tag:theconversation.com,2011:/ca/topics/veterans-administration-18713/articlesVeterans Administration – The Conversation2023-09-27T12:28:13Ztag:theconversation.com,2011:article/2140402023-09-27T12:28:13Z2023-09-27T12:28:13ZWhat will this government shutdown shut down? Social Security and Medicaid keep going; SBA loans and some food and safety inspections do not<figure><img src="https://images.theconversation.com/files/550335/original/file-20230926-25-7ftzlh.jpeg?ixlib=rb-1.1.0&rect=13%2C6%2C4587%2C3014&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A shutdown's effects will be broad and deep.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/government-shutdown-in-washington-interstate-road-royalty-free-image/1095019568?phrase=government+shutdown+congress&adppopup=true">gguy44/ iStock / Getty Images Plus</a></span></figcaption></figure><p>The U.S. is moving toward a government shutdown. House and Senate appropriators are divided on <a href="https://apnews.com/article/politics-us-republican-party-thomas-emmer-united-states-house-of-representatives-hockey-744b602f30285f3398da09d1489f37dd">spending levels</a>, <a href="https://www.politico.com/news/2023/09/13/defense-bill-house-republicans-00115530">policy riders</a> and additional items, such as support for Ukraine.</p>
<p>As a political scientist who studies the <a href="https://gai.georgetown.edu/wp-content/uploads/2022/08/Under-the-Iron-Dome-2022-Blessing-book-chapter-on-eroding-budget-process.pdf">evolving budget process</a>, as well as <a href="https://gai.georgetown.edu/wp-content/uploads/2022/08/Blessing-HBC-testimony-debt-ceiling-2-16-22.pdf">brinkmanship</a> in Congress, it is clear to me that this episode prompts many important questions for how the U.S. is governed. </p>
<p>There’s the larger, long-term question: What are the costs of congressional dysfunction? </p>
<p>But the more immediate concern for people of the country is how a shutdown will affect them. Whether delayed business loans, slower mortgage applications, curtailed food assistance or postponed food inspections, the effects could be substantial. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An airplane landing near an air traffic control tower." src="https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=520&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=520&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550339/original/file-20230926-15-he7bob.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=520&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Air traffic controller training will be halted in a government shutdown.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-air-traffic-control-tower-is-seen-at-the-miami-news-photo/1700958797?adppopup=true">Joe Raedle/Getty Images</a></span>
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<h2>Affected: Farm loans to Head Start grants</h2>
<p>The total federal budget is almost US$6 trillion. <a href="https://www.cbo.gov/publication/58890">A little over one-fourth</a> is discretionary spending that is funded by the annual appropriations process and thus debated in Congress. This portion of spending provides money for virtually every federal agency, roughly half of which goes to defense. The rest of yearly federal spending is on mandatory entitlement programs, mainly Social Security and Medicare, as well as interest on the national debt. </p>
<p>The Office of Management and Budget, which oversees both development of federal budget plans by federal agencies <a href="https://www.whitehouse.gov/omb/">and their performance</a>, regularly requires agencies to <a href="https://www.whitehouse.gov/omb/information-for-agencies/agency-contingency-plans/">develop shutdown plans</a>. Because agencies continually update these plans, no two shutdowns are exactly alike. A week before the expected shutdown, 40% of the plans posted had been updated since July 2023, and 80% had been updated since 2021; late-breaking updates can be consequential for policy.</p>
<p>Details depend on the agency, program and duration of the shutdown, as well as laws passed with funding since the previous shutdown, and the administration’s priorities. These plans identify a <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/09/20/extreme-house-republicans-chaos-is-marching-us-toward-a-government-shutdown/">variety of ways</a> the shutdown will affect Americans. </p>
<p>If a shutdown happens this year, new loan approvals from the Small Business Administration <a href="https://www.sba.gov/document/report-sba-plan-operating-event-lapse-appropriations">will stop</a>. The Federal Housing Administration will experience <a href="https://www.hud.gov/sites/dfiles/Main/documents/ShutdownFAQs.pdf">delays</a> in processing home mortgage loans and approvals. The Department of Agriculture will not offer new <a href="https://www.usda.gov/sites/default/files/documents/usda-2021-contingency-plan.pdf">farm loans</a>. Head Start grants will not be awarded, initially affecting 10,000 young children from low-income families who are in the program. </p>
<p>Some food inspections by the Food and Drug Administration, workplace safety inspections by the Occupational Safety and Health Administration, and environmental safety inspections by the Environmental Protection Agency could be delayed, as they have been when the government stopped functioning in the past. </p>
<p>During the <a href="https://www.npr.org/2019/01/14/685369719/government-shutdown-leads-to-a-spike-in-cancelled-immigration-hearings">last shutdown</a>, about 60,000 immigration hearings, organized by the Department of Justice and not the courts, <a href="https://crsreports.congress.gov/product/pdf/R/R47077">were canceled and</a> had to be rescheduled. <a href="https://www.aila.org/advo-media/aila-practice-pointers-and-alerts/government-shuts-down">This year</a> would also see cases involving noncitizens who are not being held by the government reset for a later date, even as other immigration services proceed. </p>
<p>Infrastructure projects awaiting approval from the Environmental Protection Agency could be stalled. The National Institute of Health’s clinical trials for diseases could also be slowed.</p>
<p>This is not a comprehensive list. Agency plans show what happens when federal workers are furloughed – that is, those who cannot report to work in a shutdown. Furloughs will apply to <a href="https://www.govexec.com/workforce/2023/09/see-who-would-get-furloughed-shutdown-year/390517/">over 700,000</a> out of <a href="https://missouriindependent.com/2023/09/20/a-disaster-nears-millions-of-federal-workers-paychecks-would-be-on-hold-in-a-shutdown/">roughly 3.5 million</a> federal employees, but even more workers will be “excepted” and required to work without pay until the shutdown ends. </p>
<p>That of course means employee hardship. But like <a href="https://www.businessinsider.com/government-shutdown-jetblue-ceo-says-air-travel-near-tipping-point-2019-1">past shutdowns</a>, unpaid workers can fail to report to work in larger numbers. Americans relying on those services will face delays. There may be air travel delays as well, as air traffic controllers and Transportation Security Administration agents <a href="https://www.barrons.com/articles/government-shutdown-affect-air-travel-flights-aad0970">go without pay</a>.</p>
<h2>Not affected: The postal service and entitlement programs</h2>
<p><a href="https://crsreports.congress.gov/product/pdf/R/R44763/3#:%7E:text=Mandatory%20spending%20is%20composed%20of,the%20bulk%20of%20mandatory%20spending.">Social Security, Medicare and Medicaid benefits</a> are entitlement programs that are not included in the annual appropriations process. Americans relying on these programs will not see those benefits affected. But these programs require administration. Federal employees would not be available to verify benefits or send out new cards.</p>
<p>There are additional funding sources for government activities, beyond entitlement programs, that aren’t included in the annual appropriations bills and thus are unlikely to be affected by a shutdown. </p>
<p>The U.S. Postal Service, independently funded through its own services, will be unaffected by a shutdown. The federal judiciary could <a href="https://sgp.fas.org/crs/misc/RL34680.pdf">operate for a limited time</a>, funded by court filings, fees and appropriations allocated off the yearly cycle. But this funding <a href="https://www.reuters.com/legal/government/us-judiciary-can-keep-operating-2-weeks-if-government-shuts-down-2023-09-19/">won’t last long</a> – 10 days was an estimate for the 2013 shutdown. The Supreme Court, which has functioned in previous shutdowns, <a href="https://www.reuters.com/world/us/us-government-shutdown-what-closes-what-stays-open-2023-09-21/">is expected to continue its typical schedule</a>. </p>
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<a href="https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign reading 'Because of the Federal Government SHUTDOWN All National Parks are Closed' is posted on a barricade in front of the Lincoln Memorial." src="https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550349/original/file-20230926-23-gcwhwp.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">National parks will be closed in a shutdown, as the Lincoln Memorial in Washington was in the 2013 shutdown.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/GovernmentShutdownFederalWorkers/db15aad4b2e8423f8579363642314974/photo?Query=government%20shutdown&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=7332&currentItemNo=5">AP Photo/Carolyn Kaster</a></span>
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<p>The IRS had <a href="https://federalnewsnetwork.com/government-shutdown/2023/09/irs-to-remain-fully-operational-if-congress-triggers-government-shutdown/">promised</a> that the additional funds from the Inflation Reduction Act meant it could be fully operational in a shutdown. In a sign of how agency plans can get updated at the last minute, the <a href="https://home.treasury.gov/system/files/266/IRS-FY24LapsePlan.pdf">IRS updated its contingency plan</a> on Sept. 28 following a ruling by the OMB, a change that will result in <a href="https://www.washingtonpost.com/politics/2023/09/28/irs-shutdown-furlough-inflation-act/">60,000 furloughed IRS workers</a>. While some activities of the agency will continue, <a href="https://www.washingtonpost.com/politics/2023/09/28/irs-shutdown-furlough-inflation-act/">customer service activities</a> to individual taxpayers will halt. </p>
<p>A <a href="https://www.whitehouse.gov/wp-content/uploads/2023/03/aaa_fy2024.pdf">variety of advance appropriations</a> also exist that provide funding for various programs one year or more beyond the year the appropriations bill was passed, including Veterans Affairs medical care; most VA benefits are unaffected. </p>
<p>The primary <a href="https://federalnewsnetwork.com/government-shutdown/2019/01/government-shutdowns-once-incomprehensible-inconceivable-unthinkable-now-the-norm/">law</a> governing funding gaps also makes exceptions for “emergencies involving the safety of human life or the protection of property,” which includes a variety of military activities.</p>
<h2>The big question mark</h2>
<p>The major unknown is, of course, how long a shutdown might last. Food assistance programs – including the federal food program for poorer women, infants and children, called WIC, and the Supplemental Nutrition Assistance Program, or SNAP – which have some contingency funds that carry over into the next fiscal year but are running low, run the risk of those accounts running out. </p>
<p>The federal judiciary has limited funds. There are also a variety of <a href="https://crsreports.congress.gov/product/pdf/IN/IN11554">federal grants to states and localities</a> that could be short on funds, such as disaster relief and economic development programs, in addition to nutrition assistance. Government officials at the federal, state and local levels will have to make choices about whether a federal shortfall should be covered by state funds, or if workers should be furloughed. Some of these funds have been protected by increased funding in recent laws: The <a href="https://www.everycrsreport.com/reports/R47573.html">Highway Trust Fund is solvent through 2027</a>, due to the Bipartisan Infrastructure Law of 2021.</p>
<p>The economy as a whole will suffer more the longer a shutdown continues. The <a href="https://www.cbo.gov/publication/54937">Congressional Budget Office estimated</a> that the last shutdown, in 2018-2019, reduced gross domestic product growth by 0.2% in the first quarter of 2019. While that 35-day partial shutdown was the longest in U.S. history, it did not affect all agencies.</p>
<p>Federal employees and contractors are disproportionately hurt. Federal employees who are furloughed or excepted and do not receive pay during the shutdown will receive it retroactively, according to a <a href="https://www.congress.gov/bill/116th-congress/senate-bill/24/text">2019 law</a> passed as a response to the last shutdown. </p>
<p>No such policy exists for contractors working for the federal government, including services ranging from janitorial to manufacturing. Beyond affecting individual workers, the private sector loses business and adjusts its hiring decisions and other practices. </p>
<p><strong><em>This story has been updated to reflect revised shutdown plans for the IRS.</em></strong></p><img src="https://counter.theconversation.com/content/214040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Blessing does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>You won’t be able to ignore a government shutdown. From delayed business loans to slower mortgage applications and postponed food inspections, the effects could be substantial.Laura Blessing, Senior Fellow, Government Affairs Institute at Georgetown University, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1609002021-05-27T12:07:23Z2021-05-27T12:07:23ZVeterans took an especially bad hit during the pandemic<figure><img src="https://images.theconversation.com/files/401648/original/file-20210519-13-1x5engy.jpeg?ixlib=rb-1.1.0&rect=17%2C5%2C3898%2C2600&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Navy veteran Faron Smith Jr. reacts as he receives a COVID-19 vaccination at a Veterans Administration pop-up vaccination site on April 17, 2021, in Gardena, Calif. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/navy-veteran-faron-smith-jr-reacts-as-he-receives-a-dose-of-news-photo/1232364610?adppopup=true">Patrick T. Fallon/AFP via Getty Images)</a></span></figcaption></figure><p>As the nation takes a day to memorialize its military dead, living military veterans are facing a deadly risk that has nothing to do with war or conflict: the coronavirus. </p>
<p>Different groups and communities have faced different degrees of danger from the pandemic, exemplified by the humanitarian disaster in India and the inequalities in U.S. health outcomes, vaccine distribution problems and outright rejection of vaccines. Veterans have been among the <a href="https://bobwoodrufffoundation.org/wp-content/uploads/2020/04/BWF_WhitePaper-COVID19-5.0-Final.pdf">most hard-hit</a>, with heightened health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death.</p>
<p>I have spent the past six years studying veterans with substance use and mental health disorders <a href="https://www.doi.org/10.1111/lapo.12142">who are in the criminal justice system</a>. This work revealed gaps in health care and financial support for veterans,
even though they have the <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199838509.001.0001/oxfordhb-9780199838509-e-003">best publicly funded</a> <a href="https://www.rand.org/news/press/2016/07/18.html">benefits</a> in the country.</p>
