05/21/2014 01:27 pm ET Updated Dec 06, 2017

More VA Changes, More VA Is Broken

Last Thursday I watched the lengthy hearings of the Senate Veterans Affairs Committee. Secretary Shinseki said he was "mad as hell," and those who testified seemed concerned if not outraged at reports that some VA's had "cooked the books" regarding veteran wait times and covered up secret waiting lists containing real (bad) data, while publicly substituting made-up lists that falsely reflected exemplary performance.


The hearing left me with a few stones in my shoe:

One, this same issue had emerged several times before, beginning in 2007. Why the fuss now? Why has the problem not been solved in seven years?

Two, if the Secretary is so passionate, why does he use life-sucking bureaucratic doublespeak, referring to "adverse events," rather than speaking plainly? Tell it like it is. Doing otherwise erodes credibility and trust. And what nerve call to Phoenix, AZ and Cheyenne WY "isolated cases"! There are eight reports and counting.

Three, how easily everyone, devoted veteran advocates included, fall prey to the silver bullet trap, agreeing one after another, like a bleating goat in an echo chamber, that VA health care is terrific but access is the real and singular problem. Tom Tarantino of IAVA did observe that veterans' experience with the VA was problematic; then he joined in the chorus. This despite copious continuing reporting by Aaron Glantz and others. Suicides, over-prescription of opiates, inept pain management, ineffective veteran outreach, insufficient programs for families -- these are but a small sampling of real problems with delivery and content of care, not just with access to it.

Four, when will our legislative and governmental leadership, and our advocacy groups, learn to think holistically, in terms of parts of a whole interacting to create problems and to effect solutions? This is not rocket science, people: the hip bone's connected to the thigh bone... Access, accountability, trust, skill, dedication, quality of care -- these are all connected and impact one another.

Five, committee members and advocates emphasized that the problem was baked into the VA culture. How quickly this assessment of systemic failure devolved into the urgency to settle on a single isolated factor. Let's call what followed by its rightful name: groupthink. Nobody seriously addressed the systemic nature of the problem. It seems that there is an entrenched arrogant, disingenuous crew of mid- and high-level bureaucrats with a circle the wagons mentality who, no matter the sanctimony of their stated views, create and sustain a culture of ineptitude and deception that not only scorns accountability but is profoundly broken. With conceit and deceit, they have, for years, played the committees, the President, the Secretary (TRMS, 5/19/14), our veterans, and we citizens like a violin, much like the alleged number fabricators they now are investigating.


Six, VA is not just a broken system, it is a paranoid system where nearly everyone is afraid of "getting in trouble." If this sounds farfetched, read about an email memo about the fear of being on the VA "bad boy list." Or try listening to VA psychiatrist Jose Mathews' story. He felt like he was in an "alternate universe."

After writing this yesterday, this morning I watched John Stewart capture this as only he can, opening up his "swear jar" full bore. How is it, he asks, that we can send 300,000 troops half-way around the world in two months, come up with two trillion to pay for it, yet, after nearly twelve years, we can't provide adequate care for those we sent into harm's way?

I'm not saying there aren't great people in VA, bucking the system, succeeding daily at helping veterans, despite the dysfunction. I know many of them. And I'm not suggesting we shouldn't have hearings and hold VA's feet to the fire. To the contrary. I'm not sayin', I'm just sayin'. Wake up everyone!