American Enterprise Institute
August 12, 2014
Newt Gingrich
(Text as prepared for delivery)
I want to thank Arthur Brooks and AEI for giving me this opportunity to propose a very large, bold rethinking of both the health system and the bureaucracy in the context of the Veterans Administration crisis. Callista and I spent over a decade as part of the AEI family and it is always good to be back here discussing ideas.
I also want to thank the CNN Investigative team who stayed on the VA scandals until they broke-through and became a national crisis. Early on, the CNN stories were dismissed as isolated, small problems, but the team’s continued effort grew the facts until they had to be dealt with.
Our thinking on the future of the Veterans Administration has been deeply influenced by the hard work of Chairman Jeff Miller and Senator Richard Burr and their fine committee staffs in the House and Senate. We are much further down the road because of their help. They have worked tirelessly and against a lot of opposition to help America’s veterans have a better future.
Finally I want to thank Ali Meshkin, who has been our chief researcher on the VA and who developed the interactive map you will see in a few minutes. I also want to thank Ross Worthington and Vince Haley at Gingrich Productions for helping think through these proposals. Callista and I owe them a great deal for their talent and hard work.
This is going to be a bold–indeed by Washington standards, a radical–speech.
I am going to use terms that are not common in Washington policy circles.
In order to avoid shocking or disorienting you let me share a few of these key new ideas ahead of time.
Smartphone.
Smartphone apps.
iPad.
Facebook.
Google.
Kahn Academy.
Duolingo.
Words with Friends.
As you can see, this is not your typical Washington policy speech.
Yet you know, in your non-policy life, that these words are now part of everyday life.
Facebook was founded in February 2004. Ten years later it has 1.3 billion monthly users. There is no government subsidy for joining Facebook and no government training program for how to be on Facebook.
Google was founded in September 1998 and has grown into a worldwide index of knowledge with well over a billion searches a day and a host of other capabilities.
Smartphones date commercially to 1994 and today three out of every four Americans owns a smartphone.
You can get a smartphone for free with a service contract or for as little as $50 online.
Many people in the developing world have revealed that they will invest in a smartphone before indoor plumbing.
Take out your smartphone.
You are holding the entry point for a massive information system. Every time you think the proposals in this speech are unrealistic look, at your own smart phone and the apps you already have installed on it.
Which is more representative of our future?
The current failing bureaucracies, or the smart phone in your hand?
WE HAVE THE OPPORTUNITY TO CREATE A 21ST CENTURY VETERANS SERVICE SYSTEM, EMPOWERING VETERANS TO USE THEIR SMARTPHONES TO RE-CENTER SERVICES ON THEIR LIVES, AT THEIR CONVENIENCE AND WITH THE VETERAN RATHER THAN THE BUREAUCRAT IN CONTROL.
This vision of a dramatically more effective, more modern, more responsive veteran-centered system to replace the current failing bureaucratic system is part of a much larger opportunity to think about the transition from late 19th century bureaucracies to 21st century citizen-centered government.
There are three major reasons to have a national dialogue about the future of veterans’ healthcare.
First, we owe it to our veterans to get them the best possible health outcomes with the greatest convenience at the least cost. It isn’t enough to eliminate the worst aspects of the current bureaucratic mess. We have to be able to answer affirmatively the question: is this the best we can do for our veterans? Anything less should be unacceptable. A slightly improved VA bureaucracy clearly fails that test.
Second, the lessons we learn in thinking through a 21st century veterans’ health system will teach us a lot about the characteristics of our future health system for all Americans. The same technologies that will improve veterans’ health will help improve everyone’s health.
Third, replacing this obsolete bureaucracy with a new 21st century system will teach us a lot about how to replace every other bureaucracy. The VA could be the forerunner in a generation of profound transformation in government.
The changes we have seen in information technology are so enormous and historic that the next few decades will be the most creative in rethinking government since the Founding Fathers.
