Congressional Oversight of the Military Health System: Lessons Learned from the Walter Reed Army Medical Center Scandal

Abstract

Background: Congress has a constitutional responsibility to conduct oversight of the Military Health System (MHS), a federal health system administered by the Department of Defense (DOD). Congress also has a practical responsibility, akin to health care organization governing boards, to conduct oversight of the MHS. Over several decades, Congress has experienced high turnover and low tenure among its staff, resulting in a “congressional brain drain.” This brain drain has raised questions as to whether Congress has adequate expertise, training, and experience to effectively conduct its constitutional and practical responsibilities, like oversight of the MHS. One way to mitigate this brain drain is to ensure Congress has the resources to bridge the knowledge gap between experienced and inexperienced staffers. To inform the development of these resources, lessons learned from previous oversight cases can be assessed to identify best practices on conducting congressional oversight of the MHS. The aim of this study was to identify lessons learned from congressional oversight of the MHS in response to the Walter Reed Army Medical Center (WRAMC) scandal between 2007 and 2009. To achieve this aim, the study had three objectives: (1) describe the motivating factors for Congress to initiate oversight of the MHS, (2) identify and describe the tools and techniques that Congress used to conduct oversight of the MHS, and (3) assess the perceived effectiveness of those oversight efforts.

Methods: To achieve the aim and objectives of this study, a descriptive program-related case study design was used to investigate one purposively selected, information-oriented event case. The selected event case was the WRAMC scandal that came to light in February 2007 after a series of the Washington Post articles describing unsatisfactory housing conditions and patient neglect of wounded, ill, and injured service members, and overall mismanagement of medical and medical support programs at WRAMC and other military hospitals. This scandal captured the attention of Congress, which convened a series of oversight hearings and conducted fact-finding activities to investigate these allegations. Congressional oversight efforts lasted over two years and resulted in significant changes to the MHS and to DOD’s wounded warrior policies and programs. This study had three research questions: (RQ1) Why did Congress conduct oversight of the MHS? (RQ2) What tools or techniques did Congress use to conduct oversight of the MHS? (RQ3) Was Congress’s oversight of the MHS perceived as effective? Data was collected from a total of 23 key informant interviews and 20 documents reviewed across three stakeholder categories: legislative branch, executive branch, and spectators (i.e., varied stakeholders). Data was examined using a narrative analysis and application of the Levin-Bean Measures of Oversight Effectiveness, which assessed stakeholder perspectives on the quality of the investigation, bipartisanship, credibility, and policy impact of Congress’s oversight activities.

Results: For RQ1, stakeholders described Congress’s motivation to conduct oversight on the MHS as emanating from the institution’s duty to act when something goes awry in the executive branch, as a responsibility to address or remediate issues relating specifically to the military, and for performative effects. For RQ2, stakeholders described Congress’s use of 36 different oversight tools and techniques to collect and document facts, identify and implement solutions, and hold DOD leaders accountable for the scandal. For RQ3, stakeholders described 11 broad themes that were mostly positive perspectives in each of the Levin-Bean Measures of Oversight Effectiveness and suggests that Congress’s oversight of the MHS in response to the WRAMC scandal was viewed as effective.

Conclusion: This case study identified motivational factors, tools, and techniques that Congress used to conduct oversight of the MHS in response to the WRAMC scandal. This study also found that stakeholders generally viewed Congress’s oversight actions as being effective, in part, because they involved high-quality probes, appeared bipartisan in nature, were conducted in a credible manner, and produced meaningful policy and program changes. While addressing the study’s research objectives, 14 distinct oversight lessons learned also emerged from the dataset. The lessons derived from multiple stakeholder perspectives were subsequently translated into an applied practice product and tailored for congressional staffers as a resource that offers 12 best practices for conducting oversight of the MHS.

Predicting when the next scandal in the MHS will occur is nearly impossible, but Congress must be ready to fulfill its oversight responsibilities. To perform these responsibilities, it is essential for Congress to have experienced and informed staffers. When there is a gap in experience or knowledge, congressional staff need relevant and useful tools and resources to help guide oversight planning and endeavors. This study’s best practices resource seeks to provide that support for congressional staffers to understand the role of Congress, the dynamics of the institution, and the art of oversight of the MHS.