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VHA Facilities Report Severe Staffing Shortages
VHA Facilities Report Severe Staffing Shortages
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
VHA Facilities Report Severe Staffing Shortages
VHA Facilities Report Severe Staffing Shortages
VA Workforce Shrinking as it Loses Collective Bargaining Rights
VA Workforce Shrinking as it Loses Collective Bargaining Rights
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
VA Workforce Shrinking as it Loses Collective Bargaining Rights
VA Workforce Shrinking as it Loses Collective Bargaining Rights
AVAHO Encourages Members to Make Voices Heard
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
VA Choice Bill Defeated in the House
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
Indian Health Service: Business as Usual During Shutdown
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.
Physicians Face Medicare Telehealth Woes Amid Federal Government Shutdown
Physicians Face Medicare Telehealth Woes Amid Federal Government Shutdown
The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.
That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.
This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.
For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.
Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.
But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.
Clinicians, Patients Already Feeling Effects
For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.
Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.
"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."
Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.
Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.
NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.
"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."
Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.
Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.
Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.
"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.
"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."
Will Telehealth Reimbursement See a Permanent Fix?
With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.
Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.
When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.
A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.
Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.
"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."
Victoria Knight is a freelance reporter based in Washington, DC.
A version of this article first appeared on Medscape.com.
The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.
That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.
This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.
For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.
Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.
But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.
Clinicians, Patients Already Feeling Effects
For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.
Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.
"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."
Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.
Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.
NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.
"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."
Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.
Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.
Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.
"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.
"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."
Will Telehealth Reimbursement See a Permanent Fix?
With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.
Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.
When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.
A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.
Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.
"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."
Victoria Knight is a freelance reporter based in Washington, DC.
A version of this article first appeared on Medscape.com.
The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.
That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.
This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.
For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.
Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.
But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.
Clinicians, Patients Already Feeling Effects
For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.
Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.
"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."
Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.
Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.
NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.
"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."
Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.
Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.
Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.
"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.
"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."
Will Telehealth Reimbursement See a Permanent Fix?
With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.
Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.
When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.
A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.
Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.
"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."
Victoria Knight is a freelance reporter based in Washington, DC.
A version of this article first appeared on Medscape.com.
Physicians Face Medicare Telehealth Woes Amid Federal Government Shutdown
Physicians Face Medicare Telehealth Woes Amid Federal Government Shutdown
Architect of VA Transformation Urges Innovation Amid Uncertainty
Architect of VA Transformation Urges Innovation Amid Uncertainty
PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.
At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system.
He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.
“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.
From “Bloated Bureaucracy’ to High-Quality Health Care System
Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation.
“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”
The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.
Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said.
Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.
“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”
Revolutionary Changes Despite Opposition
Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.
One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”
The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.
To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”
Innovation From the Ground Up
Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.
The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”
The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”
This experience reinforced his belief in harvesting ideas from staff at all levels.
Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said.
Inside the Recipe for Innovation
Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture.
He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.
In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.
Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”
The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”
Kizer highlighted 2 opposing strategies to handling challenging times.
According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?”
In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”
Kizer made it crystal clear which option he prefers.
Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.
PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.
At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system.
He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.
“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.
From “Bloated Bureaucracy’ to High-Quality Health Care System
Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation.
“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”
The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.
Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said.
Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.
“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”
Revolutionary Changes Despite Opposition
Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.
One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”
The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.
To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”
Innovation From the Ground Up
Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.
The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”
The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”
This experience reinforced his belief in harvesting ideas from staff at all levels.
Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said.
Inside the Recipe for Innovation
Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture.
He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.
In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.
Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”
The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”
Kizer highlighted 2 opposing strategies to handling challenging times.
According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?”
In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”
Kizer made it crystal clear which option he prefers.
Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.
PHOENIX – Three decades after he initiated the transformation of the Veterans Health Administration (VHA) into a model research and clinical health care system, former US Department of Veterans Affairs (VA) Under Secretary of Health Kenneth W. Kizer, MD, MPH, urged cancer specialists to embrace this challenging moment as an opportunity for bold innovation.
At the annual meeting of the Association of VA Hematology/Oncology (AVAHO), Kizer acknowledged that the VA faces an “uncertain and turbulent time” in areas such as funding, staffing, community care implementation, and the rollout of a new electronic health record system.
