The Washington Post

VA’s reputation for health care takes a thrashing


The Department of Veterans Affairs’s reputation for providing good health care can’t stand many more thrashings like the one it took at a congressional hearing this week.

The House Committee on Veterans’ Affairs met in Pittsburgh on Monday to hear testimony about problems with health care at agency facilities in that city and others.

Joe Davidson writes the Federal Diary, a column about federal government and workplace issues that celebrated its 80th birthday in November 2012. Davidson previously was an assistant city editor at The Washington Post and a Washington and foreign correspondent with The Wall Street Journal, where he covered federal agencies and political campaigns. View Archive

“What you’re about to hear may be painful,” Chairman Jeff Miller (R-Fla.) warned the audience as the hearing, which can be viewed online, began.

It was so painful that the first witness had trouble getting through her statement.

Brandie Petit spoke through sobs about her brother Joseph, who injured his knees during parachute training as a U.S. Army Ranger. After he had sought the VA’s help for year, the agency finally said “the problem was in his head and sent him home with meds for his head, not his knees,” she told the panel.

At one point, Joseph, who suffered hallucinations, was forced to leave a VA facility, according to Petit, because he didn’t have an appointment.

“The VA police physically removed Joseph and put a standing order into place to arrest him if he showed up again without an appointment,” his sister said. “I’m outraged at his treatment that day.”

Joseph committed suicide in the Atlanta VA Medical Center in Decatur, Ga., in November, “locked in a hospital bathroom dead in his wheelchair, a plastic trash bag tied over his head with a blue cord around his neck,” reported the Atlanta Journal-Constitution.

His case calls to mind my colleague Steve Vogel’s story about Daniel Somers, once a Humvee turret gunner in Iraq. He became so frustrated with his attempts to get VA medical and mental health treatment that he felt the government had “turned around and abandoned me.”

He wrote those words not long before he shot himself in the head on a Phoenix street in July. The note to his family said he was “too trapped in a war to be at peace, too damaged to be at war.”

The VA failed him, as it has too many others.

It must do better.

“We need to make sure you’re getting the veterans’ health care you’ve been promised,” President Obama told the Disabled American Veterans convention last month. “We also need to keep improving mental health services, because we’ve got to end this epidemic of suicide among our veterans and troops.”

When it was time for VA officials to speak at the Pittsburgh hearing, Robert A. Petzel, undersecretary for health, turned toward Petit and others who felt victimized by the VA to “offer my absolutely sincerest condolences and sympathy and empathy.” He said he found their testimony “deeply compelling and very upsetting. I’m saddened by these stories of loss.”

Compounding the loss of Joseph Petit, the VA had previously upset Miller and other members of Congress by not informing them of Petit’s death when they visited the Atlanta facility in May to investigate inspector general reports about hospital mismanagement and patient deaths, including two other suicides.

In addition to the Georgia cases, Miller also complained that:

●VA officials in Pittsburgh knew of an outbreak of Legionnaires’ disease, “but they kept it secret for more than a year.”

●VA staff in Buffalo potentially exposed patients to hepatitis and HIV by reusing disposable insulin injection pens. “At least 18 veteran patients have tested positive for hepatitis so far.”

●VA workers, patients and family members had “a series of allegations” regarding “poor care” at the Dallas VA Medical Center.

●Employee whistleblowers at the VA medical center in Jackson, Miss., reported “poor sterilization procedures, understaffing and misdiagnoses” to the Office of Special Counsel, an independent federal watchdog.

After the hearing, Petzel said that “when patient safety incidents occur at [the Veterans Health Administration], we are committed to identifying, mitigating, and preventing additional patient safety risks within the VA health-care system.”

In response to problems at individual hospitals, Petzel said new management in Jackson is “making significant improvements;” VA staff discovered the insulin pen problem in Buffalo, and that “triggered a national change in how our system manages the use of insulin pens;” the VA is “extensively monitoring” mental health services in Atlanta, where a new director of the medical center “is committed to restoring trust with the veterans of Atlanta;” and lessons learned in Pittsburgh are being employed “at all VA medical centers throughout the nation.” He reserved comment on the Dallas VA until a task force report is reviewed.

Also under review by the VA’s Central Office is the Presidential Distinguished Rank Award to Michael Moreland, director of a network of VA health facilities in Pennsylvania, West Virginia, Delaware, New Jersey, New York and Ohio.

Miller complained that Moreland accepted the $63,000 award even though the agency’s inspector general reported that the Pittsburgh response to the Legionnaires’ disease outbreak was, in Miller’s words, “plagued by persistent mismanagement.”

Petzel told the committee he would not ask Moreland to return the award money, which reflected work over a “lifetime of service to America’s veterans.”

Moreland, who was sitting next to Petzel, acknowledged “the timing of it [his award] was very bad.”

The hearing wasn’t completely critical of the VA.

Miller said that “the vast majority of the department’s more than 300,000 employees are dedicated and hardworking, and many veterans are satisfied with the medical care they receive from VA.”

But he and others sharply doubted the ability of the department’s leadership to avoid “heartbreaking situations” like those reported to the committee.

“By now,” he said, “it’s abundantly clear to most people that a culture change at VA is in order.”

Twitter: @JoeDavidsonWP

Previous columns by Joe Davidson are available at

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