems of almost all other industrialized nations: a full-service health care system that both pays for and delivers all types of care to those it serves.”

The VA’s health care providers are salaried, rather than paid by the service, meaning they can actually spend time with their patients, and its integrated system cares for the whole patient, from when they leave the military to end-of-life care. This makes the VA uniquely invested in keeping its patients well.

Study after study has found that such care leads to better results than the private sector, even as the VA’s patients are in many ways uniquely hard to care for. As Gordon wrote, “Apart from the low-income patients served by Medicaid, no other health care population in the United States includes as many poor, unemployed, or homeless people or ones suffering from mental illness, drug addiction, or alcohol addiction.”

Phillip Longman, author of Best Care Anywhere: Why VA Health Care Would Work Better for Everyone, argues that VA workers themselves “took that institution by the neck and turned it into something really world class.” Frontline doctors and nurses in the 1970s and 1980s, overworked and frustrated, turned to new computing technology and created an electronic medical records system years before anyone else.

“To this day, nobody else in the U.S. health care system has an integrated health record that is remotely as clinically effective as this thing that VA doctors wrote for themselves,” he says.

Roger Maduro worked as a consultant on that system, known as VistA (Veterans Health Information Systems and Technology Architecture), in the 2000s. He notes that the VA system is designed for quality medical care, rather than billing codes, and can easily track patients when they move, see new doctors, or are prescribed new medications. “What drives physicians insane . . . is entering all of this useless data and having to deal with all of the screens that keep popping up that are designed to add all of the billing codes,” he says.

The incentives in the private health care sector push patients toward expensive and sometimes unnecessary care at the expense of investing in primary care, says Dana Brown, director of the Next System Project at the Democracy Collaborative, where she has done extensive research on health care systems. The VA’s system uses a collaborative approach, where health care workers are in contact with one another.

“The job of this team is to look after the whole individual and think about the ways that all the bits of this person’s medical history, but also their social and economic life, fit together,” Brown says. “That kind of coordinated care and care for the whole person is something that you basically can’t buy on the health care market in the United States.”

That means the VA tackles homelessness as a health care issue, as well as suicide prevention and other problems. “The VA is the place where you can go and you can get a heart stent or a liver transplant,” Longman says. “But you can also get a mortgage, you can get a student loan, you can get family counseling. It is addressed to the socioeconomic determinants of health, not just stitching people up when they get busted up in a car accident.”

Yet, Gordon notes, the VA is still embedded in the nation’s health care supply chain, for better or worse. This means that the majority of the country’s medical residents cycle through the VA while training, as do 40 percent of other health care professionals. However, the shortages that affect American health care as a whole do not spare the VA.

“There’s a shortage of primary care doctors because the whole nation has a shortage of primary care doctors,” Gordon says. The same is true for nurses and PPE.

Because the U.S. health care system is for the most part built around private profits, VA workers are constantly fighting for the life of their institution—its existence as a quality public health care provider is a threat to the idea that the private sector is necessarily better.

The coronavirus crisis is demonstrating that what private health care sees as inefficiencies are in fact life-saving preparations, and a national system is the best way to ensure that such preparation can be carried out.

According to Gordon, the push to privatize the VA began in earnest during the administration of George W. Bush, and—like the push in education for charter schools and private school vouchers—has only gotten worse in recent years. In 2014, an effort by Senator Bernie Sanders, Independent of Vermont, to increase funding for the VA was defeated, mostly at the hands of the late Senator John McCain, Republican of Arizona.

The resulting compromise—the Veterans Access, Choice, and Accountability Act of 2014—allocated $18 billion less than Sanders had sought. It instead gave $10 billion to a trial program called Veterans Choice, which allows patients who live more than forty miles from a VA center, or who face appointment delays of more than thirty days, to go to private facilities at the VA’s expense.

“No one tells them that the waiting list might be longer in the private sector,” Gordon says. “A private sector hospital could have a waiting list of months and it would never be reported. A VA [facility] has one and it’s front-page news.” The VA, she says, is “the only accountable health care system in the nation.”

Longman, for his part, says he’s gotten into the habit of asking, whenever some new problem comes to light about health care at the VA, “Compared to what?”

Even with the creeping privatization and hiring difficulties, the fact that the VA is a public institution means it is subject to much more oversight than the private sector. Unions attempt to provide that oversight at private hospitals, as well as at the VA. Ibidun Roberts, a supervisory attorney at the American Federation of Government Employees’ National VA Council, says the Veterans Affairs Accountability and Whistleblower Protection Act of 2017 has been used to get rid of employees who raise alarms, and that this has gotten worse during the pandemic.

