In his opinion piece, “Health equity for women, minority veterans can be achieved only through choice,” Darin Selnick argues that VA has failed to ensure equitable access to quality care for all veterans, and that the solution to this problem is to “get the VA out of the way” by completely privatizing Veteran healthcare. [SJL1] It seems like a simple and straightforward solution … except that it glosses over basic facts about health equity and the quality of care at VA.
First, health equity advocates have long argued that increased choice in health care providers does not lead to more equitable health outcomes. More than just access to the right doctors or the right procedures, health inequity is a result of a constellation of factors—medical, social and economic — that lead to worse health outcomes for many. Even with expanded healthcare options, structural inequities and social norms dictate the quality of care that patients receive even from the best doctors or the best hospitals.
It must be noted that health disparities are not unique to VA. In fact, the problem is widespread across the entire American healthcare system and negatively impacts underserved communities regardless of where they get their healthcare. Selnick notes for example that women only report receiving equal or better services than men within the VA in 16 out of 22 measures of quality of care. That is unacceptable, and VA will continue to strive for equity across all measures. But women in general are systematically dismissed and misdiagnosed by their providers, leading to poorer health outcomes regardless of where they get their care. The same could be said for all other underserved communities, and we now have a large body of research showing that health inequity is a systemic and persistent fact of healthcare in America.
As an institution founded on the goal of ensuring access to care for those who served in uniform, health equity is at the core of VA’s mission. Institutional mission accomplishment requires us to focus on the needs of our patients and close any gaps to access that we can identify. As such, available data demonstrates that the centrality of health equity in the work that VA does has resulted in reduced disparities compared to other healthcare systems.
Black women who receive their care from VA, for example, do not experience the disparities in all-cause or cause-specific mortality that Black women who receive non-VA care experience, and the gap in mortality rate between Black men and white men is smaller within VA than outside of it. Disparities between ethnic groups on accessing colorectal screening did not exist among those receiving VA care, while the huge gap in access to screenings in non-VA settings is driving the 19 percent disparity in mortality due to colorectal cancer between Black men and white men. Even the study that Selnick references shows no statistically significant difference in access to vaccines, health screenings, mental health services, and doctor visits within VA regardless of gender, race, or ethnicity.
To be sure, these advances should not mask the areas that VA still has to improve. For example, gaps in access persist for those who are poor or live in rural or isolated areas. Native Veterans continue to face disproportionate barriers to quality care, resulting in outcomes such as higher rates of all-cause mortality. The data is also sparse at best when it comes to LGBTQ+ Veterans, and we simply do not have a full picture of what disparities they face. Lastly, while VA patient surveys show that Veterans across the board are highly satisfied with the care they receive, other studies found that satisfaction ratings vary based on specific aspects of interaction between the Veteran and VA.
VA has made significant advances in closing disparities and advancing health equity, but much work still needs to be done. This is why Sec. Denis McDonough called for a system-wide examination of how VA incorporates inclusion and equity in everything that we do and has committed to tracking VA’s progress in meeting that goal.
However, Selnick’s argument for “more choice” as a fix-all is merely a convenient mirage. The truth of the matter is that there is no miracle cure to health inequity and this complex problem requires a deeper and often painful examination of how systemic issues, individual bias, and widespread injustice affect health outcomes. VA is focused on doing that hard work, not illusory quick fixes and easy solutions.
Joseph Albino is a Navy Veteran and he is the Executive Director of the Center for Minority Veterans at the Department of Veterans Affairs. He previously served as the Deputy Assistant Secretary for the Office of Intergovernmental Affairs at VA and as the Executive Director of the President’s Task Force on Puerto Rico.
Lourdes Tiglao is an Air Force Veteran and she is the Executive Director of the Center for Women Veterans at the Department of Veterans Affairs. She previously served as the Global Partnership Manager for Disaster Response & Relief at Airbnb and as the Strategic Partnership Officer for Team Rubicon Global.
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