By Lambert Strether of Corrente.

Before they sink beneath the waves of the latest moral panic or election horse-race hot take, I want to draw your attention to two stories that are presented as separate but are in fact intertwined. Both concern the Veterans Administration (VA), one of America’s several eligibility-determined single payer systems. (Like Britain’s NHS, but unlike Canadian or American Medicare, the VA owns its facilities and employs its own medical personnel. That makes it a target-rich environment for neoliberals.)

1) A newly-signed contract with Cerner Corporation for a new VA Electronic Health Record (EHR), the same as the Defense Department’s

2) The VA Mission Act, now on President Trump’s desk

The stories intertwine because they look like they’re part of the neoliberal privatization playbook, here described in a post about America’s universities:

It’s almost like there’s a neo-liberal playbook, isn’t there? No underpants gnomes, they! [1] Defund [or sabotage], [2] claim crisis, [3] call for privatization… [4] Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama’s first response is send patients to the private system. Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it’s gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I’ve helpfully numbered the steps, and added “sabotage” alongside defunding, although defunding is neoliberalism’s main play, based on the ideology of austerity.) We can see this process play out not only in public universities, public schools, the Post Office, and the TSA, but in Britain’s NHS, a national treasure that the Tories are systematically and brutally dismantling.)

I’ll begin by looking at the VA’s EHR project, and then move on to the VA Mission Act.

A New EHR for the Veterans Administration

After a year or so of deliberation, the VA finally signed off with Cerner on an EHR “modernization” project in mid-May:

According to the announcement — and a budget forecast — the Cerner EHR at the VA will be identical to the one currently in the pilot phase at the Department of Defense. Currently, officials at both agencies are working together to impart lessons learned into the VA project. ‘We expect this program to be a positive catalyst for interoperability across the public and private healthcare sectors,’ said Cerner President Zane Burke in a statement. ‘We look forward to moving quickly with organizations across the industry to deliver on the promise of this Mission.’

(“positive catalyst.” Hoo boy). It does seem reasonable that DoD and the VA should both use the same EHR, but there’s… a snag: The DoD EHR project (“MHS Genesis”) is a debacle. HealthCare IT News, also mid-May:

The Department of Defense, along with EHR vendor Cerner and contractor Leidos, held a call with reporters late Friday in response to a report finding that MHS Genesis implementation is not effective and slamming the massive modernization work’s survivability as well as recommending DoD delay the project. MHS Genesis “ is not operationally suitable because of poor system usability, insufficient training and help desk support ,” according to the Initial Operational Test and Evaluation. Behler pointed to a lack of workplace functionality needed to document and manage patient care as examples, and noted that clinicians using MHS Genesis only completed 56 percent of the 197 tasks used to measure performance . “Poorly designed user roles and workflows resulted in an increase in the time required for healthcare providers to complete daily tasks,” according to the report. In some instances, EHR issues caused providers to work overtime or see fewer patients . In other cases, users actually questioned that accuracy of the data exchanged between external systems and MHS Genesis — which could have put patient lives at risk. “Users generated 22 high severity incident reports that the testers attributed to inoperability, including interoperability of medical and peripheral devices,” according to the report. Users ranked usability at 37 out of 100 on the system usability scale.

More from Politico:

The first stage of the Pentagon’s $4.3 billion MHS Genesis project has been plagued with severe usability and interoperability problems, according to an April 30 report obtained by POLITICO. Pentagon inspectors who visited three of the four Pacific Northwest treatment centers in the rollout found 156 “critical” or “severe” incident reports — i.e. flaws typically serious enough to result in patient deaths. They canceled the fourth visit until problems could be resolved at the first three centers.The report concluded that MHS Genesis, is “neither operationally effective, nor operationally suitable” — and recommended freezing the rollout indefinitely . That, in effect, is what the MHS Genesis project management office has done, though leader Stacy Cummings says it’s still on track to finish on time in 2022.

