Unhealthy Skepticism

The Department of Veterans Affairs was back in the news this spring—and, as usual, the news wasn’t good. In March, Donald Trump fired VA Secretary David Shulkin, who had come under fire for misusing public money. His proposed replacement, White House physician Ronny Jackson, then withdrew his nomination after reports emerged of his being drunk on the job, handing out pain-killers to staffers, and indulging in other bad behavior. In May, responding to perceived systemic care problems, the House and Senate passed the VA Mission Act to allow veterans more access to private-sector doctors and hospitals. 

Reporters were ready to put these stories “in context.” They reminded audiences that the VA was, as the New York Times put it, “one of the largest, most complex and troubled cabinet agencies in the federal government.” Other outlets described it as “scandal ridden” and subject to “scathing reports” of dangerously long wait times and substandard care. In an episode explaining the Jackson scandal, the Daily, the Times’s popular daily news podcast, repeated the claim that “forty veterans died while they were waiting for medical care” at the Phoenix VA. 

But here’s a different story about the VA, from the exact same time period, that major media outlets didn’t bother to report: In March, researchers at the nonprofit research organization RAND published a study revealing the gross inadequacies of New York State’s health care system to effectively treat veteran patients. A month later, RAND found that the quality of VA care was generally better than private health care. These were just the latest of scores of studies that have come to the same conclusion for nearly two decades now. 

How can this be? How can we all know that the VA health system is a disaster, when study after study shows the opposite—that when it comes to actually providing care for nine million veterans, it outperforms the competition? 

The answer is that studies like the RAND report are virtually ignored by the press. This isn’t just a Fox News problem. Consumers of neutral and even left-leaning news sources are largely unaware of the many studies showing the general excellence of America’s largest integrated health care system, and the country’s only true example of socialized medicine. 

As the U.S. continues to debate what to do about its unsustainable health care system—and as conservatives continue to push for “free market” solutions, including privatizing the VA itself—the fact that a government-owned and -operated system is outperforming the private sector should be a major story. If VA care is as good or better than the alternative, how would pushing vets into private-sector care make them better off? But that question rarely gets asked, because too many people are unaware that the premise guiding these policies—that the private sector inevitably outperforms government—is false. 

The “Forty vets died waiting for VA care” meme continues to show up over and over again in stories about the VA. It’s a great example of a fact that is literally true but as good as a lie.

Why is that? In trying to understand why media coverage of the VA so often winds up giving the public a deeply and dangerously distorted picture, we’ve identified five general sources of the problem. These patterns apply more broadly to the ways in which many journalists cover other government agencies as well. Understanding them is a crucial first step toward having a media that better performs its job of keeping Americans informed about the workings of government. 

The first and most profound way in which coverage of government programs so often creates a distorted picture is the failure of news organizations to ask the “Compared to what?” question. Suppose, for example, that some Republicans in Congress call attention to unacceptable wait times for new patients seeking a first appointment at the Phoenix VA. The chairman of the House Veterans Affairs Committee further claims, as did Representative Jeff Miller in 2014, that “there could be as many as forty veterans whose deaths could be related to delays in care.” Finally, it’s revealed that some VA employees tried to juke the stats to hide how long some veterans were waiting to see a doctor. 

That all sounds bad. But just how bad is it? Do these facts prove, as many have argued, that we should privatize the VA, or outsource more veteran care to the private sector? Engaging with these questions depends on learning how these facts compare to what’s going on throughout the rest of the U.S. health care system. Once we ask the “Compared to what?” question, it turns out that this isn’t particularly a story about the VA. To begin with, as other RAND research has concluded, VA wait times for new patients are actually shorter than the times found in studies of the private sector. Indeed, according to a Commonwealth Fund study, one in four Americans reported having to wait six or more days for an appointment with their primary care physician, even when they were “sick or needed care.” 