<p>Here are eight ways the pandemic continues to threaten veterans.</p>
<h2>1. Age and other vulnerabilities</h2>
<p><a href="https://www.pewresearch.org/fact-tank/2021/04/05/the-changing-face-of-americas-veteran-population/">73% of veterans are over 50, and 89% are male</a>. </p>
<p>The largest group served in the Gulf era, were exposed to dust storms, oil fires and burn pits <a href="https://www.cbsnews.com/news/burn-pit-military-lung-disease-thousands-of-veterans-fear-burn-pits-exposed-them-to-lethal-disease-2019-08-17/">with numerous toxins</a>, and perhaps as a consequence have high rates of asthma and other respiratory illnesses. </p>
<p>The second-largest group served in the Vietnam era, in which <a href="https://www.forbes.com/sites/nicolefisher/2018/05/28/the-shocking-health-effects-of-agent-orange-now-a-legacy-of-military-death/#31b9dbbc21c6">2.8 million veterans were exposed to Agent Orange</a>, a chemical defoliant linked to cancer.</p>
<p>Age and respiratory illnesses are both risk factors for COVID-19 mortality. As of <a href="https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary">May 13, 2021</a>, 258,078 people under Veterans Administration care have been diagnosed with COVID-19, of whom 11,941 have died.</p>
<p><a href="https://www.kxxv.com/news/central-texas-living/fewer-number-of-veterans-receiving-second-dose-of-covid-19-vaccine">Reluctance to be vaccinated</a> <a href="https://www.stripes.com/news/veterans/vaccine-refusal-rate-at-3-among-veterans-slightly-higher-in-rural-areas-1.668100">continues to hamper</a> full vaccination efforts, particularly in rural areas. The Veterans Administration <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953856/">has set up</a> successful vaccine distribution sites that now administer to <a href="https://www.va.gov/health-care/covid-19-vaccine/#who-can-now-get-a-covid-19-vac">veterans, their spouses, caregivers and others receiving VA health care</a>. Approximately 2.5 million of 19 million veterans have been vaccinated through the agency. </p>
<p>But <a href="https://covid19militarysupport.org/2021/04/va-making-the-case-for-vaccines-as-demand-starts-to-drop/">demand is dipping</a> from 75,000 appointments a day to 30,000, and President Joe Biden recently decided <a href="https://www.military.com/daily-news/2021/04/30/biden-making-covid-vaccine-mandatory-troops-im-going-leave-it-military.html">not to mandate</a> vaccinations in the armed services, where <a href="https://www.military.com/daily-news/2021/04/22/navy-pulls-way-ahead-of-other-military-services-race-100-vaccination.html">vaccine rates</a> remain low.</p>
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<a href="https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An employee of a VA hospital in Brooklyn who is outside the building at a staff protest for more protective equipment and staff assistance during the pandemic." src="https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=382&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=382&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=382&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=480&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=480&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401749/original/file-20210519-19-5l6db6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=480&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">VA Hospital employee Wayne Malone joins staff outside the Brooklyn Veterans Administration Medical Center, Monday, April 6, 2020, in New York, where they called for more personal protective equipment and staffing assistance to care for COVID-19 patients.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakNewYork/9eb665f138794b739bd79103d3ed54a8/photo?Query=Veterans%20Administration%20hospital%20COVID%20short%20staff&mediaType=photo&sortBy=creationdatetime:desc&dateRange=Anytime&totalCount=1&currentItemNo=0">AP Photo/Kathy Willens</a></span>
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<h2>2. Benefits unfairly denied or delayed</h2>
<p>When a person transitions from active military service to become a veteran, they receive a <a href="https://www.va.gov/records/discharge-documents">Certificate of Discharge or Release</a>. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as “honorable,” “other than honorable,” “bad conduct” or “dishonorable.” These are crucial distinctions because that status <a href="https://www.benefits.va.gov/BENEFITS/docs/COD_Factsheet.pdf">determines whether the Veterans Administration will give them benefits</a>. </p>
<p>Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have <a href="https://www.swords-to-plowshares.org/wp-content/uploads/Underserved.pdf">disproportionately more</a> of these negative discharges than <a href="http://www.legalservicescenter.org/wp-content/uploads/Turn-Away-Report.pdf">veterans from other eras</a>.</p>
<p>The Veterans Administration frequently <a href="https://today.law.harvard.edu/new-report-from-harvard-law-schools-veterans-legal-clinic-documents-the-vas-systemic-denial-of-health-care-to-veterans-with-bad-paper-discharges/">and perhaps unlawfully</a> denies benefits to veterans with “other than honorable” discharges.</p>
<p>Many veterans have requested upgrades to their discharge status. There is a <a href="https://www.va.gov/oig/pubs/VAOIG-16-01750-79.pdf">significant backlog of these upgrade requests</a>, and the pandemic added to it, further delaying access to health care and other benefits. </p>
<h2>3. Diminished access to health care</h2>
<p>Dental surgery, routine visits and elective surgeries at Veterans Administration medical centers have been postponed as individuals await the full reopening of offices. <a href="https://www.va.gov/oig/pubs/press-releases/VAOIG-VHAOccupationalStaffingNewsRelease.pdf">Veterans Administration hospitals are notoriously understaffed</a> – just before the pandemic, the agency reported 43,000 vacancies out of more than 400,000 health care staff positions. </p>
<p>The pandemic added to these problems. An Inspector General <a href="https://www.va.gov/oig/pubs/VAOIG-20-01249-259.pdf">report</a> from fall 2020 found that 95% of Veterans Administration health centers are missing a key staff member, most commonly medical providers such as psychiatrists, primary care physicians and nurses, but also custodial staff necessary to keep facilities clean and sanitary. </p>
<h2>4. Mental health may get worse</h2>
<p>An average of 20 veterans die by suicide every day. A <a href="https://www.federalregister.gov/documents/2019/03/08/2019-04437/national-roadmap-to-empower-veterans-and-end-suicide">national task force</a> is currently addressing this scourge. </p>
<p>The effects of the pandemic on veteran mental health are not yet clear. The VA continues to <a href="https://www.ksat.com/news/local/2020/03/20/san-antonio-va-moves-away-from-in-person-mental-health-appointments-for-vets-amid-covid-19-crisis/">encourage digital mental health treatment</a> since office visits remain limited. Suicide hotline calls by veterans were up <a href="https://connectingvets.radio.com/articles/veteran-crisis-line-calls-rise-over-coronavirus-wilkie-says">by 12% on March 22, 2020, just a few weeks into the crisis</a>. Recent <a href="https://www.stripes.com/news/veterans/va-tracks-suicides-among-its-patients-during-pandemic-finds-no-increase-1.651889">information from the Department of Defense</a> suggests the already troubling suicide rates have not changed, with Black and Hispanic veterans at higher risk.</p>
<h2>5. Complications for homeless veterans and those in the justice system</h2>
<p>The latest available data, from prior to the pandemic, documented <a href="https://www.bjs.gov/index.cfm?ty=pbdetail&iid=7308">107,400 veterans</a> in state or federal prisons, and <a href="https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-019-0086-9">181,500 were incarcerated</a> if we also include jails. While many facilities responded to the pandemic by releasing eligible veterans, there is a <a href="https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-019-0086-9#ref-CR208">revolving door</a> between time served and homelessness. </p>
<p>After years of declining rates of homelessness, there was a <a href="https://www.hudexchange.info/resource/6292/2020-pit-estimate-of-veteran-homelessness-in-the-us/">0.5% rise</a> in homelessness from 2019 to 2020. Before the pandemic, in January 2020, an estimated <a href="https://www.stripes.com/news/veterans/veteran-homelessness-increased-from-2019-to-2020-according-to-new-hud-report-1.666387">37,252 veterans</a> were homeless on any given night.</p>
<p>Thousands more veterans are under court-supervised substance use and mental health treatment in <a href="https://justiceforvets.org/what-is-a-veterans-treatment-court/">veterans treatment courts</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25767963">More than half</a> of veterans involved with the justice system have either mental health problems or substance use disorders. </p>
<p>Courts quickly <a href="https://www.nadcp.org/wp-content/uploads/2020/03/Treatment-Courts-COVID-19-Examples-3-26-20.pdf">moved online</a> after state shutdowns, and many continue in this new mode. While often useful to meet treatment court obligations, online justice administration can be an obstacle for individuals looking for the camaraderie that came with meeting in person. <a href="https://www.doi.org/10.1007/s12103-020-09553-1">Other challenges</a> relate to access to technology and due process.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A homeless Navy veteran in Los Angeles, on a sidewalk with a blanket and some possessions." src="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As veterans’ facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go and may become homeless, like this Navy veteran in Los Angeles.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/travis-stanley-who-said-he-has-been-homeless-for-three-news-photo/1153992307?adppopup=true">Mario Tama/Getty Images</a></span>
</figcaption>
</figure>
<h2>6. Disability benefits delayed</h2>
<p>Veterans Administration office closures have exacerbated the <a href="https://www.latimes.com/nation/la-na-veterans-appeals-backlog-20151123-story.html">longstanding backlog</a> of disability claims, which <a href="https://federalnewsnetwork.com/veterans-affairs/2021/03/vba-says-it-will-reduce-the-disability-claims-backlog-by-fall-but-congress-isnt-so-sure/">more than doubled</a> over the course of the pandemic. Approximately <a href="https://www.benefits.va.gov/reports/mmwr_va_claims_backlog.asp">200,000 veterans</a> wait more than 125 days for a decision. Anything less than 125 days is not considered a delay in benefit claims. </p>
<p>There is a long delay for medical exams to determine disability benefits. As of March 2021, there was a backlog of <a href="https://www.americanprogress.org/issues/security/reports/2021/05/17/499517/challenges-facing-department-veterans-affairs-2021/#fn-499517-17">357,000 medical exams</a>, nearly three times the backlog from February 2020. </p>
<p>The closure of the National Personnel Records Center, which houses the physical records frequently required to obtain benefits, led to an estimated <a href="https://www.rollcall.com/2021/04/20/veterans-hit-by-huge-pandemic-related-records-backlog/">18- to 24-month backlog</a> of 499,000 document requests. These documents are often necessary to receive medical benefits as well as military honors upon death. </p>
<h2>7. Dangerous residential facilities</h2>
<p>Veterans needing end-of-life care, those with cognitive disabilities or those needing substance use treatment often live in crowded Veterans Administration or state-funded residential facilities. </p>
<p>State-funded “soldiers’ homes” are notoriously starved for money and staff. The <a href="https://www.cnn.com/2020/04/06/us/holyoke-soldiers-home-coronavirus/index.html">horrific situation</a> at the soldiers’ home in Holyoke, Massachusetts, where <a href="https://www.westernmassnews.com/news/the-latest-state-reports-89-resident-deaths-at-holyoke-soldiers-home/article_88b3a4d8-791d-11ea-b3b7-f37420fe3e63.html">76 veteran residents died from a COVID-19 outbreak</a>, leading to <a href="https://www.npr.org/sections/coronavirus-live-updates/2020/09/25/916977736/leaders-indicted-at-soldiers-home-where-at-least-76-people-died-in-covid-19-outb">criminal charges</a>, and the deaths of <a href="https://www.wsj.com/articles/among-nursing-homes-hit-by-covid-veterans-homes-struggled-the-most-11607977327">46 veterans at an Alabama facility</a> illustrate the risk that veterans in residential homes faced early in the pandemic. </p>
<h2>8. Economic catastrophe</h2>
<p>There are <a href="https://bobwoodrufffoundation.org/wp-content/uploads/2020/04/BWF_WhitePaper-COVID19-5.0-Final.pdf">1.2 million veteran employees in the five industries most severely affected</a> – mining, oil and gas extraction; transportation and warehousing; employment services; travel arrangements; leisure and hospitality – by the economic fallout of the coronavirus. Veteran unemployment was at 3.5% before the pandemic and rose to <a href="https://www.militarytimes.com/opinion/commentary/2020/10/25/understanding-the-economic-impacts-of-covid-19-on-veterans-and-military-families/">6.4%</a> by September 2020.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>A disproportionately high number of post-9/11 veterans live in some of the hardest-hit communities that depend on these industries and had even <a href="https://ivmf.syracuse.edu/article/the-employment-situation-of-veterans-september-2020/">higher rates</a> of unemployment than their nonveteran peers as well as other veteran cohorts. Many veterans may face evictions when the national <a href="https://www.legion.org/veteransbenefits/251825/va-extends-its-ban-evictions-and-foreclosures-june-30">moratorium on evictions lifts</a> on June 30, 2021. </p>
<p><a href="https://bluestarfam.org/wp-content/uploads/2020/05/200501_PPP_Most_Acute_Pain_Pts_wk6.pdf">Military spouses</a> are suffering from the economic fallout, as are children affected by school closures.</p>
<p>With veterans, many of the problems they face now existed long before the coronavirus arrived on U.S. shores.</p>
<p>But with the problems posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.</p>
<p><em>Editor’s note: This is an updated version of <a href="https://theconversation.com/8-ways-veterans-are-particularly-at-risk-from-the-coronavirus-pandemic-135619">a story</a> that originally ran on April 16, 2020.</em></p><img src="https://counter.theconversation.com/content/160900/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Rowen receives funding from the National Science Foundation.</span></em></p>As the coronavirus pandemic played out, veterans who were already lacking adequate benefits and resources found themselves in deeper trouble.Jamie Rowen, Associate Professor of Legal Studies and Political Science, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1392512020-05-22T18:37:50Z2020-05-22T18:37:50ZMemorial Day: Why veterans are particularly vulnerable to the coronavirus pandemic<figure><img src="https://images.theconversation.com/files/337086/original/file-20200522-124851-ztqdu3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">U.S. war veterans' graves at Fort Rosecrans National Cemetery, San Diego, California. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/general-view-of-united-states-war-veterans-graves-at-fort-news-photo/1226296422?adppopup=true">Sean M. Haffey/Getty Images</a></span></figcaption></figure><p>As the nation takes a day to memorialize its military dead, those who are living are facing a deadly risk that has nothing to do with war or conflict: the coronavirus. </p>
