Editor's note: At a time of strained relations over Veterans Administration health care, last summer's plan to shut down seven VA hospitals across the country led many veterans to believe "it's all about the money." The following is an excerpt from an article scheduled to appear in the February issue of the American Legion Magazine.
The announcement arrived at a sensitive moment for veterans in Canandaigua, N.Y. The community's first soldier killed in Operation Iraqi Freedom was freshly buried, with full military honors. The next day, the list of proposed CARES casualties – hospitals lined up for execution under VA's controversial Capital Asset Realignment for Enhanced Services process – was released. Included on the list was Canandaigua VA Medical Center, which had been serving veterans in upstate New York for more than 60 years.
Rebellion came almost instantly. The Coalition to Save the Canandaigua VA Hospital took shape, and more than 90,000 signatures were swiftly collected onto a petition against the plan. More than 2,000 people attended a "Save the VA" rally. The city, the county and the schools got involved. Websites popped up. Veterans were wheeled out at halftime of a high-school football game.
Buttons were made that said, "Keep The Promise. Keep It Open. Save the VA." They had a candlelight vigil and a motorcycle rally. A logo was designed connecting the Canandaigua campaign with the other six communities where facilities were recommended for closure under CARES. The rallying cry: "7 Cities Solidarity: United to Save Our VAs." Congressional representatives poured into town, stood before veterans and promised to intervene.
The CARES draft plan, released last August, landed at a particularly tense moment in the often-rocky relationship between U.S. military veterans and the Department of Veterans Affairs. It came after $1.8 billion in earlier-approved funding was stripped from the congressional budget request for VA health care. A half-year earlier, some 236,000 veterans were waiting six months or longer to see overbooked VA doctors in understaffed facilities throughout the country.
VA Secretary Anthony Principi responded to the pesky backlog of patients by restricting enrollment to only the sickest and poorest among them, suspending those classified in Priority Group 8, a move that was seen as an administrative retreat from the congressionally approved Veterans Health Care Eligibility Reform Act of 1996, which had opened VA care to all who honorably served.
The CARES draft plan also hit at a time when veterans were seeing more and more of America's sons and daughters coming home sick, wounded or dead from war in the Middle East. In the eyes of the returning soldiers, they saw themselves and a new generation of VA patients.
"The VA picked a very, very bad time to pick on veterans," says Bill Mahon of Waco, Texas, a disabled Army retiree who fought in the Vietnam War and today fights to keep the VA hospital in his community open.
The CARES process recommended new missions for 23 VA health-care facilities from coast to coast, a $4.6 billion realignment project. For seven of those – Canandaigua; Waco; Brecksville, Ohio; Lexington, Ky.; Gulfport, Miss.; Livermore, Calif.; and the Highland Drive division of the Pittsburgh VA Health-Care System – the recommended new mission was to pack it in.
Veterans in targeted communities were shocked into action. They believed the CARES plan revealed a glimpse of a long-hazy federal vision for VA health care, suddenly coming into focus – a smaller, cheaper, more consolidated system with capped enrollment and increased dependence on the private sector. "It's not about veterans anymore," says Vietnam War veteran Bob Sloma of Pittsburgh. "It's all about the money."
Waco was flat-out aghast. Veterans there could not believe VA intended to board up its stately 70-year-old hospital after having spent millions on recent improvements. Waco was not pegged for closure when regional market plans were submitted to the VA national headquarters in Washington last spring. Many in the central Texas city of about 125,000 claim they were told the facility was actually in line for expansion through CARES, that it was to become a regional "psychiatric center of excellence."
But at some point last summer, the word "expansion" was scratched out, and "extinction" took its place. Veterans protested. They summoned the state's chapter of Rolling Thunder, which led a mid-August motorcycle rally from Waco to nearby Crawford, within earshot of President George W. Bush's ranch home. The demonstration received national media coverage, ignited the community and opened the floodgates of a public-relations disaster for the VA.
More than 2,000 gathered on a Waco football field to howl in opposition. Nearly that many showed up when members of the National CARES Commission came to Texas for a field hearing in October. The mayor got behind the effort and assembled a blue-ribbon task force of community leaders to fight for the hospital, which provides about 800 jobs and produces an estimated $203 million a year in the local economy. Waco media covered the story relentlessly.
Waco Mayor Linda Ethridge said she and her task force wanted cost-benefit information from VA and did not get it. "In the first round of planning, which came from VA officials out in the field [in Texas], they recommended a plan that included keeping this hospital open," Ethridge says.
They were advocates of a continued presence for this hospital. After that plan was submitted, someone higher up in the organization came back and said, "You need to do some more cost cutting." Our concern is that the same people who are making management decisions that reduce the census at the hospital are now the people saying we have to close it because the census is low. And so we are not sure that the number of people in the hospital at any given time is really a function of demand. It's a combination of demand and internal protocols and internal decisions that we don't really understand. We have had enough concerns that we want to investigate it.
At Livermore, Calif., a similar story played out. When the initial regional VISN (Veterans Integrated Service Network) market plans were submitted last spring, the Livermore facility – a 120-bed nursing home with a brand-new state-of-the-art Alzheimer's/dementia unit, a short-stay sub-acute care hospital, and a diverse collection of outpatient services – was not mentioned. That all changed suddenly, however, after regional VISN directors were asked by the national office go back and rethink their first impulses.
Veterans advocates in central California say Livermore – where wild turkeys and black-tailed deer calmly wander 113 acres of vineyard-surrounded grounds – was hoisted up for sacrifice by top VA officials in Washington. In the land of fast-rising real-estate values, long-term care patients would be sent to facilities in the Bay Area or farmed out to the private sector. Two new clinics would need to open to handle the outpatient load. The idea, lacking any cost-benefit analysis at the time, did not go over well with local veterans.
