Who Broke the VA?

There's plenty of blame to go around.


In an outstanding series for National Journal, Jordain Carney and Stacy Kaper investigate “Who Really Broke Veterans Affairs?” It turns out to have been broken for a long time and that lots of people and institutions are to blame.

Part I, “Obama Has Every Reason to Fix the VA. Why Hasn’t He?” asks the wrong question.

In short, because fixing the VA backlog isn’t just a question of putting the proper resources into an overwhelmed agency. Solving it would require not only untangling a Gordian knot of dysfunctional bureaucracy surrounding the VA claims system and decades of neglect, it would also mean overcoming a perfect storm of factors in the past few years that has made the problem much, much worse.

Surge in Claims

The VA received 1 million new claims during Obama’s first year in office—the most it had ever received at one time—and the count climbed from there. Annual claims peaked in 2011 at 1.3 million, falling to 1.04 million claims received in 2013.

What’s driving the surging number of claims? In short, a pair of wars that have created more veterans and new Obama administration rules that have made veterans from all wars eligible for more disability compensation.

The VA is dealing with a sudden influx of Afghanistan and Iraq veterans as the U.S. draws down its troop levels. Nearly 970,000 Iraq and Afghanistan war veterans deployed overseas since 9/11 have filed a disability claim, according to a Freedom of Information Act request released to Veterans for Common Sense this month by the Veterans Benefits Administration.

And due to medical advances, many service members who would have died from their injuries in past wars are now being saved, but they are returning home with more numerous and more complicated injuries. Vietnam veterans typically claimed three or four injuries. Now a single veteran from Iraq or Afghanistan routinely submits a claim with the number of injuries in the double digits.

Meanwhile, the Obama administration has also changed the rules to give more benefits to veterans. In 2010, the administration expanded coverage related to exposure to Agent Orange, a Vietnam War-era defoliant that has created a vast list of health problems. Veterans have long tied an assortment of illnesses to Agent Orange, and now more of those illnesses are covered.

Additionally, the administration made it easier for veterans to get coverage for posttraumatic-stress disorder, a disease less easily diagnosed and adjudicated than physical injuries. Since 2010, service members no longer have to provide documentation that supports their PTSD claims. Instead, a doctor performs an exam to determine that the veteran’s symptoms are related to PTSD and that the cause of the PTSD, such as being under attack, is consistent with the veteran’s military duties.

The road to Hell is paved with good intentions. But it’s rather odd to cast blame on President Obama for making it easier for men who have been suffering from the effects of Agent Orange for four or five decades to finally get their due.  Similarly, easing the rules for treatment for PTSD claims is the right thing to do. The Bush 43 administration rightly deserves more blame. It launched two major wars in Afghanistan and Iraq and did too little to expand the infrastructure to support the needs of the wounded veterans that were being created.

Still, while presidents are ultimately responsible for decision-making, they inherit bureaucracies with longstanding organizational cultures. And the VA’s* is broken.

Not all of the VA’s problems, however, come from external factors. The agency is haunted by its painfully slow embrace of technology: It did not have a digital way to process claims nationwide until 2013, and it long handled claims with a paper filing system. Victoria Dillon, a spokesperson for the VA, acknowledged that “these offices used to be stacks of papers everywhere,” with claim files “18 inches thick on average.”

By comparison, the IRS rolled out its electronic filing system across the country—albeit with some problems—in 1990.

The VA also uses a complex regulatory code for dealing with claims that slows down the process. “The regulation dealing with [traumatic brain injury] is so complicated that some people call it the ‘Da Vinci Code,’ ” Ronald Abrams, joint executive director for the National Veterans Legal Services Program, told lawmakers late last year.

The VA attempted to solve the problem by hiring more claims workers to handle the influx, but it takes approximately two years to fully train a claims worker to handle the complex process.

“Thousands of new PTSD and Agent Orange claims starting in 2010 overwhelmed an agency with a history of  poor planning, chronic understaffing, and a lack of training,” said Glenn R. Bergmann, a partner at Bergmann & Moore, a former VA litigator who represents veterans with VA disability-claim appeals.

In his first years in office, Obama’s VA was a disaster, as a flood of new claims overwhelmed an antiquated process for handling them. In 2009, there were about 423,000 claims at the VA, and the official backlog of claims that had been pending for more than four months sat near 150,470. By 2012, claims had exploded to more than 883,000—and 586,540 of those sat on the agency’s backlog list.

But in recent years, the administration has made progress in getting veterans more timely answers. The backlog list was cut to more than 300,000 as of May 10. If the VA maintains the current average monthly rate, the backlog could vanish by mid-2015. That would meet Veterans Affairs Secretary Eric Shinseki’s 2010 pledge to eliminate the backlog by the end of next year.

Critics, however, say the shrinking backlog is something of a farce, the result of an administrative maneuver that has not delivered results for the veterans in the backlog, but has instead moved them into a different waiting line. When taking into consideration all VA claims, including those where the veterans died waiting for a decision, those stuck in appeals, and award adjustments—often adding a spouse or child—the VA’s inventory of claims is much higher, still hovering just under a whopping 1.3 million. (By comparison when Obama took office in January 2009, the inventory of claims was about half that amount: 631,000.)

As of May 10, the VA’s number of appealed claims stood at 274,660, almost 100,000 more than the 174,891 appeals in late 2009. Between 2012 and 2013, the number of claims that ended up in appeal grew 5 percent, and between the end of 2013 and March 31, the number of appeals kept rising 2.7 percent. Once in the appeals process, veterans can wait in limbo for an average of two and a half years.

Critics contend that list is growing because, as the agency endeavored to quickly work through the claims, it has made more errors.

Part II, “Who Really Broke Veterans Affairs?” oddly rehashes much of the above but then notes, “the sheen of shame over the VA’s failures spreads across time and party affiliation. It stains the legacies of presidents as far back as John F. Kennedy and condemns past Congresses whose poor oversight allowed the problem to fester.”

The VA could be overhauled to better address the needs of modern veterans, including reforms to the way it processes claims, assesses the performance of its employees, and measures its overall performance. But putting many of those reforms in place would require an act of Congress—and thus far those haven’t happened.

