Department of Veterans Affairs watchdogs and journalists have reported about veterans being hurt by or dying because of underqualified or negligent VA doctors and other medical providers for years.
In the past months, a former VA pathologist was charged with manslaughter in the deaths of three veteran patients and is alleged to have botched diagnosis in 3,000 cases, a former nurse has been charged with stealing pain medication from veterans, a VA staff member is accused of sexual assaults and another former staff member is a person of interest in multiple veteran homicides, among others.
A recent VA Inspector General report showed that VA hired and then allowed an under-qualified eye doctor to perform cataract surgeries for two years. The VA announced it was disciplining nine employees at a nursing home where a veteran reportedly died covered in ant bites.
Marine veteran Brian Tally, who nearly died because of medical malpractice and still feels its effects, is championing multiple pieces of legislation in Congress to fight back.
At a House Veterans Affairs Committee hearing Wednesday, members of Congress pushed VA leadership for answers and heard from representatives from the VA Inspector General and Government Accountability offices.
"These reports are sickening," Rep. Chris Pappas, D-N.H., said, adding that VA leaders have shown "disregard for patient safety risks ... and ignored concerns raised by staff" about substandard care and mismanagement.
"It appears many of these problems are, in large part, failures of leadership," Rep. Jack Bergman, R-Mich., said.
Collectively, the recent string of cases "speaks to a wider problem" at VA, Pappas said, adding that he wanted to know "What red flags are VA's facilities missing or overlooking or choosing to ignore?"
And this is not new territory for VA, Pappas said.
In 2017, Congress held a similar hearing on medical harm to veterans at VA and at that hearing, VA leaders committed to changes to improve veteran care and safety.
But since then, VA has not made those changes.
"This needs to serve as a wake-up call," Pappas said. "We need to see that VA leaders are as outraged as we are."
VA leaders said policy changes were in progress, expected to be complete in summer 2020.
"Our veterans deserve better and we must give them our best effort because they have given us their best effort through their service," Bergman said. "We have to mitigate the risk of future failures."
In testimony submitted to Congress, the Government Accountability and Inspector General's offices found that VA did not always address medical staff who didn't meet license requirements and did not always document reviews of medical staff.
Steven Lieberman, acting principal deputy undersecretary for health at the Veterans Health Administration emphasized that VA is treating more veterans than ever, and said it was "a shame" that the actions of "a few" VA staff members could "overshadow" the work of thousands of other VA workers, and said most medical mistakes "are unintentional."
"VA removes people who willfully cause harm in patient care," Lieberman said. "We have not found a common thread between the recent incidents. Instead, there are a small number of people who acted inappropriately."
VA has a "robust" system for background checks and vetting of hires, Lieberman said.