Monty Dalrymple was feeling dizzy and had just lain down in his motel room when the pain hit. It is nearly impossible to explain that kind of pain to someone who has never had a heart attack. "It's almost like Arnold Schwarzenegger takes your chest and twists it like a washcloth," he says.
It was 3 a.m. on March 2, 1997. Earlier, Dalrymple, a 46-year-old disabled veteran with a history of heart trouble, had finished a $100-a-night gig playing drums with a country-Western band at a Leadville bar. "I couldn't get off the bed," he says. "I couldn't even crawl to my pants where I had my heart-attack pills." A buddy drove him to the closest emergency room, where doctors told him he was in big trouble. They wanted to fly him by helicopter to Denver.
Dalrymple told them that he was a veteran and needed to go to the Veterans Administration Medical Center in Denver. Under federal guidelines, a veteran who can prove financial need or who has a medical problem connected to his time in the service can receive free medical care if he seeks treatment at a VA facility. Some veterans can also be treated at private or non-VA hospitals and have the bill paid for by the VA if they meet three criteria: The condition must be "service-connected," the medical problem must be life-threatening, and there must be no VA facility readily accessible. There are 148 VA hospitals spread across the country; in Colorado, there is one in Denver, one near Las Animas and one in Grand Junction.
The Leadville medical staff told Dalrymple that the VA hospital in Denver was not equipped to handle helicopter landings and that he would go to Centura St. Anthony Central Hospital instead.
"Of course I said okay. What am I going to say? I was dying," Dalrymple recalls.
At dawn the helicopter touched down on St. Anthony's roof, and staffers rushed Dalrymple to the intensive-care unit, where he was treated and his condition was stabilized. It was Sunday, and Dalrymple would have to wait until Monday before a cardiologist could see him. Finally, on Tuesday, when doctors determined that he was stable enough to be moved, he was transferred by ambulance to the VA hospital. He stayed there for three more days and was released on March 7.
Three months later, Dalrymple got notice from the VA that his claim for treatment at St. Anthony's--he estimates it to total about $30,000, including the helicopter transfer, doctor bills and hospital stay--had been denied because he had failed to go to a "feasibly available" VA facility.
Dalrymple was sure it was a mistake. He had told the staff at St. Anthony's that he needed to be at the VA, and they had told him he should not be moved. Certainly the VA could understand that. "What was I supposed to do? I'm wired up and doped up. Am I supposed to get out of bed and call a taxi?"
Dalrymple went to the claims department at the VA to complain, and administrators told him he could appeal the decision to the Board of Veterans' Appeal in Washington. That board is the highest authority within the VA system for a veteran to appeal a denied benefit. But the Denver VA also warned Dalrymple that it could take up to five years for his case to be reviewed. In July 1997 he began the appeal process.
A few weeks ago--nearly two years after he appealed--Dalrymple checked with the VA and found out that his case was stalled. Officials told him it could take at least another year to be resolved.
While Dalrymple has been waiting, he has been bombarded by medical bills from St. Anthony's. He says he has tried to explain that he is in an ongoing dispute with the VA, but the collection agency hired by St. Anthony's has little sympathy. In June, a bill collector demanded more than $12,000 for a portion of his hospital stay, told him the hospital was "ready to go to court" and threatened to put a lien again his mobile home and eighty acres of land in rural Yoder.
Dalrymple, who left the service in 1993 after ten years, has been designated by the VA as 70 percent disabled and "100 percent unemployable" because of his medical problems. Over the years he's tried to stretch his disability payments by working at convenience stores and playing drums, but as a single father of two sons, he is barely making ends meet.
Michael Swan, chief of health administration at Denver's VA Medical Center, says he's sympathetic--but a review of Dalrymple's case showed the denial was appropriate. The VA paid for Dalrymple's care in Leadville, but not the helicopter transfer or any of the costs at St. Anthony's, because he should have gone directly to the VA hospital despite his critical condition.
"We transfer patients all the time with tubes in them," Swan says. Often, he adds, a patient misunderstands his situation, thinking he's in more critical condition than he really is. That is why the VA's staff does a medical and administrative review of each claim. "The seriousness in their mind versus the evidence medically are two different things."
James Foster, 43, has been waiting two and a half years for the VA to pay his medical bills. In November 1996 Foster went to the emergency room at Evans Army Community Hospital at Fort Carson because of a severe headache. Foster had a history of service-related hypertension. While he sat in the waiting room, he began to feel chest pains, and he thought he was having a heart attack.
Foster says an electrocardiogram showed a potential problem, and the staff became concerned. "They told me they didn't have the facilities to treat me, and they wanted to transfer me," Foster says. He was taken by ambulance to Memorial Hospital in Colorado Springs, where he told the doctor he needed to be treated at a VA facility. But it was in the middle of a snowstorm, and he says the doctor balked at releasing him to drive to Denver while he was having chest pains.
