This Week in Veterans
Would it surprise you to learn that much of the "scandal" discovered in the VA health system was manufactured for private profit? How about if we told you the Koch Brothers were involved? Starting to make sense now?
The CVA [Concerned Veterans for America--ed.], it turns out, is the creation of David and Charles Koch’s network. The Koch family has famously poured hundreds of millions of dollars into think tanks, candidates, and advocacy groups to advance their libertarian views about the virtues of free markets and the evils of governments and unions. Seldom, however, has one of their investments paid off so spectacularly well as it has on the issue of veterans’ health care. Working through the CVA, and in partnership with key Republicans and corporate medical interests, the Koch brothers’ web of affiliates has succeeded in manufacturing or vastly exaggerating “scandals” at the VA as part of a larger campaign to delegitimize publicly provided health care.
The Koch-inspired attacks, in turn, have provided the pretext for GOP candidates to rally behind the cause—only recently seen as fringe—of imposing free market “reforms” on the federal government’s second largest agency. The attacks have also damaged the reputation of the VA among the broader news-consuming public, and, not coincidently, undermined morale within the agency itself. And they succeeded in stampeding bipartisan majorities in Congress into passing legislation in 2014 that under the guise of offering veterans “choice” has instead created a deeply flawed and unworkable process of outsourcing VA care while also setting in motion a commission that seems intent on dismantling VA-provided health care altogether.
All this has been happening, ironically, even as most vets who use the system and all the major veterans’ service organizations (VSOs) applaud the quality of VA health care. Adding to the perverse twists of the story is a mountain of independent evidence, including studies mandated by the 2014 law itself, showing that while the VA has an assortment of serious problems, it continues to outperform the rest of the U.S. health sector on nearly every metric of quality—a fact that ought to raise fundamental questions about the wisdom of outsourcing VA care to private providers.
The VA has had a long history of providing excellent care, and it was perhaps never better than when the agency was run by Clinton appointee Dr. Kenneth W. Kizer.
To implement these changes, Kizer radically decentralized power within the VA, pushing it out of the central office in Washington and into the field. For example, Kizer embraced a dissident, previously persecuted subculture of front-line employees, known as the “Hard Hats,” who had been experimenting with using their personal computers to improve the practice of medicine. The result was software written by doctors, for doctors, that pushed the VA roughly twenty years ahead of the rest of the U.S. system in its use of what we today call electronic medical records and telemedicine. Kizer also allowed regional managers far more autonomy over the operations of local VA hospitals and clinics, while at the same time using the VA’s new capacities in information technology to hold managers accountable for meeting measurable performance metrics.
During the Kizer era, the major veterans’ service organizations joined health care policy wonks in applauding the high quality of care offered by the VA. Indeed, the American Legion, while initially skeptical of his reforms, would wind up giving Kizer a lifetime achievement award, while measures of patient satisfaction generally showed the VA outperforming Medicare and the private insurance plans. Veterans also applauded the decision made by the Clinton administration in 1996 to relax eligibility standards, so that any honorably discharged veteran could receive VA care for life, no questions asked.
Under George W. Bush’s administration, studies continued to show the VA outperforming the rest of the U.S. health care system on most metrics of safety, quality, health IT, and patient satisfaction. Often, the administration seemed not quite sure what to do with this fact. In 2004, when Bush announced an initiative to push for greater adoption of electronic medical records throughout the U.S. health care system, he did so by traveling to the Baltimore VA Medical Center and showcasing the world-class health IT in place there. “I know the veterans who are here are going to be proud to hear that the Veterans Administration is on the leading edge of change,” Bush explained, without showing any evident discomfort with praising the largest actual example of socialized medicine in the United States.
Yet behind the scenes, the administration took many measures to undo the quality transformation that had occurred under Kizer’s leadership, including the freedom given to front-line employees. Partly this was the result of the tendency of top managers in all large organizations to want to exercise control. But it also reflected the Bush administration’s commitment to outsourcing more and more VA functions.
Bush’s political appointees at the VA, for example, quickly squashed software innovation in the field by reconsolidating bureaucratic control over all things digital in Washington and then contracting with venders of private, proprietary software. At one point, the VA even lost control of its own lab software system to Cerner, a private corporation that dramatically ramped up spending on lobbying during the middle of the last decade.
