Wednesday, July 2, 2014

Obama Following Bush Path to Killing VA

If you're familiar with Phillip Longman's work on the VA's healthcare system, you know he is by far the premier expert on the subject.

When he says this administration is doing exactly the opposite of what needs to be done to save VA healthcare, you know there's a bigger problem here.

Sad to say, the Obama administration seems clueless about what might be broken at the VA and how to fix it. Either that, or it is just cravenly saying and doing whatever it thinks is necessary to make the story go away.

Evidence for the clueless hypothesis came on Friday, when White House Deputy Chief of Staff Rob Nabors weighed in with his diagnosis (pdf) of what ails the VA. The document is extraordinary in its contradictions, sloppy formations, and non-evidence-based conclusions.


People who truly know the VA culture will tell you the opposite story. The VA emerged as a leader in health care quality beginning in the 1990s precisely because its cental management then let go of power. This devolution unleashed the incredible talent and idealism of frontline doctors, nurses and pharmacists who were doing extraordinary innovation in the field. The VA’s vaunted electronic medical record system, for example, which still sets the worldwide standard, is essentially a bundle of open-source health IT programs written by VA docs for VA docs.

But that culture of innovation came under attack starting in the Bush Adminstration. The Bushies’ political appointees began recentralizing power in Washington partly in the name of security, after a highly publicized incident in which a VA employee had a government owned laptop stolen from his home. Then as now, sensational and misleading headlines played into the conservative forces trying to undermine the VA, as most news consumers were left with the false impression that patient records had been breached. The Bushies then went on to do further damage to the VA’s culture of innovation by outsourcing key health IT projects to favored private contractors.

Sadly, rather than reversing that trend, the Obama administation just let the centralizing continue. As Ken Kizer, Deputy Undersecretary for Health in the Clinton administration and the man most responsible for turning the VA around in the 1990s observes in a recent piece in the New England Journal of Medicine: “In recent years, there has been a shift to a more top-down style of management whereby the central office has oversight of nearly every aspect of care delivery. Indeed, over that period the VA central office staff tasked to health care adminstrative duties has grown from about 800 in the late 1990s to nearly 11,000 today.

Clueless? Yeah it would seem. Except over the weekend, the White House announced that after deep and thoughtful deliberation, it had come with just the man to turn things around at the VA, and he turned out to be a Republican soap and toothpaste salesman—a man with no experience whatsoever in running a health care or social services organization but who happens to be a close financial backer of Republican House Speaker John Boehner. No, that’s not clueless—it’s a cynical sellout of veterans by an adminstration that, in the wake of a monumental failure of the press to put this story in context, just wants to move on at any cost.

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