Rural care and the VHA w/ Suzanne Gordon – Ep 147

[00:00:00] When I made it to my home place, I found trial for God will.

[00:00:11] Where once lay a shining city stood a fortress on a hill.

[00:00:23] This is Fortress On A Hill with Henry Danny Kagan, Giovanni, Shiloh and Manisha.

[00:00:28] Welcome everyone to Fortress On A Hill.

[00:00:30] A podcast about US foreign policy, anti imperialism skepticism and the American way of war.

[00:00:37] I'm Henry thank you for being with us today.

[00:00:40] I'm here with the lovely Suzanne Gordon of the Veterans Healthcare Policy Institute to discuss.

[00:00:47] A recent report that you wrote about the Veterans Health Administration and rural health care Suzanne welcome to work on a hill how are you today?

[00:00:57] I'm good thank you.

[00:00:59] I'm delighted to be chatting with you today.

[00:01:03] So what do you give us a short rundown on the report and what why it's so important?

[00:01:10] So as I've been tracking and veterans healthcare policy institute, the HPI has been tracking a variety of bills in Congress that are essentially dedicated to privatizing the VA.

[00:01:25] The Veterans Health Administration which is the largest healthcare system in the country, the only publicly funded fully integrated comprehensive health care system in the country.

[00:01:38] One who that delivers care that I think we should all be able to enjoy not just veterans.

[00:01:48] I've been covered covered the VA right about the VA wrote a book about a coal wounds of war.

[00:01:57] And increasingly there has happened efforts that are successful to privatize the VA and outsource more care to the product sector this this ever began with the choice program in 2014, which started it was supposed to be temporary program.

[00:02:16] The effort of John McCain, the who is then alive and the public and Senator from Arizona and Bernie Sanders from Vermont.

[00:02:25] It was supposed to be temporary it was supposed to give the VA more money for staffing but it opened the door to privatization by allowing veterans to go to private sector providers at the VA's expense if they lived more than 40 miles from the facility or had to wait more than 30 days for an appointment.

[00:02:45] Well, was supposed to be temporary McCain turned around and basically live Sanders said oh no I want this to be permanent and that then led to this VA mission at the 2018 which started this program called the Veterans Community Care Program which is essentially a parallel private sector provider network of you know,

[00:03:14] millions of providers that millions of veterans are being shunted to and this whole privatization movement has been justified.

[00:03:26] I began to realize by suggesting or promising that it was going to solve the problem of world veterans and so world veterans who represent 25% of the veteran population.

[00:03:41] They became the wedge or the ramp has been used the justification to privatize the system and really demolish the system.

[00:03:55] And it became increasingly clear to me that we as a think tank at BHPI needed to look into what is the situation of world veterans and do the assumptions and promises that these people who favor VA privatization outsourcing may

[00:04:16] are the promises fulfilled and are the assumptions correct.

[00:04:21] And so that led me and my colleagues to really delve into the problem of world veterans health care which is embedded in and you can't understand if you don't understand the larger real health care crisis that has been ongoing in the United States for quite some time and was really worse and following the COVID pandemic.

[00:04:45] Let's take a minute before we move further and talk a little bit about what you mentioned about the rural crisis, how it affects the average American not just the veteran America.

[00:04:58] So in our rapport, I say that basically these Congress people and it might be, you know, important to stop from it and say that it's very interesting that if you look at the composition of the House and Senate veterans, Ferris committee or committee some veterans chairs.

[00:05:21] So in the Senate, there are 17 members and out of the 17 members 14 represent Burrow and Highly Highly rural states, including Jerry Moran of Kansas who's the Republican ranking member of the Senate committee and John Tester who's the chairman who's from Montana which very, very rural state.

[00:05:47] So 12 of the other people on the committee will also represent rural states and that's really interesting because there's only 25% of veterans that are rolling you have like the vast majority of folks on the Senate committee.

[00:06:03] Being from rural states or states a lot of rural areas and then when you look the House committee about 50% of the Congress people represent districts that are rural so that's kind of interesting right so there's this free occupation with the problems of rural veterans, the now the browser of veterans are significant but as we said.

[00:06:30] You know, they can't be extracted from the problems of rural other rural Americans and you know the assumptions that have guided.

[00:06:44] The assumptions that have guided people like Tester and Moran and you hear it in their speeches, you know, and then and these assumptions by the way are being promoted by hard right groups like concerned veterans for a meal cut which is this phony veteran service organization that's funded by the Koch brothers.

[00:07:05] So basically they're telling rural veterans that you know if we pass these outsourcing bills and we pay for you to go to the private sector that they tell you, first of all, that the problem that you have accessing health care in rural America as a role veteran are.

[00:07:29] Not have nothing to do with the lack of services in rural America, but rather have to do with the fact that you rural veteran.

[00:07:38] You know in Montana or Kansas or wherever you just are entrapped in the day and you lack the choices of your neighbors and your family members who aren't veterans and you know you just have don't you don't have enough choices.