What about those forty veterans who reportedly died while on a VA wait list? In the private sector, too, people die all the time while having a pending doctor’s appointment. Sometimes, this is malpractice; most often it isn’t. Remember, many people also die while having an appointment to see their dentist. In the case of the Phoenix VA, a subsequent review by the VA inspector general uncovered that six, not forty, veterans had died after experiencing “clinically significant delays,” and that even in those six cases it wasn’t certain that the delays caused the deaths. In other words, they may have died while waiting for an appointment rather than because they were waiting for an appointment. Yet the “Forty vets died waiting for VA care” meme continues to show up over and over again in stories about the VA, as if it provides the context readers need to understand what’s wrong with the VA and why so many people want to privatize it. It’s a great example of a fact that is literally true but essentially misleading without more context—that is, as good as a lie.

Again and again, spotlighting VA issues that are common-place throughout the private sector has the effect of making VA care look as if it is exceptionally bad, when in reality it’s as good or better than the care most American receive elsewhere. In the U.S., private hospitals and physicians kill more than 250,000 patients a year (and seriously injure 1.5 million) due to preventable medical errors. Prestigious hospitals like the Cleveland Clinic, New York University’s Langone Medical Center, and the Stanford University Hospital have all had serious patient safety problems. Yet no one suggests that these hospitals should be socialized. 

Does the VA have difficulty recruiting primary care and mental health specialists? Yes, it does. But the health care system as a whole faces acute shortages of these professionals. More than eighty-four million Americans live in federally designated primary care shortage areas. One study shows that 77 percent of U.S. counties face a severe shortage of practicing psychiatrists, psychologists, or social workers; 55 percent of U.S. counties—all rural—have no mental health professionals at all. Without the VA, these numbers would be even worse. 

Are too many VA employees receiving untoward bonuses, as USA Today charged in a series of articles in 2016? Perhaps. But a false picture of the VA is created if no comparisons are made with the huge bonuses or salary increases given to executives of private-sector hospitals, including nonprofits. To cite just one example: Between 2010 and 2013, the Cleveland Clinic risked being suspended from the Medicare program because of serious patient safety violations. Yet its CEO, Toby Cosgrove, was given a raise of hundreds of thousands of dollars each year without a peep from Congress, or the media. 

The point is not that the VA has no problems; it does. The point is that by failing to compare it to other health care systems, journalists can present a distorted impression that plays into ongoing efforts to privatize an agency that outperforms the rest of the U.S. health care system on most metrics. 

What about the VA employees who rigged the stats to conceal wait times? Of course, that’s unacceptable. But it also points to another imbalance between how we talk about the VA and how we talk about private health care. Most private systems don’t even attempt to collect such data, much less make it public. The VA may have failed to live up to the standards it set for itself, but at least it set a standard, and took action after its own employees and inspector general came forward to report problems. Similarly, the VA has received highly negative press for the number of medical errors it commits. But this news only came out because the VA was publicly reporting medical errors at a time when other health care providers were routinely covering them up.

This asymmetry is far from limited to the VA. Consider how the press plays stories about business failures. Most new companies fail; when they do, the narrative is not that entrepreneurship or venture capital is a flawed concept. When it turns out that fraud was involved, the narrative is not that capitalism is a rigged game. But when a startup company that has received some public investment fails, as was the case of Solyndra during the Obama administration, this becomes a “scandal,” which conservatives then use to prove that it’s time to shrink the government and give more power to private capital. 

When Time magazine named neuroscientist Ann McKee to its 2018 list of the world’s 100 most influential people, it didn’t even mention her position as chief neuropathologist for the Boston VA.

In the case of the VA, this asymmetry is particularly acute. To begin with, VA managers have to answer not only to a 535-member board of directors known as Congress, but also to two standing congressional committees that oversee the VA’s every operation, from setting and tracking its spending to micromanaging its treatment of individual veterans, employees, and contractors. Meanwhile, the VA faces scrutiny from Congress’s Government Accountability Office, from an independent inspector general, from the executive branch’s Office of Management and Budget, and from a wide range of highly vocal veterans service organizations. Finally, the VA faces intense scrutiny by the media, both because it is a huge and expensive public institution serving a major segment of American society and because at any given time the VA’s performance is a major political story with the potential to severely damage the reputation of the party in power. 

