There are bureaucratic messes, and then there are Department of Veterans Affairs (VA) bureaucratic messes, and ne’er shall the twain come close to the other in terms of actual human costs. The stark reality is that the messes within the Veterans Health Administration (VHA), as within VA generally, are more often than not driven by a toxic mix of institutional politics and politics generally—sometimes partisan, sometimes ideological, sometimes electoral—intermixed with general public ignorance of what the VA is and how it actually operates. The shame is that the result has repeatedly proven deadly to veterans. And yet the eternally repeated hope is that in the wake of a deadly scandal, Congress’ mandated reforms, programmatic expansions, and crescive budget lines will magically disappear the systemic problems in play, forcing the VA critics to silence in the face of new customer satisfaction surveys.

There are poisonous fault lines in this latter dynamic: That any criticism of VA-delivered health care is a nakedly partisan attempt to shut down or “privatize” VA; likewise, that VA always knows and always acts and actually can provide what’s best, in every individual case, for a population of millions of veterans aged anywhere from barely twenty to over one hundred years old, and spread out over a landmass measuring around 3.8 million square miles.

A confluence of recent investigative stories, reports, and new medical research on mental health, traumatic brain injury (TBI), and “excess deaths” among the Post-9/11 veteran cohort newly retell the century-long story. It reveals what I’ll call the “debacle dynamics” of VA-delivered care, juxtaposed against truly wonderful VA-sponsored research emphasizing the life-savingness of preventative care avenues for veterans with TBI and mental health needs.

This particular retelling revolves around Mission Act community care implementation in San Diego—the fifth most veteran-populated county in the United States—but also nationwide. The plot is that nameless, faceless, unreachable VA administrators are overruling VA doctors’ judgments about veteran patients’ treatment plans because “it’s often best for patients to come to the VA even if that’s not what their doctors want” (as San Diego VA chief of staff Dr. Kathleen Kim so unabashedly put it). The twist is that even as VA administrators are claiming that VHA has the capacity to treat increasing numbers of veterans, VA’s Office of Inspector General has found that VA has little accurate information or clarity about either its actual capacity for care in particular geographic areas or the size in real-time of its health care staff. Furthermore, the physical age of the majority of VHA facilities—averaging sixty years old—is a material hindrance to VHA’s ability to deliver technology-reliant modern health care.

Denying the Community and the Care in “Community Care”

Last November, in collaboration with USA TODAY, inewsource published an extensive five-part investigative story outlining how VHA administrators in San Diego and elsewhere have been taking it upon themselves to overrule VA doctors’ treatment plans and recommendations for care, when those involve treatment outside of the VA—what’s known as community care. Community care is now a permanent feature in the suite of health care options available to veterans through their veterans’ benefits, thanks to the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, what’s commonly called the Mission Act. Under the bipartisan VA Mission Act, the government agreed to cover eligible veterans’ medical costs inside and outside of the VA health care system, under any one of six circumstances, to ensure that veterans neither die while waiting for care nor have to forgo the care they need just because their local VHA doesn’t offer it (or in the [common] event there is no local VHA).

The Mission Act was the latest in a string of reactive legislative fixes that successive Congresses and presidential administrations attempted in the wake of the Phoenix VA secret health care waitlist scandal in 2014. The culmination of multiple iterations of the VA Choice Act, the Mission Act, was a controversial compromise between those who argue that today’s veterans need access to private care for their health care needs and those who argue that allowing veterans to use government funds to access health care outside of the VHA system is a dastardly ploy to shutter the VA. Meanwhile, the reality of the matter is that VA’s health care model is limited; it originated “in an era in which medical care was synonymous with hospital care,” as former VA Secretary Anthony Principi recently testified, so the VHA facilities and model of care that were built reflected a “health care commitment to most veterans as access to a hospital bed to the extent beds were available.”

American medicine and—largely thanks to Principi’s reform efforts in the 1990s—even VA health care has since pivoted toward patient-centered treatment, though in the VA’s case, it’s often still more a theoretical pivot than a real one. That is what the inewsource investigation revealed: Despite so much legislative ink having been spilt to ensure that veterans benefit from modern patient-centered treatment that allows for preventative care and healing through a variety of proven approaches, VA administrators are still locked onto the idea of numbers, of the number of veterans in VA patient gowns as denoting success. Since 2019, the VA has evidently used a “referral coordination initiative” utilizing “referral coordination teams” to bring veterans “back” to its hospitals, which has shifted referral responsibility away from doctors. With hospital leaders being told “to monitor health care costs as a ‘key performance indicator of success,’” administrators are denying or voiding physicians’ treatment plans, and ordering veterans to leave their community care physicians and return to the very VHA facilities that harmed, or couldn’t help them, in the first place.

