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.