In an era when political partisanship has become a blood sport and the members of Congress have become almost completely detached from the U.S. military – except for the funding of spending bills – there is still one member who manages to keep his connections to both institutions. Sen. Lindsey Graham, R-S.C., is now the only senator who sits on both the Senate Armed Services Committee and the House Committee on Veterans Affairs, along with maintaining his status as a JAG [judge advocate general] lawyer in the Air Force Reserve. Considered by many to be one of the last truly bipartisan members of the Senate, he has a unique perspective on the issues of military and veterans’ health care in America. We recently sat down with Graham to get his thoughts on the present and future issues regarding health care for those who serve:

John D. Gresham: As a member of Congress and the armed forces at the same time, what do you feel is America’s debt to its service members and their families and our veterans’ community?

Sen. Lindsey Graham: I think George Washington said it the best: “The day that the country fails to take care of those who have served and fought for our freedom, basically our best days are behind us.” That’s not an exact quote, but from Washington up until now, every major political leader in this country, Republican or Democrat, has one thing in common, and that is the belief the nation as a whole owes a great debt to those who serve and sacrifice. That’s one area where bipartisanship strongly exists — in fulfilling the obligations we have to the men and women in uniform.

You have an unusual status within Congress, being one of a handful of members in either House who’s on both the Armed Services and Veterans Affairs committees. What made you want to gain membership on both of these committees in the Senate, and what value do you feel there is to you and the other members who have that dual membership?

I wanted to serve on both the committees because of the target audience. I’ve been a military officer since I graduated from ROTC at the University of South Carolina. I’m the only member of the Senate who continues to serve in the Guard or Reserves. As I do my Reserve duty, I want to make sure that they know they’ve got an advocate in the Senate. Serving on both of these committees gives me a unique opportunity to understand the needs of our veterans’ community and active-duty components.

What kind of reaction do you get from your fellow committee members on the Senate Armed Services and Veterans Affairs committees to your military service combined with your dual committee membership?

It’s a positive reaction. Let me just say that some of the best members of Congress who support our veterans have never served a day in uniform. It is by no means required to have been a member of the military to serve effectively as a member of Congress. Having said that, my fellow committee members and colleagues understand that having done military service and being involved still with the Guard and the Reserves, they listen to what I say. I don’t try to overdo it. My contribution to the Air Force Reserves is very small, but it does give me a unique perspective.

An example of this was our effort to get TRICARE for the Guard and Reserves, which was an effort that came about from my work with former Sen. Hillary Clinton of New York. When she was in the Senate, we joined forces to make sure the Guard and Reserves would be eligible for TRICARE. I understood the need to expand this program because our Reserve forces are being called to active duty in record numbers. Many of them are unable to deploy because of health care problems. That is an example where, because of my being in the Reserves, I was able to learn about a need, communicate it to my Senate colleagues, and they responded. Now every member of the Guard and the Reserves and their families are eligible for TRICARE. It also helps in recruiting, retention, and improving the overall quality of the force.

Let’s talk a little more about TRICARE and the active-duty military medicine side. What kind of trends, as a member of the armed services, have you seen in the past year or two regarding funding and legislation associated with military medicine in general and the TRICARE system in particular?

Well, I ask this question of all the family groups that come before our committee: How would you rate TRICARE? Their comments are usually pretty high for quality of service, but average or below average when it comes to access. Presently, the biggest challenge to TRICARE is making sure you have enough providers to meet the needs of our service members and their families. A big problem I see with TRICARE is making sure we have a large enough provider network to provide a variety of services. Funding is strong and I think the reforms that we’re looking at in TRICARE will make it more likely that doctors and hospitals will sign up to join the network. Because of reimbursement rates, one of the biggest challenges we face is getting physicians and hospitals into the network. We are going to work to improve that area.

Let’s talk a little bit about that in terms of the probable actions that Congress may take regarding TRICARE in the next few years. What sorts of additions, deletions, and reforms do you feel might be in the offing for that?

A few things. To ensure people have better access to prescription drugs, we’re adding a beefed up mail-order program. We also need to look into some preventive health care opportunities that don’t exist today to keep our military members and their families healthy.

Another thing we have got to be honest about is that the percentage of the DoD [Department of Defense] budget that is being absorbed by health care for active-duty and retired members could be up to 15 percent in the next decade, especially with the “graying” of our retired community. We haven’t had a TRICARE premium increase for the retired community since 1989, and we’re going to have to look at adjusting premiums to get it more in line with civilian health care programs. If we do that, we’ll try to do it slowly and in a means-tested fashion, so you don’t have to ask people for more than they can afford to give. The Bush administration wanted something like a 30 percent increase a few years ago, and that was just too much to ask. But I do think we’re going to have to adjust premiums over time.

