Tag Archives: Veterans Administration

Bits and Pieces: Tesla, Titus, Heller, and Amodei

Jig Saw Puzzle ** It’s a done deal. TESLA’s coming to Nevada, brought to us by $1.2 billion worth of ‘incentives.’ [RGJ]  Meanwhile, watch that multiplier! The state is assuming a 2.5 multiplier for revenue generation, i.e. for every one direct job with TESLA there will be 2.5 ancillary jobs created – that’s a big multiplier. [RGJ] See also [LVRJ]

**  Representative Dina Titus (D-NV1) asked the VA to move its regional office from Reno to Las Vegas. [LVRJ]  Much as it might pain a northern Nevadan to say so, but the Las Vegas metropolitan area does have more of the 246,000 Nevada veterans than those living in the north, [VA] and the northern office hasn’t covered itself in glory. [LVRJ]  I’d not want to hang by my hair waiting for a definitive answer from the new VA leadership.

** From the Department of No Surprises:  Senator Dean Heller (R-American Bankers Association) voted against the cloture motion to consider S.J. Res. 19, a bill to propose a Constitutional amendment to allow the Congress to enact meaningful campaign finance reform.  Senator Heller was one of 42 (all Republican) votes to continue to filibuster any attempt to overturn the decision in Citizens United.  [roll call 261]

Representative Mark Amodei (R-NV2) voted in favor of H.R. 3522, a bill which would allow insurance corporations to offer small businesses group  insurance plans which DO NOT meet the standards for comprehensive health insurance coverage for their employees under the terms of the ACA.  [RC 495]  One organization summed up the problem with the bill:

“This legislation would allow health insurers to continue offering coverage outside of the insurance marketplaces established by the health law even if those plans do not comply with its coverage requirements. In addition, the inferior plans that would be allowed to continue under Representative Cassidy’s bill discriminate against people with pre-existing conditions, force women to pay more than men for the same coverage and impose annual caps on the amount of care received by enrollees.” [NCPSSM]  (emphasis added)

Those three issues, pre-existing condition discrimination, gender discrimination, and junk policies with capped coverage are some of the main reasons the ACA was necessary in the first place.

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Filed under Amodei, Health Care, health insurance, Heller, Nevada economy, Nevada legislature, Nevada politics, nevada taxation, Titus

VA Health Care: “Postponed Proceedings”

The bills to improve the performance of Veterans Administration operations have passed the House and the Senate, in fact they’ve been waiting for a conference committee to iron out the differences between the two bills since mid June. That’s why it’s disappointing to find the following update on the progress of the final bill posted as follows:

“7/17/2014 POSTPONED PROCEEDINGS – At the conclusion of debate on the Barber motion to instruct conferees on H.R. 3230, the Chair put the question on adoption of the motion to instruct conferees and by voice vote, announced the noes had prevailed. Mr. Barber demanded the yeas and nays and the Chair postponed further proceedings until a time to be announced.”

No instructions from the House, no conference, no conference no conclusion.  What are the differences between the House and Senate versions?

# The House bill specifically bans the use of bonuses for VA employees, while the Senate version does not. The VA has already suspended performance awards of this nature.

# The Senate bill would allow the VA to lease 26 new facilities for veterans’ health care and would allocate $500 million for hiring new staff.  The House version doesn’t contain these provisions.

# The Senate bill provides for guaranteed in-state tuition for veterans at public colleges and universities; the House version of the bill does not.

# The Senate version of the legislation provides for expanding access to care for military sexual assault victims. The House version does not include this provision.  [WaPo]

# The House version assumes a maximum wait time of 14 days, the Senate version could allow up to 30 days. [CBO]

# The CBO analyzed the costs of implementation for securing private health care services when VA service could not be provided

“The Senate bill would require that all privately provided care be implemented through contracts. CBO expects the costs of contracted care to be closer to commercial rates, which are generally higher than Medicare rates. Although such contracts would probably be used under the House bill to cover some care, CBO estimates that the average payment rate under the House bill, including both contractual and non-contractual payments, would be lower than that under the Senate bill.” [CBO]

# The House version would allow direct reimbursement to private facilities, while under the terms of the Senate version as analyzed by the CBO the VA would negotiate contracts with providing facilities.  Thus, the access might be faster under the House version, but with less expense predictability than if the terms of the Senate version were applied.

