How Not to Run a Department: Obama, Shinseki, and the VA Hospital Scandal

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Gil C /

My father, a World War II U.S. Navy veteran, died in a VA hospital in Providence, Rhode Island 25 years ago. A proud guy who never wanted to be a burden to his two sons, he discovered he had an advanced case of colon cancer. Despite a big operation removing a chunk of his large intestine, the cancer spread, and after a while, my father decided to refuse further life-saving treatment.

It would never have crossed my mind that he might not have been able to be treated at the VA hospital in time to stop his colon cancer while it was still possible to save his life. It would never have occurred to me that that VA administrators might have fudged and manipulated a waiting list to camouflage inappropriate wait times and scheduling.

In the wake of the revelations about doctored patient charts, duplicate sets of books on patients, and concealed and fraudulent waiting lists at the VA facility in Phoenix, which may have contributed to the deaths of as many as 40 veterans waiting for treatment, the Center for Investigative Reporting has revealed the VA medical center in Providence where my father spent his last days has made payments in at least three wrongful death cases concerning post-9/11 patients due to “delays in treatment, failure to diagnose, delays in referral, improper supervision and failure to monitor.”

Twenty-six VA hospitals are under investigation by the Inspector General of the Department of Veterans Affairs to find out if they engaged in fraudulent manipulation of waiting lists and appointments for veterans expecting treatment at VA medical facilities. Having previously said (through press secretary Jay Carney) that he learned of the burgeoning VA scandal from CNN (which broke the story), President Obama called Veterans Affairs Secretary Eric Shinseki, a retired four-star general, to the White House yesterday and then held a carefully controlled, two-question press conference—without Shinseki—to express his outrage. The president called the alleged duplicate waiting lists and other VA hospital practices “dishonorable” and “disgraceful.”

President Obama’s press conference, the first time he has personally addressed the VA scandal in a public setting, was a sad muddle and may have been the president’s most perplexing and disappointing performance ever. He called for the preliminary results of General Shinseki’s review by next week to determine whether the allegations of fraudulent record-keeping were true. “I will not stand for it,” the president said, but the truth is that this stuff has been well known and well documented for a very long time. The decision-making process and the president’s explanations constitute a case study of what most nonprofits know shouldn’t be done, and contain partial examples of how nonprofits sometimes delude themselves as well.

Finding the Truth

“We have to let the investigators do their job and get to the bottom of what happened,” the president said. Can you hear the echo of Jack Nicholson’s Colonel Nathan Jessup barking, “You can’t handle the truth?” The president’s call for speeded-up investigation may not get us any closer to the truth. There are two big reasons why.

The first is that the practices behind the scandal are already well known and have been for many years—throughout the entire Obama presidency, and even before, when Senator Obama was a member of the Senate committee in charge of overseeing the VA. If word about altering paperwork to obscure inappropriate and potentially harmful delays in VA hospital appointments and treatment for veterans hadn’t seeped into the Secretary’s office and the White House over the years, it was certainly well documented by the General Accountability Office last year. A follow up study by the Institute of Health confirmed the GAO report, concluding that excessive wait times for military veterans had led to more frequent incidences of preventable hospitalizations and deaths.

These practices need to be fixed now, including restructuring VA management and oversight as appropriate. Perhaps the purpose of this new phase of investigation is to go after potential criminal indictments. But if that were so, a better mechanism would be to send in the FBI, not an acting VA Inspector General. The president’s speeded-up investigation won’t add much that isn’t already known, and it won’t be sufficient for the White House to make changes in VA management and procedures to correct the problems behind the hospital scandal.  

After watching the president’s press conference after his meeting with Shinseki, the CNN reporter who broke the story about the Phoenix VA facility, Drew Griffin, politely said he was “caught off guard” by the President’s message:

“I hate to be curt, but these GAO reports, these Office of Inspector General reports, these memos dating back to 2010 and 2008—this problem is real. It exists. It really doesn’t have to be studied as to what’s going on. The government has done its job studying these issues. And to say that you’re going to now wait for yet again more studies to come back and more fact-finding to come back, I would think that the vets I’ve been talking to wanted much more direct action of what actually is going to happen going forward, instead of, ‘Wait and see and then we’ll decide what’s going to happen going forward.’” Griffin said. “I was a little confused by the president’s remarks today.… At the same time he was saying he’s known about this problem for years and years and years and it goes back decades, far past into other people’s presidencies, and yet we’re five years into his presidency and the problem seems to be certainly not better and perhaps even worse.”

