Thursday, March 05, 2015

Iraq snapshot

Thursday, March 5, 2015.  Chaos and violence continue, while allegedly saluting women Iraq's prime minister makes two insulting remarks about women, residents of Tikrit flee, Nimrud is attacked by the Islamic State, the US Senate Veterans Affairs Committee wonders where the money is for research, and much more.

"The Choice Act has been shocking underutilized," declared Senator Richard Blumenthal at last Thursday's Senate Veterans Affairs Committee hearing.  Blumenthal is the Ranking Member, Senator Johnny Isakson is the Chair.  The hearing was about the VA's budget request and the first panel was composed of VA employees led by Secretary of the VA Robert McDonald.  The others were Dr. Carolyn Clancy, well known fabulist Allison Hickey, Ronald Walters, Stephen Warren and Helen Tierney.

Ranking Member Richard Blumenthal:  As I outlined earlier, Secretary McDonald, the choice card program basically seems not to be working.  I think you and I, in our conversations, have talked about the potential reasons that it is so underutilized a small fraction of the veterans who are eligible to use it in practical terms are doing so.  The 40 mile rule may be a cause.

Before we go further, let's all get on the same page.  The House Veterans Affairs Committee offers the following highlights of The Veterans Access, Choice and Accountability Act of 2014:

To improve access to and quality of care for veterans, the law:
  • Requires VA to offer an authorization to receive non-VA care to any veteran who is enrolled in the VA health care system as of August 1, 2014, or who is a newly discharged combat veteran if such veteran is unable to secure an appointment at a VA medical facility within 30 days (or a future published goal established by VA) or resides more than 40 miles from the nearest VA medical facility, with certain exceptions.
    • Requires VA to provide a Veterans Choice Card to eligible veterans to facilitate care provided by non-VA providers.
    • Provides $10 billion for the newly-established “Veterans Choice Fund” to cover the costs of this increased access to non-VA care. Choice program authority would end when funds are exhausted or three years after enactment, whichever occurs first.
  • Requires an independent assessment of VA medical care and establish a Congressional Commission on Care to evaluate access to care throughout the VA health care system.
  • Extends the ARCH (Access Received Closer to Home) pilot program for two years.
  • Extends for three years a pilot program to provide rehabilitation, quality of life, and community integration services to veterans with complex-mild to severe traumatic brain injury.
  • Improves the delivery of care to veterans who have experienced military sexual trauma as well as care for Native Hawaiian and Native American veterans.

To expand VA’s internal capacity to provide timely care to veterans, the bill would:
  • Provides $5 billion to VA to increase access to care through the hiring of physicians and other medical staff and by improving VA’s physical infrastructure.
  • Authorizes 27 major medical facility leases in 18 states and Puerto Rico.

To provide real accountability for incompetent or corrupt senior managers, the law:
  • Authorizes VA to fire or demote Senior Executive Service (SES) employees and Title 38 SES equivalent employees for poor performance or misconduct.
    • Provides an expedited and limited appeal process for employees disciplined under this authority. Appeals would go to a Merit Systems Protection Board administrative judge, who would have 21 days to decide on the appeal. If a decision is not reached within that 21-day period, then VA’s decision to remove or demote the executive is final.
    • Prohibits SES employees from receiving pay, bonuses and benefits during the appeal process.
  • Reduces funding for bonuses available to VA employees by $40 million each year through FY 2024.

To improve education benefits for veterans and dependents, the law:
  • Requires public colleges to provide in-state tuition to veterans and eligible dependents in order for the school to remain eligible to receive G.I. Bill education payments.
  • Expands the Sgt. Fry Scholarship Program to provide full Post 9/11 G.I. Bill benefits to spouses of servicemembers who died in the line of duty after 9/11.

According to the Congressional Budget Office, the bill would result in net spending of roughly $10 billion from 2014 - 2024, making it less expensive than previous VA reform packages passed by the House and Senate.

Along with backlog claims issues, the VA has suffered from the scandal of not delivering timely care and inventing a system not to fix that but to hide it.  The simplest explanation is that the VA kept two sets of books on appointments -- the false one had veterans receiving timely care when they called in to schedule appointments, the reality version -- which was hidden from Congress --documented the lengthy wait times.

As a result of veterans being denied timely care -- and the health problems and, yes, deaths that resulted from these actions led to the passage of the 2014 act.

It was hoped that this measure allowing veterans living "more than 40 miles from the nearest VA medical facility" to utilize a non-VA facility and doctor would allow for more timely health care.

