Blog No. 39 The Mess at the VA and the Need for Bipartisan Solutions.

You never let a serious crisis go to waste. And what I mean by that it’s an opportunity to do things you think you could not do before.

– Rahm Emanuel

Rahm Emanuel’s observation has never seemed more appropriate than in the current crisis enveloping Veterans Affairs hospitals. That crisis could bring important and long-needed reforms to the medical service provided by the Department of Veterans Affairs.

On Friday May 30, a beleaguered Eric Shinseki finally resigned as Secretary of the Department of Veterans Affairs. His resignation was propelled by the release two days before of a devastating interim report by the Veterans Affairs Inspector General. The report confirmed allegations that a VA hospital in Phoenix had maintained a secret list of veterans seeking appointments. According to the report, an appalling 1,700 veterans at the Phoenix hospital had been excluded from the official list and their treatment delayed. The purpose of the secret list was to avoid showing the full extent of the unacceptable delays experienced by veterans seeking treatment at that facility. Worse yet, the IG report characterized the crisis in Phoenix as a “systemic problem nationwide.” Not surprisingly, the report had quickly generated bipartisan calls for Shinseki’s resignation and referral of the matter to the Justice Department and FBI.

The VA practices disclosed thus far clearly amount to a major scandal and one for which not only Secretary Shinseki but President Obama must accept responsibility. Like Shinseki, the President was presumably unaware of the fraudulent record keeping, but both men may be fairly charged with failures of leadership and management. The indictment of both may be not so much that they created the chaotic management at the VA as that they had failed to improve the management of the Department—as Obama had expressly promised to do in his 2008 campaign.

Equally disturbing, the initial responses of both Obama and Shinseki were surprisingly tepid. President Obama was slow to react, taking several weeks after the initial disclosures to address the situation and even then his response seemed lackluster. Dana Milbank, ordinarily a supporter of the Administration, headlined a May 21 in the The Washington Post “Obama is President Passive over the Veterans Affairs scandal.”

The only action taken by President Obama prior to Shinseki’s resignation was to dispatch his deputy chief of staff, Ron Nabors, to conduct an investigation at the VA Hospital in Phoenix where the allegations of unconscionable delays and their concealment first arose. While the assignment of a senior staffer was doubtless intended to demonstrate the level of the President’s concern, it is not clear that Nabors’s background as an administrator qualified him to conduct the kind of investigation required by the circumstances. The assignment of Nabors also seemed to reflect some lack of confidence in the ongoing investigations by the VA’s Inspector General and Secretary Shinseki. That in turn raised the question as to why the matter has not yet been referred to the Justice Department for investigation. Referral to the Justice Department is a step that, even now Obama seems reluctant to take but which seems increasingly inevitable

A few days later, speaking at a Memorial Day ceremony, the President blandly observed that “As we’ve been reminded in recent days, we must do more to keep faith with our veterans and their families to make sure they get the care and benefits and opportunities that they’ve earned and that they deserve.” One might imagine a similar comment from the owner of the Titanic, “As we’ve been reminded in recent days, ships in the North Atlantic must do more to be on the lookout for icebergs.”

For his part, Secretary Shinseki had made an appearance at a Congressional hearing that was widely regarded as unimpressive. While expressing anger, (“mad as hell”), he appeared impassive and promised no specific action—except to remain in office. The VA subsequently announced the resignation of the Under Secretary of Veterans Affairs, but selection of his replacement gave rise to new concerns. Investors Business Daily reported that the nominee, Jeffrey Murawsky, had oversight responsibility for a number of hospitals including at least one with very serious problems.

Despite the ineptitude of the Administration, the mess at the VA is not something from which Republicans should try to reap political gains. The scandal, however shocking, is merely a symptom of the underlying mess at the VA and as to that, blame must be shared by Congress and by both political parties. Shinseki’s resignation is not a solution but merely one step in arriving at one. As the process moves forward, Republicans must scrupulously avoid giving the impression that they are more interested in scoring political points than developing genuine reforms.

The trickiness of the political waters has already been demonstrated by Senator Richard Burr of North Carolina, ranking Republican on the Senate Veterans Affairs Committee. Burr attacked veterans organizations that had failed to follow his lead in demanding Shinseki’s resignation and received predictably sharp rebukes from several of the organizations. The letter to Burr from the Veterans of Foreign Wars made the point that problems with the VA had long been well known but had gone without a serious attempt by Republicans or Democrats to address them:

The fact of the matter is this; every year the VFW, Disabled American Veterans, AMVETS and Paralyzed Veterans of America have been trying to call attention to the issue, warning Congress of the consequences, and trying to work with Congress and VA on solutions.

Each year our organizations build an analysis of VA benefits and services known as the Independent Budget, and each year since 2005 the Independent Budget has warned Congress about the dangers of long wait times and care rationing due to improper resources, oversight and accountability.