In virtually every field, pioneers of the future are developing new technologies, new science, new solutions, new products, and new ideas. These breakthroughs are occurring in the private sector, in the nonprofit sector and, in some rare instances, in government. They are going to continue and accelerate.
Just as the Founding Fathers had to think through the relationship between organized power (government) and free citizens, so we will have to think through the relationship between organized public effort and the technologies which are revolutionizing our lives.
My recent book, Breakout, outlines the scale of change that is occurring around us and begins to imagine a new 21st century model of government that takes advantage of this emerging world.
Our current federal government is trapped in the late 19th century. Bureaucracy is largely an intellectual pattern developed around 1870, about the same time as the manual typewriter.
They were the clerical requirements of the manual typewriter and carbon paper that led to a Pentagon of enormous scale. Its 17 miles of hallways and 6.6 million square feet were an extraordinary symbol of American power when they were completed 71 years ago. Yet to fulfill clerical and administrative purposes dating back to the 1940s, 31,000 people still work at the Pentagon.
Modern information technology should enable us to turn the Pentagon into a triangle. We should be able to replace at least 40 percent of the clerical effort with modern information technology and modern systems of operating.
This potential for dramatic rethinking exists throughout government.
Every year the speed, convenience, accuracy, quality and affordability we see in most private sector products and services grows.
As a result, with each passing year the gap between the obsolete manual-typewriter bureaucracies we have and the modern, decentralized, citizen-directed government we could have grows too.
The smartphone and the iPad are symbols of this gap between failing bureaucratic systems and the speed, accuracy, and convenience we are experiencing in our private lives.
Consider another: the international network of ATMs. You can go virtually anywhere in the world, find an anonymous machine, insert a plastic card, punch in a four-digit code, and get local currency in less than 11 seconds.
By contrast, it takes 175 days for medical records to move from the Department of Defense to the Veterans Administration.
Virtually no one has a problem with the accuracy of their credit card statements or ATM transactions.
The IRS, on the other hand, sent out $4 billion in bad refunds last year including 343 checks to one house in Shanghai, China.
Medicare and Medicaid have an estimated $70 to $110 billion in fraud every year. Almost every government redistribution program has substantial fraud.
The simple fact is that a manual-typewriter–based bureaucracy that goes home at 5:00 can’t keep up with crooks using iPads and working into the evening and on weekends.
Beyond efficiency and honesty, there is an even more powerful reason to rethink all modern bureaucracies.
The manual typewriter bureaucracy inevitably is focused on the bureaucrat. It is devoted to rules that make the citizen subservient to and dependent upon the bureaucracy.
YET THE 21ST CENTURY, IN CARLY FIORINA’S ELEGANT PHRASE, WILL BE DIGITAL, MOBILE, VIRTUAL, AND PERSONAL.
A government that used digital, mobile, and virtual capability to empower citizens to lead their lives focused on their values and their concerns would be dramatically different from the current federal bureaucracy which increasingly uses its discretionary power as a tool for social control.
Gavin Newsom, the lieutenant governor of California and former mayor of San Francisco, has intriguingly outlined the potential for a citizen-centered, smartphone enabled, 21st century model of government in his book Citizenville.
As Newsom writes, technologies like smartphones and the cloud “‘enable [an] enterprise to organize itself in a distributed fashion, without central power, to deliver and collaborate in ways that you couldn’t before.’ In other words, it gives power to the people, which is the first crucial step in moving away from the top-down, bureaucratic, hierarchical government that’s choking our democracy today. Understanding this concept is central to understanding how the government must change and what it must become.”
WHILE THIS APPROACH APPLIES EVERYWHERE, THE VETERANS ADMINISTRATION IS A PARTICULARLY GOOD STARTING POINT.
The scandals, corruption, dishonesty, and failures in serving our veterans are so deep at the VA that it is especially ripe for a fundamental rethinking that shifts from the manual typewriter to the smartphone and from a system centered on the bureaucrats to a system centered on the veterans.