"He said, 'My advice to you is to keep you here. I think there is something wrong. I can't make you stay.' But he said if I left I would have to sign this paper saying he and the hospital were not liable if anything happened to me. I don't think anyone would sign that," Foster says.
The next day, further tests revealed that Foster hadn't had a heart attack, so he was released. Like Dalrymple, Foster never suspected he would have a problem with the VA paying for his care at Memorial. Three months later, though, he, too, found that his claim had been denied.
In his case, he was turned down for failing to meet all three of the criteria necessary for having his private care paid for. The VA found that since Foster hadn't actually had a heart attack, he could not link his chest pains to his service-related hypertension. Additionally, since it hadn't been a heart attack, his condition was not an emergency and he should have driven to the VA in Denver for treatment.
In Foster's case, as in Dalrymple's, the VA's denial was appropriate, says Swan. He says just because someone thinks he is having a heart attack and feels it would be unsafe to drive an hour for treatment does not make the situation an actual emergency. "We get calls like this all the time," Swan says. "We tell them to get the care they need, but we can't guarantee we'll pay."
Foster has also appealed the denial. In the meantime, though, he took out a loan to pay about $1,000 in medical bills. He works as a $24,000-a-year maintenance man for the Federal Center in Denver, and his wife works part-time at the center's commissary. They can barely afford the payment plan but feel they have little choice. "I was getting threatening letters twice a week. They were going to wreck my credit," he says.
Should Foster win on appeal, the VA will pay his medical bills, and he will be reimbursed by the individual doctors and the hospital he's already paid--but he doesn't have much faith that he'll ever see his money again.
And, he says, the VA is painting him as a liar, as if he made up the chest pains and panic he felt.
"I did my twenty years," he says. "I served my country, and I was proud to do it. But when I went to [the VA] for help, they treated me like this."
Willie Dennis, 77, also served his country--for 31 years through World War II, Korea and Vietnam. He, too, is disgusted with the way he says his country is repaying him.
He is considered 100 percent disabled, with a heart condition and other medical problems. On July 1, 1996, he went to the U.S. Air Force Academy Hospital with pain in his chest that was starting to streak down his arm. Doctors there determined that his condition was critical, and they immediately transferred him to Penrose-St. Francis Hospital in Colorado Springs for cardiac treatment. His records show that a cardiologist at the Air Force Academy noted, "It would have been extremely imprudent if the patient had been transferred to the Denver VA Hospital, which is a much longer trip."
"All I was thinking about was not dying," Dennis remembers. He remained at Penrose-St. Francis for five days.
Three months later, in September 1996, Dennis learned that the VA would not pay his medical expenses at Penrose-St. Francis because the agency had concluded that he should have gone to the VA facility in Denver. "I just couldn't believe it," he says. "I'm 77 years old. Who in their right mind would get in their car and drive 75 miles?"
With the help of the Disabled American Veterans in Colorado Springs, Dennis filed an appeal to Washington. This past March, two and a half years after he filed his appeal, Dennis learned that the Board of Veterans' Appeal had overturned his denial--just like that, with no requests for further evidence to support his claim.
That proves Dennis's claim was a legitimate one in the first place and the VA had simply been stalling, says Kent Hoffman, a national service officer in Denver for the DAV.
The Board of Veterans' Appeal has now ordered the VA to pay Dennis's medical bills. But in the two years his case has been on appeal, Dennis says, he has paid more than $6,000 to keep the bill collectors at bay. He doubts he will ever be fully reimbursed.
Just days after his release from the hospital in 1996, Dennis was readmitted to a private hospital because of chest pains. About a month later, he was back in the hospital a third time, again with severe chest pains. Ultimately, his doctors determined that he needed quadruple bypass surgery.
The VA initially denied the claim for his second hospital stay because it was not considered an emergency. After the DAV again applied pressure, the VA Medical Center in Denver reversed its decision. The VA has now agreed to pay part of that bill, and the third claim is still pending.
The entire process has been a nightmare for Dennis and his wife. "They promised they would take care of us," Dennis says of the VA. "That's the first thing they told you when you raised up your hand [to volunteer for the armed services]. They promised us that if you stay in, 'we'll take care of you for the rest of your life.' I did everything they ever asked me to. All I ask of them is to do what they told us they would do."
The DAV's Kent Hoffman has helped file appeals to the Board of Veterans' Appeal in Washington on behalf of Monty Dalrymple and other veterans.
He is incensed by Dalrymple's case. "What were they going to do, fly low and drop him out the window?"
Hoffman believes there is more to the denials--and reversals--than just bureaucratic review and decision-making. He says he thinks appropriate claims are being denied as a cost-saving measure by the local VA Medical Center. (Each VA hospital is individually funded and makes independent decisions regarding its budgets; individual hospital directors are governed by a regional director who in turn reports to Washington. In this area, the regional director is in Denver.)
"They're saving this year's budget by delaying or denying payments," Hoffman says.
