The Veterans and their Administration

Veterans PopulationThe Numbers Game: Issues pertaining to the management of Veterans Administration services have special meaning to 225,933 people in Nevada, 169,255 of whom served this country during war time, and 56,678 who served during peace time.  [VA actuary]  69,190 Nevadans served during the Gulf War era, 79,281 served in Vietnam, 20,462 served in Korea, and we have about 9,444 remaining veterans from World War II. [VA actuary]  Meanwhile, 13 years of operations in Afghanistan and in Iraq are adding to these numbers.

The United States deployed 2,333,972 people to Iraq and Afghanistan between 2001 and 2011, of whom 1,353,627 have since left the forces, and 711,896 used VA health care services between FY 2002 and FY 2011. [ABC] Veterans during the period 2008 to 2011 saw deployment time increased by 28%. [Rand pdf] The Iraq operations, we were told, could last “six days, six weeks, I doubt six years.”

“We don’t talk about deployments in the specific, but we have brought a good many Guard and Reserve on active duty. Fortunately, a great many of them were volunteers. We have been able to have relatively few stop losses. There are some currently, particularly in the Army, but relatively few in the Navy and the Air Force. And it is not knowable if force will be used, but if it is to be used, it is not knowable how long that conflict would last. It could last, you know, six days, six weeks. I doubt six months.” [Rumsfeld, Aviano Air Base February 7. 2003] 

We may not want to talk of deployments, but warfare creates veterans and the longer the warfare lasts the more veterans there will be.

Estimates during the debate over initiating operations in Iraq which projected totals over $3 trillion (Stiglitz) were dismissed out of hand. Instead Lawrence Lindsay, Chair of President Bush’s Council of Economic Advisers estimated the war might cost $200 billion at the most, but during the 2002 campaign season this projection was determined to be “shockingly high,” Lindsay was fired and replaced by Mitch Daniels who argued the Iraq war would cost no more than $50 to $60 billion.  [EconMonitor]

The $60 billion figure is dwarfed by the estimated $135 billion estimated as minimally necessary to provide services to veterans.

Making the situation even more tenuous for veterans, the Sequester budget deal cut  services from other agencies (HUD, Defense, Labor) for veterans while ostensibly leaving the VA untouched — except that “administrative costs” might be cut by 2%, and what constituted an “administrative cost” remained ambiguous. [WaPo]

The Management Game:  The VA Inspector General’s office has expanded its investigation to 26 VA facilities regarding allegations of falsified records and delayed care.  One former administrator in Phoenix, AZ offered his opinion that 40 veteran may have died while waiting for care.  To date no link has been established between the delays and those deaths. [ABC]  The lack of direct linkage notwithstanding, it is certainly possible that care delayed can all to easily become care denied.  Instead of listening to carping, finger pointing, and generally distasteful politicizing of the situation at the Veterans’ Administration, here’s what I’d rather hear from our pontificating pundits and politicians:

Reducing delays and other problems within the VA system, which have long be evident, may well require a significant shift in the way in which services are perceived and administered.

#1. Future Congressional calls for war or large military operations should be accompanied by calculations projecting a reasonable TOTAL cost of the actionsincluding services and benefits for veterans. As there should be an accounting for individuals who falsified records to artificially reduce wait times, there should be an accounting for those whose minimalist estimations for the cost of operations in Iraq and Afghanistan made those actions appear “affordable.”

The failure of the VA to provide timely services is a function of staffing and facilities, infrastructure which should be considered before we launch wars in which we have an option to defer, delay, or avoid action altogether.

#2. Administration of VA services should be predicated on veterans’ needs and not dubious or inappropriate management theories.  The VA is not a commercial or manufacturing entity. Its sole function is to provide customer/client services.  In this wise, the VA perspective ought to be one in which client service is acknowledged to be labor intensive, and hiring should be adjusted accordingly.

For example, while demand for VA care services has increased by 38%, the VA has hired only 9% more medical professionals.  Public-private partnerships with local medical service providers has been applied, and more such partnerships may be one part of a larger strategy to appropriately staff the facilities.   Actions by Senate Republicans who blocked a $24 billion veterans’ health bill in February  2014 which included funding for 27 new medical facilities are unhelpful. [Reuters] [Roll Call 46 – all 41 votes blocking  S. 1982 were cast by Republican Senators]

The treatment of and for veterans should reverse the perspective that all claims are “costs” and “cost containment” is an ultimately desirable institutional goal.  If one is manufacturing widgets for WalMart this might be an acceptable perspective, but we are not talking about a price driven retail commodity — we’re speaking of veterans who have been promised a level of support services (educational, medical, and employment) which have not been delivered on a timely basis.

The much maligned Internal Revenue Service is a far more trusting agency than the VA appears to be.  When I file my return electronically the IRS assumes I am being honest. I may be audited at some point in the future, but for the latest fiscal year the assumption is that I meant what I affirmed at the end of the document — that the return is the most honest and accurate it is within my power to provide.   The VA claims process might be improved by adopting the same attitude.

Unfortunately, the VA is giving the appearance of an institution for which a claim is as much an opportunity for fraud or misuse as it might be a legitimate request for service.  This attitude could quickly spawn a multi-layered bureaucracy  devoted to weeding out any untoward claims. It’s essentially the pre-ACA attitude of health insurance corporations which sought to deny as many claims as possible in order to manipulate its medical loss ratio.  This situation might have been predicted since politicians of every imaginable stripe have loudly proclaimed their affinity for rooting out “Waste, Fraud, and Abuse.”  In the instance of the VA all this cat-calling from the bleacher seats simply serves to reinforce the “cost containment” proclivities and diminish the “service to the client” perspective.

#3 The core of the manipulation problems in the Phoenix office is said to emanate from a bonus system for “meeting the numbers.”  I’ll have to admit to a jaundiced view of bonuses.  Bonuses are what you pay employees when you don’t want to pay them up front what they are really worth. It’s close to an analogy in which the cafe owner justifies sub-minimal wages because the wait staff receives tips.

No one should be particularly surprised when people emphasize on the job what the institution/company/corporation rewards.  If the company rewards speed in delivery, speed we will get — even if a NOAA drone is delivered by FedEx to the wrong address.  If the company/agency rewards fast service, then the service will be fast, and if that can’t be done in the real world then the numbers are fudged to gain the reward and make the boss happy in the bargain.  If the disturbing consequences of the testing furor in education has taught us nothing else, it should have told us that we will get what we measure, not necessarily what we want.

How much less traumatic might the problems with the VA be if we could admit to ourselves that there are immeasurable things which are nonetheless important to the delivery of competent and complete care for veterans and their families?

#4. Technology moves faster than our fingers.  Granted that the inability of computer data systems to share information quickly and accurately is a problem, especially it seems between Department of Defense and VA systems.  At some point we need to acknowledge the hard horrible fact that older stand-alone data systems were never designed to function in a file-sharing world.  No amount of patching or plugging is going to make them compatible.

Until we accept that if we want compatible systems we have to buy them.  They are expensive, they are complicated, and they are unintelligible to most voters — however, the old retail saw holds true — we will get what we are willing to pay for.

Meanwhile there are 225,933 veterans in Nevada who deserve to receive the educational, employment, and medical services they were promised when they signed on to serve us, and who deserve more than a political outrage du jour, and a brief turn in the media limelight.

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