[00:07:55] And if the VA just paid for you to go to, you know, your nearest rural provider or hospital, you'd be just fine that's assumption number one.

[00:08:06] So based on that, you know, they're also killing people that there are enough conveniently located and that's big conveniently located in rural America where distances are, you know, enormous.

[00:08:21] You'll be able to find a well in the corner, practically I mean, I'm exaggerating a bit for effect but you'll be able to find conveniently located hospitals and primary care providers and you know, cancer specialists and folks to knew your heart valve in place within all of that right there in rural America isn't that great and they'll be able to, you know, substance give you mental health care and deal with your substance.

[00:08:48] There's just orders, et cetera and give you high quality care and you know just go out of the VA and all will be well.

[00:08:57] Then, you know they also base their, you know, proposals of outsourcing on this assumption that rural health care providers to the extent there are any, you know will accept the payment rates on the VA which is essentially Medicare rates or even any insurance right and finally.

[00:09:19] You know that if all these rural veterans go outside of the VA and get care in the private sector don't use the VA not to worry the VA will still be there as a giant, federally funded security blanket for you.

[00:09:37] In 20 years when you find me decided you needed or you lose your, you know, whatever and so these are these are the assumptions and the only way of course.

[00:09:49] You can show that these assumptions are wrong is if you look at the situation on its health care in rural America and why do you find is as any role to be able to tell you not a pretty picture right.

[00:10:06] You have huge short diseases of providers.

[00:10:11] You have.

[00:10:15] The virus who won't accept insurance because they can you have hospitals closing in rural America I mean let me just give you a brief picture so veterans felt veterans felt as it as all of us depends on having enough primary care providers to take care of you to refer you to a specialist provider right.

[00:10:41] Veterans 50% of them are more have mental health conditions so you need mental health providers a lot of veterans felt had substance abuse substance use disorder problems so you need.

[00:10:53] You know clinics and programs in rural America to deliver those and then of course you need emergency rooms and which are in hospitals you can't have an emergency room if you don't have an ICU and a hospital.

[00:11:10] Like there's so such things like a free standing e on there's urgent care right but not the ours well if you look at rural America to which I did and a lot of people have done I mean this is not news you know you're a Marita is a disaster from the point of view health here.

[00:11:32] It has 70% of let's just look at mental health care and you know we should sort of define rural Henry because you know rural I mean the reality is rural and highly rural are far away from urban areas so by definition if you live in rural America.

[00:11:58] And you choose to live in rural America because you want to get away from people some of those people that you want to get away from will be doctors and nurses and pharmacists and oncologists and choreologists or the beaters right.

[00:12:17] And if you want to live in a sparsely populated area then just as you have to drive to a one mark or a movie theater or even a pharmacy you're going to have to drive to a health care provider and increasingly that drive will take you out of rural America and into suburban urban America because there's nobody there in urban.

[00:12:47] In rural America, in rural America, she cares so let's just look at primary care there's a I would really recommend to your listeners on any website called the rural health information hub and it has these amazing maps of what are called healthcare professional shortage areas.

[00:13:11] And these are clearly defined areas where there are shortages of professionals and it's absolutely worth a look when you look at primary care mental health care down care at the map of the miracle which the rural health information happen thank you so much to them has has created these maps where in a very dark blue every county and in the country is listed.

[00:13:41] Whether it as a I mean there are severe shortage areas and then shortage areas and then no shortages and if you look at the map most of the country is this deeper blue talk about blue.

[00:13:57] Blue state of America most of America when it comes to Malale's their primary care and down here is a desert there's a quite easily a kind of lighter shade of deep blue and then there's very sporadically mostly in urban areas this kind of light blue that is no shortage.

[00:14:23] When you go to the rural health information hub and you book at state by state it is such a great resource you know because you can take your state like chances which we didn't report where during Miranda's telling folks all you know go to rural go to a print such a primes and rural areas and you'll be fine what you find is complete.

[00:14:47] Disnaster in primary care and Melville here which are the things that are in sneak right and then you have on hospitals right they tell you you can go to your rural hospital the situation is so dire between between I think it was 2000 and 2000 and not more than.

[00:15:17] More rural hospitals have closed and down from the center for healthcare quality in payment reform says that 150 rural hospitals close between 2005 and 2019 during the pandemic another 20 shuttered and now in large part to the pandemic another 600 or at risk of closure it's the wonderful new publication called barn raise or the barn raise or.

[00:15:47] Did a story about the dire situation of hospital closures in rural America said so when the hospital closes that he are closes so news you know you heard yourself.

[00:15:58] You don't need to go to the city you could just go to the year but they're ain't no we are so you can have a problem that a world hospital could deal with right you have a heart attack a minor or the type get a terrible injury that could be repaired in a.

[00:16:15] In a small community hospital but there are none and so these private equity firms have created these air ambulances and they are now sending patients via air ambulance often out of state even.

[00:16:32] Had to the tune of 50 grand or whatever because there's no place for people to be taken care of this article came out after the publication of our report so I mean.

