It's been nearly two years since the Department of Veterans Affairs came under fire for the amount of time veterans had to wait to see a doctor. The agency scrambled to find a fix, including allowing vets the option of seeing a private doctor via a program they call Veterans Choice.
But the fix isn't working, so some VA clinics are coming up with other ideas to reduce wait times. In the city of Clarksville, Tenn., the VA clinic decided it simply couldn't take any new patients.
The facility is so overcrowded that unused wheelchairs are being stored in the hall, and nurses are stationed in what used to be a corridor. There's even a computer set up in what used to be a bathroom.
"This is actually a converted toilet," says Robert Lim, who works for the Tennessee Valley VA health care system, which serves tens of thousands of veterans in Tennessee and parts of Kentucky. "We're literally like sardine cans in here. You can't go around any place without bumping into somebody."
Lim oversees primary care clinics like the one in Clarksville. He's not one to sugar coat the situation. Yes, he says, this is pretty bad.
"If you go into Clarksville, you will actually wonder: 'How in the world did they get things done?'" Lim says.
One problem is the building just isn't arranged well for a growing doctor's office. There are too many hallways and not enough rooms. It opened eight years ago, and Lim says it was the best space the VA could find to lease at the time.
There are also more patients than eight years ago, because the veteran population here has been growing. It's right next door to Fort Campbell, one of the largest military bases in the country.
So in 2014, wait times at the Clarksville clinic were rising — at a time when Congress and the VA were clamoring for clinics to see patients faster.
"Patients were calling in and we're saying, 'Well, you can't get in for 90 days, 120 days,'" says Michael West, the chief medical officer at Clarksville. "It was just logistically impossible for us to take care of the patients we had, so we had to draw a line and say, 'Look, we've got to do something.'"
So last March, they did.
The clinic in Clarksville decided to only see veterans who already went there. If someone new wanted an appointment, clerks were instructed to say that the site had temporarily stopped taking new patients.
Instead, veterans could go to the VA hospital in Nashville, about an hour's drive away. They could go 35 miles north to a small clinic in Hopkinsville, Ky., or 35 miles west to an even smaller clinic in Dover, Tenn.
They could also apply for the Veterans Choice Program, which is when the VA pays for a private doctor — although that's had many problems too.
And it's been like this for more than a year. The clinic used to take about 50 new patients each week – about 2,500 a year – but now it's down to just a few emergency walk-ins.
Lim says the best option right now is to not accept new patients.
"It made sense to actually take care of who we have here already, rather than continuing to take new patients and lack the ability to take care of everybody. So it was the lesser of two evils," Lim says.
NPR found nearly a dozen VA health facilities around the country that have done something similar in the last couple of years. For example, a few clinics in Washington state are having trouble hiring enough doctors for all the patients trying to get in.
It's hard to know for sure how common this is around the country. The national VA keeps a tally of wait times, but it doesn't track which sites are seeing new patients and which are not.
Mike Davies, who oversees clinic access for the VA, says it's "very common" for clinics to refer at least some patients elsewhere. But he believes this problem is inevitable in a big health care system.
"Remember, VA has 1,700 sites of care," he says. "It's hard to have every single clinic open for accepting new patients every single day, just because life happens, right? We have providers that get sick, we have providers that move."
But when asked if it's a problem that some clinics cannot take new patients, he says yes.
"And we're doing everything we can to provide care as close to home as possible. But if we're in one of those relatively rare situations where the clinic close to home is full, we'll do our best to accommodate you by sending you to the closest, next-best place," Davies says.
By some measures, that policy works pretty well. Wait times at the Clarksville clinic are now among the lowest in the state. Lim says the patients there — the ones who were already in the system — are much happier and the staff is less stressed.
But it still means that new patients – when they need a doctor—can't get into the clinic they want. This affects people like Steve Singleton and his wife, Janet. Both are Navy veterans in their early 60s who moved to Clarksville last spring. Shortly after their move, Steve came down with bronchitis and went to the Clarksville clinic for treatment.
"I went in and I showed them my VA card, and they told me that I couldn't be seen because they had no room for any more new patients," he says.
He ended up paying out of pocket for a private urgent care clinic. Now, he and his wife have doctors at the VA in Nashville. They're OK with the hour-long drive for now, he says, but "it would still be nicer if I could just drive 10 minutes from my house instead of having to drive to Nashville for my medical care."
It also means that the other nearby clinics are now strained. Scott Cobb, the Dover clinic's manager, estimates that about a third of his new patients are coming from Clarksville. Dover now has the highest wait times in the region, while the Hopkinsville, Ky., clinic — the other clinic where Clarksville patients are referred — comes in second.
Clarksville is hoping to squeeze in one more doctor soon, which means a couple hundred new patients can get in. But the best solution won't come until the VA can build a brand-new clinic.
It's working on plans for a building three times the size of the current clinic, but that won't be ready for another year. And by the time it's built – with more and more veterans moving into the area – even that might not be big enough.