The Mirror We Refuse to Look In

Andrew Donaldson

Born and raised in West Virginia, Andrew has since lived and traveled around the world several times over. Though frequently writing about politics out of a sense of duty and love of country, most of the time he would prefer discussions on history, culture, occasionally nerding on aviation, and his amateur foodie tendencies. He can usually be found misspelling/misusing words on Twitter @four4thefire and his writing website Yonder and Home. Andrew is the host of Heard Tell podcast.

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29 Responses

  1. Mark says:

    Aren’t there studies looking at outcomes that show the VA doing as well or in some cases better than regular health care? When I worked in the VA, I was struck that, yes, it did not emphasize the speediness of throughput that the private system does, but its clientele tended toward lower socioeconomic strata which is why they sought out the VA in the first place. Also, slowness isn’t always bad. A friend had three back surgeries in the private system. Each time he was out the same day and given a referral to a physical therapy provider in a different site. His pain continued. He got into a VA program which sent him to a hospital far away specializing in back problems. He was there for six weeks with daily rehab. He is fine now. No private insurance in America gives six weeks of in-patient rehab.
    Of course, there are issues, problems, and failures at the VA as in every other system. We should be vigilant for problems, but in fact the VA does pretty well for many.Report

    • Andrew Donaldson in reply to Mark says:

      The primary cause of doubt for outcome studies is the same reason the 2014 scandal was such a issue: when there is wide-spread changing, removing, or just ignoring data that makes the system look bad to protect positions, budgets, and status of those administering it, everything comes into question. And fairly so.Report

  2. J_A says:

    I have never personally interacted with the VA, but that doesn’t stop me from offering my own anecdote

    The father of a very close friend is a Korean War veteran. He lives just outside of Waco, TX. He is almost 90, with mild dementia, heart problems, breathing problems, and mobility problems. In the last three years he’s had four surgeries, including two heart surgeries. All this medical care provided by the VA.

    This is far more health care than most people could dream of in America, and much more that his family could arrange for without the VA.

    I’m sure there are tons of problems with the VA, but there tons (probably a larger number of tons) of problems with health care for those that cannot access the VA. Like the NHS on the UK, it’s probably the worst health care delivery system except for all the rest.

    Honest, non snarky, question: I wonder if PTSD might not be a major contributor to the feelings -probably not the right word- of frustration of many VA users, and might make the system look or feel worse than what it really is. Killing yourself, as you describe, is not how most non-veteran people react to care denials from insurance companies.Report

    • Em Carpenter in reply to J_A says:

      I would argue that that’s exactly why veterans need special care. Their issues are not like those that most of the rest of us deal with. As far as the great care some receive from the VA, I imagine it all varies by location and staff, as with most things. There are systemic issues though, and that is undeniable.Report

      • J_A in reply to Em Carpenter says:

        I fully agree that PTSD is a (or THE) major difference between veterans and the general public, and, therefore, PTSD considerations should be very high up in how the VA manages their patients.

        But, not an excuse, but a partial explanation, recognizing PTSD as a serious metal/physical problem and concern is something very new at all levels, and for which we, as a society, still don’t have the proper procedures clear. Barely a hundred years ago, shell-shocked soldiers faced the firing squadron as “cowards” .Report

        • Maribou in reply to J_A says:

          @j_a But there’s also this:
          “the suicide rate among VA patients is higher than that of veterans who are cared for elsewhere.”

          I don’t think that’s adequately explained by your suggested partial explanation.

          (I also think the idea that PTSD is the major difference between veterans and non-veterans fails to recognize how very common non-combat PTSD (and especially c-PTSD caused by serial childhood abuse) is in the “general public”, veterans and otherwise. But that’s probably too off-topic for this post…)Report

        • PD Shaw in reply to J_A says:

          I think PTSD is just a species of anxiety disorder triggered by trauma, which isn’t unique to vets. Back in the oughts, my therapist-wife was seeing some national guard members back from deployments through Tri-Care (which I believe is not VA, but DOD?). One of the things I remember her mentioning was she would get fairly regular e-mails through Tri-Care about ongoing PTSD research, particularly whether it might be caused by concussions and giving her resources. And the concussion angle is related to the sports injury area. And I don’t know that she was necessarily seeing someone for PTSD at any given time, once she was approved by tri-care as a provider, she was in their system.

          So I think its more that the military has particular interests, resources and networks that may be unique, and might improve our knowledge base and outcomes. But all that doesn’t have to relate specifically to a VA building.Report

    • Oscar Gordon in reply to J_A says:

      The thing to remember about the VA is that once you have navigated the bureaucracy and you become a ‘known quantity’, the VA works very, very well.

