The Moral Contract

When Marine Corps and Iraq war veteran Seth Moulton went to the Washington, D.C., VA Medical Center for hernia treatment last winter, hospital staff told him they had no record he was a veteran. After the Boston VA agreed to send verification that Moulton was eligible for care, a broken fax machine created another problem.

Before it was all over, Moulton – a Democratic congressman from Massachusetts – was sent home from surgery without the painkillers his doctors prescribed. If this is the sort of care a congressman receives, Moulton told National Public Radio, imagine what it’s like for other veterans who seek treatment from VA.

Moulton’s experience is one among thousands that illustrates VA’s ongoing struggle to make the transition into the 21st century and provide care for a new generation of war veterans. When the United States went to war in Afghanistan and Iraq, VA was still mired in a 1940s approach to claims processing, infrastructure and computer technology. No one prepared VA for the dramatic increase in demand for services the wars would generate, and the agency continued to predict a decrease in veteran numbers long after the wars had bogged down. VA stuck with plans to close some hospitals and reduce services at others, as if world peace was imminent and the aging Vietnam War generation would not continue to need more and more care.

Things got worse. VA was also unprepared for a dramatic increase in survival rates and more complex injuries. It also didn’t plan for expensive new treatments for perplexing illnesses such as hepatitis C, which affects Vietnam War veterans at a much higher rate than the general population. The agency was late to respond to the record number of female veterans who came home looking for VA health care relevant to their needs. Signature conditions of the wars included traumatic brain injury, post-traumatic stress disorder, military sexual trauma and debilitating back, knee and hip injuries, all of which have been treated with heavy emphasis on pharmaceuticals for pain, depression and anxiety. Add multiple deployments for most servicemembers, with little recovery time between stints, and it’s easy to see why half the all-volunteer force is eligible for permanent disability benefits and VA continues to struggle to get in front of demand.

The scandal that erupted in the spring of 2014 drew national public attention to the long-brewing catastrophe of VA’s inability to provide timely access to quality care for all the veterans the department is responsible to serve. More than a year after the falsification of appointment records and other actions to cover up VA’s access problems, the pressing question today is this: how can a bureaucracy of its magnitude, with more than 310,000 employees, transform itself into a health-care system veterans can trust? 

FIRST RESPONDERS The initial response to what was headlined “the Phoenix VA scandal” was promising. VA Undersecretary for Health Robert Petzel, a defiant denier of the department’s shortcomings, was forced out in the weeks after the story broke. That was followed by the departure of VA Secretary Eric Shinseki, who distinguished himself from his VA peers by accepting responsibility for the crisis and acknowledging that he was too trusting of senior managers.

Acting VA Secretary Sloan Gibson and, later, new VA Secretary Robert McDonald, quickly dug in. They eliminated fiscal 2014 performance bonuses for VA health-care executives. Disciplinary action was proposed against 130 VA employees implicated in falsifying patient wait times and keeping secret patient waiting lists at more than 100 VA medical centers nationwide.

VA hired nearly 1,100 new physicians and 2,730 nurses after April 2014, as well as about 4,700 other staff members in what the department regarded as  “critical occupations.”  It leased new clinic space and has handled 2.7 million more patient appointments than in the previous year. 

McDonald dropped VA’s legal challenge to a federal court order that the department stop leasing pieces of its West Los Angeles campus to commercial businesses and instead use the property to care for veterans, as the deed transferring the land to the federal government in 1888 dictated. He also acknowledged that VA has to address the massive homeless-veteran problem in Los Angeles if it is serious about ending veteran homelessness overall. 

Congress dug in as well, with emergency appropriations to address the patient backlog and funds for a new program that allows veterans to get care outside VA when appointment delays and distance to VA facilities are too great. It passed legislation making it easier to fire poor-performing senior VA executives.

The American Legion, meanwhile, conducted town hall meetings, crisis command centers and benefits assistance events across the country, inviting local VA officials to hear veterans’ grievances and get them connected to care. Thousands of veterans had their claims fast-tracked as a result of the Legion’s outreach. More than $1 million in retroactive benefits was awarded.

Yet, more than a year after the Phoenix scandal broke, many of VA’s problems persist, and some have worsened. Fifty percent more veterans are waiting a month or longer for their medical appointments this year than they were in the spring of 2014, according to The New York Times. The number of medically complex patients each VA health-care provider is required to see is staggering, and there is danger that the workload will lead to provider burnout and life-threatening mistakes, warns Katherine Mitchell, one of the Phoenix VA physicians who sounded the alarm about poor patient care there in 2014.

