01 Jul 2014 Veterans Will Suffer Another Scandal As Long As Bureaucracy Runs Their Health Care, by David Hogberg, Ph.D.
The Federal Office of Special Counsel recently revealed that a mental patient at the Veterans Affairs facility in Brockton, Massachusetts, had to wait eight years before he received a psychiatric evaluation.1 This was while he spent those eight years actually living at the VA facility!
This story is curious in light of Phillip Longman’s explanation for the VA wait-times scandal. Longman is the author of the book Best Care Anywhere: Why VA Health Care Is Better Than Yours that is partially to blame for the scandal.2
Longman claims the scandal isn’t due to any problem stemming from the VA but from failure by Congress to spend enough money on the VA facilities with the most need. He states that the scandal…
…results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as Phoenix, VA capacity is indeed under significant strain.3
He argues that the standard of a maximum 14-day wait for seeing patients that the VA is supposed to meet might make sense in areas such as New England, but “trying to do the same in Phoenix and in a handful of other Sun Belt retirement meccas is not workable without Congress ponying up for building more capacity there.”
However, Brockton is not in the Sun Belt. Indeed, neither are many of the VA facilities that have had problems with wait-times.
The states that are generally considered to comprise the Sun Belt include Alabama, Arizona, California (Southern), Florida, Georgia, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, South Carolina and Texas. But even using a more expansive definition that includes Arkansas, Colorado, Oklahoma, Virginia and Utah doesn’t lend support to Longman’s argument.
For example, the VA’s Access Audit cleared a number of facilities of wrongdoing. But pages 38-40 of the audit list 81 facilities that require “further review.” Forty-one of those facilities are in the Sun Belt, while the other 40 are not.4
A review of Government Accountability Office and VA Office of the Inspector General reports that examine wait times shows a similar pattern. Examining reports from 2000-2014 that contained wait-time data on specific locales reveals 21 in the Sun Belt and 22 located elsewhere.5
In short, the evidence shows that the problem is one that infects the entire VA system regardless of geography. Factors inherent in the VA cause wait-times and not lack of money or migration patterns.
Yet, Best Care Anywhere suggests that this wasn’t supposed to happen. Longman gives much of the credit for the great strides the VA supposedly made in improving care during the 1990s to its Undersecretary of Health, Ken Kizer. One of Kizer’s reforms was pushing…
…budget and policy making authority away from the [Veterans Health Administration] central headquarters in Washington. As part of this decentralization plan, he created a series of twenty-two regional administrative districts… Decentralization, combined with the VHA’s state-of-the-art information systems… meant that it became possible to hold regional administrators accountable for a wide range of performance measures.6
The administrative districts — called Veterans Integrated Service Networks (VISNs) — now number 23. According to the VA’s Access Audit, 20 VISNs contained VA facilities that needed “further review.” So, why were the administrators of the VISNs unable to stop wait times from proliferating?
Bureaucracies behave in certain ways regardless of how they are structured. Even if authority is dispersed, as it is in the VA, the administrators are still only accountable to Congress and the Administration since that is who provides their funding. If Congress and the Administration believe that the VA provides great health care — as many of them did due to the influence of Longman’s book7 — then they’re less inclined to worry about wait times at the VA, if they hear about them at all. Administrators won’t address concerns that Congress and the Administration don’t have.
Another problem with bureaucracies is they don’t get their funding from the people who are seeking their services. In the private sector, those people are generally called “customers,” although in the health care sector they are usually referred to as “patients.” If customers have to wait too long to receive a service from “Business A,” they will take their money to businesses that offer shorter wait times. Business A will see its revenues decline and either have to shape up or go under. Like most bureaucracies, the VA has no such “feedback loop” since the people seeking their services aren’t the same ones paying for them. In short, there is no financial consequence for poor customer service.
Finally, most government employees have a greater incentive to cheat, since most have civil service protections that make it exceedingly difficult to fire them. In the case of the VA, many employees manipulated wait-times data so that their facilities appeared to meet the 14-day waiting standard. When employees have goals they can’t meet and not meeting them means they don’t receive promotions, raises and bonuses, the incentive to manipulate the data is much higher when they can’t be fired. We’d like all people to be honest, even those who have civil service protection, but the odds are on honesty going down the drain when there are few consequences for dishonesty. Thus, it’s little wonder VA employees created false data on wait times.
While the proponents of the VA having the best care anywhere would like to believe that the wait-time scandal is limited to a specific geographic location, the data indicates otherwise. Rather, the scandal is the result of the incentives faced by bureaucrats. Given the nature of bureaucracies, those incentives won’t change, meaning that future veterans will suffer from wait-times as well.
David Hogberg, Ph. D., is senior fellow for health care policy at the National Center for Public Policy Research.
1 Bryan Bender, “2 patients languished at a Brockton VA facility,” Boston Globe, June 24, 2014.
2 David Hogberg, “Intellectuals and the VA: How A Bad Idea and Bad Reporting Contributed to a Health Care Catastrophe,” National Policy Analysis No. 660, National Center for Public Policy Research, June 2014, at http://www.nationalcenter.org/NPA660.html.
3 Phillip Longman, “VA Care: Still the Best Care Anywhere?” Washington Monthly, Political Animal, June 3, 2014, at http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_still_the_best_care_an050598.php (June 30, 2014).
4 Department of Veterans Affairs, “Access Audit: System-Wide Review of Access. Results of Access Audit Conducted May 12, 2014, through June 3, 2014,” June 19, 2014, pp. 38-40.
5 National Center for Public Policy Research, “Table 1: Geographic Locations of Veterans Health Facilities Investigated for Wait-Time Problems, 2000-2014,” at http://www.nationalcenter.org/NPA661_VA-SunbeltWaitTimes.pdf.
6 Philip Longman, Best Care Anywhere: Why VA Health Care Is Better Than Yours, Sausalito, CA: PoliPointPress, 2007, p. 52-3.
7 Hogberg, June 2014.