Fixing the VA: It's not that easy

Proposals for new legislation to fix the Department of Veterans Affairs (VA) are flying in Congress. Unfortunately, each is problematically simple and pretends that the VA system represents an isolated case of inadequate healthcare services in the U.S. The reality is that there is no simple fix for the VA, and the VA case is no different than the daily circumstance of low- and middle-income Americans both in and out of the VA system, except that Americans owe a special debt to veterans that surpasses even the most ardent argument for healthcare as a fundamental right for all people. None of the proposals for increased regulation, increased accountability, increased funding to hire more providers, or allowing for access to civilian providers will fix the problem.

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The United States has an intensely regulated civilian healthcare environment, with entropic systems of accountability. Yet millions of Americans lack access to basic healthcare services outside of the emergency room, and thousands of people die every day due to preventable yet untreated complications of diabetes and heart disease. Allowing veterans to access this system, or modeling the VA to be more like the civilian system, will yield exactly zero change in the overarching problem of access to care for veteran and civilian populations alike.

Calls for increased funding are meaningless without an adequate workforce of healthcare providers. There is no question that the VA system is understaffed. So are community health centers, primary care practices and tertiary care medical centers. According to the American Health Care Association in 2008, prior to the passage of the Affordable Care Act (ACA), the United States had a registered nurse shortage of over 8 percent. And according to the Health Resources and Services Administration, there is presently a shortage of 8,000 primary care physicians, assuming that each provider cares for exactly twice the number of people recommended by the American Academy of Family Physicians. The ACA has designated funds for training more primary care physicians. In 10 years, those funds will account for 500 new physicians — a far cry from the workforce requirements.

Many analysts have turned to advanced practice clinicians (nurse practitioners and physician assistants) as a solution to fill the primary care workforce gap. But here again, dramatic shortages and inadequate training capacity stymie the system. And incidentally, recent efforts to expand the scope of independent practice for nurse practitioners and physician assistants in the VA system were attacked by physician groups and some legislators as undermining the current system of physician-led care.

This discussion of primary care workforce shortage doesn't address the dramatic shortages in the specialty care workforce, where some fields face shortages that leave even the best-funded civilians waiting months for an appointment.

Iraq and Afghanistan Veterans of America has proposed a so-called "Marshall Plan," which contains some valuable higher-level ideas that acknowledge the intense complexity of the VA system, echoing the healthcare system writ large. Some of the points seem to focus on the same types of regulation and accountability objectives as currently proposed legislation. But some of the points do suggest a way forward. In particular, the recommendation to build a "21st century VA" as a system that can find, diagnose and respond to its own problems by employing best practices to manage a complex system using modern information technologies. Iraq and Afghanistan Veterans of America founder Paul Rieckhoff suggested that the VA must transform from a Borders into an Amazon, referring to technology-driven shifts in the bookselling industry. The metaphor is apt, reflecting the need to recognize complexity and embrace fundamental changes in the work of delivery healthcare.

Does the VA need to transform? Of course. Will one piece of legislation do the trick? Well, maybe. But it is difficult to legislate systemwide transformation, and none of the proposals so far will do that.

Ross, DNP, is a nurse practitioner in cardiac electrophysiology at Arizona Arrhythmia Consultants and a faculty member at Arizona State University. She teaches in the Doctor of Nursing Practice program, as well as the Master's in Science and Technology Policy program. In addition to faculty responsibilities, she is also a Ph.D. student in Human and Social Dimensions of Science and Technology, where she studies complex healthcare systems and the social construction of new therapeutic technologies.

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