For Amelia "Mali" Templeton, this doctor's visit is cause for both joy and fear. She is nearly into her second trimester of her second pregnancy, but this is the first time she has seen an obstetrician since an initial brief "yes, you're pregnant" confirmation of her home pregnancy test results. She has been desperately seeking prenatal care ever since.
"I didn't want to tell anybody until I'd heard a heartbeat," says Templeton. "I had some close friends that had gone through some pretty traumatic pregnancies over the past few years. So I wanted to wait until I had at least had my first appointment when a doctor would say, 'It looks good' before I even told my family."
Thankfully, everything checks out within normal parameters. Templeton's baby is viable and growing well. She's clear to tell her 85-year-old grandfather that he's got a new great-grandbaby on the way. She'll be bringing a brother or sister home for her nine-year-old daughter.
Her happiness is a little bittersweet, though. This trip to her new doctor is costing her $700 out of pocket, and with a sigh of regret, she declines the offer to have her baby screened for genetic indicators for conditions such as Down syndrome. The $1,500 price tag is just too much for the pocketbook of a full-time student living on a single income with her EMT husband. It's another sad story of how the uninsured are not able to get necessary care that has been told and retold for decades in America.
Except that Templeton isn't uninsured. Far from it. She is supposed to be receiving the best health care money can buy as a reward from a grateful nation through the Veterans Administration. A Hitchcock, Texas, girl who wanted to see the world, she entered the U.S. Marine Corp at the age of 19 in 2002 and found herself working in avionics. Stationed in Iraq near Fallujah, she helped tend a fleet of Sikorsky CH-53E Super Stallion helicopters, craft so monstrously huge and powerful Templeton jokes that marines no longer require the Navy to get them to the war.
In 2004, she was involved in a Jeep accident that left her left foot and lower leg crushed. She qualified for early discharge for the disabling injury, but Templeton insisted on toughing out her deployment since she felt leaving would let down her friends still serving overseas. She finished out her term in 2007, retiring as a corporal with 50 percent disability. At first she tried to make a go at civilian avionics, but missed the structure and discipline of the military in the field. Instead she returned to Texas to study drama at the University of St. Thomas, where the Yellow Ribbon Program is paying completely for her courses in set design.
Ever since she left the military, Templeton has had nothing but wonderful things to say about her health care through the Michael E. DeBakey Veterans Affairs Medical Center. The massive facility -- popular legend claims it is the second-largest federal building after the Pentagon -- is a leader in veterans care, with its work in heart disease and pneumonia in particular being ranked among the best in a 2005 report by the Joint Commission.
"I never have a problem if I have a cold or an allergic reaction," she says. "I've had some very positive experiences. I love my gynecologist at the VA. He is awesome."
When she got pregnant, though, she discovered that she'd entered a whole new world. Templeton's obstetrician, as wonderful as he is, cannot deliver her baby. The DeBakey Medical Center handles Pap smears and mammograms but does not offer in-house obstetrics.
Even though there are an estimated 10,000 female veterans in the Houston area, at least some of whom might conceivably get pregnant, the VA farms it out. As Templeton and others have discovered, the search for a private doctor willing to accept payments from the VA for pregnancy services is both daunting and disheartening -- resulting in months-long delays in treatment -- and clearly not falling under anyone's best-practices model.
Improving health care for veterans through the VA was one of the bigger promises that President Obama made when he first sought election. In a speech he gave in Kansas City, Missouri, in 2007, he drew attention to a backlog of nearly half a million claims for care older than 125 days at that time as well as error rates in the system topping more than 100,000.
The fact-checker website Politifact has kept a careful eye on Obama's promises over the course of his administration and continues to rate this one as broken. The President did indeed fulfill his promise to hire more workers to try to alleviate the pressure, adding about 2,500 employees to process claims. However, the backlog continued to grow as veterans returning home in huge numbers from the second Iraq War flooded into the system. In 2011, more than a million claims were filed for care through the VA.