Unfortunately, the White House response to the VA hospital scandal mirrors its response to the terrible problems that plagued the rollout of the website of the Affordable Care Act—an inability to take swift and decisive action providing grist to opponents of the programs and policies because of entirely distinguishable and curable managerial problems. By permitting years of obvious, documented mismanagement of healthcare services in the VA, the Obama administration may have given General Shinseki a lengthy term in the cabinet, but it has given red meat to the ideologically motivated critics who think that the VA ought to be privatized because government can’t do the job.

The second is President Obama’s unbelievably laggard approach to the appointment of Inspectors General, who are supposed to be the internal watchdogs over federal agencies, and his occasional propensity to eliminate IGs who deliver the bad news that his compatriots appear to not want to hear, as in the case of the IG of the Corporation for National and Community Service. At the VA, where scandals that clearly predated Obama’s election have been cascading onto the administration throughout the duration of the Obama presidency, the office of the Inspector General has been vacant since the end of December of 2013. To date, the President has not nominated anyone to be the permanent IG of the department. That’s 143 days without a nomination for the post, much less having it filled.

Were the president and General Shinseki caught by surprise when the last IG left? Had they had no one under consideration as a potential replacement? The reality is that this White House has been characterized on the issue of IG appointments as “downright sluggish, if not outright negligent, in taking action.”

This stance isn’t unique to President Obama. “Every president, including Obama, talks about the need to root out government misconduct,” says Dr. Paul C. Light, a New York University professor and a frequent writer for Nonprofit Quarterly. “But when it comes to strengthening the IGs and appointing highly qualified individuals, they go MIA. It just curls my hair.” According to Dana Liebelson, writing in 2012, “Light believes there is no shortage of highly qualified auditors and investigators who would be honored to take on this tough job. Instead, he said, the White House is failing to pursue candidates because it doesn’t think it’s a priority, and federal agencies, which can be hostile toward inspectors general, offer no encouragement.”

Although General Shinseki is reviewing what happened and the White House’s Deputy Chief of Staff, Rob Nabors, is flying to Phoenix to interview medical center executives, the acting IG of the VA is supposed to complete his official investigation by August. In the interim, if VA officials who might have had a role in inappropriate, fraudulent, potentially criminal actions decide to shred documents, erase e-mails, and cover up their culpability, this scandal—known and documented to Shinseki and others for the past four years—will persist due to a sluggish response that may be too little, too late.

In this instance, it may not be a matter of handling the truth. Colonel Jessup might say to this administration that, at least since Shinseki took the helm of the Veterans Affairs Department in 2009, it appears that “you don’t want the truth.”

Correcting the Problems

Although he looked a bit like a deer caught in the headlights, Shinseki told a congressional committee that he was “mad as hell” about the alleged wait times and cover-ups that led to the deaths of veterans waiting for urgently needed medical care. Immediately following Shinseki’s congressional testimony last week, the Department announced the retirement of the Dr. Robert Petzel, the VA’s undersecretary for health. White House Press Secretary Jay Carney tried to convince the press corps this was evidence of a step toward accountability. Reporters then immediately skewered the hapless Carney, pointing out that Petzel had announced his intent to retire 20 months ago, making this example a Potemkin Village of accountability.

The president’s press conference added layers of commentary that, as a manager, serve as examples of what makes solutions harder to find.

Lots of medical appointments: In response to a question from Jim Kuhnhenn of the Associated Press, the President reminded his audience that the VA has to deal with scheduling 85 million appointments each year. The president is obviously referring to VA statistics that counted in fiscal 2012 83.6 million outpatient visits and 703,500 inpatient admissions. There are actually 152 VA medical centers and some 1,400 additional community-based outpatient clinics and veterans centers in the VA system, treating 8.3 million veterans every year.

The health benefit of VA hospitals and clinics is one of the core reasons why the VA exists. That’s why the Veterans Affairs Department is the largest federal agency in the U.S. government—next to the Department of Defense—with some 341,000 employees. That is up more than 100,000 from the VA’s civilian employment in 2007. The VA is the one domestic department of the federal government whose budget has continued to increase at a healthy rate despite federal budget constraints, cutbacks, and sequestrations.

