Why the VA Scandal Really Occurred and What Can Be Done About It

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The unfolding scandal at the Department of Veterans Affairs (VA) agency is a reminder about some enduring truths about government bureaucracies. The most important is that an agency’s operators – those responsible for carrying out its core task – respond most immediately to situational imperatives rather than the agency’s stated mission or purpose. This is particularly true when the agency’s stated goals are vague or open to interpretation. So it is with the VA. Its mission is to “fulfill President Lincoln’s promise ‘To care for him who shall have borne the battle, and for his widow, and his orphan’ by serving and honoring the men and women who are America’s veterans.” This mission statement has little meaning, however, to those VA operators responsible for scheduling medical appointments for veterans. Instead, the operators quite understandably defined their task in response to the performance standards on which they were evaluated, which in the case of the VA meant minimizing the wait time between when a veteran requested a medical appointment and when she received one. When it became clear to schedulers that the performance standards on which they were evaluated were increasingly unrealistic, given the VA’s burgeoning case load and the failure to ramp up resources to match that increase, schedulers quite rationally responded by making it appear that they were meeting those standards by, in effect, falsifying records. They did so in large part because of the politically sensitive nature of their task, which was to help people who in many cases had compromised their health in service of their country. This created additional pressure to make it appear that these veterans were being treated well, and it encouraged VA supervisors to be less than vigilant in insuring that performance measures were actually being met.

My point is that we should not be surprised by the VA operators’ behavior. Nor should we expect that the solution to the problem lies in hiring more “honest” schedulers, or in replacing the recently fired VA Secretary Eric Shinseki with a more competent executive. Operators, such as the VA schedulers, define their tasks in response to situational imperatives, and not the well-meaning directives of reformers. Calls for “clearer standards” or “more transparency” are unlikely to have much impact as long as there remains a disjunction between what schedulers are asked to do – and how they are evaluated – and what it is possible to do, given limited time and resources. Like most bureaucratic scandals, the fault lies less with the failing of individuals than it does in systemic factors that govern how those individuals behave within a particular bureaucratic context.

Similarly, it is easy to blame Shinseki for his failure to “manage” the VA, but the truth is that Shinseki was not hired by President Obama because of his working knowledge of the situational imperatives that dictate how VA schedulers do their jobs. Instead, he was appointed for his symbolic value as a former military officer who served two tours of duty in Vietnam and earned a Purple Heart. And, in truth, most government executives are not chosen for being “good managers”. Moreover, they are often rewarded for being associated with a good policy outcome, or blamed for a bad policy outcome (see Clinton and Benghazi!), about which they often have little influence. That means they have little incentive to actually manage the bureaucracy, and every incentive to appear to be in charge by cultivating relationships with those who count – particularly the President, Congress and any external constituency – in this case our nation’s veterans – that wields particularly strong influence over an agency.

The response to the VA scandal has been both predictable and largely uninformative. President Obama, expressing outrage, has fired Shinseki, thus satisfying media and veterans’ calls that someone be held accountable for this mess. Congress, which arguably is more responsible for the scandal than is Shinseki, has sprung into action with promises of reform coupled with criminal investigations. On Thursday our own Bernie Sanders, chairman of the Senate Veterans’ Affairs Committee, which has oversight of the VA, will chair Senate hearings on a bipartisan reform bill that seeks to reduce veterans’ wait times, give the VA secretary power to fire “incompetent” senior VA officials, and modernize the VA’s scheduling system. This type of “fire alarm” reaction typifies how Congress conducts bureaucratic oversight. Conservatives, meanwhile, argue that the VA scandal is a reminder of the pitfalls of government-run health care.

The truth behind the VA scandal, of course, is more mundane and thus far less newsworthy. Rather than criminal malfeasance or corruption at the individual level, the scandal illustrates how the public’s contradictory impulses, as expressed through our elected representative and those they hire, often set public sector bureaucracies up for systemic failure. In this case, the VA developed a system to increase agency efficiency by monitoring how quickly our veterans received medical help. However, a measurement designed to make the VA operators more accountable for their performance, and thus to encourage efficiency, largely failed to achieve its objective because it meant operators were assessed on quantitative standards that did not truly measure how well schedulers were serving veterans’ needs. Alas, this is not the first time we have seen good intentions go awry in this way. As James Q. Wilson observed in his magisterial work on bureaucracy, “the American political system is biased toward solving bureaucratic problems through rules.” This is partly because agency managers in our system have a strong incentive to force rules on operators in order to prevent a politically controversial outcome – not servicing veterans in a timely manner – from happening on their watch. But if the rule does not alter the incentives that operators’ value – such as getting good performance reviews and associated bonuses – it is not likely to achieve its desired outcome. If the VA is to be reformed, then, it will occur only by understanding what operators do, and why they do it, and devising performance measures accordingly. In the absence of that understanding, firing departmental heads and leveling criminal charges on hapless schedulers, although perhaps beneficial at the ballot box, is unlikely to correct what really ails the VA. Nor will it help our veterans.

8 Responses to Why the VA Scandal Really Occurred and What Can Be Done About It

  1. Peter Rothschild says:

    Hi Matt,

    Two points…

    Re Shinseki’s appointment, I wonder if that was in some way a reward for speaking the truth about inadequate troop levels during the early part of the War in Iraq and getting fired for his accurate, but politically unacceptable comment. Apparently no good deed goes unpunished, and in Shinseki’s case, perhaps twice over.

