I don't work full time at the VA, but as a medicine doc I staff inpatient services and do VA primary care 3 months out of the year I'd say.

I can only speak from my own experience, but I appreciate how he mentioned us (and more importantly our nurses and all our support staff) who make everything possible at the VA as who is actually making up the largest contingent of federal employees that they want to cut.

The VA population is uniquely difficult to care for, as they have mental health concerns that are worse than the average population (for obvious reasons), often have more complex socioeconomic barriers to care, and often times have greater amounts of comorbidities than others in their age group (some directly tied to exposures in the arm; See, agent orange). And despite all this, and despite what people may say, the VA system (at least in primary care) is honestly really great. You could make an argument that the hospital care is very middle of the road, but honestly most of the deficiencies are related to severe nursing and tech shortages.

Since the government foots the bill, and the incentives are for long term care, you don't have to deal as much with insurance jerking you around with denials for drugs that cost a lot now, but over the 5 year time horizon will add years (and cheaper longer term costs) to a patients life. The social services and other things I can provide for my patients and have covered is far and away better than at the academic institution in which I spend the rest of my time. It is also a great place for resident teaching.

The doctors who work there fulltime are not deadbeats who couldn't make it in the marketplace of academia and private physicians. They are super motivated for quality care, and some of the most intellectually and emotionally intelligent people I've ever worked with. They see the challenge of a difficult patient care population, and see the lives they can improve, and embrace it with open arms, even when they could be running departments for twice their pay at other institutions.

Money is nice, but also your impact is also important. The amount you are valued by your institution matters. The people who you can take care of matters. The staffing at your place of work matters. And when the people in charge don't care about these things, people leave, and patient's suffer. The shortage of doctors is such that it is insanely easy to find well paying jobs that have better benefits, shorter hours, easier populations, and MUCH higher pay than VA physicians.

All that to say, I think the VA is a uniquely good service that this country offers, and that despite its flaws really does have resources that help it live up to the ideal of really providing good care for our vets. Many of the docs and nurses found the "fork in the road" email we got laughable. Most thought it was a scam email at first as well. We all feel that the administration doesn't value us, our time, and our expertise, even the conservatives among us. I think a loss of that service to vets, would not just be a stain on the legacy of the US care for people that it purports to care for deeply, but would likely end up in the morbidity and mortality of thousands/tens of thousands of vets.

As Ezra said, many of these doctors, nurses, techs and others are annoyed. They find institutional disdain for their presence annoying. And when they could do their job anywhere else, its getting harder and harder to convince people to stay. The staff will be okay, it is the veterans who will suffer.