A New Era for the VA

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Yesterday, the U.S. Senate confirmed Denis McDonough, in an 87–7 vote, as the new Secretary for the U.S. Department of Veterans Affairs. Secretary McDonough is an unusual choice for the position. He is not himself a military veteran (he’s only the second non-veteran to serve as VA Secretary). He also lacks health care experience, which could be a challenge for the person charged with overseeing the single largest health care system in the United States.

So what makes him the right person for this job? He’s an experienced leader with a solid track record of delivering results, and he has good relationships in Washington. Former VA Secretary Bob McDonald praised McDonough as “a crisis-tested leader of character with great knowledge, skills, and experience in using the levers of government.”

Four years ago, I shared advice for Dr. David Shulkin when he was appointed as President Trump’s first VA Secretary; I did the same when Robert Wilkie took over the position. Much of that advice still holds; Secretary McDonough will face many of the same persistent challenges his predecessors did. But new challenges have also emerged.

Here are some top priorities for Secretary McDonough to tackle:

1. Manage the COVID-19 pandemic’s impact on veterans — and beyond. The VA provides care at more than 1,200 health care facilities, serving more than 9 million enrolled veterans. During the past year, VA facilities have seen more than 200,000 COVID-19 cases and more than 9,000 deaths among patients and staff — a higher death toll for American veterans than the Iraq and Afghanistan wars combined. Those numbers account only for those seeking care at the VA; there are no reliable estimates of the number of veterans nationally who have contracted and/or died from the coronavirus. The VA has an urgent task to administer the COVID-19 vaccine to patients and staff, and to continue screening, testing, providing care, expanding telehealth, and protecting its frontline workers.

Ideally, the VA can reach beyond its own patients to spearhead the nation’s vaccination campaign. Part of its vision is to “…contribute to the nation’s well-being through education, research and service in national emergencies.” The VA has facilities in every part of the country and hundreds of thousands of trained personnel. It can step up and lead the way in the national pandemic response.

2. Curb the epidemic of veteran suicide. Veteran suicide was an urgent issue even before the pandemic. While making up 7.9% of the U.S. adult population, veterans accounted for 13.5% of all deaths by suicide among the adult population in 2017. Increases in the suicide rate are also growing faster among veterans than among the general population. COVID-19 has exacerbated the problem. In April of last year, VA researchers warned that our nation’s response to the COVID-19 pandemic could create a “perfect storm” of conditions that increase the risk of veteran suicide. Factors include the toll of growing economic stress and social isolation, barriers to mental health, and an increase in firearms sales. A recent survey of post-9/11 veterans who experienced illness or injury while serving found that 52% of respondents said their mental health has worsened during the pandemic; 30% reported having suicidal thoughts in the past two weeks. And mental health services were lacking for veterans; during the pandemic, 51% of veterans surveyed reported having a mental health appointment canceled or postponed, and 48% of those said they did not receive needed information from the VA on how to continue their mental health care.

I’m encouraged that Secretary McDonough said in his confirmation hearing, “The first and most important thing I will do if confirmed is underscore that comprehensive health for our veterans includes mental health.” Improving the availability and quality of mental health services should go hand in hand with addressing issues of access to firearms and other lethal means. Every VA Secretary has named suicide prevention as a top priority, but we have yet to turn the tide.

3. Restore trust. The VA has experienced scandals and cover-ups, from manipulating data about wait times at VA facilities to smearing the reputation of Andrea Goldstein, who reported being sexually assaulted at a VA hospital. These are egregious examples, and it will be a challenge to recover from these breaches of trust. But more mundane lapses, like a widespread lack of transparency, have also eroded trust. For example, we don’t have a clear idea of the outcomes of the MISSION Act, which expanded access to community-based services for veterans. Sunlight is the best disinfectant, so Secretary McDonough should be open and honest about all of the department’s activities, its successes, and its shortcomings.

4. Adapt to an increasingly diverse modern military. It can’t be your grandfather’s VA; today’s veterans are different from yesterday’s in numerous ways. The share of veterans in the U.S. today is shrinking; today, only about 7% of Americans are military veterans. Women are the fastest-growing segment of the veteran population. Upon his nomination for the position, Secretary McDonough pledged to “make our VA even more welcoming to all veterans — including our women veterans, veterans of color, and LGBTQ veterans.” That’s an important promise to keep because the newest generation of veterans is both more diverse and has been engaged in different types of warfare than those who came before. Drones may have different psychological effects on veterans than we have seen in past conflicts. Burn pits present a new and not fully understood risk to the health of veterans.

5. Listen to veterans themselves. This is perhaps the most important principle for anyone, but especially so because Secretary McDonough is not himself a veteran. What are their priorities, needs, and preferences? VA leadership should be in regular conversation with veterans and ensure their voices are represented and responded to.

Secretary McDonough has a tough task ahead of him. The VA is a large and sprawling organization with many complexities even in usual times; the pandemic adds another layer of challenges. At his confirmation hearing, Secretary McDonough noted that with every decision he and his team make, he will ask, “Are the decisions we’re taking increasing access for veterans and are they improving outcomes for veterans?” That’s the right question to ask, and I am confident that our nation’s veterans will be well served when he follows through.

David Sandman, Ph.D., is President and CEO of the New York State Health Foundation. www.nyshealth.org www.twitter.com/DavidSandman1

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