In November 1993, the Veterans Health Administration, the largest subagency in the Department of Veterans Affairs, was in big trouble. It had an antiquated patient records system and a troubling lack of primary care and outpatient services in an almost entirely hospital-based system. There were also rising concerns about patient safety and quality of care. Politicians in both parties had floated the idea of privatizing veterans’ health care. One of them was First Lady Hillary Clinton, whose health care plan proposed slashing the VHA’s hospital budget by 20 percent.
Because, among other reasons, the Clinton health care plan was so complicated, it crashed and burned. In response, President Bill Clinton changed his approach toward the agency. In 1994, he appointed Kenneth Kizer as the VHA’s undersecretary for health. A respected physician, public health expert, and Navy veteran, Kizer checked all the boxes. In short order, he and his team devised and executed a plan—known today as the “Kizer revolution”—to transform the nation’s largest health care system.
First, Kizer supported a crew of VA computer scientists (known as the “hardhats”) who had then been toiling for more than a decade to create an effective electronic medical record system. While previous VA leaders had blocked the hardhats at every turn, Kizer unleashed these pioneers, who created the first, and best, electronic medical record system in American health care.
Kizer also moved the VA away from its largely hospital-based system by building hundreds of community-based outpatient clinics. Moreover, he inaugurated a robust patient safety program, decentralized VA operations, supported staff, and encouraged VA innovators to tell their stories to Congress and the media. By the end of the millennium, some of the most prominent—and conservative—business publications were lauding the VA as a model for U.S. health care. Among them was the Harvard Business Review, which deemed Kizer’s revolution the largest and most successful “turnaround” of any health care institution in the nation’s history.
Today, the VA is again at a crossroads. While the “Kizer revolution” has vastly improved the quality and cost of VA care, and made the VHA especially resilient and adept at dealing with the pandemic, ongoing challenges are damaging to patients and also have the potential to be politically poisonous to the entire VA enterprise. Many of these issues were created through Republican mismanagement, as part of the party’s quest to undermine and privatize the VA. Today the agency is saddled with a totally dysfunctional Trump-era IT overhaul, an out-of-control outsourcing office, and an anti-union accountability office set up under the previous administration. What’s more, some toxic managers empowered at local and regional levels have jeopardized stellar programs, leading to low staff morale and a high number of resignations and early retirements.
Equally disconcerting, the current political climate provides a unique opportunity for the right. Republicans are looking for any way to undermine the Democratic president, and are armed with a powerful misinformation machine that understands the mechanics of using veterans to score political points.
In fact, Republicans don’t have to turn too far back to remember how to exploit the VA’s challenges. In 2014, Concerned Veterans for America, a Koch-funded group, used a VA whistleblower complaint—which said that administrators in several VA medical centers were falsifying data about wait times—to manufacture a scandal just in time for the midterms. It was the perfect opportunity to discredit the VHA despite its notable successes as an example of public medicine and, by extension, Barack Obama and the Democrats—even though the House Republicans had blocked greater funding for veteran services just one year before.
The GOP gained 13 House seats and nine Senate seats in the 2014 election cycle. The party took control of the upper chamber for the first time since 2006, which they maintained until Democrats recaptured a narrow majority in the 2020 elections.
Now, with another Democratic administration in office and critical midterm elections coming up, Republicans and their allies will once again seek an opportunity to capitalize on the VA’s weaknesses, even if they themselves caused them.
One of the main challenges the VHA faces is a direct result of the partial privatization of veterans’ health care that accelerated because of Trump’s signature veterans’ policy initiative, the VA MISSION Act of 2018. The law was largely crafted by Darin Selnick, who worked for Concerned Veterans for America and became, along with Pete Hegseth of Fox News, one of Trump’s most trusted veteran advisers. The MISSION Act, which was supported by both Republicans and Democrats, shifted the care of millions of veterans from the VHA to the private sector. The ramifications of this policy have been dire. Since 2017, the VHA budget for private-sector care has ballooned by 223 percent. (Its budget for in-house care, meanwhile, has grown by only 12 percent.) According to a new study in JAMA, private-sector care appointments increased by 18 percent between April 2019 and December 2020, while those at VHA decreased by 25 percent.
When it comes to quality of care, the return on this massive investment is minimal, if not nonexistent. One recent study found that Medicare-eligible veterans are twice as likely to die in a private-sector emergency room than at the VA. At the same time, the cost of these private-sector visits is 21 percent higher than at the VA. Psychologists and other sources have told us that some veterans are waiting months for private-sector telehealth appointments, which are the easiest to schedule.
If these holdups lead to even a single veteran suicide or death, the right wing will pounce. In their sly framing, it will be the VA, not the private sector (or the congressional architects of the MISSION Act), that takes the reputational hit. A replay of the 2014 scenario could again torpedo Democrats in the midterms, helping Republicans regain control of Congress.
