Why My Trips to the Dentist Involve a Long Detour

A dispatch from VHPI Senior Policy Analyst Suzanne Gordon:

Every time I drive to a dental appointment, I think about the debate about veterans’ access to healthcare. My dentist’s office is about 28 miles from my home in the East Bay of San Francisco. It’s a real schelp to get there and I often have to sit in traffic either coming or going or both. There are many more conveniently located dentists nearby. (AI tells me there are about 1600). One is actually located down the hill from where I live. But I make the long trek because I have never had a dentist who is both so competent or so nice.

My dentist is a whiz at taking out a tooth with a minimum of pain or keeping a tooth alive and covering it with a crown. At the beginning of every appointment, he always asks about my family, tells me about his, and we briefly commiserate about the state of the world. He gives his patients his cell phone number to use in an emergency. A couple of years ago, I had a question after a procedure and called his cell, rather than office, by mistake. When I tried to apologize, he stopped me. “I’m so glad you called, I wanted to call you to find out how you were doing but I didn’t want to bother you.” Are you sure you’re a dentist I wanted to ask.

My decision to travel longer to get to my dentist’s office is also grounded in a much more harrowing lesson in what happens when you prioritize convenience over quality. Twenty years ago, my husband and I left our home in Boston for a leaf-peeping weekend in rural Vermont. Two days into our stay I was overcome with crushing abdominal pain. Instead of driving 30 minutes to a larger medical center in Burlington, Vermont, or four hours back to an even larger hospital in Boston, we followed the sign with the H to a small, community hospital in nearby Middlebury. In the ER they diagnosed me with appendicitis and called in a surgeon to operate. My husband and I both assumed, wrongly it turned out, that all would be well, because I would have uncomplicated surgery in an accredited hospital.

The surgeon did indeed remove my appendix but left me with a urinary retention injury that forced me to catheterize myself five times a day for eight months (sorry if this is too much information but it’s kind of important). I later discovered that the surgeon had lots of complaints filed against him and was only kept on the rolls because, as someone later told me, “it’s so hard to find physicians who are willing to practice in rural areas.” He I learned the hard way that access should never trump (pun very much intended) quality.

In discussions about veterans’ healthcare, the opposite is almost always the opposite: access is consistently prioritized over quality. Indeed, quality is often totally ignored when Congressional overseers consider policies that will impact the VA healthcare system and veteran patients. The former chairman of the Senate Veterans’ Affairs Committee, Jon Tester (D. MT, for example, relentlessly prioritized access over quality even when warned that he could be jeopardizing veterans’ health and even their lives. Tester refused to require privates sector providers in the Veterans Community Care Program (VCCP) to have even minimal training in how to deal with veterans’ complex health conditions. He worried that private providers would refuse to sign up to care for vets if they were mandated to spend even a few hours understanding military related health conditions and culture.

As my colleague at VHPI Russell Lemle pointed out in an article I recently did on women veterans for The American Prospect, “A section in the MISSION Act requires the VA to develop competency standards for non-VA providers offering care to veterans with MST and other conditions for which the VA has special expertise. The VA developed a 30-minute core training in MST. But under Trump, the VA waived it as a mandatory requirement for community providers. The [Government Accountability Office] recently issued a report that documents that less than 1 percent of [Veterans Community Care Program] mental health providers have taken the training. It was only 30 minutes of their time, and they still wouldn’t do it.”

When private sector providers who are paid to care for veterans refuse to learn about veterans’ complex problem, they are actually making a rational calculation. As a 2022 study reported, most doctors would need an impossible 26.7 hours per day to follow national guidelines on delivering appropriate preventive, chronic, and acute care to an average load of (non -VA) patients.”patients, Why should they bother devoting hours to learning about veterans when they represent between only 1 and 5% of their patient load, if that.

