Trump’s VA Plans Look Too Much Like Biden’s VA Reality, The American Prospect, Feb. 19, 2024, by Suzanne Gordon and Steve Early

While Project 2025 plots VA dismantling, its Biden-appointed leader tells workers to ‘stay out of politics.’

During a recent campaign speech in North Carolina, former President Donald Trump claimed that, when he first entered the White House seven years ago, there were “sadists” working at the VA who “would beat up old wonderful soldiers. Beat the hell out of them … and we weren’t allowed to fire them.” In a meeting with New Hampshire veterans, Trump urged them to support his re-election effort so, next year, he can fire “every corrupt VA bureaucrat who Joe Biden has outrageously refused to remove from the job or put back in the job.”

Such threats are not MAGA rally rhetoric. They constitute Trump’s plan of action for the Department of Veterans Affairs (VA), which has the second-largest workforce and third-largest budget of any federal agency.

As the Prospect and other media outlets have warned, Trump and his supporters will be much better prepared next January to seize the levers of power than they were in 2017. According to one former Trump official, their collective mission will be to act as a “wrecking ball” aimed at “the administrative state [from] Day One.”

Right-wing policy wonks, who are part of a Heritage Foundation–sponsored group called Project 2025, have developed a detailed agenda to slash federal spending and cut taxes, dismantle key agencies, strip 50,000 workers of civil service protections, renegotiate union contracts, and privatize even more government functions, like providing medical care to nine million patients of the VA-run Veterans Health Administration (VHA). …

[T]he current administration does not offer enough of an alternative to Trump’s own VA agenda, past and future. Biden’s VA leaders continue to ignore the elephant in the room: the already swinging wrecking ball of privatization. One sign of this is the rare Project 2025 praise of Biden appointees, for “adopt[ing] some of their predecessors’ governance processes” at the VA.

… Biden’s VA secretary Denis McDonough has dragged his feet on reversing Trump-era administrative rules determining veteran eligibility for private-sector care. The Veterans Community Care Program (VCCP), launched by his Republican predecessor and authorized by the MISSION Act, has been expanded to include 1.6 million outside medical care vendors. VCCP utilization is growing by 17 percent a year, 42 percent of VA patients are now channeled into the private sector, and the program is consuming over 30 percent of the VHA’s clinical care budget. That has, of course, weakened the VA’s direct-care capacity, strained its finances, and made working conditions worse for frontline caregivers.

As a result of this and other management decisions, the VHA is now facing a $4 to $5 billion budget deficit and will have to curtail new hiring. …

VA headquarters has already informed local and regional medical center leaders that they must maintain “neutral FTE’s.” Dr. Shereef Elnahal, the VA’s current under secretary for health, has repeatedly acknowledged that the resulting workload increases will add to job stress and burnout. But he is already contributing to that with his drive to increase patient loads for clinicians via a much-disliked system of “bookable hours,” a productivity measurement of the sort favored by Project 2025.

Prospect interviews with VHA facility managers around the country reveal that they are warning VA headquarters that local program cuts and staff layoffs will be necessary soon, if outsourcing costs continue to drain local budgets. As one VA medical center chief of staff predicted, “If the Secretary does not revise the access standards to community care so we are actually able to meet them, in five years, we won’t be able to deliver care, we’ll be just another insurance company.”

… the Biden administration plans to spend $23.5 billion over the next decade on an “Integrated Critical Staffing Program” (ICSP), a gravy train for HR outsourcing firms that will fill VA jobs by hiring non-union temps. Another just-announced initiative allocates $14 billion to hire “commercial health care consultants” and other vendors who will advise the agency on modernization of its service provision. The VA will be adding many more contractors to its roster even though its own Office of Inspector General has just released a report documenting that the agency isn’t adequately vetting and monitoring those already on the payroll.