That sounds like another public health care debate that’s been in the news lately.

It is. When you look at DoD’s budget, the health care part of their budget is growing exponentially, just like any other business. And just as any business with limited resources, commanders will have to make hard decisions between growth in health care and the equipment we need for modernizing our weapons programs. I think we can do this in a way that would be fair, that would be phased in over time, but I don’t want to mislead people.

The TRICARE system needs to be about more choices and more providers. We’ll have to look at sustainability and right now, on its current course, TRICARE is not sustainable. We need to take a look at ways to put it on sounder footing.

When I retire from the Reserves, I’ll be eligible for TRICARE.  I hope, and I think that in my case and at my income level, I can pay a little more than the current rate. I would be glad to do so.

Can you give us your personal thoughts on the current state of wounded-warrior care, and the programs for re-assimilating them into both the military and society?

The desire is great, with a lot of talented people involved, but right now the programs are too bureaucratic. We recently had a hearing with Sen. [Ben] Nelson [D-Neb.], the chairman and my counterpart on the Personnel Subcommittee, and we had a bunch of wounded warriors come in to tell us about how it works, and the Army, Navy, Air Force, and Marines all have different versions of the program. The desire to get this right is terrific, and the Pentagon is reforming this system as we speak to make sure when you go from the Department of Defense [DoD] to the Department of Veterans Affairs [VA], you don’t get “lost.” They want – and I think all the members of the committee do as well – want going from one government bureaucracy to another to be a seamless transition.

For example, with treatment for traumatic brain injury [TBI], we need to open up access into rural areas so our veterans can continue to get the care that DoD provides. That’s one area. Another is compensating family members who may lose their jobs to take care of a wounded warrior. I’m a big advocate of expanding economic opportunities to family members who are basically having to give up their jobs to take care of these wounded warriors once they’re discharged from DoD care. The big concern I have is what happens when you leave the DoD facility, go back into the civilian community or into the VA system. We’re constantly monitoring how to make sure people don’t fall through the cracks.

If a soldier is traumatically wounded, the healing process can takes months or years. You’ll never have a complete recovery. The benefits for the wounded service member and the chance to rehab and go back into the job market are pretty good. I think the one thing we need to look at is helping the family members for having to basically give up their careers to take care of these wounded warriors. I think they should be eligible for compensation just like any in-home contract service would be.

As a member of the Veterans Affairs Committee, what trends have you been seeing the last couple of years regarding funding and legislation of the department in general and the VHA in particular?

Well, the VA has gotten more money in the last couple of budget cycles than in any time that I can remember. But the number of injuries coming from Iraq and Afghanistan and the need for VA services is also at an all-time high, really since World War II or Vietnam. We have a lot of service members being injured.

One thing that I’ve been pushing is for the VA to do more partnerships. The Charleston project is a good example of what I’m talking about. The VA wants to build a new hospital in Charleston, [S.C.]. It’s going to be a tremendous facility and I’m very pleased, generally speaking, with the quality of care being provided by the VA Gen. [Eric K.] Shinseki is a good guy to have in charge in an important time. But the Medical University of South Carolina also wants to build a new hospital.

So what we’ve done is created a partnership between the VA and the Medical University of South Carolina, where they can combine their resources and build a single hospital facility that serves both needs. The one thing I would like to see the VA do more of is collaboration with the civilian community.

What kind of long-term trends do you see for the VA, as well as the VHA, in terms of funding and support by the administration and Congress in the next five to 10 years?

I think it will be robust funding and support because the needs are growing exponentially.

Bipartisanship is hard to find in Washington, but it exists when it comes to wounded-warrior programs and taking care of the veteran. But the goal for me is to make sure that the VA is tied into other service networks. In my state there are a lot of people who have to travel a couple of hours in South Carolina to go to a VA health care center. I want them to be able to access their VA health care services closer to their homes. The VA clinics going out into rural areas are really helping veterans with chronic illnesses. So what I advocate is an expanded footprint where the VA will join forces with civilian health care networks to increase coverage.

There are a lot of health care providers out there that the VA could collaborate with, that would allow our veterans to get quality health care closer to home and, all in all, be a better deal for the government.

While the Department of Veterans Affairs and the VHA get strong endorsements for the volume, value, and quality of care they deliver to the customer base, there’s still criticism over the average of 175 days needed to get a response for a claim, an appeal, or other inquiry. What do you feel should be done to improve this particular metric?

