Part 3: All the VA News that’s Fit to Print?

Poor VA coverage has spanned all the major media outlets, from CNN’s sensationalized television coverage of the Phoenix scandal to USA Today’s attack on VA employee bonuses. The world’s paper of record – The New York Times – is also a prominent example of this flawed reporting on the agency.

A University of Pennsylvania dissertation by Mollie Rubin analyzed the Times’ coverage of veterans’ issues between 2000 and 2010 and found the gray lady frequently missed the mark. In 2005, for example, Times coverage dealt exclusively with political and budget fights over the funding of the VA. “The stories of veterans, the care they were receiving, and the state of the VA were completely absent,” Rubin found.

Occasionally, the Times and other outlets have reported on the VA’s achievements.

In 2006, as veterans began returning home from war in the Middle East, the Times’ coverage improved, according to Rubin’s analysis. “These stories delved into the lives of people going through the experiences of adjusting to civilian life, depending on the VA system for healthcare and disability benefits, and trying to make peace with their experiences of war,” Rubin writes.

This reportage not only spotlighted the VA’s crucial work caring for the wounded; it also revealed the incredible stress the agency faced as thousands of new veterans flooded into the system.

On July 23, 2006, the Times followed then-U.S. Sen. Hillary Clinton to Long Island, New York for a town hall on veterans’ issues. Before a standing-room only crowd, the New York Democrat demanded more federal VA funding, charging that ''we're still not where we need to be to make sure that everybody who returns has access in a timely manner to quality health care.”

One of the attendees at Clinton’s rally was Michael Zacchea, a wounded Iraq veteran. He bluntly told the Times that “the VA is underfunded, which means that veterans are waiting beyond the critical first six months for benefits and critical health care that will help them readjust to living a civilian life.”

Despite reportage highlighting bureaucratic and funding woes at VA facilities across the country, the agency was generally framed in the press as fulfilling its public service mission to veterans before Phoenix. The Times highlighted not only VA scandal, but also success in its pages, including positive coverage on the VA’s establishment of a suicide prevention hotline, the department’s easing of eligibility rules for disability claims, and the increase of agency-backed mortgage loans.

Most importantly, the Times’ coverage in the early aughts sounded the alarm on growing capacity problems that would crystallize more than a decade later in Phoenix.

In 2002, the Times reported that “elderly veterans struggling to cope with rapidly rising drug costs are pouring into the healthcare system of the federal Veterans Affairs Department, so severely straining its resources that in some parts of the country, thousands of them are waiting years to see a VA doctor.”

Since 2014, the Times has written about some of VA’s successes, from its alternative PTSD treatments to its efforts to combat homelessness. But much of the coverage from the Times and other mainstream outlets has been a steady stream of negative news reports about the VHA, mainly quoting sources who referred to the agency as a “troubled health system” with a “corrosive culture” that has lost the “trust” and “confidence” of its patients, and continues to be a “demoralized and dysfunctional agency.”

This slanted coverage leaves out critical information that would add more nuance to the story.  An excellent example is David Phillip’s September 2015 article: “In Unit Stalked by Suicide, Veterans Try to Save One Another.

The article catalogues the myriad ways that the VHA – rather than war itself or the Pentagon –  is responsible for the tragic spate of post-deployment suicides in a Marine battalion that was deployed in the Helmand Province of Afghanistan in 2008.

Although the article does convey the trauma of war and cites experts who explain how difficult it is to engage veterans in mental health therapy, it virtually ignored the VHA’s expansive suicide prevention efforts, including a suicide crisis hotline that has fielded 1.8 million calls and initiated 50,000 rescues since 2007.

(Interestingly the hotline number, which was not included in the print version of the story, is given on the online version under Where to Call For Help. One wonders why anyone who read the piece would bother to dial in.) There was also no acknowledgement of the private health care sector’s failings on suicide prevention, which ironically was highlighted in a front page story on rural suicide that ran in the Times shortly after Phillips’ story appeared.