Both initiatives are very much in the spirit of Project 2025’s encouragement of private-sector partnerships “to improve the overall patient experience,” which most studies confirm is better inside, rather than outside, the VHA. …

In a New Year’s message, the VA secretary warned about “controversies and challenges … that will get accentuated during this presidential election year.” During this trying period, he wrote, “our noble mission, our singular purpose and our critical responsibility to always keep Veterans at the heart of everything we do … requires each of us to stay out of politics” (emphasis added).

…As one former AFGE official told us, “That message was threatening, dangerous, and factually wrong—something you’d expect of his Republican predecessor. The original intent of the Hatch Act was to protect federal workers from political pressure and patronage. It does not mean they should ‘stay out of politics.’”…

This year’s general-election contest will indeed be noisy, but 2024 is not a year for political inaction by federal workers, either organizationally or individually. At the VA, where a third of the health care workforce consists of former service members like Hayes himself, nobody is better positioned to counter Trump’s demonization of “VA bureaucrats” as “sadistic” and “corrupt” than its frontline caregivers.

Only they can put a human face on who actually delivers “high-quality care” and helps veterans gain “timely access” to other service-related benefits. And if they fail to do that in sufficient numbers, particularly in key battleground states, just 11 months from now the keys to VA headquarters will be handed over to conservative promise-keepers from the Heritage Foundation. Their agenda has already proved disastrous, for VHA patients and providers, during Trump’s first term and, unfortunately, in its Biden-era iteration as well.

Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

The Veterans Health Administration provides some of the most efficient and clinically effective care in the US, as revealed in various studies, many covered in HJM. It is living proof of the benefits of a mission focused on patient care and simplified (single payer!) financing.

Yet it is under attack by the MAGA GOP, as described in the Project 2025 plan. But also by the Biden administration with the current VA leadership pushing the ill-conceived privatization and incorrectly discouraging political involvement by employees in the pivotal upcoming election.

To be clear, a GOP/MAGA White House will destroy the VHA. A Democrat administration will permit us to fight for the integrity of the public VHA.

We, the people, must elect government legislators and administrators who do understand how well the public policies have been working for our veterans – officials who are dedicated to supporting them. Not only do we have to go to the polls to prevent the turnover of control to the Heritage extremists and their ilk, but we must communicate clearly to the current administration that we need to perpetuate the public VAH program that has served our veterans (and the taxpayers!) so successfully. We owe that to them!

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Finland Sees Housing and Health as Inextricably Linked, The Commonwealth Fund, International Insights, Vol. 24, by Munira Z. Gunja

It’s hard to imagine that just four decades ago, there were some 20,000 people in Finland without a home. By last year, this number had fallen to less than 3,700, a roughly 82 percent decline that represents the most significant decrease in homelessness within the European Union.

It’s a completely different story in the United States, where the number of people experiencing homelessness is the highest it’s been in decades. About 20 of every 10,000 Americans lacked stable housing in 2023, a 12 percent increase over the previous year. Black people, Native Americans, and Pacific Islanders are unhoused at disproportionately high rates, while Asian Americans had the sharpest percentage increase in homelessness compared to all other races and ethnicities.

The health consequences of not addressing the U.S. housing crisis are clear:

• People who experience homelessness have higher rates of illness and die an average of 12 years earlier than the general U.S. population.
• Unhoused people are more likely to have behavioral health needs.
• Low-income and unhoused people are the top 5 percent of hospital users and account for 50 percent of health care costs.
• One-third of emergency department (ED) visits are made by people experiencing homelessness, with nearly 80 percent of those visits for concerns that could have been preempted with preventive care. ED visits are estimated to cost $18,500 annually for each unhoused person.

The evidence shows that stable, affordable housing improves mental and physical health outcomes.  Finland’s government recognizes this and has worked to ensure that thousands of its residents who would otherwise be forced to sleep on the streets have access to dignified housing.

