Who'd have thought that a couple decades of war would cause the VA health system's costs to explode? Unfathomable and unpredictable. No way anyone could've seen that coming.
The chief two problems are (1) there isn't any more money and (2) the root of the issue isn't money.
So the solution will need to involve ... not spending (a lot) more money. Maybe there are some shell games to spend money more wisely. Sure. Whatever.
But the obvious answer is to shift to a medical corps that is primarily reserve. This won't happen because the decisions will be made under the advice and influence of senior active duty people who'd rather put their fingers in a blender than admit any piece of the active duty force can or should be reduced.
There is plenty of demand for physicians in the civilian sector. It's insane that we are watching our active duty physicians, particularly those in surgical specialties, just ROT at military hospitals, and the best "solution" leaders come up with is the same handwaving bull**** about simulators and online CME and powerpoints highlighting "knowledge skills and abilities" and "civilian partnerships" and "resource sharing agreements" and "hey let's let some trauma in the gate" ... meanwhile we continue to defer care of sick and old people from MTFs to the surrounding civilian infrastructure that frequently struggles to carry the extra load.
I'm a 2002 USUHS grad and spent the next 20 years on active duty until retiring in 2022, deployed multiple times to Afghanistan and Iraq and other places. My busiest deployment was to the Role 3 in Kandahar when we typically saw multiple combat casualties per day. As an anesthesiologist I worked side by side with other US active and reserve and non-US/coalition anesthesiologists and other physicians ... and as great as my USUHS education was, I can't point to a SINGLE thing that I was able to do better than any of the others because I took some military studies classes as a MS1 and MS2, or because my practice in previous years was at a CONUS MTF. The Australians with us came from their country's reserve and their normal practice was at normal civilian hospitals in their home country. They were excellent. The most experienced US anesthesiologist with us was a reservist from the Univ of Florida.
The active duty MTFs don't need more
funding. They need to be folded into the VA system and mostly staffed by civilians +/- reservists, and 90% of the active duty physicians either
permanently stationed at civilian institutions or gradually shuffled into the reserves. So many of our residency programs are becoming mediocre or actually dying on the vine because of terrible case load - we can't
spend our way back to excellence there even if there was money to throw around, which there isn't.
I spent the last 20 years watching the handwringing and helplessness of medical corps leadership as they failed to see (or care about?) this slow motion caseload and skillrot trainwreck developing and at best gave lip service to non-solutions. When I returned from FTOS fellowship and my MTF abruptly closed my new subspecialty line of care, I was the one who had to spend months hammering out a MOU with the VA to permit me to go work with them to scratch out a miniscule case load, and ultimately the only solution was for me to spend 90% of my leave for the next FIVE YEARS moonlighting simply to bite scratch and claw cases numbers to maintain the minimum load recommended by my board certifying authority.
It would take more than money to fix these fundamental problems with strategy, leadership, and force structure. Their first step needs to be admitting that they have a problem and that the proposed solutions of the last two decades aren't working and won't work.
That article you linked made a big deal about having a surgeon on a helicopter to put in a chest tube (or maybe it really was a field thoracotomy & pinky finger in a ventricle and not just journalistic embellishment), and I'm certainly glad that Ranger is alive and well today. But there's an important and clearheaded conversation that we should be having about the wisdom of having that sort of medical asset in the first place, i.e. if the cost and risk is really worth the once-in-a-decade edge case made-for-TV save like that. And of course ... completely unmentioned is the question of where that surgeon trained and practiced when he wasn't riding around in helicopters, and if future helicopter-surgeons (if they should exist at all!) should be twiddling their thumbs on active duty at Premier CONUS Army MTF or cranking out case after case as a reservist at Ordinary Civilian Hospital.
Funding isn't the problem.
