Alaska's Vanishing Care

Last fall, an Alaska veteran made the five-hour drive from Homer to Anchorage for macular degeneration treatment. But after eight phone calls to VA’s Veterans Choice program, Alaska Retinal Consultants couldn’t get authorization for an injection vital to maintaining his eyesight. Out of concern for the veteran’s health, the clinic provided the treatment free of charge – then told VA it was done with the Choice program.

“We were talking with people in five different states,” says Katie Reilly, former operations manager for Alaska Retinal Consultants. “It was not unusual to talk to four to eight people to get one thing authorized. There was no reliability, no consistency and conflicting information – things you fire people for in a normal business.”

That’s a common sentiment among veterans, families and health-care providers throughout Alaska who were suddenly forced to switch to Veterans Choice in mid-2015 after VA ran out of money in other programs. Advertised as a congressional solution for the patient backlog at Phoenix and other beleaguered VA medical centers, the Choice program sabotaged a successful multiyear effort to provide Alaska veterans access to health care close to home.  

“All of the programs we were using to provide care to veterans in Alaska communities were gone,” says Verdie Bowen, director of the state’s Office of Veterans Affairs. “We were getting hundreds of complaints a day from veterans and family members.”

The ensuing health-care disaster was akin to a “five-alarm fire,” in the words of Marine Corps veteran and U.S. Sen. Dan Sullivan, R-Alaska. Surgeries were canceled. Everything from chemotherapy to colonoscopies was delayed for weeks, if not months. Veterans were then forced to start from scratch, enrolling in a new VA health-care program and finding doctors and clinics willing to jump through the hoops to qualify as Choice providers. (The private contractor for Choice failed to sign up any Alaska physicians before it rolled out the program.) Not to mention enduring an onerous new process for getting approval for even the most routine medical care. 

“Veterans Choice is like laying out the carpet,” says Frank Lazo, commander of Prince of Wales Post 26 in Craig, “and then jerking it out from under you.”

“This was a knee-jerk reaction by Congress to the Phoenix problem,” Bowen adds, referring to the patient backlog scandal that cost VA Secretary Eric Shinseki his job in 2014. “They completely misunderstood how this would affect care in Alaska.”

Bureaucratic blunder Alaska has long recognized the challenges of caring for veterans in a state more than twice the size of Texas but equipped with just five VA clinics and no VA hospital. Because roughly half of Alaska communities are not on a road system, seeing a VA doctor means traveling by airplane, boat or both. “It’s quite the traveling ordeal if you are going to have an appointment with VA,” Lazo says. And veterans with less than a 30 percent VA disability have to pay for that travel out of their own pocket. 

In 2010, Alaska began working with DoD, VA, private medical providers and Native health centers to give veterans access to VA-reimbursed medical care in their local communities, Bowen says. The result was a trio of programs that made the best of what was available in different parts of the state: the DoD/VA Joint Venture agreement at the state’s military hospitals and clinics, the Care Closer to Home initiative – VA-reimbursed medical treatment from private physicians – and the VA/Alaska Native Healthcare program. The latter alone, brought to fruition by years of negotiation and 26 separate agreements, made VA-reimbursed care available to native and non-native veterans in 122 clinics across the state. 

Volunteers coaxed reluctant former servicemembers into enrolling in the rural health programs, resulting in many Vietnam War veterans getting medical care for the first time, says Jan Storbakken, veterans service officer for Post 26. The Alaska VA worked with veterans to find the most logical way to see a doctor. 

“It was fabulous,” Storbakken says. “If it was cheaper and easier, Southeast Alaska veterans could go to Seattle for care.”

Getting that approval was comparatively easy. “I could make one phone call and get an appointment quick,” says Korean War Navy veteran Budd Burnett, who lives on Prince of Wales Island in southeastern Alaska.

Veterans Choice turned all that on its head. A private contractor took over scheduling, and routed Alaska veterans’ requests for medical appointments first to a call center in Louisiana and later to one in Washington state. What once took a phone call became weeks-long scheduling marathons. 

“They are completely ignorant of Alaska cities and distances,” Burnett says. “They think the Alaska Marine Highway System is a road you can drive on, not a ferry you take.”

