* The Veterans Affairs (VA) Scandal


BACKGROUND INFORMATION

Beginning in April 2014 and continuing for a number of weeks thereafter, an ever-growing amount of information was learned about a massive scandal that quietly had been infecting the Department of Veterans Affairs (VA) for several years. Initially it was reported that VA patients were being forced to wait for inordinately long periods of time before they were permitted to see a doctor and get medical treatment — particularly at one VA hospital in Phoenix, Ariziona. To be seen by a primary care provider, for example, generally required a 115-day wait. These long wait times sometimes resulted in dire health consequences for the patients: According to CNN, as many as 40 veterans had died while on wait lists at the Phoenix hospital.

But VA hospital officials in Phoenix chose not to report the long wait times to the federal government, so as not to jeopardize the pay bonuses that the hospitals received for keeping wait times short — i.e., within 14 days of a requested date for an appointment. Instead, hospital administrators sent false documents that dramatically understated the length of time it generally took for VA patients in Phoenix to see a doctor.

The scandal at the Phoenix hospital subsequently led to greater scrutiny of other VA-run facilities, and it quickly became apparent that the problem was widespread and systemic throughout the VA system. In June 2014 it was learned that more than 1,000 veterans may have died as a result of VA ineptitude and malfeasance over the course of the preceding ten years. And the Government Accountability Office (GAO) concluded, in multiple reports, that federal oversight over VA officials had long been practically nonexistent.

Particularly significant is the fact that in 2008, VA officials had informed the Obama-Biden transition team that its (the VA’s) facilities were apparenty concealing the true amount of time that veterans were being forced to wait before receiving medical care. But for almost 6 years thereafter, President Obama never did anything to address the problem. Then, when news of the scandal broke in the spring of 2014, he pretended to have just learned about it through news reports.

TIMELINE OF EVENTS

• 2008: In a memo, VA officials brief the Obama-Biden transition team that its facilities might be concealing the true amount of time that veterans had to wait before receiving medical care. “The problems and causes associated with scheduling, waiting times and waiting lists are systemic,” the officials write. (Source)

• 2010: An internal VA memo reveals that officials have again warned of “inappropriate scheduling practices” to cover up excessive waiting times for veterans seeking medical appointments. (Source)

• Early 2012: Dr. Katherine Mitchell, a VA emergency-room physician, warns Sharon Helman, incoming director of the Phoenix VA Health Care System, that the Phoenix ER is overwhelmed and dangerous. Within days, senior administrators tell Mitchell that she has deficient communication skills and transfer her out of the ER. (Source)

• December 2012: The GAO tells the Veterans Health Administration that its reporting of outpatient medical-appointment wait times is “unreliable.”(Source)

• March 2013: The GAO’s Debra Draper tells a House subcommittee: “Although access to timely medical appointments is critical to ensuring that veterans obtain needed medical care, long wait times and inadequate scheduling processes at VAMCs (VA medical centers) have been persistent problems.” (Source)

• July 2013: In an e-mail exchange among employees at the Carl T. Hayden VA Medical Center in Phoenix, an employee questions whether administrators are improperly touting their Wildly Important Goals program. “I think it’s unfair to call any of this a success when veterans are waiting six weeks on an electronic waiting list before they’re called to schedule their first PCP (primary-care provider) appointment,” program analyst Damian Reese complains. “Sure, when their appointment was created, (it) can be 14 days out, but we’re making them wait 6-20 weeks to create that appointment. That is unethical and a disservice to our veterans.” (Source)

• September 2013: Dr. Katherine Mitchell files a confidential complaint intended for the VA Office of Inspector General, channeled through Arizona Senator John McCain’s office. Her list of concerns instead goes to the Office of Congressional and Legislative Affairs and eventually back to the VA. Mitchell, meanwhile, is placed on administrative leave. (Source)

• October 2013: Dr. Sam Foote, a doctor of internal medicine at the Phoenix VA, files a complaint with the VA Office of Inspector General alleging that purported successes in reducing wait times stem from manipulation of data, and that vets are dying while awaiting appointments for medical care. (Source)

• December 2013: Foote retires, assuming the role of whistle-blower by meeting with Arizona Republic reporter Dennis Wagner. He details allegations that patients have died while awaiting care at the Phoenix VA and that wait times have been falsified. The same month, inspector general’s investigators visit Phoenix to look into whistle-blowers’ complaints. (Source)

