On a wet and dreary afternoon in mid-February, Mick Cole and a half-dozen other members of the Veterans for Peace–backed “Save Our VA” campaign climbed the steps of the Capitol to meet with U.S. Rep. Mark Takano, the Democratic chair of the House Committee on Veterans’ Affairs. They were there to laud the care they’ve received from the Veterans Health Administration (VHA) and warn that massive staffing shortages were putting their health at risk.
From 1965 to 1969, Cole flew bombing missions over Vietnam as an airborne voice intercept operator in the Air Force. Having learned Vietnamese, Cole’s job was to monitor the communication of the North Vietnamese air force and provide real-time intelligence to American pilots. Because of his combat duties, Cole eventually lost hearing in one ear. He also had several prostate operations, likely related to Agent Orange exposure.
Yet his most debilitating problem is post-traumatic stress disorder (PTSD), a condition made worse by his unique military role, in which he experienced the battle from both sides. “When I was monitoring the Vietnamese pilots and one of them got shot down I could hear the anguish in their voices,” he recently recalled. “They were just like us.”
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After he left the Air Force, Cole spent years self-medicating with alcohol. “Finally, 15 years ago someone convinced me to go to the VA,” he told Takano. “If it weren’t for my weekly therapy groups, I wouldn’t be here today.”
But now, Cole continued, the department’s staffing crisis, in which tens of thousands of positions are unfilled, is compromising the high-quality care he has received for years. His local VA facilities, in upstate New York near the Finger Lakes, are now sagging under 235 vacancies.
“My psychiatrist left to go into private practice and hasn’t been permanently replaced,” he said. “So every time I have to go get checked up on, I have to tell my story to someone new; it is very painful to relive that trauma over and over again.” Cole added that the psychologist who runs his weekly group therapy sessions is overburdened and struggles to schedule timely individual appointments with veterans in crisis.
After meeting with Takano, Cole and his fellow veterans sat with a young legislative staffer in the office of another member of the Veterans’ Affairs Committee: Rep. Elaine Luria (D-VA). When Luria’s aide asked Cole how the vacancy crisis had personally impacted him, he hesitated, explaining that it was hard to tell the same story over and over again. “It’s very, very …” he began, choking up. A second later, Cole broke down, and wept quietly, before apologizing. “I am sorry,” he said. “I am so sorry.”
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Testing for COVID-19 outside a Veterans Affairs facility in Colorado Springs
Given the current coronavirus crisis—and the VA’s mandated “fourth mission” as the backup civilian health system in emergencies—Cole is now even more worried. “What will happen if nurses and doctors at the VA are infected or quarantined?” he asked. “How is an understaffed VA going to handle all of this?”
Cole’s concerns are common to veteran patients who depend on VA facilities across the country. The department is now reeling under roughly 50,000 vacancies—a number larger than the Departments of State, Labor, Education, and Housing and Urban Development combined. These shortages make it difficult to deliver timely care to veterans under normal circumstances. Given the current pandemic, shortages may cripple the VHA’s ability to take care of an influx of veteran patients who need to be hospitalized because of COVID-19. Since so many veterans, like Cole, suffer from chronic problems due to their military service, the VHA risks being even more overwhelmed with cases than the private sector. If staff caring for these veterans become sick themselves, die, or are quarantined, crippling staffing shortages could turn catastrophic, particularly as private-sector hospitals increasingly look to the VA to fulfill its fourth mission.
Massive as this vacancy number appears, it fails to fully capture the extent of the department’s staffing problem. That’s because this metric only includes positions that have not been filled after an employee has left a job. Excluded are the many new positions needed to address emerging needs.
The most obvious new burden is to administer and coordinate the massive outsourcing of care resulting from the 2018 VA MISSION Act. President Donald Trump has also issued and implemented a number of unfunded executive orders, including one that mandates the VA contact—and provide mental-health services to—every newly discharged service member. All these challenges are compounded by the fact that roughly 40 percent of the department’s workforce are approaching retirement, and the number of veterans over 75—a population more reliant on VA services—is expected to jump 46 percent by 2028.
Although staffing problems at the VA predate Trump, his administration has exacerbated them. Since coming into office, Trump has undermined recruiting and retention efforts by cracking down on labor protections and gutting employee benefits. VA leaders have installed, promoted, and protected incompetent administrators who have violated labor agreements, leveled threats against employees, and instituted punitive management practices. This has driven many dedicated staff out of the agency entirely, and discouraged potential recruits from filling their positions. These developments, combined with one of the most aggressive federal privatization agendas in American history, have placed the future of the VA in jeopardy.
