Transforming Veterans Affairs: A Plan and a Kick in the Pants

Oct 26, 2015

Based on a speech delivered by Dr. Kahn to Veterans in Politics, International Las Vegas, Nevada 8/27/2015       

The U. S. Department of Veterans Affairs (VA) as a whole system is failing miserably and the culture of the Department and all its facilities is miserably dysfunctional. Yes, there are some wonderful, skillful and dedicated professionals in VA medical centers, outpatient clinics, community-based clinics (“storefront vet centers”) and veterans’ nursing homes. Yes, a few VA health facilities provide high-quality care. Yes, the VA has a history of research into the signature injuries of war – most recently prosthetics for amputated limbs and Traumatic Brain Injury. Yes, a new administration has voiced commitment to solving identified problems. However, the VA is a deeply flawed Department and only a true system-wide transformation of how we provide care and benefits to our veterans will bring meaningful change. This article summarizes the VA problems, recommends a powerful transformational approach, and ends with a “kick in the pants” action to jumpstart change.

A Summary of VA Problems

Here are the facts. Right now, more than 100 VA medical facilities are under criminal investigation for falsifying wait-time records by putting tens of thousands of veterans waiting for medical or mental health appointments on secret lists that no one counted. Although there are rankings of VA health centers, there are no valid and comprehensive studies of the quality of health care at VA facilities and limited studies show wide variability in infections and other patient outcomes. A 2014 survey of veterans found more than 73% did not believe soldiers and veterans are getting the care they need and only 57% of new veterans even register for VA health care. This may have changed over the past year as June 2015 data shows 50% more veterans waiting for care than when the 2014 scandal of excessive wait times became national news.

A recent investigation by the Office of Special Council (such investigations are only begun when a federal employee asks for “whistleblower” protection after witnessing illegal or unethical agency behavior) found evidence supporting employee allegations of unqualified VA medical staff; patterns of patient neglect; and agency retaliation against VA employees who courageously complained about secret wait lists or poor patient care. Fully 40% of the Office’s whistleblower caseload currently relates to retaliation against VA employees.

The VA also has extensive problems with the processes and systems for determining eligibility for veteran benefits. A September 2015 report by the VA Inspector General regarding the VA’s Health Eligibility Center found that of the 867,000 veterans waiting for eligibility determination, Social Security records showed that 307,000 were deceased! The report also determined that 10,000 records were deleted when VA workers incorrectly marked them as completed and nearly 40,000 unprocessed applications were “discovered” in 2013.

Although the eligibility backlog has been significantly reduced, some of the reduction was due to the denial of eligibility which led to more veterans filing appeals and now a growing backlog of about 290,000 veterans waiting – generally a few years -- decisions on their appeals. A recently filed lawsuit would force the VA to act immediately on appeals languishing longer than one year.

The VA cannot get a handle on its own numbers. When a Texas congressman did his own survey in El Paso, he found veterans waiting 77 days for a primary or specialty care appointment and waiting 64 days for a mental health appointment (with 34% saying they could not get access to any mental health provider at all). This, while the VA Secretary said wait times were 3 days for mental health care, 4 days for a primary care provider and 5 days for a specialty care provider.

Mental health needs among veterans are poorly addressed while recent studies suggest counseling and related services will be needed for decades. Post Traumatic Stress Disorder (PTSD) may follow any violent event and has been called a growing epidemic in America with symptoms ranging from numbness of feelings to aggressive behavior and alcohol abuse. An independent review cited VA estimates that PTSD affects 31% of Vietnam veterans, 10% of Gulf war veterans, 20% of Iraqi war veterans, and 11% of veterans who served in Afghanistan. These numbers may be over-inflated as another study found only about 9% of Vietnam veterans currently have PTSD symptoms. No one is helped if we see PTSD in every sleepless night or every raised voice of every veteran.

