“to care for him who shall have borne the battle”
President Lincoln — March 4, 1865
Even in our profoundly politically divided country, one issue has gained substantial bipartisan support — improving health care for America’s military veterans. This motivation, coupled with a need to improve the entire American health care system, offers an opportunity to address another pressing issue, finding shelter for homeless veterans. In the process, there might be a way to fix three massive national, organizational, politically-charged problems with one simple, cost-effective solution.
The Trump administration should consider halting most inpatient health care in Veterans Administration medical centers, moving that care to community hospitals, and converting the VA beds to housing for homeless veterans.
Several facts make this proposal medically appropriate and cost-effective.
Considering medical care for veterans, one recalls the crisis uncovered during the Obama administration — excessive wait lists for treatment that reportedly contributed to early mortality. Other evidence suggests that Veterans Administration health care delivery, particularly for inpatients, may also not be as good it can be.
There are 152 Veterans Administration medical centers offering inpatient care; 20,350 inpatient beds handle about 500,000 admissions per year. Putting this number into perspective, VA medical centers constitute 3 percent of America’s total hospitals and 2.6 percent of the nation-wide inpatient beds; yet they result in only 1.4 percent of admissions. That is, VA medical centers do not operate at full capacity.
Also, one study found that over 30 percent of VA admissions contributed to over-utilization due to admission for unclear reasons or prolonged hospitalization. Average length of stay in VA hospitals was 5.2 days in 2012, compared to 4.5 days for community hospitals.
This difference in performance can also be described in financial terms. Although finding comparable data for federal government versus community hospitals is difficult, a study by the American Action Forum found that the VA spends $12,658 annually per patient, compared to $7,025 annually per patient in community hospitals. Even comparing the VA numbers to only the elderly Medicare population, the VA still spends more.
In most studies community hospitals provide at least comparable, and often better, care than that delivered at VA medical centers. A study by Jackson Healthcare of physicians who worked in both VA and community hospitals found half of them thought care in the VA medical centers was not as good as community hospitals.
Community hospitals have other issues with which to contend. Despite the US population rising from 216 million in 1975 to 320 million in 2015, the number of US hospital beds fell from 1.4 million in 1975 to 924,000 in 2015. Also, hospital occupancy rates have decreased over the last several decades, in part due to dramatic changes in length of stay, with many surgical patients, for example, now going home within a few days instead of weeks.
The falling occupancy rates have contributed to the closure of too many hospitals, including 80 since the implementation of Obamacare. Another 600 hospitals are at risk of closure, according to Nonprofit Quarterly.
The obvious conclusion is that community hospitals, despite the drastic decrease in beds, have excess capacity and are even anxious to identify populations to improve occupancy rates.
The final fact that deserves our attention is the estimated number of homeless veterans in the United States: varying from about 40,000, according to the Department of Labor, to about 50,000, according to Wounded Warriors. The homeless situation in the US is a stain on our national character, and even less tolerable for those who have served to protect our country. This plan would help to house about half of them.
Thus, closing most VA inpatient beds, allowing veterans needing inpatient care to utilize community hospitals, and then making those VA rooms available for housing homeless veterans, has solid medical and financial foundations.
Retaining care for direct military-related medical issues, such as, combat wounds or PTSD, in military-focused medical centers may be prudent.
Closure of VA outpatient clinics need not be a part of this change.
Since many Americans now recognize the growing troubles with our health care system in total, this may be the perfect time to consider an option that might provide more cost-effective, and maybe better, inpatient care for veterans, and contribute to stabilizing community hospital budgets, while at the same time helping the underserved, and profoundly deserving, subpopulation of homeless veterans. This proposal would go a long way toward keeping our promises to our veterans.
Dr. Cary W. Akins is a retired cardiac surgeon at Mass. General Hospital and clinical professor of surgery at Harvard Medical School.