How to Reform the VA: Trust Veterans
The United States Senate recently passed a bill to reform the Department of Veterans Affairs (VA). The bill, if ratified in its current form, will enable expedited firings and demotions of senior VA agency personnel as well as targeting corruption that contributes to the excessive wait lists. It also authorizes $35 billion over three years hire new doctors and allow veterans to seek outside care.
While this bill is a welcome step in the right direction, it misses key organizational, policy and process reforms that extend beyond simply terminating a few key offenders. As a start, comprehensive reform should emphasize proactive medical processes rather than the current bureaucratic focus that emphasizes success by administrative metrics. These metrics inadvertently make money, in the form of performance bonuses, a behavioral driver that resulted in the manipulation of wait times by VA personnel. By minimizing the focus on monetary gain and careerism, VA administrators can re-focus on making veteran health outcomes the primary objective instead.
The reform bill is also a moot point without a determined leader to take Secretary Shinseki’s place. Unfortunately, the current debate around his replacement largely misses the point by focusing on the latest military, corporate or celebrity leader who might fill the thankless job of VA administrator. What is truly required is a veteran of the private sector who has not only been successful, but comes with a reputation of turning around failing enterprises with entrenched bureaucracies. This person should have the capacity to transform a culture from the ground up and be empowered to make the personnel or policy changes to do so unimpeded.
In fact, this invokes a broader leadership analogy to a similar veterans the Department of Defense faced several years ago with wounded warriors returning from Southwest Asia. Poor treatment conditions at facilities such as Walter Reed created a firestorm of public outrage. Initially, senior Army leaders including the Secretary of the Army and Surgeon General minimized the situation. But a newly-installed Secretary Gates promptly fired them and established an excellent blue ribbon committee to investigate and recommend effective course of action that were subsequently championed personally by the Army’s Vice Chief. In short order, the problems began to be resolved, the Army’s reputation was repaired, and most importantly, the troops and their families began to receive the care they deserved. The parallels with the VA scandal are striking, yet the vital difference is that the VA continues to ignore its core mission by obfuscating with bureaucratic double-speak and protecting its employees at the expense of veterans.
This lack of focus highlights the biggest reform needed at the VA – changing the pervasive culture of mistrust that has resulted in so many of the tragedies detailed in the recent VA Inspector General’s report. Our veterans need to be trusted to exercise more control over their health care decisions and the Senate-approved reform bill partially addresses this issue by providing funding that allows veterans to rely on private and community providers that can increase access to quality care. The follow through on this investment is particularly important in bolstering community mental health capacity that makes mental health services widely available for veterans. In addition, the VA should leverage existing active duty military hospitals and provide healthcare vouchers at the more than 6000 Federally Qualified Health Centers, clinics, and hospitals across the country. By entrusting our veterans with their own health and locally available options, we free them from the tyranny of the centralized VA facility and its associated bureaucracy.
However, it’s not just a lack of trust in veterans alone that led to fatal delays in the timely delivery of vital mental and physical healthcare solutions. It’s a fundamental lack of faith in VA leadership. The status quo reveals a VA leaders’ basic mistrust of medical service providers outside the VA system, driven in part by the American Federation of Government Affairs (AFGE) union at the VA, as well as a pervasive inability to take the word of doctors over administrators regarding patient decisions.
Whether you are a veteran of the Vietnam War or recently returned from Afghanistan, the VA claims process begins with presumptive skepticism. It begins as an adversarial exercise in which veterans are forced to prove that they have earned the care they are trying to access. Perversely, this allows the VA to hid their healthcare capacity deficit of doctors behind a wall of pending claims and appeals. What’s needed is a system based on presumptive approval of claims that neither exists currently, nor is forthcoming in pending legislation.
There are approximately 2,800,000 veterans of the Iraq and Afghanistan wars on top of another 20,000,000 from previous wars. America’s duty as a nation is to trust them with the same confidence that they demonstrated to us in selflessly protecting our national security. This trust extends beyond simply waving our flags at welcome home ceremonies and applauding their presence at football games. It extends, and matters most, in continuing to look after the physical and emotional burden they will always shoulder. In order experience true reform, the VA must trust them, and their medical providers, as well.