not quite as bad as turtle logic, but all the same:

"Good Luck, Bad Luck"

Forgive me if I've already told you the story about the Chinese man whose plough horse runs away.
"Oh, you poor man, what bad luck!" his neighbors commiserate. "Perhaps," replies the man.
Then the horse comes back... followed by a wild horse it has befriended.
"What good luck!" his neighbors gush, "Two horses in place of one! And there might be a third horse on the way!" "Perhaps," says the man.
The man's only son starts to train the wild horse, but the horse throws him off and he breaks his leg.
"What bad luck! Your only son injured, and you're already behind on the planting!" "Perhaps."
Then the warlord's army comes through town, and conscripts all the able-bodied young men for soldiers or slaves. The old man is too old, and his son is rejected due to the broken leg.
"How lucky you are to have your son spared!"
"Perhaps."

Soldiers learn not to trust luck, or even justice, too often.

Ernie won the lottery for VA health care when his knees got injured during a 196-hour "flight ops." (Launching and recovering aircraft on a US carrier during the "peacetime" bombing runs in the prelude to the Gulf War).
There's no quicker way to get 6'6" down under the wing of a plane than dropping to your knees, but ordinary human-issue kneecaps aren't designed for that kind of wear. Ernie's are now made of superior materials, mainly aircraft epoxy, possibly sprinkled with fragments of the original bone dust. He spent several months in the military hospital complex in Naples, on crutches, while his knees adapted to their new composition. They warned that he could lose the ability to walk within 5 years.

He did not use the VA after his discharge. He took private ballet lessons and athletic training, worked on boats and ships where the constant motion strengthened his ligaments and joints. Fifteen years later, still walking, he was training for US Nationals in rowing, riding his bicycle on long-distance races and tours, and performing with a Corvallis-area ballet troupe.

He fractured his ankle in 2003. It healed slowly, and he rebuilt his strength. He had resumed training in rowing and bicycling, and worked as a building apprentice, cook, site caretaker, and community volunteer.

Then he was hit by a car in 2006.

OHSU patched him up; the car's insurance paid for most of the initial 3 weeks in the hospital, plus a year of follow-up appointments. It took that long to get the paperwork going, and get Ernie into the VA computers. Finally, 8 months after the accident, the VA scheduled an evaluation to confirm service-connected disability. They rated him at 20% SC (10% for each knee), which made him eligible for health care on more recent injuries as well.

So, almost 2 years after the accident, we just finished a series of appointments with the VA's ortho- (bone) and pain specialists. Conclusions:
- Why are you here today? Oh.
- yes, it's healing; the dye scan and X-rays both confirm bone growth.
- no signs of infection or "sympathetic dystrophy," whatever that means.
- yes, continue with current meds. Pain clinic and scan interpreters both suggest increasing one med twelvefold in an effort to "reset" nerves. (Doubling the dose previously had Ernie feeling like "there's an ice cube in my chest," as nerves all over the body registered numb or cool. That's a little scary, especially when accompanied by nausea, so I somewhat doubt that a twelvefold increase will be comfortable or even safe.)
- no, we probably won't recommend amputation: there's still some intact muscle on both front and back. Recent studies show that with this level of nerve pain, amputation doesn't necessarily stop the pain; the nerves can easily get stuck in the "on" position instead, leaving you with all the pain and no leg.
- no, there's not much more we can do;
- yes, it's a good idea to keep exercising and building up. That's pretty much the best way to achieve any improvement; animal tissue (collagen) of all kinds heals better with exercise, and it may eventually help reset the pain threshold as well. If you can't feel it, you're going to have to look at it to see if it's turning red or purple, and cut back if it takes more than a day to recover from a training program.
- yes, Physical Therapy is available, but as an athlete you'll probably want to do more than they're trained for. Rowing, bike, walking, etc. Build up gradually, bone, muscle, and ligament all at once.

After making "Monsters, Inc" jokes with the receptionist, we went back to the pharmacy to refill prescriptions. There's no charge for the medicines, but refills by mail sometimes result in random bills for shipping, months after the fact.

We went to the pharmacy, took our number, sat down, got up, reported in, made photocopies/smoked a pipe, went for lunch, came back, checked for Ernie's name, waited in line. People were very considerate about letting others in and out of the crowded space, especially the walkers, wheelchairs, and scooters.
One patient was not: "The doctor called it in, it's not like it has to be filled, it's an inhaler, all they have to do is pick it up off the shelf. Why do I have to take a number and wait in line to tell them I'm here and then wait an hour and come back and pick it up?"
Another patient kept asking, "Does anyone want number 51? I took two by mistake. Does anyone want an earlier number?" I took it back to the dispenser for him, then let the pharmacist know it wasn't in use when she called it, then retrieved it so no-one would take it by mistake, and began to fold its corners idly.
The procedure is the same regardless of rank, disability, which medications are being picked up, etc. It's complicated slightly by the frosted glass privacy partitions that make it impossible for the staff to see the waiting room, meaning that they call a number and then wait a considerable amount of time to see if someone will hobble up to their frosted cubbyhole. But the numbers are also posted overhead on a glowing board, opposite the cubbies, and on the whole it works OK.
We waited in line twice, because with four prescriptions (one of which was on order to be mailed later) it's easy to miss one. Then when you get to the car and find it's not in the bag and your name is no longer on the screen, waiting in line seems like the smoothest way to remedy the situation.
We chanced to get the same pharmacist both times. He apologized; there's not really a system for cross-referencing if you have multiple medications and they're ready at different times. We checked off the two he'd accounted for in the first batch, and he quilkly found the other two. I gave him a small paper coyote I'd made from the "number 51" paper tag.
On the way home we debated the merits of filling "quick" prescriptions first, and decided it could be more trouble than it's worth. People get bent out of shape when they're hurty, tired, or stressed; the VA, and any pharmacy, is full of people who have all those conditions and more, and have probably run out of meds.
They're going to get upset if things don't go their way; if someone else gets served first, or if it takes longer one time than another, or if they perceive others as unreasonable. To establish a "mob mentality" or peer pressure that supports success, the process has to be consistent, create coherent expectations that patients can understand and enforce upon each other, and be reasonably effective and "fair." Pharmacies the world over seem to use the "first come, first served" system. It's methodical enough to allow the pharmacist, at least, to stay calm even while the customers boil over.