      It’s getting to that point that can be hell, especially if what you need is not something the VA can do, or is very good at. The system is very resistant to seeking outside help to treat it’s members, with a handful of exceptions*.

      *The VA hospital in Madison was connected, literally, via a skywalk, to the UW Medical school. UW Doctors and Med students would take rotations at the VA in order to help out, and the two hospitals had longstanding cooperative agreements so should a VA patient need help at the UW, they could be seen over there with a minimum of fuss.Report

      • This is how Duke University/Durham VA is, across the street from one another, and the latter full of residents and interns getting extra work in. Which is a good thing for Durham, but not a replicatable system for the rest of the country with few exceptions.Report

        • Oscar Gordon in reply to Andrew Donaldson says:

          Yep, and when it can be done, it can work exceptionally well. But it can’t be done everywhere. One nice thing is that (at least back in my day) VA hospitals can transfer patients within the system relatively easily. So if a vet in Milwaukee would be better served by the UW hospital in Madison, the Milwaukee VA could transfer the vet to the Madison VA, who could then get them seen by the UW pretty easily, rather than having the Milwaukee VA try to get the vet into the UW directly.

          But of course, the vet would have to be able to travel the hour one way to get to Madison from Milwaukee.Report

          • This of course gets complicated in rural areas. I was at a family event last weekend back home which had rented out the local senior center, and I was reading on the bulletin board all the different notices for veterans for transportation, since the two closest facilities are 58 and 79 miles away, respectively. The VA does compensate mileage, but you can imagine how problematic this is for those too old/infermed or without reliable transportation to do for simple appointments.Report

            • Oscar Gordon in reply to Andrew Donaldson says:

              Yep, which often means a choice between living close to family & friends, or living close to the hospital.

              One of the dumbest rules the VA has is the whole distance from care rule, which essentially locates a VA hospital and draws a big circle around it, and says “if you live inside the circle, you have to go to the VA before you can go to a private doctor.”, which is great, if you live in, say Kansas City. Near Seattle, the VA hospital is in Seattle, which sucks for people in, say, Bremerton, who now have to take an hour ferry ride to see their doctor.Report

            • J_A in reply to Andrew Donaldson says:

              But this is not a VA problem, it’s a deliver health care to rural communities problem.

              No matter how good the VA ever gets to be, there will be many people who are far away from a VA hospital. The fact that rural communities provide a large part of the armed forces for various reasons just makes the problem worse.Report

  3. Oscar Gordon says:

    I both love and loathe the VA. There were there when I needed them, to rehab my body, and my career. And the people in the VA are awesome, even though they are so constrained by the bureaucracy.

    But that bureaucracy… I recognize that there are a lot of good people there, which is why I only interact with them when it is absolutely necessary, so that I am not taking up time and resources that other people need way more than me.Report

  4. Kolohe says:

    The possibly hardest thing that the VA has the manage these days is that there are two main and very distinct patient tracks. There are all the recent veterans, with service related problems as a result of injuries received in Iraq and Afghanistan*.

    And then there is the Vietnam era cohort, which is *huge* (much larger than the recent vet numbers) and whose main problem is that they’re all now in their 60s and 70s and having the medical issues related to being in their 60s and 70s (and which may be caused, amplified, and/or correlated with being in Vietnam, but also most likely just being in the socioeconomic status who got drafted in that era)

    *and other places, but these are the overwhelming majorityReport

    • Elderly are rushing it, but also new type of patients the VA has had to redo how they do things to accommodate. Women’s health, many of them younger veterans, is one of the faster growing areas, and has had to be built nearly from the ground up over the last 20 years or so.Report

  5. Philip H says:

    Sitting in another part of the federal bureaucracy I’ll start my response with my usual, tired but still too often necessary plea – lets not discuss government as if the executive, legislative and judicial branches are some monolithic thing. Congress is the “government” and much of what federal agencies including the VA does is directly attributable to the vagaries of the debates and decisions of 535 people on Capitol Hill. The VA professional staff (from the Secretary on down to the custodians) are “the government” who are all filling important, overworked, and often unsung roles to keep the VA going. Sure, both rely on the other to complete the relationship and get the thing done, and you all may well be frustrated with both. Nonetheless, expressing your outrage at the appropriate part of government will actually go a long way toward solving these issues.

