Slash the VA! Make our veterans pay for increasing corporate profits!

Given the heavy-handed, mean-spirited, cruel, anti-democratic, un-Constitutional, and penny-wise (maybe) but pound-foolish actions of the current GOP/Trump/Musk administration, it is hard to know where even to begin to discuss it. Certainly many, many intelligent and well informed people, including luminaries such as politician Bernie Sanders and historian Heather Cox Richardson, as well as many news sources such as the Contrarian (established by reporters and editors fired by or resigned from Jeff Bezos’ Washington Post and the New York Times). Even in the narrower realm of health, we have outrages like the vaccine denier and proponent of ineffective and even dangerous therapies, Robert F. Kennedy, Jr. heading the Department of Health and Human Services, and Mehmet Oz, RFK, Jr’s fellow traveler, nominated to head the Centers for Medicare and Medicaid Services, presumably so those services can continue to be slashed. And even more narrowly, in health and medicine and social justice – well, all of these actions and cuts tie to social justice!

So, let’s look at the Veterans Administration (VA). The VA is tasked with providing health care for our veterans, those who have served in the military, many of whom have suffered very serious, life-threatening injuries, physical and mental (of course not counting those never got to be veterans because their lives were lost). Veterans have also had higher rates of cancers and lung diseases linked to the use of burn pits (horrific incinerators used “in country” to dispose of garbage, waste, bodies, munitions, toxic materials, using jet fuel as the source of fire, running 24/7 close to camps). The death of President Biden’s son Beau was linked to burn pit exposure, and finally during the last administration Congress passed the PACT act (Honoring Our Promise to Address Comrade Toxic Exposure) to compensate and care for those veterans whose diseases were likely caused by such exposure, often called “the Agent Orange of the Gulf wars”.

The VA was already highly stressed by underfunding and understaffing due to previous cuts made by the pro-veterans-in-words-only GOP Congress and that stress was dramatically increased by the hundreds of thousands (at least a quarter million) claims under the PACT act. Amazingly the VA clinical operation, also very short-staffed, was able to continue to provide health care to veterans. Although there were many complaints of waits and slowdowns, they were in fact much less than the routine waits and slowdowns in the non-VA health care sector (anyone tried to get a doctor’s appointment lately?) and virtually every measure of quality has shown that the VA has outperformed the civilian sector. Of course, its mission is to provide health care for veterans, not to make a profit; this distinguishes it from the civilian sector in which profit is “Job One” and accessible, quality, effective health care a distant second. The NY Times’ recent article titled ‘Chaos at the V.A.: Inside the DOGE Cuts Disrupting the Veterans Agency’ notes that the VA

…treats 9.1 million veterans, provides critical medical research and, according to some studies, offers care that is comparable to or better than many private health systems. Even Project 2025, the conservative governing blueprint assembled by Trump allies, said the V.A. had transformed into “one of the most respected U.S. agencies.

Many of the VA’s successes, as well as its challenges, are documented by journalist Suzanne Gordon in journals including these in Jacobin, Veterans Starting to Mobilize, and the American Prospect.

Then came Trump, Musk, and DOGE. Under the banner of “cutting government waste” the already far-too-lean staffing of the VA is proposed to be cut by another 80,000 jobs! This will certainly result in major delays in accessing care, in lower quality, and unconscionable disservice to our veterans. It seems like heartless cruelty, and of course it is. But the nauseating thing is that while it certainly is not about cutting waste, it is not even about the heartless cruelty. It is about one thing: transferring “government” dollars – that is, YOUR tax dollars (not Musk’s, or his companies’, they don’t pay taxes!) – to private corporations. THAT is the goal.

Think about it. Slash funding and positions from the VA, which will naturally lead to complaints about inadequate service (even the VA can only do so much when cut not only to, but deep into, the bone) and protests from veterans’ groups and maybe even GOP members of Congress. So, what will they do? We don’t even have to guess – they’ll do their favorite thing and privatize it! Contract out the care of veterans to private corporations so they can have the wonderful experiences all the rest of us have in trying to access quality care. Of course, they won’t be able to, maybe even less than the rest of us, but heck, those companies will make a lot of money!

And that is the goal. It is not saving government money, it is about transferring it to private corporations, as acknowledged by Treasury Secretary Scott Bessent. This will cost more, be less efficient, and have lower quality. This is the consistent track record of almost every government service that has been privatized – they almost never either save money or work better, they put taxpayer money in private pockets. In health care, it is even worse; it is almost impossible to think of an example where privatization has not cost far more and had worse service, accessibility, and quality outcomes. If the funding is the same, it is always worse.

But, of course, this is not an accidental outcome, it is the intention. Privatization is sold as saving money, but it always costs more, and as increasing quality but it always goes down. What it is successful at is moving public dollars to the private sector. So, it doesn’t save money by eliminating waste, it eliminates basic care and then “solves” the problem by spending even more money! The heartless cruelty is not the goal; it is simply the byproduct. It hurts our veterans, but this is not a concern to the heartlessly cruel, non-empathic (Musk thinks empathy is “destroying Western civilization”) greedheads making these decisions.

