In the six decades following World War II, national veterans policy was unusually stable. Even as the tone of American politics shifted dramatically, veterans’ issues remained insulated from an increasingly polarized public and Congress. But for the Department of Veterans Affairs (VA), a perfect storm of disruptive forces coalesced after the 2010 elections: the declining power of traditional veterans service organizations, a whole new level of partisan posturing, and the arrival of aggressive, corporate-funded lobbying in a place that previously saw little of it. The VA governance structure and organizational culture were thoroughly unsuited to navigate this new environment. The department is now being bombarded by criticism, and the VA’s health care arm, the Veterans Health Administration, is facing persistent calls for more privatization.
In this context, the return of divided government is cause for cautious optimism. The Democrats’ recapture of the House has the potential to invigorate debates surrounding the VA. Critically, it might create a counterweight to proposals written by advocates of privatization.
But any attempt to thoughtfully shape the VA’s future will require engaged and informed legislators. And here, there’s cause for concern. Only a single member of the House Committee on Veterans Affairs, Florida Republican Gus Bilirakis, also serves on one of the House committees in charge of setting America’s broader health care policy. The current House can and should fix this. But until it does, congressional oversight of the Veterans Health Administration—the nation’s largest integrated health care network—will remain essentially divorced from oversight over the rest of America’s medical system.
Even worse, most House members do not see much value in working on veterans’ health care. As former Democratic Representative Beto O’Rourke bluntly observed, the Veterans Affairs committee “is not a place from which a member can successfully raise money from the special interests who have a stake in the legislative outcomes. It’s also not a high-profile committee, and the work is really tough.” Consequently, the panel’s representatives generally leave for more prestigious committees as soon as they can. California Democrat Mark Takano, the committee’s current chairman, just started his fourth term in office. Ten of the sixteen Democrats now seated on the panel are freshmen.
These new representatives would do well to read Suzanne Gordon’s Wounds of War. Over the course of seventeen chapters, Gordon provides a comprehensive introduction to VA health care, and she proves that the agency is a national treasure within America’s fragmented and dysfunctional medical system. (Disclosure: the book cites some of my research.) VA primary care providers are able to spend adequate time with their patients and get to know them because their assigned patient loads are relatively small. Routine visits of thirty minutes are the norm rather than the exception. The VA’s Primary Care–Mental Health Integration Program enables interdisciplinary teams to address veterans’ physical, emotional, and social work needs. And the Comprehensive End of Life Initiative allows “concurrent care,” where veterans dying from cancer can receive radiation and chemotherapy while also benefiting from palliative and hospice care. In contrast, Medicare’s hospice program requires patients to “forgo all active, disease-modifying cancer treatment.”
Gordon illustrates the importance of the Veterans Health Administration through a combination of facts and individual testimonies. She discusses, for example, Navy veteran Susi Black, who was severely injured in a hit-and-run automobile accident. Black attributes the VA’s collaborative team-based care with saving her life because it holistically addressed her medical and social needs. At no out-of-pocket cost, the VA provided Black with state-of-the art prostheses, managed her diabetes, and enabled her to lose (and keep off) more than 100 pounds. It even drove her to and from appointments.
Readers will also appreciate the myriad ways in which the VA improves health care for all Americans. The agency, for example, conducts research that involves following millions of patients throughout their life in a way that no other American health care system can. VA researchers played pioneering roles in developing the shingles vaccine, the nicotine patch, and implantable cardiac pacemakers. With an eye to the future, the VA is studying the role that genetics play on health through its Million Veteran Program.
Above all, Gordon dismantles some of the most egregious and commonly repeated narratives about the VA. Citizens unfamiliar with the agency, for instance, may associate it with the 2014 Phoenix wait time scandal, where media outlets reported that the VA was not delivering care to its patients within its self-imposed time frame, and that several dozen veterans may have died as a result. But as Gordon notes, numerous third-party studies show that wait times for VA providers are shorter than those in the private sector and have improved since the 2014 scandal. They also show that veterans who receive their health care from the VA are overwhelmingly satisfied and generally support the existing government-owned, government-operated delivery model.
Wounds of War delves into the individuals and organizations amplifying false narratives about the agency. These actors range from veterans groups who have received funding from privatization advocates, private insurers and third-party administrators hoping to skim a portion of the VA’s cases, and property investors looking to gobble up VA real estate. None of them fully realize that America’s already burdened private sector does not have the capacity to accommodate the VA’s patient population, which is generally older and sicker than the national average.
Gordon attributes much of the VA’s current political plight to an organizational structure and bureaucracy that are artifacts of an era in which the agency did not have to negotiate a 24-7 media cycle and fight against well-funded actors with a stake in privatizing its functions. Other federal agencies are facing similar problems, but they are able to respond by marshaling a wide cadre of presidential appointees. The VA, unfortunately, has relatively few such officials. In 2014, the Obama administration estimated that an arcane 1989 statutory provision allows the entire VA to have, at most, around forty presidential appointees. The Department of Health and Human Services, by contrast, had over 160 at the end of 2016. The Veterans Health Administration, with more than 300,000 employees—four times the size of the entire HHS—has just one presidential appointee, the undersecretary for health.
As a result, the organization underestimates the political dynamics it faces. Most controversial matters, and even some mundane ones, are elevated to the secretarial level, where the handful of appointees struggle to manage the many complex congressional and media issues that would elsewhere be handled by lower-level political officials. This leads to missed opportunities for press coverage that would shine a positive light on the agency, and it worsens media fiascos like the Phoenix crisis. Eric Shinseki, then VA secretary and a former Army chief of staff renowned for his integrity, was felled by the scandal, which percolated at least three reporting levels below his skeletal selected leadership and advisory staff. In Phoenix’s wake, many complex proposals have been floated to modernize the Veteran Health Administration’s governance structure. But none of these, to my knowledge, includes removing the cap on the number of political appointees.
Given who occupies the White House, liberals may be hesitant to embrace a policy that seemingly gives the president more power over the VA. But despite drama at the top, lower-level presidential appointees in headquarters and at the regional level exist without controversy in federal agencies as diverse as FEMA, HUD, and the HHS. These officials manage their own share of high-consequence crises, such as influenza pandemics and natural disasters, with high political saliency and in a largely nonpartisan manner. Advocates for a robust veterans health care system should take a step back from today’s media cycle and appreciate the long-term organizational benefits that would come from allowing the president, the VA secretary, and the VA undersecretary for health to select teams large enough to inspire career staff and drive priorities.
But internal reform will only get the VA so far. To thrive, the agency needs strong advocates outside of the government, something it increasingly lacks. The advent of the all-volunteer military means that veterans are a shrinking percentage of America’s population. Veterans policy is migrating from issues of universal concern to ones that primarily impact areas where veterans are now clustered. As a result, the mainstream veterans service organizations that help defend the VA (and which generally oppose privatization), such as the Veterans of Foreign Wars and the American Legion, have diminishing political clout.
For better or worse, the course of VA health care now depends on a citizenry and health policy community that possesses little firsthand experience with its services or achievements. Wounds of War is a tremendous starting point for those interested in understanding the importance of getting these decisions right.