This story, part of a series of investigative reporting projects by Military.com on service member and veteran health, was supported by the Pulitzer Center.
The Department of Veterans Affairs needed staff. A lot of staff. And a lot more psychiatrists.
In the wake of the largest expansion of veterans benefits in a generation after the signing of the PACT Act in 2022, more than 700,000 veterans had newly enrolled in VA health care, including more than 150,000 who were freshly eligible because of the law and now asking for medical support.
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To handle that influx of new patients, the VA's Veterans Health Administration hired nearly 62,000 new employees in 2023. That included bringing on 340 psychiatrists, the second biggest category of physician hires behind only primary care doctors, according to data obtained by Military.com through a public records request.
Psychiatry has long been known as a critical shortage in VA staffing. Professional associations have urged the VA to beef up its psychiatry staff for more than a decade, and a government watchdog report last year said 73 VA facilities face a "severe shortage" of psychiatrists.
About half of the new hires at the VHA, according to the data obtained by Military.com, were in the so-called "big seven" occupations of physician, registered nurse, practical nurse, nursing assistant, medical support assistant, food service worker and environmental services technician.
The PACT Act, which became law exactly two years ago Saturday, extended VA eligibility to millions of veterans exposed to toxins during their military service. While much of the public discussion of the law centered on the issues of respiratory illnesses and cancer from exposure to burn pits, the hundreds of thousands of new veteran patients also come with the same overarching medical needs as other veterans, and were added to a system already under stress, with appointment wait times a constant issue.
"Coming out of the pandemic, there are a lot of mental health care providers, nursing staff, other health care staff that has been burned out and decided to opt out of the system," said Allison Jaslow, CEO of Iraq and Afghanistan Veterans of America, or IAVA. "VA has been really smart in how they've taken the resources they were given, not only focusing heavily on hiring, but also trying to basically outbid the private sector even with bonuses and things. If this is a part of that broader effort, I'm glad that they leaned into essentially [using] a lot of funding they got to treat toxic exposure to treat another high-priority area for veteran care."
While the 2023 hiring was touted as part of PACT Act implementation, the VA did not use funding specifically dedicated for the PACT Act in order to fill the jobs, according to an initial public records request response received by Military.com. The bill also contained provisions to allow the VA bypass some red tape on new hires that VA officials have credited with enabling the hiring spree.
The long-term effects of 2023's hiring sprint remain to be seen, with questions lingering about the VA's history of employee vetting failures or uncertainty over the department's future staffing levels.
But the psychiatry hiring could help fill a hole that experts and advocates have long identified as a critical shortage in VA health care staff.
"With this hiring push, we're bringing on new people with one goal in mind: providing world-class care to every veteran who entrusts us with their health," VA Under Secretary for Health Dr. Shereef Elnahal said in 2023 news release hailing the record hiring.
'A Pressure for the System'
The largest category of "big seven" hires was registered nurses -- another field watchdogs have long identified as facing critical shortages -- at nearly 12,000 new hires, according to the data obtained by Military.com. A little more than 3,000 physicians were hired. By comparison, the VA employed about 22,000 physicians for medical care in 2022 before the hiring spree, according to budget documents.
Of the newly hired physicians, the biggest number came from primary care doctors, the generalists who serve as the initial doctor seen by veterans before referrals to specialists, at 410 new hires. The second-largest category for the influx of doctors was the 340 psychiatry hires.
Overall, the hiring at VHA in 2023, combined with what VA officials have described as high retention, grew the workforce by 7.4% with a net increase of more than 28,000 employees, the department has said.
Psychiatry has been one of the department's top five clinical shortfalls since at least 2018, according to last year's watchdog report from the VA's inspector general.
"While VHA generally increased the number of staff in these occupations, these increases did not resolve the shortages," the report added, referring to psychiatry and the other jobs with shortfalls.
The psychiatry hiring in 2023 was an uptick from previous years, which had steadily been declining. In 2022, the VA hired 288 psychiatrists, compared to 314 in 2021 and 324 in 2020, according to the data.
"Psychiatrists are an integral component of VA's team-based approach to mental health care, providing a unique combination of medical, diagnostic and treatment expertise that seeks to optimize the quality of mental health care offered to veterans," VA press secretary Terrence Hayes told Military.com in an emailed statement when asked why psychiatry was a top category of hires during the hiring spree.
Amid the shortage, many veterans have reported box-checking experiences with VA psychiatrists, according to the Wounded Warrior Project, a veterans advocacy organization.
"In the clinical outpatient setting, most veterans only see the psychiatrist every 90 days, coinciding with [prescription] refills and adjustments," the nonprofit told Military.com in an emailed response to questions. "Most warriors' complaints center around the encounter being very transactional and lacking any true therapeutic value except for getting the needed refills."
