Should the VA be merged into the Department of Defense to prmilitary members with recruitment-to-grave continuity of service?
Thatu2019s how it used to be done, and there was very good reason why the functions are now distinct and separate. I canu2019t think of a single efficiency that would be gained by going backwards.This isnu2019t me being a precious VA employee who wants to protect my old stomping grounds. This is me being a bureaucrat whou2019s seen the innards of the two largest bureaucracies in government - VA and DoD - and is telling you, in as direct a way as possible, why you do not want to combine those sausages.Letu2019s start from the beginning. Like, the beginning-beginning.Veteransu2023 compensation in the United States literally goes back to the Pilgrims. The Plymouth Colony determined in 1636 that those who were disabled in their fight with the Pequot Indians should receive regular compensation for their service.Flash forward 150 years, and Revolutionary War veteran Daniel Shays, angry that he was still owed compensation for his service (as were basically all veterans), took up arms against the Massachusetts government in a rebellion that literally shaped the nation as we know it today[1].The first Congress under the Constitution established a pension for veterans as one of its first acts, and so began the bureaucratic nightmare.The pension program (and its growth with various amendments) was run by the War Department until 1849, when it grew too large and was moved into the newly formed Department of the Interior.Any health care for veterans, meanwhile, remained principally a state responsibility until the end of the Civil War, when the influx of disabled veterans was too great for the patchwork of Soldiersu2023 Homes (some of which were Federal) to manage. In 1865, as the Civil War was coming to a close, the government formally established a network of facilities to prlong-term care for severely disabled veterans.Over time, Congress expanded the eligibility criteria for admission into these homes; and in so doing, they gradually transformed to being able to prhospital level care.Americau2019s entry into WWI had, perhaps, the longest repercussions for veteransu2023 care and benefits.The number of disabled veterans overwhelmed both military hospitals (where many were undergoing long-term recovery) and the Soldiersu2023 Homes network. In 1919, broad responsibility for veteransu2023 health care spun off to the Public Health Service and contracted private hospitals; and in 1921, Congress authorized the construction of hospitals specifically for veteransu2023 care.Also in 1921, Congress attempted to consolidate the various veteransu2023 programs under a single umbrella (the Veteransu2023 Bureau), but their efforts were incomplete. While the Veteransu2023 Bureau took on responsibility for insurance, outpatient care, and education benefits, the Bureau of Pensions (Department of Interior) still had responsibility for, um, pensions, and the National Homes for Disabled Volunteer Soldiers remained a separate entity.In 1930, Congress tried again, and so created the Veteransu2023 Administration to consolidate the Veteransu2023 Bureau, the Bureau of Pensions, and the National Homes.For the first time, the Federal government assumed, under a single organization, total health and compensation responsibility for veterans and their dependents.Between the influx of WWI veterans and the retirement of Spanish-American War veterans, spending on veteransu2023 services shot up through the 1920s. Moreover, Congress continued to expand eligibility requirements and levels of compensation. This led to a fateful decision in 1924 to authorize bonus payments to WWI veterans, payable beginning in 1944.When the Great Depression hit, many veterans found themselves out of work with the rest of the population. In the spirit of Daniel Shays almost 150 years before - but much, much less violently - veterans marched on Washington to demand that their compensation be cashed out so that they could support their families.Congress said, u201cNo,u201d and the Hoover Administration responded by sending in the military to disperse the encamped veterans and their families at bayonet point[2].So that was a great episode in American history (and in 1936, Congress relented and authorized early payment).But the trauma of the Bonus Army and the general experience of WWI veterans during the Great Depression spurred Congress to make significant reforms to veteransu2023 compensation and care leading up to and during WWII. This included wide expansion of education benefits, home loan assistance, and unemployment compensation.However, as with WWI, the rapid demobilization at the end of WWII caught VA under-prepared. By the end of 1947, it had doubled its staff to operate 126 hospitals and 721 offices to manage care and process claims. The Korean War further expanded VAu2019s operational capacity.To get ahead of the problems encountered with rapid demobilization of forces abroad (and, if youu2019re wondering, Iu2019m now starting to get to the crux of the question), VA in 1967 sent field officers to Vietnam to educate soon-to-separate servicemembers on their entitlements as veterans. This was the forerunner whatu2019s now codified as the Transition Assistance Program (TAP).What was then a loose affiliation between the Department of Defense and Veteransu2023 Administration is now a statutory, funded program that includes DoD, VA, the Departments of Labor and Homeland Security, and the Small Business Administration. Attending the program - which not only covers veteransu2023 benefits but includes financial literacy and general career advice - is mandatory for separating servicemembers.The VAu2019s on-the-ground assistance to returning Vietnam veterans made it clear that many of them would need long-term assistance readjusting to civilian life. This spawned the establishment of the Readjustment Counseling Service (ie, the Vet Center program) to prongoing services to combat veterans who may be having difficulty making the transition back to civilian life - and, uniquely, the services are run by counselors who themselves are combat veterans.But the influx of veterans from Vietnam put