Excellent Care If You Can Get It: The Debts to Our Warriors, Part II
The VA—formerly the Veteran’s Administration and now the Department of Veterans Affairs—adopted its motto from one of the finest presidential speeches in U.S. history, Abraham Lincoln’s Second Inaugural: to care for him who shall have borne the battle and for his widow, and his orphan.
Pretty words alone, however, don’t heal broken soldiers.
Veterans of WWI—what they called “The Great War” or “The War to End All Wars” until WWII came along—got $60 and a train ticket home. After much agitation, that was supplemented by the Bonus Act, but Congress put off the expense of actually paying the bonuses until 1945, not anticipating the country would be back at war in 1941.
The violence in the streets against the Bonus Army from WWI was so recent when WWII began and the need for military service was so great, smart politics called for more attention to the needs of veterans. WWII service came with new expectations about how returning warriors would be treated and the politicians who got bloody noses from the WWI vets were mostly still in charge.
Still, the WWII GI Bill was controversial on the grounds of cost and of moral hazard. Opponents feared that the taxpaying “makers” would be bankrupted by a new class of “takers.” Moral hazard was the point made by the chair of the House Committee for Veterans Affairs, John Rankin (D-Mississippi) when he remarked during discussion of the GI Bill "the bane of the British Empire has been the dole system."
The WWII GI Bill passed over both objections. Instead of bankruptcy, the country began a period of unprecedented prosperity. Instead of creating a class of bums, the middle class expanded by the GI Bill became the primary engine of that prosperity.
GI loans drove postwar demand for housing, creating construction, financing and sales jobs. GI education raised the skill levels and therefore the wages of an entire generation. These outcomes balanced out the substantial costs to the taxpayers by creating more taxpayers in higher tax brackets than had existed before the war.
The 16 million men and women who served active duty in WWII were a larger portion of those eligible for military service by age and health than we’ve pressed into service before or since. The timing of the enlistments was as important to planning for veterans as the number of enlistments. Just about everybody was in uniform “for the duration.”
The upside to the duration hitch was the motivational saying “the way home is through Berlin (or Tokyo).” The downside was so many people hitting the civilian economy and becoming eligible for GI Bill benefits at the same time, perhaps overwhelming the fragile new system. As it happened, the predicted flood of newly discharged GIs hit colleges and the housing market that had been moribund during the war harder than it hit the treasury.
The most fearsome benefit in the GI Bill to the budget hawks, the one most like “the dole,” was the controversial 52-20 clause, offering $20 a week (about $270 in today’s dollars) for a year to vets seeking work. The cost turned out to be trivial rather than a budget-buster. Less than 20 percent of the funds set aside for 52-20 were ever paid out because most returning GIs found work right away or took advantage of education benefits.
VA medical care also took leaps forward after WWII. With the numbers of eligible men at an all-time high, as well as more women veterans than ever before, the VA was off on an expansion that has never stopped and seldom paused.
When the first head of the VA resigned in 1945, the man picked to navigate the major changes in store was Gen. Omar Bradley, hero of the North African campaign and commander of most of the American ground forces in the final push from Normandy to Berlin. Bradley’s appointment signaled that the VA would be a serious post-war priority.
Bradley recruited Gen. Paul Hawley, chief surgeon for the European Theater, to form the VA Department of Medicine. Hawley got more bang for taxpayers’ bucks by matching VA hospitals with medical schools. The hospitals got the services of interns and the medical schools got a set of research subjects that could not be duplicated in the civilian world.
Bradley’s first report on the Department of Medicine described 97 VA hospitals on line with 25 more under construction and major additions to 11 more. All that amounted to a bit over 100,000 beds to serve a tsunami of 15 million veterans coming home from Europe and the Pacific as the armed forces dialed back to occupation duty.
All beds were full in no time and both the Army and the Navy had to share available beds with the VA while the building of new VA hospitals and the expansion of existing ones continued. The population to be served was the greatest number of returning veterans in U.S. history, but the degree of difficulty was further ramped up by the fact that they all showed up at once.
The wave of wounded warriors from WWII was a major shock to the new medical system. Since the system was built out to accommodate the end of WWII, injured veterans have entered into the system from battles in Korea, Vietnam, Grenada, Panama, Somalia, Kuwait, Iraq and Afghanistan.
In addition to the devastating physical trauma military doctors have always seen, there have been modern hazards like Agent Orange exposure from Operation Ranch Hand in Vietnam and Gulf War Syndrome from breathing the chemicals released when Saddam Hussein torched oil fields. The constant recycling into combat zones since 2001 has ramped up what we now call post-traumatic stress disorder (PTSD), formerly known as soldier’s heart, shell shock, and battle fatigue.