Phillips’ story argued that, since the VA had failed them, veterans were forced to help one another through peer-to-peer exchange and intervention. Yet it did not mention that the VHA is actually a leader in such peer counseling, training veterans who reach out to and aide fellow veterans.

The story clearly had a significant impact. In one letter to the editor, a clinical social worker, commented, “your article about suicides among veterans of heavy combat should lead to one conclusion: If you are a veteran with post-traumatic stress disorder or other psychological problems, don’t go to the VA. Go to a private facility of practitioner.”

After she read Phillips’ story, Suzanne Gordon immediately sent a letter to the editor commenting on what was left out of the story, which was published the following week. Shortly after Phillips’ piece went live, Gordon spoke with a national VHA leader. The official confided that VA leadership were ‘batting around the idea” of responding to the story. Yet no public rebuttal occurred.

In another front page Sunday Times story from February 2016, Phillips and Steve Eder attacked U.S. Sen. Bernie Sanders in an article titled, “Faith in Agency Clouded Bernie Sanders’ VA Response.”

The piece begins by rehashing the overblown figure that “as many as 40 veterans had died waiting for appointments” before alleging that Sanders was so blinded by his faith in government that he “initially regarded the complaints as overblown.”

The story leaves out that Sanders has long been pushing for comprehensive legislation that would remediate many of the issues that were revealed in Phoenix. In fact, two months before the Phoenix scandal became public, Sanders introduced S.1982, a bill that, if it had been implemented, would have improved accountability, sped up claims processing and expanded veteran health benefits. The Times, however, declared Sanders was “quick to defend the agency and slow to aggressively question V.A. officials and demand accountability.”

More recently, the Times depicted the VA as “one of the largest, most complex and troubled cabinet agencies in the federal government.”

Part 4: What’s Missing from the Picture

When it covers private sector hospitals and other providers, the media presents a far more balanced picture than it does when covering the VA.

When problems in the private sector are revealed in the press, there has been follow-up reporting describing efforts at remediation. Consider, for example, the case of the New York Times and its coverage of the death of Rory Staunton, a 12-year-old boy who died following a faulty diagnosis at New York University’s Langone Medical Center. Years after the paper’s initial report, the Times followed up on the efforts of Langone administrators to solve problems that had led to the young boy’s death. This terrible patient safety story about a confirmed death did not dissuade the Times from covering research and innovations at Langone Medical Center, including the center’s work on face transplantations or its use of hallucinogenic mushrooms to reduce anxiety in cancer patients.

This kind of balanced coverage is missing when it comes to the VA. There have been few reports on reductions in VA wait times or on stemming the use of opioids among veterans. Other VA advances have gone under the radar, including the agency’s work addressing veteran homelessness, innovations in mental health treatment, managing chronic pain without narcotics, or implementing alternative therapies like yoga, meditation and acupuncture. Few, if any, stories highlight VA’s global leadership in telehealth, which brings both mental and physical health treatments to rural veterans who lack access to health care services.

The mainstream media often criticizes the VHA for activities that are routinely applauded when they occur in the private sector. After former Veterans Affairs Secretary Bob McDonald answered a question about patient wait times by comparing the goals of VA administrators to those running Disney World, he was pilloried in Congress and in the press, and forced to apologize.

“The sacrifice that accompanies earning that care is not the same as the sacrifice of taking a road trip to Florida,” a CVA statement declared. “Shame on Bob McDonald for trivializing veteran wait times this way.” American Legion National Commander Dale Barnett lambasted McDonald and House Speaker Paul Ryan called the remark “disgusting” and “beyond the pale.”

Yet what the media ignored is the fact that comparing the Magic Kingdom to the world of healthcare is commonplace in the private sector.  Indeed, for over a decade, the private sector hospital industry has been guided by Fred Lee’s book “If Disney Ran Your Hospital: 9 ½ Things You Would Do Differently,” which encourage hospitals to provide an exceptional “patient experience.” The sustained media outrage over McDonald’s answer on wait times also neglected to acknowledge that wait times in the private sector are comparable, or even worse, than at the VA.  

