Open wound: privatizing the Veterans Health Administration (VHA)

After spending more than 30 years researching health care delivery and nursing in the American private, profit-driven health care marketplace, I decided to explore how the Veterans Health Administration (VHA) delivers healthcare to 9 million of the nation’s veterans. Although neither I, nor anyone in my family is a veteran, I knew that the VHA had made impressive strides in implementing healthcare teamwork and improving patient safety. I knew the system was more accountable than the settings in which I –a non-veteran– get my healthcare. I had, however, no idea how impressive the system really is.

Nearly five years observing and interviewing veterans, their families, and their caregivers, showed me how the VHA delivers excellent care –at far lower cost than is available in the private sector– to the nation’s most complex patients.

In Wounds of War, I introduce you to the veterans who receive this care and the dedicated employees who deliver it. I take you into exam rooms, hospital wards, therapy groups, homeless and legal programs, and even cooking classes where the VHA caregivers are interacting with their patients.

And you’ll find that while our broader healthcare system delivers fragmented healthcare services, the VHA is grounded in an integrated model.

It has perhaps the only functioning mental and behavioral health system in the United States and delivers high quality geriatric and end of life care, all while simultaneously addressing patients’ housing, employment, and legal problems.

True, we should all have this kind of integrated care; but it is critical to veterans. After all, military training and service places them at high risk for mental health and substance abuse problems, suicide, chronic pain, homelessness, and legal issues, to name a few.

The VHA has done something really rare in American medicine. Today, many hospitals may advertise team-based care, but will not spend their resources to teach people to work together. The VHA has devoted enormous time and energy to train employees to work on teams. You’d be surprised to find out that a veteran’s primary care provider will actually consult with his or her mental health therapist or orthopedist, social worker, dietician, or physical therapist in a face-to-face conversation –not only through notes entered into a shared electronic medical record–, in order to determine the best plan of care.

Over and over again, I am reminded how lacking this kind of integrated care is outside the VHA.

The other day, a friend who’d been suffering for years from back pain, consulted with a high- priced orthopedic specialist. The specialist peered at his X-rays and declared that he wasn’t a candidate for surgery. Maybe, the physician told my friend, PT would work, or chiropractic, or acupuncture, or even yoga.  Check it out, he advised, as he rushed on to his next appointment. My friend was on his own.

If my friend was a veteran, he would have been scheduled for a visit with an integrative pain team. He would have been helped to enroll in the kind of pain classes that significantly reduce patients’ perceptions of pain and enhance daily function. He would have been scheduled for physical therapy and even signed up for classes of yoga and mindfulness meditation. And all of this would have been coordinated by caregivers, not left in the hands of a vulnerable patient.

Plus, it wouldn’t cost the veteran one dime.

Today, President Donald J. Trump and Congressional Republicans are attacking and trying to privatize the entire system, rather than to improve and strengthen it. They are following the game plan of ultra right wing-libertarian billionaires like the Koch brothers, who have carefully crafted a narrative of a broken government-run healthcare system. Aided and abetted by some Democrats who fail to understand the promise and problems of the VHA, they have passed legislation like VA MISSION and VA Accountability Acts. These laws will outsource more VHA care to the private sector, starve the system of resources, close facilities, vilify VHA employees and shift billionaires of tax payer dollars into the hands of private sector hospitals, doctors, mental health practitioners, medical equipment companies, and even real estate developers.

That’s why I hope you will not only read Wounds of War but also join me and the veterans, healthcare reform groups, and unions that are fighting for the VHA. We owe it to the veterans who have sacrificed for their country to maintain and improve a healthcare system designed to serve their specific needs. And it would also be an important step towards promoting the kind of successful models of care that should ultimately be available to all of us, not just veterans.


For more information on Wounds of War and the VHA, listen to our latest #1869podcast:

 

About the author of this blog post: Suzanne Gordon is an award winning journalist and author who writes about healthcare delivery, health care systems and patient safety. Her last book, The Battle for Veterans’ Healthcare: Dispatches from the Front Lines of Policy Making and Patient Care was published by Cornell University Press in May of 2017.  She received the Disabled American Veterans (DAV) Special Recognition Award for her work covering veterans’ healthcare. Ms. Gordon is the Senior Policy Fellow at the Veterans’ Healthcare Policy Institute.

