Black Shadows

by hilzoy

From the Washington Post:

"Army Spec. Jeans Cruz helped capture Saddam Hussein. When he came home to the Bronx, important people called him a war hero and promised to help him start a new life. The mayor of New York, officials of his parents' home town in Puerto Rico, the borough president and other local dignitaries honored him with plaques and silk parade sashes. They handed him their business cards and urged him to phone.

But a "black shadow" had followed Cruz home from Iraq, he confided to an Army counselor. He was hounded by recurring images of how war really was for him: not the triumphant scene of Hussein in handcuffs, but visions of dead Iraqi children.

In public, the former Army scout stood tall for the cameras and marched in the parades. In private, he slashed his forearms to provoke the pain and adrenaline of combat. He heard voices and smelled stale blood. Soon the offers of help evaporated and he found himself estranged and alone, struggling with financial collapse and a darkening depression.

At a low point, he went to the local Department of Veterans Affairs medical center for help. One VA psychologist diagnosed Cruz with post-traumatic stress disorder. His condition was labeled "severe and chronic." In a letter supporting his request for PTSD-related disability pay, the psychologist wrote that Cruz was "in need of major help" and that he had provided "more than enough evidence" to back up his PTSD claim. His combat experiences, the letter said, "have been well documented."

None of that seemed to matter when his case reached VA disability evaluators. They turned him down flat, ruling that he deserved no compensation because his psychological problems existed before he joined the Army. They also said that Cruz had not proved he was ever in combat. "The available evidence is insufficient to confirm that you actually engaged in combat," his rejection letter stated.

Yet abundant evidence of his year in combat with the 4th Infantry Division covers his family's living-room wall. The Army Commendation Medal With Valor for "meritorious actions . . . during strategic combat operations" to capture Hussein hangs not far from the combat spurs awarded for his work with the 10th Cavalry "Eye Deep" scouts, attached to an elite unit that caught the Iraqi leader on Dec. 13, 2003, at Ad Dawr.

Veterans Affairs will spend $2.8 billion this year on mental health. But the best it could offer Cruz was group therapy at the Bronx VA medical center. Not a single session is held on the weekends or late enough at night for him to attend. At age 25, Cruz is barely keeping his life together. He supports his disabled parents and 4-year-old son and cannot afford to take time off from his job repairing boilers. The rough, dirty work, with its heat and loud noises, gives him panic attacks and flesh burns but puts $96 in his pocket each day.

Once celebrated by his government, Cruz feels defeated by its bureaucracy."

Read the whole thing. It's horrible. More below the fold.

The problems are systemic:

"A new report by the Defense Department's Mental Health Task Force says the problems are even deeper. Providers of mental-health care are "not sufficiently accessible" to service members and are inadequately trained, it says, and evidence-based treatments are not used. The task force recommends an overhaul of the military's mental-health system, according to a draft of the report.

Another report, commissioned by Defense Secretary Robert M. Gates in the wake of the Walter Reed outpatient scandal, found similar problems: "There is not a coordinated effort to provide the training required to identify and treat these non-visible injuries, nor adequate research in order to develop the required training and refine the treatment plans.""

Though, as always, sometimes the incompetence of individuals makes things vastly worse:

"For the past 2 1/2 years, the counseling center at the Marine Corps Air Ground Combat Center in Twentynine Palms, Calif., was a difficult place for Marines seeking help for post-traumatic stress. Navy Cmdr. Louis Valbracht, head of mental health at the center's outpatient hospital, often refused to accept counselors' views that some Marines who were drinking heavily or using drugs had PTSD, according to three counselors and another staff member who worked with him.

"Valbracht didn't believe in it. He'd say there's no such thing as PTSD," said David Roman, who was a substance abuse counselor at Twentynine Palms until he quit six months ago.

"We were all appalled," said Mary Jo Thornton, another counselor who left last year.

A third counselor estimated that perhaps half of the 3,000 Marines he has counseled in the past five years showed symptoms of post-traumatic stress. "They would change the diagnosis right in front of you, put a line through it," said the counselor, who spoke on the condition of anonymity because he still works there."

As I have said before: we owe them much, much better treatment than this.

***

I have not been uniformly pleased with the Democrats thus far. But I think that it's important to bear in mind some of the less well known things they've accomplished. I mention this now because, a few days ago, I was eating dinner and watching CSPAN, and what happened to be on was the House debate over the Military Construction and Veterans Affairs Appropriations Bill. This was not one of those Big, Contentious Debates that people pay attention to, so there was a minimum of bombast and idiocy. And I was struck by a couple of things.