In the VA, which is a population health system, learning about veterans’ health conditions makes total sense because every single patient is a veteran. In other words, the VA is a population health system in which every patient is a veteran. In their 2019 RAND testimony on VA community care, Carrie Farmer and Terri Tanelian explained the nuance privatizers completely ignore. “The VA health care system was established primarily to address the needs of veterans who had experienced significant service-connected health related problems, including those considered catastrophically disabled. .. The VA health care system has been systematically, over time, designed to serve this unique population, even as Congress expanded eligibility for enrollment to other veterans with less complicated health or economic needs. The VA health care system has also prioritized creating settings in which veterans feel welcome by providers who understand military culture. It is unclear the extent to which the veterans eligible for community care under the new MISSION Act rules will experience similar settings in the private sector.”

When Farmer testified at a 2022 VA hearing, she elaborated on this concept, noting that the VCCP’s promise of easy access has been a unfulfilled ( “In many parts of the country and for some types of care, veterans may face a shorter wait time for care from VA than an average person would face getting care from the private sector,”) She also reminded Senators that, “ quality matters as much as timeliness. It is critical,” she emphasized, “that discussions about veterans’ access to care always consider care quality. An appointment available tomorrow that provides poor care could be worse than waiting for good care. As prior RAND research has demonstrated, VA typically provides care that is equal to or better than care from the private.”

The take home message? Poor care that’s delivered in a timely fashion or that is more conveniently located can hurt you or even kill you.

I am sure that when the Senators and Congressional representatives seek their own healthcare, they are more concerned about quality as convenience. They should be just as concerned with the quality/access ratio when they, as the board of directors of the nation’s largest healthcare system, consider how best to serve veterans. Sadly, for too many of them the only ratio that seems to matter is the one that calculates amount of ideological purity they should manifest so they can increase the campaign contributions that fill their coffers.

As for the VSO representatives who have largely acquiesced to -- or downright abetted -- the privatization of the VA healthcare system, there’s no doubt that they are deeply concerned about access. Just not the kind of access that counts for the vets they claim to serve. Their obsession is access to the administration or to Republicans who currently threaten to withhold information if they don’t toe the line. As for quality? The only way Congress and VSOs will learn to value that is if more veterans and their families begin to protest the current policies that could soon deprive them of a mission-driven system delivers high quality care with wait times that are shorter than those in the private sector.

Every time I drive to a dental appointment, I think about the debate about veterans’ access to healthcare. My dentist’s office is about 28 miles from my home in the East Bay of San Francisco. It’s a real schelp to get there and I often have to sit in traffic either coming or going or both. There are many more conveniently located dentists nearby. (AI tells me there are about 1600). One is actually located down the hill from where I live. But I make the long trek because I have never had a dentist who is both so competent or so nice.

My dentist is a whiz at taking out a tooth with a minimum of pain or keeping a tooth alive and covering it with a crown. At the beginning of every appointment, he always asks about my family, tells me about his, and we briefly commiserate about the state of the world. He gives his patients his cell phone number to use in an emergency. A couple of years ago, I had a question after a procedure and called his cell, rather than office, by mistake. When I tried to apologize, he stopped me. “I’m so glad you called, I wanted to call you to find out how you were doing but I didn’t want to bother you.” Are you sure you’re a dentist I wanted to ask.

My decision to travel longer to get to my dentist’s office is also grounded in a much more harrowing lesson in what happens when you prioritize convenience over quality. Twenty years ago, my husband and I left our home in Boston for a leaf-peeping weekend in rural Vermont. Two days into our stay I was overcome with crushing abdominal pain. Instead of driving 30 minutes to a larger medical center in Burlington, Vermont, or four hours back to an even larger hospital in Boston, we followed the sign with the H to a small, community hospital in nearby Middlebury. In the ER they diagnosed me with appendicitis and called in a surgeon to operate. My husband and I both assumed, wrongly it turned out, that all would be well, because I would have uncomplicated surgery in an accredited hospital.

The surgeon did indeed remove my appendix but left me with a urinary retention injury that forced me to catheterize myself five times a day for eight months (sorry if this is too much information but it’s kind of important). I later discovered that the surgeon had lots of complaints filed against him and was only kept on the rolls because, as someone later told me, “it’s so hard to find physicians who are willing to practice in rural areas.” He I learned the hard way that access should never trump (pun very much intended) quality.

