Scapegoat?

English: Official image of Secretary of Vetera...

English: Official image of Secretary of Veterans Affairs Eric Shinseki (Photo credit: Wikipedia)

Relative to the VA scandal, there is much to ponder. Even MSNBC’s sainted Rachel Maddow said the other night that it is “a test of government”, or words to that effect. Why does Medicare work and the VA healthcare system not?

None other than retired Colonel Jack Jacobs, recipient of the Medal of Honor, has written  a startling essay urging that the VA healthcare system be abolished and that veterans be afforded access to the regular system under a system modeled on Medicare. Big bureaucracy as a tool of government has clearly failed in this instance. Why is that? Is it because the VA is too big to manage, or is it fixable? I think there is more than mere size at issue here. There are other large bureaucracies that are successful, after all, including the Armed Forces, Medicare and Medicaid. They’ve got their problems, but on the whole they do a good job with relatively little corruption.

From news accounts I gather that General Shinseki, himself a wounded veteran, may have been overgenerous in seeking to treat difficult mental conditions like PTSD. There is no test for PTSD, nor for most other mental disorders. It is subjective. Blood tests don’t identify mental illnesses, nor MRI’s nor EEG’s. The doctor asks, “how do you feel” and proceeds from there. On the other hand, there’s no doubt in my mind that PTSD is real and is often debilitating. It arises from trauma and while more commonly caused by the stress of military service, I ‘m confident it is widespread among civilians as well, just not as much so. Causes don’t have to involve violence – stress alone is enough, and especially prolonged stress.  Vulnerability is a continuum. “Going postal” is symptomatic and “domestic disputes” derive from a common form.

So, Shinseki loaded his bureaucracy with difficult, maybe impossible work, and at the same time applied pressure to demand results. For carrots, he implemented a bonus system and dangled promotions rewarding good patient through-put. For sticks, he held doctors and administrators accountable for not meeting standards. But patients are not widgets and doctors aren’t soldiers.  Pills have a woeful track record for fixing mental problems.  That’s my sense of why the system broke down. Who was it that said, “the road to hell is paved with good intentions”?

MentalHealth-HeadGraphic-250px_2

credit: umc-gbcs.org

All this is preliminary. Teams are searching for answers. But I think at this point Congress is wrong to judge Shinseki or the VA administration too harshly. Those who deliberately falsified or destroyed records and hid appointment data need to be held accountable.  That was criminal.  But we need to be careful not to destroy the good with the guilty. In the meantime, however, Colonel Jacobs’ suggestion deserves respect and consideration, and I hope there will be a renewed national interest in mental health. President Obama has been pursuing improvement in that since last year and has declared this month, “National Mental Health Awareness Month, 2014.” I hope the VA crisis results in more than mere lip service to this serious problem.

Modern medicine has convinced most people that it can handle almost every problem.  This is due mainly to the invention of antibiotics and anesthetics.  Mental health is a different and formidable challenge.  If we spent a tenth of what we now do on foreign intervention and nation-building on mental health research, just think what a different world it might be.

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About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Independent, tending progressive as the GOP recedes from its Eisenhower roots.
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17 Responses to Scapegoat?

  1. This story is so disturbing. I just finished teaching my students about problems Vets had after Vietnam, specifically access to VA benefits for mental health and other combat related illnesses, especially with Agent Orange. They were horrified and one commented, “Well I’m glad we don’t do that today.” That led to another upsetting discussion about the revelations coming out of Arizona.

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    • Jim Wheeler says:

      @ Indiana,

      Disturbing or not, Jen, you are doing your students a service by exposing them to controversy and real news. I’m confident that with your help they are discovering that reality history beats reality TV every time. 🙂