<p>Different groups face different degrees of danger from the pandemic, from the <a href="https://thehill.com/homenews/state-watch/490715-coronavirus-creates-emergency-in-nursing-homes">elderly who are experiencing deadly outbreaks in nursing homes</a> to <a href="https://www.vox.com/identities/2020/4/7/21211849/coronavirus-black-americans">communities of color with higher infection and death rates</a>. Veterans are among the <a href="https://bobwoodrufffoundation.org/wp-content/uploads/2020/04/BWF_WhitePaper-COVID19-5.0-Final.pdf">most hard-hit</a>, with heightened health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death.</p>
<p>I have spent the past four years studying veterans with substance use and mental health disorders <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/lapo.12142">who are in the criminal justice system</a>. This work revealed gaps in health care and financial support for veterans,
even though they have the <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199838509.001.0001/oxfordhb-9780199838509-e-003">best publicly funded</a> <a href="https://www.rand.org/news/press/2016/07/18.html">benefits</a> in the country.</p>
<p>Here are eight ways the pandemic threatens veterans:</p>
<h2>1. Age and other vulnerabilities</h2>
<p><a href="https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf">In 2017</a>, veterans’ median age was 64, their average age was 58 and 91% were male. The largest group served in the Vietnam era, where <a href="https://www.forbes.com/sites/nicolefisher/2018/05/28/the-shocking-health-effects-of-agent-orange-now-a-legacy-of-military-death/#31b9dbbc21c6">2.8 million veterans were exposed to Agent Orange</a>, a chemical defoliant linked to cancer.</p>
<p>Younger veterans deployed to Iraq and Afghanistan were exposed to dust storms, oil fires and burn pits <a href="https://www.cbsnews.com/news/burn-pit-military-lung-disease-thousands-of-veterans-fear-burn-pits-exposed-them-to-lethal-disease-2019-08-17/">with numerous toxins</a>, and perhaps as a consequence have <a href="https://academic.oup.com/milmed/article/179/11/1273/4159900">high rates of asthma and other respiratory illnesses</a>. </p>
<p>Age and respiratory illnesses are both risk factors for COVID-19 mortality. As of <a href="https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary">May 22</a>, there have been 12,979 people under Veterans Administration care with COVID-19, of whom 1,100 have died.</p>
<h2>2. Dangerous residential facilities</h2>
<p>Veterans needing end-of-life care, those with cognitive disabilities or those needing substance use treatment often live in crowded VA or state-funded residential facilities. </p>
<p>State-funded “soldiers’ homes” are notoriously starved for money and staff. The <a href="https://www.cnn.com/2020/04/06/us/holyoke-soldiers-home-coronavirus/index.html">horrific situation</a> at the soldiers’ home in Holyoke, Massachusetts, where <a href="https://www.westernmassnews.com/news/the-latest-state-reports-89-resident-deaths-at-holyoke-soldiers-home/article_88b3a4d8-791d-11ea-b3b7-f37420fe3e63.html">more than 79 veteran residents have died from a COVID-19 outbreak</a>, illustrates the risk facing the veterans in residential homes. </p>
<h2>3. Benefits unfairly denied</h2>
<p>When a person transitions from active military service to become a veteran, they receive a <a href="https://www.va.gov/records/discharge-documents">Certificate of Discharge or Release</a>. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as “honorable,” “other than honorable,” “bad conduct” or “dishonorable.” These are crucial distinctions, because that status <a href="https://www.benefits.va.gov/BENEFITS/docs/COD_Factsheet.pdf">determines whether the Veterans Administration will give them benefits</a>. </p>
<p>Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have <a href="https://www.swords-to-plowshares.org/wp-content/uploads/Underserved.pdf">disproportionately more</a> of these negative discharges than veterans from other eras, <a href="http://www.legalservicescenter.org/wp-content/uploads/Turn-Away-Report.pdf">for reasons still unclear</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">VA hospitals across the country are short-staffed and don’t have the resources they need to protect their workers.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-New-York/e8aae7013aaf4a3f95e600a474b325e9/4/0">AP/Kathy Willens</a></span>
</figcaption>
</figure>
<p>The Veterans Administration frequently <a href="https://today.law.harvard.edu/new-report-from-harvard-law-schools-veterans-legal-clinic-documents-the-vas-systemic-denial-of-health-care-to-veterans-with-bad-paper-discharges/">and perhaps unlawfully</a> denies benefits to veterans with “other than honorable” discharges.</p>
<p>Many veterans have requested upgrades to their discharge status. There is a <a href="https://www.va.gov/oig/pubs/VAOIG-16-01750-79.pdf">significant backlog of these upgrade requests</a>, and the pandemic will add to it, further delaying access to health care and other benefits. </p>
<h2>4. Diminished access to health care</h2>
<p>Dental surgery, routine visits and elective surgeries at Veterans Administration medical centers have been postponed since mid-March. <a href="https://www.va.gov/oig/pubs/press-releases/VAOIG-VHAOccupationalStaffingNewsRelease.pdf">VA hospitals are understaffed</a> – just before the pandemic, the VA reported 43,000 staff vacancies out of more than 400,000 health care staff positions. Access to health care will be even more difficult when those medical centers finally reopen because they may have far fewer workers than they need. </p>
<p>As of May 4, 2020, <a href="https://www.nbcwashington.com/news/local/more-than-2250-va-hospital-employees-test-positive-for-coronavirus-nationwide/2291955/">2,250 VA health care workers</a> have tested positive for COVID-19, and thousands of health care workers are under quarantine. The VA is <a href="https://www.militarytimes.com/news/2020/03/23/coronavirus-threat-prompts-va-request-for-doctors-nurses-to-come-out-of-retirement/">asking doctors and nurses</a> to come out of retirement to help already understaffed hospitals.</p>
<h2>5. Mental health may get worse</h2>
<p>An average of 20 veterans die by suicide every day. A <a href="https://www.federalregister.gov/documents/2019/03/08/2019-04437/national-roadmap-to-empower-veterans-and-end-suicide">national task force</a> is currently addressing this scourge. </p>
<p>But many outpatient mental health programs are on hold <a href="https://www.ksat.com/news/local/2020/03/20/san-antonio-va-moves-away-from-in-person-mental-health-appointments-for-vets-amid-covid-19-crisis/">or being held virtually</a>. Some residential mental health facilities <a href="https://wwmt.com/news/local/veterans-in-battle-creek-forced-out-of-transitional-residences-to-prevent-covid-19-spread">have closed</a>. </p>
<p>Under these conditions, the suicide rate for veterans may grow. Suicide hotline calls by veterans were up <a href="https://connectingvets.radio.com/articles/veteran-crisis-line-calls-rise-over-coronavirus-wilkie-says">by 12% on March 22, just a few weeks into the crisis</a>.</p>
<h2>6. Complications for homeless veterans and those in the justice system</h2>
<p>An estimated <a href="http://nchv.org/index.php/news/media/background_and_statistics/">45,000 veterans</a> are homeless on any given night, and <a href="https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-019-0086-9">181,500 veterans</a> are in prison or jail. Thousands more are under court-supervised substance use and mental health treatment in <a href="https://justiceforvets.org/what-is-a-veterans-treatment-court/">veterans treatment courts</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25767963">More than half</a> of veterans involved with the justice system have either mental health problems or substance use disorders. </p>
<p>As residential facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go. They may stay incarcerated or become homeless. </p>
<p>Courts have <a href="https://www.nadcp.org/wp-content/uploads/2020/03/Treatment-Courts-COVID-19-Examples-3-26-20.pdf">moved online</a> or ceased formal operations altogether, meaning no veteran charged with a crime can be referred to a treatment court. It is unclear whether those who were already participating in a treatment program will face delays graduating from court-supervised treatments. </p>
<p>Further, some veterans treatment courts still require participants to take <a href="https://www.dailyjournal.com/articles/357665-california-s-veterans-treatment-courts-during-the-pandemic">drug tests</a>. With COVID-19 circulating, those participants must put their health at risk to travel to licensed testing facilities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As veterans’ facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go and may become homeless, like this Navy veteran in Los Angeles.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/travis-stanley-who-said-he-has-been-homeless-for-three-news-photo/1153992307?adppopup=true">Getty/Mario Tama</a></span>
</figcaption>
</figure>
<h2>7. Disability benefits delayed</h2>
<p>In the pandemic’s epicenter in New York, <a href="https://s3.amazonaws.com/documents.nycbar.org/files/2019531-PublicInterestVeteransLawPractitioners.pdf">tens of thousands of veterans</a> should have access to VA benefits because of their low income – but don’t, so far. </p>
<p>The pandemic has exacerbated existing delays in finding veterans in need, filing their paperwork and waiting for decisions. Ryan Foley, an attorney in New York’s Legal Assistance Group, a nonprofit legal services organization, noted in a personal communication that these benefits are worth “tens of millions of dollars to veterans and their families” in the midst of a health and economic disaster. </p>
<p><a href="https://www.benefits.va.gov/benefits/offices.asp">All 56 regional Veterans Administration offices are closed</a> to encourage social distancing. Compensation and disability evaluations, which determine how much money veterans can get, are usually done in person. Now, they must be done electronically, via telehealth services in which the veteran communicates with a health care provider via computer.</p>
<p>But getting telehealth up and running is taking time, adding to the <a href="https://www.latimes.com/nation/la-na-veterans-appeals-backlog-20151123-story.html">longstanding VA backlog</a>. Currently, more than <a href="https://www.benefits.va.gov/reports/mmwr_va_claims_backlog.asp">100,000 veterans</a> wait more than 125 days for a decision. (That is what the VA defines as a backlog – anything less than 125 days is not considered a delay on benefit claims.) </p>
<h2>8. Economic catastrophe</h2>
<p>There are <a href="https://bobwoodrufffoundation.org/wp-content/uploads/2020/04/BWF_WhitePaper-COVID19-5.0-Final.pdf">1.2 million veteran employees in the five industries most severely affected</a> by the economic fallout of the coronavirus. </p>
<p>A disproportionately high number of post-9/11 veterans live in some of the hardest-hit communities that depend on these industries. Veterans returning from overseas will face a dire economic landscape, with far fewer opportunities to integrate into civilian life with financial security.</p>
<p>In addition, severely disabled veterans living off of VA benefits were <a href="https://thehill.com/blogs/congress-blog/politics/490906-treasury-is-needlessly-requiring-millions-of-veterans-seniors-to">initially required to file a tax return to get stimulus checks</a>. This initial filing requirement delayed benefits for severely disabled veterans by at least a month. <a href="https://www.aarp.org/home-family/voices/veterans/info-2020/beneficiaries-stimulus-checks.html">The IRS finally changed the requirements</a> after public outcry, given that many older and severely disabled veterans do not have access to computers or the technological skills to file electronically.</p>
<p>There are many social groups to pay attention to, all with their own problems to face during the pandemic. With veterans, many of the problems they face now existed long before the coronavirus arrived on U.S. shores.</p>
<p>But with the challenges posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.</p>
<p><em>Editor’s note: This is an updated version of <a href="https://theconversation.com/8-ways-veterans-are-particularly-at-risk-from-the-coronavirus-pandemic-135619">a story</a> that originally ran on April 16, 2020.</em> </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/139251/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Rowen receives funding from the National Science Foundation. </span></em></p>With the challenges posed by the coronavirus pandemic, veterans who were already lacking adequate benefits and resources are now in deeper trouble.Jamie Rowen, Associate Professor of Legal Studies and Political Science, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1356192020-04-16T12:19:35Z2020-04-16T12:19:35Z8 ways veterans are particularly at risk from the coronavirus pandemic<figure><img src="https://images.theconversation.com/files/328182/original/file-20200415-153330-10hiiuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cleaners enter the Holyoke Soldiers' Home in Holyoke, Massachusetts, where a coronavirus outbreak has killed more than 40 veterans.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cleaners-enter-the-holyoke-soldiers-home-in-holyoke-ma-on-news-photo/1208729316?adppopup=true">Getty/Jessica Rinaldi/The Boston Globe</a></span></figcaption></figure><p>From the <a href="https://thehill.com/homenews/state-watch/490715-coronavirus-creates-emergency-in-nursing-homes">elderly who are facing deadly outbreaks in nursing homes</a> to <a href="https://www.vox.com/identities/2020/4/7/21211849/coronavirus-black-americans">communities of color facing higher infection and death rates</a>, different groups face different challenges from the coronavirus pandemic.</p>
<p>Among the <a href="https://bobwoodrufffoundation.org/wp-content/uploads/2020/04/BWF_WhitePaper-COVID19-5.0-Final.pdf">most hard-hit</a> are veterans, who are particularly susceptible to both health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death.</p>
<p>I have spent the past four years studying veterans with substance use and mental health disorders <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/lapo.12142">who are in the criminal justice system</a>. This work revealed gaps in health care and financial support for veterans, even though they have the best publicly funded benefits in the country. </p>
<p>Here are the eight ways the pandemic threatens veterans:</p>
<h2>1. Age and other vulnerabilities</h2>
<p><a href="https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf">In 2017</a>, veterans’ median age was 64; their average age was 58 and 91% were male. The largest group served in the Vietnam era, where <a href="https://www.forbes.com/sites/nicolefisher/2018/05/28/the-shocking-health-effects-of-agent-orange-now-a-legacy-of-military-death/#31b9dbbc21c6">2.8 million veterans were exposed to Agent Orange</a>.</p>
<p>Younger veterans deployed to Iraq and Afghanistan were exposed to dust storms, oil fires and burn pits, and perhaps as a consequence have <a href="https://academic.oup.com/milmed/article/179/11/1273/4159900">high rates of asthma and other respiratory illnesses</a>. </p>
<p>Age and respiratory illnesses are both risk factors for COVID-19 mortality. As of <a href="https://www.militarytimes.com/news/pentagon-congress/2020/04/13/va-reports-big-increases-in-coronavirus-deaths-employee-cases-over-the-weekend/">April 13</a>, 241 patients in Veterans Administration health care facilities had died of COVID-19 and 4,000 have tested positive.</p>
