Those We Leave Behind

Running head: THOSE WE LEAVE BEHIND !1

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Those We Leave Behind: Veteran Health Care Policy

Ian Witherby

Boston College

Graduate School of Social Work

THOSE WE LEAVE BEHIND !2

Those We Leave Behind: Veteran Health Care Policy

As of May 2014, more than 1.4 million Americans are currently serving in their nation’s

armed services. The apparatus of recruitment, training, and logistical support for America’s

soldiers, sailors, and airmen are well-known; what is not regularly reported or discussed are the

significant rates of psychological and emotional trauma suffered by so many patriots. Routinely,

service members are marginalized after they cease active service. This paper does not attempt to

value the Department of Defense’s efforts in managing our national defense; rather, it endeavors

to address a fatal mismanagement of post-combat veterans’ needs.

Problem Definition

Inadequate post-combat care for America’s veterans leads to a number of preventable

problems — which are exacerbated by public rejection, moral injury, and ideological differences

— at disproportionate rates when compared to the civilian population. Veterans’ needs are

fundamentally different from civilians’, and traditional methods of intervention are insufficient

in identifying and treating those issues.

One key indicator for mental health issues is suicidality; although they comprise 1% of

the population, Kemp & Bossarte claimed in 2012 that veterans “comprised approximately

22.2% of all suicides reported” in a year.

Risk of suicide is exacerbated by alcohol and substance abuse. In collaboration with the

National Institute of Health and the National Institute on Drug Abuse, the Millennium Cohort

Study found that

Reserve and National Guard personnel and younger service members who deploy with

reported combat exposures are at increased risk of new-onset heavy weekly drinking,


binge drinking, and other alcohol-related problems. Results also suggest an increase in

smoking initiation and relapse among those deployed.

(National Institute on Drug Abuse, 2011).

A Department of Defense survey from 2008 also found heightened abuse of prescription

medication; “prescription drug abuse doubled among U.S. military personnel from 2002 to 2005

and almost tripled between 2005 and 2008” (ibid.).

Lack of access to treatment is only one issue; according to a Pentagon analysis of

enlistment and zip codes, “nearly half [of recruits are] coming from lower-middle-class to poor

households” (Tyson, 2005) — from rural areas with fewer resources. Mental illness and

reintegration difficulty make transition tenuous and lead to a higher instance of homelessness

than civilians (National Coalition for the Homeless, 2009), which when coupled with high levels

of alcohol and substance abuse, combine with deadly results.

Finally, VA researchers distinguish a kind of “moral injury” as “inner conflict due to

combat-related transgression of core ethical and moral beliefs… not just from things that

happened… but from an inability [for veterans] to live with themselves knowing all that they

have done to others” (Kinghorn, 2012). Veterans have unique experiences which set apart their

treatment needs from those of civilians. These causal differences require different interventions,

few of which are implemented. Even fewer are effective, as evidenced by increased rates of

suicidality, substance abuse, and homelessness among veterans.

Citizens have a moral responsibility to care for those from whom they ask protection; it is

clear that this responsibility is being shirked — or at the very least, is not being taken seriously.

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Policy Objectives

The baseline objective for the following policy alternatives to the traditional veteran care

model is an elimination of the civilian-veteran differential in several key mental health

indicators, including but not limited to those mentioned above: suicidality, substance abuse, and

homelessness. These three measures of inadequate post-combat veteran care carve out our arena

for policy-level intervention. For the purposes of this analysis, it should be assumed that (1)

society recognizes an obligation to provide as much medical & mental health care for veterans as

civilians; (2) existing intervention methods fall short of their obligations; and (3) cost and

efficiency of service delivery are interconnected.

