VA comes up short for Iraq vets

FORRESTON, Ill. — A year ago on Thanksgiving morning, in the corrugated metal pole barn that housed his family's electrical business, Timothy Bowman put a handgun to his head and pulled the trigger.

He had been home from the Iraq war for eight months. Once a fun-loving, life-of-the-party type, Bowman had slipped into an abyss, tormented by things he'd been ordered to do in war.

"I'm OK. I can deal with it," he would say whenever his father, Mike, urged him to get counseling.

The Department of Veterans Affairs (VA) is facing a wave of returning veterans such as Bowman who are struggling with memories of a war where it's hard to distinguish innocent civilians from enemy fighters and where the threat of suicide attacks and roadside bombs haunts the most routine mission. Since 2001, about 1.4 million Americans have served in Iraq, Afghanistan or other locations in the war on terror.

The VA counts post-traumatic stress disorder, or PTSD, as the most prevalent mental-health malady to emerge from the wars in Iraq and Afghanistan.

VA Secretary James Nicholson and other top administration officials have said the agency is well-equipped to handle any onslaught of mental-health issues and that it plans to continue beefing up mental-health care and access under last week's administration budget proposal.

But an investigation has found that even by its measures, the VA isn't prepared to give returning veterans the care that could best help them.

McClatchy Newspapers relied on VA reports, as well as an analysis of VA data released under the federal Freedom of Information Act. McClatchy analyzed 200 million records, including every medical appointment in the system in 2005, accessed VA documents and spoke with mental-health experts, veterans and their families.

Among the findings:

• Despite a decade-long effort to treat veterans at all VA locations, nearly 100 local VA clinics provided virtually no mental-health care in 2005.

• Mental-health care is wildly inconsistent from state to state. In some places, veterans receive individual psychotherapy sessions. In others, they meet mostly for group therapy. Some veterans are cared for by psychiatrists; others see social workers.

And in some of its medical centers, the VA spends as much as $2,000 for outpatient psychiatric treatment for each veteran; in others, the outlay is only $500.

• The lack of adequate psychiatric care strikes hard in the western and rural states that have supplied a disproportionate share of the soldiers in the wars in Iraq and Afghanistan — often because of their large contingents of National Guard and Army Reserves.

Moreover, the return of so many veterans from Iraq and Afghanistan is squeezing the VA's ability to treat yesterday's soldiers from Vietnam, Korea and World War II.

"We can't do both jobs at once within current resources," a committee of VA experts wrote in a 2006 report, saying it was concerned about the absence of specialized PTSD care in many areas and the decline in the number of PTSD visits veterans receive.

While the debate in the VA about the level of its psychiatric care often is frank, the public assurances of top officials are oddly optimistic.

"Mental health is a very high priority of ours," VA Secretary Nicholson said last March. "The VA possesses ... the best expertise in post-traumatic stress disorder in the world. ... So we are ramped upward, and we have a terrific cadre of experts in that area, and we are adequately funded to deal with it."

But soldiers coming home today walk into a VA health system that's nothing like it was when veterans returned from World War II, Korea, Vietnam or even the first Gulf War.

The change began more than a decade ago, when the agency decided to shift from focusing on high-cost inpatient hospital care and toward outpatient clinics that could tend to veterans' primary-care needs.

In addition, the VA scrapped its organizational structure and created about 20 networks, more than 150 hospitals and — as of today — more than 800 outpatient clinics. The new system would provide "easier access to care and greater consistency in the quality of care," the VA said in a March 1995 report.

Its committee of experts, however, said specialized mental-health services were declining and that the VA's use of unadjusted dollars in an era of high inflation in medical costs rendered its annual reports "meaningless."

At the same time, the VA began treating many more people for mental-health ailments, so the amount spent has plummeted from $3,560 per veteran in 1995 to $2,581 per veteran in 2004 — even before correcting for inflation. (Overall, mental-health spending during that period went from $2.01 billion to $2.19 billion.)

In the past two years, the VA has committed more money to mental-health care and brought services to previously underserved areas. But it's also changed its accounting system, so it's difficult to compare spending after 2005 with that of prior years.

What does this all mean for veterans?

It means that veterans receive fewer visits to mental-health professionals, on average, than they did before.

VA experts said the system already was straining to provide veterans with what they needed before the United States attacked Afghanistan in October 2001.

The nearest VA outpatient clinic to Tim Bowman's hometown is part of the Madison, Wis., network. Like one-third of all VA medical centers in 2005, Madison didn't have a specialized PTSD clinical team, according to VA records.

That's the case despite two decades of urging by VA experts that each medical center should have such a team.

Its absence in many centers exemplifies a significant — and growing — problem in the VA: wide disparities in mental-health services.

The VA's mental-health experts started pushing for specialized PTSD programs in all medical centers in the 1980s. Top VA officials agreed "in concept" that it would be a good idea. But in 2005 and 2006, despite telling Congress that it was setting aside an additional $300 million for expanding mental-health services, such as PTSD programs, the VA didn't get around to spending $54 million of that, according to the Government Accountability Office.

At medical centers with no specialized PTSD teams, veterans still receive PTSD treatment, but not from specialists.

In all, only 27 percent of veterans receiving PTSD care received it in one of the VA's specialized programs, VA data show.

The uneven mental health-treatment of veterans can be traced to the VA's health-system reorganization, which gave a lot of leeway to local managers.

McClatchy reviewed two dozen mental-health measures, based in part on an analysis of every inpatient and outpatient visit in the VA health system.

Among the findings:

• Some veterans get in for visits far more than others. The average number of visits per veteran with PTSD ranged from 22 in the Hudson Valley, N.Y., medical center and clinics to a low of 3.1 in Fargo, N.D. The national average was 8.1.

• Some VA medical centers spend far more on mental-health care than others. In Connecticut, it was an average of $2,317 for each veteran's outpatient psychiatric care. In Saginaw, Mich., it was $468.

• Some veterans get in quickly. Others wait. At the Loma Linda, Calif., VA network, only 39 percent of new mental-health patients were able to get appointments within 30 days, the VA's standard. In other networks, 90 percent or more did.

• Once they're in the door, some veterans get visits of 75 to 80 minutes, while others get 20- to 30-minute appointments, the shortest psychotherapy appointments listed in the system.

Asked about the disparities, Antonette Zeiss, a VA health official who is helping to oversee the mental-health system, said: "It's true there are disparities. ... Disparity is a part of health care. ... I can tell you that the data you're looking at we're looking at, too, and we're using it to make decisions about how to close the gap and ensure a standard of care nationally."

The VA's top mental-health services official, Dr. Ira Katz, added that variation in of mental-health measures could reflect different strategies being tried in different.

Through such trial and error, variations likely would decrease over time as, for example, expensive medical centers become more efficient and underserved medical centers were given more resources, he said.

So far, that hasn't happened, McClatchy found.

For starters, the variations in many mental-health measures are growing, not shrinking, according to a McClatchy analysis of key measures back to the time of the reorganization.

In addition, the variation in mental-health spending is far wider than it is in primary and hospital spending.

As for the wide variation in spending per veteran on mental-health care, Katz said it could be explained by the presence of special programs in various medical centers. There's a national PTSD research center at the Connecticut VA, for example, that inflates spending figures there.

Among other things, the VA has begun to pump more money into local clinics to ensure that they begin to provide mental-health treatment, Katz said. The 2008 budget released last week will continue those efforts, the VA said.