“We now turn our attention to the legislature to maintain Montana’s bipartisan Medicaid expansion and protect those enrolled from harmful restrictions that would take away health insurance coverage,”  from Chris Laslovich, campaign manager with the advocacy group Healthy Montana, which supported the measure.

The initiative, , was the single most expensive ballot measure in Montana history. Final fundraising tallies aren’t in yet, but  to defeat the initiative. That’s more than twice as much cash as supporters were able to muster.

Most of the money in favor of I-185 came from the Montana Hospital Association. “I’m definitely disappointed that big money can have such an outsized influence on our political process,” said Dr. Jason Cohen, chief medical officer of North Valley Hospital in Whitefish.

The ballot measure would have tacked an additional $2-per-pack tax on cigarettes. It would have also taxed other tobacco products, as well as electronic cigarettes, which aren’t currently taxed in Montana.

Part of the expected $74 million in additional tax revenue would have funded continuation of  in Montana.

Unless state lawmakers vote to continue funding the Medicaid expansion, it’s set to expire in June 2019. If that happens, Montana would become the first state to undo a Medicaid expansion made under the Affordable Care Act.

In September, that if the Medicaid initiative failed, “we’re going to be in for a tough [2019 legislative] session. Because if you thought cuts from last special session were difficult, I think you should brace, unfortunately, for even more.”

Republican State Rep. , who opposed I-185, disagrees with Bullock’s position. “I think one of the mistakes that was made continually with I-185 was the belief that there were only two options: If it failed, Medicaid expansion would go away; if it passed, Medicaid expansion would continue forever as it was.”

Ballance, who didn’t receive money to campaign against the initiative, said Medicaid expansion in Montana can be tweaked without resorting to a sweeping new tax on tobacco products.

“No one was willing to talk about a middle-ground solution where Medicaid expansion is adjusted to correct some of the things that we saw as issues or deficiencies in that program,” she said. “I think now is the time to roll up our sleeves and come up with a solution that takes both sides into consideration.”

Ballance said conservatives in the legislature want recipients of expansion benefits to face a tougher work requirement and means testing, so those with low incomes who also have significant assets like real estate won’t qualify.

In any event, Ballance said she suspects that if the initiative had passed, it would have immediately faced a court challenge.

North Valley Hospital’s Cohen said he hopes Montana will pass a tobacco tax hike someday. “We all know how devastating tobacco is to our families, our friends and our communities,” Cohen said. “And I think we also all know how important having insurance coverage is, and so I think people are dedicated to fighting this battle and winning it.”

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Fearing legislators might not renew funding for Medicaid’s expanded rolls, Montana’s hospitals and health advocacy groups came up with a ballot measure to keep it going — and to pay for it with a tobacco tax hike.

If ballot initiative passes Tuesday, it will mean an additional $2-per-pack tax on cigarettes and levy a tax on e-cigarettes, which are currently not taxed in Montana.

The tobacco tax initiative has become the most expensive ballot measure race in Montana history — drawing more than $17 million in opposition funding from tobacco companies alone — in a state with fewer than 200,000 smokers.

 works for the American Heart Association and is a spokeswoman for , the coalition backing the measure. She said coalition members knew big tobacco would fight back.

“We poked the bear, that’s for sure,” Cahill said. “And it’s not because we were all around the table saying, ‘Hey, we want to have a huge fight and go through trauma the next several months.’ It’s because it’s the right thing to do.”

Most of the $17 million has come from cigarette maker Altria. According to records from the , that’s more money than Altria has spent on any state proposition nationwide since the center started keeping track in 2004.

Meanwhile, backers of I-185 have spent close to $8 million on the initiative, with most of the money coming from the Montana Hospital Association.

“What we want to do is — No. 1 — stop Big Tobacco’s hold on Montana,” Cahill said. Also, she continued, it’s imperative that the nearly 100,000 people in Montana who have gotten Medicaid under the expansion will be able to keep their health care.

Cahill said I-185 will allocate plenty of money to cover the expansion, though some lawmakers say the state can’t afford the expansion even with higher taxes.

Nancy Ballance, a Republican representative in the Montana Legislature, opposes the measure.

“In general I am not in favor of what we like to refer to as ‘sin taxes,'” Ballance said. “Those are taxes that someone determines should be [levied] so that you change people’s behavior.”

Ballance also isn’t in favor of ballot initiatives that, she said, try to go around what she sees as core functions of the legislature: deciding how much revenue the state needs, for example, or where it should come from, or how it should be spent.

