Mission Creep

...Remaining static and reducing the number of those using our services forces the system to go out of business...

...In 1990, the VA began charging a modest fee to veterans with outside insurance, but its gradual expansion has rendered the system’s mission ill-defined and vague...

...This would seem to be moving the system in the direction of offering veterans vouchers and choice...

...Dictating VA procedures was a cumbersome, seemingly random set of regulations spelling out which veterans were eligible to receive what benefits and for how long...

...VA officials warn that their hospitals specialize in the treatment of injuries common among veterans, such as spinal cord and mental health problems...

...It employs 194,000 people, serves around 3.5 million vets over the course of three to five years, and has an annual budget of $17 billion...

...When the VA was established in 1930 to take care of growing demand from World War I veterans, the country had virtually no private health insurance, and veterans who used the system had few other options...

...And as the VA moves away from regulations that encourage long hospital stays, occupancy rates will likely fall at scores of other VA facilities...

...Not coincidentally, Travis’ congressman, Republican Frank Riggs, was in the battle of his political life against Democrat Michela Aliota, the daughter of a politically powerful California family...

...And so far, Congress has shown little inclination to stop them...

...Still, critical reports on the VA system from places such as the GAO identified problems across the board...

...During the Bush administration, Derwinski suggested opening up three under-used VA hospitals in Alabama, Virginia, and Montana to non-veteran Medicaid patients...

...And it does so with a tacit nod to veterans groups and nervous bureaucrats that, even as it cuts, the VA wants to expand its mission dramatically, to become the primary outpatient health provider for as many as triple the number of veterans who use it now...

...But the protest didn’t have much to do with commemorating the slain ADAM PPIORE is a reporter for The Record of Hackensack (N.J...

...A better course of action would be to dismantle the VA health care bureaucracy and use its $17 billion annual budget to fund a voucher system...

...It was about jobs, respect, and a faceless government bureaucracy that seemed to want to do away with both...

...Kenneth IGzer, VA Undersecretary for Health, unveiled a reform plan to restructure the VA’s 950 facilities and 190,000 employees into 22 regional fiefdoms called ‘Veterans Integrated Service Networks” (VISN...

...Veterans groups mobilized and Derwinski was soon forced to resign...

...That encouraged local VA officials to keep costs high even if the number of patients seeking treatment declined, as they have in recent years in many parts of the Northeast and Midwest...

...The VA argues the 235-bed hospital is needed to serve veterans who previously used a VA hospital in Martinez, Calif., that closed after the 1991 earthquake...

...There’s more...

...The logical solution: Close down the crumbling, underutilized VA system and offer the 10 percent of American veterans who are dependent on it (an average of 2.5 million people each year) their choice of local care through a voucher system...

...Meanwhile, the VA continues fighting its on-agaidoff-again battle with Congress to construct two new hospitals that would cost hundreds of millions of dollars each...

...One example commonly cited by critics: Prior to the Eligibility Reforms of 1996, a veteran with a broken leg could not be given crutches unless he stayed overnight in the hospital...

...So far, the results aren’t very encouraging...

...Many fear the destruction of any tangible infrastructure would make it easier to cut care for vets in times of fiscal crisis...

...By changing this requirement, VA officials project they could earn $1.7 billion by 2002...

...Slutsky and his army of protesters have drafted Chicago’s congressional delegation, the state’s two Senators, veterans’ groups, and state, local, and county officials to join their battle...

...It’s not surprising, then, that as the VA embarks on its most ambitious restructuring in the last 50 years, it does so only because its faults have become so glaring in the current atmosphere of fiscal austerity and managed care that many believe its very existence is threatened...

...There have also been more immediate changes, equally dramatic...

...Even more troubling was the quality of care...

...Efforts to consolidate hospital operations have ground to a virtual standstill...

...Veterans often wait eight to nine weeks to obtain appointments at speciality clinics...

...In rural areas with limited access to major private care providers, VA hospitals could be transformed into public hospitals and opened up to everyonerather than operating well below capacity for the benefit of a few, as is so often the case now...

...As a result, no VA hospital has been closed for economic reasons since 1965, despite the fact that more than 50 VA hospitals are currently operating with half their beds empty, and some former VA officials openly admit they should be closed...

...Selling off or leasing some of the VA’s real estate and chopping the mammoth bureaucracy could also raise enough money to provide better-quality care to veterans and, in the short term, design a sensible transition plan...

...The protesters were outraged...

