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Dominguez exit interview: Fixing health care

Michael Dominguez, who is stepping down after 2½ years as principal deputy undersecretary of defense for personnel and readiness, said he was caught short when the Walter Reed scandal broke just months after he took office, but he added that he’s proud of how the military has reacted to the crisis since.

Still, he acknowledged that the cultural change necessary to help troops deal with post-traumatic stress disorder and traumatic brain injury will be a long time coming to a military that he said too often still thinks: Service first, service members second.

Fortunately, he said, the Obama administration approved “every last dime” he requested for wounded warriors in the 2010 budget.

Since the Walter Reed scandal hit in February 2007, Dominguez said he has spent about 80 percent of his time working on wounded warrior issues.

In a wide-ranging interview in his Pentagon office shortly before his departure, he offered his thoughts on how those issues have unfolded during his tenure.

The shock of Walter Reed

In February 2007, first Military Times and then the Washington Post unveiled investigative series on treatment of wounded troops, particularly at Walter Reed Army Medical Center, as they returned from war.

Military Times found that the disability retirement process was taking as long as two years for some troops because of lost records; poorly trained adjudicators; little or no command oversight; discrepancies in disability ratings, especially between services and between enlisted members and officers; a disability retirement budget that stayed flat long after the wars in Iraq and Afghanistan began; and service members with traumatic brain injuries and mental health issues trying to swim through a bureaucracy so dense that even system administrators didn’t understand it.

Dominguez took his post in July 2006, about seven months before the Walter Reed scandal broke.

“Certainly, I did not expect it, but the job is characterized by a series of crises,” he said. “What the [media] brought forward was a very clearly crystallized gap between our performance and the expectations we have even of ourselves, ... but clearly a gap between what the American people and wounded soldiers and their families expected of us.

“I was not picking that up in the background noise of issues and problems and challenges you run into every day in this place,” he said.

“Here’s my personal diagnosis of the failure: Medics are so good at their jobs that everyone else was overwhelmed by the number of patients — the revolution in medical care was not matched by a comparable revolution in our admin systems and processes.”

At that point, “the war was clearly not new,” he said. “Why did it take so long to catch up? My hypothesis and speculation: This is a huge institution and its legacy and origins of its processes and administrative procedures are still very much anchored in the draft.

“Thirty years into an all-volunteer force, the dominant decision-making criterion is for the good of the service. You’ve got a problem in your room? Suck it up, soldier. The other part of it is that you have these soldiers there, airmen, Marines, Coasties: Where’s their chain of command?

“We sent them to the hospital — the docs are taking care of them. Well, yeah, the docs are taking care of them medically. [But] they didn’t have commanders and first sergeants and platoon sergeants to be the advocates for these soldiers. So we didn’t recognize the fact that we had all these people out there in limbo status because they weren’t mine, but they weren’t theirs, and the docs were doing what they thought they needed to do with them, which is heal them.”

Warrior Transition Units

Dominguez said once the magnitude of the problem was laid bare, the Defense Department immediately began to work with the Veterans Affairs Department, the administration and Congress to try to fix things.

The first thing they did was create Warrior Transition Units, with a combat-qualified chain of command all the way down to the squad leader level, along with a promise to give service members a chance to heal.

Since then, a Government Accountability Office report found that the units had too little staffing, and the Army sought to narrow the population coming into those units, taking only troops with complicated cases and, some complained, leaving commanders preparing their units for deployment with non-deployable soldiers filling key slots.

According to a Military Times report about the Warrior Transition Unit at Fort Lee, Va., and a Salon.com series on the WTU at Fort Carson, Colo., soldiers complain they can’t get appointments, their case managers are overworked, their first sergeants don’t know how to handle troops with mental health issues, and their disability retirement cases are being handled improperly.

“To put a chain of command there with these soldiers — that was revolutionary, Dominguez said. “That was responding to the situation — doing what was needed and fast. If you can’t move, shoot and communicate with your unit, you’re in a Warrior Transition Unit or a wounded warrior regiment and you’ve got a first sergeant and you’ve got a commander whose mission is with you to make you well.

“It’s new, so we’re going to learn. And the first thing we did is we moved everybody over here. Now they’re trying to say come back and find the middle. If there are some things you can do, OK, yes, stay with your unit. There’s a real cost to moving people into the WTUs because that chain of command is not in the battle. Those facilities need to be built.

“There are financial challenges with Army — well, with all the services — with how much you can spend, how fast, to get the facilities up to where you want them to be, for sure.

“The leadership issues I find surprising, because of the emphasis the Army and Marine Corps in particular have put on the WTUs. Combat commanders and combat NCOs — they were there and understand the importance of taking care of their comrades, so [the problems are] surprising.

“I guess I would say there’s always another side to the story. You are a soldier, so we do expect you to do some things for yourself, and we expect you to work through adversity and we expect you to challenge yourself. Leaders do challenge people; sometimes they hate it.

“We are not perfect. I don’t want to convey to you that I think we are. We have, I believe, turned corners, but it’s a huge institution and there’s so much more to do to get excellent at every place in the delivery in these services under these new concepts.

