The recent scandal involving the VA healthcare system is easy to criticize and difficult to decipher. It is one issue where there is a gratifying sense of unity among divergent political groups, and for this veteran, in that there is an odd sense of satisfaction.
I will measure out my observations carefully, in an attempt to avoid the obvious and already-announced conclusions. There is no merit (nor gain) in blaming the current administration for the VA’s troubles, for the nature of such organizations is such that problems take root early and are unswayed by short-term changes in political administrations. The VA healthcare system is a complex organization, as expected for its size, and within its sprawl are many areas of excellence as well as unsatisfactory performance. How can these coexist for so long?
My starting observation is that true understanding of the fundamental flaws of large organizations is not within easy reach—certainly not easily grasped by political pundits, editorialists, and even leaders within the organization itself. In my few years at a regional headquarters for a very large healthcare organization, I was prone to saying that I was “two levels removed from reality.” Pride kept me from admitting that it was probably more than that. There may be justifications for a change in leadership, but it is highly unlikely that Secretary Shinseki’s experience in the Army enables him to have a fundamental grasp of what truly keeps the VA healthcare system from doing what he wants it to do. Good luck finding someone who can understand it, put it into words, is able to make changes against huge inertia, and perseveres long enough in such an organization to see it through.
We might, as many have done, use that as an argument against creating large healthcare organizations. That appeals to many, but a practical view of our changing society, with its enlarging population, economic strains (producing pressures for economy of scale), and demands for (and technological enabling of) standardization mean that while we may cringe at centralization, we want what it produces. Think Walmart. Throughout our society we can expect more of the dynamics that produced the current state of affairs at the VA.
Therefore, a conversation that produces productive changes requires that we step back and recognize the broader realities of our society, and that what we say we want in one breath contradicts what we ask for in another. That is one critical step for the next one we will have to take, including in this area of healthcare for veterans: to actually decide what we can have, and admit what we can’t.