This process of thinking in 21st century terms requires adopting three key principles:
The problems are systemic and not episodic and models like Deming’s Red Bead Experiment are central to refocusing our thinking and our analysis.
Modern information technology and its ability to empower the citizen and to dramatically improve how we organize public activities is at the heart of how we will rethink government.
Systems thinking and modern information technology can only work if the bureaucratic model of the 1870s is replaced with a new, flexible, adaptive, agile system of continuous improvement, continuous measurement of metrics, continuous learning, and continuous willingness to reward achievement and take steps to eliminate failure and dishonesty.
These three key steps require the Congress to shift from traditional oversight—based on reviewing bureaucratic failure and playing “gotcha” with individuals—to a new model of foresight hearings that focus on breakthroughs in the larger world, models that work, new technologies that empower, and best practices from throughout the world, not merely from the best bureaucracies. (See my paper on 21st century congressional committees and hearings).
APPLYING THESE PRINCIPLES OF BREAKOUT TO RETHINKING THE VETERANS ADMINISTRATION GOES FAR BEYOND THE RECENT REFORM BILL
That bill represents a fascinating balance between the reformers pushing for new solutions and the prison guards of the past protecting their bureaucratic turf no matter how bad its record.
The VA scandal has been big enough that the reformers won a great (although legislatively time-limited) victory of allowing veterans who have to wait longer than 30 days for an appointment to have the choice of any doctor who accepts Medicare.
This step toward choice and competition was probably worth the whole bill but there were a number of other positive reforms. For instance, in one of the most remarkable steps, it permits the secretary to expedite firing of senior officials.
In order to get these reforms the reformers had to agree to open 27 additional clinics and provide $5 billion to hire more people for the VA bureaucracy even though the current productivity is so low that modest improvements in performance would have improved veterans’ health without a larger bureaucracy.
That extra $5 billion was the price of having an avowed socialist who believes in bureaucracy and a government-run health system chair the Veterans Affairs Committee in the Senate.
The bill that President Obama signed into law on Thursday is only a start. Thankfully, there is some bipartisan agreement that the reform effort needs to go much further.
President Obama himself said, “This will not and cannot be the end of our efforts.”
American Legion National Commander Daniel Dillinger said in a statement that “The VA reform package…is an important step in the process to begin repairing systemic problems in the Department of Veterans Affairs. But it is only one step, and only a beginning.”
Sen. Richard Burr of North Carolina, the ranking Republican on the Veteran Affairs’ Committee, agreed that the bill was only the beginning of what it will take to repair a “horrendous blemish on the VA’s reputation.”
House Committee of Veteran Affairs Chairman Jeff Miller said: “It starts a conversation…about the VA for the future. The VA is not sacred. The veteran is.”
Congressman Mike Michaud: “Getting a bill signed into law is only the first step. Now, the real work begins.”
Senator John McCain, the most famous veteran in the Senate said, “This bill is a beginning— not an end— to the efforts that must be taken to address this crisis.”
House Majority Leader Kevin McCarthy may have offered the most forward thinking analysis of any member of Congress when he wrote in a USA Today oped:
A modern VA must accept the modern world and not cling to its old bureaucratic past. It must give veterans the ability to access private care, streamline its system, and remove bad employees who retain their jobs at the expense of our veterans.
“Real reform is possible, but only if we unshackle ourselves from the old idea that more bureaucracy, more government, and more money will solve today’s problems. It’s time to try something new. It’s time to build a 21st Century VA.”
The scale of reforms needed is suggested by this interactive map that Ali Meshkin has developed for Gingrich Productions, which you can find here:
DESPITE ALL THE EVIDENCE, THERE ARE STILL SUPPORTERS OF BUREAUCRATIC BIG GOVERNMENT WHO CONTINUE TO BELIEVE IN THE CURRENT VA.
In 2007 Ezra Klein stated that “the VA’s lead in care quality isn’t disputed.”
