Best Care Anywhere

by Phillip Longman

  To a limited, and regrettable, extent, these marketing efforts worked. The tour was a variation on a tried-and-true strategy in health-care marketing: when drug company salesmen, or more commonly comely saleswomen, present doctors with samples of pricey new name-brand substitutes for equally good generic drugs, time and again doctors start prescribing the more expensive medicine. And they are likely to be even more suggestible when they don’t know enough about computing to evaluate vendors’ claims skeptically.

  The VistA Solution

  What can be done to counter this lobbying and marketing offensive and keep proprietary companies from locking up the health-care IT market? Two cardiologists at the Johns Hopkins Medical Institutions, Sammy Zakaria and David A. Meyerson, have proposed a simple solution in an op-ed piece for the Washington Post. They begin by noting that “most currently available electronic medical record software is unwieldy and difficult to quickly access, and there is still no vehicle for the timely exchange of critical medical data between providers and facilities.” The government is spending billions trying to work out the standards for a uniform record-keeping system, they further note, even though “a proven system already exists. The software is called the Veterans Health Information Systems and Technology Architecture (VistA), which the Veterans Affairs Department developed. VistA requires minimal support, is absolutely free to anyone who requests it, is much more user-friendly than its counterparts, and many doctors are already familiar with it.”7

  Seems simple, doesn’t it? Except for the politics.

  TEN

  Growing the VA

  Gary Nickel never liked to talk about his experiences in Vietnam. It’s only recently that his wife, Terry, has gotten some details out of him about why he’s started screaming in his sleep and locking his hands as if he is choking someone. He told her about an incident at the giant Bien Hoa Air Base twenty miles northeast of Saigon, where his job was to load and unload aircraft. One time he noticed that just after this plane landed, all the men who had been aboard jumped off puking. Inside the aircraft, Nickel discovered the rotting head of a U.S. soldier stuck on a post.

  Gary told her, too, about his flashbacks to the many times during the Tet Offensive when he shook in bunkers while under mortar attack. After much objection about “not wanting to be pegged” with a mental illness, Gary at last relented to his wife’s insistence that he seek treatment for post-traumatic stress syndrome and now takes pills prescribed by a private physician to treat it. But that’s not his greatest medical need. Gary also suffers from Parkinson’s disease, a degenerative disorder of the central nervous system that impairs motor and cognitive skills. Parkinson’s is most often found among the elderly, but Gary was only fifty-six when he was first diagnosed, and he degenerated quickly.

  Within two years, Gary had to give up his job at the water treatment plant in Moorhead, Minnesota, and Terry had to give up her job as a nurse to stay with him around the clock. (The couple has no children.) Forced to live on a reduced income, including a $450-a-month Social Security disability check, they sold their home and bought a smaller, easier-to-navigate house furnished with a hospital bed, a trapeze, and special pillows to help with Gary’s bedsores. Terry is also responsible these days for looking after her eighty-year-old mother, who now lives with them.

  This might be just another sad story of another working-class American family struggling with poor luck and bad health, except that it gets worse in ways that involve us all. Terry thought it very important that she get her husband enrolled at the VA Medical Center in nearby Fargo, North Dakota, which would provide, among other benefits, equipment like the ramps he needs and, importantly, respite care for herself. She knew that, because of Gary’s modest Social Security disability check, the couple wouldn’t meet the VA’s strict means test for admission. But she’d been reading about growing scientific evidence linking Parkinson’s disease to exposure to Agent Orange—a chemical defoliant widely used in Vietnam. And as it happens, the Bien Hoa Air Base was and remains an Agent Orange hot spot in Vietnam, so much so that the U.S. government committed in 2008 to helping the Vietnamese government clean up the high levels of dioxins and other contaminants left behind. So in 2007 Terry applied for Gary to be admitted to the VA, based on consideration of Parkinson’s as a service-related illness.

