What Can We Learn from the VA Scandal?

by Reihan Salam

I don’t have a deep understanding of the problems plaguing the Department of Veteran’s Affairs (VA) and the Veterans Health Administration (VHA). The Arizona Republic has published a timeline of what went wrong and when. Pat has briefly touched on some of the main issues, and I defer to his basic take. What I find interesting is what the VA scandal might tell us about the workings of bureaucracies. Chris Hayes, the author and MSNBC host, observes that the “[c]urrent VA story is a classic example how metrics ordered from above often just lead to books being cooked rather than better performance,” and he reminds me of Jane Jacobs on the “commercial syndrome” and the “guardian syndrome,” concepts I first encountered via the late Seth Roberts. He wrote the following in the context of the British phone hacking scandal:

Should police officers be paid per arrest? Most people think this is a bad idea, I imagine, but the larger point (what can we learn from this?) isn’t clear. In Systems of Survival, Jacobs tried to spell out the larger point. She wrote about two sets of moral rules. One set (“guardian syndrome”) applied to warriors, government officials, and religious leaders. It prizes loyalty and obedience, for example. The other set (“commercial syndrome”) applied to merchants. It prizes honesty, avoidance of force, and industriousness, for example. The two syndromes correspond to two ways of making a living: taking and trading. The syndromes reached the form they have today because they worked — different jobs need different rules. When people in one sort of work (e.g., guardian) follow the rules of the other, things turn out badly. Ayn Rand glorified the commercial syndrome. When Alan Greenspan, one of her acolytes, became a governor, he did a poor job.

What about journalists? As a journalistic business becomes more powerful, it becomes more guardian-like. A powerful newspaper isn’t inherently bad; we want a powerful newspaper to keep other powerful institutions (government, large businesses) in check. Murdoch’s News International, of course, has became very powerful. Yet Murdoch newsrooms retained commercial norms, especially an emphasis on selling many copies. Reporters in Murdoch newsrooms were under intense pressure to produce — like policemen paid per arrest. Other journalists, with guardian norms (e.g., at the New York Times), didn’t like the commercial norms of Murdoch newspapers. The mixture of commercial values and guardian power led to the phone hacking scandal. Friends of mine blame Murdoch himself — but commercial norms are not unique to Murdoch. The problem is their mixture with great power.

When newspapers are small, they are not powerful, not guardians, and must adopt commercial norms — they must try to sell more copies or they will be crushed. When a small newspaper becomes large and powerful, however, its norms must change to guardian ones or things will turn out badly. This suggests that the phone-hacking scandal happened because Murdoch became very powerful too fast — too fast for a shift in values to accompany much greater power.

One way of understanding the VA scandal is that when the VHA sought to become more “consumer-friendly,” it struggled to adapt. Many of the VHA’s admirers have pointed to the way its “quasi-military culture” shaped its relationships with beneficiaries. In 2005, Philip Longman praised the VHA’s idealism:

The system’s doctors are salaried, which also makes a difference. Most could make more money doing something else, so their commitment to their profession most often derives from a higher-than-usual dose of idealism. Moreover, because they are not profit maximizers, they have no need to be fearful of new technologies or new protocols that keep people well. Nor do they have an incentive to clamor for high-tech devices that don’t improve the system’s quality or effectiveness of care.

So what changed? It could be that while earlier generations of VHA beneficiaries were more inclined to be deferential and accommodating when facing long waits and lackluster care, younger veterans were less so. The VHA found that it had to shift from a guardian ethic that prized loyalty and obedience to a more commercially-minded ethic, in which the customer is always right, and it struggled to do so. It is extremely difficult to transform an institutional culture. Long after institutions are founded, they reflect the values, priorities, and the pathologies of their founding generations. That is why it so important to allow for the creation of new institutions to meet new and evolving needs.

Tomorrow, the YG Network is launching Room to Grow, a collection of essays focusing on how conservatives can help revitalize the American middle class. (You’ll be hearing a lot about it.) I had a small part in putting the book together as a policy advisor to the YG Network, and I’m very proud of it. The central idea uniting the essays is that, as Yuval Levin argues in his chapter, we need to do a better job of drawing on the creativity of the institutions that exist between the individual and the federal government — families, communities, civic and religious organizations, state and local governments, and private firms — to solve our problems. Rather than rely on centralized institutions that struggle to adapt to new circumstances, we need to facilitate the rise of new institutions and new service delivery models that aren’t weighed down by past practice. The VA scandal is just the latest sign that America is being weighed down by outdated, brittle institutions. The federal government shouldn’t be a collection of top-down bureaucracies — it should relinquish power, and serve as a platform for new solutions tailored to new needs as they emerge.