[00:16:45] Where on earth are you going to find the gear in rural America you know and that if you look at we honed in.

[00:16:58] On on two states in particular then I think it's worth talking about those states we took on to go Montana because of tester John tester who has promoted this bill that is now.

[00:17:14] Running to the Senate that would outsource more care really mental health care to.

[00:17:23] But I think to providers and Jerry Moran who really in Kansas who just really wants to kill the VA you know he claims to be a friend of veterans.

[00:17:34] And I know anybody can believe that because he wants to kill the health care system that is absolutely indispensable to veterans and should be expanded in my view not dismantle so we looked at Montana.

[00:17:50] And and Kansas and to try to think about you know where is the care there because these guys these guys should know this I mean if I know this if I could go on Google and find the sound and re hours they lit there right how could they not know this right.

[00:18:12] Well in Montana.

[00:18:15] For example it's a stay with a million people spread on over 150,000 square miles gas how many psychologies there are in the state of Montana to serve 150 psychologist in Montana most of them are in urban areas a lot of them won't take any insurance whatsoever so the idea that they would take you know.

[00:18:41] VA rates of payment to this you know community care program was laughable right there are 100 license italologists psychiatrist in Montana.

[00:18:54] The health health resources services administration has said that you know they need 170 more to meet demand and the expectation is that rather than increasing.

[00:19:12] You know by over 50% the number of psychiatry is a Montana will decrease in just a few years by 30%.

[00:19:24] So where Senator tester all your veterans with mental health problems going to get care well and then when you look at substance use care there's hardly anything in these places at all.

[00:19:38] When it comes to primary care in Montana.

[00:19:42] Montana has 56 counties 53 of them have shortages of pride now care providers and of the 55 roll hospitals in Montana 64% of law services 25% are at risk of closing and 7% are at risk on media closures so what does that tell you.

[00:20:04] What is that tell you about the library sector care in Montana you know and you're recommending senator gesture.

[00:20:14] That you send veterans who have lip services that could by the way be expanded by the VA you're telling them that the VA should be defunded to pay for non existing care so what you're doing is you're saying that they're going to have to go to the cities.

[00:20:33] Because there ain't no care near there and then to pay for a lower quality care at higher cost.

[00:20:41] Defunding the VA further there will be closures of facilities several areas and you will be out of luck is the lesson if you look at chances you see the same thing you know Jerry Moran's Kansas I mean he apparently doesn't listen to the news right because you know.

[00:21:02] There in for the one you know 3 million Montana residents a million of them live in rural areas there been 190,000 veterans living in Kansas but there's only 314 licensed psychologists and 300 psychiatrists to serve the 3 million residents so they're really is pretty much the same situation as in Montana.

[00:21:30] You know the news reports in Montana that I guess Moran and his staff don't listen to show that you know money psychiatrist and the state are aging.

[00:21:43] And they have a very poor ratio of psychiatrists to you know 100,000 population there and yet in these psychiatrists and psychologists don't take many of them don't take insurance because if you're in high demand right in a state where there's high demand why would you take insurance when you know you could find enough rich patients to pay you $325.

[00:22:11] So now or why would you take Medicare rates or insurance rates right I mean let's your of VA psychologists and you are mission rather than profit of it.

[00:22:21] And again you know we take you see the same thing in Kansas with with the primary care shortages we have 105 counties in Kansas only 9 don't have a shortage of primary care providers.

[00:22:40] And you know we have 104 rural hospitals 83% of the services 58% are at risk of closing and 28% are at risk of immediate closure.

[00:22:52] So it bottles who might you know to I mean either they're ignorant or they're on the tape but whichever one of those you choose is not good.

[00:23:10] And I think it's probably a little bit of both certainly from Iran.

[00:23:15] But it's very tragic because as you know is a veteran and you lived in a rural area right me what was there for you.

[00:23:26] I have lived there in quite a while now but while I was living there they had a they actually had up a VA clinic there in my my little hometown.

[00:23:39] And that clinic service so many other outlying areas and around it we also had a veterans home that sits just it's almost on the same campus next to the clinic.

[00:23:51] And that also meant that everybody that was there and was going to utilize the VA for health care actually had an option.

[00:23:59] Prior to that I'll try to remember when the clinic opened maybe 2013 2014 something like that it was all Portland Portland was the ending the only the only shot we had at it.

[00:24:12] They had a clinic further to the for closer to my hometown that wasn't quite all the way into Portland but it was close.

[00:24:20] But no is it it's I know that looking my home county on one of the maps from your report that were low on primary care and also low on psychologist psychiatrist those kind of things aside from that aside from the VA.

[00:24:38] That everybody else had to go to pretty expensive private care in the surrounding community.

[00:24:45] I remember what it was and I first learned about some of this when I was looking for a psychiatrist in my hometown in the Dallas and the vast majority of them don't take if they took if they took any insurance it was the best ones they wouldn't take Medicare they wouldn't take VA payments.

