Déjà vu: Another scandal, another scapegoat?
As I write this, calls for Eric Shinseki’s resignation are everywhere. President Obama has spoken about the VA without mentioning him. I suspect we are within a week or two of his resigning and with that the administration and our elected representatives will tell us they have "done something" and the problems are being fixed. But the truth is: “We know better!” Eric Shinseki is not the problem, he’s just the guy left standing when the music stopped and his resignation neither fixes nor changes anything. We should be mad as hell if this scenario plays out.
I recall growing up in 1950s Ellsworth. After playing outside all morning we’d head back inside, often finding Mom on the phone with our grandmother or one of her friends. I recall some of those conversations and none more vividly than the anger at the treatment World War II and Korean veterans were receiving (or not receiving) at the VA. My mom’s uncle worked at a veteran’s hospital in New York and was doubtless the source of some of what she knew. Togus, the nation’s oldest VA facility, was practically an obscenity in conversations about WWII veterans who had been her classmates in Ellsworth.
In recent weeks legions of politicians have expressed anger, shock and dismay at "learning" that Gulf and Vietnam war veterans were not receiving timely care at VA hospitals. While it’s possible they were surprised to learn that administrators had resorted to keeping secret waiting lists to mask the real wait times, it requires "suspending incredulity" to believe politicians were unaware of longstanding problems at the VA.
The Veterans Administration was created in 1930 to “consolidate and coordinate government activities affecting war veterans." Prior to that, a patchwork of state and federal hospitals and programs, themselves plagued by scandals, provided care for veterans going back to 1834 when the first federal facility was opened. At the close of WWII, the VA was hit with a five-fold increase in veterans and the centralized bureaucracy was overwhelmed. Delays in approval and treatment became commonplace. Attempts were made by multiple administrations to improve the performance of the VA even as additional benefits were added to the mix. It’s unclear whether any of these managed to improve cost, quality, or wait times without impacting one or both of the others.
Veterans today are "categorized" into one of eight priority groups, with subgroups. Eligibility is based on multiple factors including income, assets, and degree of disability. Once the veteran had to provide the proof of eligibility and that became its own scandal in the post-Vietnam era, particularly regarding Agent Orange exposure. In a well-intentioned effort to correct that injustice, the VA was charged with yet another responsibility of providing veterans specific help to complete their paperwork, including necessary medical evaluations. All of that, along with the grossly under-estimated influx of new veterans coming from the Middle East campaigns, many with serious disabilities, even further stressed the VA resources. Long delays were accepted as "normal." We should also keep in mind that an eligibility determination affects more than treatment at a VA Hospital. Those same conditions determine eligibility for pensions and disability payments, medical devices, home and vehicle modifications, and the rest of the VA entitlement packages.
The Executive Service bonus program incentivizes meeting assigned performance objectives, one of which was reduced wait times at the VA. But, in reality these senior VA executives have at best limited ability to control wait times. For instance, major structural or systemic changes would require Congressional approval. One tool they do have is performance evaluation but it’s uncommonly difficult to sustain an "unsatisfactory" performance appraisal and the people who prepare most evaluations are not eligible for the large bonuses. They have little incentive to expose themselves the administrative and possible legal repercussions of such an appraisal. Even when they are, it takes several consecutive periods of unsatisfactory performance and unsatisfactory efforts to improve performance before dismissal proceedings can begin.
I worked in bureaucracies alongside and for military officers for almost 50 years. I am certain that nobody makes the rank of General (O-10) without being able to diagnose the kinds of problems in the VA. I’m equally certain that the problems in the VA are beyond fixing. The organization is too large with too many competing and conflicting objectives. For example, without central control, benefits will be allocated differently for veterans with (arguably) the same eligibility factors in different states. However, central control means the delays will continue. Furthermore, there is no incentive to streamline anything because doing so leads to smaller organizations with fewer workers and therefore fewer executives. Add to that, well-meaning reformers continuing to "tinker" with veterans benefits, creating new entitlements with irresponsibly optimistic cost impact assessments and seriously underfunded budgets and the result is ever increasing workload and management issues. The needed changes must come from (far) above, not from within, the VA.
Surely the vast majority agree veterans deserve the best and timeliest care we can deliver. Surely also, we recognize that in an election year politicians will be inclined to take no risks and seek superficial "solutions" that push the issue forward. We as voters must use our common sense and steadfastly insist that Congress and the President identify the real problems and implement real ‘fixes’. Fundamental systemic and structural changes are needed in the VA. The question is: “Are we ready to face that?” Consider carefully because we all know that what’s true of the VA is equally true regarding Social Security retirement and disability, Medicare, Medicaid, welfare, the IRS, and the Affordable Care Act.