By contrast, not only are there no inspectors general or standing congressional committees for private health care, but hospitals and doctors in the private sector excel at keeping damaging information about themselves, well, private. This includes nonprofit institutions and those associated with academic medicine. For example, researchers in Texas conducted a review of malpractice settlements among the 6,000 physicians in the University of Texas health care system. The report, published in JAMA Internal Medicine, found that nine out of ten settlements included nondisclosure provisions. Nearly half of those prevented patients even from discussing their injuries. 

The asymmetry of scrutiny shows up in other contexts as well. Consider the issue of veteran suicide. Suicide is a major cause of death among veterans, for reasons that include the specific traumas of military life. It is also a major and rising cause of death among Americans in general. So, sadly, are various other “diseases of despair” such as those caused by alcohol and opioid abuse, which are now so common that they are causing life expectancy to fall among broad segments of the U.S. population. This phenomenon is ultimately rooted in broad socioeconomic factors that may well be beyond the reach of medicine.

Unlike most private health care providers, the VA at least tries to ameliorate the effects of the socioeconomic determinants of health through broad, nonmedical interventions. These efforts include a suicide crisis hotline that has fielded 3.3 million calls and initiated 93,000 rescues since 2007, and innovative peer-to-peer mental health programs. Yet news reports frequently single out VA care for its failure to prevent suicide, substance abuse, homelessness, and other forms of despair among its patients, while not holding other health care providers responsible for fixing such broad social problems. This asymmetry leaves audiences with the false impression that the VA is failing in ways that the rest of the health care sector is not.

It would be bad enough if the problem were just more scrutiny for the VA than the private sector. But compounding that, the private sector gets to advocate for itself. It’s as if the VA has one arm tied behind its back—and the private sector has three arms. Private health care advertising spending this year is expected to surpass $10 billion, and a single hospital typically invests more than $1 million in advertising annually, with high-profile hospitals spending substantially more. The St. Jude Children’s Research Hospital, for example, spent $129 million on advertising in 2015, according to an analysis by Kantar Media. The VA, by contrast, didn’t launch its first television ad campaign until 2010. It was aimed chiefly at alerting service members to their eligible benefits, and cost $5 million.

The vast majority of VA medical centers have only one or two public affairs officers. They typically have to maintain their own computers and make do with minimal budgets. Worse, like many government agencies, the VA public relations efforts are compromised by excessive hierarchy and risk aversion. 

Describing what happens when reporters from national media outlets call, one local public affairs officer, who requested anonymity out of fear of reprisal, said, “You have to get permission from a regional office public affairs officer, who then has to send the request to [VA] public affairs staff in Washington, D.C. The two offices may not be in touch with one another.” This cumbersome process, the officer said, means that deadlines are missed. If it’s a negative story, the response is to duck and cover. 

Even journalists who try to write a positive story about VA care may find that they can’t get the necessary access. This is what Daniel Zwerdling, a reporter for National Public Radio, discovered when he wrote about the fact that the VA, unlike private-sector hospitals, was installing lift equipment on its wards to reduce injuries to nursing staff. “I found terrific local people working at specific hospitals who were anxious and eager to help me because they felt this was so important,” he said, but “they couldn’t do it without permission from on high.” 

This helps explain why, for example, the media often fails to give the VA credit for medical breakthroughs. When Time magazine added neuroscientist Ann McKee to its 2018 list of the world’s 100 most influential people, it didn’t even mention her position as chief neuropathologist for the Boston VA. 

New, corporate-sponsored “veterans groups” peddle negative stories about the VA to journalists whose lack of exposure to military life prevents them from seeing these groups for what they are.