In 2011 Paul Krugman promoted the VA as a model to be “emulated by the rest of our health care system.”
Even after all the recent revelations the true believers stayed firm.
Krugman wrote in a recent New York Times Op-Ed, “It’s still true that Veterans Affairs provides excellent care, at low cost.”
Senator Bernie Sanders maintained in the wake of the recent scandals: “I’m Chairman of the Veterans Committee, let me tell you some news, the veterans Administration provides very high quality health care.”
Before we propose a bold new 21st century veterans service system, let’s examine those claims.
IT IS IMPORTANT TO UNDERSTAND HOW BADLY BROKEN AND HOW DEEPLY CORRUPT THE CURRENT VA BUREAUCRACY IS.
The current public outcry started when we learned that at least 40 veterans died on a secret wait list in Phoenix. But that was only the beginning.
Back in February, we learned that VA employees in Los Angeles destroyed veterans’ medical records to hide their backlog.
It soon became clear the corruption of the appointment system was pervasive.
The preliminary June 2014 audit found what investigators called “a systemic lack of integrity” throughout the VHA health care system.
The final audit confirmed corrupt scheduling practices across the Department (at 70 percent of VA medical facilities surveyed) finding that 57,000 veterans had been waiting more three months for an appointment.
But the scheduling practices and the appointment backlog are only the beginning.
It takes 175 days to transfer a veteran’s medical records from the Defense Department to the VA.
The VA and Defense Department have spent $1.3 billion over the past four years attempting to build a joint system for electronic health records before announcing in February that they were giving up.
As of February, there were 400,000 disability claims considered “backlogged”–they’d been in processing for more than 125 days.
An IG report that found that an electronic record system developed at the VA to help manage this problem had cost $500 million was crippled by poor planning, design, and implementation.
The care is often alarmingly bad.
In Albany, a VA employee injected dying veterans with water instead of morphine in order to steal the drugs. There are lots of instances of narcotics theft, although this is one of the most disturbing.
In Mississippi and elsewhere, patients were prescribed narcotics without seeing a doctor
Waiting times at VA emergency rooms are twice the national average.
Senator Tom Coburn’s office produced a report that found “the VA has spent over $200 million in the last ten years in an attempt to compensate victims for its mistakes. More than 1,000 veterans needlessly died under the VA’s watch, and the Department in turn paid these veterans’ families $200 million in wrongful death settlements – the median payment per victim was $150,000. Most families of the victims agreed it was not about the money; they just wanted the VA to be held accountable for its action.”
But the system serves the bureaucrats perfectly.
Between 2006 and 2013, the number of full-time employees jumped more than 40 percent, from 220,000 to 314,000. The VA’s budget is up even more—90%–over the same period.
Yet with 94,000 additional government employees and almost twice as much money, the Left still believes the problem is that the VA is under-funded.
The VA workforce is larger than the Marine Corps. More than 314,000 work full time for the VA compared to 202,000 in the Marine Corps (potentially shrinking to 150,000–at which point there would be half as many Marines as VA bureaucrats).
Despite the widespread incompetence and corruption, VA leadership has seen fit to reward the vast majority of senior officials with performance bonuses. Last year, 78% of VA senior managers received these bonuses when they got performance ratings of “outstanding” or “exceeds fully successful.”
470 of them got ratings of “fully successful” or better.” So despite the disaster they’re overseeing, all of the VA’s top 470 employees are performing wonderfully.
In some cases, these bonuses were outrageously unwarranted. The former director of the VA medical center in Atlanta was paid $65,000 in bonuses over four years even though the VA’s inspector general blamed several preventable deaths on “widespread mismanagement” there, according to the House Committee On Veterans’ Affairs.
The senior executives aren’t the only people with nice VA jobs.
The Coburn report found that “As of February 2013, there were 277 VA employees performing as union representatives on 100 percent official time. In 2011, the VA spent $42.6 million in costs related to maintaining official time employees.”