And, increasingly, Bush’s political appointees at the VA began outsourcing more care to private health care providers, often with unhappy results. For example, between 2002 and 2008, the Philadelphia VA outsourced its prostate cancer unit to a team from the University of Pennsylvania. Investigators later found that of the 114 patients who went through the treatment, ninety-two received either too much or not enough radiation to the prostate, and in some cases the physician missed the prostate altogether. Outsourcing also led to financial waste and fraud. For example, the VA inspector general found that in the last year of the Bush administration, 37 percent of the $3.2 billion the VA spent on outsourced care was improperly paid.
The Bush administration's push to privatize virtually every aspect of government has led to, among other things, the vast network of private contractors who do work that was formerly done--more efficiently and inexpensively--by the military. The administration was, fortunately, prevented from privatizing Social Security. But VA care wasn't as lucky. Elected Republicans and the CVA have long been trying to privatize its functions, and the first step was making it look like there was a real problem, regardless of how dishonest they had to be.
Then, on April 9, 2014, at a hearing in the House Committee on Veterans’ Affairs, Representative Miller (R/FL) dropped the bomb. He announced that his staff had been quietly investigating the VA hospital in Phoenix and had made a shocking discovery: some local VA officials had altered or destroyed records to hide evidence of lengthy wait times for appointments. And worse, Miller claimed, as many as forty veterans could have died while waiting for care.
This latter charge guaranteed screaming headlines from the likes of CNN, but was later shown to be unsubstantiated. An exhaustive independent review of patient records by the VA inspector general uncovered that six, not forty, veterans had died while on waiting lists to see a VA doctor, and in each of these six cases, the IG concluded that “we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.” In other words, the reality behind the headlines had little, if any, more significance than the fact that people die every day while waiting for an appointment to see their tax accountant or lawyer.
Those who showed up on waiting lists usually turned out to have been waiting for a routine visit with a primary care doctor rather than facing an urgent health care problem. Moreover, among those shown as waiting to see a primary care physician, many turned out to be already under the active care of a VA or non-VA specialist. In only twenty-eight out of the more than 3,000 patient cases examined by the inspector general was there any evidence of patient care being adversely affected by wait times. During the worst of the “crisis,” fully 89 percent of patients received appointments within thirty days of their preferred date. There was a long backlog of people waiting to see a urologist, but the nation as the whole faces an acute shortage of specialists in that field.
Moreover, the wait times in Phoenix were not typical of the system as a whole. Capacity constraints, for example, were greater in Phoenix than in most of the rest of the country due to the large number of retirees who had moved to the area in recent years, including “snow birds” who used the Phoenix-area VA system only during the winter months. In most VA facilities, wait times for established patients to see a primary care doc or a specialist were in the range of two to four days, which compares favorably to the experience of most patients seeking care outside the VA. For the VA system as a whole, 96 percent of patients received appointments within thirty days.
In short, there was no fundamental problem at the VA with wait times, in Phoenix or anywhere else. But there was evidence of specific VA employees in Phoenix and other facilities using unorthodox scheduling practices to make wait times look shorter than they were, just as had happened during the Bush administration. Under Shinseki, the VA’s central office tried to crack down by issuing flurries of admonishing memos. Unfortunately, however, these edicts had little effect, in part because Shinseki had upped the ante. His metric demanding that all newly enrolled patients within the VA be offered an appointment with a primary care doc within fourteen days was a benchmark worth striving for, and one that few other health care providers would dare hold themselves accountable for meeting. But in trying to impose this ambitious goal on already-overstrained employees and facilities, the VA made itself vulnerable to enemies who were already set to pounce.
The VA has a long history of providing cost-effective health care to our veterans. But industry groups--and the Koch Bros--think the profit motive should be a bigger part of veterans' care. We don't see how that's likely to make it better. It will make it more expensive, and more importantly for those involved, it will push more Americans' hard-earned dollars into the pockets of the wealthiest few. The Koch Brothers and their allies are beyond shame--but next time someone runs down the VA, it couldn't hurt to point out that the freer from private-sector interference the agency was, the better the care it provided.
This Week in Voodoo Economics
It's probably not surprising that voodoo economics won't stay dead.
During last week's Republican presidential measuring contest--to call it a "debate" is to overly glorify it--Chris Wallace rightly questioned candidate Donald Trump on his absurd economic plan, which would do the opposite of what Trump promises--it would add to the national debt and the deficit, not subtract. Wallace pointed out, using facts and charts, how Trump's numbers don't add up, to which Trump's response was to deny the truth of Wallace's facts.
