Story by Rehana Asmi, photos by Parker Seibold
Something was wrong.
It wasn’t just his father’s health issues, which were troubling on their own. It was all the moving parts: the miles to get there, the bureaucracy of trying to schedule a proper doctor’s appointment.
Wes Headdress, an Army veteran who served a tour in Iraq during his 2001-2005 service years, helps others wade through the Indian Health Service and Veterans Affairs programs. He makes sure the veterans on the Fort Peck Indian Reservation can get to their appointments and that doctors and hospitals make the proper reimbursements.
But this time, it was his father, Mitchell Headdress, who is also a veteran. Wes fielded phone calls about his father’s health, dealing with the IHS clinic and coordinating with the Fort Peck Warrior Center where his father was staying.
Then he felt like it went wrong. The local clinic, run by IHS, turned Mitchell Headdress away after a perfunctory checkup. They told him his symptoms weren’t serious and suggested he go to a medical center 2.5 hours away, to the VA clinic.
“He needs immediate care and (IHS) told him that it’s not an emergency,” Wes Headdress said, shaking his head. “They said you need to follow up with your VA medical provider, which is in Miles City, so that’s the latest problem I’ve had dealing with that garbage.”
The hand-off was more frustrating considering Headdress’ unique position. The father and son, like most of Wes Headdress’ clients, have been promised twice over that they’d be covered. As members of a recognized Native American tribe, the federal government has agreed to provide them health care in historic treaties. Then in exchange for their military service, VA provides medical benefits and assistance.
American Indians and Alaska Natives serve in the military at a higher rate per capita than any other race, according to a 2012 Veterans Affairs Report.
However, despite falling under the protection of these two federal programs, Native American veterans often end up volleyed between the agencies, which are separated by hundreds of miles.
In 2010, the VA and IHS signed a Memorandum of Understanding to better coordinate health care between the two systems for Native American veterans. Taking effect in 2012, the agreement allowed IHS and other tribal health programs to bill the VA for direct care.
Between 2012 and 2015, the VA reimbursed IHS and tribal health programs $16.1 million for direct care. Both the VA and IHS have been experimenting with telemedicine, a way to virtually connect rural patients in their clinics to doctors in other cities.
The IHS also plans to expand the partnership in 2017 to improve its pharmacy program and the way Native American veterans can be reimbursed for their medication on a national level, according to a statement published by Mary L. Smith, principal deputy director of IHS.
The lack of IHS resources continues to be a problem on the Fort Peck reservation, which has two clinics: the Chief Redstone in Wolf Point and Verne E. Gibbs in Poplar, about 20 miles apart. Clinics deal mostly with outpatient services, such as dental, labs, nursing, pharmacy prescriptions and preventative care. The reservation lacks a full-blown IHS hospital.
Therefore, it’s not uncommon that IHS refers patients to off-reservation centers if it can’t provide the needed service. If a patient needs a service that the IHS clinics cannot provide, they may be referred out to a partnered hospital off the reservation or one of the smaller community hospitals in Wolf Point and Poplar. However, not everyone can be referred out, and the prioritization usually comes down to what is known as a “life or limb” policy.
Lana Engelke has worked at the Verne E. Gibbs Health Center in Poplar for over 20 years as a nurse and as part of the electronic records team. The Fort Peck Service Unit is unique because of how far they are from tertiary care and other hospitals.
“It’s always got to be in our mind how far we are from hospitals,” Engelke said.
But even the nearby community hospitals in Wolf Point and Poplar are limited, since they’re just as rural. When Engelke first started working on the reservation in 1997, IHS had just started billing more services to Medicare, Medicaid and later the VA, allowing them let those reimbursements free up IHS funding for other projects.
IHS as a whole is handicapped due to its lack of funding. In 2017, the proposed national budget for IHS was $6.6 billion to cover about 2 million American Indians and Alaska Natives. In comparison, the 2017 proposed budget for VA health care services was $65 billion to cover over 6 million veterans.
Being a veteran who is eligible for care from the VA is a “double-edged sword,” Wes Headdress said, as they can be passed along to VA outpatient clinics in Glasgow, Miles City or Billings where the patient, if eligible for VA medical benefits, is also promised access to appointments and medical services.
