Please Hold: Why our Veterans are Dying for Care

Imagine for a moment you are a young combat veteran struggling to make it in the civilian world after two tours to Iraq as an Infantryman. You have a wife and two little girls who are counting on you as the breadwinner for the family, but you’re struggling to make ends meet. You’ve been trained for combat and when you returned, these skills weren’t easily transferable to the civilian job market. Worse, newfound problems with alcohol abuse, PTSD, and depression are holding you back. Your life is spiraling out of control.

You reach out to your local VA hospital seeking help. Frustrated after being denied care twice, you are finally placed on a waitlist for an indeterminate amount of time. In the meantime, you call the Veteran’s Crisis Hotline. You’re contemplating suicide as an escape and you need someone to talk to. Instead of getting through to a trained and ready staff member, you are put on hold for two minutes. Nobody ever comes on the line. Eventually your call is routed to voicemail. What do you do?

Not possible, you think? Think again.

A Perfect Storm

In March 2016, after two tours in Iraq and seven years in the Army, veteran Tom Young reportedly called the Veteran Crisis Line and, reaching voicemail, left a message. A day later his message was returned. Too late, it turns out, as Tom had already taken his life. At the time, Tom was on a waiting list for care at the Hines VA hospital. Painfully, the same day his voicemail was returned, the Hines VA called to inform Tom that space was available for him in their alcohol treatment program.

Tom’s family, including his two young daughters, are now left to pick up the pieces and carry on without him.

It turns out that Tom’s story, as heartbreaking as it is, is staggeringly common. Stories of veterans taking their lives while waiting for care at the VA or to speak with someone on the VA’s Veterans Crisis Line are brought to our attention with almost shocking regularity.

In July 2016, Army sergeant Brandon Ketchum, a combat veteran who served three tours between Iraq and Afghanistan, took his life just hours after family members reported he was turned away from the Iowa City Veterans Affairs Medical Clinic. More recently in November 2016, 32-year-old Curtis Gearhart, a combat engineer with two tours to Iraq, took his life while waiting for an appointment at the Des Moines VA clinic.

These are just a handful of recent cases of veterans committing suicide while waiting for care from the VA. Hundreds of thousands more have simply died while waiting for the VA to process their healthcare applications.

Their stories underscore the need to think differently about how our society provides care for our veterans.

An Organization Plagued by Crisis and Scandal

The U.S. Department of Veterans Affairs enterprise is absolutely enormous by any standard, operating the nation’s largest integrated health-care system, providing health care, vocational rehabilitation, education benefits, and other services to over 8 million veterans at more than 1,700 locations. In fact, at over $182 billion, the VA’s budget request for 2017 rivals that of the entire defense budget of China, or from another perspective, it exceeds the defense spending of the U.K., France, and Japan combined.

The VA provides tremendous benefit to the majority of veterans who use its services. But with a total veteran population of over 21 million men and women, and only 8 million veterans being served by the VA, it is evident that for the overwhelming majority of American veterans the VA is not their first choice for healthcare. And for that minority of veterans in the VA’s care who are not receiving the highest standard of care, they are literally paying for it with their lives.

The organization came under fire in 2014 after it was revealed that 40 or more veterans may have died while awaiting care on secret waiting lists at the Phoenix VA, and worse, that VA employees actively conspired to conceal the secret waiting lists and substandard care. These revelations resulted in the resignation of then-VA Secretary Eric Shinseki and were an impetus for the Veterans Choice Act, of which a key provision allowed for the federal government to clean up the VA by firing incompetent executives.

In 2015, the Department of Veterans Affairs again came under scrutiny after the VA Inspector General released a staggering report confirming that as many as 307,000 veterans may have died while awaiting care throughout the VA’s integrated health-care enterprise.

Since the VA began publishing data on wait times and access to care in October of 2014, it has been revealed that as many as many as 300,000 veterans have to wait more than one month to receive an appointment after it has been scheduled. While this represents a small percentage of the veteran population waiting on care, given that the VA schedules nearly 7 million appointments annually, this figure is an absolutely staggering total number of people.

The Veterans Crisis Line, a voice and text hotline for suicidal veterans, has similarly been a mixed bag.

Since its opening in 2007, the Veterans Crisis Line has received over 2.6 million calls, dispatched emergency services to respond to imminent crises nearly 70,000 times, and forwarded over 416,000 cases for referral to local VA suicide prevention coordinators. Without a doubt, the Veterans Crisis Line has saved veteran lives and has proven an important resource for most of those in crisis.

However, it has also had its fair share of scandal and mismanagement.

In January of 2016 the VA’s own Office of the Inspector General released a damning report that confirmed allegations that calls to the Veterans Crisis Line were going unanswered, being routed to backup call centers, or were being sent to voicemail. Consequently, the VA brought in Gregory Hughes to lead the beleaguered Veterans Crisis Line out of its own crisis.

After less than six months as Director of the Veterans Crisis Line, the Military Times reported that Gregory Hughes was stepping down. Hughes’ resignation was likely in response to a scathing late-May report of the Government Accountability Office, the federal government’s own watchdog organization, that revealed the Veteran Crisis Line’s continued inability to answer calls in a timely manner.

After sixteen months of reviewing the VA’s policies and two months of covert testing of the Veterans Crisis Line, the GAO found that only between 65% to 75% of calls by veterans were answered within the first minute, after which time calls were routed to backup call centers with less experienced personnel. Worse, the GAO also found that 10 of 14 text messages to the Veterans Crisis Line took from two to five minutes to receive a response and nearly 28% of text messages to the Veterans Crisis Line went without a response at all.

