While we’ve entered a new year, the thing that still dominates our collective attention is the COVID-19 pandemic. This virulent virus has confronted many with what is an unwelcome but critical fact: what one does as an individual – like wearing a mask or social distancing – can dictate whether friends, family, and neighbors live or die.
We hope the public learns another key lesson from this terrible time: a coordinated national healthcare system is best suited to battle a national health emergency. Those of us who aren’t veterans don’t enjoy the benefits of such an integrated healthcare system. But the Department of Veterans Affairs (VA), time and again, has demonstrated the best public health practices during this national emergency, both through its provision of veteran care and also through the implementation of its Fourth Mission, which is to serve as a backup system for the American people. This mission has been activated in hotspots across the country, including New York, Louisiana, and New Jersey. Every VA in the country also set aside ICU beds and other resources to accommodate non-VA patients facing an overburdened private sector healthcare system.
Former VA Secretary David Shulkin, who served under Presidents Obama and Trump, said he saw tremendous consolidation and contraction in his private sector health care work, all in the name of profit. “Folks in the VA have seriously and professionally embraced this fourth mission,” he told us. “The VA can and does lend an important hand when a national tragedy or crisis plays out.”
As we look back on a terrible year, we want to take the opportunity to highlight and celebrate some of the VA’s achievements in battling COVID-19.
As soon as this pandemic took hold, VHA staff embedded with the Centers for Disease Control and are today largely running the country’s 65 emergency coordinating centers. The department has also deployed nurses to screen American soldiers coming home; built a website landing page to inform veterans of updates through the crisis; restricted non-essential hospital visits across the country; and instituted strong protective measures at their nursing homes, which are much better staffed and safer than their private sector counterparts.
Because the VA is mission, not profit-driven, and has a global budget it does not face the same financial restrictions as the private sector. Hugh Foy, professor emeritus of surgery at the University of Washington and a new VHPI advisory board member, explained that, “the VA can react more nimbly now because it’s not profit-driven and physicians are employees not private contractors.” The very first thing agency leaders were able to do, in early March, was cancel all elective procedures. It did this to keep staff and patients safe and also to expand capacity. This swift action was in sharp contrast to private sector hospitals, which depend on fee-for-service revenue and were therefore reluctant to cancel treatments and procedures. As one VA medical center director told us early on in the pandemic, “I feel very lucky to be working in the VA today. I’m already on a hair trigger to cancel total knee replacements or other elective surgeries. When I talk to colleagues in the for-profit sector, they are much more reluctant to do this because they will lose money.”
The VA also quickly utilized its vast telehealth network to substitute virtual for face-to-face visits. It has done this not only for medical, but also for mental health visits. The VA has also pioneered the use of tele-ICUs, in which doctors and nurses can consult over video chat and help with intensive care patients in other locations. Using telehealth ICUs cannot solve fundamental problems around capacity or equipment shortages, but it can help with staff shortages. That’s because when nurses and doctors are put in quarantine after potential exposure to the virus they can virtually remain on the job, safely isolated and at home.
As a report in the New England Journal of Medicine noted in July, “the Veterans Health Administration (VHA) offers a blueprint for rapid expansion of telehealth services during the COVID-19 pandemic that can be used to maintain those advances after the pandemic.” The article went on to describe how the VHA faced the “unique challenges” of dealing with a population with serious underlying healthcare problems, as well as serving as the backup system to the private sector in times of national emergency. The article praised the VA for its ability, through telehealth, to continue with the provision of essential non-COVID care, stem the spread of COVID-19 within its facilities, and quickly deploy staff and resources to COVID-19 hotspots.
As VHPI fellows wrote in The American Prospect in March, “because the VHA is a highly coordinated system, agency staff have begun rejiggering its supply chain to get necessary equipment to hospitals in hardest hit areas, and have started setting up command centers to assist with this national emergency. The department is ready to contribute 16,5000 acute care beds, 1,000 isolation rooms, 3,000 ventilators, six mobile nutrition units capable of churning out 1,200 meals a day, 12 mobile command units, and a network of nearly 4,000 deployable volunteers known as Disaster Emergency Medical Personnel.”