Amid an ongoing and deep mental-health crisis among veterans—and repeated pronouncements from lawmakers and the VA secretary that suicide prevention is the number one clinical priority—the most common vacancy positions are for psychiatrists. In New Mexico’s VA system, for instance, chronic mental-health shortages led to four-month wait times for new patients. Facing similar issues in Rhode Island, mental-health counselors were ordered to double their number of weekly visits in order to meet demand.
“They kept pushing the numbers, the numbers, the numbers,” said Ted Blickwedel, a Marine Corps veteran and former VA counselor who was caught up in the order. “We had counselors taking leave, burning out, facing suicidal thoughts, or obtaining their own therapists.”
Not only is the quality of care suffering under this vacancy crisis, but in some cases, whole programs are shuttering. The Brooklyn VA’s ear, nose, and throat clinic has closed, as has an outpatient clinic in Buffalo. PTSD support groups at the West Los Angeles VA hospital have been shut down, and last March, the VA closed a clinic in Kokomo, Indiana less than a year after it opened, despite praise from veterans who said it was easing access to care. The Trump administration sought to quietly shut down services across the Upper Midwest, including a 29-bed nursing home in Miles City, Montana. This effort was halted largely because of Montana’s U.S. Sen. Jon Tester, the powerful ranking Democratic member of the Senate Veterans’ Affairs Committee.
According to internal agency documents, efforts to increase capacity at the VA North Texas Health Care System, the second-largest in the country, were quashed last year despite internal projections that the patient population is set to increase by 12 percent in the next decade. Even a small veterans’ woodshop program in northern New Jersey became a casualty of this belt-tightening.
One of the Trump administration’s most disturbing moves was to shutter the VA’s Interim Staffing Program (ISP)—a critical, national service that provided physicians, nurse practitioners, and physician assistants when staff retired or went on leave. The program, launched in 2013, reduced the use of costly private-sector temp agencies. As an added benefit, the VA’s providers were familiar with the system and with veterans’ specific health care conditions.
According to an internal analysis, relying on private-sector temp agencies created “headaches and inefficiencies,” including “delayed services” and “erratic quality control.” ISP cost just $2 million in administrative costs in FY 2018 and yielded $11 million in care.
Trump’s first VA secretary, David Shulkin, was poised to double the program’s size and open it up to new positions, including psychologists. Yet Shulkin was ousted after pushing back on Trump’s privatization agenda, and was never able to move his plan forward. Last May, the program’s 76 providers were told that it would end. Replacing ISP is a new telehealth initiative in which providers treat patients virtually.
In December, 31 former ISP staff sent a letter to Shulkin’s replacement, VA Secretary Robert Wilkie, protesting the dissolution of the program and raising concerns over the quality of telehealth care. Almost all who had left the VA said they would come back if the program was reinstituted.
ISP providers were supported by testimonials from current and former service chiefs across the country. “When we used the ISP program in the past we had great face-to-face patient care that not only we appreciated but the veterans really embraced,” one wrote in an email provided to the Prospect. Wilkie never responded to the letter.
Wilkie and other top VA leaders contend the VA has never been stronger. Most recently, they point to the White House’s historically high VA 2019 budget and 2020 budget request as evidence that Trump is the most pro-veteran president in American history.
One VA clinician described this as “the Big Lie,” which ignores many facts, including that the administration is slyly initiating hiring freezes (euphemistically referred to internally as “pauses”) and funneling thousands of patients and billions of dollars into a private-sector system largely unprepared to handle the complex problems of those who served.
While Wilkie has admitted that the VA is dealing with millions more appointments now than in the recent past, he candidly told the House Committee on Veterans’ Affairs last year that “I would not be honest with you if I told you that my focus would be filling [departmental] vacancies.” This posture potentially violates U.S. codes mandating the VA Secretary “maintain the bed and treatment capacities of all Department medical facilities.”
THE VA HAS long faced difficulties recruiting and retaining staff. Some of these problems are due to forces beyond the department’s control and plague private-sector health care systems as well. They include critical shortages of primary-care and mental-health professionals and challenges enticing staff to practice in rural areas, where over a quarter of the nation’s veterans live. It’s also quite difficult to staff systems where there are annual influxes of snowbird veterans moving to the South or Southwest during the winter months.