To avoid this fate, the VA must proactively fix these problems before Republicans try to use them to rig the next elections. The first step on this path is for the Biden administration to take a page out of the Clinton playbook and swiftly appoint a strong undersecretary of health in the mold of Kizer. The president also needs to fill the post of undersecretary for benefits at the Veterans Benefit Administration, the subagency responsible for administering more than $100 billion per year for disability, education, and other benefits that veterans and their dependents have earned.
In important ways, the Biden administration has worked to undo problems caused under Donald Trump. They’ve pushed for increased investments in infrastructure and tempered some of the previous administration’s attacks on unions and VHA employees. Yet the administration appears to be influenced by a narrow, almost negative view of the system. “The attitude seems to be ‘Just don’t produce any embarrassing headlines,’” one former VA official told the Monthly.
But a strong undersecretary, who can build on the work of Kizer’s revolution, can help to safeguard the agency against Republican attacks and ensure that it remains a bastion of public health that improves the outcomes for veterans needing medical care.
Choosing a qualified candidate for the position of undersecretary of health must be one of the Biden administration’s most pressing tasks. Finding someone with the necessary qualifications is inherently difficult. To qualify for the job, the candidate must have deep experience in a public- and private-sector health care system. They must also have significant familiarity with academia—the VHA trains 70 percent of America’s physicians and thousands of other health care professionals—and research, since the VHA runs one of the largest research programs in the country. To properly steer the VHA, a health undersecretary must also be able to navigate the turbulent waters of Congress, where many Republicans are actively hostile to the system. What’s more, Congress is often negligent in its support and oversight roles.
In short, the undersecretary of health serves as the CEO for the largest health care system in the country but is paid a small fraction of what a private-sector counterpart would earn. The undersecretary’s salary is less than $200,000; according to Becker’s Hospital Review, the highest-paid hospital CEOs in the country make between $25 and $10 million. The undersecretary job, moreover, is always time limited, since no one can promise that their boss—the president of the United States—will be reelected. The average tenure of a VHA health undersecretary is under two years. Kizer, who held the position for five years, was the longest-serving undersecretary of health in VA history.
To entice candidates requires both an exhaustive national search and a major charm offensive. Unfortunately, this is not what the Biden administration seems to have done. According to some VA experts and observers, the agency has mounted a lackluster search, checking the necessary boxes but doing little more, trapping the position in a never-ending bureaucratic shuffle.
In line with federal statute, the VA assembled a national commission earlier this year to recommend candidates for Biden to review. The commission met first in April, when it ranked the top three candidates who were interviewed. Members concluded that only one candidate was properly qualified, and in the end, the White House rejected all three. In August, the VA presented another list of candidates to a reconstituted commission. Those applicants, too, were rejected by the White House. In September, Donald Remy, the deputy secretary of the VA, disbanded the commission. On October 19, the VA announced the formation of yet another commission to vet a new set of candidates for the position. (While the launch of these commissions was announced, unlike in the past the names of its members have never been publicly revealed.)
In the meantime, the VHA is being run, on an interim basis, by Steven Lieberman, who served in the Trump administration as acting deputy undersecretary for health. (Lieberman, it’s worth noting, was rejected by the Biden White House in the first round of the commission’s deliberations.)
“What we need at the VHA is a visionary leader,” says the physician Andrew Pomerantz, who recently retired after spending more than three decades at the department. “Instead of that, what we’ve gotten for the past five years is a manager, someone whose primary qualification for the job seems to be to tell the secretary what he wants to hear.” A retired central-office official echoed these sentiments. “There’s nobody in authority at the top,” the official said. “So people at the local level think, ‘Why should I listen to them, they’re just temporary or acting?’”
If not quickly reversed, this dynamic will make the position of undersecretary of health unattractive to interested, qualified candidates. As another former VA official commented, “Who’s going to want to take a pay cut and then go in there with a lot of great ideas only to be told, ‘No, you have to do what’s politically expedient’?”
The job will become even more unattractive should the conservatives precipitate another VA scandal. Earlier this year, Koch-backed forces filed a lawsuit seeking a massive trove of public records in hopes of finding evidence that veterans are being put on wait lists for private-sector care. They are already claiming this assumption as fact, as are allies inside a new think tank of former Trump VA officials, as well as by former VA Secretary Robert Wilkie, now a visiting scholar at the Heritage Foundation.
Wilkie has been actively trying to undercut the VA. “When the Obama-Biden administration left, the approval rating of VA was at 31 percent. When Trump left, it was 91 percent,” Wilkie told Breitbart late last month.
The right knows how undermine veterans’ health care while simultaneously winning political points based on the negative outcomes their own policies have wrought. This is a dangerous trend, and one that will be replicated time and again if the current administration doesn’t go on the offensive and promote the VHA as a shining model of government-provided health care.
The Biden administration needs to make finding a talented undersecretary of health a priority. Failure to do so could put the success of its agenda and ability to hold power in jeopardy.