<h2>2. Dangerous residential facilities</h2>
<p>Veterans needing end-of-life care, those with cognitive disabilities, or those needing substance use treatment often live in crowded VA or state-funded residential facilities. </p>
<p>State-funded “Soldiers’ Homes” are notoriously starved for money and staff. The <a href="https://www.cnn.com/2020/04/06/us/holyoke-soldiers-home-coronavirus/index.html">horrific situation</a> at the Soldier’s Home in Holyoke, Massachusetts, where <a href="https://www.westernmassnews.com/news/the-latest-state-reports-40-resident-deaths-at-holyoke-soldiers-home/article_88b3a4d8-791d-11ea-b3b7-f37420fe3e63.html">more than 40 veteran residents have died from a COVID-19 outbreak</a>, illustrates the risk facing the veterans in residential homes. </p>
<h2>3. Benefits unfairly denied</h2>
<p>When a person transitions from active military service to become a veteran, they receive a <a href="https://www.va.gov/records/discharge-documents">Certificate of Discharge or Release</a>. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as “honorable,” “other than honorable,” “bad conduct” or “dishonorable.” These are crucial distinctions, because that status <a href="https://www.benefits.va.gov/BENEFITS/docs/COD_Factsheet.pdf">determines whether the Veterans Administration will give them benefits</a>. </p>
<p>Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have <a href="https://www.swords-to-plowshares.org/wp-content/uploads/Underserved.pdf">disproportionately more</a> of these negative discharges than veterans from other eras, <a href="http://www.legalservicescenter.org/wp-content/uploads/Turn-Away-Report.pdf">for reasons still unclear</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328194/original/file-20200415-153298-1xrzzea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">VA hospitals across the country are short-staffed and don’t have the resources they need to protect their workers.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-New-York/e8aae7013aaf4a3f95e600a474b325e9/4/0">AP/Kathy Willens</a></span>
</figcaption>
</figure>
<p>The Veterans Administration frequently <a href="https://today.law.harvard.edu/new-report-from-harvard-law-schools-veterans-legal-clinic-documents-the-vas-systemic-denial-of-health-care-to-veterans-with-bad-paper-discharges/">and perhaps unlawfully</a> denies benefits to veterans with “other than honorable” discharges.</p>
<p>Many veterans have requested upgrades to their discharge status. There is a <a href="https://www.va.gov/oig/pubs/VAOIG-16-01750-79.pdf">significant backlog of these upgrade requests</a>, and the pandemic will add to it, further delaying access to health care and other benefits. </p>
<h2>4. Diminished access to health care</h2>
<p>Dental surgery, routine visits and elective surgeries at Veterans Administration medical centers have been postponed since mid-March. <a href="https://www.va.gov/oig/pubs/press-releases/VAOIG-VHAOccupationalStaffingNewsRelease.pdf">VA hospitals are understaffed</a> – just before the pandemic, the VA reported 43,000 staff vacancies out of more than 400,000 health care staff. Access to health care will be even more difficult when those medical centers finally reopen. </p>
<p>As of Monday, April 13, <a href="https://www.militarytimes.com/news/pentagon-congress/2020/04/13/va-reports-big-increases-in-coronavirus-deaths-employee-cases-over-the-weekend/">1,520 VA health care workers</a> have tested positive for COVID-19, and thousands of health care workers are under quarantine. The VA is <a href="https://www.militarytimes.com/news/2020/03/23/coronavirus-threat-prompts-va-request-for-doctors-nurses-to-come-out-of-retirement/">asking doctors and nurses</a> to come out of retirement to help already understaffed hospitals.</p>
<h2>5. Mental health may get worse</h2>
<p>An average of 20 veterans commit suicide every day. A <a href="https://www.federalregister.gov/documents/2019/03/08/2019-04437/national-roadmap-to-empower-veterans-and-end-suicide">national task force</a> is currently addressing this scourge. </p>
<p>But many outpatient mental health programs are on hold <a href="https://www.ksat.com/news/local/2020/03/20/san-antonio-va-moves-away-from-in-person-mental-health-appointments-for-vets-amid-covid-19-crisis/">or being held virtually</a>. Some residential mental health facilities <a href="https://wwmt.com/news/local/veterans-in-battle-creek-forced-out-of-transitional-residences-to-prevent-covid-19-spread">have closed</a>. </p>
<p>Under these conditions, the suicide rate for veterans may grow. Suicide hotline calls by veterans were up <a href="https://connectingvets.radio.com/articles/veteran-crisis-line-calls-rise-over-coronavirus-wilkie-says">by 12% on March 22, just a few weeks into the crisis</a>. </p>
<h2>6. Complications for homeless veterans and those in the justice system</h2>
<p>An estimated <a href="http://nchv.org/index.php/news/media/background_and_statistics/">45,000 veterans</a> are homeless on any given night, and <a href="https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-019-0086-9">181,500 veterans</a> are in prison or jail. Thousands more are under court-supervised substance use and mental health treatment in <a href="https://justiceforvets.org/what-is-a-veterans-treatment-court/">Veterans Treatment Courts</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/25767963">More than half</a> of veterans involved with the justice system have either mental health problems or substance use disorders. </p>
<p>As residential facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go. They may stay incarcerated or become homeless. </p>
<p>Courts are <a href="https://www.nadcp.org/wp-content/uploads/2020/03/Treatment-Courts-COVID-19-Examples-3-26-20.pdf">moving online</a> or ceasing operations altogether. It is unclear whether participants will face delays graduating from court-supervised treatments. </p>
<p>Further, some Veterans Treatment Courts still require participants to take drug tests. With COVID-19 circulating, participants must put their health at risk to travel to licensed testing facilities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/328196/original/file-20200415-153330-o2nyw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As veterans’ facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go and may become homeless, like this Navy veteran in Los Angeles.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/travis-stanley-who-said-he-has-been-homeless-for-three-news-photo/1153992307?adppopup=true">Getty/Mario Tama</a></span>
</figcaption>
</figure>
<h2>7. Disability benefits delayed</h2>
<p>In the pandemic’s epicenter in New York, <a href="https://s3.amazonaws.com/documents.nycbar.org/files/2019531-PublicInterestVeteransLawPractitioners.pdf">tens of thousands of veterans</a> should have access to VA benefits because of their low income – but don’t, so far. </p>
<p>The pandemic has exacerbated existing delays in finding veterans in need, filing their paperwork and waiting for decisions. Ryan Foley, an attorney in New York’s Legal Assistance Group, a nonprofit legal services organization, noted in a personal communication that these benefits are worth “tens of millions of dollars to veterans and their families” in the midst of a health and economic disaster. </p>
<p><a href="https://www.benefits.va.gov/benefits/offices.asp">All 56 regional Veterans Administration offices are closed</a> to encourage social distancing. Compensation and disability evaluations, which determine how much money veterans can get, are usually done in person. Now, they must be done electronically, via telehealth services in which the veteran communicates with a health care provider via computer.</p>
<p>But getting telehealth up and running is taking time, adding to the <a href="https://www.latimes.com/nation/la-na-veterans-appeals-backlog-20151123-story.html">longstanding VA backlog</a>. Currently, approximately <a href="https://www.benefits.va.gov/reports/mmwr_va_claims_backlog.asp">75,000 veterans</a> wait more than 125 days for a decision. (That is what the VA defines as a backlog – anything less than 125 days is not considered a delay on benefit claims.) </p>
<h2>8. Obstacles to getting stimulus checks</h2>
<p>Veterans with the greatest financial need <a href="https://www.cnbc.com/2020/04/13/coronavirus-why-veterans-could-miss-out-on-stimulus-checks.html">may not automatically receive</a> their stimulus checks. Currently, those living on tax-exempt income from the VA must file a tax return to get a check. </p>
<p>But e-filing a tax return is a <a href="https://www.stripes.com/news/us/disabled-veterans-could-get-left-out-of-stimulus-money-lawmakers-warn-1.625198">significant obstacle</a> for many, especially severely disabled veterans who may not have computers or know how to use e-file software.</p>
<p>There are many social groups to pay attention to, all with their own problems to face during the pandemic. With veterans, many of the problems they face now existed long before the coronavirus arrived on U.S. shores. </p>
<p>But with the challenges posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklysmart">You can get our highlights each weekend</a>.]</p><img src="https://counter.theconversation.com/content/135619/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Rowen receives funding from the National Science Foundation.</span></em></p>With the challenges posed by the coronavirus pandemic, veterans who were already lacking adequate benefits and resources are now in deeper trouble.Jamie Rowen, Associate Professor of Legal Studies and Political Science, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/960922018-05-18T10:41:35Z2018-05-18T10:41:35ZPrivatizing essential human services like the VA can come at a high social cost<figure><img src="https://images.theconversation.com/files/219498/original/file-20180517-26295-1rk05l0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For-profit service providers may use discrimination as a way to make more money.</span> <span class="attribution"><span class="source">wavebreakmedia/Shutterstock.com</span></span></figcaption></figure><p>Over the years, countries have <a href="https://www.downsizinggovernment.org/privatization">privatized dozens of services and activities</a> once the sole domain of governments, such as the provision of electricity and water, road operations, prisons and even health care, with the ostensible aim of making them more efficient. </p>
<p>In the U.S., the Trump administration <a href="http://theweek.com/speedreads/754859/trump-proposes-privatizing-federal-assets-including-airports-freeways-international-space-station">has said it wants</a> to add airports and the International Space Station to that list. Some even <a href="https://www.nytimes.com/2018/03/28/opinion/shulkin-veterans-affairs-privatization.html">suggested</a> – though <a href="https://www.politico.com/story/2018/03/29/david-shulkin-veterans-affairs-secretary-privatizing-491590">vehemently denied</a> – that there was a plan to privatize health care services for veterans. </p>
<p>Before going down that road, the question needs to be asked whether privatizing essential human services serves the public interest. New research we <a href="https://academic.oup.com/jpart/advance-article/doi/10.1093/jopart/muy009/4938536">recently published</a> suggests that privatization may come at a social cost. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219502/original/file-20180517-26300-1k7ihgt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cornell Brooks, national president of the NAACP, and others spoke out in 2017 against a plan to privatize Atlantic City’s water supply.</span>
<span class="attribution"><span class="source">AP Photo/Wayne Parry</span></span>
</figcaption>
</figure>
<h2>Economic incentives of privatization</h2>
<p>Privatization theory assumes that organizations, including those that <a href="https://academic.oup.com/jpart/article/17/3/501/943117?searchresult=1">deliver social services</a>, thrive on competition and monetary gain. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1540-6210.00157">Supporters of privatization</a> argue that companies can perform government functions more efficiently. More competition and more choice for clients are expected to put pressure on providers to be more innovative and aware of financial costs. </p>
<p>In the public sector, however, competition is almost by definition absent, either because users of services cannot be excluded from the service – breathing clean air, for example – or because there is little monetary gain to be made – such as with services to the homeless. </p>
<p>So in situations where there is no real market, governments have attempted to mimic their conditions, such as by giving citizens the freedom to choose a public service provider or negotiating contracts that include certain performance incentives. </p>
<p>But this reliance on performance contracts can lead business providers to focus on short-term financial targets – such as the number of people processed per dollar spent – oftentimes at the expense of long-term outcomes for the people served. That’s the conclusion of a <a href="https://academic.oup.com/jpart/article/17/2/189/894972?searchresult=1#15497641">study</a> of a for-profit, welfare-to-work training program in the United States. </p>
<p>This gives business providers a strong incentive to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/pam.21695">concentrate their efforts</a> on serving people that are most likely to help them achieve these goals by either focusing on those clients who are most likely to succeed or disregarding the ones that are harder to serve. Examples may include supporting primarily motivated job seekers to apply for employment or trying to avoid chronically sick patients. By focusing on easier-to-serve clients and shunning the ones who are costly, service providers are more likely to make a profit.</p>
<p>However, it’s often difficult to know in advance who’s going to cost more than someone else. As a result, many service providers end up relying on imperfect, discriminatory cues to help them weed out potential cost burdens. <a href="https://academic.oup.com/qje/article/133/1/191/4060073">Companies do something similar</a> when they use stereotypes about race or ethnicity as discriminatory proxies for unobserved characteristics in job applicants.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219484/original/file-20180517-26286-p6ddyp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Former Veterans Affairs Secretary David Shulkin believes he was ousted as part of plan to privatize the agency.</span>
<span class="attribution"><span class="source">AP Photo/Andrew Harnik</span></span>
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</figure>
<h2>Makrini and Maes</h2>
<p>To learn more about whether for-profit service providers treat people of marginalized ethnic backgrounds differently, <a href="https://academic.oup.com/jpart/advance-article/doi/10.1093/jopart/muy009/4938536">we ran a field experiment</a> in the Belgian elderly care sector. We chose Belgium because the industry includes both public and private homes, and one of us is based there. </p>
<p>We sent basic information requests to all public and for-profit nursing homes in Flanders, the Dutch-speaking part of Belgium. Half of the requests, randomly assigned, appeared to come from a Belgian citizen (Kenny Maes), while the rest bore the signature of someone with a North African name (Mohammed El Makrini). The names were chosen based on the results of a separate survey we sent out to 2,000 Belgians asking them to rate several names on their perceived ethnicity, age, level of education and wealth. </p>