Instead, Congress has taken a more reactive approach. When incidents—such as the recent hospital deaths—capture public attention, lawmakers hold hearings where they berate VA officials with juicy sound bites they can later play back for their constituents. It’s good political theater, but it’s unclear that the payoff is anything other than political.

“Congress has been totally exasperated by the VA’s inability to get on top of the problem for a long time,” said Linda Bilmes, a senior lecturer in public policy at Harvard University’s Kennedy School. “But they haven’t been willing to really contemplate anything other than throwing more money at the problem.”

Congress is taking some legislative steps now: The House is slated to vote this week on a VA accountability bill to make it easier to fire senior executives, and the latest VA funding bill banned bonuses to department executives. But neither measure contains changes on the structural level.

The last meaningful change, interestingly, took place nearly three decades after we left Vietnam and just before the recent wars kicked off. And it made matters worse, not better.

In 2000, lawmakers passed the Veterans Claims Assistance Act. The law was signed by President Clinton and was, by all accounts, a well-meaning attempt to make it easier for veterans to get VA claims approved.

The law required that the VA tell a veteran what to do to prove a claim, help the veteran obtain necessary records, and inform the veteran when the VA could not obtain the information it needed. The law required the VA to retrieve the veteran’s service medical records and provide exams when the VA did not have sufficient evidence to substantiate a claim.

But the law was ambiguous and left much open to interpretation, which had to be fought out in the courts. It wound up adding several additional layers of bureaucracy to an already clunky VA claims process without appropriating additional funds or human resources to manage the increased workload.

“So the situation wasn’t getting better; it just added another forum that made it harder to get things done,” said Sherman Gillums, an associate executive director with Paralyzed Veterans of America. “We attribute a lot of the early trouble—not the current backlog, but early trouble—to this, because it created an institutional laziness or institutional inefficiency and made that a part of the culture at the VA. People just accepted claims sitting around a long time because they had to do all of this other stuff.

Both the Clinton and Obama era reforms, then, were well-intentioned but exacerbated the problem.

“It’s not surprising, really, that the VA ended up being poorly prepared for what happened, given the way that they were planning,” said Harvard Kennedy School’s Bilmes. “There was absolutely a lack of planning, a lack of capacity for planning. … They didn’t know what hit them. They were completely overwhelmed.”

Additionally, the VA’s claims-processing time skyrocketed early in the Bush years. In 2002, it took the VA an average of 224 days to complete claims, as compared with 166 days in 1999.

Note that this was before the Iraq War and at a time when our footprint and casualty rate in Afghanistan was tiny.And, while the Bush 43 administration deserves blame, it was getting really bad advice from the experts at VA on whom it reasonably relied.

Even by the mid-2000s, several years after 9/11, the VA was using out-of-date claims projections it had based on injury estimates that used assumptions from older wars. Due to medical advances, many service members who would have died from their injuries in past wars are now being saved. That means fewer deaths, but it also means more wounded veterans, a development the department failed to anticipate and was slow to adapt to.

The report goes on to note the decades-long struggle to compensate veterans exposed to Agent Orange, first authorized for use in Vietnam by President Kennedy, and concludes,

The government’s long-standing failure to address the damage done to veterans by Agent Orange mirrors the larger failure of the VA. It spans generations and party affiliations, and every effort to fix it comes with unintended consequences.

“This goes across party lines,” said Ronald Abrams, the joint executive director with the National Veterans Legal Services Program, and a former VA official who has worked on veterans claims cases for 40 years. “Democrats and Republicans have allowed this festering sore to continue.”

Part III of the series is “coming soon” and will ask, “What Would It Take to Really Fix the VA?” I’ll be interested to read their answer but their own reporting makes it clear that we should be skeptical of easy fixes.

Mostly, I think, the VA’s mission is simply inimical to the nature of government bureaucracies. That is, the goal is to provide speedy, high quality assistance to those injured during service to the country in the armed forces. Yet, rightly so, bureaucracies are also charged with jealously safeguarding taxpayer money. The upshot, then, is that the system by default forces the veterans seeking treatment and/or compensation to prove that they’re actually injured and that those injuries were the result of their military service. That’s at direct odds with the mission.

Nor is that fixable. First, because the mere fact of prior military service doesn’t preclude fraudulent intent. A not insignificant number of veterans file disability claims who either aren’t disabled or whose injuries were not related to their military service. Second, it’s often very difficult to know whether injuries were related to military service.  It took decades to sort out the myriad effects of Agent Orange and we’re still trying to figure out Gulf War Syndrome. And, despite experience going back more than a century, our understanding of post-traumatic stress is still in its infancy.

That doesn’t mean we can’t insist that VA get properly staffed, be equipped with modern technology, and be adequately led. We can and must do those things. But the natural tension in their mission won’t and can’t go away.

*Some object vigorously to referring to the Department of Veterans Affairs as “the VA,” which is a holdover from the pre-1986 Veteran’s Administration. But DVA has ostentatiously maintained the VA brandingand even its longtime Secretary, retired Army four-star Eric Shinseki, refers to it as “the VA.”

FILED UNDER: Government, Military Affairs
James Joyner
About James Joyner
James Joyner is a Security Studies professor at Marine Corps University's Command and Staff College and a nonresident senior fellow at the Scowcroft Center for Strategy and Security at the Atlantic Council. He's a former Army officer and Desert Storm vet. Views expressed here are his own. Follow James on Twitter @DrJJoyner.


  1. OzarkHillbilly says:

    Saying “Everybody is to blame.” is about the same as saying “Nobody is to blame.” and all too likely to have the same effect, even if it is true.

    Jus’ sayin’….

  2. John Peabody says:

    When, exactly, was the VA considered a tight, well-run organization? I have read contemporary accounts from the 50s and 60s, bewailing the lack of funds for proper veteran care. Parades are nice, but the other side of war is in the decaying bodies inside the decaying buildings.

  3. Dave Schuler says:

    The answer to your question is the same as the answer to just about every question affecting the federal government: the Congress. That’s the nature of our system.