Then, in 2014 a more troubling revelation came to light. In Phoenix, Arizona, VA facilities were found to be falsifying lists and using other accounting tricks to hide their backlogs. Dr. Sam Foote and other whistleblowers in Phoenix spoke out regarding bonuses that were paid to executives and doctors if they could reach a goal of a 14-day wait time for a patient to see a physician, a program that was started in 2011 to incentivize faster care. By using secret or hidden waiting lists to organize patients and then officially scheduling them once slots opened up, VA officials could collect the rewards even though wait times were being measured in months, not days. Further internal audits showed that this practice was not uncommon throughout the VA system, which led to a rare bipartisan initiative by Congress to reform the VA through the Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014. Internally, the VA banned executive bonuses and re-budgeted $390 million toward helping veterans receive non-VA facility care.
Which includes veterans who are pregnant. All of them.
The DeBakey Veterans Hospital houses nearly 500 beds, or a little less than half of Memorial Hermann Texas Medical Center's capacity. However, none of those beds lie in a maternity ward because DeBakey doesn't have one. It's not alone, either. No VA facility in America is set up to deliver babies despite the increasing number of female veterans. "Currently at this time, OB care is not offered because at this facility we don't have the capability of handling premature birth and infants," says Dr. Rola El-Serag, director of the Women's Health Program at DeBakey. "So, although we have trained gynecologists here who could conceivably deliver a baby, we don't have a NICU (newborn intensive care unit). The liability and the responsibility of the possibility of having a premature birth when, for instance, we don't have an incubator, the risk would not outweigh the benefit."
According to El-Serag, the number of female veterans has doubled since 2005, and women ages 20 to 40 are the fastest-growing population of veterans in the country. The number of veterans seeking maternity care from the VA has risen from one or two a week when she began working there a decade ago to as many as five a week now.
Even with the increase, though, maternity patients make up less than 0.03 percent of the outpatients seen last year at DeBakey. The construction and staffing of at least two new specialty wards for so low a patient population does seem unfeasible, even with a $900 million operating budget. Instead, pregnant veterans are sent into private care.
"We provide our veterans, first off when they meet with our RN, a lot of prenatal counseling, usually immediately," says El-Serag. "Their charts are reviewed and their medications are reviewed and they are started on their prenatal vitamins. So a lot of the prenatal counseling is offered right then and there along with their primary-care physician as well. Then the RN in the women's center will follow their care to make sure that they get to their appointments." From the initial consultation visit with one of the two available RNs in the women's center at DeBakey, women have two options once the VA has confirmed their pregnancy. The first is that they may -select a doctor of their choosing, and provided that he or she accepts payment from the VA, that person will then be the veteran's physician.
The other option is to contact TriWest Health Alliance, which won a five-year contract at an estimated $4.3 billion to administer the Patient-Centered Community Care (PC3) initiative in 2013. TriWest will then provide a list of health professionals in its network and help the veteran select a doctor. This is supposed to occur within three days after the VA sends confirmation of the pregnancy to TriWest.
"Most of our veterans, we're able to get them care immediately," says El-Serag. "In our process, we follow our veterans very carefully. We're very committed to making sure that our maternity patients' care is coordinated efficiently and that they're able to get to their OBs immediately. We are aware that sometimes it can be challenging when we're not providing the care in-house, and for that reason we help them find where they want to go, whatever works for them. If they can't find something that's close to them, we tell them to find something within 30 miles of where they live. I think we have a very generous policy to try and accommodate our female veterans, especially with maternity because that's a time when they need all the support they can get."
At least that is what is supposed to happen. It doesn't always.
Fond as she is of her in-house gynecologist at DeBakey, Templeton had problems involving her pregnancy before she even had a pregnancy to begin with. In May 2014, she was set to marry her fiancé, and the couple planned to start having a baby right away. Initially she informed her doctor of this in February and inquired about having her IUD birth control removed. She was told to wait until she was actually married.
