Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation's Veterans

WOUNDS OF WAR

How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans

SUZANNE GORDON

ILR PRESS

AN IMPRINT OF

CORNELL UNIVERSITY PRESS

ITHACA AND LONDON

To my daughters Alex and Jessica Early

My most beloved advocates of patients and their caregivers

CONTENTS

Acknowledgments

List of Abbreviations

Introduction: What Kind of Care for Veterans?

1. Promises Broken and Kept: A Short History of the VHA

2. Those Who Have Borne the Battle: The VHA’s Patient Population

Profile—What It Means to Be a VA Volunteer

3. Primary Care the Way It Should Be

4. Healing Minds and Bodies: Integrated Mental Health Care and Primary Care

5. Dealing with a World of Hurt: VHA Treatment of Chronic Pain

6. When Wounded Warriors Are Women: Caring for Female Veterans

7. Mental Health the Way It Should Be

8. Unpacking PTSD: From Diagnosis to Effective Treatment

Profile—Karen Parko: A Special Kind of Professional Development at the VA

9. Returning to Civilian Life: Veterans on Campus

10. Suicide Prevention: VHA Programs That Save Lives

11. Overcoming Disability: VA Rehabilitation Services

Profile—Mark Smith: No Ordinary Bike Shop

12. Transcending Trauma: The Martinez Cognitive Rehabilitation Program

13. Off the Streets: Reducing Veteran Homelessness

14. Alternatives to Jail: Veterans’ Justice Programs

Profile—Cops and Vets: The Memphis Crisis Intervention Model

15. Specializing in Elder Care: The VA and Geriatrics

16. Knocking on Heaven’s Door: The VA and End-of-Life Care

17. Better Care Where? The VHA Compared to the Private Sector

Conclusion: A System Worth Saving—and Making Even Better

Epilogue: Thank You for Your Service?

Notes

Index

About the Author

ACKNOWLEDGMENTS

This book had many sources of inspiration, and I owe its publication to an entire battalion of friends, colleagues, VHA caregivers, veterans, and, of course, family members. It’s not possible for me to list here by name everyone I spoke with for this book, so the shout out below is for those interviewed not once but multiple times. Many people have helped me better understand the specific nature of veterans’ health care and the difficulties involved in delivering it. Others have helped me put current issues into historical context, or navigate the maze of congressional politics and policy making, especially in the chaotic environment of Washington, DC, since January 2017.

I want to express my gratitude to all the VA caregivers and staff, and veterans and their family members who shared their time and insights with me, or who allowed me to follow them as they worked or went to appointments. Some people who have helped me prefer to remain unnamed.

I am particularly indebted to Rajiv Jain, Rebecca Shunk, Bernie Sanders, and Philip Fiermonte, who encouraged me to pursue my idea of a book on VA health care. As then chairman of the Senate Veterans Affairs Committee, Bernie helped pave the way with the VA Central Office. I could never have parsed the complex issues of VA eligibility without the expertise of Steve Robertson, then serving in Bernie’s Senate office in Washington. I also want to thank Katie Van Haste, Sanders’s staff member in Vermont, for her continuing assistance, and Larry Cohen for his friendship and encouragement. I cannot do enough to express my gratitude to Bill Outlaw, who helped me get critical introductions to VHA staff across the country. And I want to thank Maureen McCarthy for her constant support.

Judi Cheary provided invaluable guidance and support in San Francisco, as did Russell Lemle, whose insights have been hugely important to me. A special thank you also to Bonnie Graham in San Francisco, and Cecelia McVey and Michael Charness in Boston. My cousin Andrew Budson generously shared his experiences caring for veterans for many years and doing related research on veterans’ memory problems. And my cousin Nan Schnitzler also helped with work in Boston. Tom Kirchberg has my perpetual gratitude for his critical support, as do Harold Kudler, John McQuaid, and Tom Neylan. Ditto to Brett Copeland.

Phillip Longman and Kenneth Kizer always made time for my endless questions and acted as a critical sounding board for refining my ideas. Robert Kuttner, Eliza Carney, Gabrielle Gurley, and the whole American Prospect team helped me cover the VA beat for them while this book was being written. At Washington Monthly, Paul Glastris and Phillip Long-man similarly encouraged and published my ongoing work. Randy Shaw at Beyond Chron consistently championed and published my work. The Prospect, the Monthly, and Beyond Chron provided an alternative perspective on veterans’ affairs often missing from the mainstream media. Indeed, these three publications are some of the only ones that actually take the time to accurately report on the VHA. Veterans should thank them all.

In the course of my doing this book and a previous one, Michael Blecker at Swords to Plowshares became an invaluable Bay Area ally, whose patience I tried during many a long conversation. Bradford Adams and Kate Richardson at Swords and Rick Weidman at Vietnam Veterans of America helped me better understand the variety and specificity of veterans’ health care problems. I also value my long conversations with Peter Dickinson at the Disabled American Veterans. Thank you also to Joy Ilem, Garry Augustine, and Adrian Atizado at the DAV, especially for an award that really spurred me on. Amy Webb at AMVETS was always available, for fact checking and information sharing. At the American Legion, Lou Celli gave me and Phillip Longman a much-appreciated opportunity to prepare a report for Legion members on what is at risk if the VHA is privatized.