“It’s really tough for us veterans to tell the IHS that we are (veterans). They automatically assume, ‘Well that’s your health care provider,’” Wes Headdress said. “We can use both, so why not take advantage of the one that’s here rather than traveling two hours one way and two hours back?”
Mitchell Headdress, 69, lounged on a chair in the corner of the wooden porch of the Fort Peck Warrior Center. Above him, a sign read “Veterans Honoring Veterans.” Headdress leaned back against the wall, taking in the fresh air. He’d get bored inside the house all day. There’s no TV or radio unless his granddaughter comes by to show him her newfangled tablet. He checked his black flip phone resting on the porch railing and then looked out toward the gravel driveway.
He was keeping an eye out for a nondescript silver van owned by the tribal Veterans Affairs office. He had a doctor’s appointment in Miles City, about 2.5 hours away from his home in Poplar. He had gone to the emergency room earlier that week for some possible kidney issues, but he was told to follow up with his provider.
He served in the Vietnam war, and he’s eligible for VA medical benefits, so that meant one of the VA clinics off the reservation.
It was almost 11 a.m. when Monica Campbell drove up in one of the two tribal VA vans. Campbell usually does secretarial and administration work at the tribal VA with Wes Headdress, but she helps out with transportation when she can. She doesn’t mind the driving, she said. It gets her out of the office.
Headdress raised a hand and waved to Campbell, but he didn’t stand up from his chair. He asked if it was alright to have a smoke before they set off. Campbell nodded, still standing in the driveway. She lit a cigarette of her own, digging the toes of her shoes into the gravel while the two chatted. She’s not a veteran, but she’s raised two sons who joined the military.
Headdress’ appointment was at 1:30 p.m. “I don’t even know where the place is,” he confessed. He had been living in Page, Arizona and came back to his hometown to take care of his health. Until recently, before being diagnosed with diabetes and having open-heart surgery in Billings, he claimed to be healthy. He’s never had to use the VA system in Montana.
Campbell told him not to worry and put out her cigarette. She knew where the clinic was.
With about 147,000 square miles, Montana is one of the largest “catchment areas” in Veterans Affairs, said Mike Garcia, the public affairs officer at Fort Harrison Veterans Affairs Medical Center near Helena. Veterans Affairs manages 17 outpatient clinics, hospitals and facilities across the state.
Even with a less dense rural population, it can become a challenge to manage all the clinics over a large area, Garcia said. That’s why partnership with other health providers becomes so important.
The closest VA clinic to the Fort Peck reservation is in Glasgow, about an hour away, but it’s a satellite clinic with fewer services. Most veterans end up going to Miles City, 2.5 hours away. If a veteran from Fort Peck needs surgery, they’ll have to travel a bit farther to a full medical center, maybe five hours to Billings, or seven hours to the VA Medical Center in Fort Harrison.
Both legislators and directors of IHS and Veterans Affairs need to seek out the Native American perspective if they want to develop future programs that address health care for tribal veterans, especially in rural Montana, Wes Headdress said. A lot of problems that plague rural veterans are the same for veterans who live on reservations, he added, but there are also unique issues.
“Get our input on it,” he said. “Don’t just go by what you hear we need. Let us tell you what we need.”
The VA has created programs to fill the coverage gaps and reach out to rural patients. However, even those are mired in bureaucratic rules and haven’t benefitted Native American veterans enough, Wes Headdress said. The Choice Program, for instance, just didn’t work on Fort Peck.
The Choice Program is a 2014 congressional initiative designed as part of the Veterans Access, Accountability and Choice Act. The act made sure veterans could receive care at non-VA clinics if they were more than 40 miles away from a VA clinic or couldn’t see a doctor within 30 days. The program received $10 billion and a time limit: three years or until the money is spent.
It was a good concept, Garcia said, but rural Montana proved to be a tough host. For one, the language in the Choice Program doesn’t specify if the clinic has the services a patient needs. So if a veteran were 39 miles away from the Glasgow VA clinic and needed to see a specialized doctor, such as a cardiologist, they’d still be ineligible for the Choice Program.
The program is also run through contracts managed by Health Net Federal Services, instead of Veterans Affairs, in Montana. In theory, Garcia said this was a way to promote the expansion of partnered providers to get more care to veterans in rural areas. It didn’t work as well as promised.