Political and media critics launched another attack on VHA in 2015 for spending $5.4 million between 2010 and 2016 on art in its facilities. Then House Veterans Affairs Chairman Jeff Miller called the spending “wanton and abusive.” The Washington Post and other papers widely broadcasted the critique. In 2016, Times columnist Gail Collins chided the VHA for spending $670,000 on two sculptures in a blind rehabilitation center, despite the fact VHA’s art spending that year represented 0.00007 percent of the VHA’s annual budget in 2017. These stories ignored the fact that private sector hospitals are constantly lauded for their therapeutic use of art.

The Wall Street Journal, for example, ran a story complimenting private sector hospitals for giving “artwork a higher priority.” One of the hospitals highlighted for its pioneering work in the field was The Cleveland Clinic and its use of the work of the Spanish artist Jaume Plensa, whose works sell for a princely sum.

In some instances, the private sector has even received undue credit for research advances spearheaded by the VA.

In 2016, for example, the PBS News Hour ran a segment on the Crisis Intervention Team and training (CIT) developed by the police force in the city of Memphis after the killing of a mentally ill man in 1988. The program has trained police officers to resist using force when dealing with the mentally ill. Since many of the mentally ill citizens the city must deal with are veterans, the VA has been a partner in developing what’s now known as the Memphis model since its inception. No mention of the VA partnership appeared in the PBS program.

More recently, Time Magazine’s 2018 list of the world’s 100 most influential people hailed Neuroscientist Ann McKee for her work on chronic traumatic encephalopathy (CTE) which plagues football players – and veterans – without identifying her as the Chief Neuropathologist for the National VA ALS Brain Bank.

Part 5: The VA has a Public Relations Problem

Why is the media presenting an inaccurate and unbalanced view of the VA –  one that contrasts dramatically with how journalists cover other healthcare systems? There are several reasons for this inaccurate and unbalanced coverage.

One reason, of course, has to do with the fact that the VHA is a government agency, whose board of directors is essentially Congress. Patients and caregivers who turn whistleblower frequently complain to their Congressional representatives about real or imagined deficiencies in care and these often become publicly addressed and, hopefully, resolved. Some complaints about private hospitals and physicians eventually make it into the media, if they are egregious enough or if healthcare reporters are trying to uncover problems. Medical malpractice and adverse events that take place in the private sector are, however, too often hidden from the public and even academic researchers or public health officials because hospitals are shielded by non-disclosure agreements reached during any legal settlement.

Researchers in Texas conducted a review of settlements at the University of Texas system, which provides malpractice insurance to its six thousand physicians. The report, which was published in JAMA Internal Medicine, found that nine out of ten settlements included non-disclosure provisions.

In an editorial accompanying the news report on the study, Michelle Mello, a professor of law and health policy at Stanford University, and attorney Joseph N. Catalano wrote, “Internal reporting and surveillance of adverse events and internal peer-review and risk-management investigations cannot be effective without a willingness to communicate openly within the organization.” They also noted that “provisions that prevent families from discussing what happened to them greatly undercut the power of their advocacy and impair patient safety efforts.”

The VA is the most transparent and accountable health system in the country, not only because of Congressional scrutiny but because it actually has its own dedicated oversight wing in the Office of the Inspector General. In addition to periodic hospital audits by the IG, the VA also publicly posts wait-time data, salary information, opioid prescription rates and other statistics, as well as reports and surveys grading quality of care and patient satisfaction –  some of which are not measured in the private sector. While this sea of publicly available information has, at times, revealed serious agency screwups and corrupt managers, it also makes it easy for reporters to cherry pick and highlight the agency’s flaws and challenges; ones that exist at private health networks with no reporting requirements.