VHA public affairs staff throughout the country made it possible to observe health care delivery at the local level. I want to thank Matthew Coulson in San Francisco; Michael Hill Thomas in Palo Alto; Cynthia Butler in San Diego; Tara Ricks in Sacramento; Pamela Redmond in West Haven, Connecticut; Palas Wahl in Boston; Naman Horn in White River Junction, Vermont; David Martinez and Charles Ramey in Las Vegas; Paul Coupaud in Phoenix; Patricia Tiernan-Matthews in Honolulu; and Willie Logan in Memphis. As undersecretary for health at the VA, Dr. David Shulkin helped open many doors for me at local facilities. In return, I did my best, in this book and elsewhere, to promote Best Care Everywhere, his limited-edition collection of VHA success stories.

At the AFGE, Marilyn Park, Ian Hoffmann, and Sara Kuntzler deserve very special recognition for their research and unstinting fight against VA privatization. Ditto Will Fisher at VoteVets.

I want to give special thanks to the veterans who have shared their experiences with me. First comes my old friend Louis Kern, who shared very painful accounts of his military service and reflections on it. (Thank you Kathleen Burke, for introducing me to your husband Lou!) Paul Cox and Denny Riley have been essential to this project, along with Diane Reppun, David Antoon, Kevin Miller, Josh Oakley, Dan Luker, and Buzz Davis. My Richmond neighbors Steve Kittle and David Moore let me go to their VHA appointments; I met Rick Karp while sitting in on David’s appointment with him. Thank you also to VHA physicians Dirk Woods, Poormina Goyal, and Ron Chueng. Many thanks to the pseudonymous Mojo and Robert Wallace (you know who you are in so many ways).

Other people at the VHA whose help was invaluable include Jason Kelley, Andy Pomerantz, Rebecca Brienza, Karen Seal, Tauheed Zaman, Jennifer Manuel, Bill Collins, Jeff Kixmiller, Sasha Best, Liza Katz, Keith Armstrong, Brandina Jersky, Joe Ruzek, Erin Finley, Anne Fabiny, Michael Drexler, Jim Lewis, Cathy Coppilillo, and my friend Kate McPhaul.

I also want to thank House Democratic leader Nancy Pelosi and her staff, Congressman Beto O’Rourke and his staff, and Josh Weitz at Congressman Mark Takano’s office for their time and attention to veterans’ issues. In health care policy and patient safety circles, I drew on the support of Don Berwick, Gordie Schiff, and Mardge Cohen. Thank you also to Charlyn Johns and Ken Watterson at the Dallas Veterans Resource Center.

At Cornell University Press, I am once again so grateful to the amazing team who got this book in print so quickly. First my coeditor and longtime friend Sioban Nelson and our equally dear colleague and friend Fran Benson, editor extraordinaire. I want to thank Dean Smith for his support, as well as Martyn Beeny for publishing—in a great hurry—The Battle for Veterans’ Healthcare and for supporting this book. I also want to thank, once again, Ange Romeo Hall, Nathan Gemignani, and Jonathan Hall. Although they are not at Cornell, Matt Rothschild and Denise Logsdon provided crucial editorial assistance. Their quick response to my pressing, sometimes panicked, questions and concerns kept this book on the fast track. Thank you to my dearest agent Anne Borchardt.

Finally, there is my husband, Steve Early, who did much near-deadline editing as well. I especially remember the morning we both woke up at seven, not very rested because we had spent the night, tossing and turning, over what to title and subtitle this book. Our daughters Alexandra and Jessica Early have been my personal correspondents from the front lines of our fractured health care system.

It was a proud moment when Jessica became a nurse and then went to work, caring for veterans, at the VHA in West Haven, Connecticut. As a staff member for Rights & Democracy in Vermont, she advocated for universal health coverage. Every conversation with Alex, about her work as an organizer and advocate for nursing home staff represented by the National Union of Healthcare Workers, contains some new reminder of patient safety or staffing problems in for-profit nursing home chains.

Hopefully in their lifetimes, if not mine, the United States will join the rest of the industrialized world in guaranteeing that everyone in our country has access to quality care, as VHA patients do today.

ABBREVIATIONS

INTRODUCTION

What Kind of Care for Veterans?

The View from Fort Miley

It’s a chilly day in late August 2015 at the facility known as Fort Miley, a medical center in San Francisco operated by the Veterans Health Administration (VHA), the largest agency in our US Department of Veterans Affairs (VA).¹

Many of Fort Miley’s cream-colored, art deco buildings provide sweeping views of the Pacific. Its hospital complex also offers one-stop shopping for Northern California veterans who need primary or specialist care, audiology or optometry services, mental health or substance abuse counseling, or many other services.

While researching this book, I’ve spent many hours at Fort Miley. I originally came to explore how the VHA, a publicly funded national health care system more European in form than our fragmented, market-driven private-sector model, serves its patients. During visits here and other veterans’ hospitals across the country, I’ve looked at innovations in clinical care, teaching, and research (the three primary missions of the VHA). I’ve asked veterans about the quality of care they receive and observed how VHA doctors, nurses, social workers, and other staff deliver their care.

My own journalistic mission shifted somewhat, as more members of Congress—encouraged by conservative activists, like the Koch brothers—began to push for privatization of VHA functions. The ongoing debate about the future of our nation’s largest health care system directly affects nine million veterans eligible for care because they are low-income or have a medical problem that is military-service related. So I began asking additional questions in my patient interviews. Do veterans prefer getting services directly from the VHA? Or has their experience, if any, with outsourced care available since 2014 through the Veterans Choice program made them converts to the private hospitals and physicians favored by the Koch brothers, congressional Republicans, some Democrats, and President Trump?