(Finland’s) Housing First moves people into stable housing right away – with no conditions – and then provides additional social services as needed. People receive a rental unit as well as access to support staff to help them navigate their finances, find jobs, and address any other needs. To build community, tenants are invited to participate in group activities and undertake charity work. To foster financial independence, they pay a percentage of the overall rent with the help of financial subsidies, if needed.

How is the U.S. addressing homelessness?

The federal government encourages the use of Housing First practices, and several U.S. cities and states have adopted the model.

But success hinges on filling significant gaps in funding. Currently, communities across the U.S. lack the financing necessary to provide housing for everyone who needs it, a problem that will likely get worse. Nationally, the number of people losing housing each year is outpacing the number of people gaining it.

Half of U.S. primary care physicians report a lack of sufficient coordination with specialists and hospitals for their patients’ care. But fully addressing the needs of unhoused patients, such as through community-based care models that offer supportive housing, requires just that.

Comment:

By Don McCanne, M.D.

Whoa. Didn’t we end this article synopsis with the resolution of this crisis up in the air? If we go ahead and address the problem of homelessness, we can simultaneously address the problem of deficiencies in mental and physical health and also the increasing need for other social services as well.

This report states that many communities lack the financing necessary to provide adequate housing, but the nation as a whole certainly does not lack the potential resources. We now have large numbers of individuals and corporate entities with great wealth which would not be impacted at all negatively by relatively modest tax policies that would be required to ensure the presence of community-based care models that included assurances of adequate housing. They’ve done it in Finland; we can surely do it here in “the greatest nation on earth.” Or are those with mega wealth going to argue that this is no longer the greatest nation?

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Letters from An American, February 18, 2024, by Heather Cox Richardson

That the American people in the twenty-first century celebrate Abraham Lincoln as a great president would likely have surprised Lincoln in summer 1864, when every sign suggested he would not be reelected and would go down in history as the man who had permitted a rebellion to dismember the United States.

The news from the battlefields in 1864 was grim. …  As the casualties mounted, so did criticism of Lincoln. …

[Lincoln wrote:] “… it seems exceedingly probable that this Administration will not be re-elected. …”

But then his fortunes turned.

… the Democrats chose as a presidential candidate General George McClellan … [and] rejected the new, popular measures the national government had undertaken since 1861—the establishment of state colleges, the transcontinental railroad, the new national money, and the Homestead Act—insisting on “State rights.”

Americans who had poured their lives and fortunes into the war and liked the new government were not willing to abandon both to return to the conditions of three years before.

Lincoln won about 55% of the popular vote compared to McClellan’s 45%, and 212 electoral votes to McClellan’s 12.

ChatGPT-4, February 19, 2024, Query by JGK: What is the role of presidents in health reform?

The role of presidents in health insurance reform in the United States has been significant, as they often serve as the primary advocates for major policy changes and help set legislative agendas. Here’s an overview of how U.S. presidents have influenced health insurance reform:

Vision and Agenda Setting: Presidents often use their platform to highlight the need for health insurance reform, setting the vision and goals for what they hope to achieve. This can include expanding coverage, reducing costs, improving the quality of care, or a combination of these objectives.

Legislative Leadership: Presidents work closely with Congress to draft and promote health insurance reform legislation. They may propose specific bills or outline key principles that they want the legislation to address. Through negotiations and collaborations with lawmakers, presidents can guide the legislative process.

Public Advocacy: Presidents engage in public advocacy to garner support for health insurance reform. This can involve speeches, press conferences, and public appearances. Effective communication can help rally public support, which in turn can influence legislators.

Political Capital: Presidents often expend significant political capital to push through health insurance reforms. This can be risky, as unsuccessful reform efforts or unpopular policies can impact a president’s approval ratings and influence over other policy areas.

Executive Actions: When legislative efforts stall, presidents may use executive actions to implement certain health insurance reforms. While these actions are generally more limited in scope compared to comprehensive legislation, they can still have a significant impact on the health insurance landscape.