To be clear, veterans can utilize that and could before the bill -- minus the 40 miles clause.  But to do so they had to get a written referral from a VA doctor and present that at whatever appointment/consultation with a non-VA doctor.  This clause in the act was supposed to simplify this process.

But that did not happen.

Today, Tom Philpott (Stars and Stripes) noted Senate VA Committee Chair Johnny Isakson is calling for the 40-mile aspect to be loosened:

  As we reported here several times last year, the law is more restrictive than early Capitol Hill tweets had indicated.  For each episode of care, regional VA healthcare managers still must authorize outside care, and VA usually will direct patients into a contracted network of health care providers.
Meanwhile, the 40-mile rule narrows eligibility to use cards in two ways.  First, the law uses “geodesic” or as-the-crow-flies distance to determine if a veteran lives more than 40 miles from VA care.  This denies access to private sector care to many vets who reside within 40 miles of VA care if one uses a map and ruler.  Actual drives for care can be much longer.
Second, the 40-mile rule applies to the nearest VA health facility, not nearest VA facility providing needed care. So veterans who reside within 40 miles of a VA clinic that can’t treat their conditions still aren’t eligible to use the Choice Card.  Those are two problems that need fixing, Isakson said.
“We need to make sure that if [VA] health care within 40 miles of the veteran doesn’t provide chemotherapy or doesn’t provide a heart transplant or doesn’t provide a specialty the veteran needs, they get to exercise the 40-mile rule because the health care they need is not available,” said Isakson.

“We also need to be certain we look at how long it takes to drive there…This straight-line application is crazy,” Isakson said.  “It needs to be the time [or mileage] from leaving the garage of the veteran to pulling into the parking lot of the Veterans Administration.”

I understand why the act was passed, I understand the reasoning behind it -- and I actually support that.  But I'm confused to this day of why the lawmakers seem unaware of what was already available.

Veterans had to jump through hoops -- whether they were VA, TRICARE or CHAMPVA to get those referrals unless their VA primary care doctor was a good one.  (A sign of a good one?  They retroactively authorize it if you're on vacation and have to see a non-VA doctor out of your area.  Which they can do but only very few will.)  (If your visit is not authorized -- prior to the appointment or retroactively -- you are responsible for the cost of the visit, your veterans plan is not covering it.)

It appears the hope was that by the wording of the 40 miles, it would be easier for the veterans to receive the referral for care.  I think it was stupid to rely on the same system that was already a problem -- VA doctors -- to give the same referrals.

I'm glad Isakson wants to reform it and I agree with his comments but more needs to be done.  The easiest thing would be to have some sort of clearance that took place online and by phone (because everyone doesn't have a computer -- shocking though that is to America's so-called 'creative class').  So a veteran would log on or dial in and enter their address -- already on file with the VA -- and request a referral for a visit to a non-VA facility.  The computer or phone system would know that the address was X number of miles from the nearest VA and if was 40 or more a referral would automatically be sent out to the veteran.

The thinking seems to have been that by putting it into law the VA doctors would be less hesitant about providing the referrals.  But the problem was more the issue of accessing the doctors and getting the referral -- the time involved for both -- and this was time while you were waiting for treatment.  The system should have been automated.

If the doctors are part of the reason for the delay -- and they are and that's chiefly because of the time involved -- then the solution was to automate the process.

Senator Patty Murray serves on the Committee (and is a former Chair of the Committee).  We'll note her remarks in the hearing in the next snapshot.  But she submitted a written statement for the record and from that we'll note these remarks, "A budget is a statement of our values and priorities. And as the daughter of a World War II veteran, I believe making sure our country keeps the promises we've made to our nation's heroes should be at the top of our list of priorities, all of the time. Taking care of our veterans when they come home is a fundamental part of who we are as a nation. It is part of the cost of going to war. And making sure the VA has the tools and resources it needs to provide care and support our veterans is critical."

And Murray knows what she's talking about the budget request "is a statement of our values and priorities."

And that's why the current budget request is so disturbing in so many ways.

Ranking Member Richard Blumenthal:  Finally, [.  . .] the issue of medical research, particularly into mental health, my understanding is that there has been no requested increase for that research.  Am I correct?

Helen Tierney:  For mental health, I'll have to check.  But overall the research budget goes up $33 million in our [20]16 [Fiscal Year budget] request.

Ranking Member Richard Blumenthal: Well for the VA's National Center for Post-Traumatic Stress Disorder -- which, as we all know, is the signature wound of these 13 years of war -- the funding is stagnant.  For centers like the Health Care System Medical Center Campus at West Haven --  which is doing enormously promising and critically important work -- to leave this funding stagnant in my view is, again, unacceptable. 

