The VA Scandal: One Hypothesis
As we celebrate the 70th anniversary of the Normandy landings, it is important to remember those who returned home as well as those who were lost. Coverage of the ongoing revelations of fake appointments and incredibly long (and possibly fatal) wait times for US veterans hoping to receive care at VA hospitals has focused on bureaucratic ineptitude, if not malfeasance. A recent poll finds that 97% of Americans are deeply concerned about these problems. Department of Veterans Affairs Secretary General Eric Shinseki resigned at the end of last month amidst continuing pressure.
Untangling the causes of the scandal will take months if not years. As some have noted, organizational politics is surely to blame for part of it, as are the enormous challenges facing one of the largest US agencies. And to some extent, current pressures are also driven by aging veterans retiring to warmer cities like Phoenix. I’d like to propose an additional hypothesis regarding one likely contributing factor to the VA scandal: dramatic improvements in military medicine.
In a forthcoming article in International Security, I show that wounded-to-killed ratios (the number of people wounded in battle who survive divided by the number killed in battle) have improved significantly over the past sixty years in particular as a result of four changes in medical care in conflict zones. First, preventive medicine, including immunization and field sanitation, has seen significant advances. Second, battlefield medicine, particularly the development of new means to control blood loss, has begun to overcome a deficit in preventable battle deaths due to hemorrhage. Third, the use of mechanized transport and helicopters has cut down medical evacuation times significantly. And fourth, the use of personal protective equipment such as modular tactical vests and helmets means that soldiers today are much more likely to survive wounds to their head and trunk that would have been fatal without such protective gear.
All these changes mean that soldiers are much more likely to survive wars today compared to the past. For US military personnel, wounded-to-killed ratios have skyrocketed since the wars in Afghanistan and Iraq started. Thus, the VA has been confronted with rising demand both as a result of increased deployments and an increased number of the returned wounded. The nature of wounds survived by soldiers today have also changed as a result of these improvements in medical care – with better helmets and body armor comes an increase in traumatic brain injury and amputation. Thus, not only has demand for care increased, but the nature of the care demanded has also shifted.
The VA is not the only US institution that has been poorly-equipped to deal with these changes. Last year, Congress passed a budget that cut military pensions (but then reversed its position two months later). And it appears that support for the GI Bill may be in jeopardy as well.
Improvements in medical care in conflict zones are to be celebrated, but their effects also must be anticipated in order for them to be fully realized. These improvements raise the costs of war on several fronts – with more injured veterans living longer, they are more likely to draw larger pensions and to rely more heavily on the VA health system. While some of the individuals charged with caring for veterans have clearly violated that trust, my guess is that most are deeply committed to veterans as patients and clients. Understanding the broader changes that have stressed the system to this point is a necessary step in fixing it.