The VHA — The Blind Men and the Elephant

eloephantOver the past year, I have traveled all over the country visiting Veterans Health Administration hospitals, clinics and other facilities for a book I am writing on the nation’s largest, and only publicly funded, fully integrated health care system.  In spite of some of the problem such a large system inevitably has,  I am a huge fan of the VHA and have found that it delivers far better care than most private systems at much lower cost.  As the title of Philip Longman’s 2007 book attests, the VHA still provides The Best Care Anywhere.   Which by the way, Longman argues, it still provides — current scandal mongering not withstanding.

This is hardly the conventional wisdom about the VHA.  As I have listened to veterans, VHA staff, conservative politicians, reporters, and even liberal and progressive supporters of the kind of national system the VHA represents, I am reminded of the classic Indian parable of the blind men and the elephant. According to this tale, there were, once upon a time, six blind men who lived in a village in which an elephant, an animal they had never encountered before, suddenly appeared. The six blind men decide that even though they could not see the elephant they could perhaps touch it and figure out what it really was And so they did. The first blind man touched one of the elephant’s legs and exclaimed confidently that the elephant was a pillar. The second touched its tail and insisted that the elephant was a rope. After touching its trunk , the third one, countered, that the elephant was the branch of a tree. You are so wrong, said the fourth, after he stroked the animal’s ear, the elephant is a fan. No, said the fifth, as he ran his hand across the elephant’s belly. The elephant is a big, huge wall. As if arriving at the final solution to the mystery, the sixth grabbed on to the elephant’s tusk and insisted that the elephant was a pipe. Needless to say, each of the men was absolutely certain that his interpretation of the elephant was accurate and that all the other blind men werenot only blind but deluded.

Their dispute  continued until village sage stumbled across the querulous group. Upon hearing the nature of the dispute, he laughed and informed them that each one of them was right. Each one had touched a different part of the elephant and so come up with a reasonable conclusion. Problem is, the elephant as a whole, looks wholly different.

In the case of the VHA, of course, far more than six blind men are trying to interpret and define the elephant. Some of those trying to define the VHA are deeply influenced by either present or past experiences. For Vietnam era veterans, the VHA evokes memories of how they were treated when they returned from a war that divided the country.  These experiences were eloquently portrayed in Ron Kovic’s memoire Born on the Fourth of July.   Others understandably cannot overcome their very righteous anger about the treatment they encountered when the Department of Defense and Congress — and some in the VHA itself  — refused to recognize the mysterious illnesses caused by Agent Orange, or acknowledge the reality of the Post Traumatic Stress Disorder PTSD, from which they suffered.

The fact that the VHA now treats those with Agent Orange related illnesses and PTSD and other mental health problems, is to them irrelevant. The VHA of today is veiled in images of denial, rejection, and even callousness. The same may be true of veterans whose health was affected during the Gulf War or from toxic spills in Iraqi facilities, or the chemicals emitted by the burn pits of Iraq and Afghanistan.  They may blame the VHA for the Deptartment of Defense’s response to their illnesses and concerns.  Or be furious because the scientific process that may eventually prove them right moves so very slowly.

Some of those trying to define the VHA have experienced the difficulties of navigating its complex eligibility requirements, requirements that it almost take s a PhD economist to parse. These have not been fashioned by healthcare providers but by decades of Congressional decisions that have limited the number of veterans the system is permitted to care for.  Others who define the VHA through their own experiences may be irate veterans, or lawyers who represent them, or veterans organizations who fight for the interests of those refused eligibility because of the discharge status they were given when they left the military.  Again, the VHA is not responsible for any discharge characterization once a person in the military is discharged.  That privilege belongs to the DOD.

Some veterans approaching the VHA may be angry because of long wait times that were revealed in 2014 in some VHA facilities, mostly those in the Southwest like Phoenix. Others are displeased because they were cared for at a large VHA medical center that is connected to a local medical or other health professional school and they do not like the fact that they lose their doctor, or NP, or RN, or OT, PT, or psychologist because he or she is graduating from a training program and not remaining at the facility.