Helen Tierney: So, yes, sir, and I think Dr. Clancy can better address this.  When we ran the model we are finding that we're having less very seriously injured people in the war coming back and our costs are stabilizing in that area but  our --

Senator Richard Blumenthal:  Well, if I may say, with all due respect your injuries may be stabilizing because you're not recognizing -- 

Helen Tierney: Thank you.

Senator Richard Blumenthal (Con't):  -- and not acknowledging their existence.  The military itself says that 30 to 50% of our returning and separating men and women suffer from these invisible wounds of war.  This passed, new law, Clay Hunt SAV Act, recognizing the importance of providing mental health care, the research into how to treat it is even more important -- or at least as important as providing funds for the treatment because we're now using pharmaceutical drugs that are actually counter productive according to the experts in this area.  So may I suggest respectfully that the research funds be increased for this purpose.

First, why is it that the Congress is always more concerned that the VA isn't asking for enough money -- always more concerned about that possibility than is the VA itself?

It's a question worth considering.

The budget request does represent priorities and the VA did not look good in that exchange.  Not only did the VA fail to make a needed request but Tierney -- the VA's Chief Financial Officer -- showing up at a hearing on the budget request and being unable to answer what the requested amount for research on mental issues was?

That's setting aside her questionable remarks and questionable wording.

People are not less wounded.

Medical care -- including in the combat theater -- has progressed to allow service members who would have died from injuries in previous wars to survive very severe wounds.

It's sad that Tierney used the wording that she did.

It's sad that so many VA officials seems to have problems speaking of veterans in an appropriate manner.

Moving over to Iraq, Ticia Verveer notes:

  • Agatha Christie was a British writer who dominated the mystery genre with novels built around characters such as Miss Marple, Hercule Poirot and Tommy and Tuppence Beresford.  In the 1979 film Agatha, Academy Award winner Vanessa Redgrave portaryed the author.

    In 2011, Laura Allsop (CNN) reported:

    Now, 3,000-year-old ivory artifacts recovered by Mallowan between 1949 and 1963 from the ancient city of Nimrud, in what is now Iraq, and likely cleaned by his famous wife using cotton wool buds and face cream, go on display Monday at the British Museum in London.
    Nimrud was a city in the Assyrian kingdom, which flourished between 900-612 B.C.. The ivories found by Mallowan and his team were originally made in what is now Syria and Lebanon and brought to Assyria as looted treasures.
    John Curtis, keeper of the Middle East collections at the British Museum says they make up "the finest collection of ancient carved ivories that have ever been found at an archaeological excavation" and are in good condition, possibly because of Christie's efforts.

    "Face cream in fact is quite a good thing to clean (artifacts) with. Obviously conservators now wouldn't use that but I don't think it's done (the pieces) any harm," he continued, adding that in fact it was quite resourceful of Christie to think of applying her Innoxa face cream to the fragile, dirty pieces.

    Nimrud is back in the news today.  The Washington Post's Liz Sly Tweets:

    Having scored a hit video by smashing up Mosul Museum (inc.some copies) ISIS turns to the ancient city of Nimrod

    As with the assault on the Mosul Museum, the above is getting non-stop jawboning.

    Yesterday's execution of an 11-year-old boy by Iraqi's military and Shi'ite militias?

    They can't be bothered.

    But the endless jawboning over what did or didn't happen in Nimrud will continue.


    Just as the assault on Tikrit continues.

    Isabel Coles (Reuters) reports that countless residents of Tikrit are fleeing.  AFP goes with the United Nations figure of 28,000 fleeing.  Margaret Griffis ( notes:

    Tens of thousands of people are fleeing the greater Tikrit area ahead of military operations. Many of those refugees, however, are stranded at checkpoints that lead towards Samarra. Relief supplies are being deployed to help them. Others are being kept in the area to serve as human shields for the militants.

    The refugees not only fear combat, but they are also suspicious of Shi’ite militiamen, who are accused of war crimes in other areas of Iraq. P.M. Abadi cautioned the militiamen that they must respect civil rights, and those who don’t will be punished. Meanwhile, Turkish Prime Minister Ahmet Davutoğlu said that the cities should be rescued by their own people, because the presence of Shi’ite militias could re-ignite sectarian war. 

    The assault is led by Iran.  Robert Burns (AP) observes, "Iran's growing influence in Iraq is setting off alarm bells, and nowhere is the problem starker than in the high-stakes battle for Tikrit."  The editorial board of the Washington Post offers:

    While any reduction in the Islamic State has benefits, the Tikrit operation raises multiple red flags. The United States was excluded by the Iraqi government of Haider al-Abadi; meanwhile, Iran has dispatched its own ground forces, artillery and drones. The assistance is being overseen by a notorious general, Qassem Suleimani, who previously supervised attacks on U.S. forces in Iraq.

