Providing Mental Health Care to All Veterans Regardless of Discharge Status

During his testimony before the House Committee on Veterans Affairs on March 7, 2017, Secretary of Veterans Affairs David J. Shulkin, MD, expressed his intent to remove the administrative barrier prohibiting other-than-honorably (OTH) discharged service members from receiving VHA mental health care. This is the first time in VA history to integrate those veterans whose OTH discharge status had previously disenfranchised them.

In his comments to Congress, Dr. Shulkin voiced his gratitude to Rep. Mike Coffman (R-CO) for helping him to “better understand the urgency of getting this right.” In March 2016, Rep. Coffman introduced the

Veterans Fairness Act, which would permit OTH discharged combat veterans to obtain emergency mental health services. Rep. Coffman cited that 22,000 U.S. Army veterans were discharged for misconduct since 2009, most with a traumatic brain injury (TBI) or mental illness.¹ Veterans often refer to OTH discharges as having “bad paper.” In 2013, National Public Radio produced a series on OTH discharged service members that underscored their struggles.² Those reports estimated that more than 100,000 veterans left the service with OTH discharges in the decade before the story.²

These individuals, many of whom have already lost a great deal as a result of their military service, lose much more when they are OTH discharged. They are unable to apply for the GI Bill, which enables them to further their education and livelihood; they cannot get a VA home loan to help them house their families; and they are ineligible for disability even for combat-related conditions like posttraumatic stress disorder (PTSD) and TBI. Most damaging of all, until Dr. Shulkin’s historic announcement, they also could not get VA health care. In effect, OTH discharge status creates a second class of service men and women, even though the discharge may have been the result of injury and illness related to their time in uniform. That consequence makes Dr. Shulkin’s proposal not only an administrative change, but also an ethical decision regarding the civil and human rights of service members, which is the reason most major veterans service and advocacy organizations have long endorsed it.

Although research on OTH discharged veterans has been limited, studies have found a high rate of mental health problems. The OTH discharged service members are significantly represented in the cohorts who face some of the most serious public health problems that the VA has tried to address through new programs that were initiated during the prior administration and continued by the current one, such as ending homelessness and preventing suicide.

A 2017 study compared rates of mental illness and substance use among veterans with routine discharges with those who had nonroutine separations from the military.³ The results showed that there was a higher rate of almost every psychiatric diagnosis in the nonroutine discharges; the rates were particularly high for those discharged for misconduct.³ Because of the established correlation of multiple deployments to Afghanistan and Iraq and incidence of TBI, PTSD, and substance use and the association of these disorders with behaviors that contribute to OTH discharge status, a clear duty to care for these men and women emerges.

Similarly, the ethical principle of nonmalfeasance provides persuasive justification for Dr. Shulkin’s proposed change in VA eligibility for mental health care. The study also found that even if not previously entitled to VA services, these veterans share the increased risk of suicide found in all those who have worn a uniform for their country and similarly need compassionate, competent veteran-centered care.³

Recent research showed that patients who receive mental health care within the VA have lower rates of suicide than that of those who receive care in the community.⁴ The results of this study contribute to the ethical imperative to grant these former service members access to potentially life-saving mental health treatment more urgent.

The elevated suicide risk of those veterans who do not have VA mental health services makes this extension of care clinically and ethically imperative and urgent. In his testimony at the hearing, Dr. Shulkin underscored this rationale, “The President and I have made it clear that suicide prevention is one of our top priorities,” Shulkin added. “We know the rate of death by suicide among veterans who do not use VA care is increasing at a greater rate than veterans who use VA care. This is a national emergency that requires bold action. We must and we will do all that we can to help former service members who may be at risk. When we say even one veteran suicide is one too many, we mean it.

The downstream consequences of OTH discharge status are the most detrimental to the veteran and have negative effects on the veteran’s family and community. Nonroutinely discharged veterans are more likely to be homeless. The new initiative would open a variety of VA mental health services to OTH discharged service members, including those available in VA emergency departments, Vet Centers, and the Veterans Crisis Line. In developing the plan to expand coverage to OTH discharged veterans, Dr. Shulkin indicated that he would consult with Veterans Service Organizations and the DoD.

We can hope that additional services will be opened to OTH discharged service members, such as case management and housing assistance, which have proven so successful in reintegrating those service members with routine discharges.