The answers I usually get may surprise some readers, whose perception of publicly funded veterans’ health care has been much influenced by largely negative mainstream media coverage of the VHA in recent years. Today, for example, I stop for coffee in the Fort Miley canteen after spending the morning observing the work of VHA telehealth specialists, who assist veterans in rural California unable to make the trip to San Francisco. I’m waiting to attend a class on mindfulness meditation for veterans suffering from PTSD. It’s close to noon, and the cafeteria begins to fill up with veterans, their family members, and VHA employees. A stocky man in his forties, looking for an empty table and finding none, stops by mine. He points to a vacant seat and asks, Do you mind if I sit down?

Please do, I respond. As he sits down, I glance at his lunch.

No, I am not sharing with you, he jokes.

As we chat, I tell him that I am writing a book about veterans’ health care. He quickly introduces himself and launches into an unsolicited testimonial to the VHA. His name is Rick Martinez,² and he tells me a story that will become very familiar as I conduct hundreds of conversations and formal interviews with veterans like him.

Martinez spent twenty years in the Marines. After he retired, he developed mental health problems and was eventually diagnosed with manic depression. Like so many men and women whose stories are told in this book, Martinez initially avoided seeking treatment, a reflex finely honed while on active duty. In the Marine Corps, he explained, they discourage you from going to the medic or doctor. It’s hard for us to get help because the majority of us don’t want to be wimpy. ‘I went to war—I don’t need help’ is the attitude. If I tell people I’m having trouble, I’ll be processed out.

In civilian life Martinez could no longer hang on to my brothers and charge on, he says. He began to drink a lot, didn’t want to get out of bed, and experienced paranoid episodes. He now gets professional help at the VHA’s downtown San Francisco clinic and also sees a psychiatrist at Fort Miley, who prescribes and checks on his various medications. At City College of San Francisco, where he is studying sociology and film, Martinez regularly visits the Veterans’ Resource Center, where a social worker named Keith Armstrong has been really helpful.

Talking with these staff members about his personal problems is still not easy for him. I don’t want to keep rehashing things. If I keep rehashing everything, it can get overwhelming, he tells me. But as a self-described proactive patient, Martinez gives his VHA helpers high marks for being good listeners and respectful of his own opinions. I watch Dr. Oz, he says. I ask questions. If I am not satisfied, I ask why. My doctor listens to me if I bring up my concerns. Martinez urges me to contact Armstrong at the Veterans’ Resource Center, where he and others have been able to find camaraderie and community on campus, thanks to the VA.

As Martinez gets up to leave, a veteran at the next table leans over and tells me he’s been listening to our conversation and would like to talk to me as well. Older than Martinez, fifty-nine-year-old Phillip Davis* has a craggy face, trim beard, and short gray hair. Davis served for twenty-three years in the Marines, most of that time as a platoon sergeant, a role in which he was a tough taskmaster. A lot of people didn’t like me, he says.

During the first Gulf War, his unit was scheduled for deployment but did not end up seeing combat. Like Martinez, Davis found transitioning to civilian life a hard adjustment. In the military, he says, things run smoothly. People do as they’re told. If they don’t, there are consequences. There are no consequences for civilians, he believes.

Later in his career, Davis suffered a noncombat injury to his back. That condition, plus PTSD, led him to Fort Miley. He confesses to having anger management issues. Medical center security was once called when he snapped and shouted at a young VHA doctor during a routine appointment. Despite that incident, he is grateful for VHA assistance with his physical and mental health problems. His wife also feels strongly supported by the VHA, he says.

While I’m still chatting with Davis, a third veteran, who has overheard our conversation, walks by and hands me a paper napkin with his phone number written on it and a scribbled note asking me to call him later. When I do, I learn that he, like one hundred thousand other VA employees, is a veteran himself. He just wants me to know that he would have found it very difficult to get employment outside the VHA and is grateful for being able to serve his fellow veterans.

As I walk out of the canteen to attend the mindfulness meditation class, I pass various waiting rooms, in which I see patients exchanging stories about their time in the military and their time at the VA. Sometimes people sit in silence, but most of the time the VA’s corridors and waiting rooms are a bustle of human connections.

As a journalist and researcher who has spent the past thirty-five years writing about health care and observing clinicians and health care workers mostly in the private sector (and, as a patient, has received health care services for the past seventy-two years), I have spent a lot of time in hospital waiting rooms and cafeterias. In all those years, what I have noticed is people sitting in isolation. At VHA hospitals and clinics, patients actually talk to each other and support each other, providing a sense of camaraderie that is a facsimile of what they had in the military.

My visit to Fort Miley that day was just one of many I made between 2014 and 2018 while working on this book about veterans’ health care and confronting how the Veterans Health Administration deals with the many wounds of war from which veterans suffer, whether they have been in combat or spent years or months preparing for it. In 2014 I decided to explore the kinds of care—and innovations in care—that can be delivered in a genuine national health care system. Rather than return to Canada, or the UK, or Australia, New Zealand, or Europe, where I have visited and even worked over the years, I decided to stick closer to home and see what our own homegrown national health care system has produced. In the course of my research, I spent months in different VHA facilities all over the country observing primary care providers and geriatricians, palliative care and hospice specialists, mental health practitioners, rehabilitation professionals, designers of prosthetic devices, pioneers in team training and patient safety, and researchers, among many others.

