Veterans face crisis of confidence with VA, secretary says

Editors Note: This article first appeared on The War Horse, an award-winning nonprofit news organization educating the public on military service. Subscribe to their newsletter.

As the 11th secretary of Veterans Affairs since President Ronald Reagan established it as a cabinet-level organization in 1988, Secretary Denis McDonough hardly has big shoes to fill.

Each secretary has made promises, and some have made changes: Jesse Brown expanded service to all veterans but particularly for women veterans, and he extended health care through a series of clinics. Edward Derwinski added some benefits for Vietnam veterans exposed to Agent Orange. Bob McDonald created the first Veterans Experience Office expressly to improve the us-against-them feeling so many veterans complain about.

But in the background, scandals arose. Eric Shinseki, beloved by his staff and by his boss, President Barack Obama, inherited a benefits backlog issue that went back years. It was first highlighted during the Walter Reed Scandal in 2007 under Secretary James Nicholson, when soldiers faced a Defense Department backlog in the military medical retirement system. After leaving the military and beginning VA’s benefits process, they then faced a second 400,000-plus case backlog at VA. Nicholson had also resigned.

Health benefits were denied to Gulf War veterans, Vietnam veterans, and veterans of the wars in Iraq and Afghanistan. Veterans killed themselves at high rates — and a VA official issued the infamous “shhh!” memo wondering if VA officials should issue a statement before someone “stumbled” on the problem. And 13,000 old benefits cases were found in a filing cabinet.

Most recently, Sec. Robert Wilkie, a President Donald Trump appointee, chose to discredit a House Veterans Affairs staffer and Navy reservist after she reported being groped and verbally assaulted at a VA facility in Washington — rather than look into the case and work to prevent it from happening again. Reporting from ProPublica led to a government investigation.

Each of those former secretaries made promises. They spoke of honoring veterans. They referred to Abraham Lincoln and the gratitude of a nation, and they laid wreaths and visited hospitals. And each time, veterans wondered what they could believe.

McDonough has come forward with a new set of promises: transparency. A proactive, rather than reactive, system. Again working for internal cultural change so veterans no longer chant: “Delay, deny … until you die.”

He runs a huge agency: More than 9 million veterans are enrolled in VA health care, which makes it the largest health care system in the United States. About 3.9 million veterans receive compensation for disabilities. About 424,000 people work for VA. And the president has requested almost $270 billion in funding for fiscal year 2022.

He knows the priorities: the burn pits. The backlog. The caregivers. Suicide rates and drug addiction and homelessness and transition, especially as veterans realize there isn’t a war to go to to avoid the problems that arise at home.

But we’ve heard these promises before. Why should we believe McDonough?

“You shouldn’t,” he tells The War Horse. “You shouldn’t.”

Still.

Enough changes have been made in the early days of McDonough’s term that even the veterans’ service organizations say they are, after years of expressing frustration, “hopeful.”

He has invited journalists, including The War Horse, in for one-on-one interviews. He holds monthly press conferences and quarterly breakfast meetings with the veterans’ service organizations. VA extended presumptive status to veterans with lung issues and some cancers related to exposure to burn pits. And McDonough seems willing to make decisions that could be hung up by controversy: He recently decided to offer gender confirmation surgery at VA facilities.

These may seem like minute changes, but in the past, journalists have struggled to get an interview for even “good news” stories out of VA. Veterans groups have complained about requests for meetings that haven’t even been acknowledged. And the burn pits? Army Times broke that story — and all of its associated health implications — in 2008.

Don’t let’s even get started about Gulf War illness.

So is it OK to hope? Is it time?

“Overall, Secretary McDonough has established laudable goals and principles to guide him,” Joy Ilem, national legislative director for Disabled American Veterans, told The War Horse by email. “Now we need to see them lead to real results for America’s veterans.”

The headlines haven’t all been good. Doctors with revoked licenses were approved to work at VA facilities. The agency has delayed implementation of its electronic health record program. And it has faced criticism of an ever-increasing budget.

