FOLLOW THE MONEY

When—or should it be if?—the inquiry into the Department of Veterans Affairs scheduling scandal moves beyond identifying which VA officials’ heads will roll, investigators will start working their way up the agency’s ladder of responsibility.

They’ll start with the intake staff who handled veterans’ applications for treatment. They’ll move on to admins who entered appointment data they knew were intended to obscure how long veterans were waiting to get an appointment with a doctor. They’ll look at supervisors who reported that veterans who needed attention were being seen in a timely manner. Those who did wrong will be punished, and they’ll deserve it.

And then, if they follow the advice that Deep Throat gave Bob Woodward in the movie of “All the President’s Men,”* investigators will follow the money. Because almost all the media coverage and official reports point to lack of resources—a severe shortage of doctors and other medical staff and of the funds needed to hire and retain them—as the root cause of almost all the evil that’s taken place at the VA.

At the head of the money trail, they will find the policy makers and appropriators who took the country into two wars but failed to recognize that 21st century warfare produces many fewer deaths and many more, and more excruciating, injuries, both physical and mental that require more, and more expensive, treatment Or who recognized it but failed to give the VA the human and financial resources that would be needed, in the words of Lincoln that form the VA’s motto, “to care for him who shall have borne the battle.”^† At the end of that road they will also find the experts who believe that lack of resources is merely an excuse made by incompetent or lazy employees who can be brought into line by goals and incentives that force people to work harder.

On the surface, it looks as though VA funding has increased substantially over the last decade and more of war. Total VA funding rose from $58 billion in 2002, before the invasion of Iraq, to $130 billion in 2013, a 142 percent increase. But a closer look shows that while VA entitlement funding for pensions and disability payments) has gone up 153 percent—as you would expect with Viet Nam-era vets reaching retirement age—discretionary funding, which pays for medical treatment, has gone up only 129 percent. In 2002, with the U.S. more or less at peace, VA discretionary funding represented 48 percent of the total. In 2013, after a flood of over 50,000 Iraq and Afghanistan wounded vets, discretionary funding represented 46 percent of the total VA budget—less than when we were at peace.

Congressional leaders admit that VA health care has been underfunded and blame the VA. “In an environment where everybody is told, ‘Keep the cost down. Don’t tell me anything costs more,’” Senate Budget Committee chair Patty Murray told Yahoo News, administrators “don’t want to be told by their bosses, ‘Don’t tell me you need more money, because we can’t say that.’… [I]f they need more money, they need to be able to tell us, because how else are we going to solve these problems?” (Congress is not always so diffident in the face of agency budget requests. Post Office requests to balance budgets by cutting service are routinely rejected, while Defense Department recommendations that weapons systems be discontinued are disregarded at the behest of defense contractors and the members of Congress who represent them.)

The underfunding diagnosis is confirmed by those who have been inside the VA. “The scheduling scandal is a symptom of a much more serious disease,” Dr. Sam Foote, a whistleblower who spent 23 years at its Phoenix hospital, wrote in the New York Times, “a mismatch between the VA’s mission and its resources.”

Rob Nabors, the deputy White House chief of staff whom President Obama dispatched to the VA to sort things out, agrees. “With regard to increasing access to care,” he reported to the president in late June, scheduling “is secondary to the need for additional resources to actually schedule—doctors, nurses, and other health professionals; physical space; and appropriately trained administrative support personnel.”

But what about the scheduling deceit and the cover-up? What about the culture of corruption? They’re real, all right, at VA and at other agencies, and in the private sector. But as VA whistleblower Foote says, they’re symptoms, symptoms of under-resourcing. I’ve never worked at the VA, but I have worked at an underfunded federal bureaucracy, and I saw how people react to not having enough people, time and money to do what needs to be done. It comes in stages: commitment, frustration, cynicism, resignation or, for some, workarounds and gaming the system, within the rules or without.

All of which doesn’t make the bad actors at VA innocent victims. They could have responded otherwise. Several whistleblowers, like Dr. Foote, for example, have come forward; more will step up. Others will surface who became discouraged and left for other agencies or the private sector. Still others soldiered on, scheduling and caring for as many patients as they could. Only a relative few of the Veterans Health Administration’s 200,000+ employees, I am confident, will be found to have cooked the books to keep their jobs or to get promotions and bonuses. There will be more than enough tumbrils for them.

But a share of guilt, moral if not legal, should be saved for those who created the situations out of which the misdeeds arose and in which they festered: the leaders who sent 2,5 million members of the armed services to war with the VA we had instead of the VA service members needed and deserved; the administrations, from two presidents and four Secretaries of Veterans Affairs on down who didn’t request adequate funding; and the members of Congress who believed that holding the line on the federal budget outweighed caring for wounded veterans.

And save a share of culpability for all those who believe that missions, public and private, that are difficult enough to accomplish with adequate resources can be done just as well without that support. For the sake of those they serve, may their delusions never catch up with their constituents and beneficiaries the way the VA’s have caught up with wounded veterans.

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