About the time the first Gulf War veterans were hitting the VA system (1997), Congress got one of the few straight up comparisons of the cost of federal medical programs ever done. Medicare was spending $5,450 per patient, but Medicare served the elderly. The VA was spending $4,798. By comparison, the Indian Health Service was a cheap date at $1,578.
Patient satisfaction can only be measured after people get into the system, and that has been the rub for the VA. While any veteran can report to a VA hospital, patients are classified by disabilities received in the line of duty. The degree of disability not only defines a place in line but also how much of the cost the veteran has to pay, if any.
The scandal of how long the VA was taking to make disability determinations began to break in 2012 and intensified in the light shined by a new vets organization, Iraq and Afghanistan Veterans of America. That average processing time was 262 days, which was then a 20 year high.
Republican Presidential candidate Carly Fiorina claimed in the September 16 GOP debate that 307,000 veterans “died waiting for health care.” The Washington Post rated that statement “two Pinocchios,” because there is no way to draw that conclusion from the VA Inspector General report she cited. Because others made the same mistake, they spared her three Pinocchios, but the 307,000 number represents the number of records coded “pending” in the VA database but coded as deceased in the Social Security database.
The VA database includes veterans who died before the beginning of the enrollment system in 1998, and veterans who never applied for anything, and persons who are not veterans at all. The Post characterized it as a “contact list.” The misunderstanding of the IG report does point out a reason for delay in processing disability claims. Until very recently, all the paper was moved by hand, as if the computer revolution never happened in the VA.
A similar but separate scandal originated in the Phoenix VA in 2014, this time involving veterans who were already enrolled in the system but were unreasonably delayed in seeing a doctor. The delay was bad enough, but, worse, the wait times were falsified to make delays appear shorter. Deaths while awaiting care were an issue, and a CNN report in April of 2014 claimed at least 40 veterans had died in Phoenix alone.
The VA had established a goal of getting veterans in non-emergency cases to a doctor within 30 days back in 1995. In spite of reports that goal was not being met, the VA shortened it to 14 days in 2011.
The reason for the delay was lack of enough doctors and nurses in light of the aging of Vietnam veterans and the growing flow of Iraq and Afghanistan veterans into the system. The delay had reason. Lying about the delay did not.
The manipulation of wait time data first discovered in Phoenix was found in many VA hospitals across the country. The number of veterans who lost their lives as a result has been argued ever since but nobody can claim that number to be zero.
As a result of the wait time scandal, Secretary of Veterans Affairs and former General Eric Shinseki lost his job. By all accounts, Shinseki was a “soldier’s general,” whose heart was in the right place, but he was handicapped by thinking that just because he gave an order it would be obeyed.
President Obama replaced Shinseki with Army veteran and former Procter & Gamble CEO Robert McDonald. The thinking was that the problems in the VA were management problems that called for the skills associated with business.
While the management shakeup was going on, the Veterans Access, Choice, and Accountability Act of 2014 was making its way through Congress with the bipartisan team of Democratic Sen. Bernie Sanders of Vermont and Republican Sen. John McCain of Arizona as sponsors.
President Obama signed the bill into law on August 7, 2014. It added $16 billion to the VA budget with $10 billion to get civilian care for veterans on the wait-list and $6 billion to hire more doctors and nurses. It also gave the Secretary of Veterans Affairs the power to fire people that had inexplicably not existed before.
Three months later, the person in charge of the Phoenix facility that kicked off the scandal was finally fired. It did the VA image no good when it came out that she had been paid over $90,000 while on administrative leave following the scandal. Other high level administrators were fired in Alabama, Georgia, and Pennsylvania, as well as at VA headquarters. The total of eight people fired almost certainly is less than the number of veterans who lost their lives over either the treatment delays or the cover-ups that prevented fixing the treatment delays.
The wait times for both disability determinations and doctor appointments have diminished substantially since the heads rolled and they continue to move in the right direction, although there is some complaint that moving the backlog in medical care has expanded the backlog in other VA programs.
VA hospitals continue to train medical students and to lead research into traumatic brain injury and the design of prosthetic devices. Care for women veterans continues to improve. Treatment for PTSD remains inadequate, but not for lack of attention.
Part 3 will examine why it took such major scandals to get the kind of resources and oversight necessary to honor the promises made to veterans in the VA motto.
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