Sen. Tom Coburn (R., Okla.) released a report Tuesday detailing the extensive wait times and mismanagement within the Department of Veterans Affairs health care system.
Coburn’s 124-page Friendly Fire: Death, Delay, and Dismay at the VA, examines information from more than a year’s worth of media coverage and government investigations into allegations of VA misconduct.
The report cites the VA’s knowledgeable falsifying of information, excessive salaries and bonus incentives, lack of accountability, and criminal employee activity, among a host of other problems.
"Split-second medical decisions in a war zone or in an emergency room can mean the difference between life and death," Coburn wrote in the report’s introductory letter to taxpayers. "Yet at the VA, the urgency of the battlefield is lost in the lethargy of the bureaucracy."
The report mentions numerous instances where the VA’s health care negatively impacted veterans—in some cases, resulting in death.
A Navy veteran, for example, was rushed to a VA emergency room in Phoenix in September 2013 but was later sent home due to a seven-month-long wait for care, according to the report.
The VA never called the patient to reschedule an appointment before his death on Nov. 30, 2013.
That patient was one of 120,000 veterans who waited months for care, the report says, citing the VA’s own statistics.
However, those numbers may be low. Records have been "fudged" so much that VA misconduct cannot be properly quantified, the report says.
"The unreliable data are not only the result of nefarious schemes and poor record keeping, incompetence and bureaucracy are also factors," the report says.
The Phoenix VA Health Care System has been at the center of the controversy since it first captured the nation’s attention in April when a whistleblower’s allegations that more than 40 veterans died due to extreme wait times reached the House Committee of Veterans Affairs.
The issue eventually ballooned into the resignation of VA Secretary Eric Shinseki on May 30.
On Tuesday, another whistleblower from the VA hospital in Phoenix told CNN that hospital management had reverted the status of various patients in its records from deceased to living.
That means the ongoing Inspector General investigation into deaths resulting from wait times may have missed some patients who had died, as their records would show them as still living, according to CNN.
Coburn’s report recommends the VA keep its data transparent and up to date and that the IG conduct regular inspections of its records. The report advises any inconsistencies suggestive of falsified information be reported to the appropriate parties so that, in extreme cases, punitive action can be taken.
‘This information would allow veterans to make the most informed decisions about when and where to access health care while holding the VA accountable for providing the most optimal and timely care at every facility," the report says.