In discussions about veterans’ healthcare, the opposite is almost always the opposite: access is consistently prioritized over quality. Indeed, quality is often totally ignored when Congressional overseers consider policies that will impact the VA healthcare system and veteran patients. The former chairman of the Senate Veterans’ Affairs Committee, Jon Tester (D. MT, for example, relentlessly prioritized access over quality even when warned that he could be jeopardizing veterans’ health and even their lives. Tester refused to require privates sector providers in the Veterans Community Care Program (VCCP) to have even minimal training in how to deal with veterans’ complex health conditions. He worried that private providers would refuse to sign up to care for vets if they were mandated to spend even a few hours understanding military related health conditions and culture.

As my colleague at VHPI Russell Lemle pointed out in an article I recently did on women veterans for The American Prospect, “A section in the MISSION Act requires the VA to develop competency standards for non-VA providers offering care to veterans with MST and other conditions for which the VA has special expertise. The VA developed a 30-minute core training in MST. But under Trump, the VA waived it as a mandatory requirement for community providers. The [Government Accountability Office] recently issued a report that documents that less than 1 percent of [Veterans Community Care Program] mental health providers have taken the training. It was only 30 minutes of their time, and they still wouldn’t do it.”

When private sector providers who are paid to care for veterans refuse to learn about veterans’ complex problem, they are actually making a rational calculation. As a 2022 study reported, most doctors would need an impossible 26.7 hours per day to follow national guidelines on delivering appropriate preventive, chronic, and acute care to an average load of (non -VA) patients.”patients, Why should they bother devoting hours to learning about veterans when they represent between only 1 and 5% of their patient load, if that.

In the VA, which is a population health system, learning about veterans’ health conditions makes total sense because every single patient is a veteran. In other words, the VA is a population health system in which every patient is a veteran. In their 2019 RAND testimony on VA community care, Carrie Farmer and Terri Tanelian explained the nuance privatizers completely ignore. “The VA health care system was established primarily to address the needs of veterans who had experienced significant service-connected health related problems, including those considered catastrophically disabled. .. The VA health care system has been systematically, over time, designed to serve this unique population, even as Congress expanded eligibility for enrollment to other veterans with less complicated health or economic needs. The VA health care system has also prioritized creating settings in which veterans feel welcome by providers who understand military culture. It is unclear the extent to which the veterans eligible for community care under the new MISSION Act rules will experience similar settings in the private sector.”

When Farmer testified at a 2022 VA hearing, she elaborated on this concept, noting that the VCCP’s promise of easy access has been a unfulfilled ( “In many parts of the country and for some types of care, veterans may face a shorter wait time for care from VA than an average person would face getting care from the private sector,”) She also reminded Senators that, “ quality matters as much as timeliness. It is critical,” she emphasized, “that discussions about veterans’ access to care always consider care quality. An appointment available tomorrow that provides poor care could be worse than waiting for good care. As prior RAND research has demonstrated, VA typically provides care that is equal to or better than care from the private.”

The take home message? Poor care that’s delivered in a timely fashion or that is more conveniently located can hurt you or even kill you.

I am sure that when the Senators and Congressional representatives seek their own healthcare, they are more concerned about quality as convenience. They should be just as concerned with the quality/access ratio when they, as the board of directors of the nation’s largest healthcare system, consider how best to serve veterans. Sadly, for too many of them the only ratio that seems to matter is the one that calculates amount of ideological purity they should manifest so they can increase the campaign contributions that fill their coffers.

As for the VSO representatives who have largely acquiesced to -- or downright abetted -- the privatization of the VA healthcare system, there’s no doubt that they are deeply concerned about access. Just not the kind of access that counts for the vets they claim to serve. Their obsession is access to the administration or to Republicans who currently threaten to withhold information if they don’t toe the line. As for quality? The only way Congress and VSOs will learn to value that is if more veterans and their families begin to protest the current policies that could soon deprive them of a mission-driven system delivers high quality care with wait times that are shorter than those in the private sector.