I have interviewed veterans of all ages, as well as their family members. I have watched veterans enter the system and be cared for after—sometimes years after—they separate from the military. I have watched older veterans as geriatric and palliative care specialists help them go through the pain and suffering of terminal illness and negotiate their last days of life with grace and comfort. (As someone who has long written about our society’s failure to provide compassionate care at the end of life, I found these encounters some of the most moving I had while writing this book.)

In San Diego I visited the ASPIRE Center, a special VA program devoted to reducing homelessness among Iraq and Afghanistan veterans.

At a VA clinic in Martinez, California, I met younger men and women who served in these same wars but experienced traumatic brain injuries and suffer from severe post-traumatic stress disorder. They are now participating in an innovative program to help them live fuller lives.

I met young women, badly scarred by the experience of sexual assault in the military, who because of VHA outreach efforts directed at female veterans are now getting treated, in Sacramento or San Antonio or Boston, for military sexual trauma.

On the streets of San Francisco, I followed a VA social worker who was searching among the homeless who now crowd our cities to find veterans who could get housing and health care from the VHA.

I followed VA staff as they helped veterans in trouble with the law navigate the system of veterans’ courts designed to help them avoid incarceration if they seek treatment for the alcohol and drug abuse problems or mental health issues contributing to their arrest records.

In upstate New York, I sat with VA employees who staff the agency’s veterans’ crisis hotline as they listened to call after call from distraught family members who worried that a loved one was about to take his life. And I watched as the suicide prevention team cautiously investigated where the veteran might be and how to help in a way that would not endanger either the veteran or his or her family.

In West Haven, Connecticut, I witnessed the work of one of the VA’s thirteen Blind Rehabilitation Centers, which serve 157,000 veterans who are legally blind and hundreds of thousands more whose vision is sufficiently impaired that they have trouble navigating daily life.

In San Diego I talked to researchers doing pioneering work on the use of telehealth for delivering mental health care.

In Las Vegas I talked with nurses who monitor video screens, using telehealth to patrol the fluctuating blood pressures or blood sugars of the veterans whose chronic conditions they help manage. While in White River Junction, Vermont, I watched a veteran, again via telehealth, as a physical therapist in North Carolina coached him through exercises that would help him recover the use of a frozen shoulder.

At VHA clinics and hospitals across the country, I’ve observed veterans in salsa dancing classes that encourage them to socialize and relate more cooperatively, cooking classes to help them make healthy meals and read food labels, and mindfulness meditation and yoga classes to help them cope with their anger and frustration.

Over and over again, veterans told me—and you will hear their voices throughout this book—that they would be dead without the VA, in a ditch without the VA, or otherwise lost without the VA. And very few, even those critical of VA failings or shortcomings, proved to be enthusiastic proponents of having private health insurance instead.

This is the hidden reality of veterans’ health care that is rarely seen. In recent years the buzz about veterans’ health care has not been good, inside or outside the Washington Beltway. Open any major newspaper, watch any TV news report, or listen to any radio talk show, and you’ll find that VA is invariably preceded by adjectives like stumbling, beleaguered, broken, or scandal-ridden. Every year, our federal government spends about $70 billion on medical care for the nine million men and women who use hospitals and clinics run by the VHA. But according to the media and Congress, much of this goes to incompetent employees, bonuses for corrupt managers, indefensible expenditures on hospital art, failed suicide prevention programs, and doctors who dispense opioids like breath mints.

This steady stream of invective was unleashed in April 2014, when a doctor, Sam Foote, exposed serious misconduct by a few VHA hospital managers. The VA central office had imposed what some considered an unrealistic goal of wait times no longer than fourteen days for an appointment at the VHA. In Phoenix and several other cities, managers had falsified data that suggested that facilities were meeting this goal. The local administrators involved got undeserved performance bonuses. Meanwhile, they papered over the need for more doctors and nurses to handle the high volume of veterans seeking VHA care in the Sun Belt. This wait-time cover-up triggered a political uproar on Capitol Hill and a journalistic feeding frenzy that has yet to subside.

Conservative Republican Jeff Miller of Florida, then chairman of the House Committee on Veterans’ Affairs, kicked things off by insisting that forty patients died while waiting for an appointment at the VHA in Phoenix. Pressure from veterans’ organizations like the American Legion led to the resignation in May 2014 of General Eric Shinseki, the first secretary of veterans affairs under Barack Obama. When the claim of forty deaths was later investigated by the VA inspector general, it was found that six, not forty, veterans died while they were on waiting lists to see a physician. The report noted, We are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. Many people die while waiting for a medical appointment. This does not mean, however, that they died because of the delay.³

Whatever the truth, the damage had been done. That July, President Obama replaced Shinseki with Robert A. McDonald, a West Point graduate and former CEO of Procter & Gamble. McDonald changed the reporting protocols of local VHA hospital administrators, fired or suspended those responsible for disguising appointment delays, and, most important, began recruiting more clinical staff to ensure faster patient access, particularly to primary care. Assisting McDonald’s reform efforts was physician David Shulkin, a VA undersecretary for health appointed by Obama, who had private-sector experience as a hospital administrator in Pennsylvania.