“An average private-sector primary care physician,” the Coburn report finds, “has an average caseload…of 2,300. Yet, the VA targets…1,200 for its physicians.”
Unlike private sector hospitals which have intensive use of operating rooms, some VA facilities are closing by 3 pm.
Getting to the truth about VA misbehavior has been unnecessarily hard. VA bureaucrats have routinely lied to Congress.
The Department mislead Congress about the number of deaths in its gastrointestinal department, claiming its findings were based on a “system-wide review” since 1999, when in fact the numbers were based on a handful of cases from a two year period.
Congressman Patrick Meehan has said that VA officials “looked me in the eye and lied to me” about falsifying records.
He continued: “At every turn, the VA has thwarted any attempt of honest, effective oversight. The basis of any relationship is trust, but the misrepresentations made by the VA in Philadelphia have demonstrated a culture of cover-up and deceit.”
Similarly, A VA director in Alabama assured Congresswoman Martha Roby that employees who falsified records there were fired. “I have now learned that wasn’t true,” she says. “No one has been fired.”
Much as its culture results in bureaucrats who mislead Congress to cover up the Department’s failures, the VA routinely silences whistleblowers.
The New York Times reports that “Staff members at dozens of Department of Veterans Affairs hospitals across the country have objected for years to falsified patient appointment schedules and other improper practices, only to be rebuffed, disciplined or even fired after speaking up…”
The Times continues: “The federal Office of Special Counsel, which investigates whistle-blower complaints, is examining 37 claims of retaliation by V.A. employees in 19 states.”
The article tells the story of Dr. Ram Chaturvedi, formerly a doctor with the VA medical center in Dallas. He “began complaining in 2008 about shoddy patient care, including negligence by nurses who had marked the wrong kidney while preparing a patient for a procedure. In another instance, Dr. Chaturvedi said medical personnel had brought the wrong patient to an operating table.
A supervisor told Dr. Chaturvedi to ‘let some things slide’ because of staffing problems, but he continued writing up complaints. Officials considered him disruptive and fired him in 2010.”
The VA’s own internal watchdog, the Office of the Medical Inspector, routinely minimized whistleblower allegations by claiming the behavior whistleblowers alleged had no effect on care, according to a review by the U.S. Office of Special Counsel.
THE CLEAR FAILURE OF THE CURRENT VA SYSTEM
This litany of deaths, mistreatment, criminal violations, dishonesty, lying to Congress and failing to treat our veterans with dignity and honor should convince any reasonable person that there is something deeply and profoundly wrong about the systems at the VA and the culture that has grown up there.
Nothing in the current reform bill will get at the underlying systemic corruption and the network of bureaucrats who protect each other and punish those who would blow the whistle on bad behavior.
Remember, in the reform bill only the top 400 of the 314,000 people who work at the VA are affected by the expedited firing procedures and some defenders of the old order in Congress have expressed worries about expedited procedures for about one tenth of one per cent of the VA workforce.
There are six different unions at the VA. There are at least four master union contracts, each hundreds of pages long, and there are hundreds of local union contracts—these include things like the hundreds of full time union employees at taxpayer expense.
All of these remain undisturbed even though they’re an enormous barrier to reform. If we are serious, all of them should be suspended just as contracts would be suspended in a private sector bankruptcy.
Let’s be honest. All of us have seen reformed bureaucracy after reformed bureaucracy with virtually nothing changing.
Bureaucracies have deep patterns of self-defense and self-preservation. To ask the people who were deeply engaged in the destructive, sometimes corrupt, often dishonest, and occasionally illegal activities outlined above to suddenly change and adopt a new work ethic, a new commitment to transparent accountability and a new enthusiasm for whistle blowers is simply asking for failure.
The scale of change we need to ensure our veterans get the best possible care is vastly greater than the recent reforms and far beyond the comfort zone of the traditional political system, which would be happy getting a few scapegoats, declaring victory and moving on until the next scandal forces new attention to the VA.
What we need are two missing components: imagination and a spirit of replacement rather than reform.