Unfortunately, the situation is reduced to a battle over money.  The CBO released its appraisal of the costs on June 17, 2014:

House Version: “Based on that preliminary assessment, CBO estimates that implementing sections 2 and 3 of the House bill for that two-year period would have a net cost of about $44 billion over the 2014-2019 period, assuming appropriation of the necessary amounts. That net amount comprises increased costs of about $51 billion for VA, less a reduction of $7 billion in federal spending for Medicare and Medicaid.” […] All told, CBO expects that if the bill was fully implemented, some veterans would ultimately seek additional care that would cost the federal government about $54 billion a year, after accounting for savings to other federal programs.”

New “scoring” from the CBO reduced the figure from the original $54 billion to approximately $30 billion, but the negotiations were still stalled. [Hill]

Conferees from the House have been looking to cover the costs by using discretionary funding, those from the Senate are supporting a mandatory funding formula.  The House sponsor, Rep. Jeff Miller (R-FL), argued: “The Senate wants to throw money at a situation that is not defined, in an amount of money that is not defined. We’re re trying to define the issue and figure out how to pay for it,” Miller said.” [MilTimes]

Miller’s assessment may be overlooking the differences in the cost predictability between the provisions for paying private entities for health care services for veterans.

Senate Majority Leader Harry Reid (D-NV) expressed his impatience with the protracted timeline of the conferencing, “We’re having a little trouble getting the House to help us complete the conference,” Reid said.. “You know … just because we want something done when we’re in conference doesn’t mean it gets done.” [The Hill]

In the mean time — proceedings are postponed.

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Tales of Two Gun Carriers

** We had to know, sooner or later, someone was going to test the Stand Your Ground law in Nevada. Unfortunately, it’s sooner. [Nevada Progressive] 73 year old Wayne Burgarello shot and killed two people who were in his vacant Sparks duplex.  Now Burgarello’s hearing has been delayed until June 12th in a Sparks JP Court. [RGJ]  Were the victims trespassing? It seems very likely.  Did Burgarello have other options than shooting the trespassers?  NRS 207.200 specifies what happens in the case the owner of the property gives an oral or written demand that the trespasser leave — the law kicks in — and further notes that the trespass is a misdemeanor.  Did Burgarello have options other than the use of deadly force?  We will hear his version of the story, however if Stand Your Ground equates to Silence the Witnesses then we won’t hear the voices of the two shooting victims.  Burgarello would have been totally within his rights to (a) issue a trespassing warning, and then (b) seek the assistance of the authorities to remove the trespassers.

Without knowing much more than that a neighbor told Burgarello that the victims were squatting in the vacant property, and that Burgarello showed up with three weapons, the impression is left that we may have yet another Angry Old Man shooting — a la Curtis Reeves.   Just as getting popcorn tossed at you in a movie theater doesn’t seem an appropriate time for lethal force, shooting a drug addled squatter when other remedies were at hand doesn’t quite square with ‘defense of property’ either.

** Now that General Eric Shinseki has been tossed to the media wolves for his inability to get the VA to clear up the wait-time morass, it’s high time to clean up the mess — for real — and that the Reno, NV VA facility has the 10th longest wait time isn’t good news. [RGJ]  Little wonder there’s been a waiting list:

“The 18,000 veterans who enrolled between October and March added to the 38,000 to 40,000 veterans the hospital already served, Farr said. The VA hospital in Reno serves Northern Nevada and as far south as Tonopah, Nev., plus nine California counties that border the Silver State.”  [RGJ

A person might have thought that the Congress would do something to alleviate the numbers problem — for example, authorizing the establishment of 27 new VA facilities — but after initial optimism last February the Senate Republicans threw up enough road blocks to stop the legislation from advancing.  Republicans wanted to attach a provision to enhance sanctions on Iran, and worried about “budget” considerations. [Reuters]  The result was that the filibuster continued on S. 1982 on a 56-41 vote. [Roll call 46]

Members of the Senate who voted to sustain the filibuster of S. 1982 were:

Alexander (R-TN) Ayotte (R-NH) Barrasso (R-WY) Blunt (R-MO)
Boozman (R-AR) Burr (R-NC) Chambliss (R-GA) Coats (R-IN)
Coburn (R-OK) Cochran (R-MS) Collins (R-ME) Corker (R-TN)
Cornyn (R-TX) Crapo (R-ID) Cruz (R-TX) Enzi (R-WY) Fischer (R-NE) Flake (R-AZ) Graham (R-SC) Grassley (R-IA) Hatch (R-UT)
Hoeven (R-ND) Inhofe (R-OK) Isakson (R-GA) Johanns (R-NE)
Johnson (R-WI) Kirk (R-IL) Lee (R-UT) McCain (R-AZ) McConnell (R-KY) Paul (R-KY) Portman (R-OH) Risch (R-ID) Roberts (R-KS) Rubio (R-FL) Scott (R-SC) Sessions (R-AL) Shelby (R-AL) Thune (R-SD) Toomey (R-PA) Vitter (R-LA)

See any D’s after those names?  Other than for the inclination of the broadcast media to interview All The Usual Suspects about their “reactions” to the VA debacle, this should be a list of people who have absolutely NO room to talk about the VA services or lack thereof.

Some people have no problem offering succor to those who take the law into their own hands and play Terminator, while dismissing the needs of veterans as “too expensive” when those legitimate gun carriers are asking for assistance; medical, educational, and in terms of employment.  It’s a strange world indeed.

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Filed under Gun Issues, Nevada, Nevada legislature, Nevada politics, Politics

The Veterans and their Administration

Veterans PopulationThe Numbers Game: Issues pertaining to the management of Veterans Administration services have special meaning to 225,933 people in Nevada, 169,255 of whom served this country during war time, and 56,678 who served during peace time.  [VA actuary]  69,190 Nevadans served during the Gulf War era, 79,281 served in Vietnam, 20,462 served in Korea, and we have about 9,444 remaining veterans from World War II. [VA actuary]  Meanwhile, 13 years of operations in Afghanistan and in Iraq are adding to these numbers.

The United States deployed 2,333,972 people to Iraq and Afghanistan between 2001 and 2011, of whom 1,353,627 have since left the forces, and 711,896 used VA health care services between FY 2002 and FY 2011. [ABC] Veterans during the period 2008 to 2011 saw deployment time increased by 28%. [Rand pdf] The Iraq operations, we were told, could last “six days, six weeks, I doubt six years.”

“We don’t talk about deployments in the specific, but we have brought a good many Guard and Reserve on active duty. Fortunately, a great many of them were volunteers. We have been able to have relatively few stop losses. There are some currently, particularly in the Army, but relatively few in the Navy and the Air Force. And it is not knowable if force will be used, but if it is to be used, it is not knowable how long that conflict would last. It could last, you know, six days, six weeks. I doubt six months.” [Rumsfeld, Aviano Air Base February 7. 2003] 

We may not want to talk of deployments, but warfare creates veterans and the longer the warfare lasts the more veterans there will be.

Estimates during the debate over initiating operations in Iraq which projected totals over $3 trillion (Stiglitz) were dismissed out of hand. Instead Lawrence Lindsay, Chair of President Bush’s Council of Economic Advisers estimated the war might cost $200 billion at the most, but during the 2002 campaign season this projection was determined to be “shockingly high,” Lindsay was fired and replaced by Mitch Daniels who argued the Iraq war would cost no more than $50 to $60 billion.  [EconMonitor]

The $60 billion figure is dwarfed by the estimated $135 billion estimated as minimally necessary to provide services to veterans.

Making the situation even more tenuous for veterans, the Sequester budget deal cut  services from other agencies (HUD, Defense, Labor) for veterans while ostensibly leaving the VA untouched — except that “administrative costs” might be cut by 2%, and what constituted an “administrative cost” remained ambiguous. [WaPo]

The Management Game:  The VA Inspector General’s office has expanded its investigation to 26 VA facilities regarding allegations of falsified records and delayed care.  One former administrator in Phoenix, AZ offered his opinion that 40 veteran may have died while waiting for care.  To date no link has been established between the delays and those deaths. [ABC]  The lack of direct linkage notwithstanding, it is certainly possible that care delayed can all to easily become care denied.  Instead of listening to carping, finger pointing, and generally distasteful politicizing of the situation at the Veterans’ Administration, here’s what I’d rather hear from our pontificating pundits and politicians:

Reducing delays and other problems within the VA system, which have long be evident, may well require a significant shift in the way in which services are perceived and administered.

