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July 01, 2014 12:38 PM Clueless or Craven? The White House Gets the VA Story Exactly Backwards

By Phillip Longman

Sad to say, the Obama administration seems clueless about what might be broken at the VA and how to fix it. Either that, or it is just cravenly saying and doing whatever it thinks is necessary to make the story go away.

Evidence for the clueless hypothesis came on Friday, when White House Deputy Chief of Staff Rob Nabors weighed in with his diagnosis (pdf) of what ails the VA. The document is extraordinary in its contradictions, sloppy formulations, and non-evidence-based conclusions.

It starts off well enough by reporting “a strong sentiment among many Veterans and stakeholders that in general VA provides high quality health care ‘once you get in the door’ and that the current system needs to fixed, not abandoned or weakened.” Then, having made the basic and important point that the VA continues to enjoy strong support among those who know from first hand experience how it actually peforms, Nabors offers an additional important point about the culture of the VA.

He observes that “The vast majority of VA employees are dedicated, hardworking, and committed to the Veterans they serve.” He notes, again accurately, that most VA doctors, nurses and staff could make more money working elswhere, but that that “they choose to work at the VA because they believe in this Nation’s promise to its Veterans, and work each day to realize that promise and deliver the quality of care Veterans have earned and deserve.”

Now that sounds like an institution with a real culture of excellence! Which makes one wonder what on earth Nabors was thinking when he next put down on the same page that the VA is beset by “corrosive culture.” If you say an institution has a “corrosive culture” you will be taken to mean that there is something fundamentally and systematically wrong with the values of the institution. And what phrase do you suppose the headline writers plucked from this report? The Wall Street Jounal was typical: “White House Review of VA finds “Corrosive Culture.”

Naturally, this is now what most casual news consumers believe about the VA. The White House told them so. But Nabors offers zero evidence that what problems the VA has are the result of anything like a systematic failure of culture. And where cultural factors are at work, he gets them exactly backwards.

The key case in point are the wait times that are supposedly at the heart of the “scandal.” Nabor quite rightly points out that the VA’s central office set an unrealistic goal in 2011 when it called for all new patients enrolling in the sytem to be seen within 14 days. The previous goal had been 30 days. Wait times for insured patients outside the VA are typically longer. There’s an acute nationwide shortage of primary care doctors and mental health professionals.

But bizarrely, the lesson Nabor then takes from this ill-advised cental management decision is that “The VA Central Office needs to be much more hands on with the [VA’s] field structure.” This is an incredible conclusion to take from a case in which too much attempted central control was clearly the root cause of the problem. Faced with impossible directives from Washington, some frontline VA employees juked some scheduling stats, and the official White House conclusion is that the frontline employees had too much automomy?

People who truly know the VA culture will tell you the opposite story. The VA emerged as a leader in health care quality beginning in the 1990s precisely because its cental management then let go of power. This devolution unleashed the incredible talent and idealism of frontline doctors, nurses and pharmacists who were doing extraordinary innovation in the field. The VA’s vaunted electronic medical record system, for example, which still sets the worldwide standard, is essentially a bundle of open-source health IT programs written by VA docs for VA docs.

But that culture of innovation came under attack starting in the Bush Adminstration. The Bushies’ political appointees began recentralizing power in Washington partly in the name of security, after a highly publicized incident in which a VA employee had a government owned laptop stolen from his home. Then as now, sensational and misleading headlines played into the conservative forces trying to undermine the VA, as most news consumers were left with the false impression that patient records had been breached. The Bushies then went on to do further damage to the VA’s culture of innovation by outsourcing key health IT projects to favored private contractors.

Sadly, rather than reversing that trend, the Obama administation just let the centralizing continue. As Ken Kizer, Undersecretary for Health in the Clinton administration and the man most responsible for turning the VA around in the 1990s observes in a recent piece in the New England Journal of Medicine: “In recent years, there has been a shift to a more top-down style of management whereby the central office has oversight of nearly every aspect of care delivery. Indeed, over that period the VA central office staff tasked to health care adminstrative duties has grown from about 800 in the late 1990s to nearly 11,000 today.

Clueless? Yeah it would seem. Except over the weekend, the White House announced that after deep and thoughtful deliberation, it had come up with just the man to turn things around at the VA, and he turned out to be a Republican soap and toothpaste salesman—a man with no experience whatsoever in running a health care or social services organization but who happens to be a close financial backer of Republican House Speaker John Boehner. No, that’s not clueless—it’s a cynical sellout of veterans by an adminstration that, in the wake of a monumental failure of the press to put this story in context, just wants to move on at any cost.

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.

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