Final of three parts

On their 6.5-acre homestead in the center of Jefferson, Aaron Greene-Morse and Walter Morse have settled into a comfortable rhythm.

They raise rabbits, chickens, sheep and two types of pigs. They sell rare, high-end pork to restaurateurs in Washington, D.C. But husbandry wasn’t the only reason the married couple settled in Jefferson over the last couple years.

As veterans of the Army, both appreciate the ease of receiving their health care just down the road in Chelsea at the Togus campus of the VA Maine Healthcare System.

Togus, the oldest veterans hospital in the country and the nerve center of Maine’s own statewide veterans health system, is marking its 150th anniversary this week at a time of change in the demographics of America’s veterans. The overall number of veterans in both Maine and the nation is slowly shrinking, as those who fought in World War II, Korea and Vietnam, and others who have served in peacetime, age and die.

But as the Maine system’s administrators look to the future, they’re not expecting the demand for their services to dry up anytime soon. That’s in part because older veterans with chronic health conditions, including diabetes and hypertension, will still remain in the system. Meanwhile, a younger, more diverse generation of veterans – people like Aaron and Walter – are enrolling in the VA system at a decent clip and are seeking more treatment than past generations, according to the administrators.

After a combined 41 years in the service, Aaron Greene-Morse and Walter Morse have health needs that require continual attention. Aaron, who is 40, spent much of her two-decade service as a stateside intelligence officer, and toward the end of her career, she was diagnosed with multiple sclerosis, an incurable disease that attacks the nervous system. A cavalry scout from 1991 to 2012, Walter, 43, is still receiving treatment for injuries he received in 2008 when, as part of the surge of U.S. troops during the Iraq War, he was hit by an explosive device. The impacts left him with shrapnel wounds, an injured back, traumatic brain injury and other ailments.

Aaron and Walter have received treatment at veterans and military hospitals in Washington, D.C., and Baltimore. But when they were considering places to settle with two young children, a 7-year-old daughter and 2-year-old son, central Maine were appealing.

For one thing, they like the area’s climate, environment and welcoming spirit.

They don’t go to Togus for all their health care needs, but when they do, they also appreciate the relaxed setting and the attentiveness of its staff, which are in sharp contrast to their experiences at the more crowded veterans facilities in Baltimore and D.C.

When Walter was growing up here, his father, a decorated Vietnam veteran, spoke highly of Togus as well as other VA facilities in Massachusetts. Those Massachusetts facilities have a renowned heart-and-lung center, Walter said, and he also takes comfort knowing he could easily get to them if necessary.

“When you’re looking at a lifetime of health care needs, it made no sense to go anywhere else,” Aaron said. “There are other VAs that truly need a microscope put on them, but Togus is a dream. The parking lot is never crammed. You don’t have drunk and disorderly people wandering around trying to take your wallet. It’s way, way more calm.”

Though the total number of veterans enrolled in Togus is projected to shrink from 54,016 in 2015 to 48,460 in 2035, the portion of women in that population is projected to grow from 6 percent to 11 percent during the same time frame, according to figures from the U.S. Department of Veterans Affairs. At the same time, veterans who served in Iraq and Afghanistan made up 13 percent of VA Maine Healthcare System enrollees in 2015, but are expected to make up 20 percent by 2035.

Those veterans have challenged the federally funded system in unique ways.

Women require a variety of health services that the VA has not always delivered at high volumes, as the veterans of past generations were more frequently men.

Those services include screenings for breast and cervical cancer, gynecological surgeries and menopause counseling, said LaRhonda Harris, manager of the women veterans program at Togus. The increased number of women in the system has also required a culture shift with the provision of more privacy and the countering of traditional perceptions that any woman passing through a veteran’s hospital is a family member or caretaker of a male veteran.

And veterans of the Iraq and Afghanistan conflicts have been seeking treatment for their own slate of afflictions.

Traumatic brain injury, or TBI, is often called the signature wound of those recent wars, just as Agent Orange exposure was seen as a common issue for Vietnam veterans. Because of advancements in battlefield medicine, veterans of recent wars have been more likely to survive high-impact trauma, leading to a jumble of physical and mental injuries that require treatment back home, sometimes several years after the fact. They’ve lost limbs and been exposed to chemicals. After wearing heavy body armor for long stretches of time, they’ve developed chronic, muscular-skeletal pain.