Criteria

Stone (2012) reminds us that

measuring efficiency is like trying to pull yourself out of quicksand without a rope. There

is no firm ground… to go beyond the vague slogans and apply the concept [of efficiency]

to a concrete policy choice requires making assumptions about who and what counts as

important. (p. 66-67)

In short, establishing a set of criteria for a policy initiative is a question of values, not of numbers

(in Munger’s (2000) words, the choice “is not a technical question, but an ethical one (p. 12)).

Bearing this in mind, efficiency in the case of veteran post-combat care should be determined in

terms of these five major criteria.

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Quality

Paramount in any discussion of mental health care is the quality of care the patient

receives. Better care is preferable to lesser care. Key components of any quality measure include

(1) provider professionalism; (2) appropriate credentialing; (3) population experience; and

(4) provider consistency and follow-up. Additionally — and perhaps most importantly — the

value of the therapeutic relationship should not be underestimated.

Cost

Financial cost must be included as a criterion; whether or not the policy enacted will find

funding from public or private sources, programs created as a result of the policy will have to be

paid for. Questions surrounding the efficacy of post-combat care and treatment often degenerate

into arguments about cost and quality tradeoffs. Regardless of the value we place on quality of

care, financial cost and distribution are intimately associated with any policy initiative and must

be taken into account.

Saddling veterans with the costs of their own care does nothing to satisfy the ethical

responsibility the citizenry assumes in requesting service in the armed forces. It is not enough

simply to provide services with no regard for final cost. As a result, it is preferable to shift costs

for care from veterans to other sources. Subsidies, reimbursements, and discounts should be

considered and implemented whenever possible. Finally, any solution must take into account the

hazards of extreme discounting and cost-cutting. These cost-saving methods (while often well-

intentioned) can potentially lead to diminished quality of care and declining standards. This

trade-off must be closely scrutinized.

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Strengths-Based Implementation

Recognizing the strengths of former service members is also necessary to effective care.

Practitioners — both physical and psychological — adhere to a strengths-based approach in their

treatment regimens, and so should any policy improving that delivery. Hill (2008) maintains that

“the best option for social workers in the policy arena is to view the strengths-based framework

as one method of analysis in an arsenal of many, rather than as the only measure of a policy’s

success or failure” (p. 107). Veterans must be allowed to choose the direction of their mental

health treatment with the input of qualified professionals and best-practice research. Rapp (2006)

also says that a “strengths-based social policy would seek goal definition from the target

population directly affected by the potential policy” (p. 5). A participatory approach is therefore

preferable to a vacuum mandate.

The impact of treatment environments should be examined. Existing social structures in

which veterans participate and from which they draw strength should be utilized wherever

possible.

Accessibility of Services & Facilities

Many criticisms of the existing veteran health care system revolve around access.

Complaints range from long wait times to inaccessibility of facilities to wide distribution of

specialists. The Department of Veterans Affairs recently admitted that

more than 57,000 new patients have waited at least 90 days for their first appointments

and that about 13 percent of VA schedulers indicated they were told to falsify

appointment-request dates to give the impression that wait times were shorter than they

really were. (Hicks, 2014)


Waiting this long is not only inconvenient. Acting Veterans Affairs Secretary Sloan Gibson

remarked earlier this summer that “at least 18 Arizona veterans died while awaiting doctor

appointments” for end-of-life care (Wagner, 2014). Because of this shortfall, a crucial piece of

any policy initiative must be accessibility — both of facilities available to veterans in a variety of

environments and of offered services. More accessible facilities mean shorter wait times and

better patient commitments. All arenas — social and otherwise — in which veterans operate

must be taken into account and — if possible — marshaled into a cohesive, comprehensive care

strategy.

Public Stigma

Public shaming and stigma are especially strong against treatment-seeking veterans (who

are one of the only cohorts society directly blames for their own illnesses). Reluctance to seek

treatment at all is responsible for a significant amount of existing service underutilization.