[00:25:06] And I didn't realize up until recently that it was probably because they above the that they didn't they didn't pay enough that they weren't willing to do it as opposed to it being something that you accept smaller payments knowing that you're helping people who don't have the means or veterans or whatever happens to look like.

[00:25:25] But that means that in those places that your actual choice of finding a shrink or primary care doctor that you feel comfortable with is that much less because a certain certain echelon up them up high won't take those kind of insurance rates.

[00:25:43] I find it kind of just stressing because if you won't take insurance let's say you charge 325 an hour just actually low right so 325 if you can see 10 patients a week at 325 an hour you know that's 3,250 dollars a week you're making if you multiply that times let's just say 50.

[00:26:12] That's 160,000 a year that's not so bad and they probably see more than generations away.

[00:26:18] So if you've seen 20 patients a week you know that's almost 400,000 a year I mean nobody why do these people have to earn 4,000,000 a year I mean they could do very well on two-year

[00:26:35] terms if she you know it's it's claimed I think the greed that is now in modern medicine I mean some of these doctors now these primary care doctors are going into concierge for you to make in a couple million dollars a year

[00:26:51] and you know I think if you want to make them which money they'll be a stock broker there's lots of things you could do you know it could be a corporate lawyer and charge 700,000 a hour I mean

[00:27:02] but I think that the reality is that in rural America by virtue of the fact that you're far away from things and that you live in a very sparsely populated area

[00:27:21] there are many reasons why there are shortages of providers right and you know one of the things we look at or I looked at in the report is why do we have this rural health crisis right I mean

[00:27:38] because why can't you find a provider well for specialty care highly spik highly special and self care you know like total knee operations or you know I don't know certain kinds of specialty care

[00:27:55] you always will have to go to an urban area because you don't have the population to support the maintenance of skills in in these doctors nurses and teams

[00:28:11] and I think veterans and a lot of people just don't understand this they don't understand that you are not going to be able to get a coronary artery bypass wrap after a hard attack in a sparsely populated rural area because if you only have 10,000 people living there

[00:28:31] you know I mean how many of those people every year are going to have that serious heart problem and need surgery if you go to a surgeon you want that surgeon to perform you know 500,000, 2000 operations a year or not 10

[00:28:50] you should not want to be operated out by somebody who's just doing it for the first time unless you know there's no other choice and you know like it's on TV right you know some I mean oh I'm you know it's like the person trying the plane in a terrorist check or something you know or I mean it's ridiculous

[00:29:13] and you know you want you when you get cancer surgery you want to go to a can rack no right you do and for many routine problems yes you could have been taken care of in a rural practice but what you need really is you need

[00:29:32] for many complex things and veterans have very complex problems right you need you need and a people who specialize in that like take mental health you have PTSD most you know psychiatrists and psychologists don't

[00:29:50] have to treat PTSD and they certainly don't have to treat military or combat related PTSD military sexual trauma they probably never heard of it I had a friend who went to psychologist on this veterans community care program

[00:30:05] and this guy had you know complex PTSD from combat and the psychologist turned to him said I know understand why you're here I take care of patients whose you know parents that divorced and they were upset it's incredible right and veterans are very particular often particularly people with PTSD they really don't feel like anybody can ever understand them

[00:30:33] and if there's you know subject to a therapist who really doesn't understand them that's not very helpful the VA has trained thousands of psychologists and health professionals in how to treat PTSD military sexual trauma this is something you just kind of picked up as she go along

[00:30:52] and it's really disrespectful to our veterans as well as to be a professional just suggest that you don't that they don't need this kind of expertise and that you don't need to learn it right

[00:31:05] I mean one of the things I don't think people understand is that these networks that have been set up with providers to take care of veterans they do not require anything but a medical license they don't require that there's trainings and suicide prevention that there's trainings and evidence based care for PTSD or other problems said you know providers understand the difference between burn fit related

[00:31:34] cancer and and respiratory problems and a cooff you know so and they claim that always we required these

[00:31:43] private sector folks to do even two hours of minimal training on a computer they wouldn't sign up and this would hurt access well access to shot a chair is not access you know

[00:31:58] and obviously the insurance companies that benefit from this and the prep and said to providers that benefit from this they have no interest in spending time you know being trained to see if taxpayer money to take care of people who sacrifice for their country

[00:32:18] and it's very disturbing to me you know it's it's it's both fascinating and humiliating to think about that the you know there are a lot of veterans that take a great amount of persuasion

[00:32:36] and family input to go to the doctor depending on what it is you know something folks about be good at going and doing with physical stuff but they won't go see a shrink or or vice versa

[00:32:49] but again this person who can't get this get the care that they need how long did it take them to convince themselves or for their family to say

[00:33:01] there's this very important thing you have wrong and we think we know what to do and oh wait we don't have anywhere we don't where are you going to go to attempt to access that care you know if it's close to home