The inewsource report follows numerous stories documenting the real-world harm of VA’s yo-yoing debacle dynamics. A group of veteran mental health patients stands out, particularly because of Congress’ emphasis (running into the hundreds of individual pieces of legislation over the past fifteen years) on meeting veteran mental health needs and ending veteran suicide. These San Diego veterans had been approved to receive ketamine therapy at a private clinic to significantly positive effect. Ketamine is a therapy for severe, treatment-resistant depression, but the therapy is delicate and must be administered in consistent, very controlled contexts. The San Diego VA abruptly cut off this treatment, saying they had their own valid ketamine treatment (they didn’t), and despite frantic warnings from their own VA psychiatry staff, including the VA Chief of Psychiatry. To no avail, and to tragically predictable results: Numerous of these veterans are now effectively incapacitated and bedridden, requiring expensive full-time caregivers. One female Navy and Marine Corps veteran had already committed an entirely preventable suicide within a week.

VA’s Self-Defeating Self-Ignorance

Justifying these abrupt denials of community care, Dr. Kim said that VA doctors don’t “understand all the services the VA offers” and so don’t make “informed decisions” when referring their own patients for community care. VA’s own Office of the Inspector General, not to mention the Government Accountability Office, and dozens of Congressional Research Service (CRS) Reports, handily undermine this statement within a single second of a Google search. How can VA physicians be expected to know the extent of what VA offers in a particular location when VA itself doesn’t have a clue? When VA itself doesn’t even know…who all its own physicians are? Perhaps, in fact, it’s the VA physicians who best know the extent and limitations of their particular location’s offerings in respect to their own patients’ medical needs.

Furthermore, why so denigrate the very professionals doing the actual life-saving delivery of care the entire system professes to rely on?

It turns out that as a respectable Cabinet-level entity, and the second-largest federal agency with the fastest-growing budget ($270 billion for 2022), since before the first Obama-era emergency community care program, VA has had little idea of what each of its medical centers did or didn’t provide; and more recently, it turns out that VHA consistently has incomplete data on the number of physicians that provide care at its medical centers; that it is consistently (and often gravely) understaffed in critical areas; that it has no staffing model to fix its systemic staffing problems; and finally, that its entire medical system operates more like a bureaucratic system of local fiefdoms thanks to the Veteran Integrated Service Networks (VISN) system that separates VHAs into regional administrative areas that don’t necessarily communicate between themselves or up the chain about processes, capacities, or much anything else.

Even more to the immediate point, VA has an absolutely opaque process by which it calculates it budgetary needs, by even Rand’s estimation—in fact, it has several different formulas, none of which are straightforward. What seems most straightforward directly coheres with the San Diego VA administrative attitude, however: being able to claim high numbers of veterans as actual or potential patients of direct VHA care. “VA uses enrollee health care projections to inform and propose staffing levels in the annual budget,” the Federal News Network reported of an August 2021 VA Office of Inspector General (OIG) report, “but the methodology has its flaws,” it concluded. I’ll say. According to the OIG report, VHA consistently misestimates the numbers needed, hours worked, and among specific specialties and at particular geographic locations of its staff. And from the first iteration of community care authorized in the 2014 Choice Act up through today, what has consistently hampered Congress’s desires with the legislation is VHA’s bureaucratic bungling—its lack of knowledge about its capacities and communities, and its lack of communication—its debacle dynamics.

So much unknown fundamental data by the very department that is in charge of it raises basic questions about its own competence to state its true capacities to treat veterans. One needs no political or partisan lenses to see this basic fact.

Standing in its Own Way

Meanwhile, federally funded research, whether through the VA or through other government entities, is resulting in actionable data about the most vulnerable veterans suffering through the effects of TBI or major depression and suicidal thoughts. In research published this February, Jeffrey Howard of the University of Texas at San Antonio discovered that contrary to the historical trend of combat veterans, Post-9/11 veterans have had an unusually high rate of “excess deaths” through accidents, homicides, and suicides. These are particularly linked with young veterans and with veterans suffering from moderate to severe TBI. (“Younger veterans who are newly separated from the military are susceptible toward engaging in risky behaviors like substance abuse, speeding, or placing themselves in dangerous situations.”) Howard sees this as a hopeful finding and his research as awareness-generating, however, in part because of what it reveals about the non-medical steps or interventions that an entire community can take: So many of these deaths are preventable, given the right care, delivered in a timely manner.

In this regard, as in so many others, the community outside of the VA is integral to the VA’s stated mission of care for those who have “borne the battle.” Not only does every VHA facility rely on that community for its doctors, nurses, and operational staff, but the veterans themselves must be a part of that community to have a successful transition into being healthy civilians. The baseline loneliness and low dispositional gratitude that researchers have found in suicide-prone veterans are needs that require “community care” to resolve. But so long as VA persists in defining the success of VHA as more veterans in VHA hospital gowns rather than as helping to return a healthy veteran body to society, it will continue to fail veterans and the entire community of the United States.