At the same time, younger veterans have been susceptible to post-traumatic stress disorder, suicide, drug addiction and mental illness, as well as homelessness.

“We’re seeing a lot of (younger veterans) with massive trauma – lost limbs, traumatic brain injury,” said John Gale, a researcher at the University of Southern Maine’s Muskie School of Public Service who has studied rural veterans health care around the country. “We have a more complex mix of those that have been more severely wounded, and also have some low grade things that aren’t necessarily as obvious or don’t always appear physically. While they may not have a very severe injury, the effects of that concussive blast can show up late.”

IN GROWTH MODE

The VA Maine Healthcare System has met, and will continue to meet, the challenges of those new enrollees in a number of ways, according to Ryan Lilly, director of the system.

In recent years, Togus has added a women’s clinic and expanded the array of integrated health and rehabilitation services – known as polytrauma care – it provides to soldiers who experienced severe trauma during their service. For many years, it has also tried to ensure that veterans in Maine’s more rural counties have access to services at outpatient clinics located around the state and in civilian clinics that have partnered with the system.

Togus officials have been able to expand those services in part because of increases to the VA budget.

“We’re still in a growth mode,” said Lilly, who noted that the number of patients in the system has been increasing at a rate of 3 to 5 percent per year in recent years. “We still see that continuing, though the projections say the veteran population will go down. We’re not really seeing that yet. We’re continuing to do more things.”

Along with offering more services, the Maine system has been planning expansions in Augusta and Portland for both medical and long-term care. Fisher House, an organization that builds housing for families of veterans who are receiving treatment, is planning to fund the construction of a facility on the Togus campus.

The system has also been growing its staff. When Lilly first started working at Togus a decade ago, the system employed 950 people, but that number has grown to 1,450, a roughly 50 percent increase.

Yet whether Togus will continue to expand in the next few decades is an open question.

“When you talk about the real long, long-term future, it’s hard to have a crystal ball that knows exactly what’s going to happen with the federal budget, military staffing, veteran populations, the state of any wars or war-type conflicts, what’s available for health care options for citizenry and vets,” Lilly said. It could be hard for Congress to keep upping the VA’s budget, said Michael Mayo-Smith, who oversees all the VA systems in New England.

“We have been generously funded, but we foresee it’s going to be difficult to continue those increases,” he said.

The VA’s funding has more than doubled in the last decade.

In 2006, the department’s budget was $73.1 billion, according to funding requests available on its website. By 2014, it was $168.9 billion, a 130 percent increase from eight years earlier. In his 2016 budget request, President Obama is seeking $168.8 billion for the VA.

Maine veterans’ expenditures have also grown, though less dramatically. They stood at $909.5 million in 2014, up 75 percent from eight years earlier. The Obama administration is seeking $1.1 billion for Maine in 2016.

But while Maine has received more federal funds for veterans care than three other states in New England – Vermont, New Hampshire and Rhode Island – its funding levels have still been on the lower end nationally. The Massachusetts system, for example, had a $2.6 billion budget in 2014. The District of Columbia’s was $4.9 billion. The highest, California’s, was $14 billion, with Texas and Florida not far behind.

If federal funding slows, and should nationwide health care costs continue to rise, Mayo-Smith said there will be more pressure on regional administrators like him and Lilly to manage their costs.

TRAUMA TREATMENT

Walter Morse and Aaron Greene-Morse have enjoyed farming. They’re part of a statewide coalition of veteran-farmers, United Farmer Veterans of Maine, who pool their resources and sell their products along the East Coast.

Walter and Aaron both retired from the Army with the rank of sergeant first class, and they’ve named their farm appropriately: Patriot Ridge Homestead.

They’ve also appreciated the newer offerings in the Togus system. Aaron said she receives good care at Togus and makes use of a women’s clinic that was opened in 2014, but is still frustrated when other veterans think of her as a wife rather than someone there for treatment.

“It’s fifth down the line,” she said. “First they see I’m a woman, then they see I’m a wife, then they see I’m a mother, then I walk in with a combat veteran so I’m a caretaker, and ‘Oh, you’re a veteran too?’ ‘Oh yeah, I am.’ ”

Still, Aaron said, that lack of recognition is not limited to people at Togus and does not reflect poorly on the care she has received.

Walter, who received the Purple Heart and Bronze Star medals for his service, moved here two years ago after going through a transition program for wounded veterans at Walter Reed Army Medical Center.

