Allowing more veterans to see private doctors has been touted for years as a solution to a difficult problem.
The Veterans Choice Program was enacted by Congress in 2014 amid a scandal over the length of time veterans were awaiting care at several Veterans Affairs hospitals. The scandal also led Congress to order a review of the Veterans Health Administration, which is the main branch of the VA and the one that oversees its hospitals. Assessors from RAND, McKinsey & Company, the Centers for Medicare and Medicaid Services Alliance to Modernize Health Care and other think tanks looked beyond the headlines and visited 87 VA sites, including 38 medical centers. That was out of a total of 1,600 health care sites the VA oversaw in 2014, among them 167 medical centers. The VA employed about 300,000 staffers and cared for nearly 6 million vets. Compared to vets who get care elsewhere, those the VA serves tend to live on lower incomes and in rural areas, to be in poorer health and to lack access to other health insurance.
The independent, outside investigators found that on average, a veteran in 2014 spent 43 days awaiting an initial primary care appointment, with a range of between two days to four months. “Comparison from a review of Massachusetts physicians in the civilian sector showed average wait times of 50 days for internal medicine and 39 days for family medicine appointments,” according to the report to Congress. “This suggests that on average the (Veterans Health Administration) is not that different from the civilian sector.”
But the VA has promised vets exceptional care, not merely average. In part, the researchers blamed Congress for the agency’s inability to make good on that promise, citing the 1996 Veterans’ Health Care Eligibility Act, which was meant to keep the VA within budget and created a confusing tangle of categories to ration care.
“When demand exceeds capacity to deliver care within the budget, the inevitable result is a decrease in access to care and unmet demand for some veterans,” Congress was told.
Like the investigators whom Congress asked to look into the VA, I thought it would be instructive to visit one of its health centers during the time I was working on my book, Home of the Brave, which I completed in 2016.
As I walked halls lined with gleaming linoleum at the 64-bed Grand Junction Veterans Health Care System in western Colorado, staff kept pointing out what was lacking. No ophthalmologist. No dermatologist. No audiologist. No equipment for mammograms or dialysis. Grand Junction, a town of 60,000, had no liver specialist, civilian or VA. One staffer, a note of exasperation in her voice, spoke of a patient who needed an adjustment in her hearing aid, and would have to go to Denver, 240 miles east, to get it. The first available appointment was three months away.
Directing vets to private doctors, though, can sound a bit like counseling them to eat cake, particularly in rural areas. The congressional researchers reviewed a project called the Reaching Rural Veterans Initiative in Pennsylvania and found that private primary care providers to whom the VA reached out frequently lacked knowledge and awareness of PTSD _ sometimes called a signature ailment of those fighting in post 9/11 conflicts. Those providers also were unaware of treatment resources available at VA that might help their veteran patients.
The situation in rural areas is of particular importance when it comes to vets, who are more likely than the general population to live outside cities. They could simply be returning to their small hometowns, where the high rates of signing up for military service may be traced to a combination of patriotic tradition and economic necessity. Some vets have told me that returning warriors deliberately seek solace and calm in isolated, sparsely populated areas.
According to estimates from the Department of Health and Human Services’s Substance Abuse and Mental Health Services Administration, a third of veterans live in rural areas, while overall a fifth of the U.S. population lives in rural areas.
Some rural Colorado communities have no psychiatrists to treat anyone, vet or not, Denver Post reporters discovered in researching a four-part series on mental health published in 2014.
“Each year in Colorado, about 260,000 adults and children need treatment for the most severe illnesses - schizophrenia, bipolar disorder, major depression and serious emotional disturbances. Yet tens of thousands go without care; nationally, only about a third of people who need treatment get it,” the newspaper reported.
When I visited the VA medical center in Grand Junction, its chief of staff was preparing to step down from that position so he could work as a cardiologist, part-time for veterans at his hospital and part-time for civilians nearly 200 miles away in Steamboat Springs, a town of 12,000 with no heart specialist. A VA staffer who can build and fit prosthetics sometimes performs those services for civilian as well as veteran patients.
Paul Sweeney, the spokesman for the Grand Junction VA hospital told me: “Partnering is something we’ve done a lot of here. With rural facilities, it comes down to being creative and using what you have. Many times, we realize we have the ability, but have to figure out how to put it to use.”
Grand Junction offered lessons in collaboration and creativity that should be kept in mind as America seeks to improve care for its vets.