So, What's the Story?

Predictably, Congress has jumped into the middle of the growing scandal at Walter Reed Army Medical Center in Washington. At least two Congressional committees will launch hearings into the matter today; one of the panels will actually meet on the grounds at Walter Reed, where wounded veterans in an outpatient facility have endured sub-standard living conditions, and bureaucratic snafus that delayed follow-up treatment, sometimes for months. These problems were highlighted in recent Washington Post reports, and the paper is continuing its investigation into veterans' health care.

In today's installment in their series, Post reporters Dana Priest and Anne Hull highlight problems at other military heath care facilities around the country, including those run by the Veterans Administration. Some of the problems reported at those institutions sound similar to conditions at Walter Reed; over-crowded billeting accomodations for wounded service members; poor living conditions in some barracks or dormitories and mounds of red tape that make it difficult to get needed treatment in a timely manner.

There is one caveat to this most recent Post report--one that the paper doesn't offer. Many of the complaints cited by Priest and Hull were submitted to the paper by e-mail, or culled from on-line military and veterans' forums. While I have no reason to dobut the validity of these claims, there is no indication that anyone from the Post has actually visited the military hospitals at Ft Knox and Ft Campbell in Kentucky; Ft Dix, New Jersey, and Fort Irwin, California--all run by the U.S. Army.

Anyone see a pattern here? Army health care is suffering for various reasons, including chronic under-funding in the 1990s. As the service reduced the number of soldiers on active duty, it made corresponding cuts in its military heath-care system, with little regard for future conflicts and potential casualties. If the first Gulf War was a template, then much of the heavy lifting would be done by airpower, with ground forces waging a short, decisive land campaign after the air component finished its job. Under that sceanario, casualties among ground forces would be limited and relatively light, allowing the Army to downsize its medical system.

At the same time, advances in military medicine were dramatically improving survival prospects for troops wounded on the battlefield. Injuries that proved fatal in the past were now survivable, thanks to improvements in trauma care and the perfection of a medevac system that delivers wounded soldiers to field hospitals within minutes, and to major military medical centers in Germany or the U.S. within 24 hours of the incident. With more troops surviving their wounds, that created the potential for larger numbers of service personnel requiring months of outpatient care and rehabilitation, but that scenario was not reflected in Army budgets or programming priorities. Extended occupations of hostile areas--with significant casualties--were simply not factored in recent Army and Pentagon budgets.

And the blame doesn't end with the Army. During the Vietnam War, there was a major expansion of the military health care system and VA facilities, to accomodate large numbers of wounded from those conflicts. When I entered the Air Force in the early 1980s, even the smallest base hospitals could accomodate combat casualties, and provide both short and medium-term care. A friend of mine, who worked at an installation hospital in South Carolina, told me that his facility could handle as many as 100 wounded troops, if required, by opening up a vacant wing of the hospital, and squeezing more beds into existing rooms. That may not sound like much, but multiply that capacity by the number of Air Force installations with "small" hospitals, and you'll see that there was a significant "surge" capacity.

So, what happened to those extra beds? Eliminated in budget cuts, beginning in the late 80s and stretching well into the next decade. By that time, "outsourcing" had become the rule of thumb. Military dependents were sent to civilian hospitals (to save money), and many AF hospitals became little more than glorified clinics, performing only minor surgery. Military patients requiring more complex procedures were sent "downtown," or flown to larger military medical facilities.

But the cutbacks weren't limited to the smaller military hospitals. In the early 1990s, I was stationed at Keesler AFB, on the Mississippi Gulf Coast. Keesler is the second-largest hospital in the Air Force; only Wilford Hall Medical Center in San Antonio is larger. But even in that era, Keesler was losing "capacity." A hospital built to handle hundreds of wounded in the Vietnam era could accomodate only a fraction of that 20 years later. I don't have any current statistics for Keesler, or some of the "other" major Air Force hospitals (Wright-Patterson, Andrews, Travis, etc), but it would be interesting to know how the reduction in their "surge" capacity has affected military health care in the GWOT. Again, there was no malicious intent in these reductions; based on the "perceived" threat environment, the military saw a chance to save money, and downsized its health care network.