During his testimony before the House Committee on Veterans Affairs on March 7, 2017, Secretary of Veterans Affairs David J. Shulkin, MD, expressed his intent to remove the administrative barrier prohibiting other-than-honorably (OTH) discharged service members from receiving VHA mental health care. This is the first time in VA history to integrate those veterans whose OTH discharge status had previously disenfranchised them.

In his comments to Congress, Dr. Shulkin voiced his gratitude to Rep. Mike Coffman (R-CO) for helping him to “better understand the urgency of getting this right.” In March 2016, Rep. Coffman introduced the

Veterans Fairness Act, which would permit OTH discharged combat veterans to obtain emergency mental health services. Rep. Coffman cited that 22,000 U.S. Army veterans were discharged for misconduct since 2009, most with a traumatic brain injury (TBI) or mental illness.¹ Veterans often refer to OTH discharges as having “bad paper.” In 2013, National Public Radio produced a series on OTH discharged service members that underscored their struggles.² Those reports estimated that more than 100,000 veterans left the service with OTH discharges in the decade before the story.²

These individuals, many of whom have already lost a great deal as a result of their military service, lose much more when they are OTH discharged. They are unable to apply for the GI Bill, which enables them to further their education and livelihood; they cannot get a VA home loan to help them house their families; and they are ineligible for disability even for combat-related conditions like posttraumatic stress disorder (PTSD) and TBI. Most damaging of all, until Dr. Shulkin’s historic announcement, they also could not get VA health care. In effect, OTH discharge status creates a second class of service men and women, even though the discharge may have been the result of injury and illness related to their time in uniform. That consequence makes Dr. Shulkin’s proposal not only an administrative change, but also an ethical decision regarding the civil and human rights of service members, which is the reason most major veterans service and advocacy organizations have long endorsed it.

Although research on OTH discharged veterans has been limited, studies have found a high rate of mental health problems. The OTH discharged service members are significantly represented in the cohorts who face some of the most serious public health problems that the VA has tried to address through new programs that were initiated during the prior administration and continued by the current one, such as ending homelessness and preventing suicide.

A 2017 study compared rates of mental illness and substance use among veterans with routine discharges with those who had nonroutine separations from the military.³ The results showed that there was a higher rate of almost every psychiatric diagnosis in the nonroutine discharges; the rates were particularly high for those discharged for misconduct.³ Because of the established correlation of multiple deployments to Afghanistan and Iraq and incidence of TBI, PTSD, and substance use and the association of these disorders with behaviors that contribute to OTH discharge status, a clear duty to care for these men and women emerges.

Similarly, the ethical principle of nonmalfeasance provides persuasive justification for Dr. Shulkin’s proposed change in VA eligibility for mental health care. The study also found that even if not previously entitled to VA services, these veterans share the increased risk of suicide found in all those who have worn a uniform for their country and similarly need compassionate, competent veteran-centered care.³

Recent research showed that patients who receive mental health care within the VA have lower rates of suicide than that of those who receive care in the community.⁴ The results of this study contribute to the ethical imperative to grant these former service members access to potentially life-saving mental health treatment more urgent.

The elevated suicide risk of those veterans who do not have VA mental health services makes this extension of care clinically and ethically imperative and urgent. In his testimony at the hearing, Dr. Shulkin underscored this rationale, “The President and I have made it clear that suicide prevention is one of our top priorities,” Shulkin added. “We know the rate of death by suicide among veterans who do not use VA care is increasing at a greater rate than veterans who use VA care. This is a national emergency that requires bold action. We must and we will do all that we can to help former service members who may be at risk. When we say even one veteran suicide is one too many, we mean it.

The downstream consequences of OTH discharge status are the most detrimental to the veteran and have negative effects on the veteran’s family and community. Nonroutinely discharged veterans are more likely to be homeless. The new initiative would open a variety of VA mental health services to OTH discharged service members, including those available in VA emergency departments, Vet Centers, and the Veterans Crisis Line. In developing the plan to expand coverage to OTH discharged veterans, Dr. Shulkin indicated that he would consult with Veterans Service Organizations and the DoD.

We can hope that additional services will be opened to OTH discharged service members, such as case management and housing assistance, which have proven so successful in reintegrating those service members with routine discharges.

