Top 10 Conclusions About the VA Crisis

Vietnam War veteran Bernie Klemanek of Louisa County, Virginia salutes with fellow veterans during a Veterans Day event at the Vietnam Veterans Memorial on the National Mall November 11, 2013 in Washington, DC.
National Journal
Norm Ornstein
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Norm Ornstein
June 4, 2014, 4:09 p.m.

What are we to make of the VA?

Over the past few weeks, I have read a lot about the scan­dal and the over­all story sur­round­ing the agency (it is ac­tu­ally the Vet­er­ans Af­fairs De­part­ment and the Vet­er­ans Health Ad­min­is­tra­tion, but we will call both the VA for short). I have tried to make sense of what is real, and what les­sons we can learn. Here are my con­clu­sions.

1. There clearly is a scan­dal here, not a faux one like the IRS or Benghazi. There were at least some malevol­ent act­ors, who cre­ated an elab­or­ate sys­tem to cov­er up the delays in schedul­ing doc­tor vis­its for vet­er­ans, in Phoenix and oth­er places. And these act­ors were en­abled by lots of oth­er VA em­ploy­ees, who either suc­cumbed to in­tim­id­a­tion or wanted to avoid in­tern­al hassles. Some of the miscre­ants be­nefited fin­an­cially from their wrong­do­ing; wheth­er the reas­on for the cov­er-up was fin­an­cial gain or avoid­ance of em­bar­rass­ment, de­mo­tion, or sanc­tion does not really mat­ter.

2. The root of the prob­lem — i.e., the long delays between ap­point­ments re­ques­ted and doc­tor or nurse vis­its re­ceived — was not in the cov­er-up plan. It was in the stark mis­match between de­mand and sup­ply, between the surge in vet­er­ans seek­ing med­ic­al care through the VA and the sup­ply of doc­tors and nurses to care for them. The surge dur­ing the Obama ad­min­is­tra­tion oc­curred for sev­er­al reas­ons. One was the highly com­mend­able ef­fort by the ad­min­is­tra­tion to open up care to more vet­er­ans; the second was the sharp in­crease in de­mand from re­turn­ing vet­er­ans from Ir­aq and Afgh­anistan. Plus, there are these re­lent­less demo­graph­ic real­it­ies: The re­main­ing vet­er­ans from World War II and Korea re­quired more care as they got older, and there has been an in­crease in the num­ber of middle-aged and older vet­er­ans from the Vi­et­nam era.

3. The short­age of doc­tors and oth­er med­ic­al pro­fes­sion­als is not just a prob­lem at the VA, but is so­ci­ety-wide. We face a phys­i­cian short­age that will grow more acute as the Af­ford­able Care Act achieves its goals of more Amer­ic­ans covered and more of them seek­ing care. Lots of oth­er things are con­trib­ut­ing to the doc­tor short­age, in­clud­ing soar­ing costs of med­ic­al edu­ca­tion and lower com­pens­a­tion for phys­i­cians, along with im­mig­ra­tion is­sues that are re­du­cing the sup­ply over time of for­eign-born med­ic­al pro­fes­sion­als. Wait times in the private sec­tor are noth­ing to write home about. But the prob­lem is worse for the VA, which can­not eas­ily com­pete with the private sec­tor for doc­tors in terms of either pay or be­ne­fits. And, of course, the prob­lem has fed on it­self in two ways. One is that few­er doc­tors and more pa­tients lead to more work­load and more pres­sure on doc­tors, in­du­cing many to quit. A second is that the way the VA has been ad­min­istered — in­clud­ing via a man­age­ment cul­ture that pre­cip­it­ated the dis­hon­esty and scan­dal — has ad­ded to the frus­tra­tion of doc­tors in­side the sys­tem.

4. As many in­side and out­side the sys­tem point out, care at the VA — as op­posed to get­ting ap­point­ments to get care — is out­stand­ing and highly re­garded by vet­er­ans who re­ceive it. By many stand­ards, it is bet­ter than that provided in most places in the private sec­tor. A main reas­on for this, which I have seen first-hand in the VA care provided to my fath­er-in-law, a World War II vet­er­an, is that the care is hol­ist­ic. In the private sec­tor, one can see a car­di­olo­gist, a uro­lo­gist, an in­tern­ist, a gast­roen­ter­o­lo­gist, etc., with each pre­scrib­ing med­ic­a­tions and dia­gnos­ing prob­lems with little or no con­tact or co­ordin­a­tion among them, with no one to see the forest for the trees or to mon­it­or drug in­ter­ac­tions. At the VA, doc­tors com­mu­nic­ate and in­ter­act much more.

5. While the VA has seen a sig­ni­fic­ant in­crease in its fund­ing over the past sev­er­al years, it is still very much un­der­fun­ded — and much of the money go­ing to the VA is mis­al­loc­ated, mak­ing the prob­lems worse. As Peter Schuck has poin­ted out, the root of this prob­lem is more with Con­gress than any­one else. Con­gress has jumped whenev­er vet­er­ans’ groups say so, and that has in­cluded de­fin­ing dis­ab­il­it­ies that can re­ceive com­pens­a­tion far more broadly and gen­er­ously than is af­ford­able. This has left the agency swamped with claims. When people in­side the VA poin­ted out that we now have 150,000 vet­er­ans re­ceiv­ing bundles of money for sleep apnea — not ex­actly a ser­vice-re­lated dis­ab­il­ity — Con­gress shrugged. That is money that could be spent deal­ing with real and deep prob­lems. When Con­gress tried to cre­ate new med­ic­al cen­ters to re­spond to the de­mand, Re­pub­lic­ans in Con­gress re­fused to fund them. Con­gress has cre­ated the rules that make it vir­tu­ally im­possible to fire or dis­cip­line em­ploy­ees — not just a VA prob­lem, of course — and has failed to do the kind of vig­or­ous over­sight that would have un­covered these prob­lems much earli­er, and res­ul­ted in con­gres­sion­al ac­tions.

