The Post-Shinseki VA

Shortly after a damning Inspector General’s report revealed widespread fraud and unacceptable wait times in Phoenix’s VA clinics, Eric Shinseki resigned on Friday. Jacob Siegel is saddened at his ouster:

The VA’s problems didn’t start with Shinseki and they won’t be solved by his resignation—in fact, they may get worse. The secret waiting lists discovered in VA hospitals exploited a lack of oversight that made cheating easy and profitable. But beneath them there are underlying structural issues that will be even harder to fix.

As I wrote last week, it didn’t have to be this way. The VA didn’t learn about treatment delays and falsified schedules when the national press picked up the story last month. This is a problem the VA has known about for years. The same “scheduling schemes” that placed 1,700 veterans on secret waiting lists in Phoenix have been extensively documented since 2005 and no one, including Shinseki, yet explained why it took so long to act.

Cassidy even thinks Obama should have kept him on:

As he demonstrated during the Iraq war, when he warned the Bush Administration that it would need a lot more troops to occupy the country than the Pentagon was deploying, Shinseki is a man of honor. Despite this scandal, he has done a number of positive things in his time at the V.A., such as expanding the treatments offered to victims of past wars, including the war in Vietnam, and helping to reduce the number of homeless veterans by a third. His remarks on Friday were made before the National Coalition for Homeless Veterans, which gave him a standing ovation.

The underlying problems facing the V.A. are well known in Washington, and they go back at least a decade. As the number of wounded veterans has increased sharply, the agency’s budget hasn’t been raised in line with the increased demand for medical services. That’s why there are such long waiting lines: there are too few doctors and beds available for all the patients that need them.

Gordon Lubold and John Hudson ponder potential replacements:

Members of Congress, individuals associated with veterans groups and others were disinclined to name publicly individuals who should replace Shinseki, but a handful of names have emerged, including a slew of retired general or flag officers, from Mike Mullen to Stanley McChrystal or Peter Chiarelli. John McHugh, a former Congressman and now the sitting Army secretary, and Navy Secretary Ray Mabus were also on the lips in Washington on Friday. And Gen. Raymond Odierno, the Army’s chief of staff, and James Webb, the former senator, Marine, and Navy secretary have all been mentioned as a possible successors. Someone with corporate leadership experience, coupled with a military background, could also be seen as a good fit. That very short list would include someone like Fred Smith, the chairman and CEO of global mailing giant FedEx, who served as an officer in the U.S. Marine Corps from 1966 to 1970.

Kleiman argues that Shinseki was felled by his preoccupation with metrics:

Apparently the systematic fudging of the waiting-list numbers was known to the Bush the Lesser administration and had started even earlier, but Shinseki was a strong advocate of numerical goal-setting, and in particular the strategy of setting “stretch” (i.e., impossible-to-satisfy) goals as a way of motivating extra effort. (One VA health-service provider, a sound progressive, told me back in 2010 that she was so frustrated at having to deal with idiotic goals imposed from DVA headquarters that planned to vote for any Republican against Obama in 2012.)

In fact, what “stretch” goals motivate is mostly deception.  If there’s no honest way to “make your numbers,” cheating seems like the only sensible strategy.

An audit released on Friday backs up this notion that the VA’s goals were simply unattainable:

Thirteen percent of staff were instructed to schedule appointments without regard to a patient’s desired date, which could indicate an attempt to falsify records. At least one instance of the practice was detected in 64 percent of the surveyed VA facilities. The survey, however, did not determine whether these activities were intentionally fraudulent behavior. The audit also acknowledged that the VA’s goal of seeing patients within two weeks of a desired appointment date “was simply not attainable given the ongoing challenge of finding sufficient provider slots to accommodate a growing demand for services.” The report also criticized other complications and technicalities in the VA scheduling system, many of which have been known for years.

Phillip Carter thinks the department’s problems won’t be easy to fix:

The VA is the second-largest cabinet agency, and the nation’s largest health care and benefits provider, with an overall fiscal 2015 budget of $165 billion (greater than the State Department, USAID, and entire intelligence community combined), including $60 billion for health care. The VA employs more than 320,000 personnel to run 151 major medical centers, 820 outpatient clinics, 300 storefront “Vet Centers,” more than 50 regional benefits offices, and scores of other facilities. This massive system provides health care to roughly 9 million enrolled veterans, including 6 million who seek care on a regular basis.

It’s hard to overstate the challenges of leading this massive agency: The ideal candidate would probably fuse the best traits of a general like Shinseki, a politician like Bill Clinton, and a businessman like Lee Iacocca or Mitt Romney. The systemic integrity problems in the VA’s health care system, coupled with the broader resource allocation problems they were masking, will remain for the next secretary, whoever he or she is.

Yuval Levin blames the disjunction between the administration’s ability to identify the problem and its willingness to fix it:

Centrally run, highly bureaucratic, public health-care systems that do not permit meaningful pricing and do not allow for competition among providers of care can really only respond to supply and demand pressures through waiting lines. It happens everywhere, but when it has happened at the VA the response has been to criticize waiting times rather than to reconsider how the system is organized.

There is no question that the quality of the VA system has improved significantly over the last three decades, thanks to a series of modernization efforts launched (and very well executed, I should note) by the Clinton administration and continued by both the Bush and Obama administrations. But these efforts began from an extremely low baseline and they have achieved improvements by essentially modernizing the infrastructure that supports a very inefficient bureaucracy. The potential of these kinds of changes to dramatically reduce waiting times was always going to be limited, and the increasingly unrealistic targets set for waiting times put pressure on the system without giving administrators any way to release it.

Byron York pans Bernie Sanders’ bill that would give the VA an additional $20 billion to expand its services:

The bill would essentially offer VA health care services to all veterans, including those who do not have service-related problems and have incomes above current cutoff levels. It would also greatly expand a program that pays caregivers of disabled veterans a monthly stipend. Congress originally passed the measure for veterans of post-Sept. 11 wars; Sanders would expand it to all veterans.

The caregivers provision is one of the single most expensive features of the bill, and it was put into the legislation over the objections of the Department of Veterans Affairs itself, which believes it would cost even more than Sanders estimated. “VA believes the expansion of benefits to caregivers of eligible veterans of all eras would make the program more equitable,” the agency noted in a statement on cost. “Unfortunately, core health-care services to veterans would be negatively impacted without the additional resources necessary to fund the expansion.”

But Beutler warns Republicans against trying to score points on the VA scandal without offering a meaningful alternative:

This isn’t a familiar Congressional impasse where Democrats want to spend a certain amount of money on something while Republicans want to spend less money. Those sorts of fights are destructive, too. In a way they’ve defined the Obama presidency. But they’re also resolvable. Veterans health care is differentthe story here is 100 percent ideological, and zero percent fiscal.

It’s not that big government foes are after spending less money on the VA, per se, or want to isolate efficiencies within its existing structure and ply the savings into building out capacity within the department. They instead want to spend more money on veterans by transitioning them into an entirely different, private-sector oriented system of care. This includes House Speaker John Boehner.

Previous Dish on the VA scandal herehere, here, and here.