The Veterans Administration is once again in the news for several scandals. My disdain for the VA system is well documented. I devoted an entire chapter to the subject in my book, American HealthScare.
However, I have some sympathy for the administrators of the VA system, so I thought I’d actually defend them here. Here are some of the accusations:
This is probably a similar complaint as one from last year connecting delayed colonoscopies and EGDs to cancer deaths. The expected assumptions that early detection cures all cancers was clearly inserted between the lines of the news stories. The reporters implied that every death could have been prevented, which is nonsense.
So now General Eric Shinseki, the current head of the VA system is being drug in front of Congress to answer questions, and one of his deputies has agreed to resign. The sacrificial lamb has been laid at the Congressional altar. And after all the testimony and groveling has ended, once again the real issues won’t be discussed, at least not in public.
In the waiting time scandal, apparently the electronic appointments were entered into the system by the local VA workers to please the bureaucrats in Washington, but the actual appointments were kept on paper. The electronic version said the waiting time was a few weeks; the real appointments were months later. I’m not sure about the details of the waits in Phoenix.
I don’t have any personal knowledge of the delayed colonoscopies in the southeast U.S. I can say that I know a family physician who could have performed colonoscopies at another VA facility a few years ago, but was not allowed to by the power structure because he was not a GI-ologist. He had years of experience of safely performing colonoscopies. A lack of funding to pay him and the nursing staff to do more colonoscopies might have been a hidden contributing factor.
The common thread of all these issues is a mismatch between expectations and resources. I’ve seen it at multiple safety net facilities at all levels of government.
Let’s start with expectations. What exactly is the VA supposed to provide? When it was created, it was only expected to help vets of WW II who suffered war injuries. What do colonoscopies have to do with that? At two of the VA facilities I have worked at, a significant minority of the patient population was Vietnam vets who had mental illness, including schizophrenia and bipolar disease. The development of these diseases had nothing to do with their military experiences, they simply became apparent at an age when they naturally occur and when young men were drafted into the service. But because they co-occurred, the VA promised them health benefits for life (100% service connection in their lingo).
Should patients and their families expect that the VA provide all medical care to vets in the future, even if the lung cancer that develops in a 60-year-old vet has absolutely nothing to do with the limb injury he suffered on patrol?
The reality is that the VA is a chronically underfunded institution, especially if the expectation is that it provides every health service for every vet.
This reality results in the constant tension between management and the front-line workers (who are next to impossible to fire). The front-line workers – doctors, nurses, clerks, assistants – then constantly game the system just to survive the workday. Good people will steal food if they are starving. VA workers will do shady things to keep their bosses from hassling them, even if the workers know they can’t be fired. No one in the food chain, and especially not the politicians overseeing VA activities, is willing to lead the difficult conversation of making the best use of scarce resources.
The real villains in this tale are the politicians, which mean the real villains are actually American voters. We don’t vote for people who tell us that difficult choices must be made and that for vets to receive a full menu of convenient care, taxes must be raised. Either VA services should be focused on only or mostly war-related injuries (including mental issues such as PTSD), or its healthcare services should be expanded and our taxes raised to pay for it.
It smells like General Shinseki will end up being the dutiful military/public servant and eventually resign, never publically challenging the politicians who put him in a no-win situation. The irony is that the soldier who was taught to fight will not fight the untenable system, and the chronic tension between expectations and reality will go unaddressed, its can kicked down the road, until the next time veterans die and the politicians wide-eyed ask, “How could this happen?”