A devastating oversight report from Sen. Tom Coburn (R-OK) reveals that the combination of malpractice and bureaucratic ineptitude infesting the Department of Veterans Affairs (VA) is far deadlier than previously acknowledged. "Over the past decade, more than 1,000 veterans may have died as a result of VA malfeasance, and the VA has paid out nearly $1 billion to veterans and their families for its medical malpractice,“ the report states.

The death total dwarfs the 23 fatalities for which the VA has taken responsibility. Coburn, a physician and three-time cancer survivor, notes the problems at VA facilities go "far deeper” than the phony scheduling schemes that brought this scandal to the national stage. “The waiting list cover-ups and uneven care are reflective of a much larger culture within the VA, where administrators manipulate both data and employees to give an appearance that all is well," the report reveals.

According to Coburn, that culture is one in which veterans "are not always a priority.” Much of that is attributable to the reality that even as the VA suffers from a shortage of healthcare providers, VA nurses are paid to perform union duties and doctors are allowed to leave work early rather than care for patients. The report further explains that good employees who try to bring attention to the Department’s shortcomings “are punished, bullied, put on ‘bad boy’ lists, and transferred to other locations.”

The report also blows away the VA’s fallback excuse, namely that it suffers from a lack of funding. Coburn notes that spending has increased rapidly in recents years, an assertion backed up by federal budget figures. Inflation-adjusted federal spending shows that the VA budget has increased 92.2 percent over the last decade, skyrocketing from $73.3 billion in FY2003 to $140.9 billion last year, measured in constant 2014 dollars. According to Military.com the VA spends more in inflation-adjusted dollars than it did following WWII and the Vietnam war, when millions of troops were returning home from the battlefield.

Coburn reveals that as much as $20 billion of that spending over the last dozen years has been on “junkets, generous salaries, bonuses, and office renovations for its employees," even as the Department ends every year with billions in unspent funds. He further notes that most of the construction projects undertaken by the VA are over budget and behind schedule. And even when state-of-the-art facilities are finally constructed, the VA is unable to staff them with a sufficient number of doctors. This reality has forced them to spend millions of dollars sending veterans to clinics in other cities and states, wasting veterans’ time and taxpayers’ money.

Some of the details of patient care illuminated by the report are truly disturbing. One Navy veteran, forced to wait months to see a doctor, died of Stage 4 bladder cancer. He had been rushed to the hospital in September 2013, but was sent home despite a medical chart saying his situation was "urgent.” His daughter made effort after effort to get him an appointment but was constantly rebuffed. He finally got an appointment on December 6 – one week after he died. Another veteran received a tooth extraction, despite having dangerously low blood pressure. On his way home, he had a stroke that left him paralyzed. In another case, doctors never spotted a growing lesion on a veteran’s lung during an annual chest x-ray. He died as the result of that carelessness.

The report also seems to validate accusations made by Texas VA whistleblower Dr. Richard Krugman. Last month Krugman alleged the Department was delaying life-saving colonoscopies. The report cites at least 82 vets who either died or suffered serious injuries because of delayed diagnosis or treatment for colonoscopies or endoscopies at the VA. It noted that an investigation by CNN could not determine whether anyone had been reprimanded or fired due to these failures – even as the possibility remains that some of the people responsible may have received bonuses.

At a news conference last week, the VA admitted that approximately 65 percent of senior VA executives were paid a total of $2.7 million in bonuses last year. That number doesn’t include tens of million of additional bonuses awarded to doctors and other VA medical providers. Both totals are part of the $3.9 million doled out to 650 workers at the Phoenix VA Health Care System. The Phoenix facility is the one where it has been confirmed that dozens of vets died awaiting treatment, even as waiting times were being manipulated.

Other parts of the report bordered on the bizarre. Coburn found that five female veterans in Kanas received "inappropriate" pelvic and breast exams from Colmery-O'Neil VA Medical Center physician Jose Bejar. Bejar subsequently pleaded no contest to two charges of sexual misconduct, in order to avoid a trial on nearly two dozen counts. Richard Meltz, the chief of police, United States Department of Veterans Affairs, at the Bedford, NY VA Medical Center pleaded guilty in January to charges arising from two kidnapping, rape, and murder conspiracies. A VA inspector general investigation determined that a Nashville, TN VA employee racked up $109,000 in unauthorized travel expenses. And Maria Kelly Whitt, a former nurse at the Lexington, KY Veterans Affairs Medical Center pleaded guilty to involuntary manslaughter for administering an unauthorized dose of morphine to a 90-year-old World War II veteran. At least two other veterans cared for by Whitt also died “under suspicious circumstances” after receiving morphine.

Other examples of overt lawlessness include a VA employee in charge of supervising patients with substance abuse problems turning out to be a cocaine dealer; another VA employee stealing a patient’s personal information and re-directing compensation benefits to himself; an employee sharing veterans’ personal information in exchange for crack cocaine; and employees accessing child pornography using VA resources.

The report also details the unconscionable delays in scheduling veterans with serious psychological problems. Dr. Margaret Moxness, formerly employed at the Huntington VA Medical Center in Charleston, WV, alleged that supervisors instructed her to delay treatment even when she reported patient needs were immediate. She says she saw at least two veterans commit suicide in the interim. Another whistleblower alleged “serious patient neglect” at the VA health care system in Brockton, MA, including one individual diagnosed with a service connected schizo-affective disorder and drug-induced Parkinsonism who failed to receive appropriate psychiatric treatment and specific lab monitoring required by VA regulations for more than 11 years.

And then there were the delays. As of March 638,000 veterans were awaiting a decision on disability claims, with 360,000 of them waiting more than 125 days. The report blisters VA schedulers, revealing that half of the 50,000 employed by the Department "did not even know how to accurately report the information needed to determine wait times.“

Unsurprisingly, Coburn lays the blame for the VA’s problems on Congress, which micro-manages decisions at the VA because "Washington politicians are more interested in claiming credit for establishing new benefits or VA centers than making sure veterans are getting the care they were promised and earned." He explains that passing laws is meaningless if those entrusted with implementing them can ignore them, even as they remain immune from any serious consequences. He insists that Congress must ensure that the VA delivers timely, quality care to veterans "while at the same time stop micro-mismanaging efforts by the VA to improve.”

Part of the solution Coburn advocates is to make every hospital in the country a VA hospital, "so when the VA cannot provide treatment it will provide coverage for a veteran to receive medically necessary care elsewhere.“

Healthcare expert Betsy McCaughey takes that idea one step further, noting that the VA should encourage vets who have Medicare coverage in addition to VA coverage to use civilian doctors and hospitals that could cut the VA's backlog in half. She further advocates that the $5 billion wasted by the VA on an annual basis could be used to buy older veterans a "medi-gap card." This would offset the cost for veterans who stick with the VA because they can’t afford the out-of-pocket costs associated with civilian doctors. An added bonus is that procedures performed more often on older veterans, like bypass surgery and angioplasty, have higher survival rates at private facilities than at most VA centers. Moreover as the backlog shrinks, VA hospitals will be better able to treat younger veterans in a more timely manner.

Coburn offers several other recommendations. They include enhancing the transparency of VA performance measures, prioritizing vets with combat-related injuries, upping the patient load for VA doctors, reading vets their healthcare rights, ending abuse of whistleblowers, ensuring doctor quality, and having Congress ensure that promises made to veterans are kept.

The report ends on a somewhat somber note, admitting that the shocking findings contained in it are "not all-encompassing” and that further Congressional investigations are necessary. Vietnam War veteran J.R. Howell undoubtedly expresses the sentiments of his fellow soldiers in that regard. “We’ve seen battle. We’ve seen combat,” he explains before asking, “why do we have to … fight when we come back home just to get proper medical care?”

It’s a question for which acting VA Secretary Sloan Gibson and members of Congress must continue to demand answers. America’s veterans deserve nothing less.

Originally published at FrontPage Magazine.