...It was Martin Luther King Day...

...All told, Quandt estimates, there are probably about $33 billion in assets in VA facilities...

...Of course, veterans’ service groups would likely at first vehemently oppose any such change...

...Each veteran will be assigned a primary caregiver to quarterback his or her care, much as private managed-care providers do...

...Since 1995, the administration has been locked in a battle of wills with Congress over whether to build two new VA hospitals-not coincidentally-in the voter-rich states of California and Florida...

...House appropriators agreed to hold onto the money until 1998, which gives them time to study the proposal further and, theoretically, reverse their decision...

...When they arrive at their destinations, the care is often substandard...

...It consists of 173 hospitals, 401 outpatient clinics, 133 nursing homes, 39 residences, and 205 readjustment-counseling centers...

...The eligibility reforms passed by Congress last year dramatically expand the V i authority to contract out for some services where convenient...

...Moreover, no politician wants to offend the powerful veterans lobby-including groups such as the American Legion, the Paralyzed Veterans of America, and the Veterans of Foreign Wars-which fears that any change is the first step toward dismantling the guarantee of health care for individuals wounded in combat and has been known to brag about its ability to mobilize massive grass-roots opposition to any perceived threat...

...The idea, at long last, is to establish a system where hospitals receive reimbursement based on the number of patients they serve instead of how much money they spent the previous year...

...By building access points and reaching out to the veterans community, VA officials are hoping to draw in the 7 million eligible vets who currently rely on private health care providers...

...To this end, the VA could either maintain a handful of specialty centers to treat veterans with injuries requiring treatment not available at most private facilities, or, alternatively, consider subsidizing specialists in these areas (with the money saved by moving to vouchers) so that private hospitals can afford to keep them on staff, regardless of the overall market demand...

...New federally funded VA facilities are a popular trophy and a concrete symbol back in the district of a Congress member’s political clout...

...No such agreement was reached for Florida, where Brevard’s Republican Rep...

...Money could even be set aside to set up programs in local community hospitals for outreach programs to help large populations of homeless and mentally ill veterans, who might have trouble signing up for vouchers and shopping for care on their own...

...They argue that dismantling the VA system would leave a gaping hole in service for veterans who suffer from such problems...

...And the money saved from the voucher system would improve the quality and scope of care for veterans...

...The VA has formulated a plan designed to lure into the system a significant chunk of the remaining 90 percent of veterans who have private insurance...

...But with the veteran population in Chicago steadily dwindling, the city doesn’t need two cardiac centers, two spinal injury centers, and two separate management teams six miles apart...

...Bloated Sacred Cow The Veterans Administration was originally intended as a safety net...

...These regional networks, which began talung shape in October of 1995, have more independence and authority to adjust to local circumstances, and are in the process of being assigned separate budgets...

...A crowd of clergy, local residents, and veterans cheered them on, while a line of solemn veterans chanted "Nam...

...Those who have dared speak out have often been driven from officeor come to work in places like Chicago to find crowds of protesters, many in wheelchairs, waving American flags and talking about sacrifice, heroism, and Iwo Jima...

...This time-in the election year-House members relented and agreed to dole out $32.1 million to construct a new hospital in the Travis Air Force Base...

...BY ADAM PIORE HERBERT SLUTSKY LED A CONTINGENT of protesters toward the entrance of Chicago’s West Side Veterans Affairs Medical Center, tailed by an entourage of cameramen and reporters...

...To save money was to risk convincing congressional appropriators that less funding was needed the following year...

...In Northern California, the VA has requested funding for a $211 million construction project at Travis Air Force Base in Fairfield...

...Under the new plan, that number is expected to increase substantially...

...While it’s true that some VA hospitals affiliated with medical schools provide top-notch treatment in certain specialty fields, the more common reality is that care-particularly in under utilized rural areas-is often substandard...

...VISN directors were instructed to downsize staffs, consolidate services where possible, and cut costs...

...There are already at least 50 VA hospitals with an occupancy rate of 50 percent or less, according to Marjorie Quandt, a former VA employee who testified before Congress...

...Waiting times often range from one to three hours before a physician examines patients in emergency rooms and clinics...

...VA officials intend to merge some of the operations of West Side with a sister VA hospital six miles across town, saving millions of dollars a year...

...But it’s not enough...

...Word has also gone out from the pulpits of local churches that jobs are in danger...

...One report by the VA’s inspector general estimated that, based on his office’s review of one medical center, the VA spent between $323 million and $831 million on ineligible outpatient treatments in fiscal year 1992 alone...