The Department of Veterans Affairs announced on December 20th, 2016 that it had expanded its Veterans Crisis Line by opening a satellite office in Atlanta and expanding its staff by hiring an additional 200 call responders. While under normal circumstances this may come as welcome news, the unfortunate reality is that it took the VA nearly six months to expand its crisis line capabilities after the GAO revealed the Veterans Crisis Line was still failing to meet performance standards - nearly a year after the VA’s own Inspector General had arrived at the same findings. While this expansion is better late than never, an infantryman would call this announcement tantamount to “a band-aid on a sucking chest wound.”

It doesn’t need to be this way.

Naval Gunnery as a Guide to Innovation

In 1900 the design of Naval gun platforms aboard American vessels rendered them inherently inaccurate at providing precision fires. Yet Junior American Naval Officer William S. Sims observed a remarkable innovation in the British Navy with the potential to solve the problem of Naval gunnery: continuous-aim-firing.

Developed by British Admiral Sir Percy Scott, continuous-aim-firing made possible improvements in Naval gunnery some 3000% in as little as six years through the development of traverse and elevation mechanisms that enabled Naval guns to follow targets throughout the roll of a ship, telescopes that compensated for the recoil of the gun, and improved targetry that simulated realistic conditions for gunnery training.(1) Excited for the possibilities that continuous-aim-firing afforded his own service, Sims reported his findings to the Navy.

Sims was first met with silence. He was then met with self-righteous indignation. Eventually, his character was impugned. At last, Sims’ persistence paid off, and to his credit, the Navy now describes Sims as, “the man who taught us how to shoot.”(2)

With that in mind, it shouldn’t come as much of a surprise that it took the VA so long to respond to either the GAO report or the report of the Inspector General. As an enormous enterprise, the VA is not designed to innovate. It is not an organization that responds well to change. Even in the face of scandal the VA simply can’t adapt.

In fact, instead of thinking differently about the problem and potential solutions, it resorts to investing more resources into a system that is already sinking under the sheer weight of the problem. It has satisfied itself with ‘band-aids on sucking chest wounds’ and fails to consider that the solution might be right before them or that the solution may be found outside of the organization.

Thinking Differently: A Roadmap to Addressing the Veteran Suicide Crisis

As noted, the VA is an enormous bureaucratic enterprise that is simply not well-organized to respond to change. Like a large ocean liner changing course, it takes a lot of effort and time to shift the VA’s organizational priorities, goals, and initiatives. Moreover, by the time the VA does make course corrections, it has often bypassed the critical decision point, rendering many of its efforts irrelevant.

To solve this problem, the VA must avoid enlisting the services of the “Beltway Bandits” and large government contractors. Most of these organizations use the exact same processes and systems as the VA and are susceptible to the same bureaucratic shortfalls. Large government contractors have thus far not provided any meaningful solutions, and the VA would be wise to look elsewhere for opportunities to explore.

Instead, the VA must leverage thought-leaders outside its organization to solve the veteran suicide crisis. Secretary of Defense Ashton Carter’s initiative aimed at using thought leaders in Silicon Valley to drive innovation at the Defense Department is a good model for what the VA should be doing.

Tech start-ups, like Objective Zero for example, are more risk adaptive and flexible than the VA, using Agile and Lean product development methodologies that cut down on development time, pushing critical technologies to market much faster than the government can.

Additionally, the VA might consider enlisting the help of non-profit organizations and universities across the country to help tackle some of their most difficult problems. The Defense Entrepreneurs Forum, for example, is a community of thought leaders committed to finding creative and innovative solutions to incredibly complex defense-related problems. Likewise, with its ‘Hacking for Defense’ programs, the Department of Defense is leveraging the talents of top universities like Stanford and Georgetown to innovate. Similarly, the VA could use the talents of academia to solve its most pressing issues and provide fresh insights for the organization to explore.

And, luckily for the VA, there are tech-startups, non-profit organizations, and universities ready to enlist and join the fight against veteran suicide.

1. Morison, From Men, Machines and Modern Times, MIT Press (1966).
2. Christensen, Gunfire at Sea: A Case Study of Innovation (Abridged); Innovation and the General Manager, p. 159 – 168, McGraw-Hill (1999).

There are many ways YOU can help:

Objective Zero is a 501(C)(3) non-profit organization committed to finding solutions to reduce veteran and service member suicide to functional zero: the point where military service can no longer be considered a distinguishing factor in suicides in the United States. To achieve this ambitious aim, we need your help.

Consider resolving yourself in 2017 to making a difference in the lives of our veterans by donating to the Objective Zero Kickstarter Campaign today at https://goo.gl/BZuG9C or by donating on the Objective Zero webpage at https://goo.gl/pqmX41

About the Authors

*The views expressed in this article are those of the authors and do not reflect any policy or position of the Department of the Army, the Department of Defense, or the U.S. Government.

Chris Mercado is an active duty infantry officer in the U.S. Army. Over the years Chris has lost several of his peers and former soldiers to suicide. Chris was inspired to act by telling Justin Miller’s story and observing the difference it made in Justin’s life. He is a General Wayne A. Downing Scholar of the Combating Terrorism Center at West Point and completed his Master of Arts at Georgetown University’s School of Foreign Service where he studied terrorism and sub-state violence. He is a military fellow of the College of William and Mary and a former national security fellow at the Woodrow Wilson International Center for Scholars.

Blake became involved in Objective Zero after Chris Mercado shared Justin Miller’s story with him. Having seen firsthand the impacts of suicide in the military, Blake was eager to use his previous tech experience to help form Objective Zero. Blake manages Objective Zero’s website and is responsible for app development. He is also a Presidential Management Fellow and graduate of Georgetown University's School of Foreign Service. Blake is an officer in the U.S. Army Reserves an