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How to Salvage the VA
“Fundamentally, I wanted a veteran experience that didn’t suck”
What This Interview Is About
A decade ago, the U.S. Department of Veterans Affairs was the punching bag of the federal government. Hundreds of thousands of veterans were locked out of healthcare they had earned through military service. The system was in shambles. The media coverage was unsparing. Congress wanted answers.
Enter Marina Nitze, our guest today. Nitze got her start in government as the first Entrepreneur-in-Residence in the U.S. Department of Education in 2012. She later became the Chief Technology Officer of the U.S. Department of Veterans Affairs in 2013. Nitze helped millions of veterans access VA health care through simple technical reforms.
Nitze focuses on user research to fix government agency processes, and she’s gone on to help foster care systems reduce their foster parent dropout rate. Currently, she’s a partner at Layer Aleph, a recovery engineering firm that specializes in restoring complex business systems to service. She’s also a fellow at New America's New Practice Lab, and the co-author, with Nick Sinai, of Hack Your Bureaucracy.
In this interview, Nitze discusses:
Click the links above to navigate directly to sections of the interview.
What You’ll Learn
Why the VA claimed veterans didn’t use the Internet
How to do user research in the federal government
Why parents drop out of foster care programs
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How did you arrive at the Department of Veterans Affairs?
I came to this work by accident. I saw Todd Park, who was Chief Technology Officer of the United States at the time, at TechCrunch Disrupt. He said they were looking for some tech savvy entrepreneurs to come in and disrupt the government. I’m a lifelong libertarian, and it sounded fun and interesting.
The form I filled out said if you sent in your resume, they would add you to the mailing list. I didn't hear anything for months. Then I got a call on a Thursday from Richard Culatta at the Department of Education asking if I wanted to be his Innovation Fellow, but I had to move from Seattle to D.C. by Tuesday. That was crazy enough to attract me. So sometimes I think that having slightly bonkers hiring and recruitment practices can actually recruit some unexpected people. Then I caught the public sector bug.
What was working at the VA like?
We were the whipping boy of the Obama administration. We were always on the front page of The New York Times for doing something horrible. We were always somewhat of a curse word.
Now the VA is leading the federal government. They're teaching other agencies about customer service. Veteran trust has gone up 26% since 2014, which should be mathematically impossible, and it keeps rising.
In my first two years at the VA, I couldn't hire a single person. I couldn't get a single dollar. I got nothing done. But it was two years of groundwork. Then finally, at year three, I was able to get things done.
If I were to point to the high level changes, it was about changing everybody's risk and incentive frameworks. For example, I wanted veterans to have a really good digital experience, yet the VA didn't believe that veterans used the internet. There were twenty million veterans in America. We had an online form where you can enroll in VA health care, and only eight veterans had ever used it, out of twenty million. Not eight million. eight!
And the VA was like, “Look, this is data that says the veterans don't use the internet.” I thought that couldn’t possibly be true. What I did wrong was argue a lot from an emotional perspective. And what happened? We're on the front page of The New York Times because of the Inspector General. I credit the Inspector General here a lot more than The New York Times.
The IG said, “There's a backlog of 800,000 veterans who are trying to get VA health care. All the 800,000+ pending applications are sitting in a warehouse. And we've estimated that 100,000 of those veterans are dead. They died waiting to get into the VA.”
That created a moment where the VA said, “This is the thing that we need to focus on.” But the VA was going to do what it always did: more mandatory overtime. It was going to solve this problem by saying, “Anybody that can type the applications into the system will do 20 extra hours of work per week.” Simultaneously, my colleagues had gone out to record veterans with their permission in the D.C. area that were trying to apply for VA health care. We were trying to understand their experience.
We met this gentleman named Dominic, who I promise was not cast. But I couldn't have cast someone better. He was funny, smart, tech-savvy, but also homeless and unemployed. He was representative of the kind of veteran we're trying to help the most, but wildly self-sufficient and personable.