Most recently a new concept has gained traction: the idea of moral injury – the ethical damage done when we train our sons and daughters to kill others and deploy them to ambiguous combat situations. Moral injury is not the trauma of violent events; it is not PTSD. Moral injury is the social reality we all share when we do not as a nation acknowledge the ethical conflicts of modern warfare. This further confirms the point made above that the mental health needs of soldiers and veterans (and their families) is poorly understood, poorly measured and poorly addressed.

Meanwhile, 22 veterans commit suicide every day.

This summary of VA problems must also address how the VA and by extension the Department of Defense cares for or does not care for 200,000 active-duty women soldiers and especially the 280,000 women veterans who served in Iraq and Afghanistan. The entire design of the VA health care system does not support the specific needs of female veterans. One recent veteran survey found only 37% of female respondents felt positive or very positive about the VA’s care and treatment of women veterans.

The insufficient care includes lack of awareness of medical staff that women are actually serving in combat; lack of medical services for women from cancer screenings through pregnancy and childbirth; and the complete inability to provide counseling and related services for sexual assault in the military which may be experienced by 25% of active-duty women even though only 5% file reports. Women who have left the armed services have reported that going forward with a rape allegation essentially ends a woman’s military career.

The Department of Defense bears some responsibility for the problems surrounding women’s health and mental health needs. A recent news story documented a female veteran’s 2½-year search for a foot that fits after her lower leg was amputated and the VA would only provide a man’s prosthetic leg! In the real world, women have the choice of prosthetic limbs that reflect personal style and even prosthetic hands made on the spot with 3-D printers! The story also highlighted the incomprehensible Pentagon policy that forces female soldiers into men’s boots despite numerous studies showing women soldiers are more likely to experience stress fractures in boots that do not take into account that women’s feet tend to be smaller and narrower than a man’s. As of May 2015, legislation is pending to demand that the Pentagon provide women warriors with combat boots designed for women’s feet.

Even a short history shows that the federal government has failed our veterans going back decades if not longer. World War I veterans marched on Washington in 1932 to demand payment of benefits promised. Blue ribbon commissions in 1947 and again in 1955 discovered waste, fraud and inadequate care throughout the VA hospital system In the 1970s, veterans protested and went on hunger strikes over poor care and especially the government’s refusal to recognize the long-lasting harm done by exposure to Agent Orange. In the 1980s, veterans protested the government’s failure to recognize post-traumatic stress and combat-related depression. In the 1990s, newspapers were reporting VA negligence resulting in veteran deaths. For the last 15 years, reports have been delivered that documented poor care, sloppy standards of cleanliness, incompetent management, backlogs of claims for benefits and then backlogs for appointments and then veterans dying while waiting for appointments. Now we have scandals related to secret lists and manipulated data to hide the VA’s inability to service the needs of our veterans.

A lot of words come to mind when I think about the Department of Veterans Affairs. I will stick with one – shameful. I apologize on behalf of the American public for how we treat our veterans – of all generations – and I apologize for the shameful failures of the Department of Veterans Affairs.

A Transformational Strategic Plan

As I did my research about reforms that will move the VA forward I looked in more detail at the 2014 Policy Agenda of the Iraq and Afghanistan Veterans of America (IAVA). This is a terrific plan. I support and agree with every priority and every recommendation for each priority. In my White House, this will be the foundation document for a transformational plan to create a 21st century VA.

The IAVA plan highlights every important issue by identifying key priorities and provides details that only veterans could identify. The IAVA agenda is organized around priorities and recommendations including:

  • Combat veteran suicide
  • Protect the legacy of honoring soldiers veterans and the fallen
  • Support military families
  • Require best practices for managing VA medical facilities
  • Overhaul training
  • Change performance metrics to focus on quality of care
  • Improve the transition from the Department of Defense to the VA
  • Invest in technology to transform the VA
  • Fully fund the VA
  • Support best-in-class non-profit organizations to fill gaps
  • Defend the New GI Bill (and eliminate exploitation by for-profit schools)
  • Improve Care for Female Veterans
  • End veteran homelessness
  • Employ our veterans and their families

