Going to London? One the best walks you can do in the city is to saunter through Chelsea (get off at the Sloane Square station), cross the Themes, and then admire Battersea Park. If you were to start this walk say, last week, you would come upon a gigantic flower show. Every so often you will also come across a wiry elderly gentleman in a black military-style uniform, shuffling through the crowd. You may notice that this remarkable show of pistils and petals is being hosted on the grounds of a hospital designed by Christopher Wren. Look more closely. This is not a hospital. And the men in black are not making a fashion statement. They live in this building. This is the Royal Hospital Chelsea, home to a remarkable collection of army pensioners. Remarkable enough, in fact, to become the stars of a current eight part series running on BBC4 (I didn’t get BBC America myself til this month, so haven’t caught this. Maybe I can get a DVD copy with a PBS renewal or something).
Going to Los Angeles? It’s hard to walk this one, but bear with me. If you drive along the Western edge of UCLA on Sawtelle, you will pass a huge cemetery. Turn west on Wilshire, go past the San Diego Freeway and you will not help but notice the huge building squatting to your left. This is a hospital, the Wadsworth VA. Per urban legend, this is the most earthquake-proof building in LA (perhaps now beaten out by USC’s newer Keck Hospital, which is on shock absorbers). I’d place a wager that you won’t even notice the large collection of low lying buildings nestled to your right. This is part of the same complex, and it is here where you will find where the Sawtelle Old Soldier’s Home once stood, with nothing to replace it in LA for decades. I’d also wager that you would not find a BBC4 film crew combing this area for landscape shots and wistful interviews of remembrance. Or looking under the neighboring freeway underpasses where homeless vets have long put up camp.
Perhaps they should, but not for the reasons you’re suspecting. If you think an indignant rant is about to hit shore here, you may be surprised to discover that this post will not focus on the respective treatment of veterans in the US and UK. The LA VA vignette above may not end as badly as you expect, and America’s relationship with her military veterans cannot be described as hopeless. Despite the superficial charms of the Royal Hospital Chelsea, our less flashy system can potentially outperform the NMS by any measure. And it is this twist in the story which will provide an opportunity to bring overlooked health care issues into sharp relief. We have heard suggestions both on this site and elsewhere that we could help "solve" our healthcare problems through expanding Medicare coverage to everyone. That’s perhaps a convenient start, but that’s simply the wrong federal program, people. The most idealistic thing this country ever did, other than to create the Peace Corps, NASA, or the Marshall Plan maybe, is to create today’s VA. It is a remarkable, truly holistic system that, if done better, could serve as a foundation for "whole human care" (not just health care) for everybody. And, no, I’m not smoking something I bummed off of someone behind a VA parking lot.
I say this, interestingly enough, as a doctor who worked at the VA for a 6 year "tour-of duty" (yes, it’s really called that), and ran from it. Even as I write this, I continue to have ambivalent feelings about the VA, because it continues to face a unique set of problems. But looking back, many of those problems have become clear to me as purely financial or cultural in origin. Which can change. What’s required is better understanding of what the VA actually is (and can become), improved visibility, and collective will for progress.
So let’s start with the understanding part. Military folks can certainly skip this, but everyone else shouldn’t, because you probably don’t know what the VA really is. Put simply, the VA is charged with servicing the needs (not just health) of discharged enlisted military personnel (i.e. "grunts"). All veterans are eligible to enroll at the VA, but none are compelled to and the most deserving are allowed to skip around this paperwork altogether. The level of each vet’s benefits is determined by regionally corrected means tests, degree of disability, and just how connected that disability is to the vet’s tour of duty. Active duty personnel and retired commissioned officers are eligible for entirely different health coverage called TRICARE and receive treatment at "fancier" military hospitals, such as Walter Reed (which is not a VA hospital and, well, isn’t fancy). So, what about freshly discharged vets coming back, say, from Iraq who are transitioning from TRICARE to the VA? Funny you should ask about that—we’ll discuss this later.