Collaboration with Stakeholders: Presidents and their administrations engage with various stakeholders, including insurance companies, healthcare providers, patient advocacy groups, and the business community, to build consensus and address concerns related to proposed reforms.

Historical Examples:

• Harry S. Truman: Failed in attempt to enact national health insurance.
• Lyndon B. Johnson: Enacted Social Security Amendments of 1965, creating Medicare and Medicaid, for elderly, long-term disabled, and low-income individuals.
• Bill Clinton: After failed comprehensive reform, implemented the State Children’s Health Insurance Program.
• George W. Bush: Expanded Medicare to include prescription drugs.
• Barack Obama: Enacted the Affordable Care Act (ACA).
• Donald Trump: Failed to repeal the ACA; implemented rules to undermine parts of it.
• Joe Biden: Temporarily increased ACA premium supports and extended Medicaid enrollment, as part of COVID response. Enacted Medicare drug beneficiary spending caps and some price negotiations.

Comment:

By Jim Kahn, M.D., M.P.H.

Lincoln’s moral vision and practical political skills saved the union and freed the slaves. Toward the end of his first term, the war was going poorly, and he faced dismal re-election prospects. Then, his opponent’s rejection of fundamental reforms intended to strengthen the nation and give a hand up to the less fortunate – along with key military victories – turned the tide to resounding victory at the polls. He was soon assassinated, undermining his legacy, and the nation suffered decades of disruption as the South resisted equality for the freed slaves. Yet his shining moral example and accomplishments reverberate more than 150 years later.

Each major health reform is properly associated with the president under whom it occurred — reflecting their vision of the needed and possible. Of course, presidential affiliation with a particular reform doesn’t tell the full story – of the perceived needs for change, a sense of the possible, advocacy by interest groups, and Congressional deal-making.

All the presidents have fallen short of the ultimate solution – universal comprehensive benefits through a greatly simplified financing system. Some tried (e.g., Truman and in a different form, Nixon); some aimed low (e.g., GW Bush); and some combined ambitiousness with perpetuation of the current flawed structure (e.g., Clinton and Obama).

In my view, there is only one reasonable way forward: the globally tried and true uniform insurance for all. In the US, that’s single payer. If we want to start with a few states to test and refine, that’s ok.

Many will say, it’s not politically possible. To which I respond that in Lincoln’s time many didn’t think it was possible to preserve the union and free the slaves, and in Washington’s time most assumed he would retain power indefinitely – but he stepped down.

The most morally visionary presidents take the US in great directions. A president who brings us universal comprehensive health insurance will become as hallowed as the two leaders we most celebrate today.

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Is the No Surprises Act backfiring on patients? And why is HHS Secretary Becerra letting it happen?, Health Care Un-Covered, February 14, 2024, by Wendell Potter

[O]ne area of real compromise, and policy achievement, in recent years came in December 2020 with the passage of the No Surprises Act (NSA).

For a decade, patients had seen an increase in “surprise bills” that were generated after an emergency room visit or some hospital-based procedures. In many cases, after a doctor provided emergency or specialist care at a hospital to a patient whose insurance was not “in-network” with that doctor, the patient received a bill for the balance left unpaid by their insurer. Sometimes those bills were into the tens and hundreds of thousands of dollars, driving a surge in medical debt.

The NSA took two years of intense deliberation by Congress and resulted in a significant bipartisan achievement for patients. It credibly addressed the problem in a way that was a compromise for insurers and doctors. It created a mechanism to set a reasonable, market-based rate for out-of-network medical procedures. As enacted by Congress, it seemed to be a fair means of resolving payment disputes between doctors and insurers, without patients in the middle. Consumers stopped receiving surprise bills and–even I believed–this was the rare problem in our health system that had been resolved fairly.

I was wrong. And to my surprise, the fault lies squarely at the feet of the Biden administration’s Department of Health and Human Services (HHS). The way the administration wrote the regulations, undoubtedly with “help” from my former colleagues, insurers scored a major advantage. In doing so a law that was meant to be a shield for patients has turned into a sword for insurers.

