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'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