And he tried, while we recorded him, twelve times to get VA health care. He was rejected all twelve times! By rejected, I mean he tried to open the website and it didn't open. He went to the library. He got one page open, but then the next step didn't open. He called the VA: we hung up on him. It was this unbelievably horrible experience for him.
You might think, after watching that, that he didn't qualify for VA health care. But he did. We cut a two and a half minute video of his experience trying and failing.
We didn’t stop the VA from doing its mandatory overtime approach. But what I wanted to try as a pilot was this: What if we also put a mobile form on the internet that worked? The video of Dominic proved that some veterans did want to use the Internet, but they just couldn't get through. It also proved that lots of veterans hadn’t even made it into the backlog. Dominic never even got that far. So that video also was terrifying. How many more than 800,000 people are actually trying to get in? When we gave Dominic our new form to try out, he said he’d use it over anything the VA had to offer. That was a pretty nice endorsement.
We were desperate in the face of the Inspector General. This pilot program with a basic web form seemed low risk and possibly high reward.
And since launching that little form, two million veterans have used it to instantly enroll in VA health care. It's amazing.
And that was 2016, not even ten years ago. If you think about the risk and incentive framework there, we didn't try to stop the tankers from moving on their usual path. We carved out a special space over on the side that seemed low risk. And we had to prove it with data, which I think the government broadly doesn't use.
I would attribute a lot to the secretary we worked under. Bob McDonald had previously been the CEO of Procter and Gamble, a consumer goods company that’s very consumer-focused. But he also understood that it was possible to measure consumer experience. That was the lever that had been totally missing. Nobody was measuring anything at all. Sec. McDonald started tying measurements to performance plans. Now your ability to keep your job, get the promotions that you want, etc. are all going to be related to improving these customer service numbers.
It was a little rocky at first. But it's pretty clear now at the VA how you improve your career. They gave people the ability to solve problems in ways that are in their best interests. That was the real key to making change. Now the VA has plenty of room to go, but it's a very data-driven agency.
Besides using readily accessible data, what are the other lessons learned?
Seeking out the end user experience. At the beginning, the VA believed it was against the law to talk to veterans because of something called the Paperwork Reduction Act (PRA). Myth busting around the PRA is one of the most effective things that the US Digital Service ever did. People who were interested in talking to constituents believed that it was against the law. So of course, they were definitely not going to do it.
Can you explain the PRA?
The PRA came out before computers were widely used. The intention of the law, as with many things, was totally good. It aimed to reduce the paperwork burden on the average American from the government. You didn't want every agency and department sending you an 18-page form that you had to fill out.
Anytime you wanted to survey more than nine people, you had to send your information collection to the Office of Information and Regulatory Affairs (OIRA). Nine is really small, but it was by design. Basically every form would have to go through OIRA. But now we're in a world of computers.
User experience and user surveys were not even really a concept back when PRA came out. But this regulation — you can't talk to more than nine people — became interpreted widely as you can't talk to more than nine of your constituent end users. The thinking was that if the VA talks to more than nine veterans in a year, it would be breaking the law.
How did the U.S. Digital Service help debunk myths about it?
They talked to the attorneys who are responsible for interpreting the law. They got the Office of Management and Budget to publish a memo explaining that user research was not meant to be covered by the Paperwork Reduction Act. It was explicitly exempt from it. User research was actually encouraged.
You talked about the power of storytelling — a real person on video failing to get through the application process. How much did that matter?
I think a lot. So many people did not realize that was happening at all. It was partially a barrier of the PRA — people thinking they couldn't talk to end users at all. Even outside of the PRA, I think a lot of people still wouldn’t talk to customers. It’s uncomfortable, right?
You have to go talk to strangers. They might have a bad experience. It requires certain extroverted skills. The storytelling was definitely important. Having skilled user researchers that can talk to people, they can lift up their insights, and also that can assimilate them. When people think of “user research,” they sometimes think about a town hall meeting where crazy people get up and talk in the microphone. That's not user research.