In other words, McDonough still has some work to do, and he must do it within the confines of a bureaucracy built bit by bit. He must keep up the morale of the employees doing good work — and veterans surveys show there are a lot of them — while dealing with holdover employees who would like to see VA fail to prove government health care doesn’t work and that VA should be privatized. And he must still work within the rules prescribed by Congress.

“I’m not asking anybody to believe me on anything,” McDonough says. “I’m saying I’m here to be held accountable to what I said last month and last year. And I don’t know, I hope, I hope it works out. But you don’t need to believe me. This is why you guys are in business.”

‘I was not looking for a job’

The challenges, which must be among the most formidable in the U.S. government, as well as the failures of qualified people in the past, seem like a pretty good reason for someone with McDonough’s resume to say no. He served as President Obama’s chief of staff before going to work for the Markle Foundation. Why risk an impressive career when VA has tarnished so many in the past?

“Well, I was not looking for a job,” McDonough says. “And I was not looking to come back to the government. But the president of the United States asked.”

Fair, but the request is also a job requirement of each prior secretary, and others have said no — famously including Cleveland Clinic CEO Toby Cosgrove, who turned down Trump.

“That’s an insufficient answer,” McDonough says. “Because I’m also really glad he did ask.”

In the 20 years after the 9/11 attacks, McDonough worked behind the scenes making sure other people’s decisions were enacted — and that included sending young men and women to war in Iraq and Afghanistan. As VA secretary, he faces a new challenge of making the decisions, rather than following others’ orders. And, he says, he can “make good on the promises that we made those men and women whose life I had a part in impacting so profoundly.”

Because of his resume, and because of his family connections, he says he came to the job feeling well-informed. His wife, Kari McDonough, founded Vets’ Community Connections, a group that introduces civilians to veterans, and may be the reason Biden thought of him for the job, Denis McDonough says. When Denis McDonough worked for Obama, Kari McDonough volunteered for the Red Cross at Walter Reed National Military Medical Center and from there started to devote time to service members and their families.

But beyond his wife, he talked to friends who are service members and veterans, as well as former VA secretaries, such as McDonald, “whom I hold in very, very high regard, and whom I got to know quite well.” McDonald replaced Shinseki after it was revealed that veterans died while waiting for care, which made headlines on national news — and after McDonough himself made the rounds trying to calm an angry nation. Veterans groups urged Trump to keep McDonald on as VA secretary because of his push for transformation — including the Veterans Experience Office, which focused on asking veterans what they needed and used human-centered design to find problems in forms, processes, and even visits to the clinic. But Trump brought on David Shulkin, who worked under McDonald and who was fired after being accused of using government travel for personal use — which he has consistently denied and wrote in his book was really a ploy toward privatizing VA.

McDonough also learned, based on past secretaries’ experience, that he may not have a lot of time: A second term for President Joe Biden or another Democrat might lead to a second term for McDonough. A second term for Trump would likely mean another move toward privatization.

‘It’s become so difficult … so bureaucratized’

What McDonough learned from his mentors could strike fear into the heart of any government official. But he says he’s decided to focus on the veterans — and to do that by taking accountability for quick action.

“I think the general sense is that — which I think is an accurate sense — is that as a country, we dedicate to do a lot for veterans, as we should,” he says. “And the institution itself has grown up in a way that, if you were to step back and build it in its whole self, from scratch, you wouldn’t build it this way. It’s built in a very kind of step-by-step fashion.”

VA contains three administrations — three large administrations: the Veterans Benefits Administration, the Veterans Health Administration, and the National Cemetery Administration. Each leadership team likes to run things the way they’ve always run things — or at least without the help of the new guy in the front office. In other words, just like any large entity, change is hard, but at VA, it’s especially hard. And it’s hard to push information from administration to administration.

“So the structure itself creates a series of management challenges,” McDonough says.