Additionally, public stigma is exacerbated by the separation of veteran and civilian services . 1

Integration of veteran treatments with those of the general population normalizes veteran

experiences and care. Rapp (2006, p. 7) reminds us that barriers to care “are identified as those

structures or phenomenon that prevent a person from achieving improved quality of life or

“normal” social standing”. A successful policy outcome alleviates either the existence or the

severity of social stigma by breaking down institutionalized barriers to veteran care.

! I.e. separate is not equal. While it is important that specific and unique veteran needs should be 1

taken into account in their care, this does not mean nor does it require that we segregate the

population entirely.


Policy Alternatives

POLICY ONE: Expand Existing VA Infrastructure via Legislature

The most recent legislative solution to the existing VA service problem was proffered

earlier this summer by Senator Bernie Sanders. Sanders’ bill covers all varieties of medical care

(including psychiatric). His solution to the barriers to care in existing VA facilities is to subsidize

veterans’ medical bills if they see a private physician. The bill

would give veterans… the option of going to community health centers, military

hospitals or private doctors, and would authorize the VA to lease 27 new health

facilities… It would authorize emergency funding for the agency to hire new doctors and

nurses. And it would authorize the National Health Service Corps to forgive college loans

for doctors and nurses who go to work at the VA. (Simon, 2014)

Benefits to this approach include ease of implementability and evaluation. However, the bill does

little to control public stigma against veterans, and has been criticized for being too expensive.

Opponents contend that a more targeted solution is warranted; the “idea of expanding veterans’

ability to seek private care enjoys strong support in the Republican-controlled House” (ibid.).

However, according to Munger (2000), “[p]olitical and organizational feasibility are constraints,

not criteria” (p. 15, emphasis in original).

Veterans are already utilizing non-VA care. A 2011 study by Davis et al. of veterans

residing in rural Alabama found that

71.4 percent [of respondents] had received non-VA primary care services within the past

year… a sizable number (33.5 percent) reported a delay in accessing, or an inability to


access, at least one basic health care service: primary care, specialty care, mental health

care, addictions treatment, dental care, or prescription medication. (p. 25)

Thus, at least in rural Alabama, a significant barrier to care is cost, not availability, limiting the

usefulness of Sanders’ bill.

Sanders’ bill relies on a tenet of the market model of efficiency in that it assumes that

veterans can make

voluntary exchanges on the basis of two kinds of information—objective information

about the price and quality of all alternatives available for trade, and subjective

information about their own needs, desires, and abilities. (Stone, 2012, p. 67-68)

Yet, information available to the polis is never complete in the sense required by Sanders’ bill; in

the polis “information is ambiguous, incomplete, often strategically shaded, and sometimes

deliberately withheld” (Stone, 2012, p. 30). It is unreasonable for Sanders’ bill to require that

veterans make an informed decision with complete information.

Finally, “though dual VHA [Veterans Health Administration] and non-VHA use provides

Veterans with additional service options, it makes it difficult for VHA to ensure continuity of

care” (Miller, 2012). Sanders’ bill may ultimately be self-defeating as it introduces additional

institutional barriers to consistent and informed treatment. Alternatively, recent research into the

effectiveness of external referrals by Benneyan et al. (2012) suggests that many successful

alternative solutions rely on non-VA sources to maximize treatment efficiency.

POLICY TWO: Expand Available Practitioner Base into Non-VA Settings

Expanding the available practitioner base as Benneyan describes above is a policy

alternative grounded in the concept of “community care”. Kudler (2013) notes that since “service


members, veterans, and their families are distributed across the nation and tend to seek care

within their own communities” (p. 171), any policy-level solution should be local. In other

words, Kudler advocates for a distribution of care, rather than focusing it on inaccessible VA

facilities in major urban areas. According to Davis et al., “[a]pproximately 40 percent of the eight

million veterans enrolled in the Veterans Health Administration (VHA) live in rural areas” (2011,

p. 15); thus, Kudler’s solution addresses the accessibility criterion in the following way.

