On March 4, Christopher Syrek, the Chief of Staff of the Department of Veterans Affairs (VA), informed his senior colleagues of a DOGE-devised plan for large-scale cutbacks at the agency that provides health care and other vital services to millions of veterans. The following day, the Associated Press cited an internal memo that indicates that 80,000 jobs – roughly 15% of the VA’s workforce – are slated for elimination. More than 25% of VA employees are veterans.
On March 6, VA Secretary Doug Collins asserted that the plan is a “pragmatic and disciplined approach to eliminating waste and bureaucracy, increasing efficiency and improving health care, benefits, and services to veterans.” He promised to “accomplish this without making cuts to health care or benefits to veterans and VA beneficiaries.” His remarks were published in The Hill.
Recently, Russell Lernie and Suzanne Gordon, two senior policy analysts with the nonpartisan Veterans Healthcare Policy Institute, disputed Collins’ depiction of VA healthcare. “That’s just not true,” they wrote in Military.com. “VHA [Veterans Health Administration]
care is, on average, less costly, less wasteful and of higher quality and value than private-sector alternatives. Strengthening — not decimating — in-house VHA staffing and infrastructure represents the more fiscally responsible use of taxpayer dollars. It’s also what the majority of the 9 million veterans it serves want.”
As I pondered the potential impact of the VA’s plan, I recalled how in Trump’s first term, cutbacks and outsourcing hurt our military health system. Is the VA next?
A Cautionary Tale
During the wars in Afghanistan and Iraq, military medicine devised and swiftly deployed a stunning series of innovations that cut the death rate from severe battlefield wounds in half, to the lowest level in the history of warfare. It is one of the most remarkable achievements in the history of American Medicine.
Unfortunately, when the conflicts wound down, this success did not protect the MHS.
Critics alleged that stateside military treatment facilities (MTFs) cost too much, deliver care of uneven quality, and do not attract enough complex cases to maintain the skills of military doctors and nurses between deployments. They urged the Department of Defense (DoD) to outsource more care to the private sector. Three months after Trump took office in 2017, I published a commentary in Health Affairs Forefront that cited strong evidence of the MHS’s quality, efficiency and value. Instead of rethinking their assumptions, DoD advocates of outsourcing plowed ahead.
Shortly thereafter, the Pentagon directed military retirees and the families of servicemembers, two large groups of beneficiaries who had long valued care in the MHS, to go elsewhere for treatment. As visits and admissions to military treatment facilities declined, the DoD downsized or closed a number of military clinics and hospitals and reduced military health manpower by thousands of positions. As purchased care costs climbed, additional money was pulled from military hospitals and staff. This left once-busy MTFs like Walter Reed National Military Medical Center half empty and understaffed.
As the impact of outsourcing mounted, the Joint Chiefs of Staff worried that it was degrading the MHS’s ability to meet its wartime mission. In a Dec 6, 2023 memo to DoD leadership entitled, “Stabilizing and Improving the Military Health System,” Deputy Secretary of Defense Kathleen Hicks ordered a change in course. “Realignment of medical personnel, coupled with a challenging health care economy and ambitious private sector care capacity assumptions, led to chronically understaffed [hospitals and clinics]
that at times cannot deliver timely care to beneficiaries or ensure sufficient workload to maintain and sustain clinical skills” She wrote. “As a result, beneficiaries are routinely referred to the private sector for services that [the MHS] should be able to deliver, with the Military Departments increasingly turning to the private sector for clinical skills sustainment opportunities for uniformed medical personnel. This has resulted in increasing overall health care costs for the Department and missing readiness opportunities for the Force.”
To rebuild the MHS, DEPSEC Hicks directed that actions be taken to “reattract beneficiaries” to MTFs and increase staffing to “…support the National Defense Strategy, increase clinical readiness, mitigate risks to [military] requirements, and reduce long-term cost growth in private sector care.” Unfortunately, when patients are turned away, it is difficult to win them back from doctors who are incentivized to retain them.
In Light Of The DoD’s Experience, Why Would The VA Head Down The Same Path?
VA healthcare has formidable strengths. Thirteen years ago, I wrote: “Early on, it embraced many of the attributes that characterize our nation’s top-performing private healthcare systems: It was an early adopter of an interoperable electronic health record; it has strong affiliations with the nation’s top medical schools; it regularly measures and applies quality data, and it has a salaried medical staff that is well-aligned with the agency’s mission.”
The VA generally delivers care that is safer and less costly than private-sector healthcare. That’s because private-sector doctors tend to over-test and over-treat to boost clinical revenue. In their commentary, Lernie and Hall observed that the “The private sector performs more ‘guideline discordant,’ ‘questionable’ and ‘low-value’ tests than the VHA, which then lead to more unnecessary services downstream, higher health-care costs and potential harm to the patient.” This happens, they explained, because “With lax oversight, private-sector, fee-for-service incentives drive overtreatment and profit-seeking that isn’t permitted in the VHA.”
Pushing more vets into private-sector care, which already costs the VA $36 billion per year, doesn’t make much sense. What supporters of outsourcing government healthcare fail to understand is that private healthcare in the U.S. is not a “system,” it’s a thicket. Navigating it is a challenge, even for well-connected physicians seeking care for themselves or their families. In recent years, many independent practices have been bought by venture capitalists whose focus is on maximizing profits, not high-quality care.
Cutbacks And Outsoucing Won’t Help Veterans Or the VA
I’m sure Secretary Collins wants the best for veterans. At the Tucson VA last week, he described the planned 15% reduction as a “goal, not a guarantee,” according to the Arizona Daily Star. Hopefully, veterans advocacy groups and their allies in Congress can convince the Trump administration to rethink its plans. It will not only help vets—a powerful constituency that holds a special place in the hearts of most Americans—it will help American healthcare. Each year, large numbers of medical and nursing students, resident physicians and other health professionals-in-training get valuable clinical training in VA Medical Centers.
The VA’s motto is “To fulfill President Lincoln’s promise to care for those who have served in our nation’s military and for their families, caregivers, and survivors.’’ May it always be so.