• April 2014: Delays in endoscopy screenings for potential gastrointestinal cancer in 76 veterans treated at VA hospitals are linked to 23 deaths, most of them in 2010-11. The delays occurred at 27 VA hospitals, and the deaths occurred at 13 of the facilities. The worst record was at the William Jennings Bryan Dorn veterans hospital in Columbia, South Carolina, where there were 20 cases of delays and 6 deaths, according to a VA report. Other deaths occurred at VA hospitals in Hampton, Virginia.; Augusta, Georgia.; Charleston, South Carolina; Miami, Florida; West Palm Beach, Florida; Huntington, West Virginia; Cleveland, Ohio; Prescott, Arizona; Tucson, Arizona; Grand Junction, Colorado; and Iowa City, Iowa. (Source)

• April 9, 2014: Rep. Jeff Miller (R-Florida), chairman of the House Committee on Veterans’ Affairs, says during a hearing that dozens of VA hospital patients in Phoenix may have died while awaiting medical care. He says staff investigators have evidence that the Phoenix VA Health Care System keeps two sets of records to conceal prolonged waits for appointments. One set of records contains the actual wait times; the other set — which is presented to federal regulators — contains falsified wait times designed to make it appear that patients are being treated in a timely manner. (Source)

• April 16, 2014:
 A Phoenix rally organized by Concerned Veterans for America and attended by Rep. David Schweikert (R-Arizona), draws 150 veterans and their supporters calling for solutions to the controversy. (Source)

• April 30, 2014: CNN reports that at least 40 U.S. veterans have died while waiting for appointments at the Phoenix, Arizona Veterans Affairs Health Care system. Many of the dead had been put on a secret waiting list. That list was reportedly part of an elaborate scheme designed by VA officials who were attempting to conceal the fact that between 1,400 and 1,600 sick veterans had been forced to wait months to see a physician. (Source)

The VA requires its hospitals to provide care to patients in a timely manner, usually within 14 to 30 days, according to Dr. Sam Foote who recently retired after working at the Phoenix facility for 24 years. He says that officials destroyed evidence to cover up the existence of the bogus waiting list. VA officials “wouldn’t take you off that secret list until you had an appointment time that was less than 14 days so it would give the appearance that they were improving greatly the waiting times, when in fact they were not,” Foote states. (Source)

According to Foote, the waiting times in Phoenix that were reported to VA headquarters in Washington were make-believe: “So then when they did that, they would report to Washington, ‘Oh yeah. We’re makin’ our appointments within — within 10 days, within the 14-day frame,’ when in reality it had been six, nine, in some cases 21 months.” (Source)

• May 1, 2014: U.S. Secretary of Veterans Affairs Eric Shinseki places Sharon Helman — who was appointed director of the Phoenix VA Health Care System in early 2012 — and two others on administrative leave pending an outcome to the inspector general’s probe. (Source)

• May 2, 2014: Dr. Katherine Mitchell goes public with her allegations about mismanagement of the Phoenix VA system and her concerns about wait times. (Source)

• May 5, 2014: The American Legion’s national leaders call for Eric Shinseki’s resignation. Shinseki says he intends to stay put. (Source)

• May 8, 2014: Shinseki orders records audits of all VA health-care facilities around the U.S. a day after U.S. Rep. Ann Kirkpatrick (D-Arizona) makes the request. (Source)

• May 12, 2014: Steve Young takes over as interim director of the Phoenix VA Health Care System. (Source)

• May 15, 2014: The U.S. Senate Committee on Veterans’ Affairs holds a four-hour hearing. Acting Veterans Affairs Inspector General Richard Griffin reveals that the team probing complaints about Phoenix VA facilities includes criminal investigators. (Source)

• May 16, 2014: Dr. Robert Petzel, the under secretary for health (and second-in-command at the Department of Veterans Affairs), departs the agency. Shinseki says Petzel resigned, though the agency had announced Petzel’s planned retirement in September 2013. (Source)

• May 19, 2014: A CNN reporter asks White House spokesman Jay Carney when President Obama was “first made aware … of these fraudulent lists that were being kept to hide the wait times” at VA medical centers. Carney replies: “You mean the specific allegations that I think were reported first by your news network out of Phoenix, I believe? We learned about them through the reports.” (Source)

• May 20, 2014: Officials disclose that White House Deputy Chief of Staff Rob Nabors will visit Phoenix for meetings with leaders of the Phoenix VA Health Care System. (Source)