Another influence on VA coverage is the fact that many of those reporters who cover the VA beat may have little contact with veterans or the VHA healthcare system.

In previous eras, journalists who covered veterans’ issues were often veterans themselves and typically had friends, relatives, and coworkers with military experience. But today’s reporters and editors, especially those working in elite media outlets in deep-blue elite coastal cities, are unlikely to know anyone who has served in the military or uses VA health care. That makes the reporting job harder to do right. A host of military news sites, including Task & Purpose and The War Horse, have largely avoided this problem by employing veterans on staff.

In 2016, a mere 7 percent of U.S. adults were veterans, down from 18 percent in 1980, according to the Census Bureau. Not only has the overall number of American veterans shrunk dramatically, but younger veterans are increasingly isolated geographically and socially from elite opinion makers. (New York’s 7th District, for example, which includes parts of Brooklyn, Queens, and Manhattan, is home to plenty of members of the elite liberal media, but has barely more than 8,000 veterans out of a total population of over 763,000.)

All of this is complicated by the fact that those who tend to cover the VA  which runs that nation’s largest healthcare system – are political and military reporters with very little knowledge of how health systems work. They rarely place problems in VA healthcare in a broader healthcare context nor do they ask a critical question – which is how VA care compares to that in the private sector.  The problem of the VA’s difficulty hiring enough primary care and mental health providers is not, for example, put in the larger context of the kind of shortages of primary care physicians or mental health professionals that plague the broader healthcare system.

This lack of knowledge about healthcare was reflected when USA Today railed against bonuses given to VA administrators.  No comparisons were made with the kind of huge bonuses or salary increases healthcare executives receive in private sector hospitals.  To cite only one example, between 2010 and 2013, the Cleveland Clinic risked suspension from the Medicare program due to serious patient safety violations. Yet the Clinic’s CEO, Delos ‘Toby’ Cosgrove, was given salary increases of hundreds of thousands of dollars during this period without a peep from Congress, nor the media. These increases often equaled two or three times what a director of a large VHA healthcare system earns in a year.

Suicide prevention is another area in which reporters unfamiliar with how to read a scientific study can get things wrong. One reporter who read a report about veterans’ suicide completely misinterpreted the fact that veterans who use the VHA are at higher risk for suicide than those who are not VHA patients. She thought that the VHA caused the problem. Until, that is, it was explained to her that veterans seeking mental healthcare have more mental health problems like PTSD or traumatic brain injuries than veterans who aren’t enrolled in the VA. To say they may kill themselves is like saying that a person who has been hospitalized for heart problems on a cardiology floor is more likely to die of a heart attack than a healthy person walking down the street.

What is even more problematic is the fact that reporters all too often seek bad stories about the VA healthcare system. Joy Ilem, national legislative director of the Disabled American Veterans (DAV), recalls receiving a call from producers at the TBS show Full Frontal with Samantha Bee requesting an interview on the plight of women veterans. “In talking with their producers, they eventually said, ‘Well I guess you’re not going to say anything bad about VA’ and that ended things. I didn’t do the interview.” This was not an isolated incident.

We notice they don’t use the quote or run a more balanced story that provides the proper contextual information.
— Joy Ilem, Disabled American Veterans

“I’ve had a number of reporters who call up about women veterans or other stories and they will call up and start the conversation with we’re looking to do something on X, Y, or Z and can you give some background information,” Ilem continued. “Then when we talk about the issue and try to be fair and balanced acknowledging that yes there may be a problem but, it’s not reflective of the big picture. We notice they don’t use the quote or run a more balanced story that provides the proper contextual information.”