Open wound: privatizing the Veterans Health Administration (VHA)

Political Upheaval: a glimpse into racial politics, state political patronage and the future of Malaysia

Since the early 1970s, capitalism and politics have been organised and rationalised in Malaysia in a distinctive way: the principal stated aim being to transform the comparatively disadvantaged social and economic position of ethnic Malays vis-à-vis ethnic Chinese. Promotion of an ethnic Malay business and state bureaucratic class, together with insistence on Malay political supremacy within the ruling Barisan Nasional (BN, or National Front) coalition, were integral to the strategy.

But in spite of initial improvements for ethnic Malays in general, the model’s real power lay in growing capital accumulation opportunities for capitalists that were closely aligned to the dominant BN party —the United Malays National Organisation (UMNO). And as inequality grew, so did BN’s reliance on repression of its opponents and critics. Ethnic and religious nationalism were both used to justify BN rule and discredit challenges to it, but yet this model’s problems would mount.

PARTICIPATION

As explained in Participation without Democracy: Containing Conflict in Southeast Asia, the unequal distribution of costs and benefits of development have exerted political pressures across the region. However, precisely how capitalism is organized affects the bases of support and opposition for particular institutions and ideologies of participation and representation. In neighboring authoritarian Singapore, for instance, the People’s Action Party’s (PAP) interests and ideological dominance link to state capitalism under technocratic rule. Hence, the PAP developed state-controlled consultative institutions and ideologies for incorporating experts, civil society actors and others into public policy deliberations.

Comparable forays in consultative representation in Malaysia were limited and counter-productive. Two national consultative committees—during 1989-90 and 1999-2000—produced governance reform proposals antithetical to the regime’s political patronage systems. As a result, the politically disaffected sought to exploit electoral politics and civil society mobilizations. These peaked under Najib with huge street demonstrations, organised by the Bersih movement pushing for electoral and other institutional reforms.

Malaysia’s May 9 general election result was a shock, ushering in the first change of government in 61 years of independence. To be sure, Prime Minister Najib Razak’s government had been on the nose for years, saved at the 2013 election by massive electoral malapportionment. In 2018, though, the scale and range of obstacles to free and fair elections was unprecedented. These included further racially-skewed boundary changes, barring of key opponents, boosts in phantom voters, deregistration of a major opposition party, and an Anti-Fake News law to blunt debate about Najib’s alleged role in Malaysia’s biggest ever corruption scandal.

Yet still one of the world’s most durable authoritarian governments fell, and the Pakatan Harapan (PH, or Coalition of Hope) formed government. Paradoxically, 92-year-old former authoritarian BN leader, Mahathir Mohamad, is again prime minister.

Mahathir’s political comeback was precipitated by allegations of at least $4.5 billion stolen from the state investment company One Malaysia Development Berhad (1MDB), including almost $700 million siphoned into Najib’s personal bank accounts. Mahathir aligned with Bersih’s call for Najib’s resignation and co-established Parti Pribumi Bersatu Malaysia (Malaysian United Indigenous Party) in direct competition with UMNO, as the authentic champion of Malays. And in early 2017, HP elected Mahathir leader.

It is an unlikely coalition of forces, comprising alienated members of the old political establishment combined with popular reformist forces, that has made this victory possible. Many of the latter seek the dismantling of racial politics and state political patronage: foundational pillars of the prevailing Malaysian political economy. But how much will government change translate then to regime change? This depends on the way that contradictions within this multi-ethnic coalition are resolved or managed, and how the PH’s technocratic, nationalist, democratic and even authoritarian elements play out to lead change.

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Related article: http://www.bbc.com/news/world-asia-44036178

About the author of this blog post: Garry Rodan is Professor of Politics and Director the Asia Research Centre at Murdoch University, Australia. He is also an elected Fellow of The Academy of Social Sciences in Australia.

 

 

 

 

 

 

 

 

Political Upheaval: a glimpse into racial politics, state political patronage and the future of Malaysia