I would turn the IAVA agenda into a transformational strategic plan organized around goals (what has to be done) with strategies (how to move forward) and then specific actions (exactly how to get results). These are my high-level goals to transform the VA and meet the many promises we have made to our veterans:

  • Goal 1: World-Class Health and Mental Health Care
  • Goal 2: World-Class Delivery of Benefits and Supports
  • Goal 3: 21st Century Technology and Data Systems
  • Goal 4: Organizational Excellence
  • Goal 5: Strong Partnerships
  • Goal 6: Performance Metrics Focused on Quality of Care

I would make every IAVA priority an action to be tracked in my administration. I would use the Independent Budget – the financial analysis of the VA created by major veterans organization and submitted to Congress and the White House annually for the past ten years – as the baseline for current and long-term budgets. I would use the insights regarding organizational design, management accountability, and data system requirements from the independent assessment recently delivered to Congress.

As President of the United States, I would add these three additional actions:

  1. Change the Mission Statement: To fulfill President Lincoln's promise “To care for him who shall have borne the battle, and for his widow, and his orphan” is historically significant but out of date. The word “care” seems to mean warehouse veterans and the words “him and his widow” are too restrictive in the 21st century. Changing the mission would send the message that old standards of sloppy care are no longer tolerated, that world-class service to veterans is the new vision, that women are fully integrated into the VA’s mission and that the only measure of success is outcomes for veterans.
  2. Demand Accountability: Accountability starts in the White House. I will have a White House Situation Room capable of tracking results of the VA and all agencies by visually showing progress on our vision for America and how our agencies are solving problems and delivering results. I will hold federal departments and agencies – and all federal executives – accountable for results. I will be honest about what works and progress made. There are VA problems that have been reported by the Government Accountability Office (GAO) for decades including confused procedures (from cleanliness of equipment to diagnosing depression); poorly trained and under-qualified medical staff; inadequate oversight of contractors or in house health services; out of date scheduling technology; medical systems disconnected from the Department of Defense; and unclear resource needs and allocation priorities.  My White House understands how change occurs in organizations. My White House knows how to read audit reports and demand greater adherence by the VA and all agencies to GAO recommendations. I will do this and make regular progress reports to the public and especially the veteran community.
  3. Use $17 Billion Saved from Cutting Waste to Fund Veteran Needs: My 7-Track Plan to Transform America begins with Track 1: Cut One Trillion Dollars of Waste Out of Our Agencies and Re-direct those Resources to National Priorities. The Pentagon is the only federal department that cannot pass a financial audit. My White House – while requiring the strongest and best equipped military on the planet – will demand financial discipline in Defense.  The Pentagon has some responsibility for the mess at VA. I will use the $17 billion dollars the Pentagon wasted on ammunition that was out of date or banned by international treaty to pay for integrating Defense and VA data systems; neighborhood-based veteran services; and my “kick in the pants.”

The Kick in the Pants

The transformational strategic plan is in the works and funding can be found by cutting waste across government. I know about complex organizational change and know how long different elements take – from months to years to decades. The best plan in the world will not transform the VA overnight or even within a few years; there is too much incompetence and too much negligence throughout the culture of the Department. So I ask myself:  “What one solution will have a quantum effect; what single action can affect the field of energy that comprises the VA and the interface with the Department of Defense?”

The Veterans Choice Program allows veterans to get health services from non-VA doctors under certain conditions such as now available appointment within 30 days or the veteran lives more than 40 miles from a VA facility. I say use the money gained from cutting waste to fully and permanently fund the Veterans Choice Program and eliminate restrictions, simplify the process, expand services, give the Choice card out to every soldier as they leave the armed services and let our veterans vote with their feet! Choice means choice. When it is clear that some facilities have dwindling numbers of willing patients then we consider elimination, consolidation or privatization.

That’s my plan to transform the VA – a key element of how we will create one America that works for everyone with no one left out. In my White House, transforming the VA into a 21st century world-class service provider will be a national priority.

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