On the VA, Ebola trials and the SHOP exchanges

Talk about sending mixed messages. Robert McDonald, the new head of the Veterans Affairs Department, wants to hire 28,000 new doctors, nurses and other clinical staff to reduce delays in offering care to the nation's growing VA-eligible population.

Rising need among Afghanistan-Iraq veterans for ongoing physical and psychological care at the same time that the aging Vietnam-era vets are reaching their years of high healthcare needs has placed heightened demands on the ill-prepared agency. To attract the new workers, he's touting higher salaries, school loan forgiveness and what he claims is an improved working environment.

At the same time, McDonald, the former CEO of Procter & Gamble, told the media that he is preparing disciplinary actions against as many as 1,000 VA workers for falsifying wait-time records at some facilities. A report he sent last month to the House Veterans' Affairs Committee contained nearly four dozen names, including four senior executives who might be fired. The rest were mostly clinical personnel, such as pharmacy technicians and nurses. They will face disciplinary actions.

There is no shortage of politicians on Capitol Hill demanding that heads must roll for the long waits at the VA. No doubt some deserve firing. But an environment where the agency's top leader is sending members of Congress the names of people up for disciplinary action is unlikely to motivate many idealistic young professionals to join a public service.

Clinical trials testing experimental Ebola drugs are about to get underway in West Africa with European scientists and regulators taking a more enlightened approach compared to their American counterparts.

As I noted in an editorial this past August (“History and the Ebola outbreak,” Aug. 18, p. 24), there is precedent for avoiding the problematic “gold standard” of placebo-controlled clinical trials when testing experimental therapies for a life-threatening disease with no known cure. Comparing outcomes to the death rates that existed before the drug's arrival can provide sufficient statistical evidence as long as the death rates are very high, which they are with Ebola.

Doctors Without Borders announced last week that two trials involving experimental Ebola drugs are about to get underway under British and French auspices. The trials will not include a placebo arm.

A spokesman for the group said that if the survival rate among those receiving the drug reaches 80%—about half of patients stricken in African settings now die—it would be sufficient to know the drug was having a positive impact. Anything less but still above 50% would merit further study.

Meanwhile, U.S. officials are still hoping to enroll patients in placebo-controlled trials. But as one European scientist told the New York Times, “It is an option that will not be accepted by the local community.”

The cliché “don't let the perfect stand in the way of the good” applies. The European-run trials will enroll patients at clinics where supportive care is high. That in itself tends to improve outcomes. If the patients taking the drugs survive in much greater numbers than those receiving comparable supportive care, that should be enough to validate wider use.

The leaders of the next Congress have put eliminating the employer mandate in the healthcare reform law high on their agenda. Some pundits suggest the Obama administration, which has already postponed implementation until Jan. 1, 2016, may find this one area where it can go along.

What gets lost in the politics is that the employer mandate doesn't even apply to firms that employ nearly half of working Americans without health insurance—those with fewer than 50 employees. Those small businesses, which are not subject to the mandate, employ 36.8 million people, 11.4 million whom were uninsured in 2012, according to the Kaiser Family Foundation.

Most of them are not well off, despite holding full-time jobs. About 40% would be eligible for Medicaid under the expansion offered in the reform law. Over 90% would be eligible for tax credits if they went on their own to purchase coverage on the insurance exchanges.

That's why the poor performance of the SHOP exchanges—where small firms can go to purchase coverage for their employees and receive tax credits in the process—is so disappointing. A Government Accountability Office report issued last week suggested the credit may be “too small and administratively complex to motivate many employers to enroll.”

The GAO, which studiously avoids making political statements, couldn't say the obvious. When both political parties are sending a signal that even larger firms needn't worry about the mandate, why should smaller firms bother?

Follow Merrill Goozner on Twitter: @MHgoozner