Posted on | August 2, 2014 | 3 Comments
The recent controversy over the performance of the Veterans Administration hospital and health system network isn’t the first, and certainly won’t be the last. With fresh casualties over the past decade of war overwhelming the system, the knee jerk reaction goes like this. In a nation whose non-VA hospitals are frequently running at half capacity, and where veterans have been forced to wait in line for basic services, why don’t we just main stream them into our existing system? Why do we segregate veterans?
The answer? It’s complicated.
A bit of history. The VA says their caring history dates back to 1776 – when the country extended pension benefits including half pay for life if you lost a limb or became seriously disabled – to their soldiers to lower the rate of desertions. There was one hitch, since the fed had no money, payments were left to the states. By 1789, the federal government caught up and assumed financial responsibility.
After the war of 1812, there were 2200 pensioners and we were feeling a bit flush. So we raised benefits a bit, and for the first time offered half pensions to spouses and orphans of deceased soldiers. The public responded favorably and by 1820 the number of pensioners had risen to 17,730 and the price tag jumped from $120,000 to $1.4 million.
This pattern of taking action, in the midst of a war or soon after, continued throughout the next two centuries, with benefits becoming more expansive, reactive care giving way to proactive and continuous care, and the VA eventually assuming responsibility for not only managing casualties, but burying them as well. The last responsibility, for national cemeteries, came after the Civil War, but only for Union soldiers. Seventy national cemeteries were established and 300,000 dead soldiers were located, buried, or reburied.
As WWI sunk in, with its 116,000 dead and 204,000 wounded, the sheer scope of the challenge forced a series of systematic adjustments. There was an attempt to develop skill sets in certain types of injuries like amputations or loss of sight or hearing. There was also a new emphasis on rehabilitation, and a recognition that many would never return to normal. For ten years there was debate over whether to call soldier subsidies pensions or compensation (with the streams only permanently segregated after WWII). And then there was the issue of neuropsychiatric casualties, which were so extreme in WWI that they led to a post-war full scale evaluation which inaccurately placed the blame on lackluster screening out of “defectives” at the time of recruitment.
While “shell shock” and residual “mental cases” were a reality post-WWI, they remained mostly in the shadows. In any case, in 1921, the government created the Veterans Bureau which consolidated the Bureau of War Risk Insurance, Public Health Service and the Federal Board of Vocational Education, but left the Bureau of Pensions in the Interior Department and the National Homes for Disabled Volunteer Soldiers under self-control. By 1924, the new department had reorganized with six divisions to cover medical and rehabilitation, claims and insurance, finance, supply, planning, and control administered out of 73 district offices.
The Depression brought special hardship for disabled veterans and their families. There were demonstrations and riots in Washington. In 1936, Congress bought a bit of calm with extra payments. By 1941, there were 91 VA hospitals, where there had been only 64 a decade earlier, with bed count rising from 33,000 to nearly 62,000. Early on in that decade, TB was a huge instigator of admissions. But by the end of the decade, neuropsychiatric cases filled over half the beds.
As the US ramped up for WWII, the Selective Training and Service Act of 1940, guaranteed reemployment after service for anyone who signed up. A new more comprehensive health insurance plan was also instituted for servicemen and vets that same year. Trying to learn from WWII, the armed forces recruitment became much more selective, refusing to enlist over 15% of the potential soldiers who appeared who they considered, with the help of psychiatrists at enlistment centers, to be undesirables – including those of “weak character” and homosexuals. And yet – with the first major campaign in North Africa – a higher percentage than ever were being shipped back to the states for “shell shock” and neuropsychiatric discharge. In response, the Army “crash-coursed” generalists (like my father) in psychiatric treatment of shell shock close to the battlefield to successfully stem the tide of psychiatric casualties.
With the end of the war, 671,817 casualties required medical care and reintroduction to American society. Initially, there were all sorts of issues, including not having enough artificial limbs to fill the needs. Gen. Omar Bradley, assisted by Maj. Gen. Paul Hawley, chief surgeon in the European Theater, was brought in to be the VA administrator. It was he who decided to affiliate VA hospitals with medical schools, with Hines Hospital in Chicago being first to agree. These emerging Academic Health Centers (AHC) were cash strapped. In return for partnering with the VA centers, they received an array of funding not only for clinical services, but also medical research grants and generous subsidies for medical education and an array of new specialty residencies. Before too long, there were nearly 125 VA hospitals with a bed capacity approaching 110,000.
With the end of the war, and the demobilization of 15 million American soldiers, even this much enlarged system was inadequate to the demand. With Korea, Vietnam, Iraq and beyond, the system continued to grow. Always in the shadows were two big issues. The first was neuropsychiatric disease burden, now with a common label, PSD, often tinctured with lifetime addiction issues. The second was financial dependency of AHC’s on their VA partnerships, through which they had expanded faculty, residencies and research labs. Add to these challenges, the post-WWII closure of mental hospitals and the massive de-institutionalization of the mentally ill, injected back into a nation dominated by a bias toward individualism and personal rights and armed to the hilt with every imaginable weapon, which together we honor as part of “American Exceptionalism”.
In 2005, the VA celebrated its 75th anniversary. It’s recent emphasis on leadership in development of primary care capability, its adoption of EHR’s and its committed clinicians had drawn a decade of praise. But now one decade later, they are once again overwhelmed with criticism. Such is the historic up and down of the VA system – reactive at times of war with heart felt expansion, recipient of a disease burden (especially mental health) covered up and understated by politicians and wartime leaders, entangled with academic health centers who are now dependent on this stream of resources, and wholly unable to manage extreme elevations of casualties which come with the end of our wars.
And we fane surprise? In 1930, the VA had 54 hospitals. At the time of their 75th anniversary in 2005, they had 157, with at least one in every state. In 2005, they treated over 5 million persons, a near 30% increase over 4 years earlier. They operated over 1300 care sites including over 900 ambulatory clinics, 43 rehab centers, 90 home care programs, and 200 Veterans Service Centers that had over a million visitors that year.
As for AHC dependence, consider these figures: In 2005, VA’s supported over 3800 researchers at 115 Centers, with nearly $750 million tied to research efforts. NIH and Industry added an additional $800 million. They were affiliated with 105 medical schools, 55 dental schools, and 1200 other higher education centers. They helped train 83,000 health professionals that year (for which they received a ample flow of federal and state dollars). And finally, nearly half of all physicians in the US had received some portion of their training at a VA hospital.
Why is the VA not an easy fix? Because the VA is us – with our tortured and tangled health system, our history of waging war, our enormous mental health burden and its ineffectual treatment, our weaponization at home and abroad, our massive academic medical establishment, and our spotty quality and high variability especially when exposed to high demand.
The only way to fix the VA is to fix us.
For Health Commentary, I’m Mike Magee