Veterans medical cap anger should be directed at government not doctors

By Dr Dan Mealey, former military doctor

Dear Australian Veterans,

I’m writing this as both a doctor and someone who has spent a considerable part of my life fighting for veterans. I understand the anger surrounding the proposed $5,000 allied health threshold. I understand why the word “cap” has caused fury, irrespective of the government’s insistence that clinically necessary treatment will remain available above it. I understand why a serviceman or woman injured in the service of this country might regard any new bureaucratic obstacle between themselves and treatment as another betrayal. If Australia broke you in its service, Australia has an obligation to help put you back together. On that fundamental principle, I stand with you.

But I need to ask you something difficult. Please stop confusing the person treating you with the institution that owes you.

There is a dangerous resentment developing on the other side of the consulting-room door. I hear it from doctors, psychologists, physiotherapists and other allied health professionals. I hear increasing numbers saying they no longer want to treat DVA patients. Some describe the administrative burden; some describe inadequate remuneration. Increasingly, however, I hear something much sadder: that treating veterans can come with expectations, demands and a sense of entitlement that leave clinicians feeling not appreciated for helping, but resented for not helping enough.

Veterans deserve healthcare for injuries and illnesses caused by their service. I don’t use the word “deserve” casually. When a government asks a citizen to surrender ordinary freedoms, submit to military discipline, accept unlimited liability and potentially surrender body, mind or life in the national interest, a reciprocal obligation is created. Healthcare for the consequences of that service is not a favour bestowed upon veterans by a generous government. It is part of the debt the nation incurred when it sent them to serve.

But that debt belongs to Australia. It does not personally belong to the physiotherapist standing in front of you. It doesn’t belong to your psychologist, your GP, your occupational therapist, your psychiatrist or the receptionist trying to find an appointment for you. This distinction has become dangerously blurred.

Australia’s health system is already under extraordinary pressure. Emergency departments overflow. Ambulances ramp outside hospitals. Psychiatric services operate beyond capacity. Elective surgery queues stretch intolerably long. General practice has spent years trying to reconcile government rebates with the actual cost of employing receptionists and nurses, paying rent, mortgages, indemnity insurance, registration, equipment, accreditation and every other expense required to keep a healthcare practice alive. The Royal Commission into Defence and Veteran Suicide itself recognised that DVA’s provider fees were contributing to difficulties veterans experienced accessing healthcare and recommended that the fee schedule be increased.

This tells us something veterans need to understand: when a health professional accepts a DVA patient at a fee materially below what that professional might otherwise charge, the difference does not magically disappear. Somebody absorbs it, and that “somebody” is the clinician.

Whatever language makes us comfortable, there has frequently been an element of professional generosity in this arrangement. Doctors and allied health professionals have accepted lower remuneration, additional paperwork and difficult clinical complexity because they wanted to look after veterans. Many have done so quietly for years. They didn’t receive medals for it. Nobody marches for them. Their sacrifice is measured in forgone income, longer days, unpaid paperwork and the decision to keep seeing a patient when the economics of doing so make no sense.

So when veterans publicly demand more treatment, immediately, without personal cost, while directing their anger towards the very providers who have been quietly subsidising the system with their own time and labour, something corrosive happens: generosity becomes obligation, obligation becomes expectation, expectation becomes entitlement, and eventually the person who once wanted to help begins asking why they should.

I’m watching all that happen in real-time, and nobody is willing to talk about it: veterans are creating resentment in an already overburdened healthcare system, primarly due to their failure to say “thank you.”

Don’t get me wrong – you shouldn’t have to be grateful to the Commonwealth for honouring its obligation to you. You should, however, be grateful to another human being who personally gives something up to help honour an obligation that was never theirs.

You can possess an entitlement under law and still thank the person who delivers it. You can hold Australia to account to live up to its promise of lifelong healthcare and still recognise that your physiotherapist does not owe you an hour of their life at a financial loss. You can demand better from DVA without demanding sacrifice from a GP. You can be furious with government and still be kind to the receptionist. You can have been terribly failed by the system without making an enemy of the person who has chosen to remain inside that failing system to care for you.

This brings me to where I believe our anger properly belongs.

For decades Australia has constructed an extraordinary and expenive chain of outsourced responsibility around the injured veteran. The Australian Defence Force creates the injured serviceman or woman, but much of the long clinical and rehabilitative responsibility ultimately outsources to DVA. DVA, in turn, operates alongside a sprawling ecosystem of thousands of Ex-Service Organisations, charities, advocates, volunteers and health providers (an enormous charity ecosystem with hands out for donations, creating “compassion-fatigue” among Australians who have already given much). At the end of this chain sits an injured human being trying to work out who the hell is responsible for putting their life back together.