6. The en­dem­ic and sys­tem­ic prob­lems in the VA go back dec­ades. Pres­id­ents from George H.W. Bush on have struggled to bring func­tion­al­ity to the VA, both when it was an agency and after it be­came a Cab­in­et de­part­ment. Some pres­id­ents, not­ably Bill Clin­ton, did bet­ter than oth­ers, but none suc­ceeded in cre­at­ing an agency that worked smoothly and well. Of course, the fail­ure to co­ordin­ate between the De­fense De­part­ment and the VA over care for cur­rent and former mil­it­ary per­son­nel, along with the sharp in­crease in vet­er­ans re­quir­ing com­plex care for phys­ic­al and men­tal in­jur­ies and trau­mas, has not helped. But neither has the re­l­at­ive in­dif­fer­ence of ad­min­is­tra­tions, in­clud­ing Obama’s, or the fail­ure, gov­ern­ment-wide, to mod­ern­ize in­form­a­tion tech­no­logy, which it­self is at the root of many of the VA’s health and dis­ab­il­ity sys­tem prob­lems.

7. The prob­lems are there in sig­ni­fic­ant part be­cause of the size and com­plex­ity of the agency and the prob­lems it is sup­posed to ameli­or­ate. As Phil­lip Carter poin­ted out in Slate, “The VA is the second-largest Cab­in­et agency, and the na­tion’s largest health care and be­ne­fits pro­vider, with an over­all fisc­al 2015 budget of $165 bil­lion (great­er than the State De­part­ment, USAID, and en­tire in­tel­li­gence com­munity com­bined), in­clud­ing $60 bil­lion for health care. The VA em­ploys more than 320,000 per­son­nel to run 151 ma­jor med­ic­al cen­ters, 820 out­pa­tient clin­ics, 300 store­front ‘Vet Cen­ters,’ more than 50 re­gion­al be­ne­fits of­fices, and scores of oth­er fa­cil­it­ies. This massive sys­tem provides health care to roughly 9 mil­lion en­rolled vet­er­ans, in­clud­ing 6 mil­lion who seek care on a reg­u­lar basis.”

8. Gen­er­al Eric Shin­seki was neither the cause nor the per­pet­rat­or of this. He had flaws. He was too pass­ive in his pub­lic per­form­ance, did not show enough in­dig­na­tion when he be­came aware of the prob­lems, or push Con­gress strongly enough for the re­sources he needed. He was too trust­ing of his sub­or­din­ates (al­though it is now clear he did not sit in his ivory tower, but traveled reg­u­larly to VA sites, in­ter­view­ing em­ploy­ees and im­plor­ing them to be hon­est with him). His prob­lem, as a mil­it­ary man, was the same as the one Dwight Eis­en­hower faced when he moved from gen­er­al to pres­id­ent; as Harry Tru­man poin­ted out: “Poor Ike, he is used to say­ing, ‘Do this, do that,’ and ac­tu­ally hav­ing it hap­pen.” Shin­seki also had many strengths, and he did some re­mark­able and pos­it­ive things for home­less vet­er­ans and many oth­ers. Giv­en the nature of mod­ern polit­ics and me­dia, where politi­cians and pun­dits call for heads to roll and journ­al­ists cov­er the blood­s­port far more than the real prob­lems, it was in­ev­it­able that he would resign. But it was not very fair and does not solve much of any­thing.

9. There is an im­me­di­ate prob­lem re­quir­ing triage, and a longer-term set of is­sues to deal with. Privat­iz­ing the VA, giv­en its high qual­ity of care and fo­cus on the unique prob­lems of vet­er­ans, may sound good, but it is fool­ish. The VA does need more money, and more flex­ib­il­ity from Con­gress to al­loc­ate it to fix the prob­lems. But it makes im­me­di­ate sense to give vet­er­ans who can­not get ap­point­ments for care or con­sulta­tion on a timely basis tem­por­ary Medi­care cards to find pro­viders now un­til the wait times can ac­tu­ally be re­duced. More broadly, we must take a truly ser­i­ous look at civil-ser­vice rules and a con­cer­ted ef­fort, per­haps led by top tech pro­fes­sion­als out­side gov­ern­ment, to find ap­pro­pri­ate ways to cre­ate 21st cen­tury in­form­a­tion sys­tems. And we need a bet­ter way to at­tract and keep med­ic­al pro­fes­sion­als, and tech­nic­al ex­perts, in gov­ern­ment. Mul­ti­year pay freezes and blanket deni­al of bo­nuses is not the an­swer.

10. It is far more im­port­ant to get a good ex­ec­ut­ive, a top ad­min­is­trat­or, to head the VA then it is to get a dec­or­ated vet­er­an. The VA needs someone who knows something about health de­liv­ery but even more about how bur­eau­cra­cies work and how to work with, or nav­ig­ate around, Con­gress. The VA needs someone who knows that es­tab­lish­ing met­rics for per­form­ance re­quires more than rub­ber-stamp­ing the com­pli­ance forms that come in. My top choice: Donna Shalala, pres­id­ent of the Uni­versity of Miami, co­chair with Bob Dole of the Bush com­mis­sion to deal with the Wal­ter Reed scan­dal, former HHS sec­ret­ary, and one of the world’s ex­perts on pub­lic ad­min­is­tra­tion. Donna is not a mil­it­ary vet­er­an — but, more im­port­antly now, she is a seasoned vet­er­an of bur­eau­crat­ic and policy wars.

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