After her wedding, Templeton found getting the device removed was no easier. A call to make an appointment in May was not returned. An email to her primary-care physician, Dr. Joy Odeta, was returned with instructions to call the Women's Center since that kind of care was not provided in Odeta's department. It was the same number she'd been calling for a month. Fed up, Templeton simply paid $125 out of pocket to have her IUD removed at a private clinic on June 11. A month later, the VA RN finally returned her call, saying that she'd been on vacation for two weeks and hadn't received any of the messages that Templeton had been leaving since May.
This was to become typical experience regarding her maternity care.
"It's always 'I didn't get your message' or 'They gave me the wrong number,'" says Templeton. "It's always someone else's fault."
Templeton received a positive on a home pregnancy test in September. At first she was elated, and her experiences with the VA went as El-Serag said they should. She showed up as a walk-in and was seen the same day, with her pregnancy confirmed by the labs the following day. On October 1, she again appeared as a walk-in patient for her consultation with an RN, and submitted the name of the OB she hoped to be able to use. She was promised a response in seven to ten days.
For the next month, Templeton fruitlessly attempted get help from the system. Messages left at the VA concerning approval of her choice of obstetrician went unanswered and unreturned. The same was true for the office of the doctor she'd selected when she called to inquire if they'd received any information regarding whether or not the VA would approve care. Frustrated, she began calling other doctors in the Cypress area close to her house to find out if any of them accepted VA payments. Either her calls went unreturned or they did not take VA patients.
Into the second month of her pregnancy and approaching her third, Templeton still had not been to see a doctor.
She then employed the other VA-approved method: seeking a doctor through TriWest. Prompting from a call from the Women Veterans Call Center finally netted Templeton a TriWest representative on the phone to help her find care. But there was a communications breakdown somewhere because the company spent the next two weeks mistakenly trying to find Templeton a reproductive endocrinologist to help her get pregnant -- something she, of course, already was.
After straightening that out, Templeton began going over her options with her representative. Templeton said that anything between Cypress and the Medical Center would be convenient for her school schedule. She claims that TriWest told her that there was nothing available in her suggested range that had an opening even though that area has one of the densest populations of medical professionals in the world. Obstetrical and Gynecological Associates or the Woman's Hospital of Texas, located a stone's throw from DeBakey? Not options, apparently.
Among the alternative clinics Templeton was offered was a doctor at a UTMB facility hours from her home and one located in Sunnyside, which was recently ranked the sixth most dangerous neighborhood in the country and the most dangerous community in Texas overall. It also has the dubious honor of containing the ZIP code with the highest concentration of registered sex offenders in Houston who are not living in sex-offender-specific housing.
"It's not a safe place that a woman alone would care to go for an appointment," says Templeton. "The doctors may be great, but it's not safe."
Templeton finally agreed to see Dr. Denise Leonard at Stork GYN, located near I-45 and FM 1960. The earliest available appointment was in early December, still a month away. When Templeton asked if there was anything that could be done to get her in faster since the December date would put her into her second trimester without her having yet seen an obstetrician, the TriWest representative allegedly told her, "TriWest patients do not receive priority over the clinic's 'real patients.'"
"I just hung up then and had a meltdown when she said that," says Templeton. "I'm sure it's not their company policy, but the fact that someone in their organization felt comfortable saying that to a patient, to a distraught pregnant woman who just wants to see a doctor, kind of speaks to me of their corporate culture."
We reached out to TriWest regarding the apparent difficulty Templeton had in securing a doctor in a timely manner and were told by email that there are currently 52 providers in network offering obstetrical care in the Houston area, with 35 in Harris County alone. (With 10,000 female veterans registered through the VA system in Houston, that works out to 192 women per provider, though obviously they are not going to all be pregnant at once.) TriWest declined to name the clinics, saying that information is proprietary. When asked why so many seemed to be located in low-income areas, company representative Lauren Herchet responded, "The providers in our network serve a wide range of patients from different socioeconomic backgrounds."