First, there seemed to be a lot of bipartisanship. On several occasions during the random slice of time that I spent eating dinner, Republicans offered amendments and the Democratic chair basically said: I commend you for your really good and thoughtful idea, and I support it; and then the amendment passed unanimously. (Other times, people of both parties proposed amendments that failed, so it wasn't as though they were just passing everything.) Second, everyone there (of both parties) seemed to think that this was a very, very good bill. I have listened to enough debates in my dinner-eating, CSPAN-watching life to know what's just boilerplate ("I would like to commend the gentleman for his great efforts on behalf of the postal workers of Delaware", blah blah blah) and what's not, and I think this really was more than just boilerplate; that members of both parties were genuinely impressed by the bill. The fact that it passed the Appropriations Committee 56-0 -- without a single vote against, Republican or Democrat -- supports this.

The third point, which is what makes this relevant to the preceding discussion, is that this bill tries hard to address what seem to a mildly informed non-expert like me to be some of the real problems facing the VA. (Here's a summary of the bill (pdf); here's another.) In particular, it appropriates money for more than 1,100 new claims processors, to cut the appalling backlog that makes vets wait for months and months to discover whether or not they'll be covered, and it ramps up spending on mental health, PTSD, and traumatic brain injury:

"Provides $600 million more than the President’s request for mental health, PTSD and Traumatic Brain Injury and makes five polytrauma centers and three Centers of Excellence for Mental Health and Post Traumatic Stress Disorder (PTSD) fully operational this year to care for those returning from Iraq and Afghanistan, including those with TBI. An estimated one-third of veterans returning from Iraq and Afghanistan are facing mental health challenges, and up to 300,000 troops are expected to return from Iraq suffering from TBI. [GAO, 11/06; PBS, 2/18/07]"

It also provides funds to try to make the transition from DoD health care to the VA work better, and also for investigators to oversee spending.

I decided to check what the veterans' organizations were saying about it. The American Legion's article is called, amusingly enough, 'Help IS on the way!':

"The American Legion, the nation’s largest veterans organization, applauds the efforts of Speaker Nancy Pelosi (CA), Budget Committee Chairman John Spratt (SC), Appropriations Committee Chairman David Obey (WI), and Appropriations Subcommittee Chairman Chet Edwards (TX) for producing an appropriations bill for the Department of Veterans Affairs that coincides with the recommendations made by The American Legion.

“Last September, I outlined The American Legion’s funding recommendations for VA to the Senate Veterans Affairs Committee,” said National Commander Paul A. Morin. “Unfortunately, the House Veterans Affairs Committee chose not to participate in that hearing because former Chairman Steve Buyer (IN) felt such hearings weren’t productive. But, obviously, many of Mr. Buyer’s colleagues were listening and, more importantly, they took action.”

The House is scheduled to take up H.R. 2642, the Military Construction and Veterans Affairs Appropriations for FY 2008, in the near future. This bill cleared the full Appropriations Committee in a 56-0 vote.

“It is my hope that this much-needed increase in VA funding is not met with opposition by Congress or the administration,” Morin added.

“We as a nation cannot ignore the cost of providing health care to the brave men and women who answer the call to arms,” Morin emphasized. “Simply put, this is an ongoing cost of war and the VA needs to be properly funded.”"

The VFW doesn't seem to have position papers on specific bills. However, they do say this on their blog:

"The House Appropriations Committee approved a $109 billion Military Construction and Veterans Affairs spending bill by a 56-0 vote. The Appropriation now moves to the full House, where a vote is expected next week. The bill includes $64.7 billion in discretionary funding, $43.2 of which is directed at VA. For VA, that is an historic, $6.7 billion increase, and meets what the VFW and the three other authors of the Independent Budget were calling for.

The VFW salutes the strong leadership of those on the Appropriations Committee, especially Subcommittee Chairman Chet Edwards (D-TX). We urge those in the House to quickly pass this bill, and VFW members should call their representatives to urge them to support the Military Construction and Veterans Affairs Appropriations."

President Bush, needless to say, threatened to veto this bill on the grounds that it increases spending too much. But after the unanimous vote in the Appropriations Committee, and perhaps some time for careful reflection on the wisdom of vetoing a bill on the grounds that it provides too much help to veterans in need during wartime, the administration softened its position (pdf) last week, saying that the President will not veto the bill if what he regards as its excess spending is not made up by cuts in other bills.

I can be as good a deficit hawk as the next person. But VA benefits are not the place to cut spending, not with veterans' health care needs going up because we are in a war, and not with people like Spec. Cruz unable to get the help he needs. There are lots of programs we could cut (agricultural subsidies, anyone?) But making good on our promises to people who have risked their lives on our behalf is not one of them. And whatever my problems with the Democrats, I am proud of them for this.