Money for VA medical facilities across the country started getting tight in 1996 when the White House and Congress hammered out the Balanced Budget Agreement. Health benefits for the nation's 26 million veterans--more than 2 million of them disabled--were then frozen at $17 billion, and no increases have been approved since. Back then, medical inflation was running at about 2 percent; today it is at about 10 percent, with the cost of everything from pharmaceuticals to surgery escalating, and the budget is simply not keeping pace.
That is putting the squeeze on VA hospitals nationwide, says Dick Wanamaker, a national legislative director for the DAV in Washington. He says there has been repeated testimony over the last few years before congressional committees on budget and veterans' affairs by VA medical-center directors who have said they have no choice but to make cuts in staff and services.
The annual operating budget for Denver's VA Medical Center has risen only about 4 percent yearly since 1996. Between fiscal years 1998 and 1999, there was actually a slight decrease--from $127.8 million to $124 million.
Wanamaker theorizes that one way to cut costs is to delay, deny or underpay veterans' claims. He tells of a veteran who retired from his office who had lost his legs in Vietnam and, after fifteen years, needed new prostheses. When he filed a claim, the money allowed by the VA was not enough to pay for replacements. In fact, it was even 15 percent less than Medicare would have paid. The veteran had to make up the difference out of his own pocket. "He said, 'That's the thanks I get for giving up my legs for this country.'"
What is happening, Wanamaker says, is not really that different from what millions of Americans in the private sector have been facing for years with the emergence of managed health care. Suddenly, treatments that once were considered routine are now being scrutinized and often denied to keep costs down.
In the past, veterans have been insulated because they had the VA to take care of them. "Ever since colonial times, the federal government has taken the position that it will take care of our veterans," Wanamaker says. "Now Congress says, 'You're out there with the rest of us.'"
"What a grateful nation gives, a less grateful nation can take away," Hoffman adds.
Wanamaker says veterans used to get the benefit of the doubt in medical claims. "They wouldn't have issued these types of denials five years ago," he says of the VA. "They're just trying to postpone, postpone, postpone and hope the veteran goes away."
That is ridiculous, counters the Denver VA's Swan. Although he admits that the VA has endured a tightening of its budget in recent years, he insists it has never come at the expense of veteran care. "We never, ever base a clinical or administrative decision on a financial issue. Further, I've never been ordered to," he says.
Still, Wayne Valey, chief of the VA hospital fee-management section, which reviews claims, says the agency has to "be prudent" about what it approves. "You have to use your resources the best way you can." In fiscal year 1998, Valey says, 767 out of 1,247 veterans' claims were denied. In the eight months of fiscal year 1999, 464 claims have been approved and 402 denied.
While the Washington office of the DAV says the VA's denial of veterans' medical claims is a nationwide problem, one case in particular turned the spotlight on Denver.
What first caught the organization's attention was a 1996 case involving a Colorado veteran who was burned over 60 percent of his body in a house fire. He had a history of service-related psychiatric problems and had tried to kill himself by turning on the gas. The veteran and his family declined to be interviewed for this story, but Hoffman says that after the fire, he was taken to the nearest private hospital. He remained in its burn unit for treatment because his family was afraid his condition would deteriorate if he was moved.
The Denver DAV became involved when the veteran's claim to have his care at the private hospital was denied. His family appealed the decision to the Board of Veterans' Appeal in Washington.
In December 1998, the BVA overturned the denial and ordered the VA to pay his medical bills. Once the BVA makes such a ruling, there is no mechanism for further appeal by either side.
Nevertheless, E. Thorsland Jr., the Denver VA Medical Center's director, continued to refuse payment, arguing that it was too expensive.
DAV officials were dumbfounded. Never had they heard of anyone blatantly refusing such a direct order for payment. "That is either total stupidity or total arrogance," says Hoffman.
But Thorsland had been "advised by counsel that in any court proceedings there is a possibility to request the [BVA] to reconsider," says Joe Dean, a spokesman for Thorsland's office. He says Thorsland didn't know that the VA had little possibility for further appeal.
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The veteran's family even went so far as to ask for help from Senator Ben Nighthorse Campbell. Once the denial was overturned but Thorsland continued to refuse payment, the senator's staff intervened, putting pressure on the Denver VA. "We've made a promise to our veterans to provide adequate medical care, and I intend to fulfill that promise," Campbell said in a statement to Westword.
Ultimately, the veteran's claim was paid, but in many people's minds, the case signaled a continuing and very real problem.
Hoffman fears there is no way to reverse the current trend. "Where this is going to end is privatization," he says. And while there is nothing fundamentally wrong with privatization, "the transition is just not going to be smooth. They're going to let the system, as it is, wither on the vine until there are no services, and then they'll come along and pick up the pieces."
In 1946, the largest number of veterans ever returned to this country from World War II. Those veterans are now in their seventies and eighties and are dying at a rate of thirty a day. Even some Vietnam veterans are now in their late fifties. "What this means is that folks are going to need long-term in-patient care, which is very expensive," Hoffman says. "The greatest demand on the VA health-care system is right now.