Better Care for our Veterans

Our veterans are not being served by the Veterans Health Administration (VHA) the way they deserve.

The VA health system needs to implement short-term and long-term reforms to ensure timely, quality, and affordable health care for veterans.

There are 18.5 million veterans of the American Armed Forces. About one-half of those utilize the VHA for some form of health care. This can range from general medical care to specialized care for service-related injuries. Through personal choice or position on the priority listing for VHA services, the 9.5 million veterans not in the VHA system utilize private health insurance. Of the remaining 9 million veterans, about one-third depend solely upon the VHA for medical care, and two-thirds are supplemented with private health insurance. A review of the purpose of the VA health system reveals that it was not created to take care of general health care needs, but the needs of those veterans who sustained an injury while serving their county. We all know about the reports of long waits and the inability to get proper care from various VA facilities in Tennessee and around the country. Our veterans deserve the best health care available, and to achieve this level of care, the VA must adapt and refocus upon its intended purpose: serving our veterans who suffered catastrophic injuries. Services the VA excels at, including treatment of veterans suffering from amputations, burns, mental health, and spinal cord injuries should be continued. 
According to the US Census Bureau, there were nearly 18.5 million veterans in the US in 2018. The VA has an enrollment of over 9 million veterans, and about 4 millions of those have service-related disabilities.
The tables below from the Pew Research Center and the Census Bureau show the changing face of our veterans over the next 25 years. Of course, with the aging population, in 25 years the Gulf War and Post September 11 veterans will make up a substantial portion of the total veterans. This is a particularly challenging hurdle as the advances in medicine both on the battlefield and in hospitals means more soldiers have survived catastrophic injuries. Their survival means they will require long term and changing care over their lifetime. This is why veterans’ health needs to be addressed now.

When we talk about the 9 million veterans who utilize the VHA for their health care, it is important to note that 4 million of those have service-related disabilities. For all of these veterans, the VA is their primary health care provider. While 70 percent of the 9 million have private health insurance, the remaining 30 percent only have the benefits of the VHA. For those with private health insurance and using a VHA facility, the VA bills the private insurance company, and provides the veteran with coverage of most of their co-pays and deductibles that are normally required by private insurance. 

History

When most people talk about the VA today, it’s the VHA that is most often the topic. In the past when people invoked the name of the VA, it had to do with benefits, such as a pension, disability checks, home mortgages, and college educations. To a lesser degree is the part of the VA that handles the National Cemeteries. 
The VHA began as the first federal soldiers’ facility established for Civil War Veterans of the Union Army. On March 3, 1865—a month before the Civil War ended and the day before his second inauguration—President Abraham Lincoln signed a law to establish a national soldier and sailors’ asylum. Renamed as the National Home for Disabled Volunteer Soldiers in 1873, it was the first-ever government institution created specifically for honorably discharged volunteer soldiers. The first national home opened November 1, 1866, near Augusta, Maine. The national homes were often called “soldiers’ homes” or “military homes,” and only soldiers who fought for the Union Army were eligible for admittance. These sprawling campuses became the template for succeeding generations of federal Veterans’ hospitals.


By 1929, the federal system of national homes had grown to 11 institutions that spanned the country and accepted Veterans. But it was World War I that brought about the establishment of the second largest system of Veterans’ hospitals. In 1918, Congress tasked two Treasury agencies -- the Bureau of War Risk Insurance and Public Health Service --with operating hospitals specifically for returning World War I Veterans. They leased hundreds of private hospitals and hotels for the rush of returning, injured war veterans, and began a program of building new hospitals.
Following WWII, the VA took on new duties and responsibilities.  These popular programs became the face of the VA for decades. The GI Bill and VA home loans are both parts of the 1944 GI Bill of Rights legislation. The GI Bill covers the educational cost of vocational training and college education. The VA Home Loan Program offers zero to low down payment home loans and reduced interest rates. 
During the 1970-80s the VHA was known for very poor health care. As our WWII veterans began entering retirement and had an increased need for health care, Congress and the President saw the need for reform. Reorganization and elevation to a cabinet-level agency in 1989, brought that era of reform to the VHA system. By the year 2000, the VA had improved its overall quality to meet or exceed private hospitals. When the VHA scandals of 2014 broke, all credibility gained since elevation to a cabinet agency was soon lost. 
Today