    In the particular case of the VA it’s too much money, not enough money, and inadequate oversight.

  4. Mu says:

    It’s congress’s preferred game coming back to haunt us – deferred expenses. We pay our active troops less and offer first rate benefits. That doesn’t cost the current congress, that’s someone else s problem 20 years down the road. The same can be said for the current waitlist scandal – politicians demand faster service, which needs more staff (not authorized) which need new facilities (not authorized) and upgrades to their IT system (not authorized).
    As usual, everybody wants something, but no one wants to pay for it.

  5. Scott says:

    A not insignificant number of veterans file disability claims who either aren’t disabled or whose injuries were not related to their military service.

    Let’s not underestimate this. We need to separate Service-related disability from Combat related disability. I work with a lot of retired veterans who have disability ratings and they work the system (all legal). But folks using VA services for back backs and knees, sleep apnea, hearing loss, etc really clog the system. These disabilities may be lifestyle hinderances but do not prevent employment especially non-physically difficult jobs.

    Part of the motivation for retired veterans, is financial. In 2004, concurrent receipt came into effect. Prior to 2004, tax-free disabiity payments were offset by reductions in retirment so the benefit was strictly in taxes. Under concurrent receipt, disability payments became in addition to retirement pay; therefore, a huge increase in benefits. In addition, achieving a 50% disability rating enters into a whole range of state and local benefits also. Bottom line: there is a lot of financial incentive to file for disability for service related disabilities even though you have a retirement income,a second job, etc.

  6. C. Clavin says:

    It’s Obama’s fault.

  7. MarkedMan says:

    The VA Medical system is currently overwhelmed with combat disabilities that are much more numerous and more severe than they can handle. They have obviously failed to change from an organization that was principally concerned with aging veterans with normal old age problems. The hide the problem and cover your a** response has been contemptible. ‘m not trying to minimize the current problem but let me add the conventional wisdom from the medical industry. Twenty, thirty years ago the VA system was shoddily run and a disgrace. But the VA had support from Dems and Repubs both, real actual veterans like Bob Dole and George HW Bush and they demanded better and gave them the resources to achieve it. And they turned the agency around and it is now considered one of the best medical systems in the country. Maybe the best.

    They started looking at every facet and they quickly realized once a vet entered the system they rarely left. Knowing they were going to have those patients for life changed the way they did preventative care. They developed programs to follow up patients and they had an incentive to intervene early. For the privately insured world, we Medical Device people know that anything we propose based on saving money due to better patient health has to pay back in less than three years, because that is the average length of time a person stays with the same insurance. The VA looks ten, twenty, thirty, forty years down the pike. They have fantastic outcomes and they do it for significantly less cost than the private system does.

  8. David in KC says:

    I started the disability VA process in March of 2011. Took around 18 months for it to go through. It was slow, but I, luckily, did not have any issues. Once they set me up for a medical exam, it took only a couple months for the decision to come down. As to fixing it? I agree a complete overhaul is needed. I have no confidence that this congress, nor the next one will be able to accomplish it.

  9. Just Me says:

    Scott service related disability may not be combat related but it still often happens while serving.

    My husband blew his knee out during PT while in the service (he served during the first Gulf War but was in school/training). The Navy did not do any kind of soft tissue exam like an MRI (turned out he tore his miniscus) so did not repair it. When he stared having knee issues on the ship 4 years later and fell down a ladder they finally did an MRI. They tried to fix it then but the scar tissue was too bad and would have required a knee replacement at that time which he wasn’t ready for.

    He also had an injury resulting in a collapsed lung.

    Just because he wasn’t in combat that doesn’t mean his injuries aren’t we ice related or that by the contract he signed when he joined he is gaming the system by using his VA benefits.

    I’ll also say that the care he has received at the. Manchester VA has been very good. I suspect the VA centers struggling the most are those in areas with a lot of retirees. Far more military retire to warmer climates than to NH.

  10. Jenos Idanian #13 says:

    @John Peabody: When, exactly, was the VA considered a tight, well-run organization?

    When Paul Krugman was looking for something to hype ObamaCare.

  11. stonetools says:

    Republican governors are also screwing over veterans by refusing to expand Medicaid:

    Many assume that all of the nation’s veterans are entitled to health care through the Veteran’s Administration, but that’s not the case; a veteran must have served for two continuous years or the full period for which they were called to active duty in order to be eligible. There are some exceptions — like for individuals who were discharged for a disability sustained in the line of duty — but about 1.3 million veterans remain uninsured nationwide.

    According to a report by Pew using analysis from the Urban Institute, approximately 258,600 of those veterans are living below the poverty line in states refusing to expand Medicaid. Without veteran’s benefits — and with incomes too low to qualify for subsidies to use on the state exchanges — these veterans are left without affordable coverage options.

    So veterans are yet another casualty of the Republicans’ sociopathic opposition to the ACA.

  12. Jenos Idanian #13 says:

    The thing to remember is that we’re only at Stage One of Crisis Management under the Obama Administration.

    Stage 1: The president only learned of this recently, from reports in the press, and is Outraged and There Will Be Consequences.

    Stage 2: It is inappropriate to discuss matters While They Are Under Investigation, but rest assured the President is still Outraged and There Will Be Consequences.

    Stage 3: Time drags on, no one is actually punished (allowed to retire, reassigned, or something similar). With the possible exception of whistleblowers, of course.

    Stage 4: This is all just a Phony Scandal Being Exploited By Republicans For Political Gain.

    Note that at no point is anything actually “fixed.” It’s not part of The Plan.

  13. edmondo says:

    Hey John McCain: Here’s an opportunity for you to actually help the veterans we have instead of you trying to create an entire new group of them with your constant military adventurism.

    Ball’s in your court, Senator

  14. stonetools says:

    @Jenos Idanian #13:

    So then we should dismantle the VA altogether then? Because this is what the libertarians are asking us to do with “Obamacare.”

    ObamaCare will produce similar horrors, and for the same reason: all economic systems serve the people who control the money. Under ObamaCare and the VA, patients don’t control the money. The government does.