The company declined to allow us to speak with the person in charge of coordinating care in this region, so the question remains: Why, in a city in which some of the finest maternal medicine in the world is happening down the street from our central VA hospital, are our pregnant veterans being sent to the outskirts of town?
There are some indications that TriWest may be in trouble. In 2011, the Phoenix-based company settled with the government for $10 million after it was shown that TriWest had negotiated discounts with doctors and clinics and failed to pass those savings on to the military's Tricare benefits plan, which TriWest was then administering. The next year MarketWatch reported on further setbacks when TriWest lost its contract with Tricare to United-Health Group, an agreement that's worth an estimated $20.5 billion over six years. It looked as if TriWest would have to close as it laid off 1,700 employees, only for it to win the contract for the VA's PC3 program.
In June 2014, TriWest CEO David J. McIntyre Jr. addressed the U.S. House of Representatives Committee on Veterans' Affairs via written statement, acknowledging that Region 3 (which includes Houston) had experienced problems setting up its network and finding the "right providers." However, he assured Congress that by July 1, TriWest would be fully ready and was "working to address the clusters of backlogged care that have materialized."
Templeton is not impressed. "The VA may love TriWest, but they probably just love TriWest's prices," she says. TriWest receives an administrative fee for every veteran who goes through them, though the exact amount is confidential because it was part of a competitive bid.
After confirming with Leonard's office that it could not get her in sooner -- she was told that the doctor's patient load was simply too high -- Templeton resolved to be done with TriWest and to once again try to find her own doctor. Dr. Marlon White agreed to accept her and the VA as a payment option and deliver her baby at Methodist Willowbrook, close to her house. All that was left to do was get authorization faxed from the Fee Basis office at DeBakey.
That went about as well as everything else had.
Templeton received confirmation from White on November 4. Throughout the next two months, the VA's Fee Basis office ignored her calls and emails, failed to fax her authorization form, claimed the form could not be faxed because of a printer error or faxed it to the wrong number. She ended up camping outside the office door of Pamela Swope, the Women Veterans Program Manager, to prod a response from anyone in charge of helping her secure payment for her doctor. In the meantime, she broke a crown that left her both unable to eat and unable to seek emergency dental care until she had gotten approval from an obstetrician. White saw her on short notice for a brief visit ($140 out of pocket), and said that he still hadn't received a fax from the Fee Basis office.
And the same was true when she finally saw her baby on the screen at her first in-depth obstetrician appointment, described at the beginning of this story.
"I'm pretty lucky to receive the continuing care we do receive," says Templeton. "When you're starting your family, you want to be excited and happy when you're going to get your ultrasound. You don't want to be worrying about a $700 bill. It just seems like they don't care. I hate to use the term 'ungrateful' because it makes me feel ungrateful, but it's disappointing. It's very second-class citizen."
Problems with women's care at the VA aren't limited to maternity, either. Rachel Blomstrom left the Navy as a second class petty officer in 2012 on a medical discharge. She'd wanted to go to school but found it difficult to both work full time to pay for classes and attend simultaneously. A stint in the military seemed like the best way to secure her collegiate future, so up she signed.
Following her discharge, Blomstrom returned to Houston and began going to the VA, where she and Templeton actually shared the same primary care provider, Dr. Joy Odeta. At the end of 2013, Blomstrom began experiencing severe pain in her pelvis and her hair started to fall out. She was shrugged off for months until she was finally able to convince the VA to perform an ultrasound to see what the problem might be.
"I was never able to see a gynecologist while I was there," says Blomstrom. "In the report, it said the mass was 'not a classical representation' of a uterine fibroid. Dr. Odeta glanced at it, said I had a fibroid and put me on birth control. The report listed three possible diagnoses: thrombosed vessel, pelvic congestion syndrome and AV malformation. The thrombosed vessel is a blood clot, the pelvic congestion syndrome is like varicose veins, and the AVM is a major problem with the veins. Basically, it looked like a blood flow issue."