• May 21, 2014: President Barack Obama addresses the VA matter publicy for the first time, and he indicates that he has just found out about the problem. But as noted above, VA officials briefed the Obama-Biden transition team about the problem nearly six years earlier, in 2008. (Source) and (Source)

• May 21, 2014: President Obama pledges in a televised press briefing that his Administration will thoroughly investigate allegations of misconduct at VA facilities in Phoenix and across the United States. He says he expects preliminary results of the review in Phoenix within a week and will punish any misconduct. In response to a question asking why as many as 40 veterans could have died awaiting treatment at the VA in Phoenix, Obama says: “Well, we have to find out first of all what exactly happened. And I don’t want to get ahead of the IG [Inspector general] report or the other investigations that are being done. And I think it is important to recognize that the wait times generally — what the IG indicated so far, at least, is the wait times were folks who may have had chronic conditions, were seeking their next appointment, but may have already received service. It was not necessarily a situation where they were calling for emergency services. And the IG indicated that he did not see a link between the wait and them actually dying. That does not excuse the fact that the wait times in general are too long in some facilities. And so what we have to do is find out what exactly happened.” (Source) and (Source)

• May 28, 2014: The VA’s Office of Inspector General releases a scathing interim report that confirms whistle-blower allegations of mismanagement and the manipulation of data related to patient wait times. Among the findings: Phoenix was reporting wait times of just 24 days, while the actual delay in appointments averaged nearly four months, and 1,700 veterans had signed up for initial appointments in Phoenix but did not appear on any wait lists. Investigators say it will take further analysis to determine whether any veteran deaths resulted directly from falsified records and prolonged waits. Angry lawmakers on the U.S. House Committee on Veterans’ Affairs blast three senior VA officials during a lengthy night hearing, accusing the agency of stonewalling and showing indifference to the suffering of veterans.(Source)

• May 28-29, 2014: There is a renewed chorus of calls for Shinseki’s resignation or ouster. (Source)

• May 30, 2014: Shinseki makes a speech in which he says he has begun the process for removing senior leaders at the Phoenix VA, and apologizes to all veterans (and to the nation) for the scandal involving the systemic delay of health care to veterans. Obama later meets with Shinseki, and the VA secretary offers his resignation. Minutes later, the president announces that he has accepted Shinsenki’s resignation “with considerable regret.” Obama names VA Deputy Secretary Sloan Gibson as interim head of the department while he selects a permanent replacement. He pledges to veterans that “we will never stop working to do right by you and your families.” (Source)

• June 5, 2014: Sloan Gibson visits the Phoenix VA hospital. He tells reporters that 18 of the 1,700 Arizona vets who were seeking first-time appointments with primary-care doctors, but were excluded from the VA’s electronic waiting list, had died before they were contacted. (Source)

• June 9, 2014: The VA releases reports indicating that VA medical centers nationwide have misrepresented or sidetracked patient scheduling for more than 57,000 former military personnel, and about 64,000 more were not even on the agency’s electronic waiting list for doctor appointments they requested. Major reforms are announced, including an administrative hiring freeze, increased transparency, and the cancellation of bonuses to employees who meet goals for scheduling doctor appointments. An additional “front line” team is sent to Phoenix to immediately rectify problems with patient backlogs, appointment scheduling, and record-keeping. (Source)

• June 10, 2014: The American Legion opens a four-day “crisis command center” at Phoenix Post 1 to offer assistance to Arizona veterans who have had difficulties trying to get appointments or other services through the Phoenix VA Health Care System. The center has a “triage team” to help veterans with benefits claims, enrollment in VA health care, and bereavement counseling.(Source)

• June 10, 2014: The U.S. House votes 421-0 to approve legislation making it easier for VA patients enduring long waits for care, to get VA-paid treatment from private doctors. (Source)

• June 11, 2014: The U.S. Senate approves its version of VA reform legislation easing restrictions on the firing of senior VA bureaucrats and, like House legislation, making it easier for veterans to get care outside the VA system when backlogs develop. Cost is a key difference between the House and Senate bills, sending the matter to a conference committee. (Source)

• June 20, 2014: At a news conference, the VA admits that approximately 65% of senior VA executives were paid a total of $2.7 million in bonuses in 2013. That number does not include tens of millions of additional dollars in bonuses awarded to doctors and other VA medical providers. Both totals are part of the $3.9 million doled out to 650 workers at the Phoenix VA Health Care System facility, where it has been confirmed that dozens of vets died while awaiting treatment, even as waiting times were being manipulated. (Source)