Kudler calls for a community-based practice of improving veteran health by taking power

out of the hands of the VA. He argues that “[e]ven the best clinical practice guidelines for

deployment health problems need to incorporate public health perspectives, and the best place

for intervention is often the community rather than the clinic” (p. 172). One drawback of

Kudler’s approach is training; his survey found that

even though rural Americans are overrepresented in the military… rural providers were

significantly more likely to report that they didn’t know enough about managing

depression, substance abuse and dependence, and suicide. (p. 171)

Nevertheless, a community-based approach fits with several important criteria. Financial costs

are spread out. Communities often have a better understanding of their patients’ needs, leading

to easier implementation of a strengths-based approach, improving patient care. Local, more

private treatment reduces social exposure and therefore alleviates public shame. Additionally, it

assumes incomplete information on the part of veterans who are seeking mental health care; if all


veteran-centric resources are evenly distributed, veterans will not need any additional

information in order to make decisions that impact their needs . 2

Drawbacks of this approach include theoretical waste in distributing resources (both

financial and human), the effectiveness of local practitioners in determining viable treatment

options, and evaluating success across hugely different geographic and sociopolitical arenas.

POLICY THREE: Implement an Internet-Based Intervention (IBI)

Community-based strategy has benefits over a top-down restructuring of the VA; it is

more cost-effective, creates more local resources, and eliminates issues with continuity of care.

Moving the lens further out and using the Internet to build new communities — instead of

retrofitting existing ones — also has potential for increased veteran care.

Earlier this year, Grubaugh et al. endeavored to discover benefits and drawbacks of using

the Internet as a care-delivery system. Traditional findings of veteran access-to-care studies

highlight the potential need for and value of mental health interventions that are privately

and easily accessible, inexpensive, and afford flexibility with regard to when and how

often they are accessed. (2014, p. 2)

Grubaugh argues that Internet-based Interventions (or IBIs) fill this need and should be used as

part of a strategy to overcome barriers as detailed by veterans and advocates. Existing care

providers cited improved access, reduced stigma, and low cost as supporting characteristics. IBIs

flatten the current disproportionality of services to veterans living across different environments.

It might be worthwhile exploring the possibility of allowing any community-based practitioner 2

to serve veterans, and place the burden of reimbursement on the practitioners, as opposed to

veterans themselves. This possibility is briefly described below.


Perhaps most importantly, Grubaugh reports that nearly all providers “believed an IBI could help

circumvent a number of access-to-care barriers such as stigma concerns regarding mental health

care” (p. 4).

If mental health care were to be outsourced to the cloud, some — but not all —

disparities between urban and rural care would disappear (accessibility would be greatly

improved, but at the expense of service variety). The IBI approach satisfies several other criteria

as well; for example, financial cost is less than either of the other two options. With appropriate

awareness, an IBI could reach almost all veterans seeking or researching mental health treatment.

Grubaugh notes that younger veterans are very likely to be online, and

even among… those aged 65 years and over[,] more than half are online… [Also,] at

least three in four minorities and two in three adults with household incomes less than

$30,000 per year are online[, and finally, that] adults from different racial/ethnic

backgrounds access IBIs at similar rates. (p. 5)

Online resources gather a wealth of quantitative data for determining effectiveness and

success rates. Access to otherwise unknown local services could be provided. Studies show that

IBIs are effective for several types of common mental health issues; “the bulk of the extant

literature suggests that IBIs yield comparable effect sizes relative to clinician administered

interventions for depression and panic disorder” (p. 5). Additional research into the efficacy of

IBIs when treating trauma-based disorders needs to be conducted.

It remains to be seen whether the strength of the relationship inherent in traditional

therapy can be translated through the Internet; the alliance between caregiver and client has

“been almost universally viewed as one of the most critical constituents of psychoanalytic,


cognitive, narrative, solution-focused and schema therapy approaches” (MacNeil et al., 2009, p.