    Iran's Foreign Minister Javad Zarif spoke with Christiane Amanpour (CNN, link is text and video) about many topics today -- including Iraq:

    AMANPOUR: Can I move on to Iraq -- a great focus right now on the town of Tikrit, where Iraqi forces, other militias, and crucially Iranian forces are engaged in trying to push ISIS back. I would like to play for you a little bit of a soundbite from the Chairman of the Joint Chiefs of Staff to Congress, regarding Iran's involvement. General Martin Dempsey says, quote: "This is the most overt conduct of Iranian support in the form of artillery and other things. Frankly, [it] will only be a problem if it results in sectarianism. If they perform in a credible way, rid the city of Tikrit and turn it back to its inhabitants, then in the main, it would have been a positive thing in terms of countering ISIL's campaign." How do you respond to what the General said, and how involved is, for instance, General Soleimani of the Quds Force of the Revolutionary Guard?

    ZARIF: Well we do not have forces on the ground in Iraq. We have always had advisors helping the Iraqi government and the Iraqi army. We were the first to come to the assistance of the Iraqis, both in Baghdad as well as in Irbil, when the ISIS started moving in in massive numbers last summer. So we've been there, we've been assisting the Iraqi people, everybody knows that without our assistance, things would have been different in Iraq. We are in Iraq in terms of advisors and other support, but without military personnel on the ground, fighting forces on the ground, as you say, boots on the ground, in order to help this very serious global fight against these extremist and terrorist groups. We hope that this could unite Iraqis, because -- and all peoples of the region -- because in spite of the short-sighted attempts in the past, now everybody has come to the conclusion that these extremist forces are a threat to everybody. They cannot be contained in Syria or in Iraq, or in only several countries in this region. This is a global threat. You see the implications in Europe, you see the fact that they are recruiting from Europe. So this is a global problem, it requires global cooperation and global work. We are there, we have been there, we have been on the right side. We recognised this threat from its initial inception. And we have been warning the international community about short-sighted policies, of playing politics with this very serious danger. And we continue to do that and we are on the side of the Iraqis. So we hope that this fight -- which is not just a military fight, it's a comprehensive fight, it should be a comprehensive fight against extremism -- could be moved forward. It is very difficult to win this fight so early on in this process, but we hope that with international cooperation, with blocking financial assistance to these groups, with blocking recruitment of these groups, with blocking easy safe havens for these groups, with blocking access from the territory of various, of our neighbours, the variety of our neighbours from their territory to provide new recruits for these groups -- all of these should come together in order to reach a useful and hopefully a positive and constructive conclusion in this very serious international fight.

    AMANPOUR: Mr Zarif, you say you only have advisors. Obviously General Soleimani is one of the most effective active military commanders that your country has. Do you believe -- and he is there on the frontlines, directing the Tikrit battle -- do you believe that they are making progress and Tikrit will be liberated by ISIL -- from ISIL?

    ZARIF: Well this is a job that the Iraqis are doing, and they are doing with great sacrifice and great vigour. And I hope that they can succeed in this battle, as well as in the bigger war against ISIL and terrorism in Iraq and in Syria. But more than just winning one battle, it requires a concerted global campaign, a campaign that must be multi-faceted and must engage all participants and not just a few.

    US military brass has made unconvincing statements where they act (a) as if there's no consultation with Iran and (b) that maybe some good could happen from it.

    The statements are weak and unconvincing.  There may be a reason for that.  Yaakov Levi (Israel National News) notes:

    Iraqi sources told the London-based Arabic-language newspaper Al-Sharq al-Awsat Thursday that the US and Iran have been cooperating in fighting ISIS forces in Iraq. The sources said that US and Iranian forces have “come to an understanding” on the deployment of forces to retake the city of Tikrit in the Salah-a-Din district from ISIS.

    The sources said that Iran has sought to be in charge of the military operation to conquer Tikrit. Iraqi officials have been reluctant to ask for US air forces to bomb ISIS targets, possibly because they are seeking to defer to Iranian forces. There are numerous Iranian advisors in Iraq, led by Kassam Suleimani, the head of the Al-Quds Brigades of the Revolutionary Guards, the sources said.

    Meanwhile, we can't afford dumb assery.  In a story dated March 5th, Jason Ditz scribbles:

    Defense Secretary Ash Carter confirmed today that the US is “concerned” by Iran’s involvement, which Sen. John McCain (R – AZ) termed as Iran “basically taking over the fight.”