There’s a minor myth that the VA was magically born from a line from Lincoln’s second inaugural address (see final paragraph--this did inspire the VA’s mission statement), but this is inaccurate because the Continental Congress successfully recruited soldiers to the Revolutionary Army partly by offering 7 year pensions to officers, and standing pensions to the disabled (the resulting pension paperwork went on to become a great genealogy resource). Widows and orphans became eligible for pensions by 1780, and all pension coverage was federalized by 1811. Today’s Department of Veterans Affairs is now an amalgam of government programs which began to coalesce through bureaucratic consolidation in the 1920’s to cope with expanded benefits authorized late during World War I. The Department of Veterans Administration was born in 1930, taking over responsibility for 54 hospitals, pension distribution, and housing of disabled veterans. In 1944, the Department took responsibility for administering the GI Bill. In 1973, it took control of all national cemeteries except Arlington. In 1989, it formally became a cabinet level department, partially as a way to protect it from zero sum funding competition with the DOD and partially as a way to ingratiate the Reagan Administration with veterans’ groups. The VA garnered a new name (Department of Veterans Affairs), an "80’s-chic" logo, and became the second largest employer in the Federal Government (ranking behind only the department which creates veterans). It currently grovels for every cent of the $80 billion it gets each year, pays the rent for 240,000 employees (many of whom are vets themselves), runs over 170 medical centers, 350 outpatient clinics, 126 nursing homes, and 124 cemeteries (including the Los Angeles National Cemetery alluded to above and 6 new ones on the way). It is so big, it is houses three potentially freestanding agencies: the Veterans Health Administration (the hospitals and clinics), Veterans Benefits Administration (home loans, pensions, rehab and vocational services, educational programs, etc.), and the National Cemetery Administration.
So, to emphasize, the VA is NOT simply a health care system. That’s just one facet of its VHA branch. Through a haphazard combination of noble intentions, political expediency, and bureaucratic streamlining only a wonk could love, the VA became a juggernaut of services which encompass all aspects of physical, rehabilitative, vocational, educational, familial, domestic, and even post-mortem care of a population of patients with whom it shares a lifetime relationship. It is a comprehensive system of benefits which, if ideally administered and delivered, would beat any social support system found anywhere. In some cases, the VA lives up to this potential. In many other ways it does not come close. But what you cannot take away from the VA is the breathtaking ambition with which it approaches its service mission. Several examples, some of which are my own personal experiences, may help to illustrate the VA’s accomplishments and immense potential:
- Let’s do the obvious and start with medical care, such as the mundane topic of medical informatics (i.e. patient charts). This may seem like an odd place to begin, but trust me. When I rotated through the VA as a resident physician in 1997, I was introduced to VistA CPRS, the VA’s brand new computerized medical record system. It absolutely, positively blew the doors off any other system I had ever used. It was a Windows based client-server interface, clearly organized, easy to use, and almost never went down. But that was just the skin deep beauty. It also kept track of meds and allergies. And Do-Not-Resuscitate orders. And contact information for relatives. And provided medical records from any outside VA facility the patient had ever been treated at. I still get goosebumps thinking about this. Why? If you have seen paper charts, black hole-dense phonebook thick paper charts (perhaps your own), you will instantly know why. Think of how much time I saved to actually do my job. Think of how easy it was to keep track of meds. Think how easy it was to look at the patient’s entire continuum of care. Think how easy it was to find out who to call about the patient’s outside treatments? All of this cuts directly to the timely subjects of patient safety, prevention of medical mistakes, and quality of care delivery. And VistA has only gotten better, now providing real-time analysis of electronic orders and meds to keep track of medical guideline compliance and drug interactions. VistA is so damn good it has its own Wikipedia entry (seriously). Something this good obviously made somebody rich, right? No. True to the VA’s core value of public service, Vista is shareware, built on top of an older award-winning shareware program. The VHA encourages other hospitals to run with it and to use it to improve healthcare for everyone. And many have, ironically enough, in foreign countries. My current hospital uses a record system which looks suspiciously like CPRS, but they deny they used the code (perhaps to support the patent application they have pending). VistA is a significant reason why the VHA is now the highest quality medical system in the United States.
- Huh? Well, this may not surprise all of you. When I was still at the VA in 2003, a stunning (at least to me at the time) article in the New England Journal of Medicine documented that a remarkable improvement in quality-of-care measures occurred at the VA during the late 1990’s, despite no significant budget increases and a 40% increase in patient load (how this happened is a story unto itself, which I’ll need to sidestep here). These improvements were so significant, the authors found that the VA outperformed Medicare fee-for-service in nearly every single outcome measure tested. This was reinforced by later reports, and was nicely reported on in 2005 by Phillip Longman for the Washington Monthly. Please take the time to read this—it’s a wonderful discussion of many salient general health care issues. Longman places emphasis on VistA and quality measures in his piece, and comes to the conclusion that, hey, maybe the VHA isn’t such a bad option for all of us civilian folks. However, he misses a chance to discuss the fallibility of health quality measures as well the larger point which I’m trying to make, which is that the VA offers far more that just health care. It offers a helping hand to all aspects of the vet’s humanity and potential for continued contributions to society. This is the true gift of VA and most important lesson we can learn from it. Onwards....