The report confirms and deepens findings from our March investigation, in which doctors and IT specialists expressed alarm about the software system, describing how clinicians at one of four pilot centers, Naval Station Bremerton, quit because they were terrified they might hurt or even kill patients

Of the 7,000 trouble tickets submitted, 1000 have been resolved. Here is the DOD’s response. Federal Times:

As for negative reports, ‘we’re disappointed stakeholder feedback continues to be taken out of context to present an incomplete, inaccurate and misleading narrative about the successful completion of the MHS GENESIS initial operating capability phase,’ the spokesman continued. ‘MHS GENESIS is already achieving meaningful improvements related to quality, efficiency and safety in the initial deployment sites. We are confident MHS GENESIS remains on track for full deployment.’

Which totally explains why clinicians decided to enter today’s labor market because “they were terrified they might hurt or even kill patients.” You have to wonder why MHS Genesis project was initiated at all. NextGov:

DoD responds to report calling Cerner EHR ‘not operationally suitable’ The VA’s electronic health system was rated the best for overall user satisfaction in a survey of more than 15,000 physicians, while the Pentagon’s current platform–the Armed Forces Health Longitudinal Technology Application–scored dead last.

So, call me crazy, but why not give consideration to making the VA system the standard for the DoD?

“It’s no surprise that a program as big as MHS Genesis…is going to have problems like this—according to all the metrics, most large federal IT programs aren’t successful,” said [former VA chief information officer Roger Baker], who held the department’s top tech job from 2009 to 2013. “[VA] need[s] to remember that the probability they’re flushing that $16 billion down the toilet is actually greater than 50 percent.”For one, most VA doctors don’t mind the current platform.

So, replacing a system that works with a new system is a $4 billion coin-flip. Perhaps Roger Baker asks a question that answers itself:

‘What’s it going to look like when VA is trying to replace the most liked [platform] out there?’ Baker said, especially when the military is having trouble convincing doctors to quit one of the least liked.

To a cynic, it might look like Step One of the neoliberal privatization playbook: Sabotage. Especially because the first time the VA and the DoD tried this, it failed.

The VA Mission Act

And now for the VA Mission Act, passed in a thoroughly bipartisan fashion MR SUBLIMINAL Count the spoons when they leave the house! with support from the Koch Brothers (fascists, we are told, but apparently fascists with friends).

This Act may be cited as the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA M aintaining I nternal S ystems and S trengthening I ntegrated O utside N etworks Act of 2018 or the VA MISSION Act of 2018.

(That acronym is almost as clever as “USA PATRIOT Act.”) If you’ve been looking for an honor roll of Democrat Senators who will defend a single payer system that actually exists, here it is:

The Senate easily cleared legislation on Wednesday overhauling medical care options for veterans, sending the bill to President Trump’s desk. Senators voted 92-5 on the proposal, called the VA Mission Act, with only a simple majority needed to pass the bill. Sens. Bernie Sanders (I-Vt.), Brian Schatz (D-Hawaii), Jeff Merkley (D-Ore.), Mike Rounds (R-S.D.) and Bob Corker (R-Tenn.) voted against the legislation.

Here is a refreshingly open headline from the Washington Post:

Congress sends massive veterans bill to Trump, opening door to more private health care

Here is a one-liner from the Metal Trades Union, in a failed attempt to halt the bill:

Congress should be investing more in the VA, not privatizing and downsizing it.

In other words, another version of Step One from the neoliberal playbook: Not sabotage, but defunding.

Here is Sanders’ reaction, in Common Dreams:

I am concerned, however, that despite some very good provisions in this bill, it continues a trend toward the slow, steady privatization of the VA . No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has . This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong. My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

Step One, defunding, again. And surprisngly good coverage, well worth a read, from Mother Jones:

Congress Is Poised to Push Veterans’ Health Care Closer to Privatization The first strike in this war over privatization occurred in 2014, when Republicans blocked a bill introduced by Bernie Sanders that would have provided the VA with much-needed funds and expanded services to veterans. A compromise measure, the 2014 VA Choice Act, gave the VA a fraction of the funds it needed while allocating $10 billion for care in the private sector. (More than one-third of all VA-funded medical appointments last year took place in the private sector.) The Choice Act, cast initially as a temporary measure, has been extended repeatedly. The Mission Act will make permanent its privatizing principles by allowing and even encouraging more veterans to seek care outside the VA. The Congressional Budget Office estimates that the act would result in 640,000 additional veterans seeking private care in the first few years after its passage, and that the agency’s current annual allocation of $9 billion for private care would increase substantially. The bill is essentially a Trojan Horse, and the provisions tucked inside it will further usher in privatization without meaningfully addressing core agency challenges.