Others grasp the imposing edifice of VHA care and feel only gratitude for its stability, endurance, and the many caregivers who seem much more committed to veteran patients than those they have seen in the private sector. But even they may only have a partial view of the breadth and depth of VHA care. I have talked with dozens of veterans who have no idea that they can get some of the best palliative care in the country, or amazing hospice care if they have a terminal illness or much better medical equipment than would be available if they had only private sector coverage. They don’t know about the Caregiver Support Program, or the Blind Rehabilitation Centers. 

Many don’t know about the programs to end Veteran homelessness  — to cite just one the Errera Center in Connecticut — and the fact that they have spilled over and to help end homelessness  in general.   One Vietnam era veteran I know who signed up with the VHA forty years after the war, was stunned at the fact he had an actual healthcare team caring for him). “It’s amazing, I came to my first visit and was introduced to my physician, my nurse practitioner and my RN. All working with me.”

Others couldn’t believe that the VHA offered nursing home care or genuine team based primary care, physical therapy, or some of the best mental health care in the nation, even ear exams, via Telehealth services that may be delivered right in a veteran’s home.  Or bariatric hospital beds, or specially designed wheel chairs, or advanced prosthetics not only for daily but athletic use.  As for the concept of integrated care, some veterans,  like most Americans,  may not  have a clue what that means or how it positively impacts them. They may have appreciated the elephant’s legs, or tail or tusks, but as for its body – the muscles, and ligaments, and tendons, and fascia and intricate network of blood vessels, cells, and neurons and  their complex myelin like connections– that is much harder for them to appreciate.

Even people who work for the VHA — people who say they would not consider working in a private sector where profit too often trumps patient need, and working in disconnected siloes makes it impossible to deliver even well planned, much less integrated care, don’t know about a lot of programs the VHA sponsors. One physician who is a total champion of the VHA, had never heard of the Veteran’s Treatment Court model , which the VHA participates in.  (I offered to take her with me to observe the one in San Francisco).

Some, like some of my progressive or liberal friends who are healthcare professionals offer an equally interesting view of the VHA.  A number of them will acknowledge that the VHA is, in fact, a great system yet attribute its excellence to its connection to the medical or health professional training school located in their particular city. In Bay Area, where I live, for example, a number of non-VHA health care professionals have confidently announced to me that yes, the VHA gives great care. Why? Because it is connected to UCSF and UCSF has great and reputed doctors connected to it. If the VHA is great, it’s because UCSF is great (by the way you never, ever hear the opposite, if UCSF is great, it’s partly because the VHA with which it is affiliated is great).

When it comes to the political debate, the parable of the blind men and the elephant becomes even more apt and distinctly more disturbing. Indeed, today, it seems that a bunch of blind men who are so committed to their positions that they would positively refuse an operation that promised a cure are actually in charge of the VHA in Washington. As one VHA staffer who spoke under conditions of anonymity told me, it’s pretty depressing when the person who is the equivalent of the CEO of your company, actually hates the company, bad mouths the product, and thinks the staff are a bunch of slackers. She was, of course, referring to Jeff Miller (R. Fla) Chairman of the House Committee of Veterans Affairs. According to these particular blind men, whose symbol is, ironically, an elephant, this particular version   is on its last legs, should be taken out of its misery, and its stunning ivory tusks should be sold to the highest corporate bidder.  Okay maybe not to a wealthy Chinese bureaucrat or Japanese businessman seeking to enhance his status.  But certainly to benefit a private sector health system,  physician group, or Big Pharma company, which who would be delighted to give far less integrated care for far more money, all of it, of course, provided by the US taxpayer.

The problem with these interpretations of the VHA is that they make it impossible for us to appreciate the way the actual system works today, to fix any problems it might have, and to build on its considerable strengths.   More on this later.


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