Anthony Hardie, a disabled Army veteran who served in the first Iraq War, suffers from the so-called Gulf War syndrome. He lives an hour's drive from the closest Department of Veterans Affairs
medical center in Bay Pines, Fla.
So when he gets lung “flare-ups” several times a year, he uses his private health insurance and goes to a private urgent-care center close to his home in Bradenton. “Forty-five minutes later, I'm walking out with a prescription,” Hardie said.
The VA is facing a torrent of criticism about long waitlists, off-the-books recordkeeping, doctor shortages, and some patient-safety problems. But one issue that hasn't gotten as much attention is the mismatch of VA facilities to where most veterans live. Of the approximately 20.8 million veterans living in the U.S., 9.6 million live in 14 Sun Belt states. Yet only about a third of the VA's 152 hospitals are located in those states.
Most VA hospitals are located in Northern and Midwestern states where more veterans used to live. Hardie previously lived in Madison, Wis., and received his care at nearby William S. Middleton Memorial Veterans Hospital. But in 2013, he moved to Florida, a state with 1.5 million veterans served by six hospitals. In contrast, South Dakota, which has only 76,000 veterans, boasts three VA medical centers.
“It reflects the relative political balance of power 50 years ago,” said Phillip Longman, a senior research fellow at the New America Foundation who has studied the VA system. “Fifty years ago, the Sun Belt was the sleepy old South.”
This is a problem that the VA has confronted before. A 1999 Government Accountability Office report found that the VA was wasting lots of money maintaining underused and obsolete facilities. An independent group known as the Capital Asset Realignment for Enhanced Services Commission studied the issue, and under then-VA Secretary Anthony Principi, drafted recommendations for reallocating capital assets. What followed was one of the largest-ever reorganizations of the VA system, involving the closure of three hospitals and partial closure of eight more; construction of three new hospitals; and opening of 156 new outpatient clinics mostly focused on rural areas.
It's a process Principi would like to see repeated. “You should have a process in place that does an assessment of all your facilities around the country, whether it be a closure, addition or realignment,” said Principi, who now does private consulting. “Circumstances change, resources change, and you need to change as well.”
A big change in circumstances is the influx of veterans from the wars in Iraq and Afghanistan. Between October 2001 and March 2014, six integrated hospital systems in Sun Belt states—out of 23 VA integrated systems in all—provided treatment to more than half of the veterans from these wars, the VA reported. But the size of the local veteran population is only one factor in determining the location of facilities, said Gina Jackson, a VA spokeswoman.
At the same time, the VA also is dealing with an overall decrease in the number of veterans, Longman said. From 2000 to 2013, the total veteran population fell 17%, primarily due to the passing of veterans from World War II, Korea and Vietnam. “Their most acute to long-term problem is the vanishing of veterans,” he said. “I've been to VA hospitals all over the country. Most places you go, it's eerie how few patients there are.”
The VA Palo Alto (Calif.) Health Care System, built in 1960, illustrates the problem. The system includes 808 beds, but according to the latest American Hospital Association data for fiscal 2012, the average number of inpatients receiving care each day in the system was 397. During 2012, 5,674 patients were accepted for inpatient service. That's low compared with other systems of comparable size, such as the University of North Carolina Hospitals, Chapel Hill, where the bed count was 805, the average daily inpatient volume was 666, and there were 37,635 inpatient admissions during the same year.
The Palo Alto system includes inpatient facilities in Palo Alto, Menlo Park and Livermore, plus seven outpatient clinics in a region that runs 90 miles south to Monterey and 130 miles east to Sonora. Those clinics have telehealth capabilities that allow veterans to see a doctor without having to travel 100 miles to a medical center.
That telehealth capacity is important because most veterans can't afford to live in the immediate Palo Alto area close to the medical center, given that the median home value is more than $1 million. Census data for 2008-12 estimated that just 2,675 veterans were living in Palo Alto. “No vet can afford to live within 150 miles of that hospital,” Longman said.
Around the country, many veterans live in rural counties away from the larger VA facilities, VA data show. But VA hospitals traditionally have been located in larger, urban settings in order to be affiliated with academic medical centers like the Stanford University School of Medicine, which shares its physicians with the Palo Alto VA system.
“For elderly veterans who are totally disabled and no longer working, perhaps they can take an entire day to get to (their) VA medical appointments,” Hardie said. “But it's an incredible challenge for veterans who are working and veterans who are students.”
To help address the geographic mismatch problem, in July 2012 the VA announced plans for 13 new community-based outpatient clinics to open gradually through 2015. In April 2013, the GAO reported that the VA was managing the construction of 50 major medical-facility projects ranging from $10 million to hundreds of millions of dollars, including an $800 million replacement hospital near Denver. A bipartisan Senate deal announced June 5 also authorizes the VA to lease 26 new facilities in 18 states.
“One of the reasons for pursuing community-based clinics is because so much care is now on an outpatient basis,” said Dr. Kenneth Kizer, who served as VA undersecretary for health from 1994-99 and is now director of the Institute for Population Health Improvement at UC Davis Health System in Sacramento, Calif. “But there were never going to be enough funds to put facilities in places where veterans had moved.”
Last month, the Palo Alto system cut the ribbon on a 10,000-square-foot welcome center at its Menlo Park location, funded not by the VA but by a California philanthropist. Longman argues that despite being “a jewel,” the Palo Alto system doesn't have enough veterans to serve. It's the same for many other VA facilities around the country, he added.
But there still are many veterans who need care and lack timely, convenient access to it from the VA, according to news reports and the VA Office of the Inspector General.
One partial solution, Kizer said, is to put more focus on telehealth, mobile health and home monitoring, as the Palo Alto system has begun to do. By Kizer's estimates, at least 30% of primary-care visits could be shifted from face-to-face to remote services. “It's not a matter of providing less care but providing smarter and more patient-centered care,” he said.Follow Bob Herman on Twitter: @MHbhermanFollow Rachel Landen on Twitter: @MHrlanden