Under Veterans Choice, Alaska veterans wait far longer for medical appointments and pay more out of pocket for that care. Take Burnett. After weeks of phone calls, Veterans Choice finally approved his finger surgery and gave him a date to have the operation at a civilian hospital in Ketchikan. He made the three-hour, $210 ferry ride from his home on Prince of Wales Island to Ketchikan, only to discover that the Veterans Choice call center had given him the wrong surgery date. By the time Veterans Choice straightened out the mess, the surgeon Burnett requested had retired and moved out of state.

It then took more than three months for the program to arrange for Burnett to get a colonoscopy after a clinic on Prince of Wales found evidence of bleeding in his lower intestinal tract. “It was ridiculous,” he says. “A person could have died if it had been more serious.”

“This new program is waste, fraud and abuse for Alaska,” Storbakken adds. “Millions of dollars that were going to care for veterans is now going to administration.”

Protests and promises Complaints from the governor, state officials and Alaska’s congressional delegation were so persistent that David Shulkin, VA undersecretary for health, restored funding to the VA/Alaska Native Healthcare program within days. But the Care Closer to Home program – which gave veterans VA-reimbursed access to private clinics – has been revived only on a case-by-case basis. 

A VA spokesman maintains that neither the Native Healthcare partnership nor Care Closer to Home ever lost VA funding. But the agency does acknowledge that using a private contractor to run Veterans Choice “created some challenges and confusion for veterans and community providers.”

The disruption in veterans’ health care was so serious that Sullivan organized a Senate Veterans’ Affairs Committee field hearing in Alaska last August. The testimony included 35 pages of complaints submitted by Alaska veterans left in pain and limbo by the sudden switch to Veterans Choice, an untested program designed for Arizona, not Alaska.

By then, Alaska Retinal Consultants had walked away from Veterans Choice.

“I can remember somewhere around that time telling the VA that if they weren’t going to fix it then we weren’t going to deal with them anymore,” says Dr. David Zumbro, who served 20 years in the Army before joining the office in Anchorage. The process was onerous. “It resulted in one of our employees dedicating the majority of her day helping veterans navigate the confusing bureaucratic morass known as Veterans Choice.” 

Alaska Retinal Consultants and its veteran patients – who are dealing with everything from diabetic retinopathy to macular degeneration – were fortunate. VA dropped the mandate that they use the Choice program. 

“Since then, my staff has been dealing directly with the VA in Alaska and we have not had a problem taking care of Alaska veterans,” Zumbro says. That’s the kind of local control that makes VA health care work for Alaska veterans. 

But Alaska Retinal Consultants has clout other physicians might not be able to wield, with the only fellowship-trained retinal surgeons in the state. Other medical practices are still struggling, particularly to get reimbursed under the Veterans Choice program, Storbakken says.

And veterans continue to fight to see the physician of their choosing. “There is often no choice in Veterans Choice,” says Dan Kosterman, a disabled veteran and Eagle River optometrist who has endured long delays getting treatment for everything from spinal pain to sleep problems. “It seems like it takes an act of Congress to get an appointment with my provider. It’s like they are trying to shove veterans out the door.”  

At Sullivan’s urging, VA agreed to pilot a Veterans Choice call center in Alaska in an attempt to have people who are knowledgeable about the state coordinate Alaska veterans’ care. “He was originally told by multiple VA officials that the program would be rolled out in two or three phases,” says Mike Anderson, Sullivan’s press secretary. 

That pilot program is still pending, VA says. Meanwhile, the private contractor running Veterans Choice has hired Alaska staff to make it easier for veterans to get authorization for care and improve the process for paying medical providers.

The combination of Veterans Choice and the Affordable Care Act has also created problems for veterans with private insurance. Veterans Choice makes VA the “payer of last resort” instead of the primary insurer. So veterans have to pay their entire private insurance deductible before VA coverage kicks in if they are being treated for an issue that isn’t connected to their military service.

“Most people can’t afford a good insurance plan, so they get stuck with high deductibles,” Bowen says. He and the National Association of State Directors of Veterans Affairs are lobbying Congress to eliminate the payer-of-last-resort provision from Veterans Choice throughout the United States.

With this and other fixes, Bowen is optimistic that Veterans Choice can be salvaged. 

“I think it will grow into something we can live with,” he says. “Is it better for the vet? I don’t think so. The networks we have in Alaska are great. I wish we could go back in time.”

Plenty of Alaska veterans think that’s the answer. “They should just eliminate the Choice program,” Burnett says, “and go back to the way it was – when we could just call VA and get an appointment.”  

Ken Olsen is a frequent contributor to The American Legion Magazine.