Though he was injured in 2008, he didn’t seek treatment for his traumatic brain injury until 2012, he said, because “there was some denial going on.” He experienced several symptoms, including memory loss and what he described as “time lapse issues.”

He also experienced constant headaches, including some he ranked as 7 and 8 on the 10-point pain scale. But for two years, he’s been taking a Botox therapy at Togus that the U.S. Food and Drug Administration has approved for the treatment of migraine headaches.

“It’s absolutely amazing,” Walter said. “I’m glad that we have that service here, because otherwise, every three months, I’d have to go to Walter Reed or D.C. to spend two days to get 40 minutes worth of treatment.”

Botox therapy is just one part of the care vets with TBI and other blast injuries receive in Maine.

Dayton Haigney, a pain management physician at Togus who works with veterans recovering from polytrauma, said it can be difficult to determine the root cause of the neuro-psychological symptoms they are experiencing, like headaches and memory loss. To that end, veterans in the program answer a comprehensive set of questions and go through a personalized care program developed by multiple providers.

RURAL SHIFT

But while VA hospitals across the country have adapted to the needs of veterans from the Iraq and Afghanistan wars like Walter Morse, Lilly and others say that the system still delivers a larger volume of care to older veterans – a trend that will continue in coming decades as younger veterans age.

Veterans over the age of 65 make up 53 percent of current enrollees, and Togus administrators project that proportion to remain about the same even as the total number of enrollees drops.

What’s more, many of the veterans treated by the system, especially in states like Maine, live in remote, rural areas that can be a several-hours drive away from Togus.

Many health experts and veterans advocates commend the work Togus has done to build a statewide network of community-based outpatient clinics and partner with private health care providers, but agree that even more resources may need to be shifted to rural areas in the coming years.

The number of Maine veterans who use those statewide outpatient clinics is growing. Just one-third of Togus users received care at the outpatient clinics in 2002, but more than 70 percent do so now.

“If veterans don’t live where there’s (a community-based outpatient clinic) or other veterans system, I think the VA – unless they start building new vets hospitals – will have to figure out how to be more collaborative or integrated with community delivery systems,” said Gale, the USM researcher. “Veterans from rural communities tend to go back to where they came from.”

Attempts at that integration have created trouble for veterans systems across the country, including Togus.

Two years ago, after widespread reports about delays at veterans hospitals, Congress approved the creation of a program that would streamline the process for veterans seeking care outside the system. Togus contracted out the implementation of that program to a company in New Hampshire called Health Net, but in January, Togus officials reported that just half of vets trying to use the system had succeeded in making appointments.

But those officials, along with at least one veterans advocate, say the system has improved since then. Health Net has hired a Maine coordinator, and by July, two-thirds of Maine veterans seeking appointments through Health Net had succeeded in doing so, Togus spokesman Jim Doherty said at the time.

One success story for the delivery of health care to veterans in rural Maine is Cary Medical Center in Caribou, which in 2008 was one of five hospitals across the country to pilot a program organized by the VA. Through that three-year program, veterans could have specialized operations, such as orthopedic surgery, authorized by Togus and performed at the Caribou facility.

“That was a tremendous win for veterans here,” said hospital spokesman Bill Flagg. “Obviously, they could now have a variety of services that they traditionally had to travel all the way to Togus for.”

Veterans reported high levels of satisfaction with the program despite some challenges along the way of getting them into surgery quickly, Flagg said. The program also allowed the hospital to expand its own capacity, he added.

FUTURE OF CARE

Even as veterans care is distributed across the state, Lilly doesn’t foresee a time when the Augusta campus – the “mothership,” as officials call it – will be become irrelevant.

For one thing, Lilly said the civilian health infrastructure in Maine is lacking in several key areas.

While surgical options abound around the state, there are few places Maine patients can go for the long-term treatment of mental illness.

But Lilly didn’t rule out that technological advances could one day transform how Togus delivers care around the state in the same way telehealth technologies have already allowed patients in rural areas to see their system doctors via an encrypted video feed.

“The big question on that is, what’s going to happen to health care? How much is it going to evolve?” Lilly said. “Can you imagine a scenario, in 30 years let’s say, where robotic surgery is so precise that you could do that in an outpatient clinic via robot and have a surgeon here running a robot on this end? Yeah, I could say that. Thirty years may be a little ambitious, but it’s imaginable.”