Since the act’s implementation in 2022, HEALTH CARE Un-covered has learned, in talking with doctors around the country, that insurers have abused their authority under the law. This gets technical, so bear with me.

The law created a new way to set the average cost of specific care in specific markets – called Qualified Payment Amounts (QPAs) – that is supposed to be the basis of patient cost-sharing. It’s also one of the factors in an arbitration process set up in the law when payers and providers can’t agree on out-of-network payment.

The problem is that the Biden Administration’s regulations empowered insurers to set the QPA amount and then made it a “rebuttable presumption” of payment in the arbitration–meaning the QPA as determined by the insurer is just assumed to be appropriate and fair–ignoring all other factors. … insurers have become the foxes guarding the hen house. …

Insurers are using the law to slash payments to doctors to boost profits.

[O]ver the past two years, the law has empowered insurers to terminate contracts and offer far lower payment rates in return. Here’s how it works: an insurer tells a group of emergency room doctors they will no longer pay $100 for a procedure. Instead, the insurer says it will pay $40. Outraged, the doctors decline, which triggers the arbitration rules set out under the NSA.

[Then, the QPA specified by insurers strongly tilts the arbitration their way.] …

There is a mechanism in the law to ensure this doesn’t happen, and insurers have to provide a reasonable QPA to the arbiter, and the QPA is supposed to only be one of several factors considered as to what rate is reasonable. And that, unfortunately, is where the failure of HHS Secretary Xavier Becerra is laid bare. Despite multiple federal court rulings against insurers and in favor of hospital-based doctors, Becerra’s agency has refused to enforce the act to ensure fair payment rates to both sides.

Now, you might be thinking, why should I care? …

[T]here has been a worsening shortage of doctors in rural and underserved areas. Emergency room wait times are increasing, and specialists are becoming more difficult to schedule. The NSA, as written by Congress, would have stopped surprise billing by bad actors while stabilizing the health care system by creating an equal playing field for resolving out-of-network disputes between insurers and providers. …

Why did CMS feel the need to give insurers a pass on this critical piece of legislation?  Well, in its recent guidance, CMS was concerned that insurers would have “significant challenges associated with the recalculations” of the QPA and that it would “require significant resources and take many months if not longer.”  This comment has been met with utter disbelief from hospitals and doctors who are struggling with significant challenges …

As insurers are using HHS’ approach to enforcement to squeeze providers to drive higher profits, the casualty is ultimately the patient. Becerra has been hounded by Republicans and Democrats alike on this issue, and he should take notice. Not enforcing a bipartisan law as Congress intended to the benefit of insurers is policy–and political–malpractice. And it affects a core constituency of President Biden’s: working Americans with employer-based insurance who deeply value the benefits they believe they have.

Comment:

By Jim Kahn, M.D., M.P.H.

The terrific post by Wendell Potter discusses a perfect example of “regulatory capture.” That is, the entities being regulated (the insurers) influence regulation rules and processes to their considerable advantage. What looks like a benign term or phrase yields out-sized benefits. Huge impact cloaked in technical minutia.

Wendell attributes this situation to Secretary Becerra* and the likely influence of insurance lobbyists. I don’t disagree. However, the “revolving door” of employment in DHHS and its insurance regulator CMS (Center for Medicare and Medicaid Services) means that regulation writers may have a mindset and incentive to lean toward insurers. On many issues (if not this one), Congress exerts a pro-insurer influence.

Other recent examples of regulatory capture covered in HJM include:

1. Multiple technical tweaks that generate Medicare Advantage over-payments of >$100 billion per year.
2. A delay in / lowering of proposed corrections to risk adjustment gaming, worth $10 billion to insurers for 2024.
3. A requirement in ACO REACH to pay participating physicians lower than regular Medicare rates … saving the corporate intermediaries money and co-opting physicians into being co-conspirators for suppressing care utilization by patients.