"This is a bunch of crap," says American Legion District Service Officer Barney LaRue, a Korean War veteran who has served as a volunteer for more than 28 years at the Livermore VA. "We need every VA facility that we have. And even then it's not going to take care of all the veterans that we've got. This has gotten under my skin. It will be under my skin until I know they are listening."
Like Waco, Highland Drive's primary mission is mental health care. Set on a bucolic 168-acre campus in the East Liberty section of Pittsburgh, the sprawling 1950-built facility has an indoor swimming pool, a softball field, a domiciliary, a huge laundry facility, a nationally acclaimed wheelchair-research laboratory, and a system of underground corridors that connects many of the 17 buildings. But little more than half of the 850,000 square feet available is used for patient care.
"It's costing millions of dollars a year to try to renovate it and keep it up to date, because it's old, and there are significant portions of it that are vacant," says Michael Moreland, director of the three-campus system that consists, generally, of a mental-health arm at Highland Drive, a newly rebuilt nursing home at nearby Aspinwall, and the acute-care hospital on University Drive downtown. "If I had to close one of the three, it would be Highland Drive."
The average daily bed census at the psychiatric-intensive facility – which before 1996 also provided acute medical care – fell from 190.5 patients in 2000 to 162.8 in 2003, a shift the director says can be attributed to a number of factors, including pharmaceutical advances and new outpatient-care choices that reduce the need for long inpatient stays.
Mary Ann Meader – a Highland Drive nurse, American Federation of Government Employees local vice president and Vietnam-era Army veteran – says patients have been deliberately squeezed out of the system by the administration in an effort to show low demand and justify closure. "There seems to be a concerted effort to divert patients. Patients have been put out and units have closed [behind them]. There's no place for them to come back to. We can't take them. They have to go someplace else. Sometimes there isn't a someplace else. Sometimes they have even been sent out of state."
The CARES deal won't work, Moreland says, unless $100 million in federal money is delivered to expand the downtown hospital, build a new parking structure and make more room at the Aspinwall nursing home. The draft plan contained no specific dollar figures for new construction in Pittsburgh.
Bob Sloma – who fought the Viet Cong in Vietnam and now works as a safety specialist for the Pittsburgh VA Health-Care System – doubts the money will materialize.
Sloma fears Pittsburgh will end up like Chicago, where the CARES process was piloted in 2001. A private consulting firm there recommended closing the city's Lakeside VA Medical Center, turning it into a clinic and feeding its inpatient veterans into Westside VA Medical Center 10 miles away. The measure would require $100 million for a new bed tower at Westside. VA concurred. Lakeside was closed. Patients were moved to other facilities in the city.
But the promised new bed tower was nowhere in sight when acute-care services disappeared at Lakeside. "It's been a disaster," says American Legion Department Service Officer Joe Petrosky. "Veterans were going to town-hall meetings, expressing their concerns, and there were petitions – organized efforts – but everything that was said fell on deaf ears. The VA kept saying it's going to be transparent; you won't even notice the difference."
"Back in the 1930s, there was a need to serve veterans," Sloma says. "That need has not changed at all. VA was not created to be an HMO. VA was not created to save money. It was not created to apportion out to the private sector. It was made to serve veterans. Veterans should be the priority in all instances. These people are forgetting all too soon the promise made years ago, the promise to take care of veterans. It started with Lincoln. What they are doing today is a travesty. It's a disgrace to this country."
The CARES process was triggered by a 1999 General Accounting Office report that estimated VA was spending $1 million a day on under-utilized buildings nationwide. The largest managed health-care system in America, VA operates 163 hospitals, 850 clinics, 137 nursing homes, 43 domiciliaries and 73 home-care programs. If indeed $365 million were spent on wasted space in 1999, the problem represented 2.1 percent of what was then a $17 billion health-care budget. And yet, it was the problem that launched CARES, the most massive overhaul in the system since the troops came home from World War II.
"They didn't care about $1 million a day when they carted our asses off to war," grumbles Mahon, a veteran whose trust in the system has been tested for years because he has been forced to pay for his own 80-percent VA disability compensation in forfeited military retirement pay, due to the century-old "disabled veterans tax," a law that denies concurrent receipt of VA disability compensation and DoD retirement pay.
"The people who are getting screwed over are the kind of people who walked the Bataan peninsula," Mahon says. "These are people who deserve to be treated. Not one of them asked to be here. Not one of them volunteered to spend their lives attached to a VA hospital."
If VA health care were funded by mandatory appropriations, American Legion National Commander John Brieden says, these kinds of problems might not exist. The Legion has supported mandatory-funding legislation in both of the last two sessions of Congress – funding provided on a cost-per-patient basis, with increased authority for VA to bill private insurance and Medicare. Such a move would not only allow VA to keep up with its infrastructure costs on an ongoing basis, it "would make the return of Group 8 veterans desirable."
Brieden says he fully commiserates with veterans whose hospitals were targeted for realignment when the CARES draft plan was released.
It is an emotional issue for people who swore never to leave their buddies on the battlefield, and this has become a battlefield. It is especially sensitive now that we have so many young men and women coming home from war, needing VA health care. When our nation makes a commitment to send our soldiers to battle, the cost does not end when the war does.
VA health care is a delayed cost of war, an obligation the public wants the federal government to fulfill. And it's a pretty tough sell when last year's problem was overcrowding, and this year's problem is too much empty space. The public has a hard time understanding that. Veterans do, too.
Â
Jeff Stoffer is the managing editor of The American Legion Magazine.
Â