Today's Post article also lists complaints about the VA medical system, where many wounded vets seek treatment after being discharged. Anyone with even a rudimentary knowledge of the agency and its workings knows that VA health care has been "hard broke" for years. Veterans and retirees with "other" health care options make it a point to avoid the system, whenever possible. Large numbers of Iraq and Afghanistan veterans entering the VA network will only make the situation worse, and certainly, our wounded warriors deserve better than that.

But wait a minute. Not long ago, the VA was being touted as model for the nation, and (potentially) a blueprint for some sort of universal health care system. This article from Time (27 August 2006) touts high-tech advances in the VA's development of computerized medical records and a high-tech system for quickly dispensing prescriptions. That "state-of-the-art" system doesn't exactly square with the complaints listed in the most recent Post article.

So, what's the real story? Behind that dilapadated building and those bureaucratic snafus at Walter Reed, you'll find a military health care system was "downsized" and "outsourced" throughout the 1990s. And, many of the decisions that produced the current scandal at Walter Reed were made before 9-11; for example, the Post barely mentions that the military has been trying to close Walter Reed for years, and consolidate operations at Bethesda Naval Hospital outside Washington--the facility where members of Congress are treated. Walter Reed is slated for closing on the most recent BRAC list, making it a lower priority for funding, despite the influx of wounded from Iraq and Afghanistan.

As for the VA, the system was never as good as Time advertised, but such articles did serve a political purpose, suggesting that government-sponsored health care could be as good, or even better than the private sector. And, it's no coincidence that some of the magazine's favorite politicians (Hillary Clinton and Barrack Obama come to mind) are pushing national health care in their presidential campaigns. The "real" VA is on display in that annecdote from today's Post story, where staffers argue over who has to bathe a badly wounded soldier from Iraq, and his parents discover that the young man was burned because a nurse left him in a shower too long.

Truth be told, the problems in military health care (and the VA) began long before Dana Priest stumbled into Building 18 at Walter Reed. And, they will continue long after the Congressional hearings end, and the Post moves on to its next scandal du jour. The real question is whether the current problems at Walter Reed--and continuing difficulties in the VA network--will be enough to prompt genuine change, and introduce market-oriented solutions into the system. The military clearly needs to develop a mechanism for increasing its surge capacity, perhaps leasing space at underused civilian facilities, or (borrowing a page from the Civil Reserve Air Fleet), paying part of the costs for building local hospitals, in exchange for access to those institutions, as needs warrant. Or, the answer might be as simply as reopening some of those smaller, near-dormant base hospitals, and utilizing them to care for wounded warriors.

As for the VA, I think Congress had the right idea in the early 90s, when key members advocated scrapping the system altogether, and starting anew. Contrary to what the folks at Time might think, the VA health care network remains woefully inefficient, and it's hardly a model for the nation. If anything good comes out of the Walter Reed scandal--other than improving care and accomodations for wounded troops--it will be the needed "debunking" of recent myths involving the VA and the supposed quality of its care.

If the Post is genuinely serious about this issue--and I have my doubts--they need to dig much deeper on this issue, and examine the underlying causes. The Post editorial board and a Democratic Congress will be tempted to dump this scandal at the feet of the Bush Administration--and they are not without blame. But some of the decisions that led to the problems at Walter Reed (and within the VA) were made years ago, and those retired officials and generals need to held accountable, too.

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On one of those talking head shows over the weekend, retired Army Major General Bob Scales said the scandal at Walter Reed was evidence of a service that was "underfunded" for the past decade. General Scales is right--to a point. Certainly, the Army didn't fare as well in the budget wars as the Air Force or the Navy. Still, the service was the master of the resources it received, and somewhere in the chain, the Army brass decided to save money in its health care system, leading to some of the conditions on display at Walter Reed. Unfortunately, Scales' comments are merely the latest variation on the theme that "Don Rumsfeld screwed the Army." I reality, the service did a pretty fair job of screwing itself, pouring billions into weapons systems that were later scrapped (Comanche helicopter, the Crusader self-propelled howitzer), while pinching pennies in other areas, including health care.