It was, for Fox "News," a rare moment of public service. But it didn't go far enough, because the other three men on that stage all propose counterfactual fiscal policy. They all want the rich to pay less in taxes and to cut government regulation and spending--the approach that George H.W. Bush called "voodoo economics."
Apparently 2008 is too long ago, and they don't remember the George W. Bush recession.
But all they'd really have to do is look around at the states that are practicing what the candidates themselves are preaching. The evidence is all around us--most recently reported in Louisiana, where the brand-new governor is trying to deal with the fiscal calamity that governor and (briefly) presidential candidate Bobby Jindal (R) left him.
The Washington Post describes the mess pretty well:
BATON ROUGE, La. — Already, the state of Louisiana had gutted university spending and depleted its rainy-day funds. It had cut 30,000 employees and furloughed others. It had slashed the number of child services staffers, including those devoted to foster family recruitment, and young abuse victims for the first time were spending nights at government offices.
And then, the state’s new governor, John Bel Edwards (D), came on TV and said the worst was yet to come.
Edwards, in a prime-time address on Feb. 11, said he’d learned of “devastating facts” about the extent of the state’s budget shortfall and said that Louisiana was plunging into a “historic fiscal crisis.” Despite all the cuts of the previous years, the nation’s second-poorest state still needed nearly $3 billion — almost $650 per person — just to maintain its regular services over the next 16 months. Edwards gave the state’s lawmakers three weeks to figure out a solution, a period that expires March 9 with no clear answer in reach.
Louisiana stands at the brink of economic disaster. Without sharp and painful tax increases in the coming weeks, the government will cease to offer many of its vital services, including education opportunities and certain programs for the needy. A few universities will shut down and declare bankruptcy. Graduations will be canceled. Students will lose scholarships. Select hospitals will close. Patients will lose funding for treatment of disabilities. Some reports of child abuse will go uninvestigated.
“Doomsday,” said Marketa Garner Walters, the head of Louisiana’s Department of Children and Family Services. If the state can’t raise any new revenue, her agency’s budget, like several others, will be slashed 60 percent.
How did this happen? It's not complicated. Louisiana was temporarily flush with billions of federal dollars of aid after Hurricane Katrina. But instead of coming up with a plan to sustain the state's economy after that money ran out, Gov. Jindal and his friendly Republican legislature decided to apply the usual conservative prescription, apparently having not noticed that it never works anywhere. The WaPo reports:
Many of the state’s economic analysts say a structural budget deficit emerged and then grew under former governor Bobby Jindal, who, during his eight years in office, reduced the state’s revenue by offering tax breaks to the middle class and wealthy. He also created new subsidies aimed at luring and keeping businesses. Those policies, state data show, didn’t deliver the desired economic growth. This year, Louisiana has doled out $210 million more to corporations in the form of credits and subsidies than it has collected from them in taxes.
Imagine that. And how does Louisiana's still-Republican legislature want to deal with it? You'll never guess.
Edwards noted that he recommended about $160 million in spending cuts, along with tax hikes and the use of onetime dollars, to erase the shortfall. But he said some lawmakers say “we can cut our way out of this.”
The House on Thursday, with little discussion, approved a $100 million spending cut bill sponsored by House Appropriations Committee Chairman Cameron Henry, R-Metairie.
The legislation first called for a $44 million cut in state aid for public schools. Before the final vote, the bill was revamped to require a $44 million reduction for the state Department of Education.
Top state education officials said such a move, an 85 percent cutback, would decimate the agency, including dollars for vouchers and student testing.
At this point, more spending cuts are bound to happen, because the legislature can't raise taxes enough to make up the shortfall. And it's the people of Louisiana--the non-millionaire people, that is--who'll pay the price for that. Take education, for instance, which more forward-looking states consider an investment in the future:
In Louisiana’s capital, on a university campus just seven miles north of the government offices, is perhaps the most acute evidence of the funding cutbacks — and the mounting concern about what will happen next. At Southern University and A&M College, a historically black institution along the Mississippi River, mold spreads across building walls, and rats scurry through dormitories. Eighteen buildings have roof leaks; in two, raw sewage occasionally belches onto the floor. An entire section of the library is off limits because of a perpetually broken fire alarm.
“One elevator has been broken since 2013,” said Taysia Marie, a junior nursing student. “I’ve never seen it working.”