Last year, and again this year, then-VFW Commander-in-Chief John Hamilton and I warned you and both the House and Senate Veterans Affairs committees about the dangers of long wait times. This decade of stern warnings has fallen on deaf ears.

In addition to Burr’s spat with veterans’ organizations, Senate Republicans may be on the defensive for having blocked a large ($21 Billion over ten years) veterans bill in February. In fairness, the bill was centered not on correcting the existing problems in the VA, but on the dubious priority of creating still more programs and benefits. On the other hand, Republicans’ opposition to the bill seemed to be based primarily on fiscal grounds rather than the fact that the focus of the bill may have been misdirected.

A May 29 article in The New York Times suggested that fraudulent record keeping may have been motivated by performance incentives in the form of raises, bonuses and promotions. The article also suggested that underlying delays in providing treatment were a result of too few doctors and nurses, which in turn may have resulted from pay scales below compensation in the private sector. Clearly such factors should be carefully investigated and evaluated by Congress. It does seem inescapable, however, that problems at the VA are broader and deeper than fraudulent record keeping.

Writing in The Wall Street Journal, Dr. Howard Scherz, a physician and faculty member at Emory University Medical School described the situations in which he and other VA doctors had found themselves. In an essay entitled “Doctors’ War Stories From VA Hospitals,” he wrote:

Most doctors have their personal VA stories. In my experience at VA hospitals in San Antonio and San Diego, patients were seen in clinics that were understaffed and overscheduled. Appointments for X-rays and other tests had to be scheduled months in advance, and longer for surgery. Hospital administrators limited operating time, making sure that work stopped by 3 p.m. Consequently, the physician in charge kept a list of patients who needed surgery and rationed the available slots to those with the most urgent problems.

No aspect of VA treatment is more problematic that the care given to veterans suffering from brain damage or mental illness, conditions that leads to suicide at an alarming rate—almost once an hour. Even before the current scandal broke, Nicholas Kristof wrote a column in The New York Times describing in poignant detail the inadequacies of the VA care for such veterans. (“A Loyal Soldier Doesn’t Deserve This”). More recently, a May 25 op-ed, also in the Times, “Thank You For Being Expendable,” recounted the personal experience of one veteran:

Once, nearly homeless and plagued with thoughts of jumping off the Golden Gate Bridge, I showed up at a V.A. hospital and told them I was in bad shape and needed some help. I was holding a coffee cup. The doctor asked me how much coffee I drank in an average day. I told her; she then advised me to cut down to one cup a day. When I asked if she could possibly prescribe any medication to go with that one cup a day, she refused. “We used to prescribe drugs all the time,” she explained. “OxyContin, Percocet, Dolophine, Methadose, Vicodin, Xodol, hydrocodone.” But veterans were getting addicted, she said, even dying, from overprescription so doctors had been told to cut back on prescribing. Go down to one cup of coffee day, she told me again, and see how you feel.

It would be beyond the scope of this blog (and well beyond the competence of RINOcracy.com) to try to prescribe any details of a cure for the ailments of the VA. Nevertheless, two general observations may be made. First, it will be the instinct of many Democrats to try to solve the problem primarily by spending more money. Republicans, however, may respond by pointing out, as Investors Business Daily has already, that “The VA’s own budget numbers indicate a more-than doubling of the agency’s expenditures to $57 billion from $28 billion since 2003. The patient load is up only about one-third over the decade. So the VA has more money than ever per patient, even after adjusting for inflation.” Such a response by Republicans would have some cogency. Nevertheless, it may well prove that more funding is required in order, for example, to attract more doctors and nurses. If so, Republicans should join with Democrats in aggressively seeking sources for the necessary funds. Declining to do so would be a moral failure of the first order.

For their part, Republicans are likely to press for the privatization of VA medical care, in whole or in part. Complete privatization seems unlikely as a political matter and may well be impractical. As one opponent of privatization argued in The Boston Globe:

The VA has singular expertise in the treatment of post-traumatic stress disorder. Many injured soldiers have returned from Iraq and Afghanistan with what is known as poly-trauma — PTSD plus traumatic brain injury and limb amputations. Few primary care physicians — or even specialists — have much experience treating such cases in the private sector. In fact, without the VA, vets would have trouble getting any primary care services given the serious shortage of primary care providers in this country.

On the other hand, a considerable degree of privatization may well be both feasible and desirable. Congressman Jeff Miller, Chairman of the House Veterans Affairs Committee has introduced legislation authorizing veterans to obtain care from the private sector, at government expense, where the VA has not made treatment available within 30 days. An existing program utilizing doctors in private practice in remote areas (Project ARCH, Access Received Closer to Home) has produced good results. In addition, Secretary Shinseki issued a statement on May 24 indicating that, in cases where officials cannot expand capacity at VA centers, the VA is “increasing the care we acquire in the community through non-VA care.”

From the perspective of RINOs, it is hoped that in this urgent situation, both Democrats and Republicans will set aside political jockeying and rigid ideologies and join together to find workable reforms.