    It seems to me that the major failure in the process, and one which would have to be managed from the top of the bureaucracy [Shinkseki], was that no one bothered to measure the opinions of the veterans regarding the service they were, or were not, receiving. Most major companies are constantly conducting customer-care surveys to get the voice of their customers. Any of your poly-sci students with a robust Survey Monkey account and a list of veterans could have polled the vets and found out pretty quickly what was being swept under the rug via hand-written reporting practices.

  2. Matthew Dickinson says:

    Peter,

    Both good points. I had the same thought as did you re: Shinseki’s appointment – that his symbolic value was not just because he was a decorated veteran, but also because he was a politically valuable general for the reasons you cite: he was on the “right” (read Democratic) side of the Iraq troop debate. Having top military brass on his side was particularly important to Obama, who is very sensitive about his lack of military background. If so, however, it reinforces my basic point: Shinseki was chosen for what he symbolized more than what he knew about running the VA.

    As for surveying vets – one reason the scandal festered so long is that schedulers were not lying to veterans about when the next open appointment was available. In fact, they were being quite honest about it. But then they would backdate the paperwork to make it look like that appointment date represented a minimal wait time for the veteran, based on when the VA SAID they requested an appointment versus when they actually requested it. Ultimately, of course, the wait times became so scandalous that the it became clear the books were being cooked.

  3. Stuart Shapiro says:

    Agree completely. Wonder what you think about “failures” at agencies that are more mission driven. In particular, I am thinking about the attempts by the President to curb deportations at DHS. I’ve long thought that in addition to attempting to overcome the obstacles inherent in any large government organization, curbing deportations is particularly difficult because it goes against the core mission at DHS (or more particularly ICE). Immigration agents don’t go into that line of work, to decrease deportations. And the resultant agency culture is not one of leniency toward illegal immigrants.

    Getting a large bureaucracy to do what you want is difficult in any circumstances. This is true when you are pushing it in the direction it is already inclined (getting EPA to issue climate change rules). It is more true when the goal is relatively value neutral and the bureaucracy is neither inclined nor disinclined to help you (getting VA to cut wait times). It might require huge amounts of political capital (which executives are rarely willing to spend) when the goal is counter to the preferences of the bureaucracy.

  4. Shelly Sloan says:

    Bonuses for government employees is craziness. They are paid to do their job. The job security is mind blowing. Abolish all bonuses, (to coin Obama’s phrase) PERIOD.

    Government cannot run a healthcare system. This is the largest we have, up to now. What does that portend for Obamacare?

    I mourn for this generation and those to come if the Republicans do not win the Senate and then the Presidency. That is the only way the best healthcare system in the world will not be utterly and irrevocably destroyed.

  5. Matthew Dickinson says:

    Stuart,

    My sense is that you are right – the ICE’s culture since its breaking off from INS and its reorganization as ICE within the DHS is not one of tolerance toward suspect illegal immigrants, although I think they are even more focused on border patrol to stop the inflow of illegals than they are on deportation. (I think it says as much on their website!) One question I have is to what degree Obama has tried to turn words into action on this issue of reducing deportations. The politics of deportation do not lend themselves to the appearance of leniency toward suspected illegals and I wouldn’t be surprised if he turned a blind eye toward the ICE’s focus on deportation. As you note, the alternative is to spend limited capital on changing the preferences of a very large bureaucracy.

  6. Matthew Dickinson says:

    Shelly,

    You are not alone in your view on this – it has become common for Obama’s critics to argue that the problems with the VA do not bode well for the implementation of the Affordable Care Act. The irony, of course, is that his supporters have long pointed to the VA as evidence that the government can and does provide effective medical services. In truth, I’m not sure running the VA hospital and mandating insurance coverage/constructing state-level insurance exchanges (among other provisions of the ACA) have all that much in common.

  7. geTaylor says:

    Schedulers are allowed to lie because of the shortfall in resources to schedule for.
    Resources always come up short for “boundless gratitude” measured by fulfilling promises of unlimited resources.
    The principles are the same for republicans and democrats regardless of the reasons for the gratitude.

  8. Shelly Sloan says:

    Matt:

    Bureaucrats are bureaucrats, wherever you find them. The violators are not Democrats nor Republicans, they are just bureaucrats.

    I began my career in the Department of Justice in Washington. I did so to accede to my father’s wishes after law school. His friend was a US Senator from our state and told him that while I was young and single was the time for me to learn about government. He was right.

    I learned the secret of dealing with any bureaucrat and getting what you want. It is simple enough. You just explain to him or her why it will go worse for them to say “No” instead of “Yes”. I know that sounds like an over simplification of the process, but it really isn’t.

    The reason why this works is that almost every one of them has opted for a life of ease and 20 or 25 years then retirement. If going up higher (read: more money)on the food chain or their precious retirement is threatened they will do anything to avoid it. They just want to keep their heads down and wait out the days until they can retire, stay on the dole, and do whatever else they want. Thus, it is “get along and go along”. This explains the VA and it explains most of the IRS (except for Lois, who was a political appointment, and whoever else was at the top of the food chain).

    I now run the Government Relations in the largest law firm in Los Angeles and I am here to tell you that bureaucrats are still bureaucrats.

    So, I repeat, bonuses for these people are just a motivation to do the wrong thing. Those resources should be redeployed to assist the private sector in caring for the veterans who so deserve to be treated properly.

    One more thing; there is a relationship to Obamacare (I won’t use the BS name some bureaucrat thought up for that fraud)and the VA. It will be run by people who don’t give a damn about the suffering people on the other side of the equation. Imagine Lois Lerner in charge of your parents’ health decisions. OK, hold that thought until November when you walk into the voting booth.

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