Videos & Speeches
May 07 2014
Mr. President, I spoke yesterday on the Senate floor about my concerns with the nature of the way the Department of Veterans Affairs is being operated. Much of my concern occurred as a result of conversations I have had with veterans back home in Kansas and their experiences both on the benefit and medical side — some real concerns with individual examples of what has happened in some of our VA facilities in our State, and this growing sense that the Department of Veterans Affairs has become unable, unwilling, to provide the necessary services in a cost-effective, efficient, timely manner that our veterans so deserve.
As I indicated yesterday, there is no group of people I hold in higher regard than those who have served our country and believe that the benefits that were promised our veterans must be provided to them, and I am concerned that is no longer the case.
As I indicated yesterday that I have served on the House and Senate Veterans’ Affairs Committee for now 18 years. I was the chairman of the health care subcommittee, I have worked with nine secretaries of the Department of Veterans Affairs, and during that time I always had the sense, until the last few years, that things were always getting better for our veterans. Today, the frustration that I bring to share with my colleagues is the belief that many veterans no longer have hope that the Department of Veterans Affairs is there to meet their needs and to care for them.
In preparing for those remarks yesterday — but really in studying this issue over the last several years — there is a real shocking development, which is the number of times we hear stories, incidents, facts about what is going on with our veterans at the Department of Veterans Affairs and the services that are being provided. Just to highlight to my colleagues, based upon inspector general reports that are then, in part, based upon press reports, here are some things we have seen and heard about the Department of Veterans Affairs and their efforts to care for America's veterans.
The one that is in the news at the moment — there is an additional IG report that is being anticipated — the Phoenix Veterans Affairs Hospital administration apparently developed a secret waiting list of up to 1,600 sick veterans who were forced to wait months to see a doctor. It is believed that at least 40 U.S. veterans died waiting for their appointment as a result of being placed on the secret waiting list. Again, this is being investigated, a report is expected, and we will see what that report says. But, clearly, this is one of huge concern, resulting in potentially the death of veterans.
There is a wait time cover-up. According to the GAO — the Government Accountability Office — last year, quoting them:
“It’s unclear how long an appointment has been delayed because no one can really give you accurate information ..... It is so bad that [GAO staff] have found evidence that VA hospitals tried to cover up wait times, fudged numbers, and backdated delayed appointments in an effort to make things appear better than they are. In addition, the GAO states that ‘nothing has been implemented that we know of at this point’ despite the fact that the GAO and the VA Inspector General reported similar findings for over a decade.”
Reports of falsifying records were stored in the VA clinic at Fort Collins, CO, where the VA’s Office of Medical Inspector found that “clerks were instructed on how to falsify appointment records so it appeared the small staff of doctors was seeing patients within the agency’s goal of 14 days.” In fact, the investigation determined that clerical staff at the Colorado clinic were punished if they allowed records to reflect that a veteran waited longer than 14 days. Let me say that again. In fact, the investigators determined that clinical staff at the Colorado clinic were punished if they allowed records to reflect that a veteran waited longer than 14 days.
No oversight in quality of care. In December, the GAO reported on VA hospitals finding that patients were not being protected from doctors who have historically provided substandard treatment. None of the hospitals examined by the GAO in Dallas, Nashville, Seattle, and Augusta, ME, adhered to all of the requirements to review and adequately identify providers who are able to deliver safe, quality patient care.
In Los Angeles in 2012, more than 40,000 requests for diagnoses were “administratively closed” and essentially purged from the books so reported wait times would be dropped. In Dallas in 2012 another 13,000 appointments were canceled. According to the Washington Examiner, the VA canceled more than 1.5 million medical orders with no guarantee that the patients actually received the treatment or that the tests that were required by those orders were given.
By the VA’s own admission in an April of 2014 fact sheet, cancer screening delays accounted for the deaths of at least 23 patients in VA facilities nationwide, and another 53 patients suffered from some type of harm due to improper care.
Reports have also linked poor patient care, maintenance issues, and unsanitary practices to at least six preventable deaths in Columbia, SC, five in Pittsburgh, four in Atlanta, and three each in Memphis and Augusta, GA.
More than 1,800 veteran patients in the St. Louis VA Medical Center may have been exposed to HIV and hepatitis as a result of unsanitary dental equipment. The facility has remained under fire for patient deaths, persistent patient safety issues, and critical reports. Despite the problems at the medical center, the facilities director from 2000 to 2013 received nearly $25,000 in bonuses during her tenure there.
CNN reported that after they obtained VA internal documents that deal with patients diagnosed with cancer in 2010 and 2011, at least 19 veterans died because of delays in simple medical screenings such as colonoscopies or endoscopies at various VA hospitals or clinics. Let me say that again. In 2010 and 2011, 19 veterans died because of delays in getting simple medical screenings related to cancer. The veterans were part of 82 vets who have died or are dying or have suffered serious injuries as a result of delayed diagnoses or treatment.
Loopholes in VA performance. An Iraq and Afghanistan combat vet, who is also a former mental health administrator at the VA Medical Center in Manchester, NH, said in April 2012 that VA hospital managers across the country regularly sought loopholes to get around meeting performance requirements. He explained that “meeting a performance target, rather than meeting the needs of the veteran, becomes the overriding priority in providing care.” He went on to say that “offering bonuses to managers to make sure they met performance requirements creates a perverse administrative incentive to find and exploit loopholes... that will allow the facility to meet its numbers without actually providing the services or meeting the expectation the measures dictate.”
Finally, this one. It is not from the inspector general’s report. But in a hearing before the House Veterans' Affairs Committee on April 9 — about a month ago — the deputy for the VA inspector general for health care inspections stated:
I believe that the VA has lost its focus on the importance of providing quality medical care as its primary mission. ... There is no good explanation for these events. They are not consistent with good medical practices, they're not consistent with common sense and they're not consistent with VA policies that exist.
It is amazing to me — it is so troubling to me — we have these reports over a long period of time across the country — not isolated incidents. It is even more troubling to me — despite these reports, these inspections, these criticisms of the VA — it is hard to find any evidence the VA is doing anything to improve its record, its performance, or to better care for the veterans of our country. We should demand more, and we need leadership at the Department of Veterans Affairs that will do so.
As I indicated yesterday, I do not believe this is a matter of money. There has been a 60-percent increase in VA spending since 2009 — normal increases of two, three, or four percent each year over the last several years. As I indicated yesterday, the President himself talked about how successful the administration has been in providing the necessary resources for the Department of Veterans Affairs.
Our veterans deserve better care and treatment. These are the folks we ought to honor and esteem. These are the people who we must live up to with our commitments to provide the benefits and health care they deserve and have earned.
If these were isolated instances, they would be a terrible thing. But because they are so pervasive, because they are so widespread, and because there appears to be no effort to correct the problems, it is important — it is critical — that Congress and the American people demand better service, care, and treatment for our Nation's heroes.