So, the Biden administration is complicit with health insurers. This is not news, indeed the Affordable Care Act (Biden’s “big f-ing deal”) is a massive gift to insurers.

But make no mistake, the situation would be massively worse under a second Trump administration. We saw in his first (we hope only) term that ACA rules assuring fair insurance policies were completely circumvented by changing the definition of “temporary policy” to anything 364 days or less.

Let’s hold the HHS/CMS regulatory feet to the fire. But also, let’s give the Biden administration, despite blemishes in the health care arena, a chance to burnish its record.

By the way … as you know … under single payer, “out-of-network” charges is a non-issue.

* In his prior California role, Becerra was a single payer supporter.

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A Call To Action To Take The Profession Back from Corporate Interests, TAKE MEDICINE BACK, October 2023, by Mitchell Li, M.D.; Sailesh Konda; and Robert McNamara

Conclusion:

The corporate practice of medicine doctrine was integral in providing an ethical basis for the practice of medicine. Today, the AMA explicitly tolerates the corporate practice of medicine, and state prohibitions on CPOM are broadly unenforced. The vast majority of physicians are now employees of increasingly consolidated corporations, while moral injury and burnout among physicians are at unsustainable levels. Rapid horizontal and vertical consolidation of non-physician healthcare corporations that employ physicians not only increases monopoly power over consumers, which in return increases costs, but also increases monopsony power over physician labor. This has resulted in anti-competitive labor practices that lead to intimidation of, and retaliation against physicians who advocate for patients. This places the public at risk through greater corporate influence over the practice of medicine. …

A new era of robust antitrust enforcement in healthcare is needed. Past FTC actions against the AMA restricting the ability to impose ethical restrictions on its members should be re-examined in the context of unintended consequences of enabling corporatization and consolidation. A national prohibition on the corporate practice of medicine is necessary to accompany the strengthening, and enforcement of existing state-based prohibitions. Physician organizations must collectively reject non-physician corporate ownership of medical practices. Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.

[HJM bolding]

The Corporate Practice of Medicine By The Numbers

• 74% – Physicians employed by corporate entities
• 34 – States prohibit the corporate practice of medicine to protect patients – and enforced in none of them
• 87% – Of physicians say patients trust them less than they did a decade earlier
• 140 million – Americans facing financial hardship due to healthcare bills
• $1 Trillion – Worth of private equity transactions in healthcare over the past decade
• 63%  – Of physicians reporting burnout in 2020 – an all-time high, and rising
• 2.51 – Replacement ratio of physicians by non-physician practitioners in private-equity owned medical practices
• 1 in 4 – U.S. Medical Students are considering quitting their studies
• 58% – of U.S. Medical and Nursing students do not intend to treat patients
• 1 in 10 – physicians working under or for United Health

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D, M.P.H.

In 1980, NEJM editor Arnold Relman, M.D. issued the warning of the relatively unheralded rise of a huge new industry that supplies health-care services for profit which he labeled the “medical-industrial complex.” He concluded, “How best to ensure that the medical-industrial complex serves the interests of patients first and of its stockholders second will have to be the responsibility of the medical profession and an informed public.”

Apparently the medical profession and the public have largely failed in this responsibility – based on the statistics showing that private ownership and profits are shifting to private equity, yielding dissatisfaction of both health care professionals and, most importantly, patients.

Today’s HJM directs our attention to an organization that is sounding a call to action to “take the profession back from corporate interests.” The name of their organization is simply TAKE MEDICINE BACK. They have produced a very easy-to-read 63-page paper. Their recommendations are complementary to those of Physicians for a National Health Program and other organizations that support health care justice for all.

We should work together to take medicine back from private equity and the corporate world and use it to fulfill our dreams of realizing comprehensive, equitable, affordable, high quality care for absolutely everyone. Those of us who really care are now busy aligning ourselves in the direction that will get us there. Let’s go!

https://healthjusticemonitor.org…

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