None of the media reports on the Phoenix scandal highlighted the problems of chronic underfunding—and thus understaffing—of the VHA.⁴ In February 2014, well before the much-needed whistle-blowing in Phoenix, Senator Bernie Sanders, then chairman of the Senate Committee on Veterans Affairs, had recognized the VHA’s staffing shortage and proposed a budget allocation of $21 billion that would have fast-tracked the hiring of thousands of additional caregivers. Conservative Republicans opposed this expenditure. So after the problems in Phoenix erupted, Sanders was forced to negotiate with Senator John McCain on compromise legislation, eventually passed in the summer of 2014.

The Veterans Access, Choice, and Accountability Act of 2014 allocated $6 billion to care at the VHA, $18 billion less than Sanders initially sought. An additional $10 billion was earmarked for a three-year trial program known as Veterans Choice. Under Choice, patients who lived more than forty miles from the nearest VHA facility or faced appointment delays of more than thirty days could seek care from private hospitals and doctors at VA expense.

Despite this initiative, the drumbeat of conservative and media criticism continued. During his final two years in office, President Obama never vigorously defended publicly provisioned veterans’ care. He didn’t do what Senator Sanders did, which was point out the VHA’s many strengths as an integrated national health care system (and personally encourage journalists like me to check it out more closely). Instead, the White House and Congress appointed a bipartisan Commission on Care to develop strategies for the future of the VHA over the next twenty years. This panel included some genuine experts, like Washington journalist Phillip Long-man, author of the widely acclaimed book Best Care Anywhere: Why VA Health Care Would Work Better for Everyone, and Vietnam veteran Michael Blecker, executive director of the San Francisco–based veterans’ group Swords to Plowshares.⁵ But commission members like Longman and Blecker were far outnumbered by those from private-sector hospitals or representatives of the Koch brothers–funded Concerned Veterans for America, which favors further outsourcing of VHA services or total privatization of the agency.

The commission did conduct an independent assessment of the VHA’s effectiveness. The resulting consultant report faulted the agency for various management shortcomings. But researchers from the RAND and Mitre Corporations also confirmed, in great detail, that the quality of the VHA’s frontline care was equal or superior to that delivered in the private sector. And their study noted that wait times for appointments with primary care providers or medical specialists at the VHA were actually shorter than those experienced by patients using private doctors and hospitals.⁶

These findings were rarely reflected in any reporting or commentary in major media outlets. Instead, the VHA was indicted for failing to prevent veteran suicides (New York Times),⁷ gaming internal ratings by keeping veterans out of small rural hospital (New York Times again),⁸ and doing nothing to stem our national epidemic of opioid overuse, whose victims include many veterans (Fox News).⁹ VHA wait times remained terrible, perhaps even lethal (according to CNN),¹⁰ plus its operating rooms were filthy (Boston Globe).¹¹ Women veterans got no services (Philadelphia Inquirer).¹² VHA services should be provided by private hospitals, its own facilities closed, and homeless veterans housed in them instead (Boston Globe).¹³

VHA staff—three hundred thousand employees in all, one-third of whom are veterans—were malingerers and a drain on the federal treasury (USA Today). Further displaying its profligacy, the VHA wasted US taxpayer money on artwork in its hospitals (USA Today again). And that was before Donald Trump targeted the VA in his campaign for the White House in 2015 and 2016. Trump declared that the treatment of veterans by their own government was horrible, horrible and unfair. He pledged that, if elected, he would fire those responsible and greatly expand VHA patient access to private-sector care.

Trump’s Electoral College victory unleashed what the Times called a potent new effort by deep-pocketed conservative activists to allow private health care to compete with Veterans Affairs hospitals for the patronage of the nation’s veterans. To advance its campaign against government-provided medical care, the Kochs’ Concerned Veterans for America pledged millions of dollars for advertising and outreach and unleashed a small army of lobbyists and donors to pressure the Trump Administration and Republican lawmakers.¹⁴ The Koch brothers and other conservative activists are determined to defund and dismantle the VHA, and use any hint of problems at the VHA to discredit the notion that government can serve the public good. They also use problems at the VHA to delegitimize efforts to create a more rational, national health care system in the United States.

Fearing the worst, many observers were thus surprised and relieved when Trump nominated Dr. David Shulkin to remain as head of the VA, becoming the only Obama administration holdover in Trump’s cabinet. Shulkin was approved by unanimous consent of the Senate. Under Obama, Shulkin praised the VHA, pledged that he would never privatize it, and even helped compile a 440-page collection of VHA case studies titled Best Care Everywhere (published in June 2017) that hailed his agency’s little-publicized role as an incubator for health care innovation.

Shulkin’s collection is dedicated to veterans, their VHA caregivers, and Longman, the Commission on Care member who showed us that VA provides some of the best healthcare anywhere, and who inspired us to disseminate our best practices and pursue the audacious goal of delivering the best care everywhere to our veterans. In his personal introduction to the collection, Shulkin noted that it takes an average of 17 years for new medical evidence to reach patients in clinic or at the bedside. VA, the largest health system in the U.S., is not exempt from this problem. But VA is leading American health care in fixing it.¹⁵

Nevertheless, in his first State of VA address, delivered a month before Best Care Everywhere was published, Shulkin contradicted his own broader assessment of the VA, declaring that his agency was still in critical condition and require[d] intensive care. Part of this assessment applied to the state of VA infrastructure and bureaucratic performance issues, like delays in handling claims for VA disability benefits, not directly related to health care delivery.