First to imagination.
IMAGINING A 21st CENTURY VETERANS SERVICE SYSTEM
The greatest failure in Washington isn’t lack of money. It isn’t lack of power. It isn’t too much partisanship. The greatest failure in Washington is a lack of imagination.
Washington is so absorbed in its own petty gossip, its own daily activities, its own definition of “practical” and “realistic” that it is very hard for Washington insiders to relax and let their imaginations develop the possibilities that are all around them.
There is a simple fact that can open up everything to the imagination.
Everything which currently exists in government was imagined by a president, a congress and a court.
Our generation has as much responsibility, and as great a right, to develop a new generation of solutions as did any generation before it.
I want to focus on one technological breakthrough to illustrate how dramatically imagination based on practical reality can open up the entire system to new thinking and new possibilities.
The smartphone is an empowering breakthrough that exists all around us and yet has not even begun to be integrated into public policy solutions.
SMARTPHONES AS EMPOWERMENT DEVICES
The first and most important question here is “what—and who—is at the center of decision and activity?”
We have grown up in a bureaucratic world built around clerical processes and the manual typewriter. The bureaucrat is at the center of things. The bureaucratic procedures define what happens. The bureaucrat’s hours, the bureaucrat’s location, the bureaucrat’s vacations, etc. all define the relationship.
In this world, the amount of power the citizens have over the bureaucrats is remarkably small. The amount of power the bureaucrats have over the citizens is remarkably large.
Too often, “We the People” has become “We the Bureaucrats.”
This bureaucratically-defined, bureaucrat-centered system extends far beyond the Veterans Administration. It was in the Pentagon that presidential appointees were referred to as “the summer help”. They were only in office for a brief period and a wise bureaucrat could simply out wait them.
The sincerity and enthusiasm of the new Secretary of Veterans Affairs will presently run up against bureaucratic rules, hopelessly (and intentionally) complex procurement policies—especially in information technology which is the biggest need—an unwieldy union contract, and a culture of polite applause with minimal change that has outlasted every president and every secretary.
It isn’t that Secretary Shinseki was incompetent. He was immersed in a system which simply ignored management and after polite applause for enthusiastic speeches went back to bureaucracy as usual.
The smartphone shatters this bureaucratic dominance because it shifts the location of power to the citizen. That is the potential implied in Newsom’s Citizenville and in Steve Goldsmith’s and Susan Crawford’s new book The Responsive City.
Consider the potential reorganizing and empowering capabilities of the smart phone.
If every veteran had a smartphone (and today three out of every four Americans have a smart phone) they would be empowered to gather information and interface with health systems 24 hours a day seven days a week.
Imagine further that the VA adopted Carly Fiorina’s model of the 21st century as digital, mobile, virtual, and personal.
The smartphone, electronic records in the cloud, and automated, instantaneous decision-making would become a new center of gravity which would replace the bureaucratic model with a veteran centric model.
Consider a VA app for the smart phone which enabled the veteran to schedule his or her own appointments. You know how this works in your own life.
Think of your OpenTable app for restaurant reservations. You tell it what type of food you want, how fancy of a restaurant, what neighborhood. You get a list of options with reviews and available tables. You tap “reserve.” You get an email confirming your reservation. The restaurant’s computer system blocks off your table so no one else can take it. Your phone reminds you when it is time to leave. You show up. There’s no question about whether you made the reservation. There’s no secret list. This company has been around since 1998.
ZocDoc is OpenTable for doctors. You open the app. You tell it what insurance you have. You tell it what type of specialist you need. It gives you 27 doctors in your area. You compare their ratings. Your read their reviews. You choose a doctor. You choose one of the open times on their schedule. You tap “reserve.” You get an email confirming your appointment. They get an email with all your paperwork and insurance information filled out. You show up. They’re ready for you. It’s free to the patient. There’s no Inspector General to investigate why you didn’t get an appointment.