The filing of a disability claim and the resolution of that claim take a long time. Far too long. We need to increase the number of hearing panels to allow the adjudication to go quicker. We just can’t – as a blanket policy – give everyone who applies benefits.

It is a process, where you authorize benefits based on merit and objective criteria. But the one thing that I understand pretty well is that we need to provide better support to organizations that assist veterans. They do a wonderful job.

I believe that it would be smart to allow veterans access to a lawyer, so they could help them put the paperwork together and present their case in a more organized fashion before the VA board or the hearing officer. The government should also pay their legal fees if they’re successful. I think that would help speed up things a great deal.

The more organized the veterans can be when they present their case, the better their chances of a successful clam. The veterans’ organizations do a good job helping get them organized, but most people who apply for Social Security have the benefit of a lawyer. I wouldn’t want the money for the legal support to come away from the federal budget, but I think that from a national point of view, allowing veterans legal assistance would be helpful to their cause. Just think about it. You know, if you’re a veteran out there, and you have a disability, you get all your records together and go sit down with a Veterans Affairs officer. They can help you, but it would also help make the case if you could secure the services of a lawyer, an expert in that area of the law. I think we ought to make that service more available to the veterans today.

You’ve had a chance to visit medical units in the field over the past few years. Can you give us some of your observations on the quality and capability of care and caregivers who are delivering medical treatment to our deployed personnel overseas?

If I had to take one group to single out to get the “Unsung Hero Award” in the Global War on Terror, it would be the military medical community.  The doctors and the Veterans Administration that take care of these people once they’re discharged are doing tremendous work.

I had a young man working for me that stepped on an IED [improvised explosive device] and had both legs blown off in Iraq.  The care he received at the battlefield stabilized him until he got to the trauma unit. Sixty-eight surgeries and three or four years later he’s going to Harvard Law School. He is a medical miracle.

When I do my active-duty tours in Iraq and Afghanistan, I always go to the hospitals. In Afghanistan, these are multinational medical providers. The one thing I can tell the families back home is that I’ve never seen so many dedicated professional people on the front lines of a war delivering health care.

We’ve learned in Iraq and Afghanistan how to stabilize people who have been traumatically injured.  It is going to help America as a whole provide better emergency health care. The combat medical teams out there are saving lives in this war that would not have been saved in any other.

What would you say are the one or two things that concern you most in DoD medicine these days?

Basically, as we reduce base footprints through the Base Realignment and Closure process, we’re reducing the number of health care providers, and access to DoD health care is shrinking. My big concern is about TRICARE members and their families getting enough physicians in the hospitals to provide adequate care for the whole family, not just for the service members. We’ve got to do a better job of signing up providers for TRICARE. As the DoD medical facility footprints shrink, as the number of Navy and Air Force and Army hospitals are reduced, that puts more pressure on TRICARE to deliver.

Let’s ask basically the same question about the VA. What do you see there that you like best and what do you see that concerns you the most?

What I like best is their customer-oriented service. They’re changing their attitude and coming up with prescription drug programs that really do deliver a higher quality of service than I’ve seen in my military life at times. I also see a real robust VA budget, and see collaboration between the VA and the civilian community to provide better service and more capacity. What concerns me, quite frankly, is as we try to build out this organization, it’s the same thing. Once you get out of the VA provider network, once you get away from a veterans’ hospital, more and more people are coming off active duty in Iraq and Afghanistan and going to the rural parts of the country where there’s no VA hospital within a couple or three hours. How do we reach them? Getting quality health care to the veteran in rural America I think is a big challenge for the VA.

How did you become such an advocate for these issues and combine this relationship of military and veteran issues with your career in Congress?

Of all the things I’ve done in my life, and I’ve lived a very blessed life, the best thing I’ve ever done personally as Lindsey Graham, as an individual, was to join the United States Air Force, become a judge advocate, and a member of the Air Force legal team. Good lawyers understand and know their clients. I think I understand the Air Force and consequently have some understanding of the military. I really have gotten more out of my service than I give. It was and continues to be the highlight of my life in many ways.

Years ago about half the Senate were members of the National Guard and the Reserves. Strom Thurmond was a two-star general in the Reserves. Barry Goldwater was a two-star general in the Air Force Reserves. It used to be that a lot of members of Congress served as Guard and Reserve members. I’m the only one in the Senate now. So, I try to rededicate myself every day and every week to make sure that I use these experiences to the benefit of the force as a whole. I do small Reserve tours in Iraq and Afghanistan, and have learned more about what’s going on there during my Reserve duties than I would in a congressional delegation, particularly in regard to rule-of-law issues.