VA efforts to refer more patients to specialists outside its health-care system are hamstrung because of the department’s  reputation for “low pay and slow pay,” Mitchell says, adding that “too many specialists have been burned by VA.” Nationally, that reputation has stymied VA’s efforts to find enough hepatitis C and mental health specialists even as up to a third of the post-9/11 generation of combat veterans come home with a PTSD diagnosis. 

The Denver VA hospital construction project is $1 billion over budget and its completion date remains uncertain. And while the chief of VA’s building program was allowed to retire with his full pension, one cost-cutting solution offered was to drop plans for a new PTSD clinic. 

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs, has been critical and vocal about VA’s failure to fire a single employee in connection with last year’s waiting list scandal. “Rather than disciplining bad employees, VA often just transfers them to other VA facilities or puts them on paid leave for months on end, ensuring taxpayer money is wasted,” Miller said during the heat of the controversy.

By May 2015, new allegations surfaced that VA employees use government-issued credit cards to make billions of dollars in unnecessary purchases every year. By mid-summer, VA announced to Congress that it would be short of the funds it needed to finish the fiscal year. VA launched a transparency initiative in June 2014 that included posting patient waiting times on its website. Within months, whistleblowers alleged that VA health-care brass in Los Angeles were fudging those numbers as well. Meanwhile, the agency has never satisfactorily explained why one of its Phoenix administrators used taxpayer money to purchase the book “How to Lie With Statistics” for his staff. 

As Mitchell puts it, “VA doesn’t tend to learn from its past mistakes. They seem to condone them by not correcting them – and the mistakes repeat themselves.”

But there isn’t just a “government fix,” says Linda Bilmes, Harvard economist and VA expert. “We shouldn’t expect a big government bureaucracy to solve the fundamental problem, which is our lack of true national commitment to veterans, not just in terms of money but in terms of caring what happened in Iraq and Afghanistan. This problem stems from the lack of shared sacrifice that was caused by a war in which only a tiny fraction of the population was directly involved in the fighting, and the rest of the population was not even asked to pay for it – we simply borrowed the money and added trillions of dollars to the national debt.”

A NATIONAL STRATEGY The VA budget has nearly tripled in the past decade while DoD has quadrupled its medical budget in that same time frame, Bilmes says.

However, more resources will be needed as the nation’s obligation to care for veterans continues to grow. Demand for World War I veterans’ care didn’t peak until 1969, and it was 1986 before it topped out for World War II veterans, Bilmes says. Care for Korean War and Vietnam War veterans hasn’t reached its anticipated  highest levels yet.  

In the face of these challenges and the surge in post-9/11 veterans seeking care, VA clings to an outdated disability claims evaluation system. Veterans must have separate specialist verification of every medical issue they are claiming. And they have to return for another evaluation every time each condition gets worse – as most chronic health issues invariably do, Bilmes says. This alone has overwhelmed both the health-care branch and benefits area of the department. 

She adds that instead of burying VA physicians in piecemeal disability evaluations, servicemembers should receive a comprehensive medical exam upon leaving the military that is identical to their enlistment physical – and automatically receive approval for obvious service-connected problems. Follow-up audits on a certain percentage of claims would serve as a check on fraud.

Mitchell, who is now the specialty medical care coordinator and a VA quality scholar with the agency’s regional office in Gilbert, Ariz., advocates three key changes: 

• Discipline VA officials who retaliate against whistleblowers. “Until someone draws a line in the sand ... there will continue to be patient problems and VA will continue to lose personnel.” 
• Reduce the number of complex patients assigned to each VA physician, and immediately provide standardized triage training for emergency room nurses and mental health nurses so they are better equipped to deal with high patient demand.
• Develop and execute a comprehensive approach to caring for today’s veterans. 

As Bilmes put it in a Veterans Day guest editorial for WBUR in Boston in 2014, “The United States has no serious strategy for tackling the full range of challenges that veterans and their families are facing. Rather than simply hoping things work out and then throwing money at problems after they surface, we need to think through, in detail, how to support America’s veterans, including financing these endeavors on a sustainable basis.” 

It’s not simply that injuries are more complicated or that battlefield medicine dramatically improved survival rates in the post-9/11 era. It’s more than our obligation to meet the needs of female veterans. It’s the entire contract America has made in return for the sacrifices of an all-volunteer force that has been poorly fulfilled if not breached, Bilmes argues. 

“Part of that contract with those who serve today is that if you have this set of injuries, these are the compensatory benefits you will be entitled to. We, the taxpayers, agreed to this bargain.”  

Ken Olsen is a frequent contributor to The American Legion Magazine.