    Returning that money to consumers would put patients first, whether they’re veterans or other civilians. But such reforms won’t mean a thing until we repeal ObamaCare.

    I truly hope that the Republicans go with the “Lets repeal both Obamacare and the VA because Big Gumint” meme. Hey, what could go wrong?

  15. MarkedMan says:

    FWIW, people are often confused by the difference between the VA and the various service medical systems. The Army hospitals, Navy hospitals, etc are for active duty people and the VA is for non-active duty. Once the services discharge someone they either go into the private insurance world or transfer into the VA. Or, of course, go uninsured. The active service medical systems are not considered topnotch systems by anyone I know.

  16. dmhlt says:

    Certainly didn’t help when Republicans blocked a Veterans’ health bill earlier this year:

    U.S. Senate Republicans blocked legislation on Thursday that would have expanded federal healthcare and education programs for veterans….

  17. Jenos Idanian #13 says:

    @stonetools: Once again, stoney, you don’t address what I said, but what I didn’t say. John asked a question, I answered it.

    Was that too simple for you? Or too honest?

  18. C. Clavin says:

    @Jenos Idanian #13:
    You forgot to type …but BENGHAZiii!!!!
    This problem has roots that go through every single President back to JFK and every single Congress.
    For you to blame Obama only shows how infantile you are.

  19. Jenos Idanian #13 says:

    @C. Clavin: Cliffy, I know you can’t handle complicated issues, so I’ll clarify what I said.

    I didn’t say that the problem was Obama’s fault. I said that it’s stupid to expect him to fix it.

    Which, I guess, means you expect him to fix it… until the narrative changes, as I predict it will.

  20. stonetools says:

    @Jenos Idanian #13:

    All I did was quote from the article that you referenced, then draw out the logical conclusion of what that article was arguing. Is that too simple for you?
    Paul Krugman’s article ( which dates to 2006, btw) isn’t wrong. Most veterans are indeed happy with VA care and they certainly don’t want the VA abolished in favor of a free market, “libertarian” solution. That doesn’t mean that the VA is perfect-it’s just better than any conceivable free market solution. For the record, Dr. K predicted the VA’s current problems. Dr. K writes:

    I don’t want to idealize the veterans’ system. In fact, there’s reason to be concerned about its future: will it be given the resources it needs to cope with the flood of wounded and traumatized veterans from Iraq?

    Apparently, going back to the source and quoting Dr. K’s own words on the VA was too honest for you.

  21. Scott says:

    @MarkedMan: Somewhat disagree. Retirees can use the DoD military medical system under Tricare. If they use Tricare Prime then their Primary Care Physician can be at a military facility.

    BTW, my family and I use the San Antonio Military Medical Center here in SA and it is top notch. Having used other medical systems (Methodist, Baptist, etc), I cannot discern any quality differences plus I don’t have the insane insurance hassle of the private sector.

  22. Scott says:

    @stonetools: What you quoted shows the writer doesn’t know what they are talking about. Everybody has to remember is that the current issue is on the front end of the medical system i.e, getting into the system. Once inside, the statistics show that the care is excellent.

    I don’t have direct experience with the VA but I do know the hassles with private insurance WRT preauthorization and networks, etc. Not very good. And consumers are not in control and never will be whether there is the ACA or not.

  23. @Mu:

    and upgrades to their IT system (not authorized).

    This hints at something that’s a larger problem. For some reason the government seems unable to successfully acquire an IT system to do anything. There’s been numerous stories over the past 10 years of various departments getting authorizations to spend hundreds of millions of dollars to replace their IT systems, at the end of which they don’t even have a functional design for what they need much less an actual functional system.

  24. Jenos Idanian #13 says:

    @stonetools: I cited the article’s references to Krugman, in response to a simple question. Funny how you’re obsessing about the other aspects. It’s almost as if you don’t want to admit that Krugman — once again — stepped all over his crank.

    He does that rgularly. Good thing for him he has legions of fanbois who are eager to cover up his crank-stamping episodes.

  25. stonetools says:

    @Jenos Idanian #13: Actually, the narrative is already changing. When the “scandal” broke, the Right Wing BS Machine was ready for several months of roasting Obama for his incomprehensible and inexcusable incompetence.
    Then it came out that the Republicans cut funding to the VA. OOPS!
    Then it came out that much of problem was caused by the flooding the system by veterans from George Bush’s war in Iraq. Double OOPS!

    McGillis nails it:

    For starters, there is the matter of funding. If there’s been one side pushing for greater resources for the Veterans Administration in the age of austerity these past five years, it hasn’t been the Republicans. It was the much-maligned economic stimulus package of 2009 that included $1 billion for the V.A. While the V.A. itself was protected from the budget sequestration that Republican fought to keep in place last year, many other veterans programs—providing mental health services and housing, among other things—were hit hard by the sequestration cuts. And when the Senate was poised to pass a $24 billion bill for federal healthcare an education programs for veterans three months ago, Senate Republicans, led by McConnell, blocked it in a filibuster, saying the bill would bust the budget and complaining that Senate Democrats had refused to allow an amendment on Iran sanctions to be attached to the bill.

    But there is a whole other level of context to consider here as well. There is a pretty basic reason for backlogs at V.A. facilities and in the disability claims process, the other ongoing V.A. mess. Put simply: when you go to war, you get more wounded veterans, and in a country without a universal health care system, they are all funneled into this one agency with limited capacity. Every one of the Republican leaders quoted above attacking Obama for the V.A. backlogs strongly supported launching the wars in Iraq and Afghanistan that resulted in nearly 7,000 fatalities and a huge surge in medical needs and disability claims. Nearly one-half of veterans returning from Iraq and Afghanistan have filed claims for permanent disability compensation.

    Now Republicans are backpedaling from the “Its all Obama’s fault” narrative. Fact-based reporting plus the Internet strikes again.

  26. Jenos Idanian #13 says:

    @stonetools: Projection… it’s such an ugly thing.

  27. anjin-san says:

    How do you get Republicans to care about the VA?