• June 23, 2014: The Office of Special Counsel sends a scathing letter to President Obama saying that the Department of Veterans Affairs consistently ignored whistle-blower warnings about dangerous practices that jeopardized patient safety. The letter says that the failure of Phoenix VA officials to heed alerts about fraudulent appointment scheduling is part of a “troubling pattern” nationally where the VA investigated and verified complaints but did nothing to correct problems. Acting VA Secretary Sloan Gibson immediately orders a review of the department’s response system for dealing with whistle-blower complaints. (Source)

• June 23, 2014: Pauline DeWenter, a scheduling employee for the Phoenix VA Health Care System, goes public and discloses that she was the keeper of a “secret list” of local veterans who waited months for medical care. She accuses others of altering records recently to try to hide the deaths of at least seven veterans who had been awaiting care. (Source)

• June 24, 2014: K.J. Sloan, a clinical social worker with the Phoenix VA, says she was stripped of an assignment overseeing an ethics review in July 2013 after writing a report criticizing the Phoenix VA Health Care System for misleading veterans and employees about appointment delays. (Source)

• June 24, 2014: A devastating oversight report from Senator Tom Coburn (R-Oklahoma) reveals that the combination of malpractice and bureaucratic ineptitude infesting the VA is far deadlier than previously acknowledged. “Over the past decade, more than 1,000 veterans may have died as a result of VA malfeasance, and the VA has paid out nearly $1 billion to veterans and their families for its medical malpractice,” the report states. This death total dwarfs the 23 fatalities for which the VA has previously taken responsibility. (Source)

Coburn, a physician and three-time cancer survivor, notes that the problems at VA facilities go “far deeper” than the phony scheduling schemes that brought this scandal to the national stage. “The waiting list cover-ups and uneven care are reflective of a much larger culture within the VA, where administrators manipulate both data and employees to give an appearance that all is well,” the report reveals. (Source)

According to Coburn, that culture is one in which veterans “are not always a priority.” Much of that is attributable to the reality that even as the VA suffers from a shortage of healthcare providers, VA nurses are paid to perform union duties and doctors are allowed to leave work early rather than care for patients. The report further explains that good employees who try to bring attention to the Department’s shortcomings “are punished, bullied, put on ‘bad boy’ lists, and transferred to other locations.” (Source)

The report also discredits the VA’s fallback excuse, namely that it suffers from a lack of funding. The VA budget has increased by 92.2% over the past decade, from $73.3 billion in FY2003 to $140.9 billion in FY 2013, measured in constant 2014 dollars.(Source)

Coburn reveals that as much as $20 billion of that spending over the past dozen years has been on “junkets, generous salaries, bonuses, and office renovations for its employees,” even as the Department ends every year with billions of dollars in unspent funds. He further notes that most of the construction projects undertaken by the VA are over budget and behind schedule. And even when state-of-the-art facilities are finally constructed, the VA is unable to staff them with a sufficient number of doctors. This reality has forced the VA to spend millions of dollars sending veterans to clinics in other cities and states, wasting veterans’ time and taxpayers’ money. (Source)

The report also seems to validate accusations made by Texas VA whistleblower Dr. Richard Krugman. who in May 2014 alleged that the Department was delaying life-saving colonoscopies. The report cites at least 82 veterans who either died or suffered serious injuries because of delayed diagnosis or treatment for colonoscopies or endoscopies at the VA. (Source)

Further, the report details unconscionable delays in scheduling veterans with serious psychological problems. Dr. Margaret Moxness, formerly employed at the Huntington VA Medical Center in Charleston, West Virginia, alleges that supervisors instructed her to delay treatment even when she reported that patient needs were immediate. She says she saw at least two veterans commit suicide in the interim. Another whistleblower alleges “serious patient neglect” at the VA health care system in Brockton, Massachusetts, including one individual diagnosed with a service-connected schizo-affective disorder and drug-induced Parkinsonism who failed to receive appropriate psychiatric treatment and specific lab monitoring required by VA regulations for more than 11 years. (Source)

As of March 2014, says the report, some 638,000 veterans were awaiting a decision on disability claims, with 360,000 of them having already waited more than 125 days. The report blisters VA schedulers, revealing that half of the 50,000 people employed by the Department “did not even know how to accurately report the information needed to determine wait times.” (Source)

• July 9, 2014: Glenn Costie, director of the VA Medical Center in Dayton, Ohio, temporarily takes the helm of the Phoenix VA, where he is slated to serve through November 6 before returning to Ohio. He is the second temporary chief to take over in Phoenix. (Source)