The second big issue? “Given the importance of the mission, the expectations for excellence are very high,” he says. “And therefore, when we don’t meet that, there’s, I think, very understandable public frustration.”

Which leads to the third big issue: How does one lead people toward change — keep up morale, celebrate the wins, invigorate them toward future progress — if the public has a hard time seeing small innovations or real successes when veterans still kill themselves in VA parking lots or line themselves up in tents on Skid Row?

“I think that public frustration too often leads to a crisis of confidence,” McDonough says. “And, a lot of times, I feel like my job around here is to just hold up a mirror to people who are doing things really, really well. So they can see and be reminded of how well they’re doing those things.”

In each speech, he tries to mention a VA employee who does good work. He tells stories of successes. He reminds his team that the job is hard, but they’re in it together. Change isn’t easy: The new electronic records system — likely tied in with the frustrations of all health care workers dealing with COVID — has folks saying in a survey at one medical center that they’ve considered quitting. And while numbers have improved in recent years, staffing shortages still make everyone’s jobs harder. Open positions at the highest levels make it hard to plan for the future, including an undersecretary for health position — which has been open since 2017.

“One long-overdue action is for the administration to nominate, and then the Senate to confirm, qualified undersecretaries for health and benefits,” Ilem says. “Filling these key leadership positions must be among the highest priorities of this administration. No organization can operate at maximum efficiency when you have long-standing vacancies and temporary leaders at the top.”

And new human resources policies from the last administration may have made hiring that much more difficult, according to a new article from The American Prospect, a progressive political magazine. The program replaced local decision-makers with a web-based system at the regional level, meaning local health facilities have to wait, often months, for simple hiring decisions to be made. If this is a problem, a new undersecretary could potentially fix it.

“Fixing it” serves as the epitome of the problems in any bureaucracy, because it goes back to change management and getting buy-in, as well as enabling employees to take the ownership and the leadership needed to get things done. This isn’t necessarily common in a good-enough-for-government-work climate that years of feeling as if nothing will ever change can build.

Add to that the belief that one mistake — any mistake — could get an employee fired, as people have seen in the fate of their secretaries, and such fear-driven paralysis creates even bigger blockers. McDonough says he’s trying to change that by building confidence in his employees — both in their capabilities and in their belief that he has their backs if they try new things.

“Because it’s in the inconfidence or the nonconfidence that we make bad mistakes,” he says. “And we don’t take appropriate risk. And we get frozen by risk avoidance, rather than informed by risk management and risk tolerance.”

He takes it further, showing an understanding of just how difficult it is to make change for the people who work at VA:

“I think people here understand that they’re going to encounter frustration, and not only they understand that they’re going to encounter it, but that they understand that it’s hard-earned frustration, in some cases,” he says. “Because, oftentimes, among the most frustrated people are the people who work here trying to get stuff done, but it’s just become so difficult, so encumbered, so layered, so bureaucratized.”

For him, that brings pride in the employees who do break through, who have managed through a pandemic, and who do keep a sharp focus on the veterans — because he says he’s also keenly aware that they can go elsewhere. VA isn’t the only organization struggling to find employees in 2022.

So far, he says the internal change is going well.

“But you know, I don’t know yet,” he allows. “And inevitably, there’s going to be debate and discord, either at the interagency or here internally. In fact, I hope there is, because it’s out of that discord that, actually, greater knowledge comes.”

He knows not everyone will agree, but he says he hopes everyone will understand and believe in the process.

“There’s still delicate questions to resolve,” he says, “which is why we also have to make sure, among those stakeholders we’re talking to are the VSOs, who have intense, elaborate, and important experiences–understand the decision-making processes, and, for example, thresholds for decisions. You gotta keep working with them, and that requires, obviously, openness to all things.”

‘Yeah. They’re frustrated’

As McDonough spoke with The War Horse, he had just come from one of his quarterly breakfast meetings with the veterans service organizations. Did they beat him up?

