Written by West Huddleston, All Points North Board of Advisors
The vast majority of Active-Duty Military personnel are significantly strengthened by their service in times of peace and war. These brave men and women, our sons and daughters, who volunteer to uphold an oath to the Constitution and serve in the defense and protection of our freedom and liberty, make up less than one percent of the population.
Even for the strong, it’s no secret that the transition back to civilian life can be fraught with challenges. In fact, more than 18% of all Veterans say they experience high levels of difficulty when transitioning. Amongst combat Veterans, more than 45% describe a difficult transition to civilian life.¹ How could they not? After service, Veterans describe a sense of loss of the camaraderie, honor, duty, and service that inspired them for years or even decades.
Veterans, with such extensive service experience, now living as our neighbors, are among this nation’s greatest assets. They are highly trained and adaptable problem-solvers who have been hard-tested in various situations, jobs, and cultures.
Tragically, too many Veterans lose hope on this side of the uniform. The transition to civilian life proves too difficult without proper support and quality care; the loss of a sense of identity, lack of connection, and too little meaningful employment can be a weight that proves crushing. They too often die by suicide, the second leading cause of death in Veterans under age 45.
Shockingly, we as a nation are now in our 20th consecutive year with 6,000 or more Veteran suicides per year. Suicide is the 2nd leading cause of death in Veterans under age 45.
The US Department of Veterans Affairs (VA), which employs nearly 280,000 highly dedicated and committed people at approximately 1,075 VA medical facilities, clinics, and benefits offices across America, is deeply committed to ending Veteran suicide. But there is a strong indication that an outdated ethos remains within the VA – that Veterans can find the best treatment within the VA Healthcare System, with little to no help from private or community care providers. Given the enormity of the Veteran suicide crisis, the VA’s referral resistance to powerful and effective care from community care providers must be put aside.
Congress recently passed two significant new laws in response to this growing crisis. The MISSION Act of 2018 directs the VA to utilize community care providers for eligible Veterans who need better access to health care and mental health services. The COMPACT Act of 2020 allows Veterans in suicidal crises to utilize any facility, VA or community, for free emergency healthcare.
Though well-intentioned, the implementation of the MISSION Act of 2018 has been deeply frustrating for many Veterans seeking quicker access to the health care and behavioral health care they have earned. Long wait times and delays in scheduling appointments persist, and community care providers across the country report lagging referrals and denials by the VA for indicated in-network Veteran treatment services.
On January 13, 2023, the VA announced the COMPACT Act of 2020. With unprecedented access to VA and community care for any Veteran in acute suicidal crisis, this act holds great promise and hope for a radical shift in how Veterans access and receive critical emergency and long-term treatment, in and out of the VA.
According to the VA’s latest National Veteran Suicide Prevention Annual Report, Veteran suicide rates dropped by an immensely celebrated 7.2% between 2018 and 2019, and 9.7% from 2018 to 2020.² We rightfully rejoice for every percent in that decrease. However, despite the encouraging downward trend in Veteran suicide, the epidemic of Veteran suicide remains a significant and unsolved problem. In some areas of the country, it remains historically high.
According to the VA, 6,146 Veterans took their own life last year. That’s about 17 Veteran suicides every day, more than twice the suicide rate for civilian Americans. But even this statistic is estimated by some to be quite low. In a joint study with the University of Alabama and Duke University titled Operation Deep Dive, the highly respected America’s Warrior Partnership (AWP) found that the suicide rate among veterans could be 37% higher among former service members (FSM) than reported by the VA between 2014 and 2018.³ The report indicates that if drug overdoses and other “self-injury deaths” were counted in the national suicide rate among Veteran mortality data (rather than as accidental deaths), the number of Veteran suicides would rise to 44 Veterans a day.⁴ The VA has expressed concerns regarding the AWP reporting methods, but the potential remains.
Whether by suicide or drug overdoses, these are all preventable deaths.