    I'm sitting there and thinking, "Huh?"

    Because it's March 4th.

    We covered the "concerned" in our report on that day's hearing.

    And I'm thinking "Huh" because that's a distortion of what was stated.  We don't have time for dumb assery.  If you don't know what you're writing about, find a topic you can contribute to.

    From the March 4th snapshot, this is the exchange being misreported:

    Chair John McCain: Today in Tikrit, Secretary Carter, the Shi'ite militia with the Iranian Revolutionary Guard leader -- among others -- and Iranian air is now attacking Tikrit -- the hometown of Saddam Hussein, as we recall.  And the majority of that effort with a couple of thousand of Iraqis are being undertaken by the Shia militia. The same militia that we fought against in the surge.  The same militia that according to estimates manufactured the IEDs which are -- which directly resulted in the deaths of some thousand or two young Americans.  Are-are you concerned that Iran is basically taking over the fight and, according to the Wall St. Journal this morning, we are observing that operation.  Does that ring an alarm bell with you, Mr. Secretary?

    Secretary Ash Carter:  It-it-it does.  It does.  Our approach to, uh, combating ISIL in Iraq is to work with the Iraqi security forces and a, uh, multi-sectarian government that takes a multi-sectarian approach to defeating ISIL and retaking its own territory.  Sectarianism is what brought us to the point where we are.  And so I do look at it with concern.  We're watching it very closely.  The, uh, Shi'ite militias involved also the Iraqi forces involved -- some Sunni forces involved. Uh-uh, I would note that there have -- Some Sunni tribal leaders in Tikrit -- and this is important -- have signaled their support for this offensive.  And if that's true, it's good news because that suggests that this is not purely a Shi'ite on Sunni thing. But this is the problem that brought Iraq low.  So I am -- So I am looking at it with great concern.

    Chair John McCain: And of course we -- There's well documented human rights violations -- significant -- by Shi'ite militias on Sunni as we all know.

    Quit misrepresenting what people say.

    I really don't see the value in dumb assery.

    "Sectarianism" is what Ash Carter looked at with "concern."

    In fairness to Ditz, his link goes to Robert Burns.  But when people chop up statements, anyone with a brain should question what was said that it couldn't be quoted in full.

    I don't have time for dumb assery.

    Criticism of Iran's involvement (leadership) with the Tikrit assault is also coming from withint he region.  Richard Spencer (Telegraph of London) reports:

     Saudi Arabia became the second key American ally in the Middle East to demand President Barack Obama change tack towards Iran on Thursday, as it called for US-led coalition "boots on the ground" to fight Isil.
    Prince Saud al-Faisal, the Saudi foreign minister, told John Kerry, the US secretary of state, that he risked allowing Iran to "take over Iraq", echoing Israel's recent concerns over the White House's policy toward Tehran. 

    And Jim Michaels (USA Today) speaks to the prime minister of another regional player, Turkey's Ahmet Davutoglu who states, "All these cities, Sunni-populated areas, should be liberated by the inhabitants of those cities.  If Shiite militias come in, then there will be sectarian war."

    Haider al-Abadi is Iraq's Prime Minister.  And he's quite taken with himself.

    On International Women's Day, PM Al-Abadi stresses commitment to increase representation of women in senior positions
    47 retweets 33 favorites

    How wonderful.  Except . . .

    PM Al-Abadi met with Baghdad's new mayor Dr. Thikra Alwash and discussed plans to rejuvenate the capital its services
    33 retweets50 favorites

    That's the Mayor of Baghdad.  A woman.

    And that speech he's congratulating himself for?

    All Iraq News reports he stated he was pressured to appoint a woman to be mayor of Baghdad.  He didn't want her.  (He was told by US officials that Iraq's black eye on women's rights since the 2003 invasion was hurting Congressional support.)

    And that's not even getting into his offensive remark that women have a role to play on the battlefield:  encouraging men to fight.

    Women in Iraq have been fighting and defending Iraq since before the 2003 invasion.

    Women since have fought in many roles.  The Kurdish Peshmerga, for example, has women fighters.  The Sunnis have offered DOI -- Daughters of Iraq -- the female counterpart to Sons of Iraq.  The DOI was paid less than SOI but didn't have an easier job.  Female suicide bombers meant the 'new' (post-invasion) police were forced to (again) hire women (men aren't allowed to search women).

    So his remarks were really insulting.

    Women's role is to encourage men to fight and the only woman he's appointed (have we looked at his Cabinet) was the Mayor of Baghdad whom he stated, on this day of observance for the rights of women, that he only appointed because he was pressured into doing so.

    the telegraph of london
    richard spencer