The VA's psychiatry shortfalls are part of a nationwide trend of falling numbers of mental health care doctors even as demand for care increases. The Health Resources and Services Administration, a federal agency focused on improving access to health care, projects that the United States will have a shortage of 42,130 psychiatrists over the next 15 years.
While shortages predate the COVID-19 pandemic, the outbreak in 2020 "created this perfect storm where it seems like many people are leaving this sector of health care," said Jeanette Yih Harvie, a research associate at the D'Aniello Institute for Veterans and Military Families at Syracuse University. With more people seeking mental health care, "this also creates a pressure for the system to provide this care," she added.
For veterans, that has translated into widely different results, with some who live in cities or who are comfortable with telehealth getting mental health appointments quickly, while others who live in rural areas or who can't use telehealth wait months.
While issues with mental health care access are caused by many factors beyond just staffing levels, hiring more psychiatrists like the VA did last year could help, Harvie said.
"Hiring is part of the challenge, but I think it's also the retention of providers and being able to maintain a more consistent staffing level," she said. "Hiring could be a solution in some areas, but maybe in some other areas it could be allowing more community providers to help."
Quantity Vs. Quality
The VA's rush to employ tens of thousands of new medical staff using expedited hiring authorities also raised questions about how thoroughly employees were being vetted.
So far, there have been no publicly reported issues of unqualified or unsuitable doctors being hired.
But there have been signs that VA officials were worried about overworking those doing the hiring, and numerous watchdog reports over the years have flagged issues with VA background checks.
Last year, the VA paid $43.5 million in bonuses to more than 6,500 human resources specialists in both VHA and the Veterans Benefits Administration. The bonuses were authorized by the PACT Act with the intention of enticing employees to stay in hard-to-fill jobs so the department had enough staff to handle the mountain of newly eligible veterans.
Meanwhile, inspector general reports in 2018 and 2023 found the VHA was not ensuring background investigation requirements were being met at medical facilities nationwide. And GAO reports in 2019 and 2023 found several facilities had hired providers whose licenses had been revoked and that the agency failed to identify potentially more than 12,000 employees with drug-related criminal histories.
In response to concerns raised by Senate Veterans Affairs Committee ranking member Sen. Jerry Moran, R-Kan., in a letter earlier this year about the repeated watchdog findings, the VA issued a 28-page plan for implementing more than three dozen of the watchdogs' recommendations to ensure adequate vetting of new hires, according to a copy of the plan obtained by Military.com. Planned improvements will "ensure VA employees, contractors and staff have been properly vetted and screened in compliance with federal vetting requirements and standards," the document assured.
The VA also told Military.com that, in response to the watchdog recommendations, it streamlined and standardized its onboarding process within the federal government's HR software and created two new personnel security programs to "assure more timely adjudication of all employees' background investigations."
"VHA takes vetting all new employees very seriously, because we know this is the first step in ensuring the highest level of care is provided to veterans and that they can trust every employee when they walk into a VA medical center," Hayes said in his statement. "That means making sure that every person who works at VA goes through a strict vetting process -- both to ensure that they are the right person for the job, and to ensure that they are fit to serve veterans."
Still, mindful of the watchdog findings, Congress is keeping a close eye on whether any problems arise from last year's hiring spree.
"I think the only reason we haven't learned of them yet is because 2023 was just last year, and it takes time for the significant issues to be identified," a Senate aide told Military.com on condition of anonymity.
What Goes Up Must Come Down?
Also casting a shadow over the VA's record hiring in 2023 is uncertainty about the future of VA staffing.
Earlier this year, the VA announced that, following the hiring spree, it would need to trim about 10,000 jobs from its medical staff. The planned cuts drew considerable pushback from employees and lawmakers, who warned reductions risked undermining efforts to implement the PACT Act and improve mental health care.
More recently, though, the VA told Congress it now expects to have about 5,000 more employees in VHA next year compared to this year. That's created a new problem, as the VA is warning it is facing a multibillion-dollar budget shortfall.
Hayes in his statement vowed that any reductions in staff that do come would be a result of attrition and "careful decisions" about what will least affect veterans.
"Additionally, our retention rates for VHA employees -- including mental health professionals -- are at all-time record rates. For FY23 [Fiscal Year 2023], the [mental health] profession retention rate was 93%, and the numbers are even better in FY24," Hayes said, adding that the turnover rate for behavioral health providers outside the VA is usually around 30%.
Veterans are still digesting what the VA's seesawing on staffing and potential budget constraints could mean for their care, IAVA's Jaslow said.
"I would hate for any progress to be stalled, whether it's making sure that people have access to mental health care resources, but also to continue to screen vets for cancer, which we've made a lot of progress on," she said. "I wouldn't want the VA to be hamstrung in this moment, given all the momentum we've created."