He also noted the grim rise of global instability, economic turmoil, climate change, infectious diseases, political violence, and mass shootings.
“This can be stressful. It can create negative energy. But this uncertainty can also be liberating, and it can prompt positive energy and innovation, depending on choices that we make,” said Kizer, who also has served as California’s top health official prior to leading the VHA from 1994 to 1999.
From “Bloated Bureaucracy’ to High-Quality Health Care System
Kizer has been credited with revitalizing VHA care through a greater commitment to quality, and harkened to his work with the VA as an example of how bold goals can lead to bold innovation.
“What were the perceptions of VA health care in 1994? Well, they weren’t very good, frankly,” Kizer recalled. He described the VA as having a reputation at that time as “highly dysfunctional” with “a very bloated and entrenched bureaucracy.” As for quality of care, it “wasn’t viewed as very good.”
The system’s problems were so severe that patients would park motorhomes in VA medical center parking lots as they waited for care. “While they might have an appointment for one day, they may not be seen for 3 or 4 or 5 days. So they would stay in their motorhome until they finally got into their clinic appointment,” Kizer said.
Overall, “the public viewed the VA as this bleak backwater of incompetence and difference and inefficiency, and there were very strong calls to privatize the VA,” Kizer said.
Kizer asked colleagues about what he should do after he was asked to take the under secretary job. “With one exception, they all said, don’t go near it. Don’t touch it. Walk away. That it’s impossible to change the organization.
“I looked at the VA and I saw an opportunity. When I told [members of the President Bill] Clinton [Administration] yes, my bold aim was that I would like to pursue this was to make VHA a model of excellent health care, an exemplary health care system. Most everyone else thought that I was totally delusional, but sometimes it’s good to be delusional.”
Revolutionary Changes Despite Opposition
Kizer sought reforms in 5 major strategic objectives, all without explicit congressional approval: creating an accountable management structure, decentralizing decision-making, integrating care, implementing universal primary care, and pursuing eligibility reform to create the current 8-tier VA system.
One major innovation was the implementation of community-based outpatient clinics (CBOCs): “Those were strongly opposed initially,” Kizer said. “Everyone, the veteran community in particular, had been led to believe that the only good care was in the hospital.”
The resistance was substantial. “There was a lot of opposition when we said we’re going to move out into the community where you live to make [care] easier to access,” Kizer said.
To make things more difficult, Congress wouldn’t fund the project: “For the first 3 years, every CBOC had to be funded by redirected savings from other things that we could do within the system,” he said. “All of this was through redirected savings and finding ways to save and reinvest.”
Innovation From the Ground Up
Kizer emphasized that many breakthrough innovations came from frontline staff rather than executive mandates. He cited the example of Barcode Medication Administration, which originated from a nurse in Topeka, Kan.
The nurse saw a barcode scanner put to work at a rental car company where it was used to check cars in and out. She wondered, “Why can’t we do this with medications when they’re given on the floor? We followed up on it, pursued those things, tested it out, it worked.”
The results were dramatic. “I was told at a meeting that they had achieved close to 80% reduction in medication errors,” Kizer said. After verifying the results personally, he “authorized $20 million, and we moved forward with it systemwide.”
This experience reinforced his belief in harvesting ideas from staff at all levels.
Innovation remains part of the VA’s culture “despite what some people would have you believe,” Kizer said. Recently, the VA has made major advances in areas such as patient transportation and the climate crisis, he said.
Inside the Recipe for Innovation
Boldness, persistence, adaptability, and tolerance for risk are necessary ingredients for high-risk goals, Kizer said. Ambition is also part of the picture.
He highlighted examples such as the Apollo moon landing, the first sub-4-minute mile, and the first swim across the English Channel by a woman.
In medicine, Kizer pointed to a national patient safety campaign that saved an estimated 122,000 lives. He also mentioned recent progress in organ transplantation such as recommendations from the National Academies of Sciences, Engineering, and Medicine to establish national performance goals and the Organ Procurement and Transplantation Network’s target of 60,000 deceased donor transplants by 2026.
Bold doesn’t mean being reckless or careless, Kizer said. “But it does require innovation. And it does require that you try some new things, some of which aren’t going to work out.”