“Yeah,” he says, “they’re frustrated. They’re frustrated about our notices to the caregivers who now have a right to appeal, that those notices could be more robust. [The notices] could give the veteran and his or her caregiver more transparency into why they were denied. I think that’s right. They’re frustrated on the fact that we need to recognize that we are bringing our personnel back in what we call a future of work. That also means that we’re bringing back into our buildings VFW, American Legion, DAV, Paralyzed Vets, Dub Dub P [Wounded Warrior Project] personnel.” (Veterans Service Organizations often have offices in VA buildings so they can help with benefits, care, and outreach.) “And they’d like us to be as clear with them as we are with our own workforce, because they’re there. I tell them all this all the time, which is that they’re the front door for so many of our vets to the VA, and so they say, ‘Well, then you should treat us like that.’ So we should have more clarity.”

In other words, the VSOs want to know what decisions are being made and why as they’re being made–and they want to know if there’s been progress on the issues the VSOs have highlighted.

The VSOs don’t disagree.

“The VA caregiver program has been a blessing to thousands of veterans and their family caregivers; however, systemic problems have plagued the program from the outset,” DAV’s Ilem says. “VA must revise regulations determining eligibility for seriously disabled veterans and implement a new appeals system that provides veterans and caregivers justice.”

Ilem allowed that there has been progress.

“Taking office in the middle of a pandemic was a challenge, and VA continues to perform admirably for the veterans it serves and in meeting its fourth mission to serve the nation as a whole during national emergencies,” she says. “The secretary has made some important and meaningful progress, such as the addition of new presumptive diseases for veterans exposed to particulate matter. There have also been important course corrections in plans he inherited, as was done with the new electronic health record following a strategic review last year.”

Ilem says VA’s “most pressing challenge” is, as it is for everyone else, responding to the Covid pandemic — but while making sure veterans get the rest of the benefits they earned. That includes making sure VA has the money to “recruit, hire, and retain” good employees.

DAV, as well as many of the other VSOs, have made toxic injuries — from burn pits, from polluted water, from Agent Orange, from anti-nerve agent pills and sarin gas — a top, if not the top, priority. (DAV’s Dan Clare was the first to leak, anonymously, the documents outlining the concerns with the Balad burn pit to a reporter back when he worked in military public affairs in 2008.)

“Veterans should never have to wait decades to receive recognition for injuries and illnesses that occurred while serving our nation in uniform,” Ilem says.

Mental health care and suicide prevention also top her list and require collaboration with other groups, she says.

She says she worries about the issues that don’t make the headlines: that the Asset and Infrastructure Review ensures VA has the capacity it needs, that IT systems across VA be modernized, that the new electronic health record system is successful. (It hasn’t been so far, instead being marked by delays, errors, and cost overruns.)

Still, her tone is hopeful.

“From our experience, Secretary McDonough has been open, accessible, and willing to have frank and honest conversations with DAV and other veterans service organizations,” she says. “We appreciate his willingness to share information with us, and, most importantly, listen to our concerns and recommendations about veterans’ benefits and health care services.”

Kerry Baker, veterans advocate and former Veterans Benefits Administration employee, also has concerns about the behind-the-news issues: He worries that toxic exposure at Fort McClellan will never be properly addressed, and he worries about what a new process to determine which health conditions can be automatically associated with service might look like. He believes the Veterans Appeals Improvement and Modernization Act of 2017 helps the segment of the population that chooses a quick appeal, but pushes those cases with errors — made by VA — in their claims to the back of the line, even as the backlog grows because of COVID and new presumptive conditions: “It goes against everything Congress and VA touted the new law was for,” he says. And he says the “fundamentals” of rating a veteran’s injury or illness have been lost in a culture of finding ways to tell the veteran no, rather than giving them the “benefit of the doubt,” as the law says they must do.

