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”?
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.