But at least a dozen Defense Department and Department of Veterans Affairs programs have sprung up to coordinate the care.
The proliferation of programs and case managers, intended to better manage health care, “may actually have the opposite effect,” Debra Draper, health-care director for the Government Accountability Office, told a congressional committee last month.
A Rand Corp. study released last week found more than 200 programs sponsored or funded by the Defense Department to help troops with psychological health and traumatic brain injury, leading to significant duplication within and across branches of service.
The bureaucratic problems for the severely wounded can range from additional paperwork to conflicting guidance.
In one situation, five case managers were working on the same life insurance problem for one person, according to a GAO report.
In another, one service member with multiple amputations was advised by his federal coordinator to retire in order to get VA services, but a military coordinator set a goal for him to remain on active duty, greatly confusing the family.
A ‘safety net’
Pentagon officials defend the programs, saying the redundancies ensure that recovering troops get help.
“This is an intentional safety net to make sure these people do not fall through the cracks,” said Philip Burdette, director of wounded-warrior care for the Defense Department.
Burdette said that when he visits hospitals, he often asks troops and their families how many business cards they have collected from program representatives. “Frequently, the number is in the dozens,” he said.
Abbie Holland Schmit, a manager with the Wounded Warrior Project, a nonprofit group that assists injured service members and veterans, said, “I’ve heard people say I need a case manager to manage my case managers — that’s a true statement.”
Retired Army Sgt. Ted Wade advocates for reform of the reform.
Wade lost his right arm and suffered traumatic brain injury in a roadside bombing while serving with the 82nd Airborne in Iraq seven years ago. In 2007, he appeared before the commission with his wife, Sarah, asking that the system be simplified.
“We were drinking from a fire hose,” Sarah Wade recalled.
Now, they say, multiple new programs with overlapping jurisdiction have further confused the situation.
“Things are no more clear to me today than they were back then,” she said. The Wades have at least six case managers. Other families have eight or more.
“It really is crazy for someone to have eight,” Draper said in an interview. “To have 25, that’s a little bit disturbing.”
After a Washington Post series in 2007 documented how recovering soldiers and their families at Walter Reed were trapped in a bureaucratic maze, President George W. Bush appointed a commission co-chaired by former senator Robert J. Dole and Donna Shalala, former secretary of health and human services, to investigate military health care.
After the panel issued its report in July 2007, VA and the Defense Department agreed to establish a cadre of federal recovery coordinators to serve as the individuals responsible for monitoring the severely wounded throughout their hospital treatment, rehabilitation and lives as veterans.
The Dole-Shalala commission urged that the federal program not be placed under the sole control of either VA or Defense, warning that it would jeopardize the joint mission. But the new program was placed under the administrative control of VA and made all federal recovery coordinators VA employees.
From the start, Pentagon officials viewed the federal recovery program as a VA operation geared for veterans rather than active members of the military. They soon set up a separate Defense Department Recovery Coordination Program, which Burdette calls “the logical expansion” of the federal program.
The office now oversees numerous programs administered separately by the services, including the Army Wounded Warrior Program, the Marine Corps Wounded Warrior Regiment, Navy Safe Harbor, Air Force Warrior and Survivor Care Program, Special Operations Command’s Care Coalition, and the Army Reserve Wounded Warrior Component.
“The structures that have evolved are not the structures that Dole-Shalala envisioned — they are exactly what they tried to avoid,” said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans’ Affairs.
Defense officials say the wounded-warrior programs are needed to help service members who have less-severe injuries and to assist with nonmedical care.
But as the military wounded-warrior programs also assist the most severely wounded, many in the Pentagon saw the federal program as unnecessary.
Federal coordinators have been very helpful to families when assigned to a service member early in recovery, advocates said. But without full support from the Defense Department, the federal coordinators often lack authority.
“What I had hoped would happen was they would be the bureaucracy batterers,” Sarah Wade said.
Those with the military wounded-warrior programs have said that because federal recovery coordinators are not in the military chain of command, they should work only with veterans. That means some seriously wounded service members are not referred to the federal program until they leave the military. Advocates say this short-circuits the goal to have federal coordinators involved at the start, build trust and stay with the case throughout.
“People seem like they get possessive over the warriors,” said Schmit, an Iraq veteran who worked for the Army’s wounded-warrior program. “I know they’re meaning well, but it doesn’t help the warrior out at the end of the day.”
No database lists all the severely wounded, leaving no assurance that all are reaching the federal program.
Burdette said that assigning active-duty troops to a VA-run program could send the wrong message “that they’re not going back to their unit.”
Nonetheless, in June, Burdette directed the military wounded-warrior commanders to refer all severely wounded who could benefit to the federal program.
The federal program has seen no change in referrals, according to Carol Weese, acting executive director of the Federal Recovery Coordination Program. “We have found some cases where we could have done more earlier if we’d known,” she said.
When Ted Wade visited doctors at the new Walter Reed National Military Medical Center in Bethesda last week because of tremors in his amputated shoulder, his federal coordinator was not involved. The military health-care providers do not routinely contact the coordinator, and the Wades have not spoken to her since May.
“This was going to be the person who would come in and challenge them and make sure things got done,” Sarah Wade said. “It needed to be someone who could work in multiple agencies and be there for the continuum of care.”
Former Army Sgt. Loyd Sawyer, who threatened suicide upon his return from Iraq in 2007, has tried since August to get an adapter for a sleep apnea machine. After waiting two months for an appointment at a sleep center and six more weeks for approval from the VA medical center in Richmond, he still doesn’t have the adapter. “He’s not sleeping, so his mental condition is spiraling down again,” said his wife, Andrea Sawyer.
She said that her husband’s federal coordinator often receives little cooperation from the VA medical bureaucracy. “It’s frustrating for us when she gets the phone slammed down on her,” Sawyer said. “It requires a lot more trouble than it should.”
Said VA spokesman Josh Taylor: “Families like the Sawyers have earned the best care VA can offer, and we are committed to providing it.”
Federal recovery coordinators often rely on space provided by the military services at hospitals. According to a GAO report in March, about half of the coordinators said there was a lack of information technology support from the Defense Department. One waited more than six weeks for a telephone and a computer.
Lawmakers are frustrated. “After four years, you begin to wonder if it’s possible that it will take place,” said Rep. Ann Marie Buerkle (R-N.Y.), chairman of the House Veterans Affairs subcommittee on health, which has held two hearings on the issue this year.
In May, Buerkle’s panel requested a report on how the programs could be integrated. But the Defense Department and VA were at such odds that they did not reply until September. The letter, signed by senior VA and Pentagon officials, said that “while we concur in principle that the establishment of a single recovery coordination program may be the preferred course of action,” there was no agreement on how to do it.
“Both departments are taking a hard look at it,” Burdette said.
“In some instances, bureaucracies are more powerful than Congress, and if it takes more teeth in the law, I’m willing to do that,” said Miller, chairman of the House Committee on Veterans’ Affairs. “We are finding it next to impossible to tear down the walls of bureaucracy between DoD and VA.”