“People [in and out of VA] like to lean on the ‘complexity’ of exposure cases as an excuse,” Baker says, referring to the difficulty in directly linking exposure to disease after a veteran has been exposed to particulate matter or carcinogens. “Looking back, I am even guilty of it. But the vast majority of mistakes in exposure cases are the simple version — mistakes in the fundamentals of rating. In that light, the ‘biggest’ problems are actually the easiest to fix — the low-hanging fruit.”

Baker wrote the first training letter about burn pit exposure while he was at VA, and he sees many of the benefits problems as training issues.

At a mid-January press conference, McDonough told reporters the backlog stood at about 70,000 claims pre-Covid, but since then the crisis and the addition of several new presumptive conditions added 174,000 claims in addition to the usual flow of new cases coming in. The backlog stands at about 260,000 cases right now, but McDonough said they’re hiring more than 2,000 claims processors, paying overtime, and making progress on scanning veterans’ records at the National Archives so they’re easier to access. At the press conference, Rob Reynolds, acting undersecretary of VA’s Office of Automated Benefit Delivery, said a new pilot looking at service-related hypertension would automate the system to get rid of unnecessary medical exams and reduce the back-and-forth of paperwork. If the veteran has enough medical evidence in their file, the rating system will fill in the disability rating and create a proposed rating system. If there’s not enough information, the system will request a medical exam.

“I am hopeful in the long run,” Baker says, “but it’s mostly more of the same in the short term.”

‘We’re just trying to put everything out there’

It’s a lot: the lack of clarity. The decades-long issues. The stakeholders coming from a dozen directions. The need to keep up morale.

“It is a lot,” McDonough acknowledges.

But in his mind, Baker’s right: It’s a matter of simplicity. Part of the problem is communication, McDonough says, hence the press conferences, breakfasts, blogs, and newsletters. The press, the veterans service organizations, the veterans and their families, and Congress all need to know what’s up.

“So we’re just trying to put everything out there,” he says. “And my theory is, the more people see the information, the more confidence they can have that the decision itself is actually — whether it’s a good or bad decision — it’s at least informed by the best available information.”

After the fiasco of the investigation into the House Veterans Affairs Committee staffer who reported assault, McDonough brought in women to help him rebuild. Kayla Williams, who had been appointed during the Obama administration as director of the Center for Women Veterans, is back as the assistant secretary of the Office of Public and Intergovernmental Affairs. She has pushed the issue of monthly press conferences and press access, and, as a veteran herself, has long been a proponent of VA facilities that reflect all of their clientele — and not just the traditional square-jawed, straight, white male image that appeared in old movies. (Williams is a War Horse fellow and past contributor.)

“I think it’s also not a mistake that several of our senior communicators are women veterans,” McDonough says.

The Veterans Experience Office, under John Boerstler, continues the work it began under Obama to map the veteran’s experience, look for hiccups in the system through human-centered design, and set up events to simply listen to veterans. When VA decided which Electronic Health Record portal to use, McDonough had Boerstler’s team ask the veterans which one they prefer.

“I love John Boerstler,” McDonough says. “I think he’s maybe the single most creative policymaker I know. And on one level, he’s not even that creative, because what he keeps just saying is, ‘We need to listen to vets.’”

Overall, he says he feels like he has a handle on it.

“I feel quite liberated because what we do here is not classified,” he says. “It’s hard. But it’s no secret. And we shouldn’t treat it as if it is.”

‘It’s the law of the land’

The Veterans Access, Choice, and Accountability Act started as a way to expand health care services to veterans who had to wait too long for services, or who lived long distances from VA facilities. Trump expanded it with the MISSION Act, saying he wanted veterans to be able to choose private care, if they preferred it.

“I think there are some people who see that as an effort to sap resources away from VA,” McDonough says. “The way I see the MISSION Act is it’s the law of the land. It gives us really important tools. It, I think, is particularly meaningful and important for rural vets.”

