Has the VA Fulfilled its Commitment to Trust and Healing?

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.