That’s why the agency is staffed and funded. It’s not that there are a few clerks with green eyeshades trying to manage the calls for appointments. This is a core function of the system, and the system isn’t working—to the point of documented findings that staff have been “gaming” the system in order to hide long wait times for appointments. Whether 10 million more or fewer appointments than the number cited by the president, the problem is one of a bureaucracy that has been more interested in papering over its problems than solving them in the arena of getting veterans into VA medical facilities for timely and necessary treatment.

Shinseki’s mission, caring, and passion: “Nobody cares more about our veterans than Ric Shinseki,” the President said in his brief presser. “Ric Shinseki I think serves this country because he cares deeply about veterans and he cares deeply about the mission.” The president also mentioned that Shinseki “has been a great soldier…[and] himself is a disabled veteran.”

That is a weak defense of the management of the nation’s second-largest federal department, and is just as weak a defense of mismanagement when a nonprofit leader justifies shortcomings in skill and talent by citing the passion of staff for the cause and mission. The veterans who didn’t get the timely medical treatment they needed at VA facilities and the families who watched some number of them die as a result of those delays are little comforted by the knowledge of General Shinseki’s caring, commitment, and military record.

Shinseki “has been a great public servant and a great warrior on behalf of the United States of America,” said the president early in his remarks. Given that Shinseki had evidence of the systemic problem of fraudulence in the VA appointment process for at least four years, the qualities that the president lauded in him do not undo the evident deficiencies in his skills at managing a large bureaucracy and rooting out problems quickly rather than letting them metastasize.

But what about the good stuff? No one reads a speech as well as President Obama, and his delivery today was the usual blend of confidence and craft. However, his statement seemed to convey a subtext of shock, as though the president couldn’t believe that this crisis of confidence in the VA was bringing down the edifice of accomplishments he had built—or thought he had built—for returning veterans.

The president noted that Shinseki put his “heart and soul” into the reduction of veterans’ homelessness and making improvements in the backlog of veterans waiting for benefit determinations and payments. He also cited the work of the First Lady, Michelle Obama, and Dr. Jill Biden, who have “helped hundreds of thousands of veterans find a job” through their Joining Forces program.

There’s some overstatement in the president’s list of VA accomplishments, especially with the little-reported finding in a report of the Iran and Afghanistan Veterans Association that 50 percent of veterans claims are still backlogged—that is, delayed in the system 125 days or longer. The report indicates that close to 400,000 backlogged claims still wait in the VA processing system, along with some 265,000 appeals awaiting decisions as of December 2013.

Shinseki had made eliminating veterans’ homelessness a goal to be achieved by 2015 as well, but he and the president seem to have forgotten that if the VA can’t deliver on the core of its mission—benefits and medical care—whatever ancillary functions it may have done better are insufficient both to the agency’s supporters and critics.

Swallowing the whistle: Despite promising to make his administration the most open in U.S. history, President Obama has crafted a White House that has been unfriendly if not punitive toward whistleblowers. According to Mother Jones, it has been a White House “war on whistleblowers” since President Obama’s election, with aggressive prosecution of whistleblowers.

It doesn’t appear that the VA whistleblowers have found much traction either with their superiors in the Department or in the White House. Rather, they were the sources for CNN’s investigation, though the VA quickly distributed information undermining the credibility of the whistleblowers. Whistleblowers such as Dr. Samuel Foote in Phoenix and intake clerk Philip Brian Turner in San Antonio haven’t been exactly welcomed by their superiors for having revealed what the VA would rather they not discuss. After being told to stop his emailing about the subject, Turner turned the FBI for witness protection services.

As a mechanism for determining the truth behind governmental wrongdoing, whistleblowers are invaluable and clearly helped to make the CNN reportage on the subject of the VA scandal happen. Whistleblowing hasn’t been the Obama administration’s forte, to put it mildly. Anyone with a knowledge of the administration’s track record on whistleblowing to date would know in a hot second that the president’s statement sounded, whether intentionally or not, somewhat disingenuous.

Fixing the VA System

The engines of the critics are already revving up. John Fund of the National Review Onlinewrites that the problems revealed in the VA hospital scandal, including the deaths of veterans waiting for assistance in Phoenix, are “a warning sign of what could happen as the pressure to ration, inherent in all government-managed health care, is applied to the general population.” In a blog for the Heartland Institute, Alan Caruba writes that the deaths of veterans in Phoenix “will seem small in comparison to the numbers of Americans who will die from the implications of Obamacare.”