But rural health facilities of all kinds are struggling right now to meet the needs of their local populations, and McDonough sees VA as part of a solution to address that need. Because of the COVID pandemic, VA created a two-year training program to “grow the health care workforce in rural communities.” Rather than allow the MISSION Act to show VA health care isn’t necessary, the administration turned the story on its head by using VA to try to improve community access for everybody.

“If we can then crosswalk our in-care — in-system care — with community-provided care, and maintain our central role as the integrator of that veterans’ care, then we will kind of get to the next level as not only the premier provider of health care to veterans, but the central pillar in the overall health care system in the country. And so that’s what the ‘tool’ of the MISSION Act can allow us to do.”

VA also geared up to provide vaccines for all veterans — including those not in VA’s system, veterans’ spouses, and caregivers — and expanded telehealth care to keep patients and providers safe during routine exams or prescription updates, as well as to provide care to veterans who are less likely to show up at an office, such as veterans without homes.

In mid-January, McDonough told reporters Omicron had hit VA hard: Admissions hit an all-time high of more than 300 a day in early January, and 15,000 health care employees stayed home after a Covid-positive test. He said VA had stepped up, and veterans should know care is still available.

But it’s still a challenge: A November inewsource investigation found that, even after doctors sent veterans to outside care for treatment, administrators refused those orders to save money and keep veterans within the VA system. The problem began under Trump and continued under Biden.

“If we’re competing with others in the system, and we’re trying to make a case to the veteran, the best way to make the case for veterans to stay in our care is to get the veteran in for timely access to care,” he says. “So under 20 days for primary care, 28 days for specialty care. And if we can’t meet those, that’s on us. That’s not on the MISSION Act.”

‘I think the interview with Jon Stewart was fine’

McDonough recently appeared on “The Problem with Jon Stewart,” where Stewart, a huge burn pit-benefits proponent, pushed McDonough for not acting quickly enough to get veterans help.

“You know, the interview with Jon Stewart, I think, was fine,” he says. “I think it’s good. I think the really important part of it is he’s raising awareness among so many people in the population about something that is so critically important to a smaller part of the population who really feel left behind. And so I think that’s an absolutely important service. And I was really — I’m really glad I did it.”

He alluded to an important change during the interview, but it was probably too nuanced for that particular moment: He’s working to change the presumptive-status decision-making process. It’s mired in bureaucracy, law, and Congress. And that’s not so different from other government agencies, so there’s a Biden directive to do things differently across the board.

“I think the best way I can answer the question is to say, how are we structuring the decision-making process so as to force decisions?” he says. “So often, what happens in government, and frankly, everywhere, is the avoidance of decision-making, rather than the forcing of decisions and then defending your decisions.”

So, they talk — all of the agencies — and they hold each other accountable. But everybody also knows what everybody else needs, he says, including the president.

“We’re actually sitting around the table with the Department of Labor who, through OSHA, has access to a lot of stuff about toxic exposure. Department of Defense, obviously, HHS, which is the parent agency for, for example, the National Institutes for Cancer. So we then not only are accountable to the president for the decision-making, we also have a wider range of information to inform the decision-making. We’re not just taking it from ourselves or from the national academies. We’re actually getting it from many, many sources.”

In the meantime, he says Biden has pledged to increase research and development on toxic injuries. That plays out in trying to figure out how to diagnose constrictive bronchiolitis in a way other than by cutting open someone’s chest for a biopsy. (Veterans’ benefits have often been denied for constrictive bronchiolitis because it doesn’t show up on X-rays or scans.) Biden has also pushed him on brain cancer, he says. Biden’s son Beau died of brain cancer after serving in Iraq, and Biden has said he believes there may be a correlation.

“The president said, ‘I want an answer early in the new year on rare respiratory cancers,’” McDonough says. “He’s also pressed me hard on brain cancers. And veterans have pressed really hard on constrictive bronchiolitis. And so we say, ‘Not only are we looking at it, and here’s how we’re looking at it, here’s who we’re responsive to look at it. But here’s a timeline on which you can expect a decision.’”