The problems with VA coverage are exacerbated by the vast amount of public relations resources that the private sector has compared to VA. Large medical systems like the Cleveland Clinic, for have dozens of PR professionals on staff and spend millions on advertising.  Private health care advertising spending this year is expected to surpass $10 billion, and a single hospital typically invests more than $1 million in advertising annually, with high-profile hospitals spending substantially more. The St. Jude Children’s Research Hospital, for example, spent $129 million on advertising in 2015, according to an analysis by Kantar Media. The VA, by contrast, didn’t launch its first television ad campaign until 2010. It was aimed chiefly at alerting service members to their eligible benefits, and cost $5 million.

The vast majority VA medical centers have only one or two public affairs officers and minimal advertising budgets. As one VA public affairs officer explained, VA PR staff is responsible for all internal communications.

“We send out at least 500 internal emails a year to build morale, better serve veterans, and encourage employee engagement,” the officer said. On top of this, the staffer added, “we must also support special events, deal with community relations … patient complaints and Congressional letters or visits. We also have no IT support, and have to write and upload as well as manage content for our website.”

Then, of course, there’s managing media relations. Until recently, the VA was prohibited from using appropriated funds for marketing – buying a billboard or purchasing radio ads. Now, the PR professional told us, an office in DC handles this but the approval process is so cumbersome few take advantage of it.

This sense that DC is not supportive of local efforts is something we’ve heard over and over again from PR staff at local medical centers as well as from VHA staff.  PR staff, for example, are only allowed to pitch local stories. Pitching any stories that have national interest, or responding to any inquiries from national media outlets must be vetted or handled by DC.  And, that’s where stories often end up in a media limbo, or simply die. “You have to get permission from a regional office public affairs officer, who then has to send the request to the VA Office of Public Affairs in Washington DC, or to VHA communication.  The two offices may not be in touch with one another.” This cumbersome process, the staffer said, means that deadlines are missed. If it’s a negative story, the response, this staffer says is to duck and cover, not to help explain the issues in a balanced way to reporters. The staffer relates a telling incident:

After Phoenix, some study came out about wait times or something like that.  Public affairs officers throughout the system were told that if they got requests from reporters about the study they should call DC and they would educate us about the study.  When I asked for the study and this education before I got a request, I was told we’ll let you know if you are contacted by a reporter. So they put us in a situation where a reporter will call and I don’t know something and have to explain that fact.  So there’s my credibility gone. They are completely risk averse. You’ve got medical centers with trained public relations professionals who aren’t given the freedom to do their jobs effectively. We’ve got golden handcuffs on.

VA staff – including researchers, medical professionals, and administrators – may also be prohibited from speaking publicly about the good work they and the VHA are doing. Because they feel the process of getting permission to talk to the press will produce a no, rather than a yes, many physicians, psychologists, nurses and other healthcare professionals told us that they don’t even bother asking. Employees who have affiliations with teaching hospitals use their academic credentials when they talk to reporters even though they are full-time VHA employees and the research or innovations about which reporters inquire were done at the VA. This results in press coverage that attributes VHA advances to non-VHA institutions.

As Stephen Trynosky has written, this PR problem began under President Obama. In his monograph “Beyond the Iron Triangle,” Trynosky described the growing insulation at VA central office in which local officials were “not fully empowered due to lack of clear authority, priorities, and goals.” According to Trynosky, the whistle-blowing in Phoenix, in early 2014, exposed “a lack of agility in responding to oversight requests, the absence of proactive engagement to oversight bodies, and inadequate capacity at the VHA leadership level to manage crises.

A veteran himself and VA staffer, Trynosky blames the agency’s Office of Congressional and Legislative Affairs (OCLA) in Washington, DC. Under Obama, Trynosky writes:

[OCLA officials] tightened their control over internal response systems designed for an earlier era characterized by a more collegial and closed sub-government. Processes never designed for a continuous media environment or the congressional politicization of veterans’ health care were rapidly overwhelmed and slowed responses at the very time more agile procedures were needed.

