The Myth of Accessible Health CareOctober 29, 2006
The Raw Story
If you were thinking of enlisting in the military and you read the press releases from the DOD and VA public relations machine, you'd think that signing up would make you part of a body of men and women who were the nation's greatest asset -- a corps that would enjoy every possible means of care at all stages of their professional and personal lives.
You'd go to the DOD's fancy Deployment Health Clinical Center (DHCC) web site and cling to the promise that its resources are devoted to "fostering a trusting partnership between military men and women, veterans, their families, and their healthcare providers to ensure the highest quality care for those who make sacrifices in the world's most hazardous workplace."
The site would assure you that all returning service members "receive a face-to-face health assessment" by a trained health care provider that includes an in-depth review of "each service member's current health, mental health or psychosocial issues commonly associated with deployments, special medications taken during the deployment, and possible deployment-related occupational/environmental exposures."
And who could blame you for feeling reassured? It's a level of medical attention and care that anyone would envy -- if, in fact, anyone were getting it at all.
"I don't believe that the DOD is having face-to-face screenings," says Paul Sullivan, Director of Programs at Veterans for America (VFA). "I have spoken with countless veterans who have advised me that at most they fill out the form, and many don't even do that."
Steve Robinson, VFA's Government Relations Director, agrees with his colleague. Although both pre- and post-deployment health assessments were mandated by law in 1997, Robinson notes that "previous reports from the US Government Accountability Office, (GAO) that looked at whether the form was being utilized correctly have already indicated that the DOD is not doing face-to-face screenings or making sure that everyone is filling out the forms."
In fact, a 2003 GAO report specifically found that "the percentage of Army and Air Force servicemembers missing one or both of their pre- and post deployment health assessments ranged from 38 to 98 percent of our samples."
"The post-deployment process was absolutely terrible and totally inadequate," recalls Paul Reickhoff, Executive Director of Iraq and Afghanistan Veterans of America (IAVA) . "Physicals were not mandatory as part of our post-deployment. There were no mental health screenings, unless you self-diagnosed by checking certain boxes on the 2796" (the post-deployment health assessment form).
Given the lack of mandatory screenings, coming forward with a possible mental health disorder is left to service members, who are both culturally and systemically repelled from doing so. The only chance they have of meeting face-to-face with anyone is if they answer "yes" to two or more of the four PTSD screening questions added to form 2796 in April of 2003 after years of lobbying by mental health professionals.
The disincentives for doing so are immense. They include the threat of being held behind at the demobilization location while the rest of the unit -- the people who have been your family for months or years -- goes out to celebrate, then goes home; the end of opportunities for advancement in the military, or as a fire fighter, police officer, or security guard; and the personal shame of being perceived as weak in one of the most macho environments this side of Giants Stadium.
Despite the DHCC web site's promise of updated forms and revamped processes, demobilization today looks a lot like it did back in1993. That's when Adrian Atizado, the Assistant Legislative Director for Disabled American Veterans (DAV), came home from the Gulf War. "You had three days of filling out forms" at the very end of your service, he recalls, usually once you were back on US soil. "Your discharge would be held up if you checked anything other than normal. That hasn't changed since Vietnam. It's the nature of the business."
"Look," says Reickhoff, who demobilized in 2004, over a decade after Atizado. "Check one of those boxes honestly and you could stand on another line or ten, talk to another round of paper pushers, and be held over at Fort Stewart for a few weeks while your buddies went home to have sex with their wives, play with their kids, and drink beer on a beach."
"Let me give you an example," says Kevin Gregory, Supervisor of the National Service Office for DAV. "There are some friends of mine that are in the National Guard. Their unit came back a few months ago, went to Fort Drum New York for out-processing before they could return home. They were told that anyone who checks that they have nightmares, flashbacks -- you know, symptoms of PTSD --would be held until a full evaluation could be made before they could go home. Every single one of them has some sort of issue or problem, but none of them complained about PTSD because they all wanted to go home."
In a companion editorial to Hoge's damning 2004 NEJM study, Dr. Matthew J. Friedman, Executive Director of the VA's National Center for Post-Traumatic Stress Disorder (NCPTSD) notes that, "concern about possible stigmatization was disproportionately greatest among the soldiers and Marines most in need of mental health care." Consequently the returning service members who most needed treatment were the least likely to seek it "for fear that it could harm their careers, cause difficulties with their peers and with unit leadership, and become an embarrassment in that they would be seen as weak."
"The sticking point is skepticism among military personnel that the use of mental health services can remain confidential. Although the soldiers and Marines in the study by Hoge and colleagues were able to acknowledge PTSD-related problems in an anonymous survey, they apparently were afraid to seek assistance for fear that a scarlet P could doom their careers."
As Shad Meshad, President and founder of the National Veteran's Foundation said when we spoke for this piece, "Whether the DOD thinks there are consequences or not, the soldiers do."
Even a service member who overcomes these powerful disincentives and answers "yes" to two or more of the PTSD questions on the 2796 is not assured of a face-to-face screening with any kind of health care provider. (In Reickhoff's unit, the form went to him and he passed it up to his commander.) And even if he does get his screening, the odds are 4-1 against him actually being referred for further evaluation by a mental health professional.
In a report issued this past May, the GAO -- the non-partisan investigative wing of Congress -- determined that the DOD could not provide reasonable assurance that all servicemembers who needed referrals were getting them. Of the mere 5% of servicemembers who answered positively to the PTSD screening questions, 78% were not referred for further mental health evaluation.
That 22% referral rate is what shocked a lot of veterans' advocacy groups and drew the attention of the mainstream media. But the report's conclusions were based not on the 22% referral rate, but on the DOD's lack of information regarding the referral process.
DOD officials claim that not everyone who responds "yes" to three or more of the PTSD questions on the 2796 needs a referral. They leave it up to their providers to make that determination. But while GAO researchers found substantial variation in the referral rate among the four branches of the military (from a low of 15% for the Marines to a high of 23% for Air Force and Army troops), it had no way of determining whether those variations represented different levels of need or some kind of difference in provider decision-making.
GAO lacked that data because DOD does not require their providers to write anything down about why they permit or deny referrals to service members. Since "DOD did not identify the factors its providers used in determining which OEF/OIF servicemembers needed referrals," GAO concluded that DOD "could not offer reasonable assurance" that everyone who needed a referral was getting one.
The GAO report's recommendation, parsed in the judicious language of research, was that "DOD identify the factors that DOD health care providers use in issuing referrals for further evaluations for mental health or combat/operational stress reaction to explain provider variation in issuing referrals."
"What we don't know is what the providers are thinking and how they are applying their clinical judgment," says Cynthia A. Bascetta, GAO's Director of Health Care for Veterans' Health and Benefits Issues, and the report's lead researcher. "And without that data, how can you do quality assurance on the appropriateness of screening, follow-up, and treatment?"
But she refrained from conjecture on the 22% referral rate. "I've done a lot of work on disability on the civilian side, specifically social security disability," Bascetta said. "And it is really very hard to assess the mental disorders that are more behavioral in nature as opposed to schizophrenia and bi-polar disorder, etc. And I honestly don't know if referring low percentages of those who check 'yes' to the PTSD questions on the 2796 is reasonable or not. It might be. But I can't make that judgment, and neither can DOD, until we know the basis. And that's what we were trying to tell them."