Things have only gotten worse under Trump. The VA’s current national press secretary, Curt Cashour, is a longtime VA skeptic who previously served as the spokesman for Jeff Miller, the former Republican congressman who pushed drastic new privatization measures following the 2014 Phoenix scandal. Rather than highlighting the agency’s fine doctors, facilities, and innovative programs, Cashour and his team instead release public statements that highlight poor-performing VA hospitals and the dismissal of problematic officials. The same is true of current VA interim secretary Robert Wilkie, who has highlighted negative news stories reported on Fox & Friends, urging Congress to outsource more VA care. 

In a May 2017 op-ed, the Republican chairmen of the House and Senate veterans affairs committees railed against VA bureaucrats who, they argued, were responsible for a “dysfunctional culture” and “terrible management.” They lamented the fact that, as they put it, “it’s virtually impossible to dismiss bad employees, no matter what they do.” 

It’s a common refrain made since Phoenix, and one many in the media have adopted. Whatever has gone wrong there, it must be the fault of lazy, incompetent, or venal bureaucrats. Sometimes it is, of course. But more often, as with other federal agencies, red tape and dysfunction is brought to you by Congress. Blaming the bureaucrats is a bit like blaming the coach when the general manager hasn’t supplied a full roster.

Consider the backlog story. Currently more than 75,000 veterans are waiting for the VA to decide whether they qualify for health care and other benefits. Though that’s down from more than 600,000 five years ago, it’s still too many. And the VA could and should do more to streamline its administrative processes. But ultimately, it’s Congress that has caused the problem by passing laws that force the VA to adjudicate impossibly difficult eligibility standards. Under current law, the VA generally must deny benefits to veterans unless they can show that they are either poor or suffer from some specific degree of disability related to their military service. But how does anyone know, for example, whether an aging veteran’s hearing loss is caused by exposure to artillery fire in Vietnam in 1967, or by exposure to too much rock-and-roll in 1969, or by the natural effects of aging? Adjudicating these kinds of cases is incredibly time consuming and expensive—and, to veterans, often humiliating. 

Similarly, it’s members of Congress, not VA employees, who decide how much money to allocate to the VA, as well as where and how to spend it. As numerous commissions have shown, the VA is saddled with billions of dollars of expenses for operating obsolete facilities because members of Congress don’t want to close or find more innovative uses for these facilities in their district. More recently, VA hospitals and clinics have become strapped for cash because Congress—not VA employees—passed the CHOICE Act, which required that the VA divert more resources to paying private doctors for the treatment of VA patients. 

In previous eras, journalists who covered veterans’ issues were often veterans themselves and typically had friends, relatives, and coworkers with military experience. But today’s reporters and editors, especially those working in elite media outlets in deep-blue elite coastal cities, are unlikely to know anyone who has served in the military or uses VA health care. That makes the reporting job harder to do right. 

In 2016, a mere 7 percent of U.S. adults were veterans, down from 18 percent in 1980, according to the Census Bureau. Not only has the overall number of American veterans shrunk dramatically, but younger veterans are increasingly isolated geographically and socially from elite opinion makers. (New York’s 7th District, for example, which includes parts of Brooklyn, Queens, and Manhattan, is home to plenty of members of the elite liberal media, but has barely more than 8,000 veterans out of a total population of over 763,000.)

Another factor that makes it hard for journalists to determine who actually speaks for veterans is the increasing isolation of America’s veterans from one another. Today’s younger veterans are less likely than past generations to join or participate in veterans service organizations. Membership in the Veterans of Foreign Wars, for example, plummeted from 2.1 million in 1992 to 1.3 million in 2013. By 2014, only 7 percent of VFW membership was forty-one or younger. 

These factors have created a vacuum in veterans advocacy into which have stepped various new, corporate-
sponsored “veterans groups” peddling negative stories about the VA to journalists who don’t have the life experience to see these groups for what they are. One prominent example is Concerned Veterans for America. A host of regional and national outlets—including USA Today, the Hill, and the Washington Examiner—regularly run columns by CVA’s executive director, Dan Caldwell, that rail against the VA and call for most of its care to be outsourced to the private sector. In 2015, the editorial board of the Arizona Republic, which is part of the USA
Today
network, released an op-ed lauding CVA’s work on veterans’ issues while faulting President Obama for not inviting them to a policy roundtable. Yet unlike the VFW, the American Legion, or other traditional veterans service organizations, CVA is not accountable to dues-paying, rank-and-file veterans. Rather, it is largely financed by the Koch brothers and their network of wealthy funders and led by a narrow band of media-savvy professional advocates.