Sanders was too nice when he said “very good provisions.” He should have said “Trojan horse.” This sets up Step Two, crisis, and provides the “solution”: Step Three: Privatization.

According to a detailed analysis by the Veterans Healthcare Action Campaign, a veterans advocacy group that opposes the law, the bill imposes stringent new quality metrics that are untested and fail to consider key health outcomes such as symptom reduction. Moreover, if a VA hospital is found to be underperforming in a certain area, a huge swath of patients can be pushed into the private sector. The act loosens other restrictions that determine a veterans’ eligibility to seek care from a private doctor or hospital. Without providing the funding to hire extra staff, the law also imposes new time-consuming bureaucratic challenges on the VA (or, potentially, a contractor), including setting up appointments with private providers, coordinating care, processing payments to private providers and making sure they provide documentation of the care delivered.

Sabotage, crisis.

The law would also require VA employees to develop and deliver training materials for the private sector.

The old “get them to train their replacements and fire them” ploy! It never gets old!

Finally, the bill would establish a nine-person commission, beginning in 2021, to assess the VA’s future infrastructure needs. The commission will make recommendations of facility closures based on utilization. The upshot is that if the push to shift veterans into private-sector care continues, the corresponding decline in utilization of VA facilities could be used to justify closing those facilities permanently—regardless of who’s providing the highest-quality care.

Step Four, profit. Let the looting begin!

Conclusion

It’s clear the VA is an institution to watch. Note that I’m by no means an expert on the VA — it’s seemed to work pretty well, so far, so there’s been little reason to pay attention to it, with so much else going on — and so I’d welcome reader comments from those who have availed themselves of its services, or work there.

APPENDIX I: Software

Remember when we could write software that worked? Good times:

This is Margaret Hamilton, NASA lead software engineer, and this is the Apollo guidance program she wrote. pic.twitter.com/veweKVHE2n — JD (@nevesytrof) December 10, 2014

APPENDIX II: Privatization

Here’s a nauseating n instructive opinion piece from Anthony Tersigni, CEO of Ascension, the world’s largest Catholic health system and the largest non-profit (so-called) health system. You can read it if you don’t already have a sense of privatizer’s choice of tropes, but this caught my eye:

Ascension’s mission calls us to care for all, especially the poor and vulnerable. It’s for this reason that the VA Mission Act truly resonates with us, and we are humbled to serve this deserving population.

Well, fine, but Mattew 7:16: “Ye shall know them by their fruits. Do men gather grapes of thorns, or figs of thistles?” Some coverage on Ascension, from the St Louis Post-Dispatch, in 2014:

But under Tersigni’s leadership, Ascension has emerged in the past decade as the nation’s third-largest health care system — acquiring dozens of nonprofit hospitals and immersing itself in numerous for-profit ventures. That dramatic growth culminates Tuesday with the grand opening in the Cayman Islands of the first phase of a $2 billion “health city” complex — a project that seems far removed from the nonprofit health system’s humble origins and its Catholic mission to serve the poor and vulnerable. Ascension executives say they hope through this joint venture with a for-profit, India hospital chain to learn ways to reduce medical costs. But the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities . Its health ministry [!!] has drawn criticism for risk-taking and its ties to Wall Street. And some critics have raised questions about its tax-exempt status.

By 2017, Ascension had backed out of this sketchy venture into greenfields medical tourism (and it certainly is odd, isn’t it, that the United States doesn’t have a thriving medical tourism system, and that in fact those who can flee from the United States for health care, do?) Apparently, the approach of Narayana Health’s Dr. Devi Shetty, Ascension’s partner in this venture, was to “standardize medical procedures to bring costs down.” One might wonder whether there was a reason Ascension did their experimentation offshore, and whether they plan to apply their lessons learned to veterans. Interestingly, Ascension’s Caymans project (“Health City”) is the subject of a Harvard Business School case study.