Among the VHA-related problems Shulkin cited were absurd delays of three to six months in hiring new nurses or nurse-practitioners, plus low salaries for health care providers at the VHA, which make it difficult to recruit and retain critical positions. In fact, by mid-2017, the VHA had an estimated thirty-five thousand open positions.¹⁶ Yet, instead of seeking money to fill these vacancies, Shulkin sought additional funds from Congress for more outsourced care through Choice, a program with $2 billion worth of cost overruns since it was created, including $90 million in overbilling by its two main contractors, TriWest Healthcare Alliance and Health Net Federal Services.¹⁷

In an approving profile of Shulkin, the Times reported that he wanted to focus the VHA on its core mission of caring for the wounded, which required making hard decisions about outsourcing services like optometry and audiology. (We make eyeglasses for our veterans. Last time I checked, every shopping mall in America has a place where you can get glasses in an hour, he told Times readers.)¹⁸

At the same time, Shulkin was floating an internal proposal to shut down VHA patient safety centers—a model program central to its core mission—to free up more money for reimbursement of private-sector providers. He has tried to shift a billion dollars in funding for—among other things—mental health programs, women’s health, and social workers who help homeless veterans, to cover shortfalls in the revenue that finances the operating costs of VHA facilities. And he embraced a scheme to outsource the VHA’s already state-of-the-art medical record-keeping system.¹⁹ Instead of resolving the current problems in the groundbreaking Veterans Information Systems and Technology Architecture (VistA) in house, Shulkin, with no competitive bidding, declared that the VHA would purchase the Cerner Millennium system, a move that would enrich the company with billions in federal money.²⁰ In February 2018, Shulkin would tell a House Veterans Affairs Committee hearing that he did not oppose a proposed hiring freeze for federal employees that would make recruiting to the VHA harder. He also supported limiting VHA services to labor-intensive chronic conditions and outsourcing the kind of expensive, episodic treatment that would further enrich private-sector providers.²¹ As we will see, this kind of outsourcing—or stealth privatization—would constitute an additional wound from which veterans would suffer.

My Pathway to the VA

Although I am not a veteran myself, the campaign to dismantle the VHA and outsource veterans’ care has been as dismaying and disturbing to me as it has been to longtime advocates in the field. I’m a seventy-two-year-old civilian whose family tree includes more health care providers than former military personnel. My father was a doctor, and my younger daughter is a nurse and former primary care provider at the VHA. Before I embarked on this project, my friends and acquaintances with military experience numbered just a few. Now they are legion and include scores of dedicated VHA caregivers around the country.

I do bring to this project more than forty-five years of journalism experience. That career includes three decades spent observing and writing about the work of doctors, nurses, and other health care providers and studying their interaction with patients and the health care systems that employ them, here and abroad. In addition to writing, editing, or coediting ten health care–related books, I have published the work of other journalists, academics, and health care practitioners as coeditor of the Cornell University Press series Culture and Politics of Health Care Work.

One focus of my own recent work is patient safety and how it can be improved through better workplace communication and information sharing among health care professionals. In the course of my health care industry consulting work, I first met VA hospital staff members, who were trying to reduce medical errors and accidents at a VHA facility in Northern California. In many other clinical settings I have encountered, it was common for hospital administrators to pay lip service to patient safety and related training without actually institutionalizing the best practices of doctors, nurses, and other staff that can save patients’ lives and spare them medical complications resulting in longer hospital stays or costly readmissions.

When I worked with the VHA, however, I was struck by its far more serious approach. Although many VHA managers displayed the same kind of bureaucratic mind-set and obsession with micro-management I had long observed in private-sector health care, frontline staff exhibited a distinctive ethic of service and a strong personal commitment to serving veterans. Unlike many other hospitals or health care systems, their employer was actually investing time and money in team training and often-neglected follow-up implementation measures. Several years after I did patient training at one veterans’ hospital, my initial impression was confirmed when I met VHA leaders in this field, like Rajiv Jain, a physician who was the director of the VHA MRSA Prevention Initiative and later became head of Patient Care Services at the VHA in Washington, or Rebecca Shunk, an internist who is codirector of the Center for Excellence in Interprofessional Education at the San Francisco VA.

Jain and his colleagues had pioneered methods for reducing the spread of a terrible hospital-acquired infection, known as MRSA, throughout the VHA system. To accomplish this goal, they created high-functioning hospital teams—including bedside nurses, housekeepers, and transport workers—that took collective steps to reduce MRSA risk factors.²² Meanwhile, Shunk introduced me to VHA teamwork training initiatives designed to improve the quality and delivery of primary care nationwide.²³

I was also very impressed by how sensitive the VHA is to patient complaints. In any private-sector health care system, incidents involving sub-standard care tend to remain a far more private matter, even if they lead to litigation (often settled on a confidential basis) or result in reprimands from state or federal regulators like the Centers for Medicare and Medicaid Services. The VA is, without a doubt, a big government bureaucracy, more top-heavy than it should be. But the very fact that it is a public institution, with an exceedingly well-organized, vocal, and politically connected patient population represented by many veterans’ service organizations, ensures a degree of transparency and responsiveness I had never encountered before.

VHA staff were very aware that if veterans didn’t get services they expected—and on time—they or someone in their family would contact their representatives in Congress about it. In periods of major controversy—for example, during the aftermath of the Phoenix wait-time disclosures—patients of the VHA, through their national veterans’ service organizations, have even demonstrated sufficient clout to secure the resignation of the VA’s top national official, plus the disciplining of local hospital administrators.