Comments

[OCSteve]

Thanks for highlighting this Hil. I’m speechless, and given other factors that may be a good thing.

[Nell]

I have a suggestion for Mr. Bush on where to find the savings to make this badly-needed vets bill revenue neutral and then some.

Ditch the freaking "missile defense" program. It doesn't work now, it won't work anytime in the foreseeable future, it's a defense contractor porkfest, and it's destabilizing.

[urban coyote]

I want to say a few things as a Vietnam veteran of the last year of that war (1972):

1. We KNEW we wouldn't be honored when we got back. So it wasn't a surprise when things were tough afterwards.

2. I can't resist pointing out that the VA coldness toward this soldier is what you can expect from single-payer government health care. They offered him group therapy, after all, did they not? The VA has developed vast improvements over the last ten years, it's probably as good as government care can get, in other words, it's amorally mediocre.

3. As an accountant, I know instinctively that the VA is afraid of its limited resources being drained away by hypochondriacs (who are ultimately the only winners of government health care). As an organization, the VA has to protect itself with its limited resources; as with any organization, the survival of the system is more important than providing good service to individuals.

4. It's gonna get worse. I live within walking distance of a VA hospital. Since I knew my Vietnam service would be spit upon, I developed a real white collar career for myself with real medical coverage, which I use instead. Other veterans aren't as cunning and grimly determined, so they depend on it. I know some of the employees at this VA center. I asked them if they noticed that the Korean veterans are worse off than the WW2 veterans? The Vietnam veterans are worse off than that? An employee agreed. "Get ready for the Iraq veterans," I said grimly. "They are going to be pariahs when they get back to the US and leave the service."

[john miller]

OCSteve, this is actually in response to something you said on the other thread. I hope you still feel proud of your service and the services themselves. I think a lot of both current and former members of the military services have the same feeling that honest Republicans like you have about your party.

It a "What the f--k happened " type of feeling.

UC, logic is obviously not your strong suit. Your point number 2 is illigical and maybe that is why you couldn't resist it. The tresults have nothing to do with single payer health-care. The same results are occuring in the private sector, but, based upon my knowledge of the MH field,the private sector is doing even a worse job of it.

[OCSteve]

john miller (and hilzoy) – I am and always will be proud, I will not let them take that away from me. It is just diminished today, to what extent I am not yet sure. I trusted too much based on assumptions that seem to have been way way wrong. Lesson learned.

[J Thomas]

I am and always will be proud, I will not let them take that away from me. It is just diminished today, to what extent I am not yet sure.

You can be rightly proud of what you were a part of.

If it's turned into something very different with the same name, perhaps it can again become something to be proud of. That took a lot of work after vietnam, but they succeeded that time. Recovery isn't entirely unprecedented.

[mightygodking]

I can't resist pointing out that the VA coldness toward this soldier is what you can expect from single-payer government health care.

Funny, considering a member of my family whose had serious depression issues has changed psychologists four times thus far (two because of a bad working relationship, one because the shrink moved, and once because my family member moved). But I guess our Canadian system is backward or something.

[Joe Thomas]

saying that the President will not veto the bill if what he regards as its excess spending is not made up by cuts in other bills.

I think you misspoke (mistyped, whatever); don't you mean he WILL veto if the spending is NOT made up for with cuts in other bills?

[Joe Thomas]

Wait, nevermind. I should have read the link a little more carefully; the President is threatening to veto other bills to allow for this one.

[urban coyote]

John Miller's criticism of my "illigical" post just doesn't hold water.

The VA has to cut costs to stay in budget, a national legislated amount that is inflexible. They don't have a choice. The VA has "moved up" to the top of federal hospital care, which is to say amoral mediocrity. This has everything to do with being federally funded.

Since Miller is in the mental health field himself, he should know that mental health issues are a bottomless pit. The government doesn't like to cover it (you don't, and never will, get Medicare coverage for comprehensive mental illnesses, the money isn't there for it) and, naturally, the big health insurance companies avoid it as the sink hole that it is. The VA is in a UNIQUE place, though, because it serves the people who have a job that really does drive them crazy. Skinny war veterans are twice as likely to commit suicide as the general population. I know people who never really got back to normal from Vietnam.

So the VA "should" be stuck with treating crazy people, because they were determined sane, sent into battle, and the wiring shorted out.

I don't entirely understand why the red-blooded, flag waving, perpetually patriotic Republican Party is so chary about ponying up the money for this. Republicans used to avoid war and support veterans. Under Bush's father and under "W," it's gone the other way.