strains on a system that hadnu2019t seen significant investment in physical infrastructure since the end of WWII. VAu2019s medical budget tripled between 1967 and 1977, and its rehabilitation and education spending increased ten-fold.In 1977, the Veteransu2023 Administration commissioned the creation of an electronic health record that could be used across its hospitals, as veteransu2023 paper-based records were too prone to being lost or inadvertently destroyed[3][4]. This was Americau2019s first electronic health record, and for a long time the only one of its scale anywhere in the world. It was designed to have a core architecture that could be modded by individual hospitals to meet their own needs.It was so successful - and free to the public, having been created by the US government - that in 1988 the Department of Defense awarded a $1 billion contract (~$2.1 billion today) to copy the system for its own purposes, and make that copy totally proprietary.u2026Yes, you are reading that correctly. DoD paid $1 billion to take a perfectly functioning, free electronic health records system that was already US government property to make a private copy.Oh, and they managed to make it worse in the process[5].That created a decades long tech schism that defied both Congress and successive Presidents to resolve. Itu2019s even spawned its own, little bridge bureaucracy[6].So now, with DoD and VA having failed to get along (and even failing to make use of the Bridge Bureaucracy[7]), both Departmentsu2023 records systems are being put in the hands of a single, private provider[8] (and lots of other happy tech vendors[9]).Because in no way, shape, or form will entrusting the private sector to reform the largest electronic health records systems, arguably, in the world lead to any kind of cost overruns[10] or become an attractive target for neu2019er-do-wells[11].Nope.Anyway, how does all this support my position that merging DoD and VA is a bad idea to ensure continuity of care?A major takeaway from the experience of Vietnam veteransu2023 return to the US is, to be quite blunt, that the military gives very few shits about its people once theyu2019re no longer connected to military operations.The Department of Defense and the services have one overarching goal: combat readiness - to train and support war fighters. Once theyu2019re no longer in or supporting combat operations, then as far as Defense is concerned, youu2019re no longer their issue[12] .Going back to TAP, the law requires that DoD ensure that all servicemembers complete the course more than 90 days before they separate. This is because servicemembers often complained that, frequently, they werenu2019t made to take TAP courses until their very last two days in the service - the two days that their minds were very much elsewhere.However, despite both the legal requirement and the length of time afforded to separating servicemembers to complete the training, more than half of servicemembers donu2019t complete the training until their last 90 days, with DoD doing the baremost to monitor compliance[13] .And going back to the (ongoing) debacle of VA-DoD records inter-operability, a major issue was that VA didnu2019t have the political clout to go toe-to-toe with DoD on the issue.The Veterans Administration did not become the Cabinet-level, Department of Veteransu2023 Affairs until 1989[14] [15]. And while the previous Administrator position still required Senate confirmation, it didnu2019t share anywhere near the prestige (which, in Washington, equals power) as a Secretary appointment.If you were to fold the Department of Veteransu2023 Affairs into the Department of Defense, well, you canu2019t have co-Secretaries; and given that DoD has higher precedence than VA, VA would be bumped down the chain. You would be organizationally sending the message that veterans are less important than the active Armed Forces.And if there were ever a conflict between the Secretary of Defense and the now-Under Secretary of Veteransu2023 Affairs, the Under Secretary would basically be stuffed. They wouldnu2019t have direct access to the President or Congress to get their point of view across without being seen as undermining their boss.VA and DoD donu2019t need to be under the same umbrella to prlifetime continuity of care. They just need to be on the same page when it comes to collecting and sharing data on servicemembersu2023 health history (which they mostly are[16]), at which point the VA can take over and focus on long-term care while DoD concerns itself with readiness.And if the assumption is that having everyone in the same organization will break down silos and improve the flow of data, well, thatu2019s not grounded in the reality of the inner workings of Americau2019s largest bureaucracies[17] [18].Of all the possible ways I could think to reform VA and DoD to improve information sharing and continuity of services, merging the two Departments would be an act of desperation at the bottom of the list.Footnotes[1] Carter Moore's answer to What was Shays' Rebellion?[2] Carter Moore's answer to How disastrous to the US would it be if all war veterans benefits got slashed to zero?[3] The 1973 Fire, National Personnel Records Center[4] A 40-year 'conspiracy' at the VA[5] AHLTA users sound off about military EHR system[6] VA Information Technology[7] EHR interoperability for VA and DoD, whou2019s responsible? Lawmakers, officials can't agree[8] VA picks Cerner to replace VistA; Trump says EHR will fix agency's data sharing 'once and for all'[9] Cerner reveals long list of VA EHR modernization partners[10] DoD raises budget on Leidos contract for Cerner EHR project by $1.2 billion[11] U.S. data breaches and exposed records 2023 | Statistic[12] 126,000 service members in crosshairs for separation as DoDu2019s u2018deploy or get outu2023 policy takes effect[13] Transitioning Veterans: DOD Needs to Improve Performance Reporting and Monitoring for the Transition Assistance Program[14] Reagan Would Elevate V.A. to Cabinet Level[15] Reagan signs bill creating veterans department[16] https://www.health.mil/Military-...[17] https://www.realcleardefense.com...[18] After A Year Of Turmoil, New VA Secretary Says 'Waters Are Calmer'