Too often the answer seems to be everyone and therefore no one. Australia’s 6000-plus ESOs should not automatically be regarded as evidence of a magnificent support system. Their sheer proliferation should also force us to ask why a wealthy nation with a Commonwealth department specifically established to support veterans requires thousands of external organisations to fill the spaces around it. Duplication, fragmentation and overlapping services do not constitute care. Sometimes they constitute evidence that responsibility has been dispersed so widely that nobody can any longer be held accountable for the final outcome.

Many extraordinary people work within ESOs, and many veterans owe their lives to them. I am one of those veterans. But gratitude for the good does not absolve us from examining the structure.

Compassion is essential, but compassion is not a professional qualification. A well-intentioned veteran who survived his own crisis may become an extraordinary mentor to another veteran, but his survival does not automatically qualify him to treat mental illness, manage suicidality, provide rehabilitation or navigate complex clinical problems. The fact that helping others gives purpose to an injured veteran does not itself demonstrate that the organisation he establishes produces measurable benefit for the people it serves. Good intentions must eventually submit themselves to the same question we should ask of every healthcare intervention.

An organisation receiving government money may do excellent work, but financial dependence creates an obvious tension when that organisation is expected to fearlessly challenge the same political system upon which its funding, access or influence may depend. An ESO executive is not automatically the voice of the infantryman in Townsville, the traumatised medic in Perth, the widow of a veteran who died by suicide, nor the young discharged soldier who has never joined an RSL and never authorised anybody to speak in his name. Institutional voices must never become so loud that the veteran himself disappears beneath them.

This is why the present argument about allied health cannot be reduced to veterans versus government, or veterans versus greedy providers. There are genuine examples of overservicing that deserve scrutiny. There are also genuinely injured veterans whose treatment costs will exceed $5,000 and who are understandably terrified of another bureaucratic gate being placed between themselves and care. There are health professionals trying to run viable practices. There are clinicians who have quietly accepted financial disadvantage because they care about veterans. There are ESOs doing magnificent work, ESOs doing mediocre work, and a system so fragmented that distinguishing between the two can be fundamentally difficult.

But underneath all of this sits the original failure.

A country sends people to war, damages some of them in the process, and then outsources responsibility for repairing that damage through departments, schemes, charities, ESOs, advocates, volunteers and private clinicians. Eventually the veteran is angry because he cannot find the care he was promised, and the clinician is angry because he is being asked to personally subsidise a promise he never made. They meet in a consulting room where they resent each other before they even start.

Meanwhile, the institutions that created the arrangement remain safely upstream.

That’s the tragedy I want veterans to understand. The doctor is not your enemy. The psychologist is not your enemy. The physiotherapist is not your enemy. The occupational therapist is not your enemy. Nor is the veteran who needs expensive lifelong treatment the enemy of the taxpayer. We are allowing people at the very bottom of a structural failure to turn upon one another while responsibility evaporates upwards.

Yet the government would not be a responsible one, if it failed to apply brakes upon a laissez faire, bottomless cash pit of funding toward one demographic in need, at the expense of every other.

So by all means, fight the $5,000 threshold if you believe it threatens your healthcare. Demand evidence for it, safeguards, and that clinical decisions remain clinical decisions. Demand that no veteran with a legitimate service-related need loses treatment because an arbitrary financial figure has been reached. Demand accountability from DVA, from Defence, from government and from every organisation funded to speak or act on your behalf.

But while you are fighting, look after the people who are looking after you.

Thank your doctor. Thank your psychologist. Thank your physio. Thank the allied health professional who could fill that appointment with somebody paying the full private fee but chooses to see you instead. Consider making a paying contribution to the services provided to you at a fiscal loss to the provider. Understand what it costs to run the consulting room you are sitting in. Recognise that professional compassion is still compassion, even when somebody is paid for providing it. And remember that if enough good clinicians conclude that treating veterans brings more resentment than meaning, more administration than medicine and more accusation than gratitude, they have another option:

They can stop seeing us.

No government announcement, DVA card or legislated entitlement can compel a private clinician to feel compassion. No bureaucratic promise can manufacture a therapeutic relationship after goodwill has been exhausted.

Australian veterans have every right to be angry. I’ve spent years arguing that they should be angry. But anger without accurate aim becomes destructive. If we direct it at the people still trying to help us, we may eventually succeed only in driving them away (most especially when real or perceived entitlement eclipses every debt of gratitude).

Our fight was never supposed to be with the people trying to heal the wounds.

It should be with the systems that keep creating the wounds, outsourcing responsibility for them, and leaving veterans and clinicians to fight over who must carry the cost.

https://medium.com/@danielmealey/dear-veterans-why-your-doctor-doesnt-want-you-as-a-patient-5b1b4fb06418