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      • The author’s argument begins with the assumption that Gen. Shinseki loaded the VA with insurmountable problems. False. I could argue with the author on this point since the Navy borne what we know today as VA with a mandate to treat ‘shellshock’ the once used now outdated symptoms of PTSD. That was a very long time ago. Shake the dust off this issue and you will find Pres. Reagan’s term cutback VA clinical service 180,000 staff mostly on the hosp side. Following were another 400,000 during Clinton-Bush. Total: 600,000 cut from the hosp program. Meanwhile, the civilian side (1980’s- )was having its healthcare revolution going into high gear when the Olmstead decision was made requiring state hospitals to deinstitutionalize; during the 1990’s it hit its peak. Patients died? Yes. Was it a good decision? Probably, because without Olmstead we would still have psychiatric dungeons. Why Pres. Clinton-Bush did not take the opportunity and propose the VA follow suit is a question for them and their secretaries of human services. Instead, Clinton-Bush stuck with the famed (not nec positively viewed) VA Secretary Kenneth Kizer who invoked a corporate scheme that would limit hosp stay and cut beds. People died from early discharges? Yes. Absolutely. By the time this Pres. and VA Secretary came along all PTSD units including the Vet Center program was not recognizable clinically. VA that once trained 90% of US doctors lost most of its academic medicine program, New York was one of the few states that required all VA mental health and PTSD clinical staff to also hold state licensing. State license breaches are hell and investigations tough, but the VA escaped this because of unwilling states. Call around to VA PTSD and Vet Centers- its now worse than ever outside NY-many mental health clinicians simply left in disgust or to make more money. This left a vacuum in VA that lesser qualified staff have filled-because what has killed the VA under a long planned closure was that it became a haven for the lesser qualified. Navy Secretary Jim Web concluded Affirmative Action trumped academic qualifications in non combat veteran job appointments. Will patient die? Yes. Col. Jacobs speaks for many veterans. It is safe to say that PTSD lasts 10 yrs. The clinical crisis is hearing loss. An unpublicized truth is the VA became a proponent of PTSD during Reagan as a measure to keep its funding level and fight Reagan’s policy. In its zeal, the VA used all sorts of ques. marketing that scared the public resulting in many combat veterans hiding their Vietnam service. Now we know today that 20% of combat veterans get PTSD and many of them resolve these symptoms in 10 yrs. Not so for Agent Orange. But a little publicized research study during the Clinton era by the VA showed the highest incidence of combat injury was hearing loss (which went hand in hand with shellshock). Many allegations were made Clinton admin officials hid this fact or the VA questioned its validity. When Centers for Disease Control reviewed it it was shocking. Hearing loss, living in a silent world forever, far outweighs the number of PTSD patients, but as during Reagan, the VA moved forward with their Vietnam PTSD fear campaign playbook. Not to say that any medical condition a combat veteran has should not be treated, but lets not choose one above the other. Citizens have already chosen to close the VA by donating $17 billion to nonVA programs last year, and by the looks of things the USA is returning to the idea that the VA needs an Olmstead revolution like the civilians had in the 1990’s. So lets get at it. Col. Jacobs proposal is just what the doctor ordered and is 20+ years late.
        Robert Osenenko
        author, Family Faith Land and Mysticism

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  2. Jeff Little says:

    My understanding was that the Veteran’s Administration was a dismal failure in terms of keeping service times down, but a smashing success in terms of keeping costs down. I know that throwing money at something that is not working is frequently a bad idea, but might this be an exception? Could just throwing a bit more money at this problem fix it?

    Note that there has been a consistent pattern of under-funding programs that the “business community” doesn’t like and then pointing fingers at the inevitable rough patches. The classic example of this occurred when Congress passed regulation requiring the Post Office to fund 50 years of retirement benefits and then try to get rid of it based on debts. Another example occurred when Congress cut 320 million from the budget that was to provide embassy defense and then talk about impeachment over Benghazi-Gate even though the number of Americans killed in Embassy attacks is a tiny fraction of what it was under Bush Jr.

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    • Jim Wheeler says:

      You raise some good points, Jeff. I am already seeing evidence in the news that Shinseki’s power to hire and fire senior civil servants was too limited. When Army generals say to the troops, “forward march”, the response is immediate and certain. Orders to bureaucrats, I know from experience, are a different matter. And while I agree with your comments about funding, the elephant in the room is mental illness and no amount of money is going to solve that quickly. It will take longer than any congressional cycle, and therein lies the problem. Thanks for commenting.

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  3. IzaakMak says:

    Great post Jim. As a VA Mental Health patient myself, I know that treating those issues require a lot of resources, and that the efficacy of that treatment can be very difficult to judge. Maybe such a heavy focus treating things like PTSD, without the necessary budget increases needed to prevent other areas from losing out in the process, wasn’t such a good idea. Perhaps the need for those budget increases should have been stressed more before going ahead. At any rate, that need should be strongly argued now.

    As for abolishing the VA healthcare system as a whole, I’m not exactly sure how a move like that would work. After all, the VA owns a lot of property dedicated to its mission, and many thousands of people are employed at those facilities – many of whom have received specialized training in dealing with the health issues faced by vets. Scrapping such a system, while expanding the rest of the healthcare system to pick up its very large slack, strikes me as a tall order indeed. A tall order I have little confidence our government can fill.

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    • Jim Wheeler says:

      @ Mak,

      Your point about the VA having special expertise in certain areas is important. It made me think of prosthetics, for one thing. One would think they would also be getting a handle on PTSD too, given all the business they’ve had in that area, but I’m not aware that’s the case. Maybe this scandal will boost some serious R&D in that area – let’s hope so. Good to hear from someone who has actual experience – thanks.

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  4. Jim in IA says:

    You make some excellent points. I have no experience with the VA first-hand. But, I agree, it is possible to organize and run a large system so it does reach important goals in its mission. In this case, I would not expect our legislators to formulate the fixes. They are too disfunctional to expect them to work together toward that goal. I would assign a special commission made up from many of the people who actually work within the system. Give them opportunity to voice how they see it could be done better. Then, accept and implement those changes.