In 2014, these problems erupted into a serious scandal when it was discovered that administrators at a VA hospital in Phoenix, Arizona, were tampering with scheduling data, leaving veterans to wait months for appointments. Lawmakers, lobbyists, and the Koch-funded Concerned Veterans for America framed the scandal as evidence of deep-seated incompetence and corruption inside the department. In fact, more than anything these practices represented an attempt by an understaffed system to meet demanding congressional care metrics.
The Phoenix affair spurred enactment of the Veterans Access, Choice and Accountability Act, which made it much easier for veterans to seek care in the private sector, and ignited a deeply divisive national debate over the government’s ability to deliver health care. Tucked into the law was $2.5 billion to hire more staff. Yet according to a 2017 NPR investigation, only a few thousand hires were made. A major reason for this disappointing result is that the hiring money was not nearly as generous as publicly projected. It essentially replaced, not augmented, the VA’s hiring budget.
As a result, neither Congress nor the Obama administration effectively addressed the crisis.
The VA’s Office of Inspector General (OIG) has issued a half-dozen reports cataloguing the extent of the vacancy problem in recent years; the last two expressed newfound urgency and warned of “severe occupational staffing shortages” across the country. The OIG’s most recent vacancy report, which was released last September and included analysis from 140 facilities, found 96 percent of departmental clinics reported at least one significant shortage; 39 percent reported at least 20.
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At the Pittsburgh VA facility in early March
When you zoom in on the types of vacant positions, the picture becomes even more troubling. The top clinical vacancy is for psychiatrists, with 61 percent of VA facilities reporting severe shortages for the role. (Other clinical positions facing severe shortages include psychologists, primary-care doctors, gastroenterologists, and nurses.)
There’s also an acute need for more human resources staff and medical staff officers, whose jobs are to recruit, vet, and credential new staff. In 2015, the Government Accountability Office found that multiple medical centers struggled to recruit and retain nurses because of massive shortages in human resources staff. Things have only gotten worse, with the process now often taking months to complete.
Russell Lemle, who, after working for the VA for 37 years, retired last year as psychology director of the San Francisco VA, said that when he left, credentialing a newly selected psychologist would take three months due to staff shortages. “It was incredibly frustrating,” he said. “In the interim, existing staff had to fill in the gaps by adding to their already heavy workloads.”
When you overlay the hospitals with the most severe shortages and the longest wait times, it becomes even more clear the VA is dealing with Phoenixes all across the country. The Atlanta VA Medical Center, for instance, has reported the greatest number of severe occupational shortages in both 2018 and 2019 and currently faces wait times of up to 41 days. Late last year, surgeries were temporarily halted in Atlanta due to, among other things, staff shortages.
ANOTHER MAJOR roadblock to VA recruitment and retention is the department’s inability to offer salaries that are competitive with those in the private sector. By law, no federal employee can make more than the president of the United States—i.e., $400,000. A VA facility chief of staff noted that an interventional radiologist or cardiothoracic surgeon can easily earn more than $500,000 in the private sector. According to the VA’s OIG, VA hospital directors make roughly 25 percent less than their private-sector counterparts, yet many hold greater responsibilities.
Although working at the VA offers many rewards unavailable in the private sector—like the opportunity to work with and give back to veterans, avoid the hassles of dealing with insurance companies, and deliver care that is truly coordinated—they may not always compensate for the high cost of living in many urban areas. To cite one particularly stark example, the VA Palo Alto Health Care System is grappling with a whopping 778 vacancies, in large part because potential staff are unable to afford a home in the region, which averages nearly $2.5 million.
At last year’s annual Palo Alto medical staff meeting, employees were informed that the slate of services offered would soon be cut, in part to reduce the number of vacancies on the books. “They told us they are trying to figure out what to eliminate because they feel it’s impossible to fill all the vacancies,” said one of the meeting’s attendees. “Leadership said this work will better ‘align the system with national priorities,’ whatever that means.”
Since coming into office, Trump has exacerbated these recruitment and retention problems through the administration’s unprecedented attacks on VA unions and employees. In June 2017, with great fanfare Trump signed the VA Accountability and Whistleblower Protection Act, which gutted due-process protection for employees and took away tools like performance improvement plans, which gave struggling staff a second chance. (It’s worth noting here that one-third of VA employees are themselves veterans, many of whom are employed through the department’s pioneering compensated work therapy program, which brings economic stability to veterans with a history of mental illness or homelessness.)
The law also established the shadowy Office of Accountability and Whistleblower Protection, which, while publicly projected as a tool to crack down on corrupt leaders, has instead been used to suspend, demote, or fire thousands of frontline employees, many of them local union leaders, often for specious reasons, from keeping a company car at home over the weekend to failing to meet stringent new work standards.
