I first went to a Veterans Health Administration hospital for treatment in 1981, when I was assigned to civilian graduate school in the Boston area and no active-duty option was available. In the words of Ernest Hemingway, it was a "clean, well-lighted place," not fancy but very functional. The medical teams were good at their jobs, and after a painful procedure or two, my problems were resolved. It left a lasting, positive impression of the Department of Veterans Affairs.
Decades later, my daughter required a medical determination after her time on active duty as a Navy nurse. While there was a fair amount of red tape as she moved out of active duty and came under VA auspices, it was again a positive experience overall.
Yet as I look at the future of this vast and critical organization — the largest integrated health-care system in the nation — I would say the seas are choppy ahead, reflecting mistakes and misjudgments that spread across several administrations.
What approach will the Biden administration take in caring for veterans, even as the population expands with the aging baby boomers alongside millennials wounded in the long wars in Iraq and Afghanistan?
Let's start at the tactical level. Over recent years, there have been a number of charges of sexism and racism leveled at the VA. The current secretary and his team have been caught up in an investigation into the possible stifling of complaints by a female veteran. (Disclosure: I know the complainant well as she is Navy reserve officer and was a student at Tufts University's Fletcher School when I was dean.)
Additionally, many Black employees believe there is a culture of racism in the department. And there has been a series of other miscues, such as the initial resistance to remove Nazi headstones from veterans' cemeteries.
Operationally, there are problems as well. Little progress has been made in reversing the high level of veteran suicides — a challenge that cuts across administrations and generations. There are more than 6,000 suicides annually, about 1.5 times the rate for non-veteran adults.
There are reports of insufficient levels of personal protective equipment in many facilities. Cuts at the post office have made it more difficult for many vets, who depend on the mail service, to get prescriptions filled easily.
In addition, the transition to a multibillion-dollar electronic health-care records system — something I worked on in the secretary of the Navy's office almost 20 years — is still plagued with missteps and delays. This is a seemingly "forever issue" for the VA and Defense Department, illustrating the perplexing failure of the two organizations to collaborate as well as they should.
Finally, results are mixed at the strategic level for the VA. A big-picture issue has been getting permission for vets to go outside the VA medical system for treatment. While there has been improvement in terms of allowing veterans to seek some level of care (primary, urgent and mental health) in the private sector when necessary, it is still incomplete. The idea was initiated by President Barack Obama in 2014 and expanded under President Donald Trump in 2018 with the Mission Act — but the department still falls short.
Additionally, it has been understandably stretched thin as a result of COVID-19, putting a number of initiatives on hold. With a shortage of almost 50,000 positions in the VA system (nurses, psychiatrists and psychologists in particular), the department must place a priority on hiring and cutting red tape.
There are 200,000 service members coming out of the military annually, many of whom will face not only health issues (some stemming from the lingering effects of the "forever wars") but also difficulty finding jobs. The combination of those factors can lead to psychological stress and attendant medical conditions. Additionally, the impact of environmental factors like "burn pits" — giant fires to dispose of waste in Iraq and Afghanistan — and going back to Agent Orange and Vietnam will remain a challenge.
The Transition Assistance Program — a joint effort with the Pentagon and half a dozen other agencies to help those leaving the service get medical treatment and employment opportunities — needs a significant overhaul to align with current hiring practices. A final non-health strategic issue is ensuring that GI Bill benefits (tuition, housing, allowances) are easily obtainable and transferable to family members when that makes sense. It is a very full agenda, and complicated by intense scrutiny from Congress and powerful veterans' groups.
The resources for the VA are big, but the new team will have its hands full allocating the $240 billion budget in smart ways. Biden's choice for secretary, Denis McDonough, is neither a vet nor a health-care professional — but having the right team around him is a smart pick. I knew him when he was Obama's deputy national security adviser, a position he held before going on to be the White House chief of staff. He is a smart, tenacious, understated team player who knows Washington inside and out. Significantly, the secretary of Defense for part of that period, Ashton Carter, has strongly endorsed McDonough.
McDonough would be well served by appointing a couple of senior deputies who are veterans (and at least one post-9/11 vet) as well as a medical professional. Coupling such senior folks to McDonough's political savvy and connection to the president would be a powerful combination.
There are challenges at all levels for the VA, and three loom large: Retaining strong bipartisan partnership with Congress; working hand in hand with the "big brother" Department of Defense; and addressing the key needs of veterans in a comprehensive fashion. The vets fought hard for every bit of the help they seek.
Stavridis is a Bloomberg Opinion columnist. He is a retired U.S. Navy admiral and former supreme allied commander of NATO, and dean emeritus of the Fletcher School of Law and Diplomacy at Tufts University. He is also an operating executive consultant at the Carlyle Group and chairs the board of counselors at McLarty Associates.