Average wait time for care is less than 24 hours. Because doctors have up to 25% last minute capacity from patients who have cancelled or rescheduled. 15-18% of patients would otherwise be going to an emergency room.
ZocDoc was founded in 2007. It is now serving 5 million patients a month (about as many as the VA). They have 400 employees total. (The VA employs 1,000 programmers.) ZocDoc covers more than 40 specialties. 1,000 types of procedures. They are in 48 states by the end of this year. A market cap of $1.4 billion.
If ZocDoc went to the VA and offered to help with their scheduling software, which they know how to integrate with lots of big insurance companies that have very complex, byzantine systems as the result of mergers and acquisitions–the VA would tell them about the 17 self-imposed requirements to prevent us from using their software, including the requirement that it be open source, which means the software has to be custom built from scratch for the VA.
One Medical is a doctors’ office right here in DC. They have an app. You can book appointments through the app. But more importantly, you can communicate with your doctor—for instance, sending pictures of a rash. They can ask you a few questions and immediately send an electronic prescription to CVS to take care of it. You don’t need to take an hour out of your day to go in, and they don’t take time away from seeing other patients.
Imagine if a 21st century VA that had this capability. Doctors could see dramatically more patients in a day.
Imagine that the veteran’s smartphone had a prescription app, too, so that every doctor could see every drug prescribed for this veteran by every other doctor.
Sometimes you need to go to the doctors office so they can take your vitals. Wello is a smartphone case that is available for pre-order today. It takes your temperature, your blood pressure, your heart rate, your ECG, and your lung function in a couple of seconds. It costs $199.
Imagine if, instead of going to the VA medical center, every veteran could send this information to their doctor right from his or her smartphone.
As a side note, AEI’s Scott Gottlieb had a great op-ed in the Wall Street Journal last week talking about how the FDA is asserting that adding these functions will subject the entire smartphone to regulation as a medical app. It’s been reported that Apple, Samsung, and Google have run into roadblocks at the FDA trying to bring these products to market.
Another example: Theranos is a company in California that has automated the 1,000 most common medical lab tests, all of which they can perform using just a few drops of blood. The service will be rolling out in Walgreens pharmacies. You will walk in, give a few drops of blood, and have the results emailed to your smartphone by the time you walk out the door. Theranos has committed to charging 50% of the Medicare reimbursement rate or less.
Imagine if, instead of waiting months for such tests at a VA medical center, veterans could go to their local pharmacy and have the results on their smartphone this afternoon—all at cheaper cost.
There are enormous challenges with veterans and mental health.
Imagine if, instead of waiting for problems to develop, support started immediately with outreach to veterans over their smartphones. Learning apps similar to Khan Academy and Duolingo could help walk veterans through the process of transitioning back to civilian life.
Imagine if online support networks using technology similar to Facebook or Google Hangouts could help veterans form a community, to talk to each other about their shared experiences, and help identify veterans who may need a higher level of support—all at very little cost, and before further challenges, like homelessness for instance, begin to compound.
Imagine that these systems—the scheduling applications, to doctors visits, the prescription functions—were automatically auditable….that they informed both the veteran and higher levels of the VA of problems in a timely way.
All of this is very different from Secretary McDonald’s commitment that “the Department will need to continue to expand the use of digital technology to free human resources that can be applied to the care of veterans.”
One of the key tests of rethinking the Veterans Administration is whether the primary focus should be internally on improving and strengthening the bureaucracy or externally on empowering and strengthening the veterans.
In his keynote address to the Disabled American Veterans, Secretary McDonald described the traditional philosophy perfectly:
“At VA, we are going to judge the success of our individual and collective efforts against a single metric—customer outcomes, Veterans’ outcomes. VA’s own Strategic Plan makes clear, ‘VA is a customer-service organization. We serve Veterans’….If we fail at serving Veterans, we fail. We have a lot of work to do”
There is a huge jump between serving veterans and empowering veterans. In serving veterans the bureaucracy remains at the center of activity. In empowering veterans the veterans become the center of activity.