#1. Future Congressional calls for war or large military operations should be accompanied by calculations projecting a reasonable TOTAL cost of the actionsincluding services and benefits for veterans. As there should be an accounting for individuals who falsified records to artificially reduce wait times, there should be an accounting for those whose minimalist estimations for the cost of operations in Iraq and Afghanistan made those actions appear “affordable.”

The failure of the VA to provide timely services is a function of staffing and facilities, infrastructure which should be considered before we launch wars in which we have an option to defer, delay, or avoid action altogether.

#2. Administration of VA services should be predicated on veterans’ needs and not dubious or inappropriate management theories.  The VA is not a commercial or manufacturing entity. Its sole function is to provide customer/client services.  In this wise, the VA perspective ought to be one in which client service is acknowledged to be labor intensive, and hiring should be adjusted accordingly.

For example, while demand for VA care services has increased by 38%, the VA has hired only 9% more medical professionals.  Public-private partnerships with local medical service providers has been applied, and more such partnerships may be one part of a larger strategy to appropriately staff the facilities.   Actions by Senate Republicans who blocked a $24 billion veterans’ health bill in February  2014 which included funding for 27 new medical facilities are unhelpful. [Reuters] [Roll Call 46 – all 41 votes blocking  S. 1982 were cast by Republican Senators]

The treatment of and for veterans should reverse the perspective that all claims are “costs” and “cost containment” is an ultimately desirable institutional goal.  If one is manufacturing widgets for WalMart this might be an acceptable perspective, but we are not talking about a price driven retail commodity — we’re speaking of veterans who have been promised a level of support services (educational, medical, and employment) which have not been delivered on a timely basis.

The much maligned Internal Revenue Service is a far more trusting agency than the VA appears to be.  When I file my return electronically the IRS assumes I am being honest. I may be audited at some point in the future, but for the latest fiscal year the assumption is that I meant what I affirmed at the end of the document — that the return is the most honest and accurate it is within my power to provide.   The VA claims process might be improved by adopting the same attitude.

Unfortunately, the VA is giving the appearance of an institution for which a claim is as much an opportunity for fraud or misuse as it might be a legitimate request for service.  This attitude could quickly spawn a multi-layered bureaucracy  devoted to weeding out any untoward claims. It’s essentially the pre-ACA attitude of health insurance corporations which sought to deny as many claims as possible in order to manipulate its medical loss ratio.  This situation might have been predicted since politicians of every imaginable stripe have loudly proclaimed their affinity for rooting out “Waste, Fraud, and Abuse.”  In the instance of the VA all this cat-calling from the bleacher seats simply serves to reinforce the “cost containment” proclivities and diminish the “service to the client” perspective.

#3 The core of the manipulation problems in the Phoenix office is said to emanate from a bonus system for “meeting the numbers.”  I’ll have to admit to a jaundiced view of bonuses.  Bonuses are what you pay employees when you don’t want to pay them up front what they are really worth. It’s close to an analogy in which the cafe owner justifies sub-minimal wages because the wait staff receives tips.

No one should be particularly surprised when people emphasize on the job what the institution/company/corporation rewards.  If the company rewards speed in delivery, speed we will get — even if a NOAA drone is delivered by FedEx to the wrong address.  If the company/agency rewards fast service, then the service will be fast, and if that can’t be done in the real world then the numbers are fudged to gain the reward and make the boss happy in the bargain.  If the disturbing consequences of the testing furor in education has taught us nothing else, it should have told us that we will get what we measure, not necessarily what we want.

How much less traumatic might the problems with the VA be if we could admit to ourselves that there are immeasurable things which are nonetheless important to the delivery of competent and complete care for veterans and their families?

#4. Technology moves faster than our fingers.  Granted that the inability of computer data systems to share information quickly and accurately is a problem, especially it seems between Department of Defense and VA systems.  At some point we need to acknowledge the hard horrible fact that older stand-alone data systems were never designed to function in a file-sharing world.  No amount of patching or plugging is going to make them compatible.

Until we accept that if we want compatible systems we have to buy them.  They are expensive, they are complicated, and they are unintelligible to most voters — however, the old retail saw holds true — we will get what we are willing to pay for.

Meanwhile there are 225,933 veterans in Nevada who deserve to receive the educational, employment, and medical services they were promised when they signed on to serve us, and who deserve more than a political outrage du jour, and a brief turn in the media limelight.

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