VHA operates as one of the largest health care systems in the world and provides training for a majority of America’s medical, nursing, and allied health professionals. Roughly 60 percent of all medical residents obtain a portion of their training at VA hospitals and VA medical research programs benefit society-at-large. The VA health care system has grown from 54 hospitals in 1930 to 1,600 health care facilities today, including 144 VA Medical Centers and 1,232 outpatient sites of care of varying complexity.
 

​Since September 11, the VA has moved to address the changing landscape of veterans’ medical needs.  Advances in battlefield medicine mean more veterans survive traumatic injuries. New programs provide treatment for traumatic brain injuries, post-traumatic stress, suicide prevention, women's health issues, and more. The VA has opened outpatient clinics, and established telemedicine and other services to accommodate a diverse Veteran population and continues to cultivate ongoing medical research and innovation to improve the lives of America’s patriots. 


The VA has been known as the organization to provide care for catastrophically wounded veterans. Even in this specific field of expertise, there are failings. There are Standards of Quality that are part of the federal record provided in the Federal Registry. Yet, as summarized by retired US Navy Captain, Bob Carey, Chief Advocacy Officer at the Independence Fund, simply getting a wheelchair can be an ordeal for wounded vets. 

 

 

Current Funding

The 2020 Fiscal Year budget request for the VA is over $220 billion dollars. That equates to about $675 for every man, woman, or child in the United States. The VA employs about 394,000 persons. The federal budget supports three branches of the VA, Veterans Health Administration, (VHA) Veterans Benefits Administration (VBA), and the National Cemetery Administration. The VHA with a 2020 Budget of $86.5 billion, or about 40 percent of the overall VA budget, is the second-largest branch of the VA. Medical research claims about $779 million of the VHA budget. The VBA is the largest branch and covers such programs as pensions, education and rehabilitation, and home loans.  

 


Legislation 

The Veterans Choice Act of 2014, granted some veterans access to community care. That meant medical services could be obtained under certain conditions without going to a VA facility. This program was designed as Community Care. Generally, if a veteran living in a rural area, or could not secure a timely appointment, they could request community care citing. Delays in care and quality of care did not improve. 

 

The MISSION Act

signed by President Trump in June 2018, expanded Community Care. The Act both shortened the distance from a facility a veteran must live to request Community Care and shortened the waiting time for an appointment. The Act also covered medical care not readily available at a veteran’s local VA facility.


Currently, there are 119 bills that have been introduced in this Congress. All funding bills have been passed by both the House and Senate and signed by the President. There are no bills that have been introduced that would have a major impact on the operations of the VA.

 

 

Current Insurance

Veterans Health Insurance
When a veteran selects Veterans Health Insurance, there is no charge for the actual insurance. The veteran is responsible to pay various co-pays and deductibles. This includes prescription drugs, primary and specialty care doctors, inpatient care, and long-term care. The veteran can qualify for lower cost through means testing and hardship annual status updates. 
If a veteran who selects the Veterans Health Insurance, and has private insurance, the VA will bill the private company for the cost of the co-pays and deductibles for non-service-related health issues. If the payment for deductibles from private insurance does not fully cover those costs, the veteran is not responsible for making up the difference. The veteran is still responsible for any co-pays.
Tricare
Active military service personnel and retirees qualify for coverage under the US DOD health program of TRICARE. This is a regionally managed comprehensive health insurance program available to the service member or retiree and their families. 


Tricare Prime Costs:          Individual - $282.60 per year – Family - $565.20
Tricare Premium Costs:    Individual - $1,553 per quarter – Family $3,500 per quarter


These policies offer low to zero deductible and co-pay on standard health care. 
CHAMPVA
CHAMPVA is a limited and specialized health insurance program. It is offered to the “Primary Family Caregiver” of a veteran. This caregiver must not be able to have other forms of insurance. It is limited to the caregiver only, not to the family members of the caregiver. Upon the change in the status of the veteran where a caregiver is no longer needed, the insurance expires.

