This commentary was written by Andrew Pomerantz, who was a primary care physician in Chelsea from 1972 to 1984 before becoming a psychiatrist. He later served as chief of mental health services at the White River Junction VA for nearly 20 years followed by over 10 years as the national director of integrated services in the VA’s Office of Mental Health and Suicide Prevention.
David McKay’s piece “Mental health care in a crazy world” merits a response from his “old friend.” Little did we suspect that the VA health care system was saving him when we persuaded him to join us in providing mental health care at the White River Junction VA. Of course, soon after that I, too, was recruited to another job, working (virtually of course) for VA headquarters in Washington, D.C. 12 years as a primary care provider in Chelsea had led me into psychiatry and then, unexpectedly, into an administrative career which, I can tell you, put down-to-earth Vermont thinking into national VA policy.
As Vermont and the rest of the nation struggle to integrate mental health care into primary care, few are aware that the game-changing integrated approach to mental health care that was developed right here in Vermont in 2004 has been national policy for nearly 15 years. Importantly, providing such care on a population level frees up scarce highly specialized resources for those with more severe illness who need more intensive care.
Prior to my retirement about a year ago, I traveled across the country to try to help those medical centers that were struggling, while learning from those that were leading the way. I saw first-hand what research has shown: this government-run VA health care system has no equal in the U.S.; the best-kept secret in health care. As Dave suggests, this secret is assured by those who benefit from maintaining a fragmented health care system that delivers poorer care at a higher cost than most developed countries in the world.
In the U.S., the dream of having a fully integrated health care system that provides comprehensive person-specific care to improve the health and well-being of the population is still just a dream for the vast majority of the population. But it is not a dream for the millions of veterans who choose VA for their health care.
It has taken war and Covid-19 for the American public and many in the health care sector to finally understand the impact of mental and behavioral health conditions on individuals, families and society, and the failure of our system to provide needed care. Contrast this with a statement made by the CEO of a hospital when I joined its board of trustees years ago: “We don’t do mental health. It loses money.” Incidentally, that CEO’s salary was about four times greater than the CEO of Vermont’s sentinel VA medical center at the time.
VA is not without its problems, many of which it brings on itself. It is a huge bureaucracy, necessary for any organization with over a third of a million employees. At the upper levels of leadership, the constant churning of people in power, lack of a permanent undersecretary of health (CEO) for almost six years (until a month or two ago), the pervasive culture of fear that limits the willingness of many to say what those above do not want to hear (and commonly results in the undersecretary being fired), and the billion dollar bungling rollout of a new, likely unnecessary electronic record are only a few.
One could not develop a more effective scenario for organizational failure; especially true for a system always in the public eye with media and politicians eager to pounce on problems in any of the nearly 2,000 points of care across the system. Yes, major and minor screwups do happen (you can get a bad meal at the best of restaurants, too). Despite these significant handicaps, VA continues to improve its care and veteran trust in the VA has never been higher.
During the Obama administration, the secretary and undersecretary for health of Veterans Affairs vowed to move the system from a culture of rules to one of principles. Unfortunately, the organization’s momentum was too great and their time was too limited to make a difference. It’s tough to run a health care system with rules designed to deliver the mail. The secretary lasted only until the Trump administration replaced him with the undersecretary, who lasted only a short time before being fired, likely for being too supportive of the system.
Despite its formidable internal handicaps and existential threats, the VA continues its work. Day after day, VA employees provide the best care in America to millions of veterans. They are proud of the excellent treatment they provide to the people who have offered their military service to our country. How else to explain why a person will work there, for the privilege of earning significantly less money than they could in the private sector, while being maligned by politicians and the press at every opportunity?
Instead of closing clinics and hospitals deemed “too small” to keep open, as has been suggested by the Biden administration, why not offer VA care to a broader population, such as veteran family members, and maybe any other Americans? It would work for everyone, especially the American taxpayers. Let those who want care in a system designed to generate profits get that care. Fine by me. Time to make the VA the elusive “public option” for those who want something else.