Five or six years ago, the VA had a deservedly bad reputation. There was a thorough study that said, on average, you had a 40% change of dying from your first heart attack or stroke in America --unless-- the VA was treating you, in which case the odds were 50%!

The VA actually did something about it. They start patient treatment with a battery of lab tests, now -- very thorough and definitive. This has improved their scores dramatically. They've also attracted, as patients, many people (like me) with real health insurance. We've paid in $10 billion to the VA.

But there are still problems. The drunks and the drug addicts suck in a lot of money and the long-term cure rate is slow. A lot of minds snap under the pressure of war, and schizophrenia remains stubbornly incurable; perhaps it is the most stubbornly incurable disease known to mankind.

Policies change in a heart-beat, it is a top-down bureaucracy with constant budget issues, and this means the turnover rate among professionals is astronomical (I think the MD turnover at the nearest VA hospital runs around 200% a year). This means I never know who I'm going to see.

There are supposed "watchdogs" to spy on the VA and lobby for good care and conditions -- the American Legion and the Veterans of Foreign Wars. As a member of both organizations, I am underwhelmed by their lukewarm support of hospital care and their absurd rah-rah enthusiasm for an unending colonial occupation of Iraq. I don't think the management of AL and VFW understands the price the young warriors are actually paying in this particular conflict. Nor do I think they understand the political cipher that military matters amount to these days -- the military and its members represent a smaller and smaller slice of the population and GNP, and Congress knows those demographics.

It behooves us to get into as few wars as possible, win them right away, and take care of our wounded. But I don't trust either party to do that.

And Iraq is a peculiar, open, ulcerating wound, proved by the inability of the Army to recruit enough new soldiers. Young men aren't ambitious about becoming prison guards or having a limb blown off while driving in a truck convoy.

Perhaps because of Vietnam, I worry that our clumsy occupation is incubating further conflicts in the years ahead. And I know the veterans won't be coming home to a warm and thankful community for the most part.

Some can't get a job, start drinking, and fall flat. THEN they come to the VA. This is the typical background of the typical patient at my local VA facility.

[J Thomas]

UC, I think you've explained most of your stuff very very clearly and it's hard to argue with it. The part that looks like sheer prejudice is the part about "single-payer government health care" and even then what you say looks accurate in itself.

I believe that what John Miller is objecting to about your second point is not that you are wrong about single-payer government health care. It's that single-payer health care in general is in the same position. Do you expect to get adequate health care payment from a private health insurer? They tend to have a mostly-fixed budget too, and so they must deny coverage to some people. Maybe you'll luck out, as you might at the VA. Or if you get denied coverage you can sue and hope you live long enough to collect. Mental health? My insurance would pay for 10 sessions with a psychiatrist, total. It would give big discounts on psychiatric drugs. If you think you might go crazy, don't use my insurer. Don't have my job.

In theory my employer should do careful comparison shopping to get the most potential health care for me for the least cost. But health care plans are extremely complicated. Very very hard for my employer (who has great expertise in a different arcane specialty) to understand which plan gives better health care. Much easier to see how much it costs. My employer has a conflict of interest when choosing my health care provider.

This is no specifically a government problem. We'd have this problem whether government was involved or not. Basicly, we started out with catastrophic health insurance -- everybody pays and the people who're unlucky enough to need healthcare get funded.

But now we have the reverse -- everybody needs more healthcare than they can afford, and some lottery winners get it.

If you work for 19 years for one company and then you get an expensive life-threatening disease and your company's insurance adjuster denies your claim, then we can make the moral argument that it's your own fault. It was your lookout to check up on that insurance company and seen that it did this sort of fraud, and you should have switched to a job with better health coverage.

Your health is ultimately your own responsibility, just like it's your responsibility not to buy a home over a toxic waste dump or drink contaminated water or breathe the air downwind from a big polluter. It's up to you to know everything about everything that might hurt you. However, I find that this moral stand is much more satisfying to me when bad things happen to somebody else than when bad things happen to me. All in all the economy runs far more efficiently when people can concentrate on their jobs and not have to know everything about everything.

This is not a problem with government. It's just a problem that government doesn't solve. But here we've gotten away from your valid points about our health care problems because in your point #2 you twice used the word "government". If the government was paying private health insurers to insure soldiers at private hospitals would things much better? All that is a side issue, but somehow when you referred to that side issue a *little* bit got responses.

[sakthi]

This is what this war given to us,loss in the both side..Still thinks gets worser day by day..I really feel bad for Cruz condition...
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