[00:33:16] you know it's like okay well close to my house I might feel a little bit comfortable with it the further you have to go in order to make that happen adds additional conditions on that that people who are so used to saying

[00:33:29] I'm not worried about these things I'm not working I died I might go get my heart looked at every once in a while but I'm going to not deal with this particular problem and that's their choice does there's to make it make it certainly ends up making families lives harder and those kind of things but there should be that kind of availability

[00:33:51] and you would think that some didn't only people in a John tester has been doing senate work for around veterans for veterans for quite a long time and they don't disagree with everything he says some things I think that he's on the money about but again if there is just no help

[00:34:11] you know people will start convincing themselves that it's not worth it because those first steps into something like that are always very tentative I think the trick is that if you could I mean there's always something a couple hours away that the VA

[00:34:30] and then the VA also provides telehealth services and also gives veterans like can't afford an iPad or a laptop or whatever I mean there is a broadband problem that Congress needs to deal with and it's outrageous that you go into certain areas of rural America

[00:34:53] and you can always find a phone line but you can't find you know broadband and Wi-Fi which you need LL but that needs to be solved and these diets should be on the forefront of that not sure they are

[00:35:08] they should be on the forefront of producing more primary care doctors in the American healthcare system which Congress could control by allocating you know forcing hospital residency programs to treat to produce more primary care doctors we could get free medical education and psychology training

[00:35:35] and so we're going to mental health professionals and they should be on the forefront of that and they're not but I think that this problem for rural veterans and I so agree with you can read about I'm you know the resistance that veterans have to getting help

[00:35:54] but I think it's this kind of macho you know the macho mentality even if you're a woman and also you're in the military discouraged from admitting to these problems because its weakness and true you know destroy your chances of promotion or whatever I think that it's very important for veterans to encourage each other to get help

[00:36:22] because you all listen to each other and to say okay if you have to drive two hours drive two hours you know but don't get an appointment with somebody who doesn't know what they're doing or don't believe it if you know they tell you there's going to be care where they're

[00:36:40] where they're aiming and I think also I mean I just started primary care provider and a VA that should go name us and this veteran lived in a town that was an hour and 15 minutes from the VA hospital medical center.

[00:37:00] He wanted to have a hard felt replacement in hospital near this town with a search and who'd never done it before but it was convenient.

[00:37:14] Yeah.

[00:37:15] I mean hey Kim it's your hard part you know what I'm saying it's not your you know stitching up your your thumb and it was very hard to congenst him that this was like a newly really good idea you know like okay getting a little basil cell cancer move that might be okay or some extremely routine process.

[00:37:41] And I think they think a surgeon's a surgeon is surgeon you know and I think veterans need to be counseling on veterans against this.

[00:37:53] There was just a study that came out and a lot of veterans have prostate problems and some get prostate cancer and there was just a study that came out that if you were veteran with prostate cancer and you went to the private sector under the veterans community care.

[00:38:11] Sorry veterans community care program they were much more likely to not follow the standard of care for watchful waiting when it was indicated and perform surgery that wasn't necessarily necessary at that point and you don't want a surgical procedure if you don't.

[00:38:35] If it isn't indicated at that moment because something can go well and I mean but it makes them money the VA has no incentives to put for surgeries or treatments that financially because they're on salary it's not a fee for service system.

[00:39:00] And I think you know both in veterans need to be getting up to speed on some of this and advising each other not only to get help but okay Joe you might have to drive two hours I mean the thing for rural Americans that is really important.

[00:39:18] Is that they have pathways to specialize care one of those pathways is telehealth and the VA is a pioneer in that but there's some things you have to go in person and you may have to go four hours but you know the VA will pay for you though there they'll pay for your hotel they'll pay for your transportation.

[00:39:42] You can be followed up in a local area right.

[00:39:47] And you can be followed up by telehealth but you have to maintain and improve the integrity of the system that you have not tear it down and I think that's what veterans don't understand you know that I think they don't understand that as I say if you don't choose VA you're going to lose VA.

[00:40:10] So the taxpayer is not going to pay for two parallel systems for veterans.

[00:40:16] You're not afford it you know and we're not going to pay for a system the veterans don't use now I think when it comes to rural health care some of these senators and Congress people actually think that they can save their role hospitals and group providers and this get a kind of double benefit you know it's like a two for.

[00:40:39] Super by injecting VA money and patients into those practices and hospitals the problem is that the payment rates the reason why these rural hospitals practices are folding is because they don't have enough patience with private insurance payment rates that cover the fact that Medicare.

[00:41:03] You know payments don't cover their costs which are too high anyway.

[00:41:11] And so if you funnel more VA patients being paid Medicare dollars into these practices and hospitals it's not going to say what could save them or for could save rural Americans as well as rural veterans is used in VA financing to expand care.

[00:41:37] And expand tell out expand create actual real partnerships that don't jeopardize the VA with them surviving real hospitals let veterans family members come to those hospitals and let veterans who are ineligible for VA care facility have a bad paper discharge or because they have don't ever prove and service connected.