The key mindset, he explained, is to “embrace the unknown” because “you often really don’t know how you will accomplish the aim when you start. But you’ll figure it out as you go.”
Kizer highlighted 2 opposing strategies to handling challenging times.
According to him, the “negative energy” approach focuses on frustrations, limitations, and asking “Why is this happening to me?”
In contrast, a “positive energy” approach expects problems, focuses on available resources and capabilities, and asks, “What are the opportunities that these changes are creating for me?”
Kizer made it crystal clear which option he prefers.
Dr. Kizer disclosed that his comments represent his opinions only, and he noted his ongoing connections to the VA.
Architect of VA Transformation Urges Innovation Amid Uncertainty
Architect of VA Transformation Urges Innovation Amid Uncertainty
VHA Workforce Continues to Contract as Fiscal Year Ends
The size of the Veterans Health Administration (VHA) workforce continues to contract according to the latest data released by the US Department of Veterans Affairs (VA). Applications for employment are down 44% in fiscal year (FY) 2025 with just 14,485 cumulative new hires and 28,969 losses. In 2024, the VHA had 416,667 workers—it now has 401,224.
The reductions align with VA Secretary Doug Collins’ goal of downsizing the VA’s workforce by 30,000 employees by the end of 2025. In August, Collins outlined how a federal hiring freeze, deferred resignations, retirements, and normal attrition have eliminated the need for the "large-scale" reduction-in-force he proposed earlier this year.
Compared with July’s numbers, the VHA now employs 139 fewer medical officers/physicians, 418 fewer registered nurses, 107 fewer social workers, and 65 fewer psychologists. Staffing of licensed practical nurses, medical support assistants, and nursing assistants is also down (reduced by 77, 129, and 29, respectively).
Retention rates for the first 2 years of onboarding hover around 80% for physicians and nurses. However, retention incentives have dropped from 19,484 to 8982 and recruitment incentives from 6069 to 1299.
In voluntary exit surveys, 78% of 6762 medical and dental staff who left said they would work again for the VA, while 79% said they would recommend the VA as an employer. These rates are down from a similar survey in May 2023 when 81% noted that they would work again for the VA and 82% would recommend the VA to others. Personal matters, geographic relocation, and poor working relationships with supervisors or colleagues were among the reasons cited for leaving in August 2025.
Of 435 psychologists, 69% said they would work again for the VA, and 62% said they would recommend the VA as an employer (71% and 67%, respectively in May 2023). Their reasons for leaving in August 2025 included a lack of trust in senior leaders and policy or technology barriers to getting the work done.
An August survey from the Office of the Inspector General found that VHA facilities reported 4434 staffing shortages this fiscal year—a 50% increase from fiscal year 2024. Most (94%) of the 139 facilities reported severe shortages for medical officers, and 79% of facilities reported severe shortages for nurses. Due to the timing of the questionnaire, the responses did not yet reflect the full impact from workforce reshaping efforts.
The size of the Veterans Health Administration (VHA) workforce continues to contract according to the latest data released by the US Department of Veterans Affairs (VA). Applications for employment are down 44% in fiscal year (FY) 2025 with just 14,485 cumulative new hires and 28,969 losses. In 2024, the VHA had 416,667 workers—it now has 401,224.
The reductions align with VA Secretary Doug Collins’ goal of downsizing the VA’s workforce by 30,000 employees by the end of 2025. In August, Collins outlined how a federal hiring freeze, deferred resignations, retirements, and normal attrition have eliminated the need for the "large-scale" reduction-in-force he proposed earlier this year.
Compared with July’s numbers, the VHA now employs 139 fewer medical officers/physicians, 418 fewer registered nurses, 107 fewer social workers, and 65 fewer psychologists. Staffing of licensed practical nurses, medical support assistants, and nursing assistants is also down (reduced by 77, 129, and 29, respectively).
Retention rates for the first 2 years of onboarding hover around 80% for physicians and nurses. However, retention incentives have dropped from 19,484 to 8982 and recruitment incentives from 6069 to 1299.
In voluntary exit surveys, 78% of 6762 medical and dental staff who left said they would work again for the VA, while 79% said they would recommend the VA as an employer. These rates are down from a similar survey in May 2023 when 81% noted that they would work again for the VA and 82% would recommend the VA to others. Personal matters, geographic relocation, and poor working relationships with supervisors or colleagues were among the reasons cited for leaving in August 2025.