People have been turned off from getting public participation, because it's either the crazy town hall meeting or it's the Federal Register. In order to even leave a comment, you have to know that the Federal Register exists. You have to know how the schedule works. And you have to know all these nuanced things, which means very few people ever do it. We don't have a lot of great mechanisms yet as a government to get quality feedback at volume.
What kind of guidance would you give to yourself on the first day of your job?
I got this advice, I didn't follow it, and I should have: you really need to just go around and have coffee and lunch with people. They will explain to you how the place works. While bureaucracies aren't people, they are entirely made up of people.
And to hold your North Star in mind. Fundamentally, I wanted a veteran experience that didn’t suck. I wanted you to get all the benefits which you are entitled to, without ever actually interacting with the VA, if possible. In my ideal interaction, you don’t interact with the VA: you just get money in your bank account. But you have to hold on to your North Star because you'll have to make a million compromises on your path there. It was a lot of negotiation and bartering.
Tell us about your foster care work.
I’d joined the VA as a political appointee, so I knew the day my job would end, at the end of the Obama administration, from the moment I got the job. Richard Culatta had gone on to be the Chief Innovation Officer for the State of Rhode Island, and he called to say they have a broken foster care system. Could I come check it out?
I went out and I talked to foster parents, I think literally that afternoon. We were just problem scoping, I was not working for them. But I asked the local foster support group if they could connect me with some people and if I could buy them a cup of coffee. I also gave them each $25, because it's important to compensate people who spend their time with you.
Immediately, I saw some opportunities. The senior leaders were saying they were having trouble recruiting enough foster parents. But talking to the families, it became immediately apparent that Rhode Island had actually recruited a whole bunch who were then dropping out.
I wanted to learn, “Why are you dropping out? Where are you going?” They said, “Look, I signed up, I went through this big commitment to get licensed, and then I’d call and ask if they got my cat's vaccination records, or if there’s training on Tuesday, and the person answering the phone would have no idea and wouldn’t call me back. If you're going to treat me like that, when you're recruiting me, how are you going to support me when I have a kid in my home?” They had an 83% dropout rate.
I realized we could make a spreadsheet of foster parent requirements, throw it on the SharePoint, use the tools that they have at their desk so that when staffer answers the phone, they could tell the foster parent the answer, or at least make a database entry with their phone number in a way everybody else in the office could see. We did some process mapping.
We built a spreadsheet, which is not exactly advanced technology. but the dropout rate went through the floor, because now when foster parents called someone could answer the phone and answer their question. Nobody had been talking to the foster parents about why they were dropping out. As I started poking around Rhode Island foster care work a bit more, I heard about a challenge with California’s child welfare system.
And here’s what was eye-opening: I had asked Rhode Island why it wasn’t doing these three practices, and they'd said it was against the law. California was clearly doing those three things.
So I started facilitating the world's simplest Zoom between California and Rhode Island, and California explained why the three things Rhode Island thought were illegal were in fact not. Then the opposite happened. It's very hard for states to talk to one another, let alone to talk to 50 states plus Puerto Rico and DC. So I cold emailed Washington, saying, “Hey, I'm creating a working group, would you like to join?” They said, yes, absolutely, we'll send a representative.
Every month, we picked a very specific topic. It might be “How to use social media for kin finding,” or “How does your background check process work?” I would just talk to the state worker like a human, and spend an hour doing user research. Then I would bring everybody together and say, “Washington has this kind of cool solution for this. Michigan said this was against the law, so we should all explain to Michigan why it's not.” That repeated every month, and now my group is in its fifth year and includes 43 states.
People really wanted to help kinship caregivers. In foster care, there are two kinds of caregivers: you can be a regular foster parent, a stranger to the child. Or you can be kin: grandma, aunt, uncle, baseball coach, somebody that the child knows. Every piece of research shows that they are better for kids. When kids live with people they know, it dramatically reduces the trauma of being removed. Every metric is infinitely better with kin. But state kin placement rates were really low. Even if they did place with kin, they paid almost none of them. As a result, we’d keep having to disrupt placements. Foster parents would say, “You just put three kids in my house, they eat, they need clothes. I'm on Social Security. I'm trying desperately to do this, but I can't.”