When she went to her follow-up visit, Blomstrom insisted on taking a picture of the results on the screen. According to her, when Odeta saw the possible diagnosis of AVM, she remarked, "I don't even know what that means." (When contacted by the Houston Press, Odeta declined to comment on Blomstrom's statement.)
Blomstrom says that receiving gynecological care at DeBakey above basic well-woman work was not getting her anywhere. She asked to be allowed to seek an outside doctor, but the VA insisted its doctors could handle her case in-house. Later, after she was prescribed progesterone, she was struck with a 27-day period. In even more pain and worried that she might have been experiencing internal bleeding, she phoned her doctor trying to find out if she should stop taking her medication. After a month of steady bleeding, she finally did, and the experience left her with little love for the VA's women's care.
"I don't know if you can imagine what it's like to worry every day that you're going to bleed out and die without knowing anything," says Blomstrom. "They're so overwhelmed there. I don't understand why they don't hire more people or send us out more. I didn't see anyone in Houston qualified to deal with the three diagnoses I was offered on my ultrasound."
According to third petty officer Christina McClendon, complaints like this are not new.
Thirteen years ago, at her first ever gynecological visit to the VA hospital, a doctor told McClendon as she stood nearly naked in the appointment room that at 5'6" and 155 pounds, she was obese and her body was "not good." McClendon is a tough woman who earned her medical billet in the Navy in 1990 by so loudly telling a recruiting officer who wanted her to sign up as a seaman instead to kiss her ass that a reservist officer across the building heard it and called her the next day asking if she was the Kiss My Ass Lady and whether she'd be interested in a medical billet through her. Tough as McClendon is, the remarks by her doctor hurt her so badly that she cried the whole way home and vowed to use Planned Parenthood afterward.
Nonetheless, when it looked as if she was pregnant, she returned to the VA after testing positive on a home test. Her hospital test came back negative, and she was again devastated.
"I thought I had miscarried," says McClendon.
Doubting the results, she tested herself again and again received a positive. She called the VA back, but wasn't able to get another appointment for a month. By then she had retested herself half a dozen times, all with positive results. Eventually the hospital confirmed that she was pregnant, got her started on prenatal vitamins and referred her to a clinic to receive maternity care.
This was a decade before TriWest would be handling such cases, but the protocol was largely the same. McClendon was sent to a clinic off the Southwest Freeway near Beechnut Street. It was a provider that accepted low payments for care and primarily served a poorer demographic.
"It was a facility for people without insurance or money," says McClendon. "Every time I went to have checkups, I was surrounded by desperately sick people, and the building itself was dirty and old. It was not savory at all for a first-time mother, and I didn't feel safe going there."
Though she never really felt comfortable being pregnant around so many people who were clearly in dire straits with their health and what they could afford to get treated, the actual pregnancy center proved to be slightly nicer. McClendon liked her doctor and had no overall problem with her care there. However, it bothered her that this was what was being provided to women who had served their country.
"I had kind of been raised that you get what you get, and I'd been down on my luck before," says McClendon. "It was free and I was grateful enough to make lemonade out of lemons, but I had friends that had gone to the Women's Hospital and different places in Houston. I'm sure all of these places are equipped to handle a situation like me. It was surprising because the VA knows they have women and women have children."
There was at least one serious problem with the location. McClendon lived in Katy and at the time drove a car with no air conditioning. With the only other option offered to her by the VA at the time being in Beaumont the Beechnut clinic was her best bet. The long drives through the late summer heat took their toll on McClendon's blood pressure. She was diagnosed with preeclampsia, which derailed her plans to have an unassisted birth at home.
When her son was just 29 weeks in utero, McClendon started seeing rainbow flashes across her vision with her eyes closed. Her parents rushed her in the back of their car to Ben Taub. By the time she was admitted she had begun having seizures. She remembers none of the experience, but her mother says the orderlies took one look at her and rushed her through halls on a bed shouting orders and expletives just like in the movies. It was Veterans Day 2001.