In private industry, concerted action on this scale by health care consumers is very rare. It’s likely to occur only in situations where hospital employees are unionized and their whistle-blowing (about short staffing or other unsafe conditions) generates sympathetic local media coverage and community pressure for change.²⁴

More to the point, it’s hard to recall the last time that the CEO of any major private-sector health care chain or hospital network even a fraction of the VHA’s size was fired or forced to resign over administrative practices or clinical failings protested by patients. To cite only one example, the CEO of the Cleveland Clinic, Delos Toby Cosgrove, was rewarded with huge salary increases even though his hospital system was under threat of suspension from the Medicare program between 2010 and 2013,²⁵ faced $650,000 in fines by CMS (the Centers for Medicare and Medicaid Services) for lab violations at one of its hospitals in 2015,²⁶ and saw its Medicare payments reduced because of high hospital infection rates.²⁷ Nor was there any decrease in Cosgrove’s pay or calls for his resignation when, in 2016, the Cleveland Clinic paid $1.6 million to the US Justice Department to settle accusations that it implanted cardiac devices into patients too soon after a heart attack or surgery.²⁸

The VHA’s Multiple Missions

The VHA is held to a much higher standard as it performs its multiple missions. Although very few members of the public actually understand how the VHA works, what we’ll see in this book is a genuine health care system in action. But first, a further word about where the VHA sits in what is known as the VA.

What is often referred to as VA health care is, in fact, the Veterans Health Administration, which is only one of three agencies within the Department of Veterans Affairs. The VHA is the largest of the three. The others are the National Cemetery Administration (providing burial for eligible veterans) and the Veterans Benefits Administration (VBA), which determines and administers a host of veteran benefits, like the GI Bill, housing benefits, vocational rehabilitation and employment, pensions, home loans, life insurance, and access to VHA care.²⁹ It’s critical to understand the difference between the three arms of the VA. When veterans complain about the VA and its hassles and wait times, they are almost never talking about the National Cemetery Administration. Their complaints, however, may not be about the VHA but about the VBA. In order to get access to the VHA, veterans have to provide documentation and file claims with the VBA. Because the claims process is unnecessarily complex (thanks to Congress) and the agency is chronically underfunded and understaffed (also thanks to Congress), there is a huge backlog of claims at the VBA, and veterans may be understandably frustrated because they have to wait for needed health care services.³⁰

The VHA delivers care to almost nine million eligible veterans at over seventeen hundred sites, including acute care hospitals, outpatient clinics, rehabilitation facilities, nursing homes, inpatient residential programs, and campus- and community-based centers. With a salaried staff of nearly three hundred thousand, a third of whom are veterans, the VHA is the nation’s largest and only integrated health care system that has full public funding.

The VHA is not a hospital chain competing with others for market share. It is not a collection of physician practices or specialty services. Nor, like Medicare, is it only a single payer for care. It resembles the health care systems of almost all other industrialized nations: a full-service health care system that both pays for and delivers all types of care to those it serves. The VHA delivers more services more comprehensively to its patients than any other system in the United States. Not only can veterans who move from one part of the country to another get services at any VHA facility; the services they get are also fully integrated. Mental health care and primary care in the VHA are closely combined, and rehabilitation services are integrated with specialty services. What’s more, much of this care is delivered in teams, often communicating face to face about their complex patients, rather than through truncated notes and orders entered into computerized medical records that may or may not be read or implemented. Plus, the VHA offers help with housing, employment, and even legal issues its patients might have, and, when necessary, it deals with family and community problems.

The VHA has four primary missions. First and foremost, it delivers clinical care in 153 hospitals, 900 clinics, 300 mental health centers, and other facilities that assist more than 230,000 people every day. At the VHA, health care professionals are not paid in a fee-for-service system but are all salaried. They do not have any incentive to engage in the kind of overtreatment of patients that is now epidemic in our health care system. Nor do they experience the kinds of insurance company denials and hassles that plague those in the private sector. In VHA primary care clinics, providers can actually spend more time with their patients, often two to three times as much as in the private sector, where you are lucky to get more than ten minutes with your doctor.

The VHA’s second major mission—unappreciated by the general public—is research. Because it has more patients that it can track more consistently over a longer period of time than any other health care system in the country, the VHA is uniquely positioned to use this data for innovative research projects. One that is now under way involves a million veterans (the Million Veteran Program) and is exploring the impact of genetics on health and various medical treatments.³¹

As a research powerhouse, the VHA has made advances in medical care, medical equipment, and pharmaceuticals that now benefit all Americans, not just veterans.

Among such breakthroughs was the shingles vaccine, the product of a research partnership between the VHA and the National Institutes of Health. The VHA also pioneered the nicotine patch and the first implantable cardiac pacemaker.³² VHA researchers also did pioneering work documenting that postoperative mortality rates among patients with known cardiac risks could be greatly reduced if they were given beta blockers before surgery, a practice now standard in US hospitals.

