WASHINGTON — Last month, Congress passed a collection of sweeping legislation designed to help prevent veteran suicide. This came as a pleasant surprise to veterans’ advocates, who feared that the bills would be caught up in partisan gridlock and had been predicting only weeks earlier that no agreement would be reached.
A bill entitled, The Commander John Scott Hannon Veterans Health Care Improvement Act (S. 785), passed the Senate in early August but stalled when it reached the House Veterans’ Affairs Committee. Chairman Mark Takano (D-CA) argued that there were gaps in the bill that should be addressed that session. To that effect, he held a hearing, looking at 26 additional pieces of legislation, which contained what Takano called “key fixes to the Senate bill package.”
“Recent Senate action to advance veteran suicide prevention legislation offers a promising start, but it is the people’s House that must complete the work necessary to tackle this crisis,” Takano said prior to the hearing. “Never before has this committee advanced monumental veterans policy without first understanding what it will cost American taxpayers, and more importantly, what impact incomplete legislative efforts could have on veterans’ lives.”
Veterans’ service organizations released statements urging the passage of the bill, suggesting that the House should not jeopardize the passage of legislation that, while flawed, contained what they saw as necessary steps forward.
“IAVA is deeply concerned about the current path forward with the Commander Hannon Act,” testified Jeremy Butler, CEO of the Iraq and Afghanistan Veterans of America at a previous Senate hearing. “While we appreciate the House committee’s well-intentioned efforts to add new provisions to the legislation, we have concerns that, given the limited number of legislative days and the upcoming elections, there will not be enough time to pass the bill by the end of the year. We feel the best way forward is for the House to take up S. 785 as written by the Senate.”
Despite grim predictions, however, Takano and Senate VA Committee Chairman Jerry Moran (R-KS) announced that they had reached an agreement on a second package of legislation—the Veterans Comprehensive Prevention Access to Care and Treatment (COMPACT) bill.
The key provisions of the Hannon Act include giving VA the authority to issue $174 million in grants over the next five years to organizations providing mental healthcare to veterans. It also calls for the hiring of additional suicide prevention coordinators and mandates that VA provide healthcare to all veterans for one year after their transition from active duty.
If the Hannon Act provides broad strokes, the COMPACT Act delves into finer details of veteran safety. Among the measures in the COMPACT Act are:
Mandating that VA to provide free care to all veterans who are in a mental health crisis;
Creating an education program for families and caregivers of veterans with mental health problems; and
Requiring VA to conduct studies that track the outcomes of the department’s outreach to transitioning servicemembers.
The legislation also requires police at VA facilities to undergo annual de-escalation and intervention training.
“This agreement will make real progress toward reducing veteran suicide, but our work is not finished,” Takano said, following the announcement of COMPACT’s provisions.
The Hannon Act passed the House on Sept. 23 and was sent to the White House for the president’s signature. The COMPACT Act also passed the House, with the Senate expected to vote on it by the end of the legislative session.
Firearm Safety Interventions
One area of concern discussed in both the House and Senate but that never made it into either bill is that of firearm safety. Gun owners are four times more likely to commit suicide, and veterans are twice as likely to be gunowners, according to testimony.
Mental health experts, including those at VA, have testified that lethal means counseling could have as much of a direct impact on whether a veteran dies by suicide than any other piece of legislation being considered. Lethal means counseling involves teaching veterans and family members about firearm safety, promoting secure firearm storage and informing them how putting a barrier between a person considering suicide and an easy way of taking their own life increases their chances of getting help. President Donald Trump even included gun safety in his administration’s veterans’ suicide prevention roadmap, which was released in August.
VA surveys of veterans have found that the vast majority would support firearm safety interventions. Several Republican legislators have spoken out against the idea, however, calling any such provision an infringement on veterans’ Second Amendment rights.
As legislators were debating how to improve VA’s response to veteran suicide, the VA Inspector General’s Office released a report demonstrating how deficiencies in care at one VA facility led to a veteran taking their own life.
That veteran, in his or her 30s and who remains anonymous in the report, had been a patient at the Memphis VAMC since 2015. The veteran had been diagnosed with post-traumatic stress disorder and had received treatment both at VA and through community care.
In the summer of 2019, the veteran arrived at the hospital’s emergency department seeking treatment for insomnia and to get a refill of a psychiatric medication. The emergency department physician evaluated the patient and, after a negative screening for suicidal thoughts, discharged the patient with instructions to go to the outpatient mental health clinic for medication management. According to the report, no formal written consult was provided or required by the hospital.
There was no record that the patient was seen at the clinic. The following day, the patient committed suicide.
The OIG report found that the lack of written or clear guidance to get the patient from the emergency department to the outpatient mental health clinic was a broken link in the chain of patient care. Also, while there was a mental health provider in the emergency department at all times, there was no clear guidance on how a physician should refer a patient to that provider.
“The OIG was unable to determine whether the emergency department physician referred the patient to the emergency department mental health provider prior to discharge due to a lack of documented patient referral,” the report stated. “Without a clear referral process, patients are at risk for receiving inadequate care.”
The investigation also found that the patient did not receive several community care counseling sessions due to deficiencies in coordination of care between the VAMC staff, community care providers, and the third-party administrator of the community care program.
The OIG identified a three-month delay between fall 2017 and early 2018 in the patient’s community mental health treatment but was unable to find any documentation showing why the delay occurred. The report suggested that changes in community care eligibility rules, which put scheduling responsibilities on the administrator, might have contributed.
In 2018, the community care counselor terminated the patient’s sessions but did not document that termination or refer the patient to another counselor. The counselor told investigators that they encouraged the patient to stay on medications and seek assistance if problems came up. The counselor did not advise the patient on the best way to obtain that assistance.
The deficiencies in handling this patient’s case extended past the veteran’s suicide. A family member emailed the facility 11 days after the veteran’s death to inform staff of what happened and described their concerns that inadequate care had been the fault.
“The family member’s email was shared with several facility leaders, but no facility staff member assumed responsibility to contact the family to address or resolve the complaint,” the OIG report states. “Facility leaders told the OIG of having thought someone from either service recovery, mental health, executive leadership, or the Suicide Prevention Program supervisor followed up on the complain or contacted the family.”
The OIG made a total of 16 recommendations to the Memphis VAMC. As of the report’s release at the beginning of September, the hospital had completed 13 of them.