April 11, 2011

Abu Muqawama Goes Jihad on the VA (UPDATED)

I have a lot of love for the hard-working people at the Dept. of Veterans Affairs, but when Foreign Policy asked me what parts of the government should shut down and stay shut down, I offered the following:

[As] veterans from World War II, Korea, and Vietnam depart this Earth,
we are likely to be left with a much smaller group of veterans who,
thanks to
the life-saving technologies developed prior to and during the wars in
Iraq and
Afghanistan, might need less care in terms of quantity but more
care. So it might make sense to get rid of the old brick-and-mortar VA
of the
20th century and replace it with something more akin to an HMO that
veterans of this generation to make use of the best care available to
them in
our nation's private health care system.

I owe a big intellectual debt of gratitude here to my friend Phil Carter, I should add, as it was in conversations with him that I came around to thinking this way. Feel free to tell me why I am wrong in the comments.

Update: There are some great and feisty comments below, so be sure to check them out. I should clarify that I do not think the entire Dept. of Veterans Affairs should go away but that it should look a lot different in 2051 than it does in 2011. I actually think the Dept. of Veterans Affairs is a great organization filled with dedicated public servants. But as the demographics of our veterans population changes, so too should the VA.

Update II: I've been going back and forth with Alex "Army of Dude" Horton over Twitter, and he provides some good statistics (.pdf) showing the way in which the number of living veterans are expected to decline from now until 2036. I see this data as confirming my belief that the VA of 2051 has to look different than it does today. But I am hardly a hard-liner on this. I suspect you can make a good argument for why some specialized care should remain in place.

Update III: Again, some really great comments. Here are two I largely agreed with, but read them all. The fact that this post has generated so many great comments -- both criticizing me for being a bourgeois to understand the condition of most veterans and lending supporting fire to my contention that the VA needs to adapt and evolve -- offers the best counterargument to those who would argue this blog should not tackle these issues!

Look, today's VA provides *fantastic* care to the ~23m veterans in
the U.S.


But tomorrow's population of veterans will look different from
today's population of veterans. The future veterans population will be
smaller, more diverse, more diffuse, and more likely to place increased
demands on the VA. How does tomorrow's VA meet the needs of this


So the question is how the VA should adapt its 20th Century
infrastructure for the 21st Century -- and beyond. One way is to
continue embracing Community-Based Outpatient Clinics. Another is to
revamp its hospitals, mirroring innovation in the private healthcare
sector, to embrace outpatient and specialty care, and push primary care
out to centers like the CBOCs. A third is to continue innovating in the
benefits and records areas, including the new joint DoD-VA medical
record. A fourth is to streamline and improve the ways VA allows care
in the private sector, especially to help veterans who don't live near a
VA facility. And there are many other ways the VA can and should
continue to innovate.


The end state should be a VA that serves the needs of veterans (and
their families). But to do that successfully, tomorrow's VA can't rest
on the laurels of today. It needs to aggressively question its
assumptions, structure, and model, and figure out the best way to
continue caring for those who have borne the nation's battles.

And another:

A 21st century VA needs to take into acct the nature of the modern
day force. An all-volunteer force means that a disproportionate number
are Reserve and Guard who come home to civilian communities and
families, not to bases or installations, certainly not to federal
agencies. For this reason and many others, a 21st century VA needs to
meet veterans "where they're at" (to parapharase an old
community-organizing adage) and recognize, uphold and invest in the
best, most efficacious, most accountable community-based providers out
there. I'm not calling for the abolishment of the VA; I'm suggesting a
new model that recognizes the shortcomings of federal bureacracies, and
capitalizes on the competencies of smaller community-based providers,
through implementation of a public-private partnership approach. Think
small-scale HMO in which a veteran can make choices (one of which is to
get services where and when they're needed, and not wait three weeks for
an appt).


A start wold be vetting critiera: VA should recognize veteran serving
orgs NOT because Congress chartered them 40 years ago but because they
meet rigorous and robust criteria for meeting the real needs of veterans
today. Second, enage those providers in bona fide contracts that hold
them to standards of service and accountabilty. Third, provide funding
so that services can be delivered swiftly and adequately. Fourth,
evaluate and revisit steps 1-3 regualry, so that a new standard for
excellence in the provision of care and services to veterans is
consisently upheld.