[00:42:06] Disability or their income is too high let them go into these practices and the VA has the money or could have more money on to really expand its real health capacity and save rural health care for not only veterans but for more rural Americans.

[00:42:30] When the reality is that the private sector corporate health care private equity first are never going to invest in rural health care because it is not profit making.

[00:42:42] The people who live in rural America are by and large old and poor and sometimes uninsured and so they're not profitable you know they're not profitable patients and they're often complex patient but the VA with the power of the federal purse you know could invest in health care in rural America for veterans and their families.

[00:43:11] And you know that could be a big hit I could be a very big help.

[00:43:15] I would I know I've seen the the and I don't know what program they're involved with the the there's sometimes mobile stops set up with VA facilities yeah mobile facilities those could be expanded so good tell a health but at some point sometimes people have to go do the doctor or the hospital.

[00:43:38] And I mean you know you could imagine I mean we end the paper I end the paper with the suggestion that people and VHPI is determined to flesh us out establish pilot programs with world providers or programs in rural America it's that I mean for example then VA has funding to train mental health providers.

[00:44:06] And it could train providers specifically for rural America or for you know part time duty in rural America it can train primary care providers I mean particularly we're given more money.

[00:44:19] It could do a lot to help the primary mental health care prices in America.

[00:44:24] I mean the VA has an incredible capacity and you know veterans could actually serve as ambassadors and for motors and advocates for more VA services as post private sector services in rural America.

[00:44:45] I mean you are now spending in 25 to 50% of the VA budget on private sector care we're talking billions and billions of dollars you know up up or worse of 60 potentially you know 30 to 60 billion dollars that's a lot of billion dollars.

[00:45:06] You know and so you could get a lot of health here if you took those dollars away from the private sector and injected them in the VA the VA is now going to pay 23.5 billion dollars to contract out help

[00:45:30] for human resources function and higher terms you know in VA hospitals these are people who are not think about veterans.

[00:45:40] Yes.

[00:45:41] I mean you know there's 20 billion here 30 billion there you know 60 billion there that's a lot of billions that could buy you a lot of staff that could buy you a lot of improvements.

[00:45:56] It makes it it.

[00:45:58] One of the things I've always appreciated about the VA is that they generally it doesn't it doesn't matter you know who the veteran is or what they come with their their overriding problem is when they come come there that somebody get like let's say somebody gets in an argument with one of the staff or they they don't believe in a treatment of some sort of they don't want to vaccine or whatever.

[00:46:22] That the staff are really well trained at dealing with those kind of things and especially you know for veterans that after having been in the military and been told you're going to live in this box for however long when you leave the box.

[00:46:36] You want to be able to make those choices for yourself you want to be able to do those kind of things.

[00:46:42] And you know we don't want you said we don't want to force anybody to do it but if people don't use it we will end up if we will end up losing it.

[00:46:53] I had more to say I dropped it sir.

[00:46:57] Actually hold on one second I have a little transcript.

[00:47:03] Oh yeah so they're going to be it's going to become acceptable for the people a lot of people in a lot of those places potentially he's saying human resources staff but I bet eventually hit it and up leading into the lower levels of medical staff and stuff people that are you know it becomes a contract thing.

[00:47:23] One doesn't give actual VA jobs to people so they can have those benefits and also is that you're bringing in people that are always going to be the new guys there are always going to be the folks that have maybe dealt with those issues in a non veteran context outside the VA system but chances are they haven't and it takes a while to get into that.

[00:47:47] But with its contract how do you know who you're ever going to be getting what kind of you know repetition is actually going to come from that and that means veterans are going to be comfortable and that means fewer of them we're going to go to the doctor which means you know closer to losing it in terms in those in those terms if somebody gets a standard care.

[00:48:05] And there isn't a way to rectify it.

[00:48:08] Well and I really believe that it's time for us all to start some kind of choose VA use that are was a campaign because I just think that this assumption that I mentioned before that you know you can maintain a robust VA and this parallel private sector system.

[00:48:31] I mean I am just beginning to do research around what's going on in different VA use around the country and so much money is going out to private sector care that they're there putting you know curtailing programs there.

[00:48:51] I'm cutting back on promised raises they are not hiring they're putting in what they euphemistically refuted the virtue is hiring for us is which isn't really higher in freezes and this is going on all over the country and veterans need to understand this you know there's I mean and you know we've discussed the problems in world America.

[00:49:16] The problems in urban America aren't that much better I mean I can't find a prior primary care provider practically in on you know in the Bay Area I mean I have one and it's very hard to find one.

[00:49:34] I have friends who are primary care providers can't find a primary care provider and get care of them you know there's tremendous way times I mean every time I want to go out of the P.G. I have to wait three months you know my husband needed it you know an appointment with a urologist it was five months because away because they're saving their appointments for people who want surgery you know.

[00:50:01] And I mean it's a disaster now American health care is a disaster veterans in about how can we explain this to people you are so lucky you know it's just terrifying to me that people think the grass is greener than there's no grass it's a desert it's like you want some tactics that's great you know the red and out your system but it's just like you know they're not going to be a good thing.