...To do this, it intends to set up hundreds of new outpatient clinics, even as it continues operating scores of expensive and underutilized hospitals that remain open only because of political pressure...

...For the vast majority of veterans, however, the voucher system would allow them to be absorbed into the local health care system of their choice...

...Any serious discussion of the VA-other than advocating its expansion-is something most politicians are wise to avoid...

...As if the issue weren’t explosive enough, he arrived in Washington tarnished from a campaign in which he had been labeled a draftdodger, only to find himself quickly mired in a political disaster over his handling of gays in the military...

...David Joseph Weldonwho was facing no such election battle-said his area didn’t need the hospital, and accused President Clinton of making the issue “a political football...

...VA officials argue that incidents of poor quality care and negligence are no more common than in private hospitals and that the VA is unfairly singled out...

...The GAO panned both projects as unnecessary and wasteful...

...The proposed consolidation is seen by some as a test of a national plan to slim down the notoriously inefficient Veterans Hospital System- the largest health care provider in the country...

...Theoretically, a VISN director could decide it’s not cost effective to bus a patient hundreds of miles for heart surgery in a VA hospital, and instead choose to pay for the operation at a local facility...

...The GAO reports on the hospitals also warned that both construction projects could damage health care in the surrounding areas...

...In many cases, veterans must travel long distances for service...

...For one thing, VA bureaucrats had never had any incentive to cut costs, and there had been little oversight for inefficiencies...

...When Clinton took office, the VA system’s faults stood out starkly as a illustration of the very problems that the President promised to solve with his utopian depiction of managed care...

...The VA estimates it would need $1.1 billion over 10 years to build and operate the new facilities...

...The cost for each new access point could range from “one million to several million dollars,” says Dr...

...In the case of California, the GAO noted that the VA “has not considered the likely negative effects the additional beds could have on other hospitals...

...However, it seems unlikely that a reversal could withstand the political pressure of the veterans groups, which now would see any change as a cut...

...Kizer’s plan calls for the VA to set up scores of new outpatient clinics at “access points” across the country...

...Certainly, there are plenty of local health care providers who would be happy to serve them...

...Many of those that do remain open are unable to fill more than 50 percent of their beds...

...Rather than compounding the closings by luring veterans away, a voucher system would help redistribute demand for care...

...I’m loolung at what’s going on in the VA, the downsizing-The majority of vets that go to the VA, that’s all they have...

...Consider this message from an article l z e r published in US...

...The situation was made worse by red tape and bureaucracy...

...Veterans have consistently listed distance as an impediment to accessing care...

...particularly those [around] Travis Ar Force Base that have occupancy rates of around 40 percent I’ Yet the Clinton administration and the VA have continued to fight for the projects...

...A Big Debt There’s no question that the country owes a debt to its veterans-especially those who put their lives on the line and came back injured...

...In exchange, they would agree not to request any increase in health care appropriations for the next five years...

...Clinton faced a political mine field...

...New Look, Same Problems In March 1995, Dr...

...In 1996, the Clinton administration resubmitted its request for full funding...

...What does this translate into financially...

...In Florida, the VA proposes constructing a new hospital and nursing home in Brevard County...

...Medicine in January, in which he lays out the VA’s five-year strategy: “We need to increase the number of VA health care users...

...But practical reforms or cut backs-even the most modest-tend to get beaten down by flag-waving rhetoric...

...Other veterans could receive care for their servicerelated wounds but for nothing else, unless varying criteria were met or unless they paid for treatment...

...Theoretically, a veteran being treated for a leg injury was not entitled to additional care if he happened to sprain his ankle on the way to his VA appointment...

...The number of additional access points that will be set up is yet unknown, but, according to VA spokesman Ken McKenna, it probably will be “a number in excess of 2,000...

...In each case, the GAO discovered that local area hospitals had, on average, 2,000 to 3,000 vacant beds that could be put to use...

...It also wants to be able to compete for veterans who have private insurance and keep the insurance payments...

...The VA says most will be leased, but some will most likely be built and could become obsolete when the current generation of World War I1 veterans is no longer around...

...then, in 1986, extended its services even further to include higher-income veterans based on availability...

...Although the VA currently charges insurance companies a small fee for treating insured veterans not eligible for free care, most of the money, by law, goes back to the Treasury...

