Mike Kilbane is a tall, ruddy, gray-haired veteran, riding in the back of a state-funded van that is taking him from his home in rural Craig to the Veterans Administration hospital in Grand Junction.
He is talking about his memories of Vietnam.
“I heard this explosion,” he says, his eyes invisible behind dark glasses. “I turned around and looked, and the shrapnel went in and took all these teeth out, one off the bottom, lacerated – my tongue was almost cut in half.”
Kilbane was a Coast Guard gunners mate patrolling the Mekong Delta and rivers in Vietnam, always seeking contact with the enemy. He will delve only so far into his terrifying memories, careful not to uncover the psychological defenses that suppress the fear that haunts him. He still has shrapnel embedded in his jaw.
Kilbane is of one of more than 400,000 Colorado veterans who served in conflicts around the world, from World War II to current wars in Iraq and Afghanistan. About 66,000 of those vets live in rural Colorado, far from any comprehensive VA services.
A Rocky Mountain PBS investigation found that the nearly one in five Colorado veterans who live in rural Colorado are not getting the same care as vets in metropolitan areas. And even though the state government and Colorado counties help fund the gaps in veteran care with transportation, nursing care and advocating for services, rural veterans are still lacking.
In La Plata County, veterans are somewhat insulated from VA issues nationwide, said Fred Riedinger, a former Veterans’ Service Officer. He called Durango’s local VA clinic, which is contracted, “one of the better clinics in the U.S.”
“I haven’t heard too many complaints about the quality of care,” he said. “But nothing’s perfect.”
Sharon Wimer-Norton, a registered nurse for the VA and speaking on her own behalf, said many concerns she hears about are related to access to care because the local clinic has a small staff.
“A lot of it goes back to issues in general of medical care in a small community,” she said. “There’s just not enough providers to go around.”
Coffman wants national reformU.S. Congressman Mike Coffman, a Colorado Republican, marine veteran and member of the House Veterans Affairs Committee, says gaps in better care for all veterans cannot be solved by state and local governments. Rather, there must be national systemic reallocation of VA resources.
“We have a growing population in Colorado and we have a growing population of veterans, but (the) northeast part of the country has lost population, yet has ... a VA footprint still there, and we don’t need it,” he said. “So, we’ve just got to be able to close ... or consolidate facilities so that we can address the needs where those veterans are.”
For now, Kilbane and the other rural Colorado veterans often must travel hundreds of miles for care from a VA system that, according to the U.S. Government Accountabilty Office, is considered a high-risk agency. That means the agency is at risk of mismanagement and is in need of transformation.
In La Plata County, the clinic in Durango offers only primary care services. For more specialized care, veterans must travel to Albuquerque, either through their own transportation, for which costs are reimbursed, or through the Disabled American Veterans’ transportation program.
“Veterans here do have a choice as far as choosing care,” Riedinger said.
To understand just how stretched the VA really is, you need only look as far as its job postings. On the medical side, its website shows the VA is looking for more than 1,000 doctors and 900 nurses across the nation. On the mental health side, the agency wants to hire more than 600 social workers and mental health counselors, just more than 300 psychiatrists and more than 600 psychologists.
And even if those thousands of empty jobs were filled, the VA still couldn’t serve all the veterans who need care, said Dr. Ellen Mangione, the chief of staff for the VA’s Eastern Colorado Health Care System, which includes Denver.
“There will never be enough providers in any health care system that allows everyone to have a face-to-face visit,” Mangione said.
At the Durango clinic, one doctor serves about 2,000 veterans, Riedinger said. But that hasn’t been a problem.
“I know veterans that walked into our local clinic and were treated on the spot,” he said. “I hear from veterans from other areas that have terrible experiences, but they get here and everything runs smooth.”
Technology bridges gapBecause the agency is stretched so thin across other rural areas, it has established tele-health connections at what it calls Community-Based Outpatient Clinics in smaller towns that are connected to a VA hospital center, like the one in Grand Junction.
Coffman says vets in rural areas deserve better.
“I think that we really need that person-to-person human interaction when it comes to mental health,” Coffman said. “In fact, I would argue there’s not enough of it in the VA today.”
Coffman argues that in lieu of such personal interactions, many vets are given psychotropic drugs to help them cope with post traumatic stress disorder. He says the VA must figure out a way to better marshal its resources, including streamlined hiring of staff, to assure better services.
Mangione agrees the current tele-health system, based in clinics, has drawbacks but says a new system rolling out now will be connected to personal devices such as smartphones and tablets. That, she says, will improve the VA’s ability to provide services, even crisis mental health services, to rural veterans.
“We can actually have an appointment with a mental health provider using an iPhone, for example, or an iPad,” she said. “So you don’t have to go into a clinic.”
And that may be particularly appealing for younger vets who are comfortable with mobile technology, but for vets in rural areas with little cellular or Wi-Fi coverage, it will not help.
Trouble with ‘Veterans Choice’The VA rolled out the “Veterans Choice” program in 2014 that was supposed to supplement the strained system.
A veteran in a rural area could visit a Choice-approved local doctor, psychiatrist or hospital and the VA would pay for it, somewhat like Medicare. But there was a lack of communication with providers, and vets like Kilbane say the red tape was overwhelming.
“Sometimes I would call five times a day, and the thing is, you get a different person and they don’t even know what I’m talking about,” he said.
Soon, providers were getting paid late or not at all, and many simply dropped out.
Wimer-Norton said having local options does make things easier for veterans. However, the approval process from the VA can make it take longer to get into the doctor’s room.
“And some of the providers don’t want to take part in a Medicare-based system,” she said.
Mangione says there is a reason the program is not working.
“Remember that in the rural communities ... there are also challenges within that community with finding providers, too,” she said. “So, I think that by definition that really presents a bit of a challenge to the program.”
Mangione says there also must be more efficiency.
“The answer is not just hiring more people – it’s looking at our process that we have in place right now and seeing where we have mismatch between supply and demand and productivity of individuals.”
Wimer-Norton said she would like Durango’s local clinic to transition from contract care to a complete federal VA office.
She said the Durango clinic was set up in 2002 after an outpouring of community demand for a veterans clinic, and establishing contract care was the fastest track.
However, she said it’s time to federalize the clinic, which brings added benefits to veterans.
“It doesn’t sound like much, but there is a difference,” she said. “We’re lucky to have this clinic in place, but I think it’s time to start pushing to federalize that clinic and all the niceties that come with it.
“We need to make sure these folks here are not forgotten,” she said.
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