  The bureaucracy at the Fargo VA, however, was unmoved. Fourteen months after making their application, Gary and Terry received a two-and-one-quarter page, single-spaced letter dated July 7, 2008, that spelled out the VA’s rationale for rejecting Gary’s enrollment. The case officer acknowledged finding a study on Wikipedia that showed that people exposed to herbicides like Agent Orange have “a 70 percent greater incidence of PD than individuals not exposed” but then went on to suggest that the real reason Gary contracted Parkinson’s at such a young age could be “a 14-year history of smoking” or “occupational hazards” at the water plant. Terry says she assembled hundreds of pages of studies to rebut these claims—a tactic that has worked for a handful of Vietnam vets with Parkinson’s. But after a year of waiting for the verdict on their appeal, she learned, with the help of local legislators, that the VA had simply closed their case. “In my eyes,” Terry says softly, “it’s all political.”

  Though she lost her battle, Terry turned out to be right on the facts. In the fall of 2009, the head of the VA, Eric K. Shinseki, acknowledged growing medical evidence linking Parkinson’s and two other common diseases to Agent Orange. Yet Gary Nickel and hundreds of thousands of other vets have been made to suffer for years without care, thanks to a system that conditions benefits on scientific proof of a service-related disability—proof that accumulates so slowly that many veterans will be dead and buried before they’re finally deemed eligible.

  An essential step in health-care reform that is not only morally overdue but also highly practical is simply this: open up the VA. All veterans should have access to VA health-care benefits, with no questions asked about the ultimate (and often unknowable) causality of their illnesses.

  Full access was once the law of the land. In signing the Veterans’ Health Care Eligibility Reform Act of 1996, President Clinton explained that it “authorizes the Department of Veterans Affairs to furnish comprehensive medical services to all veterans.”1 But then in 2003, under the Bush administration, the policy changed. The VA, having failed to receive the funding it needed to make good on the health care promised to millions of veterans, restricted new enrollments to those who either can meet a strict means test or have ailments directly and demonstrably related to military service. This is why Gary and Terry Nickel found themselves being chewed up by the VA’s claims bureaucracy. It’s also why, according to one recent study, there were fourteen times more vets under age sixty-five who died in 2008 due to lack of health insurance than there were soldiers killed fighting in Afghanistan.2 And it is why, ten or twenty years from now, many veterans of Afghanistan or Iraq will face ordeals similar to those faced by Nickel if they are forced to prove, for example, that they are afflicted by long-term complications from traumatic brain injuries (early onset dementia would not be a surprise). The better way forward, both for vets and for the country as a whole, is to open up the VA, even to the point of allowing family members of vets to buy into the system. Under that plan, which the major veterans service organizations endorse, the VA would become a model delivery system for a significant and diverse segment of the population, and it would point the way by example toward the creation of equivalent civilian institutions.

  The Lessons of Agent Orange

  The ludicrousness of forcing vets, or anyone else, to prove that they are deserving of health care is underscored by the long and continuing struggle over Agent Orange, which offers a mirror to our society’s confused thinking about the relationships among science, morality, and just deserts. You might well believe we took care of the Agent Orange problem years ago. Those of us beyond a certain age can remember the headlines, the angry demonstrations, the acrimonious hear
ings. We can remember how the government long denied that exposure to Agent Orange could contribute to any ill health save a case of chloracne—a disfiguring skin condition. How the gigantic class action suit against Dow, Monsanto, and other manufacturers of Agent Orange left Vietnam veterans furious over its miniscule out-of-court settlement. How Reagan’s VA administrator, Robert Nimmo, used an appearance on NBC’s Today show to call Vietnam veterans “a bunch of crybabies.” How conservative think tanks denounced as “junk science” any studies implicating Agent Orange as a cause of illness. And how, finally, the federal government acknowledged the mounting scientific evidence linking Agent Orange to a variety of diseases and promised to make its victims whole.

