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SAMS Monograph Prospectus Beyond the Iron Triangle: Implications for the Veterans Health Administration in an Uncertain Policy Environment A Monograph by Stephen K. Trynosky Veterans Health Administration School of Advanced Military Studies United States Army Command and General Staff College Fort Leavenworth, Kansas 2014-02 Approved for public release; distribution is unlimited. Monograph Approval Page Name of Candidate: Mr. Stephen K. Trynosky, GS-14 Monograph Title: Beyond the Iron Triangle: Implications for the Veterans Health Administration in an Uncertain Policy Environment Approved by: __________________________________, Monograph Director Jeffrey Kubiak, PhD __________________________________, Seminar Leader James MacGregor, COL ___________________________________, Director, School of Advanced Military Studies Henry A. Arnold III, COL Accepted this 4th day of December 2014 by: ___________________________________, Director, Graduate Degree Programs Robert F. Baumann, PhD The opinions and conclusions expressed herein are those of the student author, and do not necessarily represent the views of the U.S. Army Command and General Staff College or any other governmental agency. (References to this study should include the foregoing statement.) ii Abstract BEYOND THE IRON TRIANGLE: IMPLICATIONS FOR THE VETERANS HEALTH ADMINISTRATION IN AN UNCERTAIN POLICY ENVIRONMENT, by Stephen K. Trynosky, Veterans Health Administration, 90 pages. The Department of Veterans Affairs is in the midst of a very serious crisis. The political and reputational fallout from the 2014 patient scheduling scandal exposed the further destabilization of the veterans’ policy subgovernment consisting of VA, the congressional veterans’ affairs committees, and large veterans’ service organizations. This subgovernment, historically referred to as the “iron triangle,” was among the most stable and insular domestic policy arenas in the six decades following World War II. Since the 1990’s a steady trend towards extreme partisan polarization has characterized both chambers of Congress. This dynamic gradually politicized an array of domestic policy realms. While veterans’ policy was long immune to the worst of these trends, events during the 112th and 113th Congresses (2011-2015) illustrate the encroachment of partisan politicization into a once relatively nonpartisan issue area. This phenomenon was visible in both the Republican controlled House and the Democratic controlled Senate. Simultaneous with the politicization of veterans’ issues, the stature and influence of large veterans’ service organizations such as the American Legion and VFW continue to decline. Although these groups were considered nearly invincible and achieved impressive legislative triumphs in the decades following World War II, events in the 113th Congress demonstrate their diminished power in a destabilized subgovernment. Inexorable demographic factors such as a declining veteran population and falling membership converge with the rise of narrowly focused veterans’ advocacy groups that compete for public attention and finite philanthropy. The trends contributing to the decline of traditional VSOs were several decades in the making, but events throughout 2014 put these developments in stark relief. The continued destabilization of the veterans’ subgovernment has profound consequences for the Veterans Health Administration. Events throughout the 113th Congress suggest that VA failed to appreciate changes within the subgovernment and adapt accordingly. In the 114th Congress and beyond, VHA can anticipate the continuation of highly politicized congressional oversight while the influence of traditional VSOs continues to decline. Expanded calls for the further privatization of VHA services are expected and these efforts will be increasingly backed by corporate lobbying expenditures. While VA itself cannot reverse trends affecting other elements of the veterans’ subgovernment, it has options that can improve the effectiveness of its congressional outreach efforts and repair its severely damaged relationships with legislators and VSOs. It can also cultivate new surrogates to augment the traditional VSOs and reach expanded audiences from their unique perspectives. Implementing the necessary institutional “shift in mind” to navigate this changed environment will not be easy for VHA, but the shared vision outlined by VA’s new Secretary, Robert McDonald, shows much promise. As a leading health care organization, VHA is fundamentally a learning organization and can leverage many of the best cultural attributes that facilitated its medical care transformation in the 1990s to reevaluate its role within a destabilized and changing policy subgovernment. iii Table of Contents Acknowledgements ......................................................................................................................... vi Acronyms ...................................................................................................................................... vii Introduction ...................................................................................................................................... 1 Part 1 The Veterans Policy Subgovernment ..................................................................................... 6 Destabilizing Trends in the Congressional Landscape ............................................................... 9 The Destabilization of Mainstream VSOs ................................................................................ 14 Demographic Trends Impacting VSOs ..................................................................................... 16 Consequences of Membership Trends on Traditional VSO Legislative Influence ................... 18 The Rise of New Veterans Advocacy Groups and Their Impact on the Policy Debate ............ 20 Part 2 The 113th Congress: The Accelerated Unravelling of the Veterans’ Subgovernment ........ 24 Emerging Trends in the 113th Congress ................................................................................... 24 The House: Increased Oversight and Aggressiveness .............................................................. 26 The Senate: Partisan Showdown over S. 1982.......................................................................... 32 VHA’s 2014 Scheduling Scandal – Competing Priorities and Role Conflict ........................... 36 House Hearings ......................................................................................................................... 37 Conflict within the Veterans Community ................................................................................. 39 Veterans Reform Legislation – The Path to Public Law 113-146 ............................................ 41 Part 3 Strategic Implications of Veterans Subgovernment Destabilization for VHA .................... 46 A Politically Charged Oversight Agenda Will Continue in the 114th Congress. ..................... 47 VSO Influence will Continue to Decline and Diminish Their Role as Third Party Surrogates 51 iv The Increasing Geographic Disparity of America’s Veteran Population ................................. 52 Calls for Increased Privatization of VHA Services will Grow in Intensity .............................. 55 Part 4 Options for VHA in an Increasingly Unstable Policy Environment .................................... 59 Changing VA’s Traditionally Reactive Congressional Engagement Posture ........................... 62 Congressional Engagement Authority Can be Decentralized and Adaptability Fostered......... 67 VHA’s Local Leaders Are Vital to Restoring Congress’ Trust ................................................ 72 VHA Must Cultivate Other Third Party Surrogates to Supplement Declining VSOs .............. 77 Conclusion ...................................................................................................................................... 81 Bibliography ................................................................................................................................... 88 v Acknowledgements When I selected this monograph topic in February 2014, I could not have anticipated how dramatically the rest of the year would unfold for VA. I learned a tremendous amount about the veterans’ policy subgovernment during the research and writing process and the experience was invaluable. I am especially grateful to VA for the unique opportunity to spend a year at Ft. Leavenworth reflecting on my previous experiences in VHA, DHS, and the Army while learning so much in the company of true professionals. This would not have been possible without the faith in my abilities that Crystal Ford, Ann Patterson, Dr. Lisa Thomas, and Dr. Robert Petzel, our former Under Secretary for Health, demonstrated in endorsing my application. I would further like to extend a special thanks to key individuals who took the time to help me develop this topic and refine my thoughts: David Ballenger, Phil Carter, Brandon Friedman, Mark Greenbaum, Glenn Johnson, Colonel John Kent, Dr. Larry Korb, Dr. Burdett Loomis, Dr. Thomas Mann, Mr. Rick Montgomery, Dan Moulton, Dr. Norman Ornstein, Dr. Bill Preston, Len Sistek, and Rick Weidman. I am indebted to the men and women of the EPA Office of Inspector General Region VII field office in Lenexa, KS who made my wife feel so at home during our time at Fort Leavenworth. Special thanks are in order to my monograph advisor, Dr. Jeff Kubiak and my two SAMS seminar leaders, Colonels John Paganini and James MacGregor,
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