Something can be done. Veterans can rise up and protest and contact their Congressional representatives. So can the various “veterans service organizations” (VSOs) including the American Legion, VFW, and many others. Maybe even some GOP Congresspeople will take the initiative and actually do something to help veterans instead of just flapping their gums! (OK, that may be a bridge too far…)

Bezos, Buffett, Dimon and Gawande: Better quality in health maybe; a solution, no

A big item of health news in recent weeks is the planned establishment of some sort of health delivery operation by three major corporations personified by their CEOs: Warren Buffett of Berkshire-Hathaway, Jeff Bezos of Amazon, and Jamie Dimon of JP Morgan. We have no details about what it will actually look like, but we are assured that it will be high-quality, efficient, and cost-effective, utilizing the most modern methods of achieving those goals, which our creaky, antiquated, and resistant-to-change health system does not. It will also be non-profit, important given that none of these companies are, but this is the most common model for health care in the US and in itself says very little. As the first concrete step toward its creation, and clue to what it may be, they have appointed Dr. Atul Gawande as its CEO. Presumably he will be instrumental in creating this new venture, and his views on quality and efficiency may provide guidance on what might characterize it.

Dr. Gawande, a Harvard surgeon and senior writer for the New Yorker, has provided us a prolific body of writing in that magazine and in several books, (including the best-seller about issues occurring at the end of life, “Being Mortal”), to help inform us of his views. He has a wide scope of interest in health care and a demonstrated willingness to learn from other industries. Perhaps his most famous article is “The Cost Conundrum”, which appeared in June 2009 and highlighted the wide variation on expenditures by Medicare for similar populations, focusing on the highest cost region, McAllen, TX, and comparing it to a similar population in El Paso, TX, where costs were much lower. Later, in January 2011 “The Hot Spotters” highlighted the work of Dr. Jeff Brenner in Camden, NJ, and others, to use modern geo-mapping techniques to identify the areas with the highest levels of emergency (911) utilization (unshockingly, in Camden, the two highest were a low-income senior citizens housing unit and a long-term care facility) and try to develop methods for addressing their health needs before they became emergencies. In “Big Med”, August 2012, he discusses application of some of the principles that work in restaurants such as the Cheesecake Factory to health care. The principles include enough variety to meet everyone’s needs without expensive unnecessary redundancy; he shows how this applies in orthopedic surgery and how quality is improved and costs saved when every surgeon in a hospital doesn’t use his (or, more rarely among orthopedists, her) favorite implant device and there is some standardization (commented on in this blog on August 24, 2012, Quality and price for everyone: Bigger may be better in some ways, but not all). A very good review of Gawande’s work and probable priorities has been done by the outstanding Dr. Don McCanne in his “Quote of the Day” on June 22, 2018 “Don’t wait for Atul Gawande”, and I will not repeat it here.

Of course, the employees of Berkshire-Hathaway, JP Morgan, and Amazon already have health insurance, so that this new scheme will not reduce the rate of uninsurance. It is possible that it – whatever “it” turns out to be – will allow enrollment from other employers, or possibly even individuals who are currently insured by another mechanism, whether through Medicare, the ACA-sponsored exchanges, or even Medicaid. This will depend in part on what “it” is – mostly an insurance plan, mostly a care delivery system, or a combination of both like many HMOs.

It is possible that this new operation may indeed succeed in achieving, or at least significantly moving toward, the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost. Certainly the third of these is a major focus of businesses that provide health insurance to their workers, and we will grant these people the benefit of the doubt that they also wish to achieve the first two. Some HMOs have had significant success in doing so already, most notably Kaiser Permanente. Other HMOs that were once “consumer cooperatives” (eliminate the middleman and pay less for the same care or the same for more and better care) have almost all been bought by insurance companies, and it is obvious that the “save money” (or really “make more money”) leg of the #TripleAim is of far greater importance to their business model than patient satisfaction or quality. The bar, as has been demonstrated ad infinitum, including in the work of Dr. Gawande as well as other policy analysts from

academia, the foundation world, and journalism, is so low that large improvements in quality can come from things that it is we already know how to do. The major obstacle to this has always been how providers are paid, and this is where the behemoth strength of this new triumvirate may have significant impact.

Unfortunately, though, there is no suggestion that this new operation would do anything to help those currently either frozen out of the system (including poor people in states that have not expanded Medicaid, undocumented people, and those who cannot afford insurance premiums even with ACA support). The average salaries at JP Morgan and Berkshire-Hathaway are high since so many of the employees are high-level finance types, raising the mean and median. However, Amazon is a different story. Jeff Bezos may be the richest person in the world, he did not get there by paying his employees a living wage; the median income for an Amazon employee is $28,446. While they may have health insurance, it would not be surprising if many of Mr. Bezos’ employees qualify for food stamps, and have difficulty making their copays; that median salary is about the poverty level for a family of four, and if it is the median, many workers make less.

It could be argued that is unfair of me to criticize a program – especially one still in the planning stage -- for not achieving what it does not set out to achieve. However, there is nothing wrong – and indeed it is quite correct – to note that it is far from being a health care panacea. By not setting out to ensure access for everyone, it will not solve the basic problem in achieving the Triple Aim. I mean, it’s good to be focusing on quality, cost and patient satisfaction but without a plan to assure that everyone has access to care it can ring a little hollow.

As was observed by Schiff, Bindman, and Brennan more than 20 years ago, and quoted by me before (Medical errors: to err may be human, but we need systems to decrease them, August 10. 2012), denial of care – or lack of access to care for financial, geographic or other reasons -- is the “gravest of all quality defects”.