As a new cabinet officer, Secretary McDonald doesn’t yet understand how big his imagination must become to be successful.
He states, “We are updating the antiquated appointment scheduling system beginning with near-term enhancements to the existing system, leading to acquisition of a comprehensive, state-of-the-art, ‘commercial, off-the-shelf’ scheduling system. I believe the Department will need to continue to expand the use of digital technology to free human resources that can be applied to the care of veterans.”
The real challenges Secretary McDonald will face are much larger and more complex than he can imagine. Nothing in his business career prepared him for the regulatory, legal and bureaucratic barriers which make progress in Washington so difficult and so slow.
REPLACEMENT NOT REFORM AS THE GOAL
In order to take advantage of modern information technologies and empower veterans through the smartphones in their hands, we have to do more than marginally reform obsolete bureaucracies.
We have to think through the principles of organizing human activity in a world of ubiquitous real time mobile computing and information available 24/7 and personalized to each individual, connected to the vast computing power and data storage of a worldwide network.
Every process of the current bureaucracies works to prevent this from happening. For example, one of the most successful medical scheduling company in America offered to provide its proven technology for real time doctor-patient scheduling to the VA and was told that federal law and self-imposed regulations made it impossible.
What is true of VA information technology acquisition is true across the entire federal government.
President Obama outlined the information technology modernization problem last year in explaining the gap between the brilliance of his two campaigns in using information technology and the failure of the Obamacare website:
“What is true is that…our IT systems, how we purchase technology in the federal government, is cumbersome, complicated and outdated. And so this isn’t a situation where — on my campaign, I could simply say, who are the best folks out there, let’s get them around a table, let’s figure out what we’re doing and we’re just going to continue to improve it and refine it and work on our goals.
“If you’re doing it at the federal government level…you’re going through, you know, 40 pages of specs and this and that and the other and there’s all kinds of law involved. And it makes it more difficult — it’s part of the reason why chronically federal IT programs are overbudget, behind schedule.”
Sadly the President didn’t leap from this absolutely correct analysis to propose that Congress profoundly overhaul the information technology procurement laws.
Google founder Sergey Brin noted the same artificial challenges in health as President Obama described in his Healthcare.gov comments.
Brin said: “Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that think it would dissuade a lot of entrepreneurs.”
Secretary McDonald will soon learn why the Defense Department and the Veterans Administration announced in February that they were abandoning a multi-year $1.3 billion joint information technology project.
Entire sections of law, involving information technology, procurement in general, employment rules, bureaucratic personnel rules, and other areas that will emerge have to be replaced and not merely reformed.
Only when Congress steps up to the plate and begins to rethink the entire structure of federal bureaucracy will we be in a position to start using our imagination to develop the replacement system which is necessary if we are truly going to help our veterans.
FIRST STEPS TOWARD A 21ST CENTURY VETERANS SERVICE SYSTEM
Ideally, President Obama would recognize that the overwhelming bipartisan vote for the VA reform bill and the speed and unanimity with which his new Secretary of Veterans Affairs was confirmed indicated that there is a rare zone of bipartisan opportunity to develop a better system for veterans.
If he would reach out to the Congressional Republicans and pursue new thinking for the VA in a bipartisan manner he could have an enormous positive impact.
The new Congress in January 2015 should launch a series of visionary hearings bringing in the new technologies and new capabilities and exploring how to move from a bureaucratically-centered system to a veterans-empowered system.
Secretary McDonald has an opportunity to outline visionary changes to improve the lives of our veterans. Because the cause of America’s veterans is such a patriotic and compelling cause, the Secretary will find pioneering leaders in every field willing to work with him, the White House and the Congress to develop a new 21st century model.
Finally each of us can tweet, Facebook, even in the old-fashioned way talk with folks about the new potential, the new opportunity and the new obligation we have to bring the best to our veterans by empowering them with all the new tools of the 21st century.