With the unanimous confirmation of Department of Veterans Affairs (VA) Secretary Dr. David Shulkin on Monday night, the Senate laid the foundational block for Veterans’ policymaking under the new administration. As VA Under Secretary for Health during the previous administration, Dr. Shulkin is intimately familiar with the challenges of serving Veterans and their families, but also the pressure of providing quality, cost-efficient, and timely care.
The VA operates a sweeping system that include healthcare administration and other benefits such as education, retirement, and loans to a network of approximately 21 million living Veterans. There are almost nine million enrollees in the Veteran Health Administration (VHA) healthcare network, with has an annual budget of $65 billion (FY 2017) and operates 168 medical centers and over 1,000 outpatient clinics.
Media coverage in recent years has highlighted shortcomings in budgetary and staff allocations and led to efforts to transform the VHA system to improve care. Legislation, including the Veterans Access, Choice, and Accountability Act (2014) and Clay Hunt Suicide Prevention for American Veterans Act (2015), streamlined selected components of the VHA system to address critical quality, access, and safety issues for both physical and mental health care delivery. Nonetheless, various management and bureaucratic hurdles remain to maximize efficiency within the VHA system, which is among the top three healthcare systems domestically in the number of hospitals and the largest in number of covered beneficiaries served.
A larger living Veteran population ― caused by substantial deployments during Operation Enduring Freedom and Operation Iraqi Freedom, coupled with longer life expectancy ― creates increased demand on the VA system. While VA staffing levels have increased to a degree, medical and mental health staff supply has not consistently met demand to ensure timely access to care and minimize wait times for Veterans seeking care across all VA facilities nationally.
There are, however, positive systemic indicators that VA healthcare access trends are improving. For example, average national wait time for a primary care appointment at a VA Medical Center has decreased (from over eight days at the end of 2015 to over five days in early 2017) and total number of appointments scheduled have increased from under six million to nearly eight million over the same time period. Policies applied by VA leadership under the new administration should leverage the tools and expertise to continue these improving trends, not undermine recent progress.
Debates over the optimal design and delivery system for VA care have persisted across sessions of Congress and administrations, but the end goal of providing the best possible care to our Veteran population within a reasonable budget is a topic of bipartisan agreement. Congressional Veterans Affairs committees and Veterans’ advocacy groups have largely resisted calls to privatize the VA healthcare system, acknowledging that a federally-funded and operated system is better positioned to provide scalable services to a population facing a unique set of challenges, especially related to mental health. This is especially relevant in the ability of a federal healthcare system like VHA to: a) leverage relationships with other federal and private sector partners to coordinate policies and align resources; and b) pursue systemic improvements to optimize care (such as strengthening existing information technology infrastructure or standardized data collection) beyond the scale of a smaller-scale, private healthcare system.
VA and its interagency partners have advanced the science by consolidating resources for mental health research. The Precision Medicine Initiative provides a model of patient-powered research to accelerate biomedical discoveries and provide clinicians with new tools, knowledge, and therapies to select which treatments tailored to individual patients. VA continues to fund Million Veteran Program, a cutting-edge genomic medicine program, in which VA seeks to collect genetic samples and general health information from Veterans.
VHA is also systematically administering and collecting data across a series of mental health outcome metrics to screen beneficiaries for posttraumatic stress disorder, depression, anxiety, and alcohol and drug misuse. While significant challenges remain, incremental reform measures rather than an overhaul of the entire system, represent a pragmatic solution agreed upon by engaged members of Congress, Veterans groups, and new VA leadership.