95). As such, quality of care and using a strengths-based, individualized approach are poorly

addressed in this intervention.

Critical Drawbacks of Previous Alternatives

What remains clear after considering these three intervention strategies is that generally,

there is no one comprehensive fix to the issue of veteran mental health care. The problem of

inadequate care is severe enough — and distributed enough — to warrant serious ongoing

inquiry and evaluation.

What also becomes clear after considering the stated alternatives is the reliance of each

solution on the existing infrastructure of the VA. Whether or not that infrastructure is bolstered,

redistributed, or otherwise amplified is not the issue — the fact remains that all rely on the VA in

some way providing additional care. Lastly, none of the solutions presented fully realizes the

potential of the physical and mental health communities to deal with the problem of inadequate

mental health care.

Simply refunding the VA at greater levels will not alleviate the issue of accessibility.

Veterans in rural or sparsely-populated areas will continue to experience difficulty accessing VA

services. Neither does additional funding address the strengths-based requirement we have set

forward. Sanders’ bill does not address the criteria of quality; while veterans may seek care from


private physicians under the bill, no guarantees of appropriate, informed, or knowledgeable care

are offered . 3

Distributing care outside the VA solves the accessibility problem at the expense of the

quality criteria. In this policy recommendation, there is no way to account for professionalism or

certification. It also remains unclear how costs would be distributed.

Internet-based intervention remains largely unstudied, and thus the efficacy of care

(especially care for trauma-related illness, a common veteran diagnosis) is unclear. It also relies

on veterans being able to access the Internet, which while common with the veteran population,

is not guaranteed — nor is access without its costs as well. While individualized, Internet-based

intervention may not be able to offer the variety of services required by today’s veterans.

Final Recommendation

The final policy recommendation of this paper is a mandate for the Surgeon General of

the United States, American Medical Association, and the VA to develop and implement a new

medical specialty for veteran care.

Without compromising the existing funding strata or physical plant of the VA, developing

a new specialty would encourage medical practitioners to focus their professional practice on a

specific group — much like pediatricians understand the unique characteristics of children, or

gerontologists study the impacts of aging. It would mean that not only VA doctors could refer

Of course, it could be argued that Sanders’ bill does address the quality issue, in that some care 3

is better than no care. However, this rebuttal only serves to try to excuse the VA from their

responsibilities for veteran care, not to offer a real solution to the shortfalls of the system

currently in place.


their patients to mental heath treatment, and that practitioners could provide a number of basic

mental-health interventions at the general care level. Indeed, physicians and practitioners at any

care level (including private clinics, community health care centers, teaching hospitals, and

trauma centers) would be eligible to specialize or sub-specialize in veteran care.

Most importantly, a specialty approach would mean that local, community-based

practitioners with knowledge of their environments and resources in situ would be much better

equipped to deal with the specific needs of this vulnerable population.

Benefits of the Specialty Approach Based on Success Criteria

Quality. To have a Board-certified veteran specialty would mean up-to-date information,

mandatory ongoing education for practitioners, and consistent standards of care. It would also

allow those medical professionals who have interest in the veteran population but no desire to

work for the VA an opportunity to practice as they desire. Access to local practitioners also

means that veterans maintain their relationships with their doctors for longer periods,

strengthening MacNeil’s important therapeutic relationship and actively contributing to positive

treatment outcomes.

Cost. This initiative carries no cost to the VA; in fact, outsourcing veteran care to other

concerned physicians means that eventually, care costs for the taxpayer would decrease. If a

portion of Sanders’ bill was retained and veterans were allowed reimbursement for care outside

of the VA system, out-of-pocket veteran costs could also be curtailed — or eliminated with the

physical plant savings (i.e. the VA may not have to maintain or expand such extensive medical

campuses).


Strengths-based implementation. The specialty approach allows veterans to tailor their

care in their communities — with professionals who also live and work in those communities.

