Changing the mindset on veteran health care

At MultiCare, we are committed to working toward health equity — ensuring all people have access to quality health care regardless of age, race, ethnicity, gender identity, religion, sexual orientation, ability, socioeconomic status or location.

But we also recognize the reality that longstanding biases and barriers embedded in the health care system, and our society, can prevent people from accessing the care they need.

In this series — inspired in part by society’s growing awareness that not everyone has the same chance to be healthy — we take a deeper look at the disparities that impact our patients and how we as health care providers and community members can reduce those disparities and improve the health and well-being of all.

Veterans face challenges unlike any other population

While checking in to a doctor’s appointment, you expect to answer questions about your age, gender identity or marital status. But what about veteran status?

You may not think of it as an important health identifier, but when it comes to health conditions or lifestyle factors that could play into your well-being, experts say it’s critical.

At MultiCare Yakima Memorial Hospital, Veteran Advocacy Program manager Matthew McCay explains how a recent query into patient records identified 70 veterans who met the criteria for diagnoses possibly related to Agent Orange exposure who weren’t receiving applicable health benefits.

Many of these veterans may have tried to receive coverage before their diagnoses were connected to Agent Orange, or their care team hadn’t identified them as veterans, he says. Because the burden has historically fallen on the patient, it’s likely more have been missed.

McCay is now on a mission to find every veteran in his community and ensure they’re receiving the care and benefits they deserve.

Identifying veteran status goes beyond benefits, though — it plays an important role in understanding overall physical and mental well-being.

Identifying veterans is the first step 

“People often have a stereotype of what a veteran looks like — the older man with his veteran hat or someone with a high, tight haircut,” says Connie Chapman, suicide prevention program manager with the Washington State Department of Veterans Affairs (WDVA). “But I dare you to stereotype a female veteran.”

We must set aside these stereotypes and recognize the importance of knowing a patient’s veteran status, she explains. Chapman’s team at the WDVA promotes the Ask the Question challenge, which encourages providers to ask about military service and suicide risk. The American Academy of Nursing also promotes the Have You Ever Served in the Military initiative, which encourages providers to ask about and document a patient’s military background, including family.

This work requires a cultural shift. Only about 30 percent of veterans receive their care from the Veterans Health Administration (VHA), Chapman says. Some may be “dual managed,” receiving primary care in the community and specialty care at the VA, or vice versa, which can bring challenges.

Troy Underbrink, DO, a MultiCare family medicine provider and veteran, says that even he faces challenges when working with dual-managed patients. Sometimes he and a patient’s VA provider are managing the same or related conditions and plans aren’t communicated.

As a veteran, Dr. Underbrink is comfortable asking service-related questions and making possible correlations between service and health conditions than nonveteran providers. But knowledge of a patient’s status is the first step.

McCay implemented a veteran status question across MultiCare’s Yakima region to ensure they’re identified at intake. He hopes to spread that practice across the state in the coming years.

Common health disparities in veterans and potential causes

Of the 18 million veterans in the U.S. in 2018, one in four had a service-related disability, according to the Centers for Disease Control (CDC).

Veterans self-reported higher rates of obesity, stroke, cancer (specifically skin cancer), chronic obstructive pulmonary disease (COPD), arthritis, kidney disease and diabetes compared to nonveterans, according to CDC data. The study concluded that the physical demands of service have increased significantly over the years, which may put veterans at greater risk for these health conditions.

Military service over the years has involved exposure to harmful chemicals, intense physical demands and mental health challenges.

Exposure to one chemical, Agent Orange — commonly used by the U.S. military during the Vietnam War to clear vegetation — has prompted disability compensation for the following diagnoses:

• Bladder cancer
• Chronic B-cell leukemia
• Hodgkin lymphoma
• Multiple myeloma
• Non-Hodgkin lymphoma
• Prostate cancer
• Respiratory cancer, including lung
• Some soft tissue sarcomas
• AL amyloidosis
• Chloracne
• Type 2 diabetes mellitus
• High blood pressure (hypertension)
• Hypothyroidism
• Ischemic heart disease
• Monoclonal gammopathy of undetermined significance
• Parkinsonism
• Parkinson’s disease
• Peripheral neuropathy, early onset
• Porphyria cutanea tarda

Repeated exposure to loud noises and blasts leads to increased hearing loss, vision loss and balance problems in male veterans, according to the CDC. And the harsh physical experiences of service can cause traumatic brain injuries that may not be caught until much later, Chapman says. It’s easy to overlook “invisible” wounds.

The causes of some conditions are harder to pinpoint, such as Gulf War Syndrome. The VA describes it as a condition affecting Gulf War veterans that presents as a cluster of medically unexplained chronic symptoms such as fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders and memory problems.

All of this can negatively impact quality of life and lead to other outcomes, such as mobility challenges, anxiety and depression.

Veterans account for 18 percent of suicides in Washington state, but only represent 8 percent of the total population, says Chapman. And 7 percent of veterans in the U.S. report having post-traumatic stress disorder (PTSD) at some point, according to the VA.

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“There’s a sort of ‘suck it up’ attitude. Not just with mental health, but all kinds of things,” Dr. Underbrink explains. “There are efforts to combat against that, but the attitude comes from being on the front line and not wanting to be the one to fall out. … The drive to finish the mission drives a lot of the stigma.”

Being in the military can put you in positions you can’t step away from that result in moral injuries, he adds. For example, sexual assault is a significant problem, and environments such as submarines are not set up with privacy — especially for women — in mind.

Many service members who experience assault or harassment keep it to themselves for fear of retaliation or shame, Dr. Underbrink adds.

“Some mental health conditions can impact your job status,” he says. “If you plan for this to be your career, that breeds a lot of pent-up things or avoiding telling (your) doctor. … it catches up to you.”

There’s no black-and-white definition of who’s at risk for mental health challenges, Chapman says. Whether you’re male or female, LGBTQ+, you served during a time of peace, or you’re a veteran of color, the need for awareness remains.

Education is key to address veterans’ health disparities 

“Our goal is to get every provider to ask every patient if they or someone in their family has served in the military, and very openly and clearly ask about suicide,” Chapman says. “Eighty percent of those who die by suicide have seen their primary care provider in the past year, and 45 percent within 30 days.”

Asking isn’t enough, though — there needs to be follow-through, she adds.

Your heart may be in the right place, but complex systems can generate a lot of disparity, Dr. Underbrink says. The most important thing civilian providers can do is get comfortable asking the question and know how to connect patients with the right resources.

The simplest next step for health conditions is a local VA advocate or call 988 for those experiencing suicidal thoughts.

These can be hard conversations to have, whether because of stigma, stereotypes or shame around military service, Chapman adds. It’s important to address the topic with care, respect and empathy.