Article 99: saving money versus saving lives

Howard Fischer
Uppsala, Sweden

 

Marine corps helicopter transporting injured. Some of these men may seek treatment as veterans
A U.S. Marine Corps helicopter transporting wounded during “Operation Urgent Fury”, the U.S. invasion of Grenada in October 1983. photographer: TSgt. M. J. Creen, USMC. Public Domain. Via Wikimedia.

“There are some patients we cannot help; there are none who we cannot harm.”

—Arthur Bloomfield, M.D.

Article 99 is a 1992 film that Glen Flores calls number three in his “top ten” list of doctor movies.1 Peter Dans2 calls it “a M*A*S*H clone with a generational connection through Kiefer Sutherland.” The movie starts as Pat Travis, a middle-aged farmer, leaves home to get a definitive diagnosis and care at a Veterans’ Administration (VA) hospital. Mr. Travis was a decorated US Marine sergeant who fought in the Korean War. He tells his wife, “Uncle Sam is gonna take care of me just fine.”

The Veterans’ Administration became the cabinet-level US Department of Veterans’ Affairs in 1989. It is charged with providing health care to eligible military veterans for their entire lives. The Department has 1,293 hospitals,3 employs 400,000 people, and had a budget of $117 billion for health care and benefits in 2021.4

When Mr. Travis arrives at the hospital’s registration area, he finds a room crowded with veterans, people shouting and swearing, long lines, and short tempers. He is told by a patient who is “the resident sage”5 at the hospital that “the enemy is behind those desks,” meaning the registration personnel. Mr. Travis tells him that his doctor thinks he needs a (coronary artery) bypass, and the “sage” informs him, “The only thing being bypassed here is you.” Mr. Travis feels more and more upset and stressed and then has a myocardial infarction with asystole (no heartbeat) in the waiting room.

One member of the team that resuscitates him is Dr. Peter Morgan (played by Kiefer Sutherland), an intern working his first day at the hospital. It is his third “code blue” of the morning. The movie will follow Mr. Travis and Dr. Morgan as they struggle with the hospital’s bureaucratic administration. Their stories will intersect several times.

Before his heart attack, Pat Travis heard about “Article 99.” The concept was real, although the name given to it in the movie is not. “Article 99” stated that if a veteran had a condition that was not a result of military service, it could not be treated by the VA system. (This was changed in 1996 with the Veterans Health Care Eligibility Reform Act.)6 In the film, a veteran with post-traumatic stress disorder who received an “Article 99” letter shoots up the registration area with an assault rifle. The blasé hospital staff, hearing about this, suppose it is “probably just another patient going berserk.”

Dr. Richard Sturgess (played by Ray Liotta) is a heart surgeon who has worked at the hospital for seven years. He has a team of attending surgeons and residents who work smoothly with him in the operating room. About one-half of the male patients have heart disease and would benefit from cardiac surgery. The hospital administrator (also a physician) is focused on cost-cutting and not on surgeries for conditions that are not from service-related events. “We’re not responsible for every . . . [person] out there just because they wore a uniform.” He is a typical example of the “money-grubbing hospital administrators (the fallback “black hat” characters in medical dramas) [who] believed in fiscal restraint.”7 Dr. Sturgess and his team have hidden stocks of surgical equipment and perform surgery—”unauthorized” by the VA—on patients who need an operation to survive. They steal pacemakers from the “monkey lab,” which has a greater supply than the surgical department.

Mr. Travis has recovered from his heart attack. The hospital administrator orders his discharge. He will not, however, live long without coronary artery bypass surgery. The Sturgess team, of which Dr. Morgan is now a willing participant, hides Mr. Travis in various locations in the hospital, including a women’s ward and the hospital laundry. His condition deteriorates and Dr. Sturgess decides that he must have the bypass immediately. While he is being taken to an operating room—unauthorized, of course—the veterans take over the hospital with the sympathy of the doctors and nurses. They make demands for improvements and lock out the administrator and the security guards. The security guards do not want to face armed veterans, and the local police have no jurisdiction over a federally-run hospital.

The VA hospital system Inspector General (with federal marshals) arrives to negotiate in good faith with the leaders of the veterans. Dr. Sturgess convinces the leaders to negotiate, instead of having an armed confrontation (which they cannot win). The Inspector General learns how badly the hospital is run, fires the administrator on the spot, and tells him he is going to need a good lawyer to defend him. “It’s sad but true,” says the General, “but s**t does float to the top.”

Mr. Travis survives his operation. A new administrator is in place, but from his first announcement, it sounds like he may be as bad as his predecessor. Drs. Sturgess and Morgan exchange looks of dismay.

 

References

  1. Glen Flores. “Doctors in the Movies,” Arch Dis Child, 89 (12), 2004.
  2. Peter Dans. “Doctors in the Movies: Boil the Water and just Say Aah, Bloomington IL: Medi-Ed Press, 2000.
  3. NA “About VA. Health. Mission Statement” 2012.
  4. René Campos. “A Battle is Brewing over the Rising Costs of Health Care,” MOAA, 2021.
  5. Dans. “Boil the Water.”
  6. H.R.3118-104th Congress(1995-1996) Veteran’s Health Care Eligibility Reform Act of 1996 congress.gov
  7. Gregg Vandekiet. “From City Hospital to ER: The Evolution of the Television Physician,” In Cultural Sutures: Medicine and Media, Lester Friedman (ed), Durham North Carolina: Duke University Press, 2004.

 


 

HOWARD FISCHER, M.D., was a professor of pediatrics at Wayne State University School of Medicine, Detroit, Michigan.

 

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