Justin Miller, a 33-year-old Minnesota veteran, took all the right steps when he began having suicidal thoughts in February. He reached out to the Veterans Affairs hotline. He promptly sought emergency treatment at the Minneapolis VA Health Care System. And he was a cooperative patient during his four-day stay, with staffers noting he grew more relaxed and was looking forward to his discharge.

Staffers assessed Miller’s suicide risk as “intermediate/moderate” before he walked out the door. They were wrong. Miller never left the hospital’s parking lot, where he was found less than 24 hours later, dead from a self-inflicted gunshot wound.

Recently released findings from the VA Office of Inspector General, which investigated Miller’s death, are careful to say that documentation and follow-up failures were not “causal” in Miller’s death. But the “deficits” uncovered in his care are deeply disturbing. In particular, how did the risk assessment go so wrong?

There are no easy answers, but another heartbreaking VA report released in late September underscored the urgency of finding answers. In plain language, the newest VA National Suicide Data Report makes it clear that there are many veterans struggling with mental health on the homefront, and far too many are taking their lives.

The report analyzed data from 2005 to 2016. During that time, the number of veterans lost to suicide has frustratingly hovered close to about 6,000 a year. Veterans as a whole, from those who served in Korea to the latest conflict, remain at higher risk of suicide than the general population. “In 2016, the age- and gender-adjusted rates of suicide were 26.1 per 100,000 for Veterans and 17.4 per 100,000 for non-Veteran adults,” the report said.

The rate is highest for those in Miller’s age group, and sadly it rose substantially from 2005 to 2016. In 2015, there were 40.4 suicide deaths per 100,000 veterans ages 18-34. In 2016, the figure was 45 suicide deaths per 100,000. The report also offered state breakdowns. A look at Minnesota’s is chilling. An older group of veterans here — those ages 35-54 — are far more likely than veterans nationally or in the Midwest to take their own lives. The suicide rate for this group is 45.6 per 100,000, compared with 33.4 in the Midwest and 33.1 nationally.

A Sept. 27 congressional hearing led by U.S. Reps. Phil Roe, R-Tenn., and Tim Walz, D-Minn., should have put a bright spotlight on both reports. Roe is the chairman of the House Committee on Veterans’ Affairs. Walz, who is a Minnesota gubernatorial candidate, is the committee’s ranking member and requested the investigation of Miller’s death.

The full committee hearing unfortunately was overshadowed by another event on Capitol Hill that day — the Senate Judiciary Committee hearing on Supreme Court nominee Brett Kavanaugh. Coverage of the public health crisis among veterans fell disappointingly short, jeopardizing the awareness needed to build support for change.

Improvements are underway at the Minneapolis VA medical center, but broader fixes are needed. Among them:

• The VA needs to fill staff vacancies, particularly those for mental health care providers.

• The agency should study medical marijuana use to treat post-traumatic stress disorder and chronic pain. Passage of Walz’s VA Medicinal Cannabis Research Act would kick-start that work.

• Congress should sufficiently fund previously passed legislation, the Clay Hunt SAV Act, to help veterans struggling with mental health.

• A national three-digit number should be considered to encourage use of the Veterans Crisis Line and the National Suicide Prevention Lifeline.

Sadly, there is no panacea to what experts have accurately called a suicide “epidemic” among veterans. But if implemented, these measures would work in concert to begin closing the cracks that Miller so tragically fell through.

To reach the Veterans Crisis Line, call 1-800-273-8255 and press 1. It is open to those not enrolled in VA health care. The National Suicide Prevention Lifeline uses the same main number: 1-800-273-8255.