It didn’t take long for opponents of the Affordable Care Act to draw a line from the VA scandal to the future of government-assisted health insurance coverage. Their message is that government provision of healthcare, whether through Medicaid in the ACA or in VA hospitals, is qualitatively inferior to healthcare controlled by private sector institutions.

Whether Shinseki is up to the job or not, forcing him out—either quickly or guiding him to the door over time, the method chosen by the White House for HHS Secretary Kathleen Sebelius—isn’t going to cure the problems of the Department of Veterans Affairs, either in the still huge backlog of benefits claims or in the mounting evidence of “cooking the books,” as the president put it, with waitlists at VA medical facilities.

Neither, however, is waiting for an IG report to be delivered in August or even earlier when the facts of the scandal are already well known and authoritatively documented—and even admitted in internal VA memoranda. Nonprofits have to get off the stick and play a big role in pushing the White House toward comprehensive, in-depth corrective actions in the VA beyond chopping the heads off a few sacrificial executive-level lambs. When they hear the weak arguments used by the White House to explain its inaction for the past four years, nonprofits have to be speaking out on behalf of the interests of veterans who are already in the U.S.—almost 23 million—and the million or so more who are likely to separate from the military as U.S. operations in Iraq and Afghanistan wind down. These veterans are their constituents, whether they self-identify as veterans or not, and deserve to have a high-functioning VA system working on their behalf.

Equally as important is the nonprofit role in making government work the way it should. Criticism of President Obama and Secretary Shinseki, even as Shinseki ducked the press for well over a month while CNN camped outside his office, has been muted for reasons that are inexplicable to us. Nonprofits should expect competent management and delivery from government, just as government demands the same from its nonprofit contract partners.

There may be roles that nonprofits can play with the VA in terms of helping with various kinds of program delivery, particularly in the arenas of housing, homelessness, and jobs. But the most important role for nonprofits is in exercising their advocacy voices and holding President Obama and General Shinseki to account for their leadership of this crucial component of the federal government. To shy away from criticizing the administration for its shortcomings with the VA because of some allegiance to the president or a fear that it will make government look bad is silly and counterproductive. Nonprofits have to be a critical, demanding partner of government, not passive and self-censoring. At risk is the design and delivery of necessary programs that, despite the criticisms of conservatives, only government is really positioned to do. It is vital that programs like those of the VA be delivered competently, professionally, and without the half-baked excuses and inadequate responses that were floated yesterday by the White House.

Coming out of World War II, my father was a disabled veteran, having broken his back on a ship in the Pacific. Like many veterans, he never conceived of himself as being disabled, because unlike someone who is born with a disability of some sort, a veteran’s disability comes suddenly to an able-bodied person due to an incident of war. Somehow, my father never received disability benefits, even though he was in constant pain and often could barely walk—but nonetheless became a mail carrier because of the good pay and benefits in those days afforded by jobs in the Post Office. When he died, I found a suitcase full of carbon copies of correspondence he had sent to the VA and to members of Congress, trying to obtain disability benefits to no avail. He had to retire in his fifties, once he could no longer walk very much, and worked as a motel clerk for a while until his health gave out completely and landed him at that VA Medical Center in Providence.

It would never have crossed my mind that my father might have been one of hundreds of thousands of veterans whose disability claims were lost or screwed up by the VA. In those days, awareness of PTSD and TBI were barely recognized or understood, compared to the appreciation of those conditions among Iraq and Afghanistan veterans today. Today’s returning veterans shouldn’t have to wonder whether they will receive the VA health protections and benefits they earned and deserve as a result of their service in the military. It shouldn’t have to cross the minds of their loved ones, either.

  • C. DeWeese

    I just finished reading your article in the Nonprofit Quarterly. I could not agree more with everything you say in the article. My husband, a U. S Navy World War II Veteran died in a VA Hospital in Atlanta, Georgia 21 years ago. The care he received there was inconsistent depending upon the doctors and nurses on duty that day, but far better that what is being described today. After suffering a major heart attack, he had heart bypass surgery at the VA hospital in Asheville, N.C. in 1981. Not all hospitals were qualified to perform heart bypass surgery at that time. The Ashville VA hospital was a top-of-the-line, well-run and family friendly hospital. I was told when I commented on that fact, that President Johnson was responsible for that hospital and the care the Veterans Received. President Johnson who also had heart problems was determined that Veterans who had served their country and who were entitled to care by their government would receive the best heart care available. A far different attitude than that of our current President. I would be interested in knowing what the Asheville hospital is like today. Someone must hold the President and the General accountable. Something needs to be started today to correct the problems, and then get to the bottom of what happened, if it doesn’t become totally obvious.