Known Drivers of Veteran Suicide
Numerous studies have uncovered the primary factors that increase the risk of suicide among Veterans. They include:
- Mental health disorders and other mental health conditions (e.g., post-traumatic stress disorder (PTSD), anxiety disorders, manic-depressive disorders, and depression)
- Traumatic Brain Injury (TBI)
- Substance Use/Misuse Disorders (e.g., opiates, benzodiazepines, alcohol)
- Social determinants of health (e.g., violence, housing instability, financial or employment problems, legal problems, familial or social problems, lack of access to health care and transportation, and nonspecific psychosocial needs)⁵
Data analyzed on more than 4.8 million Veterans found that Veterans with substance use disorders had twice the risk of suicide compared to those without a substance use disorder.
According to the RAND Center for Military Health Policy Research, 20 percent of Veterans who served in Iraq or Afghanistan suffer from either major depression or PTSD. Nineteen and a half percent of Veterans in these two categories have also experienced a traumatic brain injury. These three service-related disorders alone have an enormous impact on the need for Veteran mental health treatment.⁶
Active-Duty Suicide Rates are an Alarming Indicator of What’s to Come
In contrast to the VA-reported decline in Veteran suicide between 2018 and 2020, the suicide rate among active-duty military members has increased over the past five years at an alarmingly steady pace, reaching an all-time high since record-keeping began after 9/11.⁷
By 2021, 30,177 active-duty personnel and Veterans who served in the military after 9/11 have died by suicide – compared to the 7,057 service members killed in combat in those same 20 years.
The latest Department of Defense Annual Report shows the suicide rate among active-duty service members increased by 9.1% in 2020 alone⁸, following a 15.3% increase from 2018 to 2020.8 Tragically, military suicide rates are four times higher than deaths from military operations. Let that sink in: active-duty military are four times more likely to die from suicide than from combat. Additionally, the Department of Defense reports that the suicide rate among Reserve members increased by 19.2% in 2020, and the suicide rate among National Guard members increased by 31.7% during that same year.⁹
This trend is devastating and an alarming indicator of what the VA may face in the coming years as active-duty military members enter civilian life.
Can the VA Solve Veteran Suicide Alone?
According to the VA, “preventing suicide among all Veterans is a top priority — including among those who do not, and may never, seek care within our system. We are working to reach Veterans where they live, work, and thrive.”¹⁰
There is no question that it will take an all-hands-on-deck approach to end Veteran suicide. High-quality, community care providers must be critical partners and resources for Veterans suffering with any of the primary factors that increase the risk of suicide. To provide the treatment Veterans need and deserve, the VA can’t do it alone.
Congressional Action Supports Better Access to Community Care
1. VA Maintaining Systems and Strengthening Integrated Outside Networks Act or the VA MISSION Act of 2018
Under the MISSION Act of 2018,¹¹ Veterans can see a community care provider if they’ve been waiting for more than 20 days for primary and mental health care and 28 days for specialty care, or if they face more than 30-minute drive to the nearest VA facility.¹¹ A Veteran can also access community care providers if the Veteran and referring clinician agree it is in their best medical interest, based on defined factors.
Congress and the VA designed those standards for the department’s own care with the intent that Veterans could receive care more quickly in the community. Community care under the 2018 MISSION Act should be a seamless alternative for Veterans who can’t quickly or easily access care at a VA facility. Unfortunately, there are significant obstacles to overcome in order to ensure Veterans can access community care providers when needed.
Delays in Community Care Services
According to VA internal data from October 2019 through June 2020, Veterans waited an average of 41.9 days for an appointment, starting from the time he or she requested the appointment to the time the meeting occurred.¹²
In some cases, delays to community care are being driven by VA schedulers that make an appointment, cancel the appointment, then reschedule the appointment to a later date. Canceling appointments resets, and therefore extends the wait-time clock for Veterans to access Community Care.
On July 24, 2019, Debra Draper, Director of Health Care at the United States Government Accountability Office (GAO), testified before the House Committee on Veterans’ Affairs, that when considering all factors, Veterans are potentially waiting up to 70 days for an appointment.¹³
In its January 2023 Report to Congressional Committees, the GAO stated that the VA “has faced longstanding challenges with scheduling facility and community care appointments as well as ensuring Veterans’ timely access to care.” And, although the VA has taken steps to improve, the department “faces continued challenges in developing an appointment scheduling process that will provide Veterans with timely access to care.”¹⁴
Records from the North Florida and South Georgia VA show that between January 2020 and May 2021, 682,739 appointments were canceled. About 63 percent of those lacked evidence that the Veteran had given permission for the cancelation.¹⁵ During that same time period in Montana, 93,000 appointments were canceled with no indication of rescheduling.
It’s devastating to know that Veterans in the United States, who are seeking treatment during crisis, could wait 70 days or more to receive care.
The VA’s Own Guidance Has Dissuaded Veterans from Community Care Options
The Americans for Prosperity Foundation (AFPF) has reported extensively on documents obtained through the Freedom of Information Act about the VA’s willingness and efficiency in approving Veterans for community care. According to the AFPF, the VA regularly fails to refer, while delaying and denying eligible Veterans for community care under the MISSION Act and its own regulatory requirements.¹⁶
According to AFPF, the VA Veterans Health Administration’s own Referral Coordination Initiative Implementation Guidebook (Updated: October 28, 2021) describes the VA’s strategy to reduce utilization of community care because of “more Veterans being referred to the community than expected.”¹⁷
The VA’s solution to the higher-than-expected access to community care among Veterans was to shift the responsibility of referring to community care from health care providers to “dedicated clinical and administrative staff” who the VA calls “Referral Coordination Teams.” This additional process of decision-making was implemented in part because “Veteran feedback suggests many Veterans prefer to receive internal/direct VA care.”¹⁸
Every day, an estimated 17.2 Veterans die from suicide. Of those, an estimated 6.8 receive VA health care. Simply put, most Veterans who die from suicide don’t seek VA health care.
The AFPF also uncovered a VA training document that creates an additional layer of review for a Veteran already eligible for community care. It states, “After eligibility has been confirmed, clinical review is performed to determine if the requested services are clinically appropriate to be authorized for delivery in the community.” This extra step is not required in the MISSION Act or implementing regulations, but it could lead to longer wait times or denial of community care.¹⁶
Sadly, some may think that these VA cost-saving measures are justified. However, in the face of a two-decades-long suicide crisis among our Veterans, it’s nothing short of inhumane, not to mention, unlawful.
2. Veterans Comprehensive Prevention, Access to Care, and Treatment Act of 2020 or the Veterans COMPACT Act of 2020
The Veterans COMPACT Act of 2020 was announced by the VA on January 13, 2023. The VA News Release states that Veterans in acute suicidal crisis will be able to go to any VA or non-VA health care facility for emergency health care at no cost – including inpatient or crisis residential care for up to 30 days and outpatient for up to 90 days. “This expansion of care will help prevent Veteran suicide by guaranteeing no cost, world-class care to Veterans in times of crisis. It will also increase access to acute suicide care for up to 9 million Veterans who are not currently enrolled in VA.”¹⁹
“Veterans in suicidal crisis can now receive the free, world-class emergency health care they deserve – no matter where they need it, when they need it, or whether they’re enrolled in VA care,” announced VA Secretary for Veterans Affairs Denis McDonough. “This expansion of care will save Veterans’ lives, and there’s nothing more important than that.”²⁰
Forty percent of surveyed Veterans with anxiety had at least one risk factor for suicide. Suicide risk was more common in Veterans who also screened positive for depression than in those who had anxiety alone.
The final rule, which took effect on January 17, 2023, allows the VA to provide, pay for, and reimburse eligible individuals at VA medical facilities and non-VA facilities for treatment of emergency suicide care, transportation costs, and follow-up care for up to 30 days of inpatient care and 90 days of outpatient care.
The COMPACT Act of 2020, the MISSION Act of 2018, and its predecessor, the Veterans Choice and Accountability Act of 2014, all signal Congress’ intent to increase the availability of timely, high-quality care, outside of the VA health care system.
In-Network Community Care Providers Are At-The-Ready
We know that approved, in-network TriWest and Optum Serve community care providers have immediate capacity, experience, and resources to reduce Veteran suicide. These in-network providers have demonstrated their suitability through local, state, and federal regulatory approvals as well as their approval by TriWest and Optum. Further, the service offerings of some approved in-network providers advance the VA Secretary’s stated goal by not only treating Veterans in acute suicidal crises, but also by treating the primary factors that increase the risk of suicide among Veterans.
Since 2010, more than 65,000 veterans have died by suicide – more than the total number of deaths from combat during the Vietnam War and the operations in Iraq and Afghanistan combined.
Congress and VA Health Care executive leaders are clearly committed to leveraging the incredible resource of community care providers. Changing the culture of resistance within the VA ranks remains the largest and most time-sensitive challenge they face. A hand-in-hand partnership with its in-network providers is something Congress has encouraged, authorized, and advocated through multiple statutory and budget approvals. After nearly a decade of efforts, the tools are in place for Veterans and the leadership of the VA to engage community care providers as teammates in care. Many community care providers have immediate capacity and, in some cases, far greater and demonstrably more effective service offerings for Veterans facing suicide and contributing or co-occurring risks such as substance use and other behavioral health conditions, sexual and combat trauma, and physical injury.
Not All Community Care Providers are Equal: All Points North Lodge (APN)
All Points North (APN) has been an approved substance misuse disorder and behavioral health treatment provider for Veterans with TriWest since January 2022. With 77+ residential beds, and another 100 coming in 2023, APN Lodge – the company’s main campus in Edwards, Colorado – provides proven talk and experiential PTSD treatment modalities, as well as extensive group therapy, individual therapy, and medically assisted treatment for substance use disorders, anxiety, and depression. A designated curriculum and Veterans’ track creates a safe container for Veterans to move through their current struggles and past traumas.
Additionally, APN offers world-class concussion/TBI treatment through their Plus by APN brand – utilizing innovative technologies, such as Hyperbaric Oxygen Therapy and Deep Transcranial Magnetic Stimulation (dTMS), in conjunction with traditional modalities. To further support clients, APN also has walk-in detox and behavioral health assessment and stabilization facilities in Colorado, California with more facilities opening soon in Texas, Florida, and London. APN also offers remote intensive outpatient programming and outpatient therapy through its virtual platform. With an extensive and effective offering of services, APN is uniquely situated to be a life-saving VA partner for Veterans in need.
While the national suicide rate among U.S. Veterans declined in 2019, Veterans living in Colorado committed suicide at the same rate in 2019 than in 2018; when Colorado Veteran suicide reached record numbers. More than one former service member dies by suicide every week in Colorado.
Even under the MISSION Act of 2018, and despite being the only community care provider of its kind on the Western Slope of Colorado for Veterans, APN has experienced the same shortage of VA referrals and approvals that have been reported by in-network community care providers in other regions of the country. The vast majority of Veterans APN has served to date have been in serious crisis and have sought help on their own, outside of the VA.
Usually, such cases have been denied for residential care by the VA for one of two reasons. In some cases, the VA clinical team does not agree with APN’s clinically recommended level of care. In other cases the VA will not refer if the Veteran has not seen their VA Primary Care Physician in the past twelve months; an especially nonsensical hurdle in the face of the current Veteran suicide epidemic.
Rather than turn them away, APN has consistently admitted and treated any Veteran at risk of suicide or overdose and provided anywhere from thirty to sixty days of intensive, residential care, free of charge. Currently, APN Lodge is treating seven combat Veterans in its residential facility, with diagnoses ranging from severe PTSD and opioid dependence to anxiety and depressive disorders. Less than half of the seven at APN have currently been approved by the VA for community care under the MISSION Act.
But there is good news. Since the January 2023 announcement of the COMPACT Act of 2020, community care referrals and approvals have increased sharply. The VA, at least in Colorado, has developed a streamlined approach to get Veterans with suicidal ideation rapid authorization for community residential care. This is a hopeful sign that the VA is beginning to lean on its high-quality community care providers for the sake of critical treatment for Veterans.
Call to Action
Receiving referrals from the VA and obtaining VA approval for clinically assessed and indicated services for a Veteran who self-refers for community care under the MISSION Act remains a serious challenge for top-tier, in-network, community care facilities (like APN) throughout the nation. This resistance to community care within the VA ranks must be immediately overcome in order to truly address the Veteran suicide crisis and the underlying factors that drive Veteran suicide in America.
On January 13, 2023, the VA announced an interim rule that Veterans in suicidal crisis can go to any VA or non-VA health care facility for free emergency health care under the COMPACT Act. On the paper of a press release, this announcement represents a new and significant opportunity to break down historic barriers to rapidly treating Veterans with emergent suicidal ideation at community care facilities. However, many community care providers have not yet received guidance from the VA on how this new law will work in terms of self-referral and VA-referral, a formal VA definition of “suicidal crisis,” the who and how of assessment and approval for appropriate level of care, reimbursement for transportation, residential care, out-patient counseling, and medicine, as well as a host of administrative issues that are involved. Policy and decision makers should immediately request that the VA provide detailed guidance to community care providers eligible to treat Veterans under the COMPACT Act and accompanying rule.
As private community care providers begin to answer the call of Veterans under the COMPACT Act, significant effort should be made to document any challenges in implementation so that effective oversight, and accompanying changes can be made to the Interim Rule, should they be needed.
Additionally, as some VA personnel have resisted referring Veterans to community care under the MISSION Act, even when the law requires a referral due to long wait-times and/or lack of accessibility and/or availability of care, Congress, the GAO, and the VA, must better work together to ensure referrals are made rapidly and efficiently.
In-so-doing, Congress, federal and state agencies, decision makers, and stakeholders should ensure that all eligible Veterans who self-refer to community care, under the MISSION Act, are quickly assessed, and the indicated level-of-care promptly approved, without the requirement that a Veteran must see their Primary Care Physician first.
Finally, without a long-term Appropriation for the COMPACT Act, funding for emergent Veteran suicide treatment is likely to fall back on the VA’s existing budget next year. Therefore, Congress should fully fund the COMPACT Act in FY 2024 and in subsequent years going forward.
About the Author
West Huddleston has been advocating for and helping Veterans who have substance misuse and/or behavioral health treatment needs for 30 years. As the former CEO of the Washington, DC-based National Association of Drug Court Professionals (NADCP) and founder and Executive Director of Justice For Vets, he led the only national organization dedicated to transforming the way the justice system identifies, assesses, and treats justice-involved Veterans.
During his eighteen years of service and executive management at NADCP and Justice For Vets, Mr. Huddleston authored 21 publications; testified numerous times before Congress, state legislatures, and international parliaments; and was interviewed repeatedly by radio, television and print media appearing on NPR, CNN, CSPAN, and in the Washington Post, Wall Street Journal, New York Times, and USA Today, to name a few. Due in part to his effort, there are now over 700 Veterans Treatment Courts across the United States, significant federal and state funding, as well as engagement by the VA, national and state Veteran Service Organizations, and a vast network of volunteer Veteran Mentors. West is on the Advisory Boards of the Harvard Medical School CHA Division on Addiction and All Points North (APN). He is the former Vice Chairman of the Board of The Independence Fund, granting mobility to our nation’s catastrophically wounded combat Veterans and the proud dad of an active-duty son in the United States Air Force.
- Parker, Kim, et al. The American Veteran Experience and the Post-9/11 Generation. Pew Research Center, 10 Sept. 2019, https://www.pewresearch.org/social-trends/2019/09/10/the-american-veteran-experience-and-the-post-9-11-generation/.
- “2022 National Veteran Suicide Prevention Annual Report.” U.S. Department of Veterans Affairs, Sept. 2022. https://www.mentalhealth.va.gov/docs/data-sheets/2022/2022-National-Veteran-Suicide-Prevention-Annual-Report-FINAL-508.pdf
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- Tanielian, Terri, et al. Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans. RAND Corporation, 2008. https://www.rand.org/pubs/research_briefs/RB9336.html
- DeSimone, Danielle. “Military Suicide Rates Are at an All-Time High; Here’s How We’re Trying to Help.” United Service Organizations, The USO, 27 June 2022, https://www.uso.org/stories/2664-military-suicide-rates-are-at-an-all-time-high-heres-how-were-trying-to-help.
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- “Safe Messaging Best Practices: A Guide for Anyone Communicating and Writing About Veteran Suicide.” U.S. Department of Veterans Affairs, 9 April 2019. https://www.mentalhealth.va.gov/suicide_prevention/docs/safe_messaging_best_practices.pdf
- “S.2372 – 115th Congress (2017-2018): VA MISSION Act of 2018.” Congress.gov, Library of Congress, 6 June 2018, https://www.congress.gov/bill/115th-congress/senate-bill/2372.
- Ogrysko, Nicole. “Without Clear Standards, Veterans Are in the Dark on Community Care Wait Times.” Federal News Network, 1 Oct. 2020, https://federalnewsnetwork.com/veterans-affairs/2020/10/without-clear-standards-veterans-are-in-the-dark-on-community-care-wait-times/.
- “Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care.” United States Government Accountability Office, 24 July 2019. https://www.gao.gov/assets/gao-19-687t.pdf
- “Veterans Health Care: VA Actions Needed to Ensure Timely Scheduling of Specialty Care Appointments.” United States Government Accountability Office, Jan. 2023. https://www.gao.gov/assets/gao-19-687t.pdf
- “Records Confirm VA’s Use of Inaccurate Wait Time Numbers.” Americans for Prosperity, AFPF, 1 Oct. 2021, https://americansforprosperity.org/records-confirm-va-inaccurate-wait-time-numbers/.
- “More Evidence the VA Is Improperly Delaying or Denying Community Care to Eligible Veterans.” Americans for Prosperity, AFPF, 28 Jan. 2022, https://americansforprosperity.org/va-denying-delaying-care/.
- “Veterans Health Administration: Referral Coordination Initiative Implementation Guidebook .” U.S. Department of Veterans Affairs, 28 Oct. 2021, pp. 92, https://americansforprosperity.org/wp-content/uploads/2022/01/21-06268-F_Responsive_Records_2.pdf#page=92
- “Veterans Health Administration: Referral Coordination Initiative Implementation Guidebook .” U.S. Department of Veterans Affairs, 28 Oct. 2021, pp. 90, https://americansforprosperity.org/wp-content/uploads/2022/01/21-06268-F_Responsive_Records_2.pdf#page=90
- “Starting Jan. 17, Veterans in Suicidal Crisis Can Go to Any VA or Non-VA Health Care Facility for Free Emergency Health Care.” U.S. Department of Veterans Affairs, 13 Jan. 2023, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5852.
- “Starting Jan. 17, Veterans in Suicidal Crisis Can Go to Any VA or Non-VA Health Care Facility for Free Emergency Health Care.” U.S. Department of Veterans Affairs, 13 Jan. 2023, https://news.va.gov/news-releases/starting-jan-17-veterans-in-suicidal-crisis-can-go-to-any-va-or-non-va-health-care-facility-for-free-emergency-health-care/.