A Two-Fisted Fix for the VA
There are two theories on what the Department of Veterans Affairs needs to fix its sprawling health-care system: Better management or more money. The beauty of the deal struck by Senators Bernie Sanders of Vermont and John McCain of Arizona is that it tries both strategies at once.
The proposed legislation, announced last week and now getting hashed out in committee, starts with the department's immediate need to provide more care. It calls for the VA to lease 26 additional major medical facilities around the country, and it would enable the department to hire doctors and nurses more quickly, with existing unobligated funds.
The plan would also expand veterans' choices beyond the VA system; those who face long wait times or live more than 40 miles from a VA facility could go to outside providers, including Department of Defense clinics and hospitals and doctors who participate in Medicare.
To fortify the system for the longer term, the Sanders-McCain plan would create two independent commissions, one focused on capital planning and the other on patient care and scheduling. Survivors of sexual assault would have easier access to treatment. And the VA would have an easier time firing poorly performing staff.
That's an excellent starting point; the plan's success, as usual, will depend on the details we don't yet know. These are the essential open questions:
- How much new funding will there be? The department's health division had about $550 million at the end of the last fiscal year in unobligated funds, but it's not clear how much of that money can be diverted toward new hiring; some may be intended for other purposes. And the needs are huge: The VA has 400 vacancies for doctors alone, and it pays those it has less than they could make in the private sector. A one-time infusion of money would be less helpful than a new pay scale that could better retain doctors once they're hired.
- Can the new funding keep up with growing demands? Veterans' health-care needs typically peak 10 to 20 years after a war ends, which means the VA's financial requirements may continue to outpace inflation for decades. Yet the agency is starting from a deficit: For the most disabled veterans, spending per patient in 2012 fell, in real terms, to less than it was in 2004. Any new funding formula has to realistically reflect the number of patients in the system and the intensity of their care.
- Exactly how long will vets have to wait for the VA before opting for outside care? The proposal calls for adopting the agency's existing two-week target, but that might not be good enough for primary care and it might be too ambitious for specialty care. Tricare, the Defense Department program for long-serving military retirees, lets beneficiaries see outside providers if they can't get into a military facility within one week for a routine visit, 24 hours for urgent care or four weeks for a specialist. The VA should consider that model -- and, while it's looking at Tricare, pay attention to the way it negotiates discounted rates with its network of independent providers.
In spelling out the details, senators can ensure that the VA health-care system, as currently configured, is given its best chance to run well. If it turns out that the enterprise is just too big to be well managed no matter how much new money or firing authority it's given, or that its web of regional networks is too decentralized, then more fundamental change will be needed.
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