Last year, the VA’s OIG found the office is often “alienating to the very individuals it was meant to protect.” It further reported that office leaders failed to draft or implement standardized procedures, ineffectively trained investigators, and on numerous occasions, retaliated against whistleblowers in service of protecting bad actors.
In March, the Project on Government Oversight released a similarly scathing report that found, among other things, that the office’s leader, Tamara Bonzanto, has created an anxiety-ridden environment. In her first meeting, she “viciously verbally attacked” an employee seeking clarity on handling evidence and later had her deputy monitor staff for “appropriate body language.” This office has taken in roughly 2,000 whistleblower complaints but, as of late last year, produced only one recommendation for disciplining a senior VA leader.
As fired VA employees have sought to be reinstated, they’ve seen their cases held up by the Merit Systems Protection Board, which Trump has also gutted. The president has also revoked union time for all Title 38 employees, which has greatly inhibited the role of labor in negotiating fair treatment by leadership. The local union at the VA hospital in Huntington, West Virginia, has effectively been shut down due to this rule, as its leaders all fall under this category.
Patty Nash, the local president of the American Federation of Government Employees and a nurse in Huntington’s intensive-care unit, said this crackdown has made it difficult to keep workers content or freely raise issues around care. “I now have to be in here an hour or two every day after work to draft union grievances or EEO complaints,” she said. Last summer, as the Trump administration proposed a series of draconian contract changes during collective bargaining, nearly 130 lawmakers from both parties accused the administration of anti-union tactics.
Just as frontline employees’ rights are jeopardized, other staff are increasingly demoralized—with some leaving the VA—because the administration seems to have empowered middle-level managers whose punitive practices are creating a culture of fear and retaliation at hospitals across the country.
This culture is sometimes enforced by the VA Police, a largely unchecked force with lots of power and a history of abuse. At the Pittsburgh, Pennsylvania, VA, for instance, a union official was handcuffed and later charged for obstructing governmental operations after demanding to know why one of his fellow union members was being interrogated by police.
Last year, the VA’s OIG documented cases where qualified applicants backed out because there is now “little recourse for staff to defend themselves from allegations.” One medical director told the VA watchdog of the anguish he experienced after being portrayed as responsible for a veteran death in the press, even as a subsequent investigation cleared him.
While the most recent departmental survey suggested improving morale, there were still many warning signs. Just 41 percent of employees felt strong feelings of trust and confidence in their supervisors. Just 24 percent felt deeply that their senior leaders maintained high standards of honesty and integrity. Many feel they have been abandoned by local or regional leaders.
MENTAL-HEALTH professionals in several VA facilities across the country have also told the Prospect that managers have created a “hostile work environment,” arbitrarily changed alternative work schedules that have allowed VA psychologists to supplement low VA salaries or accommodate child care responsibilities, and driven professionals out of the workplace, thus creating untenable workloads for those who remain. In Northern California, psychologists told the Prospect this has led to an exodus of psychologists, psychiatrists, and social workers from the VA Northern California Health Care System.
In Memphis, five psychologists and psychiatrists said poor management has led almost 20 professionals to leave. According to Kathleen Pachomski, president of AFGE Local 3930 and a retired VA nurse, there was a special investigation done recently whereby the psychologists in mental health made a complaint to the VISN 9 director, Cynthia Breyfogle, and VA central office. “They sent some folks in from the VISN to do an investigation, we still have no results of that investigation. It’s a mess,” Pachomski concluded, adding that the system’s training program as well as programs and efforts to wean veterans from opioids are suffering as a result.
When questions about VA privatization and the internal staffing crisis arise, Trump allies proudly boast that, on the president’s watch, the VA budget has hit historic highs. There is plenty of money to spend on hiring and care, they insist. What this claim fails to mention is that a major driver of Trump’s VA spending is on private-sector care, which now makes up nearly 20 percent of total health care spending.
As a result, VA hospitals are still being starved. Rather than having plenty of money for recruiting and retaining staff, a senior VA administrator told the Prospect that 14 out of 18 of the VHA’s integrated service networks are virtually out of money. Other sources point out that the 2019 budget did not provide funds for cost-of-living adjustment increases for staff or cover the cost of each medical center’s increased contribution to the federal retirement plan.