McClendon recovered in the ICU and her three-pound premature boy clung to life in the NICU. Watching his wife and son struggle to heal, her husband was pulled aside to be given an unpleasant shock; though McClendon's care at Ben Taub was provided for by the VA, their son's was not. Her husband had just lost his job, she was in school to be an acupuncturist, and they were now racking up a bill that threatened to cripple them financially. No one had told them.
Ben Taub took good care of the McClendons. It also assisted her husband with signing up for the State Children's Health Insurance Program, which covered their son's care. Nonetheless they received a bill from a collection agency four years later totaling $450,000. Both Ben Taub and the VA said that it had not come from them and that they would take care of it. McClendon has heard nothing further, but it was a terrifying reminder of what they might have been facing if a program to help people with little to no income had not been available to them as their son spent a month in the Ben Taub NICU.
"I appreciate the care I get from the VA," says McClendon. "Anytime I've needed care I've gotten it. Yes, sometimes there's a wait, but I've gotten it. That said, it's crazy to me that you would grow a person inside of your body and that they would not cover the baby."
At the DeBakey Hospital, they're trying to fix the system. By spring, the Women's Center will employ a new RN whose sole responsibility will be helping women coordinate their maternity care off-site through a dedicated database. The goal is to give pregnant veterans a single contact point that will avoid the mass of missed calls and confusing departments that have plagued Templeton throughout her maternity.
"We're really, really committed to giving our female veterans high-quality care," El-Serag says. "When individual problems come up, we try our best to get our patients taken care of immediately. We will accommodate the veteran. If they're not happy with their care, we ask them, 'What do you want?' Whatever they want to do, we'll go with. We're a group of individuals here who are particularly sensitive to the special needs of our veterans."
After our interview with El-Serag, she offered to have maternity patients who have had positive experiences with the current system contact us with their stories. As of press time, we had received no calls or emails.
Blomstrom has since left Houston to attend school in Chicago but continues to use the VA there as her primary care. She is still trying to get someone to nail down what is going on in her reproductive system. Recently her doctor there suggested another ultrasound, but Blomstrom demanded an MRI.
"I'm tired of these people sticking things up me with no result," she says. Her confidence remains low. Arriving early for a recent appointment, she found the employees having a pizza party, blowing up latex gloves like balloons while she waited.
McClendon's son grew up big and strong despite his tense beginnings. He remains on CHIP while his mother uses the VA facility that has opened in Katy since he was born. Though she finds the facility bare-bones in comparison with what is offered at DeBakey, it's convenient and close and fulfills her needs.
Recently she and other veterans received "choice cards" in the mail as a result of the VA reforms passed by Congress. Veterans can use the cards at other facilities if they're unable to secure an appointment within 30 days or live outside a certain range from a VA provider. The program, which included a letter signed by the President, touched McClendon deeply and made her feel appreciated.
The good news for Templeton is that she recently had her very first appointment after her physician received all the necessary paperwork from the VA. For the first time, she can go to the doctor and not have to worry about out-of-pocket expenses, just as she does when she seeks her non-maternal care at the VA. Another ultrasound revealed that she was having a baby girl, with her due date pushed slightly back, to June 1. She's ecstatic.
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Sort of. At that same appointment, she found out her lab work is handled at her doctor's office but not by her doctor's office. Different company, different forms, you see? Dreading another months-long chase for a fax, she had her doctor print out the same form she used for him and turned it over to LabCorp. She has her fingers crossed that the situation works out.
She is considering abandoning her VA coverage to get on her husband's insurance through the City of Houston once the next open-enrollment period begins. She feels as if she just can't trust the system to help her find and keep an OB, and talking with the staff at her doctor's office, she's heard that they deal less and less with VA because of hassles similar to hers.
"I don't want to make this a men-versus-women thing, but if a male veteran goes in with reproductive issues, he gets his little blue pill right away, but when it's a woman, it takes five months to get a paper faxed," she says.
McClendon agrees. "It's like they just don't know what to do with us."