As he stood on the steps of the U.S. Capitol's East Portico in early 1865, President Abraham Lincoln articulated what would become the motto of the Department of Veterans Affairs, "To care for him who shall have borne the battle and for his widow and his orphan." This lofty goal, though, has not been fulfilled in recent years and millions of combat veterans returning from tours of duty in Afghanistan and Iraq are experiencing debilitation injuries such as posttraumatic stress disorder and traumatic brain injuries without being provided adequate access to the healthcare services for which they are eligible. To its credit, the Department of Veterans Affairs has taken a number of steps to help improve access to healthcare services for its veteran population, but reports from across the country confirm that tens of thousands of eligible veterans are still being denied timely access to healthcare services. The long-term implications of this lack of access are discussed in this study, and important findings are presented in the conclusion.
Veteran Access to Healthcare Services
Following the military debacle in the highly unpopular war in Vietnam, the American public has rallied behind their military forces in ways that are reminiscent of other periods in U.S. history such as World War II following the attack on Pearl Harbor. This trend has become particularly pronounced following the terrorist attacks of September 11, 2001, and the capture and subsequent executions of Saddam Hussein and Osama bin Laden have been cited as proof positive of the effectiveness of the nation's military forces. Despite these achievements, it is becoming increasingly clear that the U.S. is either unwilling or unable to deliver on its promises to the armed forces that have been on the front lines of the Global War on Terrorism, and hundreds of thousands of combat veterans in desperate need of treatment are being denied access through bureaucratic delays and a basic lack of resources. To gain further insights into these trends, this paper reviews the relevant literature concerning key issues, trends, practices, as well as demographic and community access. A discussion concerning the future implications of healthcare service in this area is followed by a summary of the research and important findings in the conclusion.
Review and Discussion
Current Trends and Key Issues
There are currently almost 22 million veterans living in the United States (Profile of veterans, 2011); of these, about 5.6 million are Gulf War veterans, defined as having served one or more tours of duty in Afghanistan or Iraq, or in a support position in a neighboring country such as Kuwait or Saudi Arabia. According to Savitsky, Illingworth and DuLaney (2009), the millions of American troops that have been deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIE) since the terrorist attacks of September 11, 2001, an inordinately high percentage has served more than one tour of duty, and some service members have actually served as many as five tours of duty in Middle Eastern combat zones (Savitsky et al., 2009).
For those combat veterans who are fortunate enough to survive the conflict and return home, the nightmare is not necessarily over and many combat veterans will develop serious mental and physical healthcare problems related to their Middle Eastern military service. As Savitsky et al. emphasize, "Postdeployment, families must adapt to the change in family structure by renegotiating roles and responsibilities, which can be a complex and anxiety-provoking task" (2009, p. 328). Many returning combat veterans will develop posttraumatic stress disorder PTSD, or will have already experienced this condition in the field. This condition can be completely debilitating and frequently requires long-term healthcare interventions to help patients regain some semblance of normalcy in their lives (Savitsky et al., 2009). In addition, the growing body of research in this area confirms that there has been an alarming increase in the number of traumatic brain injuries, or TBIs, being experienced in combat areas in Afghanistan even as the war grinds to an uncertain conclusion.
Consequently, TBIs and PTSD are among the most common types of healthcare issues facing returning combat veterans, and both of these conditions require extensive healthcare interventions. In this regard, Secretary of Defense Robert M. Gates emphasizes that, "Post-traumatic stress, traumatic brain injury, and associated ailments are, and will continue to be, the signature military medical challenge facing the Department for years to come" (2009, p. 37). This point is also made by Steele (2010) who stresses, "The overall problem is big. As improvised explosive devices (IEDs) are the signature weapons of the wars in Iraq and Afghanistan, TBI is fast becoming the signature injury" (p. 37). In fact, to date, as many as 360,000 Iraq and Afghanistan combat veterans may have experienced some level of TBI and of these, as many as 45,000 may go on to develop long-term symptoms that will require specialized treatment (Steele, 2010). Likewise, Vlahos (2010) recently reported that, "By the thousands, [combat veterans] are returning with horrifying injuries, the most pervasive being the IED's especially vicious souvenir: traumatic brain injury. Symptoms range from memory loss, fatigue, irritability, mood swings, and a change in sleep patterns in milder cases to loss of co-ordination and balance, seizures, migraines, confusion, and agitation in more severe instances" (p. 21). To date, the VA has treated approximately 8,000 cases of TBI among combat veterans who returned from tours of duty in either Iraq or Afghanistan, or both (Steele, 2010).
Demographic and Community Access
Currently, the Department of Veterans Affairs (VA) operates the largest healthcare system in the country and employs tens of thousands of clinicians and support staff (Medical centers, 2011). The VA's Veterans Health Administration (VHA) provides healthcare services to approximately five-and-a-half million veterans each year through an elaborate network of nationwide facilities, including tertiary services delivered in VA medical centers, community-based outpatient clinics and so-called "Vet Centers" where veterans can receive counseling services in a nonthreatening environment (Medical centers, 2001). According to the VA's description of their outpatient clinic network, "To make access to health care easier, VHA offers over 800 Community-Based Outpatient Clinics (CBOC) across the country. These clinics provide the most common outpatient services, including health and wellness visits, without the hassle of visiting a larger medical center. VHA continues to expand our network of CBOCs to include more rural locations, making access to care closer to home" (Medical centers, 2011, para. 3). The respective numbers for these various VHA facilities are shown in Figure 1 below.
Figure 1. Total National VA Healthcare Facilities
Source: Based on bar chart in Veteran statistics, 2011
To help improve access to healthcare services, a number of medical centers and outpatient clinics collaborate as a Healthcare System (HCS) in their provision of services in several areas of the country (Medical centers, 2011). According to the VA, "By sharing services between medical centers, Healthcare Systems allow VHA to provide Veterans easier access to advanced medical care closer to their home" (Medical centers, 2011, para. 2). Some examples of this type of collaborative effort include (a) VA Pittsburgh Healthcare System (which serves the Pittsburgh area of Pennsylvania), and (b) the VA Puget Sound Healthcare System (which serves the Seattle and Tacoma areas of Washington state) (Medical centers, 2011). In addition, the VHA has organized itself into a nationwide network comprised of 23 Integrated Service Networks to facilitate the provision of healthcare services as shown in Figure 2 below.
Figure 2. National network of VHA Integrated Service Networks
Source: Medical centers, 2011
Despite these and other initiatives that have been intended to improve access to healthcare services and the efficiency with which they are provided, hundreds of thousands of combat veterans are still not receiving the level of care they need as the result of bureaucratic delays and a fundamental lack of resources. Given the seriousness of PTSD and TBIs, it would seem logical to assume that the VA would have made access to such care and the treatment of these conditions a very high priority.
Unfortunately, in spite of the efforts made to date, many returning combat veterans are not receiving timely healthcare services for a number of reasons that relate to access to care. For instance, the Chairman of the U.S. Senate Committee on Veterans' Affairs recently reported, "I have heard from veterans who have walked in to VA clinics and asked to be seen by a mental health provider, only to be told to call a 1-800 number. I have heard from VA doctors, who have told me VA does not have enough staff to take care of the mental health needs of veterans" (Murray, 2011, para. 2). In addition, other veterans are experiencing significant delays in the processing of their claim forms to establish initial healthcare eligibility in the first place. For example, one veteran recently observed that, "The most frustrating thing for me are the reasons my claim has been held up. The people I've encountered at the VA are doing the best they can [however] there is…