  On February 6, 1991, President George H.W. Bush signed the Agent Orange Act into law. It seemed like a great victory to Vietnam vets at the time. The legislation codified the provision that any Vietnam vet with any of three conditions known by then to be strongly associated with Agent Orange would automatically qualify for VA health care—no questions asked. And the bill called upon the Institute of Medicine (IOM) to continuously look for new evidence of Agent Orange’s long-term health-care effects. Backed by the great champion of veterans’ causes, the late Democratic Congressman G.V. “Sonny” Montgomery, as well as by then Republican senator Arlen Specter, the bill promised to bring closure to what Bush called “this very complex and very divisive issue.”

  For a while, the legislation seemed to stand as an example of an overdue, but morally sound, workable policy based on science. In 1993, the IOM found a positive association between Agent Orange and Hodgkin’s and several other comparatively rare diseases, and the VA dutifully added these to the list of conditions presumed to be service-connected for anyone who served in Vietnam. But as the years went by, the IOM and other researchers kept turning up more and more evidence of more and more complications from exposure to Agent Orange. A huge shocker, both to most Vietnam vets themselves and to federal budgeters, came in 2000 when the IOM reported a link between exposure to Agent Orange and type II diabetes—one of the most common diseases in America. It turns out to be substantially more common among Vietnam vets, and though it cost a bundle, the VA, under the waning Clinton administration, changed its rules so that all Vietnam vets with the condition are now presumed to have a service-related illness and therefore eligible for VA care.

  Then, though it attracted little attention in a country that had moved on, the news kept getting worse. As Vietnam vets passed through their fifties and sixties, they turned out to be afflicted by high rates and early onsets of an increasing number of chronic diseases, such as hypertension, and cancers of the lung and prostate, for which Agent Orange turned out to be a serious risk factor. Science also began confirming many suspicions about vets’ children’s health. In 2007, for example, the VA reported that 1,200 children of Vietnam veterans had spina bifida, a birth defect closely associated with a key ingredient of Agent Orange.

  Then, in July of 2009, a bombshell landed on VA secretary Eric K. Shinseki’s desk. In the most recent of a long series of reports titled Veterans and Agent Orange, the IOM added Parkinson’s, ischemic heart disease, and hairy cell leukemia to its list of conditions associated with Agent Orange exposure, a list that has now grown to include, as well, hypertension, prostate cancer, cancer of the lung, and several more conditions.

  In response, Shinseki ordered a rule change redefining Parkinson’s, ischemic heart disease, and hairy cell leukemia as service-related illnesses for any Vietnam vet. Today, people like Gary Nickel and some 200,000 other vets have a much easier time claiming benefits.

  But what about vets who suffer from other conditions that have not yet been, but may someday be, linked to Agent Orange? For now, their only hope is to follow the route Gary Nickel took: try to prove the disease was caused by exposure to Agent Orange, to the satisfaction of some overwhelmed VA service officer who may well try to settle the matter with some scratching around on Wikipedia.

  Dusted Off

  Whether or not one’s ill health is related to military service or any other experience is often a metaphysical question. By their very nature, almost all chronic disorders are multi-causal, influenced by factors such as genetics, diet, behavior, and environmental influences, often all acting together. In Vietnam, the environment was saturated, not just with Agent Orange, but also with a stew of other toxic chemicals whose effects could have been harmful in combination, though it would be extremely difficult to determine that scientifically. “Operation Flyswatter,” for example, sprayed 1.76 million concentrated liters of the insecticide malathion over major bases and cities every nine days as part of efforts to prevent malaria. Troops in the same areas were given “Monday pills,” weekly doses of the antimalaria drug chloroquine, which turns out to inhibit an enzyme the body uses to help metabolize neurotoxins. “Bottom line,” says Alan B. Oates, who heads the VA’s Agent Orange committee, “Vietnam veterans were taking prescribed medication that reduced their body’s ability to detoxify itself while being subjected to exposures of neurotoxins.”3