[00:50:31] There was this recent study of veterans who had Medicare and and VA in care so they called dual eligible and they could go to a VA ER private sector.

[00:50:42] If they went to a private sector or they had to wait a 6% increase chance of dying in the first 28 days so I read that and I think how come my kids total of VA are you know it's because there's comprehensive co-ordinate care and I guess the real you know.

[00:51:00] Mystery to me is how you reach veterans and get them not to believe these false promises I mean I wish you could live in a one tier area where there's you know less than whatever 25 hundred people or wherever so well I wish you could live there and get a total knee replacement around the corner I wish you could wouldn't that be lovely.

[00:51:28] You know I also wish that you know I could have a billion dollars and you know a house in Hawaii it just ain't going to happen and I think that you know we are less than most critical of that those were closest to us so I think that's a stunning great thing about the VA and the VA has problems no question of course the VA has problems but how do you solve those problems do you solve those problems.

[00:51:57] Problems you saw the problems by you know it's like you love your wife but you know you kind of are irritated by her or your better and husband when you're irritated by well do you get ready the guy or the woman or do you like figure it out you know now obviously there's something times when you really do want to leave.

[00:52:17] But in this case this is a great health your sister it specializes in veterans problems it needs more money and these more staff people should be you know I don't know there's various things that you know you can you can improve clearly for women veterans.

[00:52:37] You know there's problems but you know even on the women veteran front I mean what health your system is good to strategize line a special program for women veterans everywhere for 7% of the patient population.

[00:52:54] I mean if women veterans think they're going to find women where they don't see men in the private sector the only place that can happen is with your kind of colleges you know I mean and it's just you know so I guess the question I'm fascinated by what you think is how do you get these veterans to see we have an incredible system people spend a lot of money to take care of us and refine our care.

[00:53:24] We wanted to improve you don't prove it by giving somebody else the money and the time and energy and attention that you need to spend on fixing your system if you want your care to improve I mean you think veterans are 7% of the population with you know increasingly fewer I mean they're increasingly.

[00:53:54] If you are a percent of the American population pretty soon it's going to be like 1% right when you get when the Vietnam bats and so forth and die off is a merit to health care systems going on like take a lot of care and attention to like 1% of their patient population or 3% really do you actually believe that I mean people you know espouse their love and sadness.

[00:54:24] But we know that how much lip service that is and how little reality is to it and you are a self-resistible they really need it and you aren't paying attention to it you know you want using it I mean my master veterans is every time they say to a veteran close up and they tell the veteran you could get an appointment in the private sector.

[00:54:51] I want to wait no I'll wait because usually you have to wait longer in the private sector which they don't tell you.

[00:54:58] You know I want to go to the VA right and I think that veterans need to start telling veterans that and I how to make that happen I don't know I really don't.

[00:55:12] Yeah it's a part of it is an American problem.

[00:55:17] Of the you know that we are lack of intellectual recognition of not wanting to subscribe to any specific bullet points when we say thank you for your service.

[00:55:32] Is that that I if people I mean it I don't want to go into the whole thank you for your service thing but just while I bring it up at the you know it has no meaning and has no I mean it and it does mean something to certain people in that way and I don't I don't want to take away from that in that way because some veterans do sacrifice greatly and that maybe that actually means something to them.

[00:56:02] But if we're going to be a nation that thanks veterans if we're going to be a nation that says veterans are heroes and we want to take care of them then the first bullet point of that has to be help the VA survive.

[00:56:16] And that means exactly what you said earlier is like when I you know somebody can get in to see their to see their eye doctor in a couple a couple weeks or they can wait a couple weeks longer and they can see the VA.

[00:56:29] Well if there's no immediacy to it will see the VA and and at the very least if you've ever gone before I hope that veterans give it a try I hope that they they do try now I've had friends that have gotten.

[00:56:42] A horrible care from the VA at different times I feel for them greatly and I talked to them about those things but the reality is is that those bad experiences and I've had some myself they can't keep us from trying to protect the system that protects everybody.

[00:56:59] And it is it is the best system that that veterans have and you're absolutely right Suzanne that we are coming to a point in the next 25 to 30 years where the majority of the Vietnam generation is going to be gone.

[00:57:12] And there's going to be a rock vets and F again vets and other people like that who have legitimate need for this system.

[00:57:20] And because it wasn't protected when there was that much population when there was that many people talk about it who knows what's going to happen at that point is it going to become another government who do go where the budget is just strong control and trunk and take it away or sent to something that we don't agree with or fighting.

[00:57:41] But it's pleasurable so yeah no this is an active this is an act of fight people need to understand that the levels of privatization are you know that they could really take giant bites out of what the VA can do out of the good services that the VA can provide so.

[00:58:01] And I think the point that you made this important is if you have a bad experience in the VA.