    It’s simple. Put a Democrat in the White House.

  28. stonetools says:

    @Jenos Idanian #13:

    Er, you probably haven’t grasped it, because you are reading the right- wing spin on Krugman, rather than Krugman himself, but Dr K is actually right about the VA and its current problems.
    Now you brought up Krugman , but the simple fact is that he tends to be right, over and over again. That’s why I agree with him, not because he’s Krugman, but because he is so often right.
    Him being right does p!ss off the RWBSM though, which is why they frequently rush to cherry pick quotes (like you did) in order to “prove” him wrong. That tends to backfire on the right wing when the quotes are put in context.

  29. stonetools says:

    @Jenos Idanian #13:

    Projection… it’s such an ugly thing.

    You should know…

  30. Rob in CT says:

    @Jenos Idanian #13:

    Krugman pointed to a possible problem coming down, in advance when he said “I don’t want to idealize the veterans’ system. In fact, there’s reason to be concerned about its future: will it be given the resources it needs to cope with the flood of wounded and traumatized veterans from Iraq?”

    So the question is whether or not inadequate resources explain the problems that have come to light. My read of post-WWII US History is that we love to spend money on fancy military technology, we’re ok about paying active duty soldiers, and we utterly suck at dealing with the injured who come home from war, basically because nobody wants to face up to how expensive that would be. This goes double for the political party that likes to wrap itself in the flag and claim it reveres soldiers, because that might mean higher taxes or fewer wizbang toys (priorities, gotta have ’em!).

    I could be wrong about this, sure, but I haven’t seen a reason yet to think I am.

  31. Rob in CT says:

    Here’s an article from 2013 that addresses some of the overall issues:


    Some data:


    It’s obvious that the VA budget has increased dramatically in the past ~12 years. I think there are lots of things going on here:

    1) Aging population. Old people’s healthcare is expensive.
    2) Iraq, The Sequel! Duh.
    3) Recognition of things like PTSD.
    4) medical care cost inflation.
    5) a bunch of other stuff I’m not thinking of…

    #3 means the VA is likely doing more than it used to (a good thing, IMO). Thus, the extra money gets spread out more than you might think, just looking at the graph. I don’t have the expertise necessary to opine as to whether the “doing more” part is overwhelming the “more funding” part.

    #4 is a thorny problem we’ve been arguing about for a long time now. I don’t see why the VA would be immune. Yes, it’s socialized system, but overall it’s a small part of our larger health care system, which is a hodge podge of this and that.

    #5 is why we need calm people with expertise to weigh in if we want to get real answers.

  32. Ron Beasley says:

    Although I am a veteran I have never made use of VA medical services and now that I am on Medicare I guess I never will. Here in Portland the VA hospital is next to a Medical School and teaching hospital. My understanding is they have a working relationship and I’ve heard few if any complaints.

  33. wr says:

    @Jenos Idanian #13: “Was that too simple for you? Or too honest?”

    Yes, baby Jenos, that is the problem. You are just too darned honest for us.

  34. C. Clavin says:

    @Jenos Idanian #13:
    Actually what you typed was:

    The thing to remember is that we’re only at Stage One of Crisis Management under the Obama Administration.

    Now why would Obama be in crisis management if he didn’t cause the crisis?
    You’re simply wrong all the f’ing time…whether you try to move the goal posts…as you are now trying to do…or not. The damned weatherman is more accurate than you have ever been about anything.

  35. edmondo says:


    That doesn’t mean that the VA is perfect-it’s just better than any conceivable free market solution.

    You mean those free-market solutions you love in ACA, like subsidies to for-profit insurers?

  36. CB says:

    I look at how we treat the VA and veterans. And then I look at boondoggle programs like the F-35. And then I drink.

  37. Just Me says:

    I think quality of care varies.

    My husband has used the VA system for years for his disabilities.

    The large hospitals are usually good and generally come with continuity of care.

    The main issue my husband hits is the turnover at the local clinic where he sees a primary care doctor. The doctor has changed frequently and every new doctor rather than listen to my husband about his treatment and things they have and haven’t tried almost always want to start foolig around with his medications.

    They also vary in how well they read charts (my husband has significant medication allergies and he has had doctors recommend or write scripts for things he is allergic to).

    He is at the VA in Manchester every two weeks. The care isn’t bad but the hospital seems to have less turnover and continuity of care is better.

    I think the VA much like any hospital is going to have variation-the difference is that in this scandal the VA personnel were seeking to hide the problems rather than get help for them and some people died or got sicker due to the problem.

  38. rudderpedals says:

    @edmondo: I suppose that’s the Free Market tax for all but disabled veterans.

    If the free market was a superior way to deliver health care (it isn’t) then veterans would have demanded and received it long ago.

  39. Rob in CT says:

    @Just Me:

    That sounds about right to me. Particularly the bit about the coverup. It’s one thing to screw up. It’s another to try and hide it rather than face up to it.

  40. MarkedMan says:

    @Scott: Scott, I wasn’t aware of that, but it seems like a good policy. I know that the VA struggles to have a presence in as many locations as possible. Working with existing service systems enlarges their geographic coverage substantially.

  41. MarkedMan says:

    @Stormy Dragon: I agree that the governet has a terrible reputation for large sack IT upgrades. As does private industry. There is study after study showing that such systems are massively late, massively over budget and frequently abandoned. One telling anecdote: many years ago a friend was asked by her Fortune 500 company to investigate switching to SAP. Very cleverly she joined the local users group which consisted of high ranking IT people from many different industries. All had horror stories of massive budget overruns of double, triple, quadruple the initial quoted price. Delays were measures in years, not months. And she noticed that not a single person she talked to one on one was the original leader of the integration project but taken over after that person had been fired.

    Oh, there was one very cool exception. A small company was quoted the low price for the base system and they place the order. Immediately SAP started asking for change orders to accommodate the inevitable differences between the SAP baseline and how the company actually worked. The IT manager responded in every case by saying “that’s ok we’ll change our business practices to match the standard”. They came in on budget. Not on time of course, because SAP ended up writing ‘stock’ modules that had never really existed.