 

Administrative Review

The latest Government Accounting Office report on the VA found the following.​

1. Between 2012 and 2018, the VA did not properly monitor wait times for appointments in either its facilities or for Community Care operations.​

2. In the GAO 2017 High-Risk Report, it found that the VA facilities were not adequately monitoring VA providers and thus could not report on the efficiency and proper care for veterans treated by these providers.​

3. In April 2019, the GAO found that the modernization of the electronic health records was in jeopardy for the fourth time.​

4. In April 2019, the GAO found that holding VA facilities administrators responsible for corrective actions on long-identified issues was not being addressed, and thus the VA was failing to hold administrators accountable.

Since 2000, the GAO has made 1200 recommendations for improvements at the VA. As of 2019, about 70 percent have been implemented. This leaves about 300 recommendations outstanding. Those listed above are the major recommendations that the GAO feels are critical to improving the operations of the VA. What needs to be pointed out is that in their reports, the GAO does not identify specific VA facilities that are deficient in implementing their recommendations. One would have to review the specific VA Inspector General Reports of a facility, or similar documents maintained by the GAO to find this.
Since 2014, investigations of the VHA have revealed glaring issues with the Administration’s policies and practices, including excessively long wait times and secret wait lists for health care at hundreds of Veterans Affairs (VA) facilities. A report from a VA whistleblower shows that as many as 238,000 veterans may have passed away before receiving care. 


The VA health care delivery system needs comprehensive reform to ensure that America’s veterans receive quality, timely, and affordable health care. The Veterans Access, Choice, and Accountability Act of 2014, enacted to address some of the access and accountability issues, sadly has fallen short.  The VA now needs to follow through on measures to correct current access problems and pursue a comprehensive reassessment and fundamental reform for the long term.

 


Changing Demands

Because of changes in demand for the VHA system and its services, determining proper policy for veteran health care is a complicated undertaking. From 2000 through 2014, the size of the US Veteran population declined by 17 percent, a significant fact being the aging and passing of WWII veterans. At the same time, the number of veterans using VHA health care increased by 78 percent, a direct result of our post-September 11 wars. Also increasing is the number of non-veteran persons utilizing VHA services. Non-veterans eligible for VHA services are dependents of permanently disabled veterans and dependents of service personal who died while in service to our country. The number of non-veteran VA patients has increased faster than the number of veteran patients. As of FY 2014, non-veteran patients represent 11 percent of all VA patients. In general, VA patients receive more than half of their care through non-VA sources, relying on the VA mostly for prescription drug benefits and inpatient visits associated with surgery. 


Just as the demand for better services from the VHA came in light of the influx of Vietnam veterans and the retirement of WWII veterans, today we must look at the demands presented by the aging and passing of Vietnam veterans and the continued influx of veterans from post-September 11 wars. The demand for future services needs to focus on: 

  • The long-term health impacts of deployment in Iraq or Afghanistan.​

  • Contingency plans for any future conflict.

  • Geographic shifts in the veteran population. 

In order to make good on the promise to “care for him who has borne the battle,” the VA needs to pursue short-term and long-term reforms aimed at providing timely access to quality care for current veterans and a reassessment of how best to serve the health care needs of future veterans.

 


Solutions

Veterans are not being served the way that they deserve by the Veterans Health Administration.  2.7 million veterans rely solely on the VA for their healthcare and the care they are getting is lacking.  There are reports of long wait times and high out of pocket costs for the patient.  These solutions will show how we can help our country's bravest get the care they need.  

Provide Private Medical Insurance for all Veterans​

Make an annual stipend for health care insurance.  No veteran can be denied private health insurance coverage.  The health care insurance will cover all non-service-related health care issues.  All veterans will receive a stipend that is designed to cover the cost of the veteran’s insurance plus annual out of pocket expenses.  The stipend can be applied toward the veteran’s cost for either private insurance coverage or employer-based coverage.

