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“Is the VA too big to succeed?” asked the father of a veteran named John, whose labyrinthine journey through the VA over the last 7 years began with a veritable bang. A remotely detonated explosive device, one that had turned his son, a decorated Army infantryman who would run toward the sound of danger to save the lives of his comrades, into something far different just a few years later. He’d become a troubled soul whose drug-seeking and erratic behavior amounted to a prison sentence for his entire family, and their love for him became his inescapable chains.
Among a love for guns, a fear of emergency rooms, a mistrust of authority, avoidance of guardianship, and delusions that could be triggered by anything—from fireworks to the sight of someone wearing a black burka in an airport—John carried within him a combustible mix of torments that would be foreseeable consequences in a tightly coordinated system of care. The system that the VA needs to be in order to fulfill its commitment to America’s veterans.
“This is what it’s like to live with a traumatic brain injury,” his father said. “A time bomb waiting to go off that has some in the VA seemingly ducking for cover instead of trying to defuse it.”
The statement is harsh because the reality is harsh. For those veterans who manage to survive shrapnel or a sniper’s bullet cutting through their brains, a new fight begins from the moment they wake up and realize they’ve survived. In many people’s view, these soldiers were lucky to see their families again. Lucky to have a chance at some semblance of recovery. Lucky to return to a grateful society that lionizes its wounded warriors. Lucky to have access to the only healthcare system with the military cultural competency to deliver the best care possible.
Unfortunately, it’s a system comprised of nearly 300,000 employees who provide healthcare to veterans at 1,243 facilities, including 170 VA Medical Centers and 1,063 outpatient sites of care of varying complexity, all under a combination of decentralized authority and obfuscated accountability. It’s a system that might indeed be too big to succeed, at least in the case of the “outliers” like John. The only way veterans like him stop being outliers is when their names get added to the fateful 22-a-day list.
For them, “lucky” is a relative term. When one considers that the families of soldiers with traumatic brain injuries are largely forced to face it alone, as well as the reality that the veterans will never actually recover, it becomes clear those families are confined for a lifetime by their loved ones’ conditions. Those veterans are lucky only until the consequences of their condition touch society through the legal system or at society’s margins, where behavioral problems are wrongly perceived as misconduct rather than a result of neurological dysfunction.
They’re lucky until VA providers begin to overprescribe opioids and/or fail to coordinate care among the multiple providers treating them. These veterans are lucky until those same doctors reach limits imposed by policy and budgets, and in the case of John’s father, stop returning calls because they have no more answers.
John’s father calls his son an outlier because he’d witnessed the more-easily treatable brain injury patients face far fewer barriers to access and receive better, more coordinated treatment at the VA. Those veterans were the statistical low-hanging fruit who were touted by the VA as proof that the mental healthcare system was working. But it is the outliers, those who beat the odds and now present the greatest treatment challenges, who will determine whether the VA is too big to succeed.
People Before Policy
Outlier or not, any veteran who served this country and suffered a traumatic brain injury at the hands of the enemy should not be misunderstood or deemed too difficult to treat as a whole person. For when their care is uncoordinated and fragmented, the enemy wins twice: first when the bomb went off and did its damage on the battlefield; then again when the affected veteran later hurts himself or others. John’s father, who has fought to get his son the comprehensive care he’d needed for seven years since his return from Afghanistan, is again at an impasse and now reduced to cynicism: “Maybe the VA will finally be there for my son when we have to bury him.”
Is the VA too big to succeed? The present and future enemies of the United States of America and her democracy presumably hope so. However, it is up to VA leadership, Congress, and the President to put that hope to rest by putting people before policy in how mental healthcare is delivered. It is also their job to ensure that outliers like John don’t pay an enduring, unnecessarily painful price as a “thank you” for their service.