“An initiative like this for a very large policy with a very large price tag — the legislature is responsible for studying that,” Ballance said. “And they do so over a long period of time, to understand what all the consequences are — intended and otherwise.”

Most citizens, she said, don’t have the time or expertise to develop that sort of in-depth understanding of a complicated issue.

Montana’s initiative to keep Medicaid’s expansion going would be a “double whammy” for tobacco companies, said , the chief strategy officer for the nonprofit Well Being Trust.

“People who are covered are more likely to not smoke than people who are uninsured,” said Miller, who has studied tobacco tax policies for years. He notes research showing that people with lower incomes are more likely than those with higher incomes to smoke; and if they’re uninsured, they’re less likely to quit.

Federal law requires Medicaid to offer beneficiaries access to medical help to quit smoking.

Plus, Miller added, every time cigarette taxes go up — thereby increasing the price per pack — that typically leads to a .

And that, he said, works against a tobacco company’s business model, “which is, ‘you need to smoke so we can make money.'”

Ballance agrees that tobacco companies likely see ballot initiatives like I-185 as threats to their core business. But, she said, “for anybody who wants to continue smoking, or is significantly addicted, the cost is not going to prohibit them from smoking.”

The U.S. Centers for Disease Control and Prevention says tobacco use is  in the U.S.

Montana’s health department says that each year more than 1,600 people in the state die from tobacco-related illnesses.

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The Republicans who make up two-thirds of Montana’s congressional delegation have said they want to repeal the current health care law because it’s causing health insurance markets to “.”

But insurance executives at the companies that sell policies in Montana’s marketplace say that’s not true in the state, and they are concerned that GOP plans to repeal and replace the Affordable Care Act would destabilize a market that is working. Jerry Dworak, the CEO of Montana Health Co-Op, said, “I don’t think that their plan is going to improve health care in the state of Montana. I think just the opposite is going to happen. And I really do think a lot of people are going to get hurt.”

The co-op is one of the three insurance companies that have been selling Montanans coverage at healthcare.gov since it started in 2013. Dworak said it has no plans to leave.

“All of our hospitals have to take any patient that comes in and serve them. That has to be paid somewhere,” he said. “And if we’re not paying that through Medicaid expansion, those costs have to be borne by someone, and so that will increase the overall cost of medical expenses.”

Hospitals have a legal obligation to examine and stabilize any patient who walks in their door, regardless of whether they have insurance. When hospitals see their unpaid bills stack up, Lovshin said, prices go up for everybody else and insurers have to charge patients who have insurance more to stay afloat.

John Doran, a vice president with Blue Cross and Blue Shield of Montana, the state’s biggest insurer, agreed with that analysis.

Doran also said that problems would likely get worse if the individual mandate goes away. That’s the requirement to have health insurance that Republican health care bills do away with.

“If there’s no mandate, and there’s no incentive for them to buy a health insurance plan, then maybe they won’t,” he said. “The people who need health care the most, and typically have the highest health care costs, are the only ones who are in the marketplace, and that results in higher health care costs, and consequently higher premiums.”

Montanans have been seeing insurance premiums go up, sometimes by more than 50 percent a year. Most people who buy on the exchange get subsidies to help defray the cost, and the co-op’s Dworak said he thinks prices are now starting to stabilize. If the health law isn’t changed, he projects his company’s premiums would go up only 5 percent in 2018.

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The ads open with Democrat Rob Quist asking, “Did you know half of all Montanans have a preexisting condition?” He then attacks Republican challenger Greg Gianforte for supporting the House-passed American Health Care Act, which would allow states to drop preexisting conditions protections.

The latest polls put the race within a single-digit margin, surprising in a mostly red state where the previous two Democrats running for the seat lost by 15 points or more. Republicans have held Montana’s statewide seat in the House since the 1996 election. It became vacant in March when Rep. Ryan Zinke resigned it to become secretary of Interior.

Quist, a political neophyte, is a Montana-famous folk singer, who has written and performed Western-themed songs across the state for four decades.

Republican Gianforte is a software entrepreneur whose only political experience is failing to unseat Montana’s Democratic governor in November, getting the fewest votes of any Republican statewide candidate in 2016. Donald Trump won Montana by 20 points.

A  for Gianforte, funded by $2.5 million that the national Republican Congressional Leadership Fund has poured into the race, pairs a photo of Quist with Nancy Pelosi and says Quist supports her agenda, including “government-run health care.”

Montana resident Jim Lynch plans to vote for Gianforte. Lynch is a member of the . Members get together once a month in Kalispