TOMAH — A top Veterans Affairs official testified before a congressional hearing Tuesday that the agency was to blame for problems linked to the deaths of at least two patients at the Tomah VA Medical Center.
Sloan Gibson, deputy secretary of Veterans Affairs, said “clear and inexcusable lack of leadership” allowed the deaths to occur and outlined steps taken to reform the facility and reduce the reliance on opioid painkillers.
“I own those problems, those failures,” Gibson said. “We had ample opportunity over a number of years to fix this … and we failed to get it done.”
His statements came after the conclusion of a Senate investigation that blamed “systemic” failures by the Veterans Administration and governmental watchdog agencies for allowing the deaths of at least two veterans.
The 359-page report by the Senate Committee on Homeland Security and Governmental Affairs that said failures “across the executive branch” allowed problems of over-medication and abuse of authority to fester in the facility for at least nine years despite attempts of patients and employees to contact law enforcement and the VA’s Inspector General.
The VA has been under fire since January 2015, when a report by the nonprofit Center for Investigative Reporting detailed high levels of opioid prescription at the Tomah VA and a pervasive culture of intimidation and retaliation against employees who spoke out. Two top officials from Tomah — Director Mario DeSanctis and medical Chief of Staff Dr. David Houlihan — were removed in the wake of that report, as were at least two other care providers.
In 2014, the VA’s Office of Inspector General concluded a three-year investigation that identified “troubling” levels of opioid prescriptions but found no criminal wrongdoing. The OIG did not release the report until its existence was revealed by the media.
Sen. Ron Johnson, R-Wis., who chairs the committee, said the inspector general’s office lost its way under the leadership of Richard Griffin, who stepped down in 2015 and that new Inspector General Michael Missal needs to “clean house.”
“I believe these tragedies could have been prevented if the Inspector General had done its job,” Johnson said. “The office of the Inspector General under Richard Griffin was loyal to the VA instead of to the finest among us and the American public.”
Tuesday’s report, the result of a 16-month investigation by the committee, said employees at the hospital had referred to Houlihan since at least 2004 as “Candy Man” because of his copious prescriptions for opioid painkillers and that the Drug Enforcement Administration has been investigating potential drug diversion for seven years with no public results.
Among the other revelations in the report:
- In the months before his death at the hospital, Jason Simcakoski called multiple law enforcement agencies, including the FBI, which denied any record of contact.
- The former chief of the Tomah VA police knew the facility had a reputation as a “big pill box” when he took over in 2009 but didn’t investigate the allegations.
- The VA did not fully investigate past allegations of misconduct against Houlihan when he was hired and later promoted to chief of staff.
- An OIG agent reported that Houlihan and another practitioner appeared to be under the influence of drugs when he interviewed them; the OIG suggested that DeSanctis consider drug testing his staff but there was no follow up.
- While handling of the Tomah scandal has been a point of contention in Johnson’s re-election campaign against former Sen. Russ Feingold, Johnson focused his criticism on the VA and denied politicizing the issue.
“I’ve done nothing political here,” he told reporters before the hearing.
The committee’s minority members released a supplemental report that largely echoed that sentiment.
“Fixing the problems at the VA isn’t a partisan issue,” said Sen. Tom Carper, the committee’s ranking Democrat. “It’s a shared responsibility among Congress, the Administration, and the VA’s leadership.”
Johnson, a proponent of privatizing the VA health system, said he believes veterans today are receiving better care at Tomah than they did under Houlihan but said problems are inherent in a government-run system.
“It’s rare that people get held accountable,” he said.
Gibson later disagreed, saying the VA is unmatched in its ability to provide care to more than 8.7 million veterans.
“No healthcare operation in America or perhaps in the world does the things VA does,” he said. “What other organization in America can bring that scope and that scale to bear on care for veterans?”
Gibson outlined other reforms undertaken in Tomah.
Under interim director Victoria Brahm, Gibson said, the number of veterans receiving opioids has dropped by nearly a quarter, to just over 9 percent, below the national rate of about 13 percent.
“She’s finding options,” Gibson said. “Other than just a bag of pills.”
Marvin Simcakoski, the father of a Marine veteran who died from a toxic combination of medications while at the hospital in 2014, said he’s encouraged by efforts to reform the VA.
“I can tell these guys are sincere,” he said after the hearing. “And I think we’re going in the right direction.”