...Also under the old law, the full gamut of VA care was officially available first and foremost to indigent veterans and those with service-related injuries that affected their ability to function by 50 percent or more...

...it is taboo to talk seriously about closing down a VA hospital, no matter how underutilized, expensive, or wasteful...

...civil rights leader’s birthday...

...The Chicago situation speaks volumes about the difficulties of reining in a $17-billion-a-year VA system that is antiquated, wasteful, and increasingly unnecessary...

...But that wasn’t enough...

...When Bill Clinton took office a few months later, vowing to overhaul the nation’s health care system, he could hardly afford to ignore the VA-one of the nation’s largest health care providers...

...Those who would know best, however, seem to disagree: Veterans who avoid the system have consistently stated in government studies that they do so, in large part, because they believe the care is poor...

...It blows my mind the number of homeless veterans who come to the VA,” Slutsky, a veteran and activist, explained later in describing the scene...

...Although the VA disagrees, many independent analysts say health care costs for the average veteran in the system are dramatically higher than they would be under most private insurance...

...Congressional appropriators say the loss in revenue from the Treasury would have to be cut from some other programs...

...The ideal access point would be no more than 30 minutes travel time from the veteran’s home...

...VA medical centers were funded according to their past costs, plus an annual increase...

...In 1995, Congress offered a compromise: It would appropriate $25 million in both Travis and Brevard to construct two new outpatient clinics...

...Anyone who doubts the clout of the veterans lobby need only talk to longtime VA employees, who were around for the public scalping of former VA secretary Edward J. Derwinski...

...The Senate vigorously objected, so another compromise was reached...

...Many doctors, however, simply ignored the regulations...

...Finally, despite all their talk about moving toward a more efficient, outpatient-focused system, the VA and the Clinton administration have been pushing several actions that belie their commitment to reform-and show just how tempting it is to play the hospital trump card in election years...

...In most urban areas, there is a 50 percent excess of beds...

...But to expand in a time of fiscal austerity, when other hospitals are closing for lack of patients, seems ludicrous-and it will likely serve no one except those employed by the mammoth VA...

...Over the last two years, the VA has closed 7,500 beds and pared its staff by 14,000...

...We have to grow and expand to become better...

...Veterans could use the vouchers to access local health care providers of their choice, which would address the two main complaints of the current system: inconvenience and poor-quality care...

...In President Clinton’s February budget proposal, the VA asked Congress to pass a law allowing the VA to treat elderly veterans not eligible for free care and to bill Medicare for the cost-thus opening up a whole new universe of paying customers...

...Currently, there are 399 outpatient clinics...

...At the same time, private hospitals across the country are closing from a lack of patients...

...Under the plan, affecting West Side and three other VA centers in the metropolitan area, none of the hospitals would close...

...The new strategy is aimed at luring millions of veterans away from the private sector...

...The VA’s plans are a classic example of bureaucratic mission creep...

...Even as the VA scales back its workforce, VA bureaucrats are pushing for another dramatic expansion of the system’s mission...

...Since 1980, hospital admissions have declined 11 percent and nearly 1,000 hospitals have closed...

...Ronald J. Gephardt, deputy assistant medical director for ambulatory care...

...Certainly, there should be no question that veterans injured while fighting for the United States should receive the best care available...

...The Clinton health care plan started the process of rethinking the VA, and even after its death, the administration moved forward with plans for dramatic reform...

...Regardless, last year, Congress passed a law extending full-care coverage to all veterans with any degree of service-related injuries, thus upping the number of veterans eligible to receive priority for full VA services by about 2 million...

...In addition, the entire emphasis of the VA system has been rethought, shifting focus away from hospital-based inpatient treatment to the more efficient, preventative outpatient care...

...In 1973, Congress extended VA care to peacetime veterans with low incomes...

...In 1996, 200 positions at VA headquarters were eliminated...

...Unfortunately for the soon-to-be-unemployed Derwinski, he chose to unveil his proposal in close proximity to a presidential campaign...

...But there are better ways to repay that debt than throwing away millions of dollars to resuscitate an underutilized system that most veterans believe is substandard and avoid using...

...As a result, more than 40 percent of admissions and days of care administered by the VA from 1991 to 1992 was inappropriate under the regulations, according to the VA’s internal studies...

...It’s not hard to see why...

...But provisions could be written into the bill to guarantee VA health care for years to come...

...Last year, it was one of the few Cabinet agencies to receive an increase in fundingand there’s a reason...

...Today, the VA system is a behemoth...