Friendly Fire: Death, Delay, and Dismay at the VA." The report is based on a year-long investigation of VA hospitals around the nation that chronicled the inappropriate conduct and incompetence within the VA that led to well-documented deaths and delays. The report also exposes the inept congressional and agency oversight that allowed rampant misconduct to grow unchecked.
"This report shows the problems at the VA are worse than anyone imagined. The scope of the VA's incompetence -- and Congress' indifferent oversight -- is breathtaking and disturbing. This investigation found the problems at the VA are far deeper than just scheduling. Over the past decade, more than 1,000 veterans may have died as a result of the VA's misconduct and the VA has paid out nearly $1 billion to veterans and their families for its medical malpractice. As is typical with any bureaucracy, the excuse for not being able to meet goals is a lack of resources. But this is not the case at the VA where spending has increased rapidly in recent years," Dr. Coburn said.
"The Administration and Congress have failed to ensure our nation is living up to the promises we have made to our veterans," Dr. Coburn added. "As a physician who has personally cared for hundreds of Oklahoma veterans, this is intolerable. As a senator, I'm determined to address the structural challenges of the Department of Veterans Affairs so we can end this national disgrace and improve quality and access to health care for our veterans. But make no mistake. Whatever bill Congress passes cannot ignore the findings of this report. While it is good that Congress feels a sense of urgency we are at this point because Congress has ignored or glossed over too many similar warnings in the past. Our sense of urgency should come from the scope of the problem, not our proximity to an election."
Key findings in the report include:
A CULTURE OF MANIPULATION PERMEATES THE DEPARTMENT.
The cover up of waiting lists for doctor's appointments at the VA is just the tip of the iceberg, reflecting a perverse culture within the department where veterans are not always the priority and data and employees are manipulated to maintain an appearance that all is well.
Bad employees are rewarded with bonuses and paid leave while whistleblowers, health care providers, and even veterans and their families are subjected to bullying, sexual harassment, abuse, and neglect. For example, female patients received unnecessary pelvic and breast exams from a sex offender, a noose was left on the desk of a minority employee by a co-worker, and a nurse who murdered a veteran harassed the family of the deceased to get them to admit guilt for the death.
The care at more centers is getting worse and some VA health care providers have lost their medical licenses, and the VA is hiding this information from patients.
Delays exist for more than just doctors' appointments--disability claims, construction, urgent care, and registries are also slow or behind schedule.
Despite a nursing shortage, many VA nurses spend their days conducting union activities to advocate for better conditions for themselves rather than veterans.
VA MADE WAITING LISTS WORSE.
As waiting lines were growing, the VA expanded eligibility in 2009 to those who already had insurance without any service related injuries, making the delays longer.
Despite having the authority to do so, the VA was reluctant to let vets off the waiting lists by freeing them go to doctors outside of its system while sitting on hundreds of millions of dollars intended for health care that went unspent year to year.
VA doctors are seeing far fewer patients than private doctors and some even leave work early.
VA EMPLOYEES BEHAVE AS IF THEY ARE ABOVE THE LAW.
Criminal activity at the department is pervasive, including drug dealing, theft, and even murder. A VA police chief even conspired to kidnap, rape and murder women and children.
Many VA doctors and staff are overpaid and underworked, some are paid not to work and more and more employees are not even showing up for work.
THE VA WASTES AND MISMANAGES BILLIONS OF DOLLARS.
The report identifies $20 billion in waste and mismanagement that could have been better spent providing health care to veterans.
The federal government has paid out $845 million for VA medical malpractice since 2001.
Most VA construction projects are over budget and behind schedule, inflating costs by billions of dollars.
THE SENATE VETERANS AFFAIRS COMMITTEE HAS BEEN AWOL WHEN IT COMES TO KEEPING PROMISES MADE TO VETERANS.
The Senate Veterans Affairs Committee largely ignored the warnings about delays and dysfunction at the VA for decades, abdicating its oversight responsibilities and choosing to make new promises to veterans rather than making sure those promises already made were being kept.
This report details how Congress was repeatedly alerted and warned of the problems plaguing the VA over decades.
The Senate Veterans Affairs Committee has only held two oversight hearings the last four years, and was even profiled in Wastebook 2012 for being among the committees in Congress holding the fewest number of hearings.