How to Fix the 'Ailing' VA Health System

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

On September 9, 2016, Dr Richard Horowitz, an eminent professor of pathology at University of Southern California and University of California, Los Angeles, and a close friend and colleague of mine since 1967, wrote a letter to David J. Shulkin, MD, undersecretary for health at the US Department of Veterans Affairs (VA).

Richard died of lung cancer on March 15, 2017. His widow, Nona, has authorized me to publish this previously unpublished letter.

Letter to David J. Shulkin, MD, Under Secretary for Health at the US Department of Veterans Affairs

Dear Dr Shulkin,

I would like to share my thoughts, based on 50 years of experience as a volunteer attending physician at one of the largest of the VHA's (Veteran Health Administration's) medical centers:

The VHA is the United States' largest integrated health care system, with 152 medical centers and nearly 1400 community-based outpatient clinics and community living centers, providing care to more than 8.3 million Veterans each year! It is working, but not well!

The VHA is also indispensable for medical education. Over 100 VHA medical facilities are currently affiliated with 107 of the nation's medical schools. Over 30,000 medical residents and 20,000 medical students receive all or some of their training in VHA facilities each year. We cannot do without these training programs!

Why the VA System Is 'Ailing'

It seems we have a system that is essential for both patient care and for medical education—but it is ailing! Why? Here are some of my thoughts:

  1. The VHA's patient population is not only uniquely deserving, but also exceedingly challenging. They are poorer than average. They have a high incidence of alcohol, drug abuse, and post-traumatic stress disorders. They are distressingly disadvantaged and are often unemployed or homeless. They tend not to seek medical care early and as a result often present with late-stage or incurable disease. This presents difficult problems not only for the healthcare team but also for society as a whole.

  2. Many of the full-time VHA doctors are also unique. They have different ambitions, goals, and agendas than doctors in either academic or private practice. They are seduced by a stress-free, relatively undemanding and easy work schedule. Their goal is their retirement and pension and they willingly compromise their professional standards and mute any initiative in order to achieve that target.

  3. The employees of the VA, from the very top system administrators to the most unskilled, are also different. The security of government employment and the promise of a pension, combined with an overbearing bureaucracy, destroy any creativity or resourcefulness. The employees are not infrequently incompetent and/or lazy but often are skilled in ways to game the system. Unfortunately there is a distinct culture in the VHA that tolerates incompetence and stifles initiative.

  4. The funding of the VHA is both inadequate and often inappropriately allocated. When a major VA medical center rents out its facilities to a private school or church, or redecorates its administrative offices every few years or remakes its hallways with new "art," yet can't find the funds to renovate empty buildings for homeless veterans, it exposes distorted values and prioritization. There is continuing and intense pressure from the top down to all levels of staff and employees to spend less and to conserve more. It appears that administrators are rewarded primarily for their fiscal restraint rather than for superior patient care.

How to Improve the VA System

What can be done? Transform the healthcare programs of the Department of Veterans Affairs to better meet the patient care and educational needs of our country!

  1. The VHA healthcare facilities that currently are affiliated with university medical schools would be operated by those medical schools. The VHA would contract with the university to provide patient care, provide faculty and staff, and to administer the facility. The school would set the standards for the patient care, research, and education similar to those they currently use in their own medical centers and hospitals. The standards for employees would also be the same—there would be no VHA employees, no Civil Service. All would be hired and evaluated by the university medical school.

  2. VHA healthcare facilities that have no university affiliation, numbering about 50, would no longer be operated as health care facilities (ie, hospitals or clinics). Rather, they could be converted to housing for homeless veterans. Those veterans previously using such unaffiliated VA health facilities would be given vouchers for use in the private medical sector or they would be included in a special Medicare program (without deductibles or co-pays). Most unaffiliated VHA facilities are in non-urban areas, and such a development would be an economic boost to these often fiscally strained regions.

This proposal might well be a win-win-win activity. Medical schools will have expanded facilities for their teaching and research programs. Rural physicians and hospitals would see an influx of patients and revenue, allowing them to survive and thrive. And, most important, veterans would get better health care!


Richard E. Horowitz, MD

Dr Shulkin's Reply

Dr David J. Shulkin politely responded on September 9, 2016:

Dr Horowitz, I cannot thank you enough for this. This is well-composed and very insightful. We will use this broadly in our strategic thinking.

Dr Shulkin, Richard and I know that you are very busy. But how about a progress report?

That's my opinion. I'm Dr George Lundberg, speaking for Dr Richard Horowitz, at Large for Medscape.


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