I kept hearing these stories, and knew there must be a solution here. From the VA, I’d learned the trick of following real people trying to get licensed and of following the workers licensing them. For two years, we did this.
It turned out tuberculosis tests are a real obstacle: you have to get childcare, take time off work, get transportation, and pay for a medical appointment. This was happening in the pandemic. The deep irony was, it didn’t matter if you test positive for tuberculosis, because the requirement was just getting the test. It didn't matter if it was positive.
Then I worked with the Washington State Department of Health, and they said, “Oh, we haven't required that since 1988. Why are you guys still doing that?” I went to Hawaii, and they removed it, I went to New Mexico, and they removed it. Dominoes started to fall. I started going requirement by requirement around states, trying to remove the really problematic ones.
The whole time, I kept sharing information up to the federal government about how kinship licensing is so problematic. It has been federal law that you have to have the exact same licensing requirements for kin and non kin.
Finally I realized that the federal law needs to change to allow separate licensing. States need the flexibility to say, “If you’re grandma and you’re safe enough to place, you should be safe enough to pay.” And if you're not grandma, then yeah, it does make sense for strangers to have more stringent requirements.
We shared all this user research, all the work we'd already done to get states to help themselves, and highlighting places that just couldn't make any more forward progress. On February 14, this year, the feds published a draft new rule. Because I had all these relations with states, I got all the states to write comments. So we had 161 positive comments, and it's very rare to get many comments at all, let alone all positive from states.
While the law hasn't been finalized, yet, we are very optimistic. People think that federal legislation is some sort of magical fix. In this case, I like the new verbiage. It was changing one sentence.
What was unexpected for you during this career phase?
States don't have ways to talk to one another. Our play wasn’t particularly unique: I have a working group, I talk to people in different states, and I connect them. This could work so well for unemployment insurance, like Medicaid, SNAP benefits, anything.
A lot of what I do is I connect. If I’m talking to Kintaro in Hawaii, and he mentioned something to me about struggling with XYZ, I’ll remember Montana did that last year. That makes us not very scalable, because most of this lives in my brain.
People think that states talk to one another a lot more than they do, and that states have more interest in implementation details than they actually do. I learned that probably in year two of this work, because I kept running into bizarre barriers. When I started this work, a requirement for foster parenting in most states that you'd have to have county run recycling services. What does that have to do with fostering or being safe home? Nothing. Where did this come from? It was too specific for all these states to have come up with it separately.
It turns out there was a report called the Recommended Model Licensing Standards from the NARA in 2016. The states all copied and pasted from it. If you talk to the authors of that report, they’ll say they never meant for it to be copied and pasted.
Knowing that now, we are publishing a new report that is literally designed to be copied and pasted. It seems like the least risky path is not to give them a 240-page PDF, it's to give them the literal form that I want them to use, and then they can copy it. I'm really excited about the change that will be possible in the next year, because states are ready. They're saying, “If you're making a new safety form, Marina, we’ll just take that one.”
You emphasized earlier that these bureaucracies are made up of people, and sometimes people are just lazy and they copy and paste.
Sometimes lazy, but often crazily overworked, and often very risk-averse. We want to leverage that: are you going to make up your own safety form, or are you going to copy Marina's nationally endorsed safety form? That's what I want them to do.
This is interesting, given your background as a libertarian. How do you think about that?
Government is still going to exist. If I can get inside the belly of the beast and make it work, so that it's not harming children in foster care and their future caregivers, and it's not harming veterans. It feels like a win. In theory, government is smaller like this, because you don't need licensing workers anymore for kinship caregivers.
There are movements to fully privatize the VA, and movements to abolish child welfare. I just don't know how to do that. But I know how to make certain parts of the system work better.
This interview was lightly edited for clarity.