“Maybe someone up there is sitting on a pot of money but no one knows,” one administrator told the Prospect. “Some people think they are sitting on the money to cover the costs of community care, which is costing who knows what.” A senior Senate aide confirmed that there are “instances where VA folks are being told to tighten their belts because a lot of money is going out into the community.”
So far, the VA has refused to brief lawmakers on the initial costs of community care through MISSION. This is part of a trend of VA–Capitol Hill intransigence, especially toward the Democratic-controlled House, whose staff last year were blocked from overseeing the rollout of the VA MISSION Act at departmental hospitals across the country.
Yet even as the department sinks untold amounts of money into administering the parts of MISSION that benefit corporate actors, some are concerned that the parts of the bill that were most sought after by membership-based veterans organizations are being neglected. One of these mandates promised to amplify an Obama-era program to support peer specialists—veterans who have themselves overcome mental-health or substance abuse problems and are specifically trained to work in mental health. Section 506 of the MISSION Act mandated the hiring of 60 peer specialists to work in 30 sites in primary-care centers around the country.
These additions would help expand one of the VA’s signature accomplishments of integrating mental health and primary care. “Those of us who agreed to participate in this were surprised that there was no appropriation to cover the salaries for the peers, which would be only a few million dollars,” one VA staffer said. “Some of us had to drop out, even after the VA found the money internally, since it was only assured through 2021. After that our facility would have to come up with the funding, which means competing with other needs in the hospital. So we would have to pick between hiring a peer or a therapist who could treat PTSD or opiate dependence.”
WHILE SOLVING the VA vacancy crisis can seem daunting, the solutions are far from a mystery. First, Congress must allocate enough money to fully fund and staff the VA. This will require calculating the VA budget based on the expected future needs, not, as is currently done, on the prior year’s utilization. In this regard, the VA could learn a lesson from the Pentagon.
“When we go to war we know how we are going to organize our footprint in theater and use the DoD’s medical assets to optimize outcomes,” said Terri Tanielian, a behavioral scientist at the RAND Corporation focused on military and veteran health. “But we aren’t war-gaming for the VA. We never plan far ahead. We went into these wars without thinking about the need to increase capacity for an impending influx of veterans.”
Additionally, the VA should effectively implement recent congressional directives aimed at streamlining and bolstering the department’s approach to hiring. This includes offering better pay to physician assistants, bolstering tuition assistance, and raising relocation bonuses.
“Congress has worked really hard in the last handful of years to give VA more tools to actually recruit and retain qualified professionals to work with the agency,” a senior Senate staffer told the Prospect. “But we have to routinely go to the VA and see whether they are—or are not—using these authorities.” (This work, by the way, would be made much easier if the VA had a permanent undersecretary and principal deputy undersecretary of health.)
The VA could also easily remedy cumbersome hiring practices, in large part by conducting various parts of the process simultaneously. During his tenure, Secretary Shulkin implemented a predictive staffing program through data that allowed him to anticipate shortages at the facility level, and act to stem problems. In some cases, the VA held job fairs that led to same-day hires.
The VA could also offer more benefits, like paid family leave, and recategorize more employees under Title 38, which allows the department to offer them more competitive pay. For his part, Shulkin wants the federal government to overturn the rule barring federal employees from making more than the president. “That rule never made any sense to me,” he told the Prospect. “What does it have to do with the VA being able to hire the best doctors to take care of our nation’s heroes?”
If the VA increases recruitment, a top initial target should be HR staff. However, as former VA Secretary Robert McDonald told the Prospect, recruitment should not be the sole responsibility of HR. “Recruitment is a leadership responsibility,” he said. “You have to go out there and talk to doctors and nurses and inspire people to join you.”
Rick Weidman, executive director for policy and government affairs at the Vietnam Veterans of America, suggested that hiring could be more centralized and that the VA could directly reach out to military service members who work in health care to recruit them to work at the VA once they are discharged. “You may not get all of them, but you’ll get a lot of them and some might be interested in working in rural areas,” he said.
Veterans’ health care advocates have also suggested expanding the Uniformed Services University (USU), a federally funded program which now educates physicians, nurses, and biomedical scientists to work in the military. During his tenure, McDonald said that he approached the USU and got several dedicated slots for the VA. “We got maybe three. It wasn’t a lot but it was a beginning,” he said.
Kenneth Kizer, one of the most prominent and respected former VHA undersecretaries, offered perhaps the most critical advice to both Congress and departmental leaders: Stop the VA bashing. “When you have talented and well-credentialed people who are shouldering a very heavy workload, you have to create an environment that supports them,” he said. “That’s not rocket science.”