<p>In the requests, we asked nursing homes for advice on how to subscribe for a place in their facility. Withholding such information would make it harder for a prospective client to apply for a spot.</p>
<p>Of the 223 nursing homes we contacted, 71 percent responded, with public facilities being a little more likely than for-profit ones to get back to us. In general, each type of home responded to our two senders at similar rates. For example, 76 percent of public facilities replied to “Kenny,” compared with 79 percent for “Mohammed.” The response rate of for-profit homes was a bit more lopsided, but it was not what we’d consider a significant difference given the sample size: 66 percent for Kenny and 57 percent for Mohammed. </p>
<p>The really interesting finding was when we analyzed the actual responses. Upon closer inspection, we found that for-profit nursing homes were significantly less likely to provide information to Mohammed on how to enroll. Only about 43 percent of the for-profit homes that responded offered him the info, compared with 63 percent for Kenny. There was basically no difference among public facilities.</p>
<p>This is direct proof of for-profit providers discriminating against prospective clients based on their perceived ethnicity. But they’re not doing it simply out of ethnic animus. If it was, we’d have seen the same discrimination at the public facilities as well.</p>
<p>Rather, the motivation seems to be primarily economic. This is what economists call “<a href="http://www.nber.org/papers/w15860">statistical discrimination</a>.” In other words, average characteristics of the minority group – such as language barriers and having different cultural needs and habits that make them more difficult to serve – are used to stereotype individuals who belong to that particular group.</p>
<h2>Unintended consequences</h2>
<p>The <a href="http://www.governing.com/topics/mgmt/pros-cons-privatizing-government-functions.html">public debate about privatization</a> tends to almost exclusively focus on its supposed financial and managerial advantages – which are <a href="http://www.pogo.org/our-work/reports/2011/co-gp-20110913.html#Executive%20Summary">hardly clear cut</a>. Meanwhile, the potential social costs of privatization are commonly neglected. </p>
<p><a href="https://scholar.google.com/citations?user=PA7TqeEAAAAJ&hl=en&oi=ao">Our</a> <a href="https://scholar.google.com/citations?user=mniink4AAAAJ&hl=en&oi=ao">research</a> suggests that privatizing human services such as health care can result in less access for groups perceived as harder to serve because of language barriers and cultural differences. </p>
<p>Unfortunately, they also happen to be the groups that need such services the most.</p><img src="https://counter.theconversation.com/content/96092/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Trump administration wants to privatize more of the federal bureaucracy. New research suggests this can lead to discrimination in essential government services.Sebastian Jilke, Assistant Professor, Rutgers University - NewarkWouter Van Dooren, Professor of Public Administration, University of AntwerpLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/957472018-05-01T10:41:50Z2018-05-01T10:41:50ZWill Trump’s ire force Montana’s Senator Tester away from political center?<figure><img src="https://images.theconversation.com/files/216876/original/file-20180430-135848-qssh8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Jon Tester, D-Mont., during a 2012 campaign stop in Helena, Montana </span> <span class="attribution"><span class="source">AP Photo/Matt Gouras</span></span></figcaption></figure><p>Democrat Jon Tester has made a name for himself <a href="http://flatheadbeacon.com/2017/08/30/calm-it-down/">by largely not making a national name for himself</a>. </p>
<p>In the last 11 years, <a href="https://www.cnn.com/2018/03/08/politics/why-democrats-supporting-republican-bank-bill/index.html">the two-term Montana senator has walked an increasingly narrow line</a> – backing many critical partisan initiatives <a href="http://helenair.com/news/politics/sen-tester-congress-must-stop-partisan-games/article_d1cae260-3c1f-11e1-9422-0019bb2963f4.html">while also trying to remain distinct from the national party</a>.</p>
<p>It is a spot that became a lot more difficult to hold on to <a href="https://www.nytimes.com/2018/04/28/us/politics/trump-tester-jackson-va.html">after President Donald Trump targeted the Montana senator</a> recently for <a href="https://www.realclearpolitics.com/video/2018/04/25/sen_jon_tester_details_allegations_against_wh_doctor_ronny_jackson.html">spreading reports, many of them anonymous and some now questioned, about the president’s nominee</a> to head the Department of Veterans Affairs.</p>
<p>President Trump has taken to Twitter and the stump to attack Tester, who is running for reelection this fall. Trump has called on Tester to resign and <a href="http://thehill.com/homenews/administration/385363-trump-i-know-things-about-tester-that-would-cause-him-to-lose-an">threatened</a> that “I know things about Tester that I could say, too, and if I said them, he’d never be elected again.”</p>
<p>He’s called the Montanan “a disgrace” and said:</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"990307626784362496"}"></div></p>
<p>This kind of public battle between politicians has been my bread and butter, first as a journalist for the PBS NewsHour and later as <a href="http://jour.umt.edu/about/faculty/?ID=2325">a professor of journalism</a> at the University of Montana here in Tester’s home state. </p>
<p>Tester, the ranking Democrat on the Senate Veterans Affairs Committee, went public with concerns, many of them based on leaked reports, that the nominee to head the Veterans Administration, or VA, Dr. Ronny Jackson, was unfit. </p>
<p>Senate Veterans Affairs Committee Chairman Johnny Isakson of Georgia, a Republican, <a href="https://www.nytimes.com/2018/04/28/us/politics/trump-tester-jackson-va.html">co-signed a letter</a> with Tester calling on Dr. Jackson to be investigated. But despite the Republican senator’s public support for an investigation, Trump has made this story about Tester.</p>
<p>In doing so, Trump is asking Montana voters to choose between himself and Tester – even as those voters have expressed support for both men. Trump won the state by more than <a href="https://www.cnn.com/election/2016/results/states/montana">20 points in 2016</a> and Tester scored a <a href="http://missoulian.com/news/local/news-analysis-how-tester-won-montana-s-u-s-senate/article_550a66e8-2bbf-11e2-ae5c-001a4bcf887a.html">narrower 3.4 percent victory</a> in his electoral battle against the state’s lone congressman in 2012.</p>
<h2>Can Tester stay independent?</h2>
<p>Tester has also taken the lead on issues like reducing red tape in the VA and protecting whistle-blowers who go public with complaints about the agency. It is no small issue in a state where nearly <a href="http://leg.mt.gov/content/Committees/Interim/2017-2018/State-Administration-and-Veterans-Affairs/Meetings/Sept-2017/Montana%20Veteran%20Demographics%20(as%20of%20Jan.%206%202017).pdf">one in 10 residents is a veteran</a>.</p>
<p>Tester is an anomaly in modern American politics – a politician who regularly bucks his party’s leadership, <a href="https://www.rollcall.com/news/politics/montanas-jon-tester-breaks-red-state-2018-democrats">often votes with Republicans</a> and <a href="http://leadersedgemagazine.com/articles/%202013/09/a-non-in-a-chamber-of-partisans">seeks to make politics about the needs of local residents rather than national parties</a>. </p>
<p>It is a line he has had to walk since his unlikely victory over longtime Republican Sen. Conrad Burns, who had been dogged by his connection with a <a href="https://www.npr.org/templates/story/story.php?storyId=5299944">GOP lobbying scandal in 2006</a>. Tester quickly sought the political middle ground. </p>
<p>It is a necessity in a state where only one Democratic presidential candidate has won the state’s three electoral votes in the past 50 years – and that was mainly because of the <a href="http://sos.mt.gov/portals/142/Elections/archives/1990s/1992/1992gen.pdf?dt=1480457264103&dt=1480523087997&dt=1483636395345&dt=1484090685147&dt=1484090818653&dt=1484091059850&dt=1484092785123&dt=1484668556665&dt=1484676687552&dt=1485286813335&dt=1485286979901&dt=1491412807839&dt=1494348815885&dt=1494348873534&dt=1497553987845&dt=1497555053569&dt=1497555121034&dt=1497555299184&dt=1497892315130&dt=1525124463112">popularity of outsider Ross Perot in 1992</a>. Perot pulled votes away from GOP candidate President George H.W. Bush, allowing Democrat Bill Clinton to win with only a plurality, not a majority. </p>
<p>Montana is also a state where Democrats have lost more and more statewide races in recent years – including <a href="https://www.greatfallstribune.com/story/news/politics/2016/11/09/bullock-defeats-gianforte-ap-reports/93539038/">all but the governor’s race in 2016</a>. The governor, Steve Bullock, has also worked hard to carve out a middle ground, working with moderate Republicans in the legislature to pass practical legislation that is seen as fairly moderate. </p>
<p>But even Bullock faced a close race against political newcomer Greg Gianforte, winning a 4-point victory on a message of moderate and pragmatic problem-solving.</p>
<p>For Tester, this has meant trying to position himself between the two partisan extremes. One example of this approach can be seen in a bill Tester has pushed for years on <a href="https://archive.nytimes.com/www.nytimes.com/gwire/2009/12/14/14greenwire-sen-testers-plan-for-wilderness-logging-roils-b-4200.html?pagewanted=all">forest management and wilderness</a>. </p>
<p>Tester crafted a bill that made neither side particularly happy. Advocates for more wilderness argued <a href="http://helenair.com/government-and-politics/rehberg-tester-still-at-odds-over-wilderness-logging-bill/article_59f514d6-383c-11e1-9ad6-0019bb2963f4.html">the bill amounted to mandatory logging</a> in national forests. Some logging lobbyists said the bill would set aside huge swaths of land for wilderness status without any clear plan to increase harvesting of forests.</p>
<p>As <a href="http://helenair.com/government-and-politics/rehberg-tester-still-at-odds-over-wilderness-logging-bill/article_59f514d6-383c-11e1-9ad6-0019bb2963f4.html">Tester described it</a>, the bill was “a well-thought-out, grassroots, made-in-Montana solution to issues in the forest.” </p>
<p>That is how Tester has positioned himself throughout his tenure in office. If you need more evidence, watch his first campaign ad this year:</p>
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<p>It is an artful presentation of the modern political moderate. The ad features the 13 bills President Trump has signed into law that were sponsored by Tester. It could be a Republican ad. But it isn’t, and it does not stop with the presentation of Tester’s close association with the president.</p>
<p>After first responders, veterans and others list seven of the senator’s achievements, Tester appears, holding up seven fingers and saying, “Eight. And I’m out of fingers!” It’s a moment that works for a couple of reasons. </p>
<p>First, he is a Democrat who has worked with President Trump on multiple issues. And second, he’s out of fingers because Tester <a href="https://www.washingtonpost.com/lifestyle/style/jon-tester-could-teach-democrats-a-lot-about-rural-america--if-he-can-keep-his-senate-seat/2017/05/01/198c03cc-251d-11e7-a1b3-faff0034e2de_story.html?noredirect=on&utm_term=.b28c0a7fb9c8">lost three to a meat grinder</a> when he was nine years old. Tester is not some polished politician, but a sort of everyman, working the farm now and having worked since he was a boy. </p>
<h2>Carefully crafted persona</h2>
<p>In that moment, the uniqueness of Jon Tester comes through clearly to the Montana voters. Here is a guy who is not a Washington, D.C. politician. He has been sure to maintain his family’s <a href="https://www.washingtonpost.com/lifestyle/style/jon-tester-could-teach-democrats-a-lot-about-rural-america--if-he-can-keep-his-senate-seat/2017/05/01/198c03cc-251d-11e7-a1b3-faff0034e2de_story.html?utm_term=.4e0b77ab3266">organic farm in rural Big Sandy even as he travels back and forth to Washington</a>. He has carefully crafted the persona of a moderate who will stand up for everyday Montanans, a regular guy with a flattop haircut and a sense of Montana values.</p>
<p>It’s one even his opponents seem to admit holds sway, primarily because they spend a lot of their time and energy fighting it. </p>
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<p>One potential opponent – if he wins the Republican primary – is Troy Downing. Downing has an ad where he accuses Tester of being not a real farmer but actually a music teacher. Others have stressed the need to have <a href="http://mtpr.org/post/republican-senate-contenders-debate-trump-tester-and-montana-residency">strong local support</a> to take on Tester, who has out-raised all of his opponents. </p>
<p>The dust-up with President Trump is a moment of uncertainty out here in Montana, though. Is this when Tester becomes a national Democrat and therefore less electable here in an increasingly red state? Can Republicans finally get more traction with their argument that Tester is really a typical Democrat in a Republican state? Or will Tester’s focus on pushing the VA to be better be the primary thing to stick in the minds of Montanans?</p>
<p>For all the tweets and statements, none have come from the top Republicans in Montana. Sen. Steve Daines, Rep. Greg Gianforte and Attorney General Tim Fox – a likely gubernatorial candidate in 2020 – have so far stayed out of the debate. Their silence may be the most telling reaction so far.</p><img src="https://counter.theconversation.com/content/95747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lee Banville does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Democratic Senator Jon Tester of Montana has a moderate image in a state that doesn’t often elect Democrats. But as he faces reelection, his move to torpedo Trump’s VA nominee may threaten that image.Lee Banville, Associate Professor of Journalism, University of MontanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/942172018-03-30T10:48:23Z2018-03-30T10:48:23ZA VA hospital you may not know: The Final Salute, and how much we doctors care<figure><img src="https://images.theconversation.com/files/212714/original/file-20180329-189804-1stfaht.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A veteran salutes a flag. There is often a final one that occurs inside a VA hospital.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/veteran-saluting-front-us-flag-588834296?src=qt1QEON_JPAlf2PI39RXIQ-1-15">flysnowfly/Shutterstock.com</a></span></figcaption></figure><p>Death is never easy. Even when expected, a person’s death leaves a void for those who remain. As a physician, it is especially difficult for me when one of my patients dies.</p>
<p>I practice medicine at one of America’s approximately 160 Veterans Affairs hospitals, so my patients are all veterans. The VA system – the largest integrated health care system in the United States – cares for approximately 9 million veterans, men and women who were willing to sacrifice greatly for our country. </p>
<p>News about <a href="https://www.nytimes.com/2018/03/28/us/politics/david-shulkin-veterans-affairs-trump.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news">transitions at the very top of the VA</a> put me in a reflective mode, thinking about the core reason that we do what we do at VA health care facilities around the nation. As a VA doctor, it is sometimes difficult to read the frequent criticism about the VA and its hospitals without getting dejected, but, fortunately, most of us are inspired by those who entrust us with their care and their lives.</p>
