COVID-19 brings overhaul of military health care to a halt

Reviewed by James Ives, M.Psych. (Editor)Apr 15 2020

The agencies that oversee the health of U.S. military personnel and veterans were pushing ahead this spring with the biggest overhaul of their health systems in three decades. The initiatives aimed to shift up to 15 million patients to private care providers, shutter clinics and hospitals, and reduce the number of military doctors and nurses.

The Army, Navy and Air Force, along with the Defense Health Agency, had begun shedding patients and providers under reforms set into motion in 2017 under the National Defense Authorization Act. Veterans Affairs was due to send scores of veterans to neighborhood doctors and hospitals instead of VA facilities, also under legislation passed more than a year ago.

Supporters of the change called it good for patients — because they'd gain access to improved care — and for the government — because it would save millions of dollars by eliminating redundant services.

What no one saw coming was the novel coronavirus, which has thrown those plans into a tailspin and exposed gaps in health care for America's service members and veterans.

"COVID-19 has shown the overall weakness of trying to base all of our systems on a goal of maximum efficiency," said Kayla Williams, an Army veteran and director of the military, veterans and society program at the Center for a New American Security think tank in Washington, D.C. "When you are running on total efficiency models, you don't have any capacity to adjust to crises."

As part of the restructuring, the Department of Defense in February released a list of 50 military health facilities that would stop seeing non-active-duty patients or be downsized, reconfigured or closed. The Army, Navy and Air Force medical commands were on schedule to trim their medical billets by nearly 18,000 front-line health care workers.

The reform efforts coincided with a Veterans Health Administration shortage of 49,000 employees, including medical officers and nurses.

But the global pandemic has put those staffing shortages in stark relief — and prompted a halt to the system overhaul. Veterans and military advocates say that, with the focus on fighting COVID-19, now is not the time to pursue major changes.

On March 24, Defense Health Agency officials placed a 60-day hold on reform. The Pentagon plans to reassess the situation every 30 days thereafter, DHA spokesperson Kevin Dwyer said.

"We are shifting our focus to support the nation in this effort and devoting all available resources to combat COVID-19," Dwyer told Kaiser Health News. "We are assessing all available medical facilities, services and personnel that can be used to provide assistance to our nation's health care providers."

The pandemic response is a call to duty for the Pentagon and VA. The Defense Department has a front-line role in treating U.S. forces and dependents, conducting medical research and opening its holdings of gear in the National Strategic Stockpile.

The VA provides backup for the Defense medical system and supports the National Disaster Medical System and Department of Health and Human Services as needed, which means its empty beds can be made available to care for non-veteran patients.

As a result, the departments are set to receive funding from the $2.2 trillion coronavirus disaster relief bill signed by President Donald Trump. The VA is slated to receive nearly $20 billion to cover the treatment of veterans for COVID-19, the cost of overtime for staff as well as personal protective equipment and test kits, and construction of temporary hospitals, clinics and mobile treatment centers.

The Uniformed Services University of the Health Sciences in Bethesda, Maryland, announced it would graduate its fourth-year medical students and advanced-degree nurses early to assist with the national coronavirus response. And the Army sent a message to retired military doctors, nurses and medics to gauge their interest in returning to the service in a volunteer capacity to assist during the pandemic.

The VA has also been cleared to hire retired health care workers to boost medical staff, including doctors, nurses, pharmacists, respiratory therapists and other technicians.

The staffing gaps have been evident at VA medical facilities nationwide. At the New York Harbor Health Care System's Brooklyn campus, intensive care nurse Maria Lobifaro said last week that before the pandemic she would typically care for two patients at a time with ample personal protective equipment, including face shields and N95 masks, to do her job.

Now she is responsible for five patients, all on ventilators and seriously ill from the pneumonia-inducing coronavirus. She is working overtime to make up for vacancies and has been conserving supplies, limited to one face mask a day, which she stores in a paper bag when not in use.

"We can't take on any more patients," said Lobifaro, who told KHN she was speaking as a representative of National Nurses United and not the VA. "Everyone is anxious for the day we may be drowning, when we don't have enough PPE or staffing. It's going to get worse."

As of Monday, 4,097 veterans under VA care had tested positive for COVID-19 and 241 had died.

The Defense Department had 4,528 total cases among troops, families and civilian employees and contractors as of Monday, including 2,941 among active-duty personnel. Two service members have died: Capt. Douglas Linn Hickok, a physician assistant and member of the New Jersey National Guard, who died March 28, and an unidentified sailor assigned to the aircraft carrier USS Theodore Roosevelt, one of the nation’s largest coronavirus hot spots, with nearly 600 cases.

"I think right now, [the Defense Department] needs to put a freeze with regard to all the changes," said Dr. Terry Adirim, a pediatric emergency medicine physician who left her job at the Pentagon as deputy assistant secretary of defense for health services policy and oversight in February. "The drivers to do this made so much sense because there were so many redundancies. But all the additional changes — cuts to the medical force, cuts to the budget, cuts to research and development — they are not the right thing to do. … It's just wrong."

Critics say the reform efforts are a thinly disguised attempt to privatize both systems, gutting services and undermining the departments' obligations to provide care for military personnel, veterans and families.

"There are forces within [the department] that would like to see more privatization," Adirim said. "You see it at the VA probably more openly because they've needed legislation, but there are forces that would like to comb down the [military] health system above and beyond what was approved by Congress."

In 2013, the Pentagon launched a major effort to reform its then-$50 billion health care system with an aim to improve service and streamline programs such as administration, IT, logistics and training that existed in triplicate under the separate Army, Navy and Air Force medical commands.

Three years later, the initiative ballooned, with plans for the oversight office, known as the Defense Health Agency, to assume ownership of 51 hospitals and 424 health clinics operated by the military services. The services were to trim their medical forces and focus on caring for active-duty personnel, while some family members and millions of retirees would be sent to the private sector under the Pentagon's purchased care program, Tricare.

Over at the Department of Veterans Affairs, similar changes have been underway since 2014, when a scandal erupted over secret appointment lists kept by some facilities that hid the length of time veterans waited to see a doctor — for months and sometimes more than a year. The solution was to send more veterans to private providers, reimbursable by the VA. And like the Defense Department initiatives, those efforts expanded exponentially in 2018 with legislation that gave millions more former service members access to care at non-VA facilities.

But with both departments supporting the federal government's response to COVID-19, some reforms have been delayed.

The Pentagon also decided to suspend rollout of its $5.5 billion electronic health record system, called MHS Genesis, which has been in use at six hospitals and clinics in Washington since 2017 and was introduced to four more sites in California and Idaho in September 2019.

Williams, of the Center for a New American Security, said health system changes at both the VA and the Defense Department should be put on hold until after the November presidential election.

"It might make more sense to put a pause on a lot of this government reform," she said, "and revisit what we as a society think would be best with fresh eyes after we’ve learned some lessons from this."