  42. anjin-san says:

    I’m wondering how much recent improvements in battlefield medicine play into the problems that the VA is having. A lot of guys with serious wounds came back from Iraq and Afghanistan that probably would have been KIA in earlier wars.

  43. C. Clavin says:

    Yeah…that number is huge.
    But stop blaming Bush ‘s wars of choice …it’s Obamas fault… Dammit.

  44. DrDaveT says:

    I don’t know anything about VA health care (VHA), but I know a lot about disability benefits (VBA). I’ve been watching the public spectacle of outrage over the backlog of claims for almost a decade now.

    Here are a few facts that everyone should know before commenting.

    1. The job of “disability claims rater” sucks. I mean really, really sucks. This is not a job you want your kid to have. As a result, retention is a problem, and those who stick around are not what you might call the shining lights of the talent pool.

    2. A typical “easy” claim might be 200 pages of medical records and documentation, related to 5 or 6 separate medical issues. As a rater, you have to determine for each of those issues whether it really is service-connected, and if so what degree of disability it represents. Oh, and you’re also responsible for determining whether VA has provided the veteran with all of the relevant assistance they can provide in developing the claim. How long do you think that might take you? If you take more than 3 hours on average, you can kiss your performance bonus (which is a substantial fraction of your income) goodbye. It would take me longer than that to even read the file.

    3. The VBA press releases like to tout how much progress they’ve made in going from paper claims to electronic claims in the past few years. Don’t be fooled — they’ve gone from paper claims (that you can at least attach post-it notes and paperclips to) to PHOTOGRAPHS of paper claims. That’s what they mean by ‘electronic’. No actual machine-readable data at all. VA and DoD can’t even agree on a common electronic medical record format (though I blame DoD for most of that one).

    4. As the article notes above, it takes 2 years for a new rater to get trained to a minimal level of competence. What they don’t note is that this is just the breakeven point, where VBA is now overall more productive than they were before you were hired. Your contributions now match the amount of mentoring and training time you suck up. It will be another couple of years before you actually become fully productive — assuming you stick it out, because see #1 above.

    5. In 2000, a typical first-time benefits claim had a couple of associated medical issues, and the big problem was establishing that the claimant really was a veteran (because of the fire in the 70’s that destroyed all of the records). These days, a typical claim has dozens of medical issues cited.

    6. A veteran who gets adjudicated at less than 100% disability can get back in line the very next day with a new updated claim on the very same issues. There is no incentive for the veteran to not do this, and every incentive to do it. So how, exactly, can VBA ever clear the backlog of claims? Only by assigning every claimant a 100% award, which would bankrupt the country.

    VBA is a seriously flawed organization, but they have been dealt an entirely impossible hand here, and then flogged repeatedly for failing to win anyway.

  45. bill says:

    @C. Clavin: ’bout time you admitted it!@stonetools: yep, see above. he’s has 5 yrs to do something and ……well?

  46. CB says:


    Can we get you on CNN to say that?

  47. beth says:

    @CB: If we had any actual news organizations left in this country, we’d be hearing facts like that and having real conversations about how to fix this mess. Instead we get a steady stream of “who knew what and when”, “should the VA head be fired” and “how will this affect the midterms”. But hey, we support our troops – stick a yellow ribbon on your car. That ought to do it.

  48. James in Silverdale, WA says:

    This example of government still being “led” by people raised in quaint age of mimeograph has to be the most shameful. America spends unspeakable amounts of money on defense to serve a paper system until 2013? It takes TWO YEARS just to train a claims agent? Is this the After-Lie from two wars based on lies, in which We’ll Take Care Of You is a deadly joke?

    Well, Mission Accomplished ™.

    The incompetence will grow deadly before the needed retirements. Lifetime appointments to anything assures disaster.

    The deep dishonor and shame this brings to America leads to great difficulty in forming words to properly express it.

  49. An Interested Party says:

    ’bout time you admitted it!

    yep, see above. he’s has 5 yrs to do something and ……well?

    Is there any problem he’s not responsible for? At this point, I’m waiting for someone like Bill to blame the President for his hemorrhoid issues…

  50. DrDaveT says:

    @James in Silverdale, WA:

    It takes TWO YEARS just to train a claims agent?

    Actually, yes, it does.

    Here’s the set of possible “issues” (claimed disabilities) the rater has to be ready to evaluate for both service connection and degree of disability.

    Let’s look at just one possible diagnosis code. This gives the criteria for assessing the degree of disability of someone with service-related pericarditis:

    7002 Pericarditis:

    For three months following cessation of therapy for active infection
    with cardiac involvement 100

    Thereafter, with documented pericarditis resulting in:

    Chronic congestive heart failure, or; workload of 3 METs or less
    results in dyspnea, fatigue, angina, dizziness, or syncope, or;
    left ventricular dysfunction with an ejection fraction of less
    than 30 percent 100

    More than one episode of acute congestive heart failure in the past year,
    or; workload of greater than 3 METs but not greater than 5 METs
    results in dyspnea, fatigue, angina, dizziness, or syncope, or;
    left ventricular dysfunction with an ejection fraction of 30 to
    50 percent 60

    Workload of greater than 5 METs but not greater than 7 METs results
    in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of
    cardiac hypertrophy or dilatation on electro-cardiogram,
    echocardiogram, or X-ray 30

    Workload of greater than 7 METs but not greater than 10 METs results
    in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous
    medication required 10

    Keep in mind that raters typically have zero medical training.

    Browse around for a while and think about how long it would take you to get confident and fast at doing any and all of these. (There is ongoing debate about the pros and cons of making all raters specialists in a small subset of disabilities. It would increase rating speed on each issue, but it would mean that no one rater would be responsible for a claim, making accountability even harder…)

  51. Grewgills says:

    These seem to be numerous but straightforward factors that go into the rating making it ideal to computerize. Now if only they would actually digitize the records rather than just digital images of records we could push through a lot of this bit quickly.