“All of these things are coming together now in this time of fear and anxiety for our employees,” Roberts says. “It really stifles our ability to even talk to the employees or the agency about it.”

A Trump-imposed hiring freeze has hamstrung the VA further, even after it was lifted for clinical staff. “There are huge vacancies in the VA, and they are not able to properly respond to this pandemic now,” Roberts says. “Who knows where we would have been had they kept some of the people that they fired for trivial offenses?” Today, Longman says, “there are still lots of really good people trying to do the right thing [at the VA], but its leadership is in such disarray.” At the end of fiscal year for 2019, the Veterans Health Administration had more than 43,000 vacancies, in part because it does not pay as well as the private sector. But the people who do work there, Longman adds, are mission-driven.

“They do it because they believe in veterans and service and, also, especially the younger ones, a lot of them believe in the model, which is an evidence-based model that is not profit-driven,” he says. “The smartest, hippest people in health care get that maximum human health isn’t achieved at the molecular level, it’s achieved at the whole body, whole community level. Where they want to work is at the VA.”

Despite its many clear advantages as a mechanism for health care delivery, notes Brown of the Next System Project, “most Americans don’t know anything about how the VA system works unless they happen to know a vet or be one themselves.”

But it’s time, she believes, for the movement toward universal health care to pay attention to the VA, and the COVID-19 pandemic provides a perfect moment to do that. In places like Spain and Ireland, the governments have nationalized private sector hospitals, at least in the short term. Even in New York, Governor Andrew Cuomo has largely taken control of the state’s entire hospital system. In an “almost apocalyptic crisis,” one health care provider told Vox, “cutting through the bullshit” is required.

To Brown, that means something beyond Medicare for All. It is time, she says, to talk about a fully public system: “It allows for coordination, enhanced planning, enabling more rapid and effective distribution of supplies and tracking cases; but, also, ensuring equitable access across geographies.”

Even with Medicare for All, she asks, “will it be functional if such a large percentage of the provision of care is still privatized?” Currently, “even nonprofit hospital systems operate like businesses and have to meet a bottom line, as dictated by what makes money and what saves money. But in a fully public system, we can choose a different yardstick.”

The VA is already an integral part of the nation’s disaster preparedness system. Cutbacks to that system are now proving shortsighted. Still, the VA has come through in previous crises, including after Hurricane Katrina in 2005, when it helped track the medical records of tens of thousands of veterans. “It didn’t matter where they ended up,” Maduro says, “their entire medical record was accessible whether it was through a computer or through phone calls. Basically, a million people lost their medical records as a result of Katrina. For the veterans, it was all accessible.”

Beyond that, he notes, it is often VA personnel who respond to emergencies, like Hurricane Maria in Puerto Rico in 2017, and VistA has a logistics module to track equipment, including emergency supplies. “They actually have the one and only electronic health records system that can actually handle a pandemic disease outbreak, period.”

The United States spends billions on jets that never get used, and stockpiles weapons for decades. But when it comes to health care, Gordon says, “we’ve known for years we need 700,000 ventilators. You need a system that allows for things to be supplied that may never get used.”

The coronavirus crisis is demonstrating that what private health care sees as inefficiencies are in fact life-saving preparations, and a national system is the best way to ensure that such preparation can be carried out.

Brown argues that the extraordinary measures now being undertaken to deal with the COVID-19 crisis have made it very clear that “the government has all the power that it needs to solve at least access issues to both health care and medicines. Everything is at [its] disposal.”

Now, with the private health care system straining and ripping at the seams, it’s time to begin thinking about rebuilding. With millions of jobs evaporating, many permanently, Brown says public sector health care could provide “a huge portion of the good jobs of the future.”

With an aging population and a health care infrastructure driven by the desire to make money, we are far from being able to properly care for the population. But it doesn’t have to be that way. A public system could plan job pipelines for home care workers and primary care doctors, technicians and nurses. It could hire more people and distribute the work more fairly.

“Health care is essential. That is obvious,” Brown said. “But we know the way that it is working right now isn’t working to meet human needs, so it is incumbent upon us to rethink it.”

is a regular contributor to The Progressive and a reporting fellow at the Type Media Center, covering labor, economic justice, social movements, politics, gender, and pop culture. Find her on Twitter at @sarahljaffe.