Another “Astroturf” organization has particular influence among progressive media organs. Paul Rieckhoff, the telegenic founder and CEO of Iraq and Afghanistan Veterans of America (IAVA), is the go-to guy when someone like MSNBC’s Rachel Maddow needs the “veterans’ perspective.” Indeed, Maddow is such a fan of Rieckhoff and his organization that she and her domestic partner personally donated more than $50,000 to IAVA in 2011. Another big fan is Maddow’s colleague Brian Williams, who recently told viewers that he had raised money for IAVA, before asking Rieckhoff for his opinion about the Ronny Jackson debacle.

Rieckhoff has used his access to progressive journalists to level particularly harsh criticism of the VA over the years. He played a key role in giving cover to Republican privatizers like Jeff Miller when they were peddling the wait time “scandal” in 2014. During an on-air interview at the time, Rieckhoff commended Miller to Rachel Maddow and said of the VA’s performance, “If you weren’t outraged years ago, you weren’t paying attention.” If Maddow had more direct contact with the world of veterans affairs, she might have asked who, exactly, Rieckhoff speaks for. IAVA’s website claims 425,000 members, but membership merely entails a mouse click; no dues are required, nor proof of veteran status. The organization’s funding, meanwhile, comes from “partners” who include major corporations that stand to gain directly from VA privatization. These notably include TriWest Health Care Alliance, which contributed more than $500,000 to the organization in 2012—not long before becoming a major beneficiary of legislation that forced the VA to outsource more care to the private sector. 

The drumbeat of negative media coverage about the VA is taking its toll. According to the Pew Research Center, as recently as 2013, more than two-thirds of Americans said they had a favorable view of the VA. But more recent Pew polling shows that the VA is now one of the least popular agencies they track, with an approval rating below even that of the hated Internal Revenue Service. Even many veterans, while generally happy with their own care, have absorbed the anti-VA narrative. 

In late March, we spoke with six Vietnam veterans at the Milwaukee VA Medical Center. All were in their late sixties and early seventies, and had struggled with PTSD, alcohol, and anger. After retiring, they had come to the VA for help. “It was really fantastic when I came here,” one said, summarizing the feeling of the group. “I have no complaints.” But, they insisted, this particular VA and its therapists were special—not like other VA centers, where vets were frequently denied care and put in danger. When they heard evidence to the contrary, the six veterans refused to budge. No, they insisted: the VA is bad everywhere else, and more VA employees should be fired. 

That even satisfied VA patients can hold such critical views shows how much peril the agency is in. The anger at agency officials at Phoenix, stoked by sensational media reports, led to the passage of the VA Accountability and Whistleblower Protection Act last year, which had the unintended consequence of purging lower-level staff—often veterans—accused of minor infractions. Most recently, with bipartisan support, Congress passed the VA Mission Act, a “reform” package that could massively divert more veterans’ care from the VA to private-sector providers—which, in turn, would likely force the closing of many VA hospitals. Meanwhile, the Trump administration would clearly like nothing better than to be able to outsource lucrative contracts for VA care to its friends in the private sector. If the press doesn’t get this story right soon, America’s biggest and most successful example of government-provided health care will soon pass into history.

Suzanne Gordon and Jasper Craven

Suzanne Gordon is the author of The Battle for Veterans' Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care and the forthcoming Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation's Veterans.

Jasper Craven is a freelance reporter interested in overlooked policy changes at the local, state and federal levels. He has written for The Nation, Vermont Digger, The Boston Globe, and the Chicago Tribune, among other outlets.