The veteran is free to get care from network doctors of the insurance program for non-service-related health issues without the prior approval of the Veterans’ Administration.  Service-related health issues may be provided by VA facilities or by private network medical persons with approval of the VA.

Health Reimbursement Account​

In addition to the stipend, each veteran will have a health reimbursement account, (HRA).  The HRA will cover a set amount of dollars for co-pays, deductibles, and other out-of-pocket health expenses.  The health provider will be able to deduct the agreed amount from the account to cover said charges.  This law will provide that said reimbursement account is to be non-taxable income or credit.

 

Service-Related Health Issues​

The VA will continue to be the primary provider of service-related health issues.  The service will include care for catastrophic injuries as listed below.  The care will be provided in various VA Specialized Health Centers, where concentrations of medical personnel specializing in that injury are available to provide the expert care some veterans need.

  • Catastrophic Injuries​​

    • Persistent Vegetative State​

    • Traumatic Brain Injury​

    • Blindness​

    • Amputations- two amputations but not of the same limb​

    • Multiple Sclerosis​

    • Parkinson's Disease​

    • Lou Gehrig's Disease (Amyotrophic Lateral Sclerosis (ALS)​

    • Neurological Disorders​

    • Psychological Conditions

    • Spinal Cord Injury-Quadriplegia and Quadriparesis or Paraplegia​

  • Non-Catastrophic Injuries​

    • Breathing problems resulting from a current lung condition or lung disease​

    • Severe Hearing Loss

    • Scar tissue

    • ​Loss of range of motion (problems moving your body)​

    • Ulcers​Cancers caused by contact with toxic chemicals or other dangers​

    • Traumatic brain injury (TBI)​

    • Posttraumatic stress disorder (PTSD)​

    • Depression​

    • Anxiety​​​​​

    • Chronic (long-lasting) back pain resulting in a current diagnosed back disability

- For Non-catastrophic injuries and health-related issues, health services will be provided at VA Clinics in a region or by private health practitioners as approved by the VA and the veteran's health insurance company.

Short-term Reforms

The VA can develop a clear and consistent strategy for ending its current crisis with the following actions:

 

  • Settle immediate access issues.​

  • Resolve internal personnel and management failures, replenish clinicians, and improve access and accountability.​

  • Make decisions about access to care based on veteran-specific health care circumstances rather than time or distance restrictions or the arbitrary judgment of VA administrators; ​

  • Streamline medical claims and payments to avoid credit issues for veterans.​

 

Long-term Reforms 

The VA can develop a long-term, fiscally responsible solution to meet the changing health care needs of veterans and improve access to quality care with the following:

 

  • Center reform efforts on veterans. 

Decisions about how and where to provide health care and how to finance those services should be based on meeting the unique and changing health care needs of veterans and not the institutional or political concerns of the VA or any other governmental organization.

  • Refocus efforts on service-connected health care needs. 

Limited resources should be used primarily to provide the best possible care to veterans dealing with injuries or illnesses received in the line of duty.

 

  • Provide appropriate services and out-source as necessary. 

The VHA provides quality service to veterans with combat-related multi-trauma and service-related conditions such as posttraumatic stress disorder (PTSD). The VA should continue to invest in the research needed to improve those services. However, if a veteran can receive better care at a non-VA facility, especially for non-service-related issues, the VA should facilitate access to those services.

 

  • Enact fiscally responsible reforms. 

Reform is not reducible to eliminating benefits or beneficiaries to balance the budget. However, reform should be fiscally responsible and provide quality care in a cost-effective way. In addition, reforms should be based on a longer-term budget window rather than short-term fixes.

 

  • Incorporate accountability. 

The VA should establish a clear line of accountability, provide access to applicable data, and publicly report on all aspects of its health care operations, including quality, safety, patient experience, timeliness, and cost-effectiveness. In addition, the VA should have the authority to hire and fire employees in a manner consistent with that in the private sector.

 
Paid for by Friends of George Flinn 2020

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