Paralyzed Veterans of America was one of the earliest and most vocal opponents of privatizing Department of Veterans Affairs (VA) healthcare when recent efforts began to gain steam in 2014, following the Phoenix VA scandal. I, along with my fellow paralyzed veterans, knew all too well what awaited us in the private health sector: well-meaning health providers who lacked the level of expertise to treat and sustain the life of veterans with spinal cord dysfunction with the competence to which we'd become accustomed.
On balance, many non-veterans with spinal cord injury or disease find themselves in capable hands at places like Craig Hospital, Shepherd Center, and Spaulding Rehab. But if the best non-VA specialized care is a Mercedes, the best VA specialized care is an Aston Martin, and veterans in VA's spinal cord injury system of care know that. For that reason, the forces for privatization—whether they were lobby groups, presidential candidates, or lawmakers—faced a counter force so formidable that the word "privatization" would eventually become a label with which no one wanted to be associated.
Enter, a new buzzword: Choice. Specifically, the Veterans Choice Program in the form of sweeping reforms across the VA that include dramatically increased private-sector options for veterans. Since its inception, the Veterans Choice Program has shifted more than 30 percent of VA appointments into the private sector, up from fewer than 20 percent in 2014. As this number increases, so too do the concerns of those who do not want to see VA privatized and believe Choice is a Trojan Horse intended to drive demand away from VA-provided health care, thus ultimately eroding the infrastructure due to lack of use.
Because of this, Veterans Affairs Secretary David Shulkin now has to spend much time trying to convince detractors that his efforts to improve the VA are not merely a ruse to privatize veterans health care. He wrote in a July 2017 USA Today editorial: "Some critics complain that letting veterans choose where they get certain healthcare services will lead to the privatization of VA. Nothing could be further from the truth...What we do want is a VA system that is even stronger and better than it is today. To achieve that goal, VA needs a strong and robust community care program."
Now, I'm not the type who takes any government official's word at face value. As an admirer of the work of Roman Emperor Marcus Aurelius, I embrace the belief that "the secret of all victory lies in the organization of the non-obvious." If Secretary Shulkin does intend to privatize VA, he will certainly not make it apparent, particularly to those who vow to resist such efforts. But the more I hear about the "fear of privatization" every time new initiatives, cost control measures, expanded care options, and workforce improvements are discussed, the more I fear that entrenched bureaucratization—the extreme opposite of privatization—will ensure that VA never improves in those places where veterans are not getting the healthcare they need and deserve.
The best state of equipoise for VA, between privatization and bureaucratization, is one characterized by customization, where delivery of care accommodates the needs of all veterans. This includes both general and special populations, such as blinded or paralyzed veterans. An increasing number of veterans want to get their surgeries, cancer treatments, and rehabilitation closer to home in the private sector, and it is Secretary Shulkin's job to ensure those systems work for those veterans. At the same time, many veterans will not be best served by providers outside the VA and want access to VA's "foundational services." Foundational services are those that require military cultural competency and are part of VA’s national commitment to provide, and it is Secretary Shulkin's job to ensure those systems work for veterans as well.
Ultimately, action trumps rhetoric, appearances, and assumptions. Recently, Secretary Shulkin took the noteworthy step of authorizing the hiring of 800 to 1,000 nurses in VA specialized services over the next year. He also directed VA facilities to invest five percent of their budgets toward building up in-house blinded rehabilitation and spinal cord injury or disease programs so that more inpatient beds could be activated and more veterans with specialized needs could be served. These actions indicate a desire on his part to improve upon what VA does well, not eliminate VA—as some claim—simply because he's finding other ways to deliver services that VA does not do so well.
Even as a skeptic of the government’s intentions by nature, I am not only convinced but certain that improving healthcare for veterans is as much about economizing its operations, with the help of community health sectors, as it is about strengthening the VA's foundation. Community care and foundational services are inextricably linked, and adequately serving both is only achievable once hackneyed reactions and persistent status-quo mentalities give way to progressive thinking and innovative approaches are embraced.
That said, some will still claim to have divined the Secretary’s motivations and hold fast to the notion that closing underused, costly VA facilities, encouraging more veterans to access care in the community, implementing tougher accountability standards, and imposing cost offset measures are evidence of a slow march toward privatization. And in a vacuum, one where rhetoric and headlines largely inform opinion, I'd likely believe the same. I see major investment in VA’s foundational services happening, though, as part and parcel of the expansion of Veterans Choice into the community. As long as that's the case, I believe the VA Secretary is on the right track and that he deserves an opportunity to execute his vision.
Sherman Gillums Jr. is a retired U.S. Marine officer who suffered a spinal cord injury in 2002, while serving on active duty. His career with Paralyzed Veterans of America started in 2004 after he completed rehabilitation at the San Diego VA Spinal Cord Injury & Disease Center. He is an alum of University of San Diego and Harvard Business School.