He expects a decision about rare respiratory disorders connected to burn pit exposure in the “early part of the year,” he told reporters Jan. 18.

The internal decision-making process has also changed at VA, McDonough says: Once a quarter, he meets with his executive board, and he comes out of those meetings with decisions made. Then he announces them — at the breakfasts, at the press conferences, at Congressional hearings.

“So we built the structure to force the decisions based on the fact that the president’s person is in the chair,” he says. “That gives us additional information. We’re developing new tools to figure out how to diagnose these illnesses. We are getting additional information to inform the decision-making. We’re putting ourselves on the hook. Well, the president puts us on the hook.”

Then, as with the decision to offer gender confirmation surgery, McDonough defends it.

He used the caregiver situation as an example: After years of service by military spouses and other family members as unofficial caregivers, VA realized it could probably save money by simply paying those spouses or moms or dads to be full-time caregivers. But as more service members came back from war with head injuries or chronic PTS, the program became more costly. Suddenly, people who either had been acting as caregivers for years or were newly caring for veterans with severe disabilities were booted from or not allowed into the program. Now, VA is pushing through a new congressionally mandated appeals process to try to fix that. But a big part of the problem, McDonough says, is that the three internal agencies don’t talk to each other — they don’t even necessarily know what their colleagues do, let alone the decisions that have already been made on a particular case. And, he says, everyone involved should better understand the consequences of war, the daily care of someone dealing with a traumatic brain injury, and how it feels to live with PTSD.

“We should know what VBA knows about the veteran before VHA makes that decision,” McDonough says. “There’s a lot of work we can do to make the decisions more round, more inclusive. … But until then, we also have to be open to downstream consequences in recognizing that they’re connected to service. And we have to hear that, learn from that. Listen to the vets, listen to survivors, caregivers, to make sure that we’re learning, because I think we learn every time we go to war that this is a very impactful experience.”

As troops stand ready to go to defend Ukraine, those lessons must be on decision-makers’ minds as they talk about VA’s ever-expanding budget.

‘That’s not a good talking point’

McDonough says there hasn’t “really” been any progress on the electronic health record situation. In 2018, Wilkie announced Spokane would be the testing ground for the 20-year battle to integrate Defense Department and VA health records. The result was a disaster, as reported by The Spokesman-Review, with long delays in care and staff threatening to quit.

“We’ve kind of been in a moment of suspended animation really trying to learn the lessons of Spokane,” McDonough says. “But we just had, I think, two good weeks of explaining to policymakers, talking to our workforce, talking to the press, about our plan for next steps. A big part of that is now having gotten people into the right positions.”

The situation served as an example of groups not speaking to each other, and then basically sitting on the fence rather than taking responsibility for a decision, he says. In March, with better plans and better decisions in place — he expects — they’ll try again at the Columbus, Ohio, site. The right people are in place, with Terry Adirim heading it up, he says.

Is everyone playing well together on the new plans?

“So far,” he says, “but it’s early. This is a little bit like an earlier question: This is a trust-but-verify one. We’ll stay on top of that.”

McDonough spent his first year at VA working with a budget from the previous administration — and spending surpassed that budget. According to data he had from October, VA had spent just over $2 billion in the community, he says, and they know they need to get a handle on it. Part of that increase probably came as veterans returned to hospitals for care they’d put off during the pandemic, he says, as well as others who learned they were eligible for care when they went in for COVID vaccinations. (By mid-January, VA had vaccinated 4 million veterans, 80,000 spouses, and 28,000 caregivers, McDonough told reporters.)

But a large portion of the money spent on care remains, as it does in the civilian health care system, for people who use the emergency room. This happens either rather than using lower-cost urgent care facilities or because they haven’t received the treatment they needed — blood pressure medications, insulin, counseling about diet, mental health treatment — and their health situation has developed into a crisis.