  52. Scott says:

    @Grewgills: Easier said than done. Just take me as an example. I left the service after 20 years in 2000. My medical records are paper, mostly hand written, rather poorly I might add. Although I have a copy, my official records have probably been stored in some warehouse somewhere. I may not be the most knowledgeable in digitization but I don’t think there is a system that can take handwritten paper files and digitize them into a workable database that can then be manipulated.

  53. DrDaveT says:


    These seem to be numerous but straightforward factors

    Yes and no. Pericarditis is pretty straightforward — if you know what a MET is, and can read a medical exam that may not have been written using the exact language of the standard. But if the exam says “mild shortness of breath”, does that count as dyspnea? Does lightheadedness count as syncope? How frequent and severe does it have to be?

    Other conditions are much worse for the rater, with the degree of disability depending on things like the difference between “moderate pain” and “severe pain”. Plus, there are lots of special cases to learn — conditions that get you an automatic service connection if you were in Vietnam, and extra flags to set for missing hands/feet/arms/legs, and temporary ratings that require re-examination within a certain amount of time, and so forth.

    And there are several hundred different diagnosis codes.

    Establishing service connection is straightforward for servicemen separating today, but vets from previous wars (and especially from the National Guard and Reserves) can have a bitch of a time establishing that the condition in question began during a period of active service.

    For claimants with a combined degree of disability of 70% to 90%, you have to decide whether they are “individually unemployable” due to their service-connected disabilities, which would then entitle them to benefits at the 100% disabled rate (which is significantly higher than the 70% rate).

    And then there’s “duty to assist”, which means that the people who develop and rate the claim have to establish that the veteran got all of the information and advice that was relevant to putting forward the best case for all of the relevant issues. How exactly are you supposed to decide that one?

    None of this is impossible — but there is a reason why new hires are a net drag on the agency’s resources until they’ve been at it for a couple of years.

  54. DrDaveT says:

    @An Interested Party:

    I’m waiting for someone like Bill to blame the President for his hemorrhoid issues…

    Well, given that Obama makes him sh*t bricks…

  55. mannning says:

    The guy at the top today has been responsibe for action to improve the VA system for 5 years. Were he a Naval Fleet Cammander he woud have been fired way long ago. It was showm that Obama knew of the VA problem as long ago as his senate joke term. He has spoken about it unteen times over the years, but ordered little or no concrete action to solve the problem, never mind who were the bad guys in previous administrations.

  56. An Interested Party says:

    …never mind who were the bad guys in previous administrations.

    Oh absolutely! As we all know, all of America’s problems, nay, all of the world’s problems started on January 20, 2009…

  57. bill says:

    @An Interested Party: well, we have “hope & change” since then- how’s that working out anyway?

  58. DrDaveT says:


    but ordered little or no concrete action to solve the problem

    This is not true. VA has hired and trained large numbers of new raters since then. The Under Secretary for VBA has implemented major automation projects, including “electronic forms processing”. (Even Shinseki probably doesn’t know that this doesn’t mean what it sounds like.) On the benefits side, the processing rate for claims has approximately tripled since Obama took office.

    …but the application rate has quadrupled, so everyone says “You’re not making things better!”

  59. James Joyner says:

    @DrDaveT: Really insightful comments throughout the discussion. Bureaucracies have intricate rules for a reason, even if some of them have long since outlived their usefulness. But even in a perfect system, I don’t know how DVA could be efficient given what it’s tasked with doing.

    Related to the application rate, I got a letter from DVA the other day regarding Gulf War Syndrome, practically begging me to sign up for benefits–with some conditions considered prima facie service related for those of us who served in that conflict. Were I in different economic circumstances, I’d already be lined up trying to get a disability rating, even though I’m pretty sure the minor ailments that plague me come from being 48 years old and relatively sedentary and not from inhaling diesel smoke in Kuwait 23 years ago.

  60. Ivy Freeborn says:

    Of course, the Bush Administration cutting the budget for the VA every year after Afghanistan/Iraq started didn’t help any.

    I’d point out that if we had a National Health Service here, we could actually phase out that part of the VA. We could solve the VA.

  61. DrDaveT says:

    @James Joyner: Thanks for the kind words.

    I got a letter from DVA the other day regarding Gulf War Syndrome, practically begging me to sign up for benefits–with some conditions considered prima facie service related for those of us who served in that conflict.

    This is an important point. VA got a lot of criticism in the 90s and early 00s — some of it justified — for not doing more to seek out veterans and make them aware of the benefits they are entitled to. Especially for Vietnam era and earlier, VA doesn’t know how many veterans there are, or where they live. The increase in outreach, combined with the “presumptive service connection” for certain conditions, is a big part of the explosion in benefits. If you were in Vietnam and have diabetes or various forms of heart disease, it is assumed that it is service connected. That’s a lot of people.

    Were I in different economic circumstances, I’d already be lined up trying to get a disability rating, even though I’m pretty sure the minor ailments that plague me come from being 48 years old and relatively sedentary and not from inhaling diesel smoke in Kuwait 23 years ago.

    And this is another important point, and the third rail of any discussion of veteran’s disability benefits.

    When we think of disabled veterans, we think of the photo up there of the guy with a missing leg, or of PTSD and TBI that have been in the news so much. But the degrees of disability were codified at a time when “able to work” still meant manual labor, and the rules for combining them never foresaw the number of issues we’re seeing per veteran. A 10% disability is almost negligible — but if you have 7 of them, for various issues, by the regs you are 50% disabled. 12 of them make you 70% disabled. Two 30% disabilities and two 10% disabilities work out to 60% “combined degree of disability”. Etc. I work with a guy who is 70% disabled, in theory, but seems pretty athletic and active.

    And finally the cultural shift. The WW2 veterans didn’t come in to claim their benefits, because their generation didn’t want no stinkin’ charity. The vietnam conscripts rightly wanted compensation for what was done to them, but didn’t know how, and couldn’t prove service connection. Now we have a perfect storm of easier barriers to application, more lenient criteria, much better evidence, and a culture that considers the disability benefit to be just part of the compensation package for having served. And that’s why we are now giving out something like $50 billion a year in disability benefits alone.