Of 435 psychologists, 69% said they would work again for the VA, and 62% said they would recommend the VA as an employer (71% and 67%, respectively in May 2023). Their reasons for leaving in August 2025 included a lack of trust in senior leaders and policy or technology barriers to getting the work done.
An August survey from the Office of the Inspector General found that VHA facilities reported 4434 staffing shortages this fiscal year—a 50% increase from fiscal year 2024. Most (94%) of the 139 facilities reported severe shortages for medical officers, and 79% of facilities reported severe shortages for nurses. Due to the timing of the questionnaire, the responses did not yet reflect the full impact from workforce reshaping efforts.
The size of the Veterans Health Administration (VHA) workforce continues to contract according to the latest data released by the US Department of Veterans Affairs (VA). Applications for employment are down 44% in fiscal year (FY) 2025 with just 14,485 cumulative new hires and 28,969 losses. In 2024, the VHA had 416,667 workers—it now has 401,224.
The reductions align with VA Secretary Doug Collins’ goal of downsizing the VA’s workforce by 30,000 employees by the end of 2025. In August, Collins outlined how a federal hiring freeze, deferred resignations, retirements, and normal attrition have eliminated the need for the "large-scale" reduction-in-force he proposed earlier this year.
Compared with July’s numbers, the VHA now employs 139 fewer medical officers/physicians, 418 fewer registered nurses, 107 fewer social workers, and 65 fewer psychologists. Staffing of licensed practical nurses, medical support assistants, and nursing assistants is also down (reduced by 77, 129, and 29, respectively).
Retention rates for the first 2 years of onboarding hover around 80% for physicians and nurses. However, retention incentives have dropped from 19,484 to 8982 and recruitment incentives from 6069 to 1299.
In voluntary exit surveys, 78% of 6762 medical and dental staff who left said they would work again for the VA, while 79% said they would recommend the VA as an employer. These rates are down from a similar survey in May 2023 when 81% noted that they would work again for the VA and 82% would recommend the VA to others. Personal matters, geographic relocation, and poor working relationships with supervisors or colleagues were among the reasons cited for leaving in August 2025.
Of 435 psychologists, 69% said they would work again for the VA, and 62% said they would recommend the VA as an employer (71% and 67%, respectively in May 2023). Their reasons for leaving in August 2025 included a lack of trust in senior leaders and policy or technology barriers to getting the work done.
An August survey from the Office of the Inspector General found that VHA facilities reported 4434 staffing shortages this fiscal year—a 50% increase from fiscal year 2024. Most (94%) of the 139 facilities reported severe shortages for medical officers, and 79% of facilities reported severe shortages for nurses. Due to the timing of the questionnaire, the responses did not yet reflect the full impact from workforce reshaping efforts.
When The Giants and Those Who Stand on Their Shoulders Are Gone: The Loss of VA Institutional Memory
When The Giants and Those Who Stand on Their Shoulders Are Gone: The Loss of VA Institutional Memory
If I have seen further, it is by standing on the shoulders of giants.
Sir Isaac Newton (1642-1727) 1
Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.
So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.2 Medical media rapidly picked up the story, likely further discouraging potential applicants.3
There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.
The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”2 They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.
It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.4 OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.
At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.2 Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.5
It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”6
What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”7
The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.6 As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”7
Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.8
The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.9 Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value.
Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.1 It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?
- Chen C. Mapping Scientific Frontiers: The Quest for Knowledge Visualization. Springer; 2013:135.