<p>Abraham Lincoln, in his second inaugural address on March 4, 1865, <a href="https://www.va.gov/opa/publications/celebrate/vamotto.pdf">gave the VA its mission</a>: “To care for him who shall have borne the battle and for his widow, and his orphan.” </p>
<p>I’ve been involved in caring for veterans since my first days in medicine, through many changes. As a medical student and resident, I cared for World War I veterans. They are now all gone. </p>
<p>I am now always honored to care for World War II veterans, most of whom have also passed.</p>
<p>Next will be veterans of the Korean War (like my father-in-law), Vietnam, Iraq and Afghanistan. It was these men and women who bravely served this country and who kept it free and open to people like me and my family – immigrants who were looking for better lives. </p>
<p>I did not sit in the foxhole with them or parachute into jungles, but I still have a duty. <a href="https://theconversation.com/caring-for-veterans-a-privilege-and-a-duty-67823">My duty is to provide America’s veterans with superb medical care</a>, delivered in a humane, compassionate and high-quality manner. </p>
<h2>The Final Salute</h2>
<p>When a veteran dies at our VA hospital, we all feel the loss. Even though I have been caring for veterans for over two decades in four different VA hospitals – as a medical student, resident, fellow and now as an attending physician – I only recently witnessed a ceremony that is both beautiful and heart-wrenching. </p>
<p>It is known as the Final Salute, and it is done for veterans who die under our care.</p>
<p>After pronouncing death, the patient’s family is called and comes in to see their loved one. The body is placed on a gurney and is draped with Old Glory, the symbol of our freedom. As the body and family are led out of the hospital room to the exit, “Taps” is played – the signal for the health care workers, and, especially, their fellow soldiers, to come to the doors of their rooms.</p>
<p>Civilians stand with their hands on their hearts. Veterans give the military salute, standing if they are able.</p>
<p>For me as a civilian, I am reminded of how lucky others and I are that we get to care for these men and women, who all too often are forgotten and are struggling with demons. Rituals and ceremonies are important links to the past, and they are reminders of what it takes to improve tomorrow. Being a VA doctor gives me pride, no more so than when I watch how our VA honors those veterans who have died. </p>
<h2>Veterans deserve top priority</h2>
<p>As the headlines point out, however, the VA should strive to provide <a href="https://www.amazon.com/dp/B0073HW03I/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1">the best care anywhere</a>. Even though studies have found that overall VA care is <a href="https://www.ncbi.nlm.nih.gov/pubmed/27422615">comparable to and often better than non-VA care</a>, the VA needs to do much more to make the VA a model system for not just this country but the entire world. </p>
<p>I think that <a href="https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4007">President Donald Trump’s call to increase the VA budget for fiscal year 2019</a> is a step in the right direction. Not only will extra resources provide veterans more choices for care, but they also will help prevent veteran suicides, reduce opioid use, and expand cutting-edge VA research on prosthetics and veteran safety.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=511&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=511&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212729/original/file-20180330-189804-udje4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=511&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most Americans and politicians can agree on at least one thing: support for veterans.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/military-veterans-holding-flags-parade-6734983?src=BxGMCPLZlDwSFceZMykwTA-3-31">Cheryl Casey/Shutterstock.com</a></span>
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<p>Support for veterans has, fortunately, remained bipartisan. Despite the change of leadership currently happening in the VA secretary’s office – and the continued <a href="https://www.nytimes.com/2018/03/28/opinion/shulkin-veterans-affairs-privatization.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region">controversy the role of the private sector</a> could and should have in providing care to veterans – my plea from the field is that our elected leaders continue to do right by veterans. </p>
<p>My colleagues and I – the men and women who have the privilege to care for America’s heroes in VA health care facilities around the country – are honored to provide the high-quality and compassionate care veterans deserve from the moment they leave the service to the time of their Final Salute.</p><img src="https://counter.theconversation.com/content/94217/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sanjay Saint works for the VA Ann Arbor Healthcare System where he serves as Chief of Medicine and received the 2016 Mark Walcott Award as the National VA Physician of the Year. He receives or has received funding from the NIH, AHRQ, CDC, Blue Cross Blue Shield of Michigan Foundations, and Department of Veterans Affairs. </span></em></p>The Department of Veterans Affairs hospitals have been criticized roundly. Sometimes lost in the chorus of complaints is the depth of feeling that VA caregivers have for the veterans, a doctor writes.Sanjay Saint, George Dock Professor of Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/930312018-03-27T10:44:45Z2018-03-27T10:44:45ZWhat the staff does matters more than what’s in an organization’s mission statement<figure><img src="https://images.theconversation.com/files/211058/original/file-20180319-31605-1vg3qc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The late Sen. Ted Kennedy, reading from "A Nation of Immigrants," a book by his brother, President John F. Kennedy</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Associated-Press-Domestic-News-Dist-of-Columbia-United-States-IMMIGRATION/aaaa17aa0fe8da11af9f0014c2589dfb/10/0">AP Photo/Dennis Cook</a></span></figcaption></figure><p><a href="http://www.businessdictionary.com/definition/mission-statement.html">Mission statements</a>, not normally in the news, are getting more attention than usual. </p>
<p>The <a href="https://www.vox.com/2018/2/22/17041862/uscis-removes-nation-of-immigrants-from-mission-statement">U.S. Citizenship and Immigration Services</a>, the Department of <a href="https://www.huffingtonpost.com/entry/hud-mission-statement_us_5a9f5db0e4b002df2c5ec617">Housing and Urban Development</a>, the <a href="https://diplomacy.state.gov/discoverdiplomacy/diplomacy101/issues/170606.htm">State</a> <a href="https://web.archive.org/web/20161227021650/http:/www.state.gov/s/d/rm/index.htm">Department</a> and other federal agencies are changing the way they express their core purpose and focus. In many cases, the Trump administration is <a href="https://www.npr.org/2018/02/23/588374709/u-s-citizenship-and-immigration-services-omit-nation-of-immigrants-from-mission-">alarming observers</a> by deleting key phrases that signal diversity and inclusion.</p>
<p>My <a href="http://rdcu.be/J3tC">research on nonprofit mission statements</a>, published in the Nonprofit Management & Leadership academic journal, however, suggests that there might be less to worry about than it appears. I have found that how people in a given organization personally understand its mission matters more than any formal statements summing it up.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/LJhG3HZ7b4o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Author Dan Heath, a Duke University professor, suggests a few ways to write strong mission statements.</span></figcaption>
</figure>
<h2>Tales of tinkering</h2>
<p>In the summer of 2017, the <a href="https://www.washingtonpost.com/blogs/post-partisan/wp/2018/03/16/trumps-edits-to-democracy-annotated/">State Department</a> replaced its mission statement with a new one. The old phrasing referenced democracy but the new one didn’t.</p>
<p>In February, the <a href="https://theintercept.com/2018/02/22/u-s-citizenship-and-immigration-services-will-remove-nation-of-immigrants-from-mission-statement/">immigration agency altered</a> its long-running mission statement to omit references to the U.S. being “a nation of immigrants.” </p>
<p>Around the same time, some Veterans Administration <a href="https://www.washingtonpost.com/news/checkpoint/wp/2018/02/14/va-employees-wanted-a-gender-neutral-mission-statement-the-agency-refused/?utm_term=.2ba02b147405">employees temporarily altered</a> its motto without permission, replacing the line “to care for him who shall have borne the battle and for his widow, and his orphan” with “to care for those ‘who shall have borne the battle’ and for their families, caregivers, and survivors.” Their superiors overrode the change, which symbolically supported female veterans through gender-neutral language. </p>
<p>Then <a href="https://www.huffingtonpost.com/entry/hud-mission-statement_us_5a9f5db0e4b002df2c5ec617">HUD Secretary Ben Carson said he wanted to change</a> the agency’s <a href="https://www.hud.gov/about/mission">mission statement</a>, removing its call to “build inclusive and sustainable communities free from discrimination.” </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=378&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=378&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=378&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211060/original/file-20180319-31614-zhs8pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Housing and Urban Development Secretary Ben Carson addressing HUD employees in March 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Carson-HUD/4828f893c953428a854321bedf11da48/5/0">AP Photo/Susan Walsh</a></span>
</figcaption>
</figure>
<h2>What does the staff say?</h2>
<p>Disagreements among managers, board members and staff regarding a group’s mission, values and other key ideas are <a href="https://www.tandfonline.com/doi/abs/10.1080/09614520050116578">relatively common</a> and <a href="http://journals.sagepub.com/doi/abs/10.1177/0899764010370869">even natural</a> at all kinds of agencies and groups. Yet a <a href="http://journals.sagepub.com/doi/abs/10.1177/0899764014523335">study of nonprofits</a> by scholars at three different universities found that nonprofits rarely change their formal mission statements. These researchers also found that the shifts that do occur tend to be driven most often by collaboration with their peers.</p>
<p>As I began my research, I expected changes in formal mission statements to be the most important signals of what an organization seeks to accomplish. But after interviewing the leaders and lower-ranking employees at a variety of nonprofits engaged in activities such as adult literacy, clean water and sanitation, I discovered that their own views mattered more. </p>
<p>Many of the same people cannot recall the exact language of their organization’s official mission statement, yet they have a clear and personal understanding of their nonprofit’s mission. These takes can be different within a single organization, as you might expect. People, after all, join nonprofits with different values and motivations. Their work requires them to focus on different activities, which absorb their attention and set distinct priorities. </p>
<p>As I compared the statements by real people to the words found in official documents like annual reports and on websites, including formal mission statements, I made another observation. Mission statements broadly establish an organization’s purpose, but they do not serve as the best guide for action. Instead, what truly guides an organization is the consensus among the people in it.</p>
<p>I also noticed two important trends. First, this somewhat informal consensus changes more often than formal mission statements. Second, the consensus may not match the personal views of senior leaders. Often, what the staff perceives is actually closer to the true mission within the organization than the formal written statement or the views of board members.</p>
<p>As for the Trump administration, it may find that changing the formal mission statements that guide agencies like HUD and U.S. Citizenship and Immigration Services will not achieve its desired political goals.</p>
<p>If civil servants continue to personally believe that they reside in “a nation of immigrants,” taking that expression out of their agency’s mission statement won’t have much of an impact. And HUD’s staff, likewise, may continue to make rooting out housing discrimination a high priority even if that’s no longer baked into that agency’s mission statement.</p><img src="https://counter.theconversation.com/content/93031/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Berlan does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Changes to the official mandates guiding nonprofits and government agencies might be less significant than they appear.David Berlan, Assistant Professor of Public Administration, Askew School of Public Administration and Policy, Florida State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/678232016-11-11T02:45:24Z2016-11-11T02:45:24ZCaring for veterans: A privilege and a duty<p>Veterans Day had its start as Armistice Day, marking the end of World War I hostilities. The holiday serves as an occasion to both honor those who have served in our armed forces and to ask whether we, as a nation, are doing right by them. </p>
<p>In recent years, that question has been directed most urgently at Veterans Affairs hospitals. Some critics are even calling for the dismantling of the whole huge system of hospitals and outpatient clinics. </p>
<p>President Obama signed a US$16 billion dollar bill to reduce wait times in 2014 to do things like <a href="http://www.cnn.com/2014/08/07/politics/obama-va-bill/">hire more medical staff and open more facilities</a>. And <a href="http://www.nytimes.com/2016/08/06/us/veterans-health-care.html">while progress has been made</a>, much remains to be done. The system needs to improve access and timeliness of care, reduce often challenging bureaucratic hurdles and pay more attention to what front-line clinicians need to perform their duties well. There is no question that the VA health care system has to change, and it already has begun this process.</p>
<p>Over the past 25 years, I have been a medical student, chief resident, research fellow and practicing physician at four different VA hospitals. My research has led me to spend time in more than a dozen additional VA medical centers. </p>
<p>I know how VA hospitals work, and often have a hard time recognizing them as portrayed in today’s political and media environment. My experience is that the VA hospitals I know provide high-quality, compassionate care. </p>
<h2>Treating nine million veterans a year</h2>
<p>I don’t think most people have any sense of the size and scope of the VA system. Its 168 medical centers and more than one thousand outpatient clinics and other facilities serve almost nine million veterans a year, making it the <a href="http://www.va.gov/health/aboutVHA.asp">largest integrated health care system in the country</a>. </p>
<p>And many Americans may not know the role VA hospitals play in medical education. Two out of three medical doctors in practice in the U.S. today <a href="http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747">received some part of their training at a VA hospital</a>. </p>