This local control accesses proximal strengths of veterans and builds social capital by ensuring

continuity of care. It would be possible, for instance, for a family with a veteran to have the same

primary care physician.

Accessibility of services and facilities. Constructing a non-VA infrastructure means that

more veterans can choose their own doctors closest to them. If Davis et al. (2011) are correct that

“71.4 percent [of respondents] had received non-VA primary care services within the past year”,

additional practitioners with board-certified expertise in veteran issues (including susceptibility

to and warning signs of mental illness) would be a huge benefit to an overwhelming majority of

veterans seeking services. Veteran specialists could marshal all the services of their respective

centers and communities in order to provide effective treatments.

Public stigma. The specialization of VA operations serves to differentiate the needs of

veterans from those of citizens while dismantling institutional barriers which contribute to public

stigma. Incorporation of veteran treatment into mainstream medical care will alleviate some of

the negative views of medical care by the general public. A certified medical specialty also

legitimizes the necessary differences in veteran health care.

Drawbacks of the Specialty Approach

Reimbursement. An alternative reimbursement scheme would have to be devised.

Currently, veterans receive care at the VA at reduced (and sometimes free) rates. Shifting costs

away from the VA means that veterans may be responsible for paying for their own care. As this


runs contrary to one of the success criteria, some kind of billable system — perhaps an extension

of Medicare or similar program — could be built as compensation.

Time. Implementing a new Board specialty — not to mention training certified

physicians — will take time. A specialty-based strategy, when compared to other possible

interventions which would take effect quickly, would not produce success immediately. Both the

content and scope of the new field would have to be delineated, examined, and developed; while

there is considerable research surrounding veterans’ unique needs already available, additional

time would be required to fill in the gaps.

Further, some kind of reimbursement, incentive, or voucher policy would have to be

developed, tested, and implemented either in tandem with or prior to any commencement of care.

Developing such a system will take both time and talent.

Consideration should be given to whether or not these delays are reasonable or justified

given the needs of the population.

Availability and interest of practitioners. This approach is grounded on the assumption

that there will be an interest in serving veterans and their families beyond the population that

desires to work for the VA. Research into this interest should be performed. Incentive schemes

for drawing potential practitioners to veteran care paid for by the VA could be considered.

Indirect response. This solution puts into place a mechanism by which veterans gain

additional access to mental health treatment and to physicians well versed in veteran needs while

not requiring access to the VA. It does not directly address veterans’ mental health needs, but

provides them only the opportunity to seek treatment. Supplemental or ancillary policies perhaps


geared towards veteran specialization specifically in the mental health fields (beyond psychiatry)

should be considered.

Loss of community. While improving veteran care overall, removing what may be the

primary source of veterans’ community and socialization from their life experience (i.e. waiting

in line at the VA) should not be taken lightly. It is expected that the increased opportunities for

care under the specialty policy will alleviate some loss of camaraderie, but the potential shortfall

should be carefully scrutinized.

Closing Remarks

As with any initiative, there exist ramifications which need to be addressed. Certainly the

specialty-based policy intervention creates new challenges to supplementing veteran care

(including a loss of community and the necessity of a new billing system). Indeed, one of the

first challenges will be convincing the American Medical Association that veteran care is distinct

enough from general medical and mental health care to warrant a specialty at all. Even with

expert input — from existing veteran caregivers and from veterans themselves — progress will

be slow. As with the existing policy alternatives detailed above, additional research into the

expectations not only of veterans, but of their advocates and providers, must be performed.

Inadequate access to veteran care (especially post-combat care) is one of the most

pressing moral issues we face today. Whether or not we adopt a legislative, redistributive, or

technological policy in order to improve others’ lives will depend ultimately on the value we

place on the well-being of those who defended our right to do so. A new specialty-based policy

mandate would be an excellent start in meeting our policy objective. The armed forces of the

United States do not leave their comrades behind. The question for policy makers is — do we?


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Documents

Those We Leave Behind