- Armstrong D, Umansky E, Coleman V. Veterans’ care at risk under Trump as hundreds of doctors and nurses reject working at VA hospitals. ProPublica. August 8, 2025. Accessed August 25, 2025. https://www.propublica.org/article/veterans-affairs-hospital-shortages-trump
- Kuchno K. VA physician job offers rejections up fourfold in 2025: report. Becker’s Hospital Review. August 12, 2025. Accessed August 26, 2025. https://www.beckershospitalreview.com/workforce/va-physician-job-offer-rejections-up-fourfold-in-2025-report/
- US Department of Veterans Affairs, Office of Inspector General. OIG determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2025. August 12, 2025. Accessed August 25, 2025. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-1
- US Department of Veterans Affairs. VA workforce dashboard. July 25, 2025. Accessed August 25, 2025. https://www.va.gov/EMPLOYEE/docs/workforce/VA-Workforce-Dashboard-Issue-27.pdf
- VA to reduce staff by nearly 30K by end of FY2025. News release. Veterans Affairs News. July 7, 2025. Accessed August 25, 2025. https://news.va.gov/press-room/va-to-reduce-staff-by-nearly-30k-by-end-of-fy2025/
- Bhugra D, Ventriglio A. Institutions, institutional memory, healthcare and research. Int J Soc Psychiatry. 2023;69(8):1843-1844. doi:10.1177/00207640231213905
- Jain A. Is organizational memory a useful capability? An analysis of its effects on productivity, absorptive capacity adaptation. In Argote L, Levine JM. The Oxford Handbook of Group and Organizational Learning. Oxford; 2020.
- Broder J. Ready to pick a specialty? These may have the brightest futures. Medscape. April 21, 2025. Accessed August 25, 2025. https://www.medscape.com/viewarticle/ready-pick-specialty-these-may-have-brightest-futures-2025a10009if
If I have seen further, it is by standing on the shoulders of giants.
Sir Isaac Newton (1642-1727) 1
Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.
So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.2 Medical media rapidly picked up the story, likely further discouraging potential applicants.3
There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.
The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”2 They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.
It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.4 OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.
At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.2 Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.5
It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”6
What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”7
The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.6 As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”7
Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.8
The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.9 Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value.
Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.1 It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?
If I have seen further, it is by standing on the shoulders of giants.
Sir Isaac Newton (1642-1727) 1
Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.
So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.2 Medical media rapidly picked up the story, likely further discouraging potential applicants.3
There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.
The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”2 They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.
It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.4 OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.
At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.2 Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.5
It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”6
What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”7
The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.6 As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”7
Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.8
The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.9 Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value.
Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.1 It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?
- Chen C. Mapping Scientific Frontiers: The Quest for Knowledge Visualization. Springer; 2013:135.
- Armstrong D, Umansky E, Coleman V. Veterans’ care at risk under Trump as hundreds of doctors and nurses reject working at VA hospitals. ProPublica. August 8, 2025. Accessed August 25, 2025. https://www.propublica.org/article/veterans-affairs-hospital-shortages-trump
- Kuchno K. VA physician job offers rejections up fourfold in 2025: report. Becker’s Hospital Review. August 12, 2025. Accessed August 26, 2025. https://www.beckershospitalreview.com/workforce/va-physician-job-offer-rejections-up-fourfold-in-2025-report/
- US Department of Veterans Affairs, Office of Inspector General. OIG determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2025. August 12, 2025. Accessed August 25, 2025. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-1
- US Department of Veterans Affairs. VA workforce dashboard. July 25, 2025. Accessed August 25, 2025. https://www.va.gov/EMPLOYEE/docs/workforce/VA-Workforce-Dashboard-Issue-27.pdf
- VA to reduce staff by nearly 30K by end of FY2025. News release. Veterans Affairs News. July 7, 2025. Accessed August 25, 2025. https://news.va.gov/press-room/va-to-reduce-staff-by-nearly-30k-by-end-of-fy2025/
- Bhugra D, Ventriglio A. Institutions, institutional memory, healthcare and research. Int J Soc Psychiatry. 2023;69(8):1843-1844. doi:10.1177/00207640231213905
- Jain A. Is organizational memory a useful capability? An analysis of its effects on productivity, absorptive capacity adaptation. In Argote L, Levine JM. The Oxford Handbook of Group and Organizational Learning. Oxford; 2020.
- Broder J. Ready to pick a specialty? These may have the brightest futures. Medscape. April 21, 2025. Accessed August 25, 2025. https://www.medscape.com/viewarticle/ready-pick-specialty-these-may-have-brightest-futures-2025a10009if
- Chen C. Mapping Scientific Frontiers: The Quest for Knowledge Visualization. Springer; 2013:135.
