Veteran Access to VA Healthcare: PTSD and TBI Challenges

Introduction

Following the military debacle of the deeply unpopular Vietnam War, the American public has rallied behind its military forces in ways reminiscent of earlier periods in U.S. history, such as the national unity that followed the attack on Pearl Harbor during World War II. This trend became particularly pronounced after the terrorist attacks of September 11, 2001, and the capture and subsequent deaths of Saddam Hussein and Osama bin Laden have been cited as proof of the effectiveness of the nation's military forces. Despite these achievements, it is becoming increasingly clear that the United States is either unwilling or unable to deliver on its promises to the armed forces serving on the front lines of the Global War on Terrorism. Hundreds of thousands of combat veterans in desperate need of treatment are being denied access to care through bureaucratic delays and a basic lack of resources. To gain further insight into these trends, this paper reviews the relevant literature concerning key issues, current trends, practices, and demographic and community access. A discussion of the future implications for healthcare services in this area is followed by a summary of the research and important findings in the conclusion.

There are currently almost 22 million veterans living in the United States (Profile of veterans, 2011). Of these, approximately 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 deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) since the terrorist attacks of September 11, 2001 include an inordinately high percentage who served more than one tour of duty; some service members have actually served as many as five tours in Middle Eastern combat zones (Savitsky et al., 2009).

Current Trends and Key Issues

For those combat veterans fortunate enough to survive the conflict and return home, the nightmare is not necessarily over. Many will develop serious mental and physical healthcare problems related to their military service in the Middle East. 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. PTSD 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 confirms an alarming increase in the number of traumatic brain injuries (TBIs) being sustained in combat areas in Afghanistan, even as the war grinds toward an uncertain conclusion.

Consequently, TBIs and PTSD are among the most common types of healthcare issues facing returning combat veterans, and both conditions require extensive healthcare interventions. Secretary of Defense Robert M. Gates emphasized 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 reinforced by Steele (2010), who stresses that "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). 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 requiring specialized treatment (Steele, 2010).

Vlahos (2007) 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 coordination 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 Iraq, Afghanistan, or both (Steele, 2010).

The Department of Veterans Affairs (VA) operates the largest healthcare system in the United States, employing 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 extensive nationwide network of facilities. These include tertiary services delivered at VA medical centers, community-based outpatient clinics, and "Vet Centers" where veterans can receive counseling services in a nonthreatening environment (Medical centers, 2011). According to the VA's description of its 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).

Demographic and Community Access

To help improve access to healthcare services, a number of medical centers and outpatient clinics collaborate as a Healthcare System (HCS) in the provision of services across 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). Examples of this collaborative model include the VA Pittsburgh Healthcare System, which serves the Pittsburgh area of Pennsylvania, and 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.

Despite these and other initiatives intended to improve access to care and the efficiency with which it is delivered, hundreds of thousands of combat veterans are still not receiving the level of care they need, owing to bureaucratic delays and a fundamental lack of resources. Given the severity of PTSD and TBIs, it would seem logical to assume that the VA would treat access to such care and the treatment of these conditions as a very high priority.

Unfortunately, many returning combat veterans are not receiving timely healthcare services for a number of access-related reasons. 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). Other veterans experience significant delays in the processing of their claim forms to establish initial healthcare eligibility. As one veteran observed, "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 too much of a paper trail to manage and the bureaucracy is too massive, too tricky to navigate" (Vlahos, 2007, p. 21). Reports from across the country confirm these experiences, and the resulting delays in access to healthcare will have inevitable long-term consequences for veterans suffering from the profoundly debilitating effects of the signature injuries of the wars in Afghanistan and Iraq, as well as for the VHA clinicians responsible for their care.

Perhaps the most troubling aspect of these trends is the fact that the problems are not a surprise. Policymakers and healthcare providers alike have long been aware of the numbers of service members being deployed to combat zones. The overall threat levels may be diminishing following the death of Osama bin Laden, but troops on the ground in the Middle East continue to face IEDs on a daily basis, and the threat of suicide bombers will linger until the last American soldier departs the region. In this environment, it would seem prudent — if not simply good policy — to prepare for the inevitable human consequences of sustained foreign military engagement, yet combat veterans appear to be paying a severely high individual price while lawmakers offer little more than lip service to their needs.

Conclusion

Taken together, the review of the literature indicated that combat veterans returning from tours of duty in Afghanistan and Iraq frequently suffer from traumatic brain injuries and posttraumatic stress disorder — conditions that both demand early interventions and long-term care. Unfortunately, the research also indicated that the organization responsible for providing these healthcare services, the Department of Veterans Affairs, has apparently been overwhelmed by the increase in demand for services. Like the predictable surge in demand associated with a major holiday, this increase was not a surprise; it was a foreseeable consequence of escalating the Global War on Terrorism through two ground wars in Afghanistan and Iraq. By failing to prepare for these inevitable outcomes, the VA is also failing to live up to its stated motto: "To care for him who shall have borne the battle and for his widow and his orphan."