Since the 2007-08 school year, Louisiana has cut funding for higher education by 44 percent, the sharpest pullback in the nation; Southern has seen its funding cut 49 percent. During that time, the burden of supporting education has flipped: Whereas the state once provided 70 percent of the money its schools spent, now the students support the bulk of the costs — in the form of higher tuition.
Those least able to bear the burden are, of course, being asked to take the brunt of it:
On Jindal’s watch, nearly every agency in Louisiana shed employees, and state lawmakers say some teetered because of the losses. The Department of Children and Family Services shrank to 3,400 employees, from 5,000 in 2008, and social workers began carrying caseloads larger than national standards. The state also cut funding for youth services and mental health treatment.
“When you cut those programs, it doesn’t change the need for people to get those services,” said state Rep. Walt Leger (D). “It just means you’re no longer providing them. Those folks end up in jail or wandering the street, not being treated for mental health issues, and all of those things have a huge societal cost.”
More spending cuts are not ultimately the answer to the Jindal disaster. Reasonable tax increases at the right time would have helped, but it's too late for that. Careful investments could have helped, too.
What's important to remember is that what Jindal did is not something new and innovative--it's standard conservative economics (the same thing is having the same effect in Kansas. In Michigan, it's the kind of thinking that's dooming the futures of kids in Flint, MI). They want to cut taxes for the richest among us, give corporate welfare to the biggest corporations, and make it up by slashing services to those who need them.
Regardless of which Republican candidate wins that party's nomination, that will be the basis of his economic plan. As Matt O'Brien reports in the Washington Post this week:
If this is a revolution, though, it's a funny kind of one. That's because the new boss sure does look a lot like the old boss, at least when it comes to what the Republican establishment cares about the most. And that's cutting taxes for the rich. Indeed, the two "anti-establishment" candidates are even more orthodox on this than the establishment ones. You can see that in the chart below. Trump and Cruz would both, according to the nonpartisan Tax Policy Center, cut taxes for the top 1 percent by twice as much as Rubio would. And though they all would give the top 0.1 percent a $1 million-plus tax cut, it's the putative outsiders who would give the plutocrats the most.
O'Brien adds:
Consider this: the top 1 percent would get 40 percent of all the tax cuts under Rubio's plan, 39.8 percent under Trump's, and 49.8 percent under Cruz's. People of more modest means, though, would not be so lucky. The bottom 40 percent of households would only get 5.3 percent of Rubio's tax cuts, 5.3 percent of Trump's, and 0.8 percent of Cruz's. And no, that last number is not a typo. Cruz's plan would, on average, increase taxes on the bottom 20 percent. It's a reverse Robin Hood: raising taxes on the poor to slash them for the rich.
And:
George W. Bush's top-end tax cuts didn't make middle-class incomes grow even though the economy did. And neither have Kansas and Louisiana's when they tried the same thing at the state level. Growth hasn't increased, deficits have, and those state and local governments have had to drastically cut back on basic services like, for example, keeping elementary schools open.
Which is why we can't let any of them win the presidency. The country would have a hard time recovering from having Louisiana recreated on a nationwide scale.
This Week in Education
Take what the Republican presidential candidates don't understand about economics and double it, and you'll have what they don't understand about Common Core. This article focuses on Trump's lack of comprehension, but in truth they've all made statements about it totally at odds with reality.
Trump repeated his nonsense at this week's Republican debate in Miami. It's still wrong.
Side Note: In other nonsensical statements at the debate, Marco Rubio reiterated his call for the US Navy to build more frigates and man-o-wars, and Ted Cruz claimed that the White House returning the bust of Winston Churchill that had been loaned to President Bush was somehow a problem (the other Churchill bust, by the same sculptor, remains at the White House), and claimed once again that President Obama went on an apology tour, which only happened in Cruz's mushroom-induced hallucinations. Trump continued to claim that his economic plan would cut the deficit, and he continued to be wrong.
This Week in the Wall
Speaking of "at odds with reality," could Trump's border wall ever be built? Answer: No.
This Week in Bears
It's been a while since we've had any bear news, but this week brings a bright spot. The population of Louisiana Black Bears (the inspiration for the "teddy bear," when Teddy Roosevelt refused to shoot one that had been tied up for a bear "hunt") has recovered sufficiently that it's been removed from the list of protected species under the Endangered Species Act.
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