- Medical research and education. The VA is essentially our country’s second NIH, albeit much smaller ($400+ million vs. $28+ billion going to Bethesda). VA R&D tends to focus on very practical areas pertaining to rehabilitation, ranging from hearing aids to diabetic foot care, PTSD recovery, substance abuse treatment, and health services delivery, but it’s certainly not limited to this. Increasing interest now is being given spinal cord and head injuries, due to obvious needs provided by current military operations. These issues are directly relevant to the VA patient population, but also address understudied needs which apply to mental health, trauma, neurological, and other civilian patients. The VA gives young investigators money to start their careers (which is a huge issue in these days of tight NIH funding), and has funded highly technical basic science work and launched some illustrious figures in American medicine. The VA is the single largest teaching system of future doctors, midlevel practitioners, and nurses in the world. It is affiliated with over 100 medical schools. Residents tend to enjoy their VA rotations, since they are afforded more hands-on experience and a more manageable clinical pace. The overall quality of clinicians and the number of superstars at the VA probably would shock many. The most legendary old school academic physician at my former medical school "retired" from Yale to head my VA before I was there. An aside for disclosure: my own research career was started by VA career development grants, and was assisted by the relative ease of starting clinical trials at the VA (I didn’t need to find funds to cover every single cost of medical procedures, as I do now at a private hospital). Just one more American civilian given a leg up by the VA.
- Family benefits. Otherwise known as CHAMPVA, to distinguish it from CHAMPUS which is provided to dependents of active duty or retired officers by TRICARE. Other than Social Security or children’s programs, show me another federal program which directly shells out to care for the health of family members of beneficiaries. The problem with CHAMPUS I can most easily discern is access, mostly due to stingy eligibility requirements and, perhaps, lack of awareness. It is also preempted by Medicare’s potentially inferior coverage for family members who are eligible.
- Long term care. Since I talked about this last week, I will summarize by saying only one other federal program, Medicaid, pays for the potentially devastating long-term assisted living costs required for the disabled and elderly. A key difference to observe is that Medicaid specifically targets the indigent. The VA, by definition, targets those who have served. All vets can apply for this as part of their medical benefits, regardless of means. Incidentally, many larger VAs provide room and board, even step-down assisted-care hospital wards, for patients traveling from a distance of extended periods of outpatient care. This is practically unheard of in the private sector, and is a tremendous source of cost and anxiety for patients requiring specialized treatment at tertiary referral centers.
- Education, home loans, vocational training (aka the GI Bill). What does this have to do with health care? Nothing and everything. Uneducated, unskilled, homeless, unemployed people tend to not wash behind their ears or see someone for that cough. What can any rational person say to dismiss the GI Bill? It fundamentally improved 20th Century America, kick starting the transition of the Greatest Generation back into productive civilian life. The VA currently administers the GI Bill’s successor, the Montgomery GI Bill of 1984.
- Prescription drugs. Talk about solving an obvious health care problem. The VA has become the largest pharmacy in the US, and this is the most utilized medical service offered by the VHA. When I was at the VA, all drug co-pays were well under $10 for service connected patients (i.e. disability due to military service). The VHA is exempt from the MMA of 2003, and is still allowed to bargain for lower drug prices with Big Pharma. The VA saved vets the headache and expense of Medicare Part D. Despite being under tremendous budgetary pressure, the VHA formulary is up-to-date. It is in the VA’s interest to keep its customers appropriately treated to avoid the significant long term costs of undertreatment (especially for conditions like diabetes, hypertension, and kidney problems), and it acts like it (unlike some other medical plans we’ve heard about).
- Burial services. This is one of the most popular benefits offered by the VA, and provides a gravesite (at a national cemetery), headstone (even at a private cemetery), a flag for burial, and even additional benefits for demonstrated need. Let this sink in. A huge faceless bureaucracy is providing this final dignity, a physical confirmation of identity and worth in recognition of a "life well lived". One vet joked to me that his headstone would be his "final medal". But he said it in a way that you knew it wasn’t a joke. This is not a trivial detail, but, in my mind, government at its greatest. And it is no less dramatic than the remarkable (and highly visible) rituals of Arlington. Providing honor. Even when no one is watching.
I could go on, but take a look for yourself.
As impressive as this may appear on a monitor screen, you may still notice that "the VA is still the VA", with all of its stigmas, stereotypes, anonymity, and smelly hospital corridors with godawful 70’s pastel color schemes. Why?
Well, that’s what Act Two is all about. Stay tuned tomorrow....