<p>The reason dates to the end of World War II. The VA faced a physician shortage, as almost 16 million Americans returned from war, many needing health care. </p>
<p>At the same time, many doctors returned from World War II and needed to complete their residency training. The VA and the nation’s medical schools thus became partners. In fact, the <a href="https://www.aamc.org/download/385612/data/07182014.pdf">VA is the largest provider of health care training in the country</a>, which increases the likelihood that trainees will consider working for the VA once they finish. </p>
<h2>Specialized care for veterans</h2>
<p>The VA network specializes in the treatment of such war-related problems as post-traumatic stress disorder and suicide prevention. It has, for example, pioneered the <a href="https://dx.doi.org/10.2105/AJPH.2015.302836">integration of primary care with mental health</a>. </p>
<p>Many veterans live in rural parts of the U.S., are of advanced age and have chronic medical conditions that make travel challenging. So the VA is a national leader in telemedicine, with notable success in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21322300">mental health care</a>. </p>
<p>The VA’s research programs have made major breakthroughs in areas such as cardiac care, prosthetics and infection prevention. </p>
<p>I can vouch for the <a href="http://dx.doi.org/10.1056/NEJMsa021899">VA’s nationwide electronic medical records system</a>, which for many years was at the cutting edge. </p>
<p>A case in point: Several years ago a veteran, in the middle of a cross-country trip, was driving through Michigan when he began feeling sick. Within minutes of his arrival at our VA hospital, we were able to access his records from a VA medical center over a thousand miles away, learn that he had a history of Addison disease, a rare condition, and provide prompt treatment.</p>
<p>I am therefore not surprised that the studies that have compared VA with non-VA care have found that the VA is, overall, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20966778">as good as</a> or <a href="http://dx.doi.org/10.1001/archinte.168.9.950">better</a> than the private sector. In fact, a recently published <a href="https://dx.doi.org/10.1007/s11606-016-3775-2">systematic review of 69 studies</a> performed by RAND investigators concluded: “…the available data indicate overall comparable health care quality in VA facilities compared to non-VA facilities with regard to safety and effectiveness.”</p>
<h2>The VA offers veterans more than health care</h2>
<p>The most remarkable aspect of VA hospitals, though, is the patient population, the men and women who have sacrificed for their country. They have a common bond. A patient explained it this way:</p>
<blockquote>
<p>“The VA is different because everyone has done something similar, whether you were in World War II or Korea or Nam, like me. You’re not thrown into a pot with other people, which would happen at another kind of hospital.”</p>
</blockquote>
<p>The people who work at VA hospitals have a special attitude toward their patients. It takes the form of respect and gratitude, of empathy, of a level of caring that is nothing short of love. You can see it in the extra services provided for patients who are often alone in the world, or too far from home to be visited.</p>
<p>Take a familiar scene: a medical student taking a patient for a walk or wheelchair ride on the hospital grounds. It is common for nurses to say “our veteran” when discussing a patient’s care with me.</p>
<p>Volunteers and chaplains rotate through VA hospitals on a regular basis, to a degree unknown in most community hospitals. The social work department is also more active. The patients are not always so patient, but these visitors persevere. “They’re a good bunch of people,” one veteran said of the staff. “I know because I’m irritable most of the time and they all get along with me.”</p>
<p>Physicians everywhere are under heavy pressure these days, in part because of the increase in the number of complex patients they care for. Yet I have spent hours observing doctors in VA hospitals around the country as they sit with patients, inquiring about their families and their military service, treating the veterans with respect and without haste.</p>
<p>Earlier this year, I cared for a veteran in his 50’s, a house painter, whom we diagnosed with cancer that had metastasized widely. We offered him chemotherapy, which could have given him an extra few months, but he chose hospice. He told me he wanted to go home to be with his wife and play the guitar. One of the songs he wanted to sing was “Knocking on Heaven’s Door.”</p>
<p>I was deeply moved. I liked and admired the man, and I was disturbed that we had been unable to save him. My medical student had the same feelings. Before the patient left, the student told me, “He shook my hand, looked me in the eyes, and said, ‘Thanks for being a warrior for me.’”</p>
<p>That’s the special kind of patient who shows up at a VA hospital. Every single one of them should have the special kind of care they deserve. And we must ensure that the care is superb on this and every day.</p><img src="https://counter.theconversation.com/content/67823/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sanjay Saint works for the VA Ann Arbor Healthcare System where he serves as Chief of Medicine and received the 2016 Mark Walcott Award as the National VA Physician of the Year. He receives or has received funding from the NIH, AHRQ, VA, and the CDC. </span></em></p>A physician who has spent 25 years working within VA hospitals reflects on what it has meant to him to serve those who have served our country.Sanjay Saint, George Dock Professor of Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/600922016-05-30T01:01:02Z2016-05-30T01:01:02ZSometimes the best medicine for a veteran is the company of another veteran<p>Many take time on Memorial Day to remember the Americans who have given their lives in service to our country.</p>
<p>For veterans and their families, that sentiment of remembrance is felt year-round. Many veterans suffer lifelong anguish over the loss of their brothers and sisters in arms. For them, Memorial Day is a day like every other day – a day they remember those who died at war. </p>
<p>This shared grief is just one way some veterans are affected by their military service. Veterans are also molded by military culture – a unique set of values, traditions, language and even humor. Military culture has unique subcultures, but it has enough consistency across different branches, ranks and time periods to make most veterans feel a kinship.</p>
<p>Recognizing this kinship has led veteran service and health care organizations to encourage veterans to build <a href="http://psycnet.apa.org/journals/prj/35/6/470/">trusting relationships</a> and support each other. Researchers have learned that veterans are more likely to share personal information and ask advice about many things, including <a href="http://www.dcoe.mil/content/Navigation/Documents/Best_Practices_Identified_for_Peer_Support_Programs_Jan_2011.pdf">health care</a>, from fellow veterans. That’s why the VA <a href="http://www.vacareers.va.gov/peer-to-peer/">offers employment</a> to veterans as peer specialists. </p>
<p>I’m a mental health services researcher at the University of Texas at Austin School of Social Work. I focus on increasing the availability of social supports and improving the efficacy of mental health treatment options for veterans and their families. Last year I had the opportunity to study the Texas-funded <a href="http://www.milvetpeer.net/">Military Veteran Peer Network</a>, a statewide program that provides peer-to-peer support in 37 communities. </p>
<p>My research supports the idea that veterans are an important resource who can be trained to support fellow veterans in need. What’s more, I’ve learned that civilian care for veterans can be improved when civilians are trained in military culture. The MVPN offers military-informed care training to civilian providers and law enforcement personnel throughout the state. </p>
<h2>Understanding the need</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/124385/original/image-20160528-903-9nb660.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The bond that soldiers share can help them stay mentally strong.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/nEKsHK">143d ESC/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Mental health issues are acute for a significant number of veterans.</p>
<p>As many as 25 percent experience <a href="http://www.ptsd.va.gov/public/PTSD-overview/reintegration/overview-mental-health-effects.asp">some form</a> of mental health concern, such as depression. The VA reports that veterans have <a href="http://www.publichealth.va.gov/epidemiology/studies/suicide-risk-death-risk-recent-veterans.asp#sthash.7gh2jBpy.dpuf">a higher risk of suicide</a> compared to the U.S. population. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMra012941">Post-traumatic stress disorder (PTSD)</a> is another well-known concern. Estimates of the prevalence of <a href="http://www.nejm.org/doi/full/10.1056/NEJMra012941">PTSD</a> vary widely due to the variety of study samples and assessment tools. A conservative measure suggests <a href="http://www.psychiatrist.com/jcp/article/Pages/2014/v75n12/v75n1214.aspx">PTSD affects eight percent</a> of service members returning from Afghanistan and Iraq. </p>
<p>Veteran peer support shows promise in addressing these common mental health issues. An example is the Vet to Vet program, a VA program developed by Moe Armstrong, a decorated Vietnam War veteran, in 2002. Research <a href="http://link.springer.com/article/10.1007/s10597-008-9146-7">has shown</a> that veterans who receive peer support have greater levels of empowerment and confidence, improved functioning and reduced alcohol use compared to those who didn’t receive peer support. </p>
<p>Researchers are increasingly understanding the value of incorporating veteran peers into health care teams. Given the large numbers of veterans returning from prolonged combat, the <a href="https://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf">documented shortage</a> of trained behavioral health providers to treat mental health problems, overly <a href="http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html?_r=0.">long wait times</a> for treatment and <a href="http://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2010.61.6.582">stigma felt</a> by veterans regarding seeking help, veteran peer support offers great promise in improving treatment outcomes.</p>
<p>While peer counseling is not new – it was formally recognized in the 1970s –
its value in treating veterans has gained recognition since President George W. Bush’s <a href="http://govinfo.library.unt.edu/mentalhealthcommission/reports/reports.htm">New Freedom Commission on Mental Health</a>, which was released in 2003. </p>
<p>President Barack Obama has also seen the value of peer support. His <a href="https://www.whitehouse.gov/the-press-office/2012/08/31/executive-order-improving-access-mental-health-services-veterans-service">Executive Order 13625</a> of 2012 sought to improve access to mental health services for veterans, service members and military families by including the hiring of peer specialists. As of 2015, the hiring of peer specialists <a href="http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2487">has exceeded</a> the goal set in the executive order. In 2015, President Obama renewed his support by calling for more peer support as part of the <a href="https://www.congress.gov/bill/114th-congress/house-bill/203">Clay Hunt Suicide Prevention for American Veterans Act</a>. </p>
<p>Research on the role of veteran peers has shown their positive impact in assisting homeless veterans to <a href="http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201200100">transition to housing</a>. </p>
<p>There is <a href="http://justiceforvets.org/veteran-mentors">early evidence</a> that veterans charged with misdemeanors and arraigned in Veteran Treatment Courts receive <a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/nejccc35&div=17&id=&page=">invaluable support</a> from veteran peers throughout their probation and treatment for mental health, substance use problems and receive help with housing, transportation and employment. </p>
<p>These are two among many other areas that veteran peers are providing effective supports.</p>
<h2>Getting civilians into the act</h2>
<p>The mental health care provided by civilians for veterans can also benefit from lessons learned from these veteran-driven programs. </p>
<p>Understanding the unique culture shared by military members and their families can be a daunting task for Americans who have not experienced the military lifestyle. Given the volunteer nature of our armed services and the historically small size of our current force, this culture is familiar to only a small proportion of American citizens. Instead of assuming this cultural gap cannot be breached, we are learning the powerful impact that civilian health care professionals can make when they become trained in military culture and practice military-informed care.</p>
<p>Research efforts are underway to understand how to best train practitioners to better understand the clinical impact of this <a href="http://www.jenonline.org/article/S0099-1767%2813%2900411-X/pdf">cultural competency</a>. Research can assess, for example, whether this knowledge can help improve veterans’ engagement in care, increase their treatment completion and improve their clinical outcomes. </p>
<p>The VA has hired <a href="http://www.vacareers.va.gov/peer-to-peer/faqs.asp">800 peers as of 2013</a> with 100 more planned annually. In addition to Texas, New York, Michigan and California, as well as Canada and the United Kingdom, have veteran peer support programs.</p>
<p>Although most of us can never truly understand what war is like, we can honor all veterans, including those who didn’t make it home, by valuing the special knowledge and connection that veterans bring to bear in therapeutic care settings. By prioritizing veterans’ experiences and knowledge, we can build a society that promotes real healing and a respectful homecoming.</p><img src="https://counter.theconversation.com/content/60092/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elisa Borah receives funding from the Patient Centered Outcome Research Institute. She is a Research Associate at the Texas Institute for Excellence in Mental Health at the University of Texas at Austin School of Social Work. </span></em></p>The culture all veterans share may provide the best support for those struggling with mental health issues.Elisa Borah, Research Associate, The University of Texas at AustinLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/496312015-11-11T10:46:36Z2015-11-11T10:46:36ZDoes psychotherapy research with trauma survivors underestimate the patient-therapist relationship?<p>When I first arrived at the Philadelphia VA Medical Center to practice psychology in 2001, my patients – mainly male Vietnam veterans – were leery. I had a PhD and could be viewed as an authority figure, a likely trigger for distress for those who felt mistreated by the military or the Department of Veterans Affairs.</p>
<p>When I suggested an intervention or put forward an interpretation of their behavior, they would bristle. Regardless, I used to say to them, “I’m planting seeds. Please don’t rake them out. I’ll water them over time.” </p>