  • linda

    Why is no one writing about the O.A.P at the Capitol Bldg, run by the Navy. For a meager $503.00 yearly fee, congressmen get state of the art, 24/7 access to medical care. And they pay this fee out of their office expense. This is a scandal akin to the “house banking scandal” because SOME do not pay the yearly fee BUT partake of the medical servce. NO NEED FOR AN APPOINTMENT. Use as many times as they wish per year. COST OVER RUNS are paid from the Navy’s federal budget! Navy, not too long ago spent millions to update this medical facility. Congressmens AIDES get better medical treating thru the O.A.P than our veterans get

  • Jean S. Logan

    It’s not that complicated if you’ve had any experience with how government behaves. 1) Legislators only address crises, not documented needs. Getting appropriate funding approved based on projected, documented demand seldom happens in a timely manner. 2). Even when additional funds are available, government personnel rules make it impossible to fill vacancies in less than 2 to 3 years. Reintegration counselors, for example, must be former service members with a masters’ in counseling. Excellent civilians with experience cannot be hired for these positions. So the personnel aren’t there when service members need them. 3). Even though the top folks in DC understand the long-term needs of returning veterans, it takes 7-10 years AFTER a conflict before the VA system is prepared and staffed to help service personnel re-integrate into society. Our military is great at saving lives–Vietnam taught us to save folks with spinal cord injuries; Iraq/Afghanistan has taught us retrieval for amputations and brain injuries. But what do we do with them now that they are alive? Put them on waiting lists, because the VA doesn’t have the manpower at the street level to serve them. 4). Long-term government middle managers have heard the rhetoric about “fixing” the system for decades. The personnel rules and other barriers do NOT get fixed. So they are stuck being ordered to cut waiting times without qualified staff. The only solution appears to be “game the system”. And folks who do this are protected. They retire with nice pensions. Stirring the pot results in termination from the VA. No one wants to know the real truth.

    I have personal experience with this both from the late Vietnam era in one state, and from the recent OEF/IEF period in another. I managed a private philanthropy project to make civilian resources available to help service personnel and their families re-integrate in a region with no military bases. The VA was very territorial & uncooperative. The Vet Centers, on the other hand, were thrilled to have additional resources to partner with. It took a year, and contacts in DC before we could even have a meeting with the VA hospital directors at two centers in our area. Even when the VA’s top mental health folks praised the work we were doing, the VA hospital refused to work with us because we were non-military and thus “incompetent” and “suspect”. Meanwhile there were 6 month waiting lists for substance abuse inpatient treatment, and it was limited to 90 days.

    I’ll share one successful technique I observed years ago in a similar situation. The VA will have to clean out their middle managers, and begin to treat their employees the way they want patients to be treated. Threatening managers, clinicians or patients with retribution from a higher level never succeeds. A clear understanding of the operational issues and personnel deficits will begin the healing. The VA is not equipped to handle its mission these days, and the waistline of its hierarchy has survived for decades (and retired with nice pensions) by failing clients and gaming the metrics.

  • Jen Brown

    If President Obama wanted to effect a cataclysmic change in some part of our broken system of health care delivery, WHY THE HELL NOT START HERE? Vets appeal to both dems and republicans and the rest of us who can’ t call ourselves one or the other without taking something for an upset stomach.

    Your article left me in tears. How poorly “a grateful nation” treated your father, a war hero and honorable member of “the greatest generation.” I am profoundly ashamed.

  • Rick Cohen

    Dear Jen: Thanks for your comment about my father. I think about him every day of my life. Since the VA crisis, I’ve wondered whether the VA could have or should have done something to make his life easier.

  • michael

    Lots of good stuff in this piece, Rick, I’ll keep my comments limited to the roles of the Inspector Generals and how they have been misused, abused, ignored by the Obama Administration. For a great look inside the process, read Bailout by Neil Barofsky, who was the Special Inspector General for TARP. It is stunning in its scope as to how little concern Tim Geithner and Barack Obama had for the taxpayer.

  • richmond saylor

    why aren’t they going to prosecute that veterans sec’