[00:58:08] You can call your congressman you can you know call your senator you can have a hearing you can have an investigation.

[00:58:17] If you have an experience in the private sector there's nothing they can do they have no influence all they can do is eliminate that provider from the network.

[00:58:27] They change the system for the better.

[00:58:30] I mean if you look at PTSD right with Vietnam beds it was Vietnam veterans experiences hundreds and thousands of them that shaking and streaming brought the VA to be the national expert on PTSD for everyone right.

[00:58:48] And if you don't have that pressure you're going to lose expertise that helps not only veterans but the entire nation because VA research and teaching it doesn't just it's not the prior to it helps everyone.

[00:59:03] And you're going to lose you know the information I mean it was near it was the fact that they had case after case after case of PTSD a burn hit exposure of aging or an exposure that allowed them to put it together and figure out oh gee there's something here.

[00:59:25] If you scatter that information out among 785,000 private central providers who's going to put you know recognize the who's done that pattern recognition and help veterans in the future with the next PTSD the next toxic exposure.

[00:59:45] So I think that you know i'd love to end on the note of you know people need to recognize that every the VA's budget is based on utilization.

[00:59:58] If you don't use the VA the budget allocation is smaller next year they're going to cut programs are going to cut staff and you're not pretty soon you know it's going to be like the frog boiling in the water there ain't going to be much later left.

[01:00:14] For your cohort or the next cohort and and we can prevent that we can expand the VA will truly improve the VA.

[01:00:23] We can make things better I mean that is the history of the VA you know it started.

[01:00:29] Sort up in the civil war right and you know it has turned into a very successful i'll be an imperfect healthier system but we can perfect it'll never be perfect I mean there's no given so much.

[01:00:43] There's no given system that is.

[01:00:46] But I think i'd like to end on the note of you know particularly for world veterans if you want to solve the problem of world veterans the solution is the VA expanding it.

[01:00:59] It's more funds to operate in rural America and you know not pretending that the problems of world veterans can be solved by outsourcing their cheer to people that just like aren't even there.

[01:01:15] The community isn't you know in urban America the problem is they don't know how to deal with veterans and often they won't accept patients the problem role is America there ain't in many many places there ain't anybody there to take care of you.

[01:01:30] And you're if you threaten the VA you're threatening some of the only care that veterans have and that's unacceptable.

[01:01:38] Absolutely absolutely.

[01:01:41] Well Suzanne I think that's a good place for us to wrap it up for today yeah right you think this worked well and me yeah yeah no i'm.

[01:01:51] I was going to I was going to ask you though that for folks veteran or non veteran who want to support the VA what do you think the best thing they can do with their time is.

[01:02:03] And I think that's a good place for us to wrap it up for the VA.

[01:02:13] And I think that's a good place for us to wrap it up for the VA.

[01:02:20] So let the things that folks could do if they would take the time and it's only a few minutes is if you have a good VA story call your political representative because all they hear is a bad stories.

[01:02:32] So call your political representative and tell them the good story you know I want to tell and send it to the H5 because this we ever website and and we're collecting those stories so that's number one.

[01:02:45] And I think that's a good place to answer your questions and I think that's a good place for us to answer your questions and tell them the good story you know if they start gripping about the VA.

[01:03:00] You need to have conversations with your legislators right it's you know and your congress people are saying we want more staffing and funding for the VA we want to in house care not you know in source care not outsource care.

[01:03:17] And if you go on to the VHVIP website you'll see you'll see legislative updates and so forth about what's in Congress and we right now we have this test through bill I think it's 2649 s26 49.

[01:03:36] And that should be opposed you know they should stop they should have pilots that expand VA care all over the country not outsource it you know so I think that's a and you know it does take very long to reach out to your congressperson or senator I mean it literally if you devoted like every six months 10 minutes

[01:04:03] to calling them up and saying we want to stop the outsourcing if you use the term privatization it's problematic because they always say there are against privatization.

[01:04:13] You know and what they mean by privatization is selling off the VA tomorrow and you know closing the whole thing down they're not against this piecemeal salami strategy privatization of the slow death and so I think using the term outsourcing care we want to stop the outsourcing care.

[01:04:32] You're using you know higher more HR people in the VA stop hiring attempts you know hire more staff I mean they can do it there are people that want to work in the VA.

[01:04:43] They're they want to take care of veterans they are mission driven so I think if if just you know 10% of veterans started raising their voices I mean there's our very powerful political force in America society and the

[01:05:01] the coax know this and they use them against their own interests and we need to just start telling you know the message I mean talk to your friends and relatives.

[01:05:14] Oh do you use the VA all the VA is so terrible wait a minute let me tell you my story every one listening knows 10 people that they can talk to about a good experience with the VA you know because you have to can you have to counter

[01:05:29] the bad propaganda that they're pouring millions into creating and only veterans can do that absolutely those are my suggestion.

[01:05:40] The this week you will gets the gets the grease so we that that's how I make that happen.

[01:05:47] I'll say thank you for being here today with us on my time.

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