    Having said that – there’s no good way to fix whats only partially broken, unless we want to get serious about what we fund with tax money (which is revenue in government) and to what extent. As noted upthread, the VA deals with a somewhat medically and psychologically unique patient base, and as a result has to provide services that would span a great range of sub-specialities out here in the civilian world. That costs money, which must come to the federal government from taxes. While no one will tell the VA to cut services in a tax debate, reducing tax rates and running the debt and deficit further up does impact the revenue stream the VA has to rely on. Unlike the Southern Border Wall which the President promised us Mexico would pay for, we can’t bill the Taliban or ISIS fro the cost of fighting them. That’s squarely on us, and to pretend the VA has all the revenue it needs is folly.

    The VA’s failures and disincentives are also well documented bureaucratically, though I have yet to see anyone take on the herculean task of analysis of Congressional action (particularly budget) and its impacts. Our agency budget has essentially been flat since Bush II, which amounts to a 3%-3.5% cut per year due to inflation, and with operating costs (non-labor) escalating at a significantly higher rate. Thankfully the VA’s budget has done better in both absolute and inflation-adjusted dollars, but the population it serves has ballooned, and its non-labor cost are not shrinking either. It was also properly pointed out that many VA patients live in rural America, where their medical options are already limited due to distance form VA facilities, and rural hospital and clinic closings (which are on the rise).

    Sadly, however, we who rely on the stitched together system of private insurance and private medicine don’t do much better. Sure, you may be able to see your local doctor sooner, but your care won’t be any better, you may have long waits for a specialist, and you will still be subject to strict rules (generally financially based) about when, for how long, and under what treatment regimes you can see specialists even when referred. The only reason the matching inefficiencies of the private system aren’t as easy to see as the VA system is that non-VA healthcare is disaggregated. Trust me, however, those inefficiencies exist.

    Finally, all of this avoids completely the subject of why we have such a growing veterans population, needing ever broader terms of care. That’s definitely a political debate which I believe falls squarely on the shoulders of Congress, who refuse to check the President’s powers of the use of military force (and have for some time). The longer we are in indeterminate, semi-permanent wars, the greater the need for VA services remains.Report

    • Maribou in reply to Philip H says:

      “. Sure, you may be able to see your local doctor sooner, but your care won’t be any better”

      That’s…. not true. Seeing a doctor *sooner* often *means* better care all by itself. Most illnesses and injuries get progressively worse over untreated time.Report

  6. Maribou says:

    Thank you for writing this post, and thank you for writing it from a place of such vulnerability and openness.

    This is the kind of writing that keeps me caring for this site (both emotionally and literally).Report

    • pillsy in reply to Maribou says:

      Thank you for writing this post, and thank you for writing it from a place of such vulnerability and openness.

      +1. I’m still chewing on the piece and how (and if) I want to respond to it further, but it’s very good.Report

    • North in reply to Maribou says:

      +2 amazing piece but so utterly outside my experience that I can’t think of much to comment regarding it.Report

  7. This is a beautiful piece Andrew. Thank you.Report

  8. Mikkhi says:

    I watch the struggles of my veteran friends & their troubles with the VA Hospital in Temple. I’ve asked them what they think would do the system the most good & get back answers such as ‘slim down the bureaucracy’ or ‘quit paying bonuses for succeeding at actively clawing back veterans’ awarded percentages.’ Usually ‘and stop over-medicating’ comes up too. None that I personally talk to would recommend going to the VA if a vet has any other sort of medical coverage to rely on. But there are no easy workable answers, that’s part of the big problem. As long as we think we’re doing our part (and our continued involvement stops there) by throwing more money into a juggernaut, the VA system won’t find an internal reason to shape up. Why should it? It never had to before to get it’s budget, why should it start now?Report

  9. dragonfrog says:

    The scale of the VA relative to other government departments is not surprising to me.

    Alberta has a population of about 4.5 million, and the provincial government has a staff count of about 30,000, for all provincial government services. Alberta health services, which provides very nearly all the healthcare in the province and basically no other service, has 110,000 staff.Report

  10. Ozzy! says:

    I think the best question here, and one the above are disseminating from, is:

    Is the VA a good model for Medicare for all / Universal health care coverage in the US?

    To me, it is striking that the typical ‘wonk’ talking points for and against such a system are starkly noted within the experiences of just a few random people who frequent this website.

    The VA does help people!
    The VA provides services and has people working within the system to change lives!
    The VA is cost effective to the user (not much talk about cost of care, but that is a secondary point)

    The VA is a bureaucratic nightmare for most
    The VA fails people on a regular basis
    The VA cannot always provide the right care for the patient

    As someone who has healthcare, I’m a nope nope nope to that option. As someone who doesn’t have healthcare or cannot afford it? Sounds pretty great.Report

  11. Aaron David says:

    This was a very nice piece, Andrew.Report