• July 10, 2014: The House Veterans’ Affairs Committee hears from families of veterans who committed suicide while awaiting mental health care from the VA. The hearing on gaps in the VA’s treatment programs includes gripping testimony from the parents of Daniel Somers, a Phoenix veteran who died by his own hand in June 2013. (Source)

• July 11, 2014: Phoenix VA Health Care System officials brief congressional staffers on strides they have made in contacting patients who were awaiting medical appointments when the VA scandal erupted. They say that hospital representatives contacted approximately 2,800 veterans and were still trying to reach about 300 others. Of those who were reached, the officials add, nearly 2,700 who wanted appointments were scheduled within 30 days.(Source)

• July 22, 2014: Elizabeth Freeman, the Southwest VA’s new regional health-care boss responsible for instituting reforms, is criticized by a national watchdog group for suspending an employee in California in June after he had reported that patients in Palo Alto were being endangered. (Source)

• July 23, 2014: The Senate Veterans’ Affairs Committee votes unanimously to support Robert McDonald’s confirmation as the new, permanent VA secretary. (Source)

• July 24, 2014: Negotiations over the VA overhaul legislation erupt in conflict after weeks of mounting tension over how much money should be spent on reforming the troubled agency. House Veterans’ Affairs Committee Chairman Jeff Miller (R-Florida) and his Senate counterpart, Bernie Sanders (I-Vermont), clash publicly after weeks of talks about merging parallel reform bills. (Source)

• July 25, 2014: Members of Arizona’s congressional delegation urge the VA to investigate allegations by a watchdog group that Elizabeth Freeman, acting director of the VA Southwest Health Care Network, retaliated against a whistle-blowing employee in her previous VA post in California. (Source)

• July 29, 2014: On the same day that the U.S. Senate unanimously confirms Robert McDonald as the nation’s next Veterans Affairs secretary, new audit findings from the Veterans Health Administration rip the VA health-care scheduling system as dysfunctional and dishonest. (Source)

• July 30, 2014: The U.S. House of Representatives adopts compromise VA reform legislation after weekend negotiations by House and Senate conferees result in a $17 billion proposal. The bill moves to the Senate. (Source)

• July 31, 2014: The U.S. Senate approves the reform bill, sending it to President Obama. The bill makes it easier for veterans to seek care outside the VA system if they live a long distance from VA facilities, or they cannot get a timely appointment through their VA center. It also makes it easier to fire VA employees, giving the new VA secretary more latitude to clean house.(Source)

• July 14, 2015: The Huffington Post reports:

More than 238,000 of the 847,000 veterans with pending applications for health care through the Department of Veterans Affairs have already died, according to an internal VA document provided to The Huffington Post…. As of April, there were 847,822 veterans listed as pending for enrollment in VA health care. Of those, 238,657 are now deceased, meaning they died after they applied for, but never got, health care.

While the number is large — representing nearly a third of those listed as pending — some of the applicants may have died years ago. The VA has no mechanism to purge the list of dead applicants, and some of those applying, according to VA spokeswoman Walinda West, likely never completed the application, yet remain on the pending list anyway. West said the VA electronic health record system has been in place since 1985, suggesting some of the data may be decades old and some of those people may have gone on to use other insurance.

About 81 percent of veterans who come to the VA “have either Medicare, Medicaid, Tricare or some other private insurance,” said West. “Consequently, some in pending status may have decided to use other options instead of completing their eligibility application.”

But [Scott] Davis [a program specialist at the VA’s Health Eligibility Center in Atlanta and a past whistleblower on the VA’s failings] disputed West on every point. For starters, an incomplete application would never be listed as a pending application, he said. Beyond that, the health records system West is referring to is just that: general health records, not pending applications for enrollment in health care. The VA has only required enrollment in health care since 1998, he said, and there was no formal application process before that. Davis provided an internal VA chart that shows backlogged applications only beginning in 1998.

As for some vets having other insurance, Davis said it is “immaterial and a farce” to suggest that means VA shouldn’t be providing vets with the health care they earned. “VA wants you to believe, by virtue of people being able to get health care elsewhere, it’s not a big deal. But VA is turning away tens of thousands of veterans eligible for health care,” he said. “VA is making it cumbersome, and then saying, ‘See? They didn’t want it anyway.'” …

This waiting list is unrelated to the VA backlog that made news last year, which left vets who already had coverage with extremely long wait times…. (Source)