<p>Week after week, year after year, I’d use psychotherapy techniques that had been shown to be effective in randomized trials to reduce post-traumatic stress disorder (PTSD) symptoms, increase effective coping and help people live more meaningful and healthy lives. My patients got better, for sure. And it might have been because of those interventions – some aspect of one or their combination. But that’s not what my patients remembered as being most effective, and that’s not what I remember either.</p>
<p>What they remembered more – what they gave the most credit to – was the time we spent together, the bond forged over years of therapy. This is called the therapeutic relationship. And while evidence suggests that it is a critical part of psychotherapy, the impact of the relationship often isn’t studied in clinical trials for trauma survivors with PTSD.</p>
<h1>The relationship can make a big difference for patients</h1>
<p>It’s telling that the relationship between patients and therapists is sometimes described as the “therapeutic alliance.” The alliance, often thought of as the quality of the partnership and the mutual collaboration between therapist and patient, is essentially our positive emotional bond.</p>
<p>And research suggests that the therapeutic alliance and empathy (the therapist’s ability and willingness to see from and communicate their patient’s point of view) are <a href="http://dx.doi.org/10.1037/a0022186">particularly effective</a> in contributing to positive <a href="http://dx.doi.org/10.1037/a0022187">change</a>.</p>
<p>For instance, a 2013 <a href="http://dx.doi.org/10.1037/a0036580">meta-analysis on the efficacy of therapy</a> for adult depression found that specific psychological techniques accounted for 17.1% of overall patient improvement, while relationship variables contributed 49.6%. That’s huge.</p>
<p>A <a href="http://www.nrepp.samhsa.gov/Norcross.aspx">series of meta-analyses</a> commissioned by the second American Psychological Association’s Task Force on Evidence-Based Therapy Relationships indicates that the effects of the therapy relationship on psychotherapy outcome are substantial – can make therapy <a href="https://global.oup.com/academic/product/psychotherapy-relationships-that-work-9780199737208?cc=us&lang=en&">more or less effective</a>.</p>
<p>Some prominent <a href="http://www.apa.org/pubs/books/4317149.aspx">trauma clinicians</a> have <a href="https://www.routledge.com/products/9780415763332">argued</a> that the therapeutic relationship is as important (or even more important) to helping trauma survivors improve as the therapy technique used. But most clinical researchers developing research-based interventions for trauma survivors with PTSD do not measure it as a variable in their psychotherapy trials.</p>
<h2>Why doesn’t the relationship factor into clinical research?</h2>
<p>When psychologists conduct research to find out how effective one type of psychotherapy is over another, we bring people into our academic laboratories and essentially flip a coin.</p>
<p>One individual goes into one type of psychotherapy and another goes into another type of psychotherapy and we compare the two to see if one type improved symptoms better than another. We sometimes include a measure of quality of life, such as increased time spent with loved ones. If the people in a particular therapy condition get better, we label that therapy as “efficacious.” </p>
<p>As a behavioral scientist, I understand the power of randomization and
believe in the gold standard of the controlled trial. But is it accurate? Is
it sufficient? Does it capture the art of psychotherapy?</p>
<p>There are a few reasons that the the therapeutic relationship isn’t evaluated in clinical trials for trauma survivors with PTSD. It may be because measuring the process of therapy and the changes that take place in the therapeutic relationship is harder than measuring the techniques. Or it could be that government funding priorities do not emphasize these “soft” variables and thus there are few dollars to support this type of research. </p>
<p>In addition, it seems that graduate training in psychology nowadays places much more emphasis on learning standardized protocols than on how to develop and maintain healthy relationships with our patients. And in the treatment of survivors of trauma, particularly trauma arising from betrayals from other human beings, the relational dynamics can be complex and perhaps difficult to teach. </p>
<h2>The power of the therapeutic relationship</h2>
<p>I spent four years working at the Philadelphia VA Medical Center, and when I left, my patients presented me with gifts. One was a plaque with all their names engraved on it and a message that said, “In appreciation for being our fearless leader and guiding us through life and leaving us a path to follow. We owe you our lives.” Before I could say a word, one veteran handed me a dozen red roses and said, “These are the seeds that you planted. Look how they’ve grown.”</p>
<p>I wept. I thanked them for their effort, honesty, vulnerability, courage and, of course, their service. And then I asked them what had helped them the most in our work together.</p>
<p>One by one they recounted stories – playful or touching moments. They didn’t attribute significant change to any of my clinical box of effective techniques, the experiential exercises, the homework assignments. Not one. Not once.</p>
<p>Some may say that my veterans didn’t accurately recall or attribute effectiveness to the techniques. Or that the techniques were what really mattered and that my patients’ relationship with me and our relationship with one another was only the vehicle to that delivery. But there is plenty of research that shows just how important that bond between patient and therapist is.</p>
<p>While psychotherapy is not solely about the relationship, it is those moments when we try to connect with our patients that make us bloom.</p><img src="https://counter.theconversation.com/content/49631/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Cook receives funding from the National Institute of Mental Health.</span></em></p>While evidence suggests that the therapeutic relationship is a critical part of psychotherapy, the impact of the relationship often isn’t studied in clinical trials for trauma survivors with PTSD.Joan M. Cook, Associate Professor of Psychiatry, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447342015-07-16T20:15:49Z2015-07-16T20:15:49ZThe people problem in government<figure><img src="https://images.theconversation.com/files/88673/original/image-20150716-5067-13m29xd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">But one-quarter of federal executives say they want to leave...</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/publicservice/4604822026/">Joshua Cogan, Partnership for Public Service</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The federal government has a people problem. </p>
<p>Any large organization is only as good as its people, and every week it seems there is another government failure in the news. The most recent is the <a href="http://www.nytimes.com/2015/07/10/us/office-of-personnel-management-hackers-got-data-of-millions.html">hacking</a> (assumed to be Chinese) of the Office of Personnel Management’s (OPM) sensitive personnel records. Before that it was the Department of Veterans Affairs <a href="http://www.huffingtonpost.com/2015/07/13/veterans-health-care-backlog-died_n_7785920.html">health care debacle</a> and the <a href="http://www.reuters.com/article/2013/11/22/us-usa-healthcare-website-idUSBRE9AL03K20131122">Obamacare website</a>. </p>
<p>Today, July 16, my <a href="http://www.vanderbilt.edu/csdi/">Survey on the Future of Government Service </a>(conducted with Vanderbilt Researcher Mark Richardson) was released at the National Press Club, and it helps explain why. </p>
<p>Vanderbilt University’s <a href="http://www.vanderbilt.edu/csdi/">Center for the Study of Democratic Institutions</a>, in cooperation with Princeton University and the nonprofit Volcker Alliance, surveyed 3,551 federal executives across more than 200 federal agencies about the skill of their workforces and the workforces of other agencies with which they work. </p>
<p>The findings are illuminating.</p>
<h2>Problems with recruitment and retention</h2>
<p>Survey results show clearly that the federal workforce is under stress. </p>
<p>Thirty-nine percent of executives report that the skill of their workforce is a significant obstacle to their agency fulfilling its core mission. </p>
<p>Executives identified a number of issues related to recruitment, retention, promotion and dismissal as sources of workforce problems. Indeed, any organization that wants to thrive needs to bring in good people, train and promote them, and then keep them. They also need to deal with underperformers.</p>
<p>Concerns about federal recruitment are well-known.</p>
<p>One of our survey respondents called the USAjobs website “a nightmare” and OPM <a href="http://www.washingtonpost.com/politics/millennials-exit-the-federal-workforce-as-government-jobs-lose-their-allure/2014/12/15/ea3d4418-7fd4-11e4-9f38-95a187e4c1f7_story.html">is well aware</a> of their own difficulties bringing millennials into government. </p>
<p>Forty-two percent of executives agreed with the statement, “My agency is unable to recruit the best employees” (compared to 37% who disagreed).</p>
<p>And it is not just young people who lack enthusiasm: just 55% of eligible career executives want to join the federal government’s leadership corps as a member of the Senior Executive Service or as a senior professional. </p>
<p>If the federal government cannot hire either nonmanagers or managers, it cannot perform.</p>
<p>It turns out that agencies that have difficulty recruiting also have difficulty keeping their best employees.</p>
<p>One-third of executives indicate that they cannot keep their best employees. </p>
<p>Twenty-four percent of the career executives we surveyed and 36% of politically appointed executives expressed intent to leave within one calendar year, either to retirement or to another job. </p>
<p>To fully grasp this finding, consider for a moment whether you would invest in Apple Inc if you knew one-quarter of their top executives were leaving in the next year. How might this influence the development of new and innovative products? The departure rate of federal executives is more than twice the <a href="http://www.strategyand.pwc.com/global/home/what-we-think/chief-executive-study">rate of private sector CEOs.</a> according to a study by the consulting firm Strategy&. </p>
<h2>Promoting and firing difficult too</h2>
<p>When asked whether promotions were based upon performance and ability or other factors like tenure or personal connections, the most common response from federal managers was “partly performance and ability and partly other factors.” </p>
<p>In some agencies, performance and ability seem to dominate, but in others, it is apparently tenure and connections that matter most. </p>
<p>Federal executives were also asked when an underperforming nonmanager or manager was reassigned or removed: within six months, after six months, or rarely or never. </p>
<p>Seventy percent of executives reported that underperforming nonmanagers were “rarely or never” reassigned or dismissed. When the US Census Bureau <a href="http://www.census.gov/mcd/mops/">asked private sector executives </a>the same question, the overwhelming majority said either within six months or after six months. </p>
<h2>An outdated system</h2>
<p>So, why is there a people problem? </p>
<p>Vice President Al Gore <a href="http://govinfo.library.unt.edu/npr/library/speeches/2762.html">notably said</a> that the federal government has “good people […] trapped in a bad system.” </p>
<p>The problem is that the United States has a personnel system that has its roots in the 19th century. It was created in an effort to prevent the abuses of the <a href="http://press.princeton.edu/titles/8663.html">spoils system</a>, the old personnel structure in which jobs were given out in exchange for work for a given political party. It never lost this cop-like mentality. It is <a href="https://books.google.com/books/about/History_of_the_United_States_Civil_Servi.html?id=q_kLAQAAIAAJ--">a structure</a> designed to stop abuses rather than empower federal agencies to fulfill democratically given responsibilities. </p>
<p>A bad system not only traps good people, it prevents government from getting (and keeping) good people. If it persists, all of the good people will leave or not come at all. </p>
<p>How, then, do we solve the people problem? </p>
<p>We upgrade to a system that reflects the best practices from other large public and private sector organizations. </p>
<p>Existing models such as that proposed recently by the nonprofit <a href="http://ourpublicservice.org/">Partnership for Public Service</a> are a good place to start. </p>
<p><a href="http://ourpublicservice.org/publications/viewcontentdetails.php?id=18">Their model</a> emphasizes measures to simplify the process of hiring, promoting and keeping the best employees. It also focuses on a shift toward people rather than programs and designing a more flexible compensation system that is occupation-specific and market-sensitive. Their proposal describes ways to create career paths and mobility and pay high-performing employees for performance. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/88678/original/image-20150716-5099-xw99z2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Claims waiting to be processed at the US Department of Veteran Affairs.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Veteran_Affairs_backlog_(2012-08-09).jpg">US Department of Veterans Affairs</a></span>
</figcaption>
</figure>
<p>It is with such changes that we can give our federal government a workforce equal to the challenges of protecting the sensitive data of federal employees and providing world-class health care to those who have served in our armed forces. </p>
<p>Both branches could begin working on such a system now. </p>
<p>In the short run, elected officials can facilitate the sharing of best practices among high- and low-performing federal agencies, direct these agencies to begin implementing proactive recruiting strategies (many do not have them) and help their executives (especially those that are political appointees) know what legal authority they have already to bring in the best people, reward high flyers, and remove or reassign underperformers.</p>
<p>In the longer term, <a href="http://www.govexec.com/magazine/magazine-analysis/2015/01/ripe-time-civil-service-reform/103347/">politicians on both ends of Pennsylvania Avenue</a> could and should begin discussions about serious civil service reform.</p>
<p>Republicans and Democrats disagree about what government should do or how big it should be but there is <a href="http://www.washingtontimes.com/news/2015/apr/8/terrence-scanlon-republicans-democrats-should-join/">surprising agreement</a> among many that what government does it should do well and that change is necessary. </p>
<p>This may be one area in which government can do something big together.</p><img src="https://counter.theconversation.com/content/44734/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David E Lewis receives funding from the National Science Foundation and the Smith Richardson Foundation.</span></em></p>Twenty-four percent of federal agency executives want to leave their jobs. A new survey reveals a federal workforce under severe stress.David E. Lewis, William R Kenan, Jr Professor and Chair of the Department of Political Science. He is co-director of the Center for the Study of Democratic Institutions. , Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.