“It takes time to hire a bunch of people. You hire a bunch of people fast, sometimes you don’t get the highest quality and you cut corners on training — I’m speculating, I don’t know that situation in this case — but I’m trying to give you a perspective of it’s hard to do these things in a very large organization.”

PTSD and TBI

Also during Dominguez’s tenure, the military began realizing that post-traumatic stress disorder and traumatic brain injuries were a bigger problem than anyone had planned for.

The Rand Corp. think tank reported that as many as 300,000 troops had PTSD and received inadequate care. Since then, the military has worked to educate its leaders about the two injuries, as well as trying to decrease the stigma associated with seeking help for mental health issues.

“Our leaders as of yet do not know how to deal with PTSD all of the time,” Dominguez acknowledged. “Some of them are getting good at it, others are not. We don’t have all the resources we need for leaders, so those psychological counselors — we’re struggling to find them, to hire them.

“What we have done at the leadership level is recognized the magnitude of that challenge. There’s been a major, major infusion of cash, largely to do two things: [One is] research. There is demonstrated medical evidence on a couple of procedures, but we need to do a lot more.

“Second is staff. We need to increase significantly the number of mental health professionals in our force, including getting mental health people down into the units. No first sergeant ever learned how to do this. We’re getting professionals down there to help them figure out how to do this. We’re beginning to teach line commanders what they need to do to lead people and destigmatize health-seeking and instead change the culture to ‘Hey, I stay physically fit, I stay psychologically fit to fight.’ When you’re injured, you go get help.”

DoD-VA cooperation

As the media also broke stories about backlogs at VA, as well as increased numbers of suicides and insufficient resources for veterans, especially in rural areas, attention became more focused on efforts by defense and VA officials to make their systems work more closely together, something that Congress was demanding.

The two departments have been asked to move quickly toward completing a system to share electronic records, creating a truly seamless transition that allows service members to start the VA disability process while still in the military, and figuring out a system of joint care when one organization can provide medical facilities and services unavailable through the other.

The Pentagon and VA also began a disability evaluation system pilot program that allows service members to go through one physical, lets the military decide whether a person is fit or unfit, and then lets VA determine disability percentages for retirement pay.

“When you join the military of the United States, you put yourself on a path that guarantees you’ll be a veteran,” Dominguez said. “They have a stake in our people. We have a stake in how they’re dealing with our people after they leave, because the word gets back about how you’re cared for.

“We ought to deliver one single service. We moved a long time toward that. I think we’ve achieved something astounding [in the pilot program with VA]. The current plan is we’re expanding in measured steps. We’re collecting data — is it saving work? Is it saving people? How do people feel like it treated them? Is it compressing the time? We’re asking all those questions as we expand.

“In the last part of May, we’ll hit the last expansion sites. In the fall, we’ll do the analysis. It could be that it works in some areas and not in others. I personally am optimistic that this will be the way we go with the whole disability system.”

‘Combat-related’

Lawmakers and veterans groups complained after a memo came out of Dominguez’s office that they said too narrowly defined “combat-related” for the purposes of a new law that lets service members with combat-related injuries keep their disability severance pay, rather than having to repay it, if they later begin receiving VA benefits.

Veterans groups said anyone injured while training for combat or performing special duty, such as jumping out of a plane, should be included, as they are under the traditional Defense Department definition of “combat-related.”

The Defense Department’s definition covered only those injured directly as a result of combat or in a combat zone.

“This is an interesting policy issue and we will thrash through it,” Dominguez said. “The current administration hasn’t thought it through and decided where they want to come down. In the past administration, our focus was on those who are wounded in combat. They’re special. These are the people to whom the nation owes a special debt.

“It’s a distinction made in Congress, as well, because that combat-related definition made it into other pieces of statute up there on Capitol Hill. That terminology is from statute. There are places in the law where Congress has said, for people coming back from combat, here’s a special thing.

“We read the law that they wrote, talked to [veterans groups] and basically came to a reasonable consensus that that was the congressional intent, or at least that’s what we could divine from the law. You’re hurt in the war, we owe you something special. Certainly, there’s a legitimate alternative policy view, so that will need to be thrashed out.”

Budgets

After years of lawmakers asking defense officials if they could use more money for health care and constantly being told no — the required answer under White House budget restrictions — Dominguez said it’s absolutely the truth for the 2010 budget.

“When President Obama sends the budget to Capitol Hill, you will see a significant increase in funding for these wounded warrior programs,” he said. “You’ll see sustained investment in brain research. You’ll see big bucks committed to family services and family support programs.

“This is not an area where we’re taking shortcuts in the budget. ... I’ve been in the business mostly in the Pentagon [on and off] since 1983. In all of that time, this is the only time where I’ve seen anyone get every nickel they asked for, and that was me for the wounded warrior programs.

“For fiscal ’10, I was not shy about anticipating what I thought I needed, and I got every nickel.”

Dominguez leaves the Pentagon on March 11 and heads for Institute for Defense Analysis.