“As I’ve said, a million times, I’ll make every decision based on increased access, improved outcomes,” he says. “And when we do that, we’re gonna see costs flattened, and we’re gonna see satisfaction increase.”

At the same time, the president tasked him with expanding outreach — which isn’t cheap.

“I say all the time, when the president has told me to be an advocate for veterans, he doesn’t mean some, he means to be an advocate for all veterans,” McDonough says.

That’s how the gender-confirmation-surgery decision came about: He reached out to the VHA Governing Board to get a recommendation for the surgery, which hadn’t been allowed at VA for 20 years. He learned that “veterans suffering gender dysphoria who are appropriately treated see dramatic improvements in mental health, dramatic reductions in suicide.” So, he said, “That’s what we should do.” Recently, VA also added a “+” at the end of the name of VA’s LGBTQ program to ensure everyone feels included. And VA announced in January that health records now display gender identity.

McDonough’s also working on outreach and care for women, he says. He cited The War Horse’s story about rising rates of breast cancer in women veterans and said VA is “getting more aggressive about gender-specific care.”

“You know, one of our talking points is we have 69 facilities where you can get a mammogram [in the] United States, which is a fucking pittance,” he says. “That’s not a good talking point. That’s a bad talking point. So, we’re dramatically increasing access to technology, like mammography. But we’re nowhere near where we need to be.”

McDonough has considered VA’s history, those years of denying problems and benefits, of telling Desert Storm veterans their symptoms were in their heads or Vietnam veterans that exfoliants were safe or treating atomic veterans as if their health concerns could not be addressed because they were top secret. What might have happened if VA had simply cared for those veterans? Could it have saved the government money as their health concerns grew chronic? It’s a big question that can’t be answered without considerable research.

“But that concept is infusing our work,” he says, “to say, ‘How do we do better at identifying something early before it manifests as crisis?’”

There’s more than that: There’s addressing mental health before it becomes deadly with mind-body work. There’s pushing for gun locks on firearms so veterans don’t have instant access at critical moments. He knows, after working with Obama on the Affordable Care Act, that preventive care saves health systems money.

“And so at the end of the day, my guess is, those kinds of steps are going to be helpful to the overall budget picture, but they surely are commonsensical,” he says. “And so if had we done a better job of recognizing? Well, look, I mean, I wish we didn’t use burn pits. That’d be the best thing.”

His dream? To address suicide and mental health in a significant way, as well as to fix the backlog.

“I think that the most important thing is to deliver on our core course requirements,” he says. “And core course requirements are delivery of world-class health care at VHA, and delivery of timely benefits at NCA and VBA. So obviously, in the first one, that includes suicide [prevention] and access to mental health [care], and the second one includes the backlog. And I have dreams about specific advancements in both of those places.”

But he wants more than just downward trends: He wants an “intensification of progress.”

“That’s what I’m looking for, is the game-changers,” he says. “And that will come from innovation. That will come from trusting one another. That will come from shaking off this crisis of confidence.”

This War Horse feature was reported by Kelly Kennedy, fact-checked by Ben Kalin, and copy-edited by Mitchell Hansen-Dewar.

Kelly Kennedy is the Managing Editor for The War Horse. Kelly is a bestselling author and award-winning journalist who served in the U.S. Army from 1987 to 1993, including tours in the Middle East during Desert Storm, and in Mogadishu, Somalia. She has worked as a health policy reporter for USA TODAY, spent five years covering military health at Military Times, and is the author of “They Fought for Each Other: The Triumph and Tragedy of the Hardest Hit Unit in Iraq,” and the co-author of “Fight Like a Girl: The Truth About How Female Marines are Trained,” with Kate Germano. As a journalist, she was embedded in both Iraq and Afghanistan. She is the only U.S. female journalist to both serve in combat and cover it as a civilian journalist, and she is the first female president of Military Reporters and Editors.

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