- Armstrong D, Umansky E, Coleman V. Veterans’ care at risk under Trump as hundreds of doctors and nurses reject working at VA hospitals. ProPublica. August 8, 2025. Accessed August 25, 2025. https://www.propublica.org/article/veterans-affairs-hospital-shortages-trump
- Kuchno K. VA physician job offers rejections up fourfold in 2025: report. Becker’s Hospital Review. August 12, 2025. Accessed August 26, 2025. https://www.beckershospitalreview.com/workforce/va-physician-job-offer-rejections-up-fourfold-in-2025-report/
- US Department of Veterans Affairs, Office of Inspector General. OIG determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2025. August 12, 2025. Accessed August 25, 2025. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-1
- US Department of Veterans Affairs. VA workforce dashboard. July 25, 2025. Accessed August 25, 2025. https://www.va.gov/EMPLOYEE/docs/workforce/VA-Workforce-Dashboard-Issue-27.pdf
- VA to reduce staff by nearly 30K by end of FY2025. News release. Veterans Affairs News. July 7, 2025. Accessed August 25, 2025. https://news.va.gov/press-room/va-to-reduce-staff-by-nearly-30k-by-end-of-fy2025/
- Bhugra D, Ventriglio A. Institutions, institutional memory, healthcare and research. Int J Soc Psychiatry. 2023;69(8):1843-1844. doi:10.1177/00207640231213905
- Jain A. Is organizational memory a useful capability? An analysis of its effects on productivity, absorptive capacity adaptation. In Argote L, Levine JM. The Oxford Handbook of Group and Organizational Learning. Oxford; 2020.
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When The Giants and Those Who Stand on Their Shoulders Are Gone: The Loss of VA Institutional Memory
When The Giants and Those Who Stand on Their Shoulders Are Gone: The Loss of VA Institutional Memory
Hematology and Oncology Staffing Levels for Fiscal Years 19–24
Background
Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.
Methods
Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.
Analysis
For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).
Results
From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).
Conclusions
Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.
Background
Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.
Methods
Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.
Analysis
For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).
Results
From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).
Conclusions
Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.
Background
Department of Veterans Affairs (VA) faces a landscape of increasingly complex practice, especially in Hematology/Oncology (H/O), and a nationwide shortage of healthcare providers, while serving more Veterans than ever before. To understand current and future staffing needs, the VA National Oncology Program performed an assessment of H/O staffing, including attending physicians, residents/ fellows, licensed independent practitioners (LIPs) (nurse practitioners/physician assistants), and nurses for fiscal years (FY) 19–24.
Methods
Using VA Corporate Data Warehouse, we identified H/O visits in VA from 10/01/2018 through 09/30/2024 using stop codes. No-show (< 0.00001%) and National TeleOncology appointments (1%) were removed. We retrieved all notes associated with resulting visits and used area-ofspecialization and provider-type data to identify all attending physicians, trainees, LIPs, and nurses who authored or cosigned these notes. We identified H/O staff as 1. those associated with H/O clinic locations, 2. physicians who consistently cosigned H/O notes authored by fellows and LIPs associated with H/O locations, 3. fellows and LIPs authoring notes that were then cosigned by H/O physicians, and 4. nurses authoring notes associated with H/O visits.
Analysis
For each FY, we obtained total numbers of visits, unique patients, and care-providing staff by type. For validation, collaborating providers at several sites reviewed visit information, and a colleague also performed an independent, parallel data extraction. We adjusted FY totals to account for the growing patient population by dividing unique staff count by number of unique patients and multiplying by 200,000 (the approximate number of unique patients in FY19).
Results
From FY19 through FY24, VA Hematology/ Oncology saw a 14.6% rise in unique patients (from 232,084 to 265,926) and a 15.4% rise in visits (from 923,175 to 1,065,186). The absolute number of attendings rose by 4 (0.6%); of LIPs, by 138 (14.4%); and of nurses, by 142 (4.9%); trainees fell by 102 (4.3%). Adjusted to 200,000 patients, the number of attendings fell by 76 (12.3%); LIPs, by 1 (0.1%); trainees, by 335 (16.5%); and nurses, by 211 (8.4%).
Conclusions
Adjusted to number of Veterans, there are 10.4% fewer staff in Hematology/Oncology in FY24 compared to FY19.