The VA also utilized its little-known Healthcare Operations Center (HOC) at VA’s central office to coordinate the response to the crisis. This center is unique in the American health care system. Stocked with state-of-the art equipment, the HOC gives the VA the ability to coordinate rapid responses in crisis situations. “In a room in VA headquarters we could watch the entire VA system in real time,” a VA official told us. “We could track the evolution of a pandemic not only in the VA but state by state, county by county, monitoring the civilian and veteran population, and determining how many diagnoses there were as well as bed capacity, and burn rate of PPE and supplies.” While Shulkin shut down the HOC, Richard Stone, now the VHA’s executive in charge, had the foresight to restore it. The VA also acted swiftly to protect nursing home patients from the pandemic. It quickly shut down VA nursing homes (called Community Living Centers or CLCs) to visitors and outside staff and sent residents elsewhere who didn’t need to be in CLCs. Residents who had completed rehab were discharged or, when possible, sent back to their families and the number of residents in CLCs was reduced. This has allowed residents to have separate rooms, which is safer for patients and staff. Most importantly, the VA benefits from the fact that it has long paid better wages and offered better benefits to its nursing staff than do private for-profit nursing homes. The VA employs more staff than private for-profit nursing homes, has more Registered Nurse staff, and trains staff more effectively in infection control. Because of this, VA nursing homes do not have the kind of employee churn so characteristic of for-profit nursing homes. These private homes have been incubators for COVID-19 because staff are overworked, poorly trained in infection control measures, and often have to work in two or three different facilities to make ends meet. Because of this, many carry the infection from nursing home to nursing home, acting as dangerous super spreaders of disease.
Because of the VA’s superior nursing home practices, the VA was actually asked to take over or help with crises that occurred in state Veterans’ Homes, which are not run by the national VA but rather state veteran agencies. One example is a veterans’ home in North Carolina run by PruittHealth, one of the largest, national, for-profit nursing home chains. The company has been repeatedly cited for safety violations in North Carolina, particularly under the COVID crisis. As the company repeatedly failed in its mission, VA professionals were placed in the home to help run it.
While other nursing homes in the state – including state Veterans Homes —have been inundated with COVID cases, this has not been true of VA CLCs in North Carolina. VA officials in the state responded early to warnings about the virus. They trained and tested staff and ordered sufficient personal protective equipment. Facilities were closed to visitors and outside staff, staff were quickly tested for the virus, group activities were canceled, and policies were quickly rolled out that required social distancing.
A critical but little noted fact is that the VA’s system of coordinated and integrated care has also meant that there have been far fewer healthcare disparities during the Coronavirus crisis. Initial reports suggest that fewer African American veterans and veterans of color have died or suffered devastating health consequences from coronavirus than has been true outside of the VA. Experts believe this is because the VHA manages chronic health problems more effectively than our fragmented, private sector healthcare system.
The VA has also been aggressively reaching out to veterans to educate them about the mental health risks of COVID-19 and also working to help them avoid infection through mask-wearing. The department even developed a calming phone application called “COVID Coach” that’s available to all.
Sadly, these efforts were greatly hampered by Trump’s White House, which has long discouraged mask-wearing and social distancing. When the VA’s National Center for PTSD was asked by clinicians to develop and post national guidelines to help encourage mask-wearing among uncomfortable veterans, the White House intervened to suppress critical information. When Suzanne Gordon and Jasper Craven – two VHPI fellows – broke this news in Battle Borne they spoke to concerned staff about this behavior, including a long-time mental health official who said, “this is the first time in my long VA career that political issues have interfered with direct clinical care. That’s unacceptable.” When the VA has had trouble with getting sufficient personal protective equipment (PPE), this is also because of Trump administration actions that have stymied developing a coordinated national response to the pandemic. We hope that under the new administration, the VA will be more transparent in acknowledging these problems and reversing the policies that have made responding to the pandemic so difficult.
At VHPI we are now monitoring the roll out of the new vaccines. Initially, the news seems to be good. One VA best practice, for example, is granting administrative leave to staff who are vaccinated and get sick because of the vaccine. Many other healthcare institutions are forcing front line staff to take their own personal leave or sick days off if they get sick. This can discourage people from getting vaccinated. Again, we see the VA as a model of best practices in a coordinated response to the pandemic.