At the VA, you'd think that because everyone is in the same computer system, they _could_ streamline the process and just fill the prescriptions before people got there. But if some patients go to several appointments, or request fill-by-mail instead of coming to pick up, or wait a few days and come back when it's less busy to fill their prescription, or even take it to be filled at another pharmacy, that could be a lot of filled prescriptions sitting around gathering dust while people sat in the waiting room waiting for prescriptions that weren't being filled yet.
Rarely do they streamline something when it can be redundantly complicated. Rarely do the busy receptionists recognize a returning patient, though with practice they may begin to use a first name as well as a last-name last-4-digits lookup code.

* * *
Such a strange combination of high-tech medicine, cost-cutting shortcuts, redundant systems, chronic oversights, and methodical plugging away at the daily flow. People and appointments and medicines falling through the cracks, being picked up weeks or months later.
Signs posted in most clinics, and printed on every appointment reminder, warn vets to call ahead at least 24 hours if they are going to miss an appointment. These messages generally go to a recorded system that forwards the message to the clinic in question; some clinics take phone calls, others don't.
The VA does not call, or allow patients to call, and schedule new appointments. Appointments are scheduled at the doctors' convenienve and request. If the doctor or clinic has a problem, they can reschedule without notice to the patient. A separate scheduling staff that sends out letters for appointments, usually without a phone call or confirmation of the vet's schedule. On at least two occasions (one for a new appointment, that went to an old address; the other for an appointment that was rescheduled by the providing clinic) the letter did not reach us until several days after the appointment.
It doesn't help that Ernie's phone and address have changed several times in his first year of recovery. It's been very difficult to get all the VA systems to correctly update the address each time.

If we're going to use a state-sponsored medical system, I'd prefer something like Medicare or Medicaid. State insurance, paid for in advance by working folks, who are also eligible for increased or early coverage due to disability. Patients select private providers, based on their needs and their physician's recommendations. Not all providers accept MedicAid, but many do.
I took Grandma to a number of doctors, clinics, and hospitals, mostly privately run, some religious. They provided excellent care, would make reminder phone-calls if requested, allowed phone-in or in-person scheduling, and on a few occasions worked out a creative compromise when Grandma was too sick to come in, but we needed advice.
Even in a universal health care system, private providers can be the main way to operate. And the "We Don't Take StateCare" providers could also survive by offering luxurious, specialized, premium care -- from cancer research to plastic surgery to herbal "tonics." If you want care that's not in the rulebook, you can pay the difference out of pocket.

The VA is susceptible to budget disconnect. Providers are busy full time, whether or not they provide effective care; patients have no choice of provider, and the popular providers may or may not be compensated for their increased workload. (On the other hand, I didn't enjoy the logistical nightmare when OHSU's treatment resulted in 5 or 6 separate billing agencies billing Ernie for the same hospital stay and emergency care, everyone from physician's group to reception to radiology to the anaesthesiology group. The latter literally had a warning to the effect of "Warning: We have no communication with the rest of OHSU, we are not aware of any arrangements you have made with them," printed on every bill. A few bills even came with no information other than "OHSU" to indicate what service was being provided. And we received at least one fraudulent claim from a predatory collections agency, for an ambulence bill that had, to the best of our knowledge, been paid a year or more ago. So private care isn't a panacaea, by any means.)
The military has financial incentive to deny coverage, either based on lack of evidence of service-connected disabilities (such evidence may be warehoused in the backlog of military service records and medical records), or because it is still covering up the evidence of harm done by its officers and experts.
Radiation poisoning from nuclear power plants or depleted uranium shells is one example that worries Ernie: some VA personnel have talked about warning vets not to marry another vet (high risk of birth defects in children) but the military doesn't offer to accept responsibility or provide disability coverage for the cancers, systemic diseases, and birth defects that result from such exposure.

Mostly, they do separate "assessment" appointments (that determine eligibility for coverage) and "treatment" appointments. But it's hard not to wonder whether the doctors and counsellors have budget as well as treatment mandates. Private care providers can tell the patient, "Here are the options, and the prices. Here's what your insurance will cover. What would you prefer?"
I wonder if the VA providers are able to do that: patients are either covered (usually fully) or they're not seen at all. So it makes no difference to the patient what the cost is. And it makes no difference to the provider whether this particular patient leaves satisfied.
That leaves the providers in a position to judge what's "worth it" with respect to budget as well as treatment, on patients they may see only once. We've only rarely had providers ask about treatments outside the scope of the VA, like acupuncture or massage.
To see the same doctor twice is rare, so it's hard to ask about proposed new treatments outside of the VA, and continuity of treatment relies on you being able to remember what the last doctor told you, and ask the right questions.
If something goes wrong -- an appointment letter doesn't arrive, or someone drops the ball, or they get a busy signal on the phone and decide you're "unreachable," it can take months to remedy. We've waited 6 months between primary care appointments, to find that the follow-up that was ordered the first time was dropped by the clinics ordered to provide it.
Soldiers aren't trained to politely agitate for what they want or deserve; they're trained to take what they are given.

* * *

There are 360 degrees of elephant, and only two eyes and two ears. Don't stand too close. Some days, you've got its attention; some days, you're just talking to the tail.