During his testimony before the House Committee on Veterans Affairs on March 7, 2017, Secretary of Veterans Affairs David J. Shulkin, MD, expressed his intent to remove the administrative barrier prohibiting other-than-honorably (OTH) discharged service members from receiving VHA mental health care. This is the first time in VA history to integrate those veterans whose OTH discharge status had previously disenfranchised them.

In his comments to Congress, Dr. Shulkin voiced his gratitude to Rep. Mike Coffman (R-CO) for helping him to “better understand the urgency of getting this right.” In March 2016, Rep. Coffman introduced the

Veterans Fairness Act, which would permit OTH discharged combat veterans to obtain emergency mental health services. Rep. Coffman cited that 22,000 U.S. Army veterans were discharged for misconduct since 2009, most with a traumatic brain injury (TBI) or mental illness.¹ Veterans often refer to OTH discharges as having “bad paper.” In 2013, National Public Radio produced a series on OTH discharged service members that underscored their struggles.² Those reports estimated that more than 100,000 veterans left the service with OTH discharges in the decade before the story.²

These individuals, many of whom have already lost a great deal as a result of their military service, lose much more when they are OTH discharged. They are unable to apply for the GI Bill, which enables them to further their education and livelihood; they cannot get a VA home loan to help them house their families; and they are ineligible for disability even for combat-related conditions like posttraumatic stress disorder (PTSD) and TBI. Most damaging of all, until Dr. Shulkin’s historic announcement, they also could not get VA health care. In effect, OTH discharge status creates a second class of service men and women, even though the discharge may have been the result of injury and illness related to their time in uniform. That consequence makes Dr. Shulkin’s proposal not only an administrative change, but also an ethical decision regarding the civil and human rights of service members, which is the reason most major veterans service and advocacy organizations have long endorsed it.

Although research on OTH discharged veterans has been limited, studies have found a high rate of mental health problems. The OTH discharged service members are significantly represented in the cohorts who face some of the most serious public health problems that the VA has tried to address through new programs that were initiated during the prior administration and continued by the current one, such as ending homelessness and preventing suicide.

A 2017 study compared rates of mental illness and substance use among veterans with routine discharges with those who had nonroutine separations from the military.³ The results showed that there was a higher rate of almost every psychiatric diagnosis in the nonroutine discharges; the rates were particularly high for those discharged for misconduct.³ Because of the established correlation of multiple deployments to Afghanistan and Iraq and incidence of TBI, PTSD, and substance use and the association of these disorders with behaviors that contribute to OTH discharge status, a clear duty to care for these men and women emerges.

Similarly, the ethical principle of nonmalfeasance provides persuasive justification for Dr. Shulkin’s proposed change in VA eligibility for mental health care. The study also found that even if not previously entitled to VA services, these veterans share the increased risk of suicide found in all those who have worn a uniform for their country and similarly need compassionate, competent veteran-centered care.³

Recent research showed that patients who receive mental health care within the VA have lower rates of suicide than that of those who receive care in the community.⁴ The results of this study contribute to the ethical imperative to grant these former service members access to potentially life-saving mental health treatment more urgent.

The elevated suicide risk of those veterans who do not have VA mental health services makes this extension of care clinically and ethically imperative and urgent. In his testimony at the hearing, Dr. Shulkin underscored this rationale, “The President and I have made it clear that suicide prevention is one of our top priorities,” Shulkin added. “We know the rate of death by suicide among veterans who do not use VA care is increasing at a greater rate than veterans who use VA care. This is a national emergency that requires bold action. We must and we will do all that we can to help former service members who may be at risk. When we say even one veteran suicide is one too many, we mean it.

The downstream consequences of OTH discharge status are the most detrimental to the veteran and have negative effects on the veteran’s family and community. Nonroutinely discharged veterans are more likely to be homeless. The new initiative would open a variety of VA mental health services to OTH discharged service members, including those available in VA emergency departments, Vet Centers, and the Veterans Crisis Line. In developing the plan to expand coverage to OTH discharged veterans, Dr. Shulkin indicated that he would consult with Veterans Service Organizations and the DoD.

We can hope that additional services will be opened to OTH discharged service members, such as case management and housing assistance, which have proven so successful in reintegrating those service members with routine discharges.