In 2016 alone, VA researchers published 9,480 papers. The VHA is currently researching the link between genes and suicide risk and the use of probiotics for veterans with traumatic brain injury.³³ In 2016 the VHA received a $50 million grant from the Prostate Cancer Foundation. Its CEO, physician Jonathan Simons, told me that the foundation was eager to work with the VHA because it is the largest health care system in America, with the most men suffering from prostate cancer of any health care system or institution. Because of this, he said, the VHA provides a unique opportunity to help solve some of the most vexing riddles about prostate cancer, democratize treatment through the VHA’s superior telehealth capacity, and accelerate the pace at which new drugs and treatments are made available to the nation’s veterans.³⁴

The third VHA mission—also insufficiently publicized—is teaching. Since 1946, the VHA has been affiliated with major academic medical centers throughout the country. It now trains 70 percent of the nation’s medical residents and 40 percent of all other health care professionals. Schools that educate nurses, physicians, psychologists, social workers, physical therapists, and many other health care professionals who rotate through hospitals and other facilities during their training depend on the VHA for clinical placements. At the VHA these future professionals learn how to perform concrete tasks like taking a patient’s history, doing a physical exam, making the correct diagnosis, or delivering the proper treatment. They also learn lessons in teamwork and patient–staff communication, and they get to work in the VHA’s unprecedented system of telehealth and one of the largest medical simulation centers in the country.

The fourth mission of the VHA, of which even fewer people are aware, is emergency preparedness. When I visited the VHA in Honolulu, the system had set up an incident command to deal with a volcano eruption on the big island of Hawaii. VHA staff were frantically calling veterans impacted by the disaster to make sure they were not hurt and had housing, medications, and medical services. In 2015 and 2017, during the disastrous California fires in Lake, Sonoma, and Napa Counties, the VHA set up similar incident commands and was calling thousands of veterans who had to flee their homes as a result of the fires. Two weeks after the fires were under control, staff were still making calls to veterans to help them recover from the trauma of lost or damaged homes or any health problems that occurred because of the terrible pollution that enveloped the area.

In this book I focus on how the VHA accomplishes its multiple missions and functions differently from its private-sector counterparts, whose care delivery is more costly, fragmented, and market-driven. As the largest health care system in the country, the VHA has its share of problems. But overall, as the studies and experiences I will cite convey, the VHA provides high-quality care to a very complicated patient population. In most health care systems, younger patients are usually the healthiest and least expensive to treat and are therefore the most sought after. That’s not the case in the VHA. Because of a complex set of eligibility requirements imposed by Congress, not all twenty million veterans can be cared for in the VHA. Only those who have service-related health conditions or low incomes are eligible for VHA care. Apart from the low-income patients served by Medicaid, no other health care population in the United States includes as many poor, unemployed, or homeless people or ones suffering from mental illness, drug addiction, or alcohol addiction. With the exception of our national Medicare population, no other group of patients has so many seniors—in this case, surviving members of the World War II generation, plus those who served in Korea and Vietnam or were in the military during these conflicts.

As directed by Congress, the VHA has waived its standard eligibility requirements and is providing care to veterans of post-9/11 conflicts for five years after they leave the military. Veterans of our occupation of Iraq and ongoing military intervention in Afghanistan have returned with combat-related injuries, illnesses, and mental health problems that are no less challenging to treat than the myriad afflictions of Vietnam veterans. Because of the military’s highly advanced methods of battlefield triage and fast transport to field hospitals, some of these young men and women have survived wounds that would have proven fatal in prior conflicts. One in six veterans who served in these conflicts also has a substance-abuse problem.³⁵

The veterans the VHA serves have service-related disabilities. But as we will see, not all these conditions, of varying severity, were the result of combat. In fact, most are not. Those who serve our country by joining the military risk injury—and, in some cases, lasting mental or physical trauma—because their working conditions include a training regime that can be brutal and callous. Their later active duty exposes them to a variety of occupational hazards even if they never leave the continental United States. Most important, those who have, in the past, been conscripted or, in the era of the professional military, volunteered to serve were promised later pensions and health care coverage, among other things, if their length of service made them eligible. Health care for low-income veterans and those with service-related conditions, regardless of how long they served, is one of those benefits. In this book, we will explore how the federal government delivers on this promise and how all Americans, not just veterans, benefit as a result. Far from being broken, the VHA serves as a model for how health care could be delivered, more effectively, for everyone in our country.

A Few Notes for the Reader

The VHA is a huge system. In the course of writing this book, I could not visit every one of its seventeen hundred sites of care. I did, however, visit many of them, and I observed many patient and caregiver interactions and talked with hundreds of veterans and their family members and VHA care-givers. No matter how harrowing their stories, these veterans and their families shared them with me because they felt it would help other veterans. Many of them wanted me to use their full names. Some asked me to change identifying details and give them a pseudonym, which we sometimes chose together. When an asterisk follows the name of a veteran, it indicates a pseudonym. And when a quote is not followed by a citation, it’s because it came from a personal interview I conducted. I also refer to people in the military as service members rather than as soldiers, because, as I have learned, the term soldier refers to someone who served or serves in the Army (Marine is used for a Marine, sailor for someone in the Navy, airman for someone in the Air Force, and for the Coast Guard, it’s Coast Guardsman).

Because the VHA is a comprehensive, full-service health care system delivering hundreds, if not thousands, of different services to veterans, I could not report on all that the VHA does. I chose instead to focus on areas of health care delivery that are particularly problematic in our larger, market-driven health care universe.³⁶ These include primary care, mental health care, rehabilitation, and outreach to the homeless, as well as help with legal issues, and geriatric, palliative, and end-of-life care. In the beginning of the book, I also describe our nation’s often neglectful treatment of veterans in the past and the challenge of caring for VA patients today. Interspersed throughout are shorter profiles of specific VHA programs and employees. (Because this book took over four years to research and write, some of the people profiled here are no longer in their jobs—some have shifted positions or retired.)

Finally, I ask a question few reporters, media commentators, or legislators seem to address these days: How does the VHA’s record of health care delivery compare to that