For veterans on the Fort Peck Indian Reservation, Montana’s most isolated, the cost is only magnified by distance and the lack of resources
“You’re paying out of pocket whether you like it or not,” Wes Headdress said, since programs like Choice often disregard time and distance when it comes to getting to appointments off the reservation.
The Choice Program had good intentions but didn’t braid together the capabilities of both IHS and Veterans Affairs strongly enough. Tribes still need to rely on fundraising, nonprofits and other programs to fill in the gaps.
Recently, Wes Headdress set up a fundraising raffle at the tribal office building in Poplar. Members of the community trickled in, buying tiny blue raffle tickets and eyeing the possible prizes: a 50-inch TV, a Playstation 4 with the newest Call of Duty game and some Beats speakers.
By 2 p.m. the tribal VA had raised almost $4,500, an even better haul than last year. This money would go towards paying for motel rooms and transportation for veterans traveling to their doctors’ appointments under the Choice Program.
Lance Elliot Fourstar, 41, has a deep, rumbling voice and the quiet confidence that comes from being over six feet tall. He joined the military in May 1997, working on medical equipment. He knew he qualified for VA medical benefits, because he helped many veterans apply for their benefits when he worked as a case management technician for the Fort Peck Warriors Center.
Veterans are usually eligible for medical benefits if they have served in active duty and received any honorable discharge or had a service-related injury. In Montana, there are about 74,000 veterans eligible for VA benefits, but only about 47,000 are enrolled, according to a 2017 VA report.
Fourstar said the role of a warrior is one of the highest honors in the community, and when a veteran returns from service, they’re usually expected to take on some sort of leadership position.
“We don’t owe it to the United States of America to serve,” he said. “But we do anyways, in disproportional amounts, because of what’s been passed on through generations, as our roles as warriors. We’re supposed to protect and provide for our community.”
Fourstar has no interest in using the VA clinics. He tried applying for his medical benefits in the past, but there was always some issue — his application would get lost on the way to Glasgow, or something would be wrong on his form. He didn’t think it was worth pursuing if he would just get lost in the system again, especially when he could use the IHS facilities as a member of the tribe.
Fourstar stopped working at the Warriors Center in December after he caught pneumonia and felt himself burning out. His background wasn’t in social work, but he brought his own life experience to help relate to the veterans who came in for help.
The Fort Peck Warriors Center is run by the Fort Peck Housing Authority with a grant from Veterans Affairs. Robin Bighorn, director of the housing authority, oversees the three dry houses while Gilana Rivkin coordinates the program. Bighorn said it can be a challenging program to operate.
Many of the veterans he and his outreach team talk to aren’t sold on the idea of a curfew and dry house. They’re used to their freedom. These temporary houses also only have single rooms, so they can’t house families.
“It’s very difficult to get the veterans to come in,” Bighorn said. “But those that are willing to utilize the houses, they’re doing good.”
The Fort Peck Warriors Center works alongside other tribal health programs so residents like Mitch can receive home visits from the Tribal Health Diabetes Program. Before his appointment in Miles City, Mitch and Wes sat around the kitchen table while Michelle Aguilar and Morgan Martell set up shop to check Mitch’s blood sugar and blood pressure.
Home visits are a distinct element of the program, since not every patient can make it to the tribal health office that’s annexed to the IHS clinic. Martell said they also help refill water coolers and do pharmacy pickups from the IHS clinic.
“One good thing about veterans is, in some places, they take care of you,” Mitch Headdress said, sitting in his chair on the porch of the Fort Peck Warriors Center. “The tribes are trying to take care of their people, but it’s the money.” Funding keeps getting cut and he wonders what future generations will have to deal with.
He wore his sunglasses this time, hoping for the sky to clear up. The wind blew the ash from his cigarette onto the floor. He doesn’t harbor any faith in IHS.
“You have to be dead before they do anything to you,” he said.
But even the VA system can be frustrating. It turned out Mitch Headdress’ appointment wasn’t until the next Thursday. It had been a wasted trip to Miles City.
“I thought maybe I could get some help,” he said. “But it didn’t work out.”
Mitch Headdress returned to Miles City the following week for his checkup with a VA doctor. He felt like they spent more time on him, and overall, it was a better experience. He was referred by his doctor to come back to Miles City to see a specialist, something like a urologist, he said, in June. Then, hopefully, he’ll know what’s wrong.
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