So, I take that knowledge and experience pertaining to the issues. In fact, I take that back to my day job and I think it’s made me a better Senator. The passion comes from knowing the people. I’m in a business where it’s tough. People talk about what they can’t do, what they won’t do. In the military, you talk about what you have to do and your mission. “We will, we can,” is the motto at the base that I was serving in Afghanistan recently. It’s good that I’m allowed to occasionally get out of Washington and go to a military environment with people of different backgrounds are working together to solve a problem. It just helps me in every way possible.

It certainly explains why you want to continue to serve in the Air Force Reserve.

Absolutely! I think it gives me an opportunity to learn about issues I wouldn’t have known about otherwise. Getting away from politics and back into uniform is a morale booster for me.

You’ve been working with the governments in Iraq and Afghanistan on the development of their legal systems and processes. Can you tell us a little about your recent work and what some of your experiences and observations have been?

I work on the rule of law programs in Iraq and Afghanistan. When you think about it, democracy is more than voting. You know, Saddam Hussein allowed people to vote. He got 100 percent of the votes. As a dictator, he was able to do that.

The point I’m making is that the rule of law protects the losers of elections. In the Middle East, if you lose the election, you can lose everything. So people fight to the death over there.

Here, if you lose the election you don’t lose anything but your job. You don’t lose your ability to come back. The rule of law is to make sure that if you find yourself in a courtroom, the questions are about what you did, not who you are.

We’re trying to develop courthouses in the outer reaches of Afghanistan. We’re trying to blend a tribal justice system with a formal justice system. We’re training judges and their lawyers.

One of the first things that General Petraeus did was to provide security for judges. No rule of law program can work if the judges are subject to assassination. We’re working to create a “Uniform Code of Military Justice” for the Afghan army that is up and running. I was involved in helping create that program. They’re starting to do courts-martial now.

No military can operate without a well-disciplined force. Military justice has to be firm and fair. So, we’re doing that with the Iraqi army. I’ve had a wonderful opportunity as a Judge Advocate to work with Afghans and Iraqis while building up their judicial capacity.

I hope we leave behind in Iraq and Afghanistan a political system that accommodates differences and a legal system that people trust and believe in. Militias are formed when the legal systems fail. My goal is to make sure that the Afghan legal system provides basic justice in a way that people do not feel that they have to take up arms against their government. We still have a long way to go but we’re making progress.

You’ve stated that TRICARE and the VA have been delivering health care in a fairly efficient model. What do you see in TRICARE and Veterans Affairs that might provide useful models for the ongoing public health care debate?

The electronic health care record system we’re trying to put in place will improve quality of care. A lot of medical mistakes are made because of a lack of good information. When you move your files from one part of the country to the other, the physician treating you in the new location should know everything about your health care history so they can make good decisions. The VA has invested billions of dollars in improving electronic health care records. DoD has a model system there because of a sort of captive audience.

Generally speaking, what I think we can learn from the DoD and the VA is collaboration in health care practices that keep people healthy. The military is very focused on keeping people fit because that’s required to do your mission. You can literally get an Article 15 [administrative punishment] if you get sunburned, if you’re negligent in the way that you take care of yourself. So I would like to stress wellness like the VA and the DoD do, because at the end of the day it’s cheaper and provides a better quality of life to keep people out of the hospital than it is to treat them inside one.

What do you have in the way of legislative goals in the next few years for expanding medical care and benefits for service personnel, their families, and veterans?

No. 1, to expand the number of options available to TRICARE recipients by getting more providers in the network. Eye care, ophthalmology, dental care, expanding health care options to ensure wellness. On the VA side, to create legislation that would allow them to partner with the civilian community to leverage their dollars. More coverage … more collaboration.

Is there anything else that you’d like to add?

One thing that I’d like to say is that every time I do a Reserve tour, I’ll hear about a story that moves me but that I think is typical.

On my last tour in Afghanistan, the first day I was there they announced the death of a 59-year-old sergeant first class who had retired from the Army. He was from Guam, had served four tours of duty in Vietnam, and came back on active duty to serve in Afghanistan.

Every morning, he would start PT [physical training], running around the track with the American flag. He was a very big guy with a strong affection for the Afghan people. This was a man who had it made, had grandchildren, came out of retirement, volunteered to go on a mission.

He got killed in an IED blast. Stories like his inspire me.

At his memorial service, there were a lot of Afghans there and there wasn’t a dry eye in the house. I just want to tip my hat to him and all like him. We’re lucky as a nation to have men and women like that.

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