This duck-and-cover response extends to reporters trying to cover VA innovations.  In 2015, Daniel Zwerdling, a well-known health care journalist for National Public Radio, was preparing a story that highlighted the VHA as an industry leader in installing lift equipment to reduce musculoskeletal injuries among bedside nursing staff.  Zwerdling, who wanted to tell a positive story about the VA, was stymied at every turn. “I found terrific local people working at specific hospitals who were anxious and eager to help me because they felt this was so important,” he said. “They couldn’t do it without permission from on high.”

Zwerdling described VA communication officials as “super, duper risk averse and nervous about saying anything substantive. Fortunately, some local people did an end run around the national office.  They said they run the program and decided they could talk about it. It took a lot of effort on my part to get the story and a lot of courage on their part to help me.” The resulting story showed the VA as an industry leader.

Things have only gotten worse under Trump. The VA’s national press secretary, Curt Cashour, is also a longtime agency VA skeptic who served in Congress as the spokesperson for Jeff Miller, the former Republican Chairman of the House Veterans Affairs Committee who pushed drastic new privatization measures following the 2014 Phoenix scandal. While former President Obama’s VA press shop routinely highlighted the agency’s fine doctors, facilities, and innovative programs, Cashour and his team routinely release public statements that highlight poor-performing hospitals and the dismissal of problematic officials.

In June 2017, the VHA was provided an enormous opportunity to showcase its cutting-edge role in healthcare delivery when the Government Printing Office published a book entitled “Best Care Everywhere.” This 440-page compilation of clinical case studies of excellence was coedited by former Veterans Affairs secretary David Shulkin, and chapters by more than 170 of the agency’s most respected researchers and health care practitioners.

As reported in the Washington Monthly, the book had the potential to boost public perception of the agency, revive institutional morale and, in professional circles, help attract a new generation of VHA staff. Instead, “Best Care Everywhere” is one of Washington’s best-kept secrets.

Under Trump, obstructionism with reporters seems to rule, including at VA. When HBO’s VICE News was doing a segment on suicide among veterans, reporter Caroline Modarressy-Tehrani was unable to get much help from national VA communications staff.  

Staffers at the San Francisco VA were able to connect her to some suicide prevention experts, but were stymied when they asked permission to allow VICE to bring a camera crew into the medical center. Requests for interviews and even background conversations with national suicide prevention staff were also greeted with an endless stream of replies summed up as “we’re still working on it.”

In the late 1990s when Kenneth M. Kizer was Under Secretary for Health under President Bill Clinton, the VA responded quickly and effectively to negative reports assertively broadcast the positive.

The VA is its own worst enemy when dealing with the press.
— Kenneth Kizer, Clinton Admin. VA Under Secretary for Health

Kizer, relates, for example, how he dealt with the launch of the VA’s patient safety initiative in 1997. The VHA commissioned a report on preventable medical errors and deaths which found 3000 errors and 700 deaths.  The report was sent to Congress, and Kizer hoped legislators, would act on it. There was total silence. Six months later, The New York Times reporter Robert Pear learned about the report and called Kizer to ask about it.  Kizer was very forthcoming and when Pear asked to see the report – assuming he’d have to file a Freedom of Information Act, to get it, Kizer asked him to come to his home and offered to give him a copy. Kizer says he sat down with the journalist for two hours and walked him through it.  “There was no way this was a good story. But the following Monday, The New York Times ran a very balanced story about the report. Pear noted that similar errors and deaths existed in the private sector. The difference between the private sector and the VA, he said, was that the VA was trying to remedy the problem.”

Over the years, this kind of transparency, Kizer said, has been lost. Under Obama, centralization was the rule. “They were control freaks,” Kizer said. Under Trump, Kizer believes things have gotten even worse. “The VA is its own worst enemy when dealing with the press.  When you have a system as large and complex as the VA, untoward things are going to happen. It’s inevitable. When bad things happen, you have to help journalists understand the issue and the broader context. But you also have to put out the good stories and give people at the local level the freedom to do that. The VA has a good story to tell. Yes, the system has warts, but overall it’s a story that needs to be told.”

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