  62. Todd says:


    I am a good example of that “perfect storm”. I just retired from the Air Force at the end of last year. I did my VA physical (on post at Fort Hood) just before I left active duty. My claim was only stuff that was in my medical records (and I did way more “sucking it up” than going to sick call during my 24 years). The VA office there on Fort Hood helped me fill out the paperwork. I got my decision a few weeks ago (just over 4 months after I retired), and my combined rating is significantly higher than I would have guess it might be (I have injuries that impacted the type of jobs I could even consider after I retired, so I don’t feel guilty, but I am none-the-less a bit surprised). My dad, who retired at about the same time as I joined has more health problems than I do, but I’m almost certain his rating is not as high as mine. If I had retired when he did, instead of just recently, I’m all but positive mine would be lower too.

    p.s. there is a VA clinic just down the block from me here in AZ, but I’m not going to use it, as I have TRICARE Prime. I think the VA hospital should be primarily for those who have no other options.

  63. mannning says:

    @DrDaveT: Ok, sounds good, but there is an obvious problem here. With the opening up of the ease of applying for various benefits during this current administration, who didn’t project the new application rate this would cause, and what the consequences would be to the VA system? If the rate has quadruped, the trend must have been noticed as early as 2008 or 2009, yet here we are in 2014 trying to excuse the VA situation actualy caused by looser application restrictions without doing the math, and without making greater resources and training available for the surge early enough to be effective.

  64. mannning says:

    @An Interested Party: How very infantile! The problem exists today, and it is the responsibility of today’s administration to fix it as rapidly as possible. That they have been less than effective at it over five years is the current problem. Who broke the system is an exercise in finger-pointing, and a waste of time and effort that should be applied to address the real and existing problems.

  65. DrDaveT says:


    who didn’t project the new application rate this would cause, and what the consequences would be to the VA system?

    Good question. I think the short answer is “it’s complicated”. I see several key factors:

    (1) VBA management is not very good. I didn’t claim they were.

    (2) VBA management has been beaten on long enough that they have developed a foxhole mentality. They are more interested in ending the beatings than anything else, and they know that this is driven by the appearance of improvement, not by reality.

    (3) In the public discourse on veterans’ benefits, the applicants are all assumed to be “our wounded heroes”. It is never permissible to talk about the degree to which veterans game the system, or pursue benefits to which they are not entitled, or submit applications that do not provide adequate documentation of the things they are asserting. As a result, all of the delays in processing that are due to trying to actually follow the law and make sure the veteran really qualifies for the benefit are seen as unnecessary insult to our wounded heroes, not as appropriate protection of public funds from fraud and error.

    (4) Congress likes to express their displeasure by withholding funds. When your problem is that you are understaffed and undercompetent, this doesn’t help. When you have a long training cycle, so that additional hiring this year won’t show a productivity improvement until 2 or 3 years from now, you really have a problem, because Congress isn’t that patient.

    (5) I don’t think anyone in or out of DVA anticipated the tremendous increase in the number of issues per claim that happened over the last 10 years. Part of it is driven by better medical records; part of it is driven by the effectiveness of the new “Benefit Delivery at Discharge” (BDD) process that eliminates the gap between military service and initial application. Part of it is unexplained; it came out of nowhere.

    (6) As others have noted, a lot of people are coming home from Iraq and Afghanistan with injuries that would have killed them in past wars. Some of these, like Traumatic Brain Injury, are especially tricky — the symptoms are intermittent but chronic, and they mimic other non-service-related conditions. We are also better at spotting PTSD than we used to be.

    (7) The enormous increase in presumptive service connection for various conditions associated with Agent Orange exposure has had a big impact on applications. It was always going to be hard to predict that impact, because nobody knew how many Vietnam vets were out there with type 2 diabetes or ischemic heart disease or non-Hodgkins lymphoma or prostate cancer — nor how many of those would apply. The answer turned out to be “lots and lots”.

    I’m not trying to excuse anyone here. As I said way up top, VBA is pretty dysfunctional. I’m just trying to counter the over-simplistic view that there are no mitigating circumstances and the fixes should be easy.

    …with one exception. At this point, the bulk of the Vietnam vet benefit application surge in response to the new laws has already happened, and the bulk of the OIF/OEF surge has already happened. Simple demographics will fix the backlog problem, assuming we don’t invade Nigeria or something. It will take a few years, but we’ll get there. The other problems — quality of adjudication problems, inadequate oversight of fiduciaries, VHA problems — those are where we should be focusing attention now. In my opinion.

  66. An Interested Party says:

    well, we have “hope & change” since then- how’s that working out anyway?

    About as well as “Shock and Awe” and “Mission: Accomplished” worked, I suppose…the problem with “Hope & Change” was that the President was naïve enough to think that the GOP would actually want to work with him on anything…no, in today’s political word, it’s all just a scorched earth policy…

    How very infantile!

    Indeed! You need to share that message with your fellow travelers, who seem to have taken the previously mentioned scorched earth policy as their way to operate ever since January 20, 2009…

  67. mannning says:

    @DrDaveT: Very informative post! It is indeed complicated, but a few good analysts might have projected a closer approximation to the actual application rates over the years, adjusted by allowing for the very surge factors you mention. But, as you also stated, the foxhole mentality would have blocked such a direct approach to managing the influx. So the question remains open! The surge will die out, and so will some more veterans that were caught up in the wait list mire until too late. Unless the use of civil medical facilities will catch their problems in time.

  68. mannning says:

    This VA problem is one close to my heart. As a Korean “Conflict” veteran, I have seen the casualties from every sort of weapon and from our own Agent Orange. This is not a partisan issue, it is extremely bipartisan, and any attempt to sully the effort to correct the long-standing problems of the VA with partisan bickering is truly infantile in my opinion.

  69. Don says:

    The VA 50 year mess is actually an easy fix! All disabled veterans 75%+
    would have a plastic card like our politicians have for Full health coverage=100%.

    Those in need of now treatment on long waiting lists–could be the PRF list that
    VA hospitals use to flag unruly patients or those who did not pay homage to the
    patient provider