  There has been little study of how Agent Orange may have interacted with other toxins common in the environment of war-era Vietnam, which included DDT, paraquat, napalm, jet fuels, and many others. Further studies should be done. But we should also ask ourselves what, exactly, would we do with any new information? Yes, it is good to know all we can about the epidemiology of disease, but there are limits to what we can know and dangers in using science inappropriately. Consider, for example, that even if all involved had acted in perfect good faith, science could not have discovered most of the long-term effects of Agent Orange and other toxic exposures except with the passage of time—time enough for Vietnam vets to start having large numbers of deformed children, and even more time for them to start developing Parkinson’s in their fifties. And even then, all science can deliver are generalizations about large populations—not a determination of what caused any one person’s chronic illness.

  And so we have seen huge numbers of vets who have had to endure the effects of Agent Orange without care or compensation until their own suffering and deaths at last produced enough scientific data to drive a change in policy. Normally, we want science to drive policy. But in this realm, waiting for science has meant waiting for an army to age and die, while also forcing sick veterans and their loved ones into the gears of a giant, overburdened, capricious claims bureaucracy—all for the purpose of trying to exclude the “undeserving.”

  Who is to say whether and how much Gary Nickel’s career in water treatment contributed to Parkinson’s, or what difference it should make in his access to government-provided health care? Today it is harried, overworked claims processors at the VA who make the call, and they may or may not be sympathetic. Or the decision is up to the Board of Veterans’ Appeals and the Court of Appeals for Veterans’ Claims, which hear some 38,000 cases a year—a huge portion of which involves disputes over questions of causality and individual just deserts that ultimately have no scientific answers.

  Back in the World

  In retrospect, justice would have been far better served if we had just presumed all along that all Vietnam veterans deserved VA care, and it is still not too late to do that. Nor is it too late to do it for younger and older vets.

  As a practical matter, the majority of our veterans are already old enough to qualify for Medicare, so taxpayers are on the hook for the cost of their care anyway. Does it make sense to exclude them from the VA when the VA delivers care at a lower cost per patient and enjoys higher patient satisfaction than Medicare?

  The VA also has excess capacity in many parts of the country and will soon have much, much more as the once-giant ranks of World War II and Korean War vets grow thin. On current course, the VA utilization of hospital beds will drop 20 percent by 2019 and 40 percent by 2029. In some parts of the country, where the current generation of older veterans are highly concentrated, such as St. Petersburg, Florida, the amount of freed-up capacity will b
e much more dramatic.4 Meanwhile, the VA provides, for those who can get in, very-high-quality care. We need to open up the VA and grow it. So long as the VA remains one of the most, if not the most, cost-effective, scientifically driven, integrated health-care delivery systems in the country, the more patients it treats, the better for everyone.

  Every vet should be able to use his or her insurance, including Medicare insurance, to receive treatment at the VA. Those who are indigent or who suffer from obvious war wounds should be given free care; others should contribute to the cost of their care as they are able. But any American who honorably served in the military should not find him- or herself locked out of the VA.

  Then there’s the effect on the taxpayers. One big, real-world consequence of the VA’s current tight eligibility rules is a far bigger bill from Medicare. “I do not understand the logic,” says Ken Kizer. He continues:

  The VA is providing more superior care, on a regular basis, than Medicare. Patient satisfaction is higher. You can show that it is doing it at a cost per patient of about half to two-thirds of Medicare. So why do you cut off people, tell them they can’t go to the VA, and force them into Medicare? And why do you not allow Medicare patients to use their benefits at the VA?5

  It’s not as if such a step involves impossible politics. What conservative believes that our military isn’t weakened when America breaks its promises to veterans? What health insurance industry lobbyist wants to be seen standing in the way of veterans getting needed health care? What liberal believes that showing solidarity with veterans and offering to restore health benefits cut under the Bush administration isn’t politically shrewd? What taxpayer can’t see the virtue of luring as many veterans as possible from Medicare and publicly subsidized insurance plans to lower-cost, higher-quality VA health care?