The VA isn't broken, yet: inside the Koch brothers' campaign to dismantle the country's most successful example of publicly provided health care.

AuthorMundy, Alicia

In past presidential primaries, when candidates wanted to win the votes of veterans they would trek to American Legion halls and Veterans of Foreign Wars conventions in far corners of Iowa and New Hampshire. While there's been a little of that in the current primary contest, a new pattern has emerged, at least on the Republican side.

Over the last year, every major GOP candidate with the exception of Donald Trump has made a pilgrimage to gatherings put on by Concerned Veterans for America (CVA), a group that had barely formed during the 2012 primary cycle. Whereas candidates back in the day were under pressure from the old-line veterans' groups to promise undying support for the Department of Veterans Affairs (VA) and its nationwide network of hospitals and clinics, the opposite has been true this season. Candidates at CVA rallies have been competing with each other to badmouth the VA and its allegedly shabby treatment of veterans. And all have pledged fealty to the CVA's goal of moving as many vets as possible out of the VA into private care. Even Trump is calling for more "choice."

This may not at first hearing seem too surprising. Nearly the whole of the Republican Party has become more radically antigovernment in recent years. And since the spring of 2014, when headlines started appearing about long wait times and cover-ups at some VA hospitals, a strong narrative has built up, including in the mainstream media, that the system is fundamentally broken. A recent front-page headline in the New York Times proclaimed, as if it were a matter of fact, that Bernie Sanders's support for the VA during the controversy over wait times proved his poor judgment: "Faith in Agency Clouded Bernie Sanders's V.A. Response."

Yet beneath the surface of events, a far different, deeper, and more consequential story is unfolding. The CVA, 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 long arc of the VA's place in American life shows that the agency has always struggled against ideological enemies and against commercial health care providers who would stand to gain business from its being privatized. The only hope is that Americans will wake up in time to save the VA from those who are trying to kill it.

The federal government's role in providing health care to veterans began during World War I, when tens of thousands of American "doughboys" came home with hideous, lingering physical and psychological injuries, including, most tragically, exposure to poison gas and what that lost generation called "shell shock." Congress responded by creating the Veterans Bureau, a predecessor to the VA, which set about constructing specialized veterans' hospitals and soldiers' homes in major cities across America. These facilities were and still are distinct from the separate military hospitals run by the Department of Defense, such as the Walter Reed National Military Medical Center, which care for men and women still in the service.

During and after World War II, the VA experienced a period of reinvention and uplift as an agency. Not only did it successfully administer all the benefits of the newly created GI Bill--from VA mortgages to subsidized college tuition--it also began a deep collaboration with American medical schools that put it at the heart of modern American medicine.

Under this partnership, medical schools conduct practical training for medical interns and residents at VA hospitals, while many VA doctors hold joint appointments on the faculties of medical schools. Today, an estimated 65 percent of all doctors practicing in the United States have received all or part of their residency training in VA facilities, while doctors employed by the VA often engage in important medical research (and have even racked up three Nobel prizes in medicine).

During the Vietnam War and its aftermath, however, the VA health care system again came under acute stress. Part of the challenge derived from medical breakthroughs: thanks to improvements in combat medicine and air evacuation, many wounds that would have been fatal in previous wars now resulted instead in severe long-term injuries and disabilities that swelled patient loads of VA hospitals. But Vietnam vets also came home to VA hospitals that were woefully underfunded and run-down. Many Vietnam vets were further outraged by what they saw as the VA's refusal to take seriously their complaints about post-traumatic stress and exposure to chemical agents like Agent Orange.

A new generation of veterans' activists brought needed, if sometimes distorted and sensational, media attention to the deficiencies of veterans' health care during the war and afterward. Recalling a lurid 1970 Life magazine photo essay about conditions in the Kingsbridge VA hospital in the Bronx, the activist Oliver Meadows would later admit that it "was totally contrived, we helped them all the way," while at least one veteran interviewed for the story admitted that activists had staged scenes to make conditions in the hospital look more awful than they really were. Yet there is also no doubt that the disrespect American society generally showed Vietnam vets upon their return extended to the lack of funding and focus given to VA hospitals.

During the 1980s and '90s, conservatives increasingly leveraged the damaged public image of the VA to make arguments against any move toward "socialized medicine," including the universal health care plan laid out by Bill and Hillary Clinton in 1993. "To see the future of health care in America for you and your children under Clinton's plan," argued the conservative activist and author Jarret B. Wollstein, "just visit any Veterans Administration hospital. You'll find filthy conditions, shortages of everything, and treatment bordering on barbarism." Deploying rhetorical strategies it would later use against the Affordable Care Act, the libertarian Cato Institute, then heavily funded by the Koch brothers, piled on with a white paper proclaiming that "the history of the [VA] provides cautionary and distressing lessons about how government subsidizes, dictates, and rations health care when it controls a national medical monopoly."

Yet just as the reputation of the VA was reaching a nadir, the organization was undergoing a transformation behind the scenes that, within a few short years, would result in its outperforming the rest of the America health care system in safety, adherence to evidence-based care protocols, and other standard metrics of health care quality. For example, in 2003 the prestigious New England Journal of Medicine published a study that used eleven measures of quality to compare veterans' health facilities with fee-for-service Medicare. In all eleven measures, the quality of care in veterans' facilities proved to be "significantly better" than private-sector health care paid for by Medicare.

Other studies began appearing in the early 2000s showing that the VA was light years ahead of the rest of the health care system in the meaningful use of electronic medical records, investment in disease prevention, and integration of care. In 2007, the prestigious British medical journal BMJ noted that while "long derided as a US example of failed Soviet-style central planning," the VA "has recently emerged as a widely recognized leader in quality improvement and information technology. At present, the Veterans Health Administration offers more equitable care, of higher quality, at comparable or lower cost than private-sector alternatives."

The change agent who led the turnaround was Dr. Kenneth W. Kizer, whom President Bill Clinton appointed as VA undersecretary for health in 1994. The story of Kizer's transformational leadership of the veterans' health system has been widely told in the peer-reviewed literature on health care quality. (It was first chronicled in the popular press by the Washington Monthly in a 2005 cover story by Phillip Longman, which subsequently led to a book, now in its third edition, called Best Care Anywhere...

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