The VA’s much-needed New Year’s revolution

Some of the vets I got to know each year that I worked at the VA didn’t make it to ring in the next. Of those, there were plenty who called out for help before it was too late. Too often, their voices weren’t heard.

One former Vietnam medic, for example, called a special VA post-operative telephone hotline just days after being discharged from the heart surgery service at the highly-regarded San Francisco VA. He had survived a technically successful bypass operation, but his weakened heart continued to struggle behind a breastbone that had been sawed open and then wired shut.

{mosads}Somehow his VA benefits didn’t include authorization for a convalescent stay at a skilled nursing facility. Instead, he was sent out of the hospital to ride a bus and a subway back to an empty apartment, where an intricate balance of heart and lung medications fell into a confused disarray. He was eventually discovered by a family member, lying dead clutching a half-empty bottle of stool softeners near a phone he had been promised would be called back by the post-operative VA hotline staff.

The Veterans Health Administration has itself been calling out, increasingly desperately, for help. But the cries for help have come passively in the form of “exposed” local VA failures and blown whistles. And like the Vietnam medic’s hotline calls, the true meaning of these cries has been falling on deaf, or at least denying, ears.

This nation not only needs to recognize and acknowledge the VA’s deep-seated problems, but also to try to understand their roots. That is, if we care enough about our veterans to try to really help the VA live up to our national promise.

On this front, our elected representatives, and even the current, well-meaning top VA leadership, have fallen short. Instead, they continue to focus only on the immediate VA transgressions themselves, applying Band-Aid solutions that couldn’t possibly address the underlying causes or prevent their future manifestations.

The problem with the VA is that it has evolved around a bloated bureaucratic core that is inherently dysfunctional, inertial and more concerned with its own self-preservation than the welfare of our vets. Ask any thoughtful person who’s worked at the VA and you can elicit stories that reflect this central truth.

VA Secretary David Shulkin, however, revealed his failure to recognize this fundamental failing of the institution when he recently authorized the redirection of hundreds of millions of dollars from a successful, independent program for homeless vets toward the already ineffective budgets of local VA hospitals.

An instant barrage of disbelief prompted an immediate reversal of this poor policy decision – but if the choice was so obviously bad to so many veterans’ advocates, why had that been lost on Secretary Shulkin in the first place?

As long as our leaders continue to tinker with deck chairs on the sinking VA, any real solution is going to remain unlikely. Like a difficult, dangerous operation for a desperately sick patient, however, we cannot let our fear of the uncertain undermine our dedication to the welfare of our vets.

Everybody that has investigated the VA in recent years has called for transformative overhaul, but none is on the legislative horizon.

Before we lose the current momentum toward meaningful VA reform that is decades overdue, here is this surgeon’s prescription for true, if likely painful and politically dangerous, VA transformation:

1. It is unrealistic to expect the behemoth of VA bureaucracy to be transformed without being completely dismantled. As long as it persists, the immense medical infrastructure draped around it will continue to provide substandard care.
2. Rebuilding an effective administrative core and a full-blown “separate but equal” healthcare system seems overly ambitious for a federal government that has a hard time passing a budget. The dream of a complete, independent healthcare system for veterans, as attractive as that vision has been for so many veteran advocacy groups, must finally be abandoned.
3. The most compelling justification for the “separate but equal” VA was the institution’s ability to focus resources on medical issues of unique importance to vets. PTSD, closed head and spinal cord injury, etc. Therefore, let’s preserve just a small portion of the current VA infrastructure and refocus it entirely on these special areas of need. But instead of burying them within a second-rate healthcare system, organize and fund them from scratch to become true, highly-respected and well-staffed independent centers of excellence led by the leaders of their respective fields.
4. Redirect the remainder of funds away from maintenance of the old VA healthcare system and infrastructure toward a novel insurance system that guarantees access for veterans of all socioeconomic situations to the absolute best of American healthcare in their local communities. Unlike a simple voucher system, the burden should not be on veterans to identify the best care to meet their needs. Instead, modern medical informatics technology could be utilized to help guide veterans in a cost-effective way toward those existing resources, and ensure that payment is not a barrier to access. Medicare as an insurance system has been reasonably successful; think of this as Medicare on steroids for veterans.

As an academic surgeon, I have not had the resources to perform the necessary economic and organizational analysis to demonstrate the feasibility of this plan. But it is a start in a meaningful direction. And it would recognize the desperate call of a dying VA for help. Let’s get our heads out of the sand, and the sand out of our collective ears. The VA needs a New Year’s Revolution. If not now, when?

Michael J. Mann, M.D., is a professor of surgery and director of the Cardiovascular Translational Research Laboratory at the University of California, San Francisco, and author of the recently published book, “Mission Betrayed: How the VA Really Fails America’s Vets.