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    • Jim Wheeler says:

      Congress is no source of creativity, that’s for sure, but they do love to criticize. It gives the appearance of progress without having to actually produce it. In that context, your suggestion sounds good to me, Jim. Your comment reminded me of one of the “related articles” I put at the end of the post, “The Comfortable Feeling of Rolling Heads”. In it, blogger Solod ends with this:

      Further inquiries will be held and outrage will continue to mount until something concrete is done. This is not a new issue. But firing Shinseki is like providing palliative care for end-of-life patients: the patient will be more comfortable but he will still die. Any investigation into the VA has to result in major changes to the system as a whole which will not be possible if the problem is “solved” by yet another head rolling.

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  5. Jim,

    Another thoughtful presentation and one that doesn’t throw rocks at the guilty as others are quick to do.

    As I read through the post, I couldn’t help but think about a movie called “The Best Years of our Lives.” Released in 1946, and subsequently winning 7 Academy Awards, including Best Picture, the film is about 3 vets who return home from WWII and the difficulties they face adjusting to new lives. One of them, Homer Parrish, played by Harold Russell, a real vet who lost both hands in the war (and also won and Academy Award for his role), gives us a heart-wrenching look at his personal courage, his frustration with his handicap, and the self-deprecating person he became believing he would never be worthy of the love of a woman. It is an awesome performance.

    The other two vets are played by Fredric March and Dana Andrews. These are the guys that have what we now call PTSD. Besides Homer, the movie follows these two as they try to go back to what they were before the war, how those efforts affected their families and friends, and, of course, how they too were changed forever.

    Shortly after its premiere at the Astor Theater, New York, a film critic for “The New York Times,” hailed the film as a masterpiece. He wrote, “It is seldom that there comes a motion picture which can be wholly and enthusiastically endorsed not only as superlative entertainment but as food for quiet and humanizing thought… In working out their solutions Mr. Sherwood [screenplay] and Mr. Wyler [director] have achieved some of the most beautiful and inspiring demonstrations of human fortitude that we have had in films.”

    It long, almost 3 hours, but definitely worth it. And if you’ve already seen it, watch it again. Think of the VA debacle as you watch, then ponder how much our human values have changed in the last 68 years.

    Herb

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    • Jim Wheeler says:

      Herb, believe it or not, I remember parts of that movie. I was a sensitive 9 years old in 1946. I understood it well enough that it scared and depressed me. The Best Years of our Lives no doubt served a purpose in improving public understanding of veterans’ problems, and it probably didn’t hurt the politics of expanding the VA to 5 times its former size after WW II. But those were times when the two parties actually cooperated, eh?

      I’m not sure that “human values” have changed in the last 68 years but it’s sad that so little progress has been made on PTSD. I can think of a couple of other things have changed. For one, battlefield medicine and helicopters have vastly reduced deaths but increased the percentage who survive with ever more debilitating handicaps. Another is the cultural nature of the military itself. Although still outwardly revered for its service, it is separate from the general population now. I have a sense that this promotes program funding but also makes reintegration in the civilian population more difficult. I’m not certain of the latter though and would like to hear from anyone with that experience.

      Thanks, Herb, for the cinematic memoir. Good one.

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  6. PiedType says:

    An excellent, thought-provoking article about a large, complex problem. The fix, I’m guessing, will require a multi-faceted approach. More money, surgically applied to specific problem areas, will help. Mak makes a good point: special expertise for vets’ problems needs to be kept. Another suggestion I saw on a talk show was to let vets who are not within easy reach of a VA facility go to a regular doctor (with a system whereby the VA still pays for it). And as you point out (correctly, I think), if PTSD and other mental health problems are what’s snarling the system, then the “fixes” need to address that area specifically. Mental health care is expensive and time consuming. Diagnosis and treatment is very subjective. And this is just as true with the general public as with vets. America as a whole needs to give much more attention and funding to mental health. We’re paying too high a price for ignoring it (eg, Newtown, Aurora).

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    • Jim Wheeler says:

      Thanks for reminding us, PT, that mental health is not just a veterans’ problem but that it is endemic in the society at large. As Herb pointed out, the problem was well known in 1946, and before, but there has been little progress. And, as you say, the costs are enormous in both quality of life and money.

      BTW, I heard in a podcast recently that there is considerable anecdotal evidence that THC is actually effective in treating PTSD. You Coloradans may be on to something out there. (Or is is just “on something”?) 🙂

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      • PiedType says:

        Not surprisingly, I’ve been hearing more about the medicinal uses of THC, but I’m not sure I’ve heard PTSD mentioned. I guess we’re going to be the nation’s laboratory for THC uses.

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  7. aFrankAngle says:

    Great post about the massive entanglement known as the VA. You were fair, but who knows the solution. One would think that the VA could be an example of Congress getting on the same page … but of course they can’t because the focal point is entrenched on the next election.

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    • Jim Wheeler says:

      Right, Frank. The politics of the VA scandal makes it especially tempting for the GOP House to force Shinseki out because it would force the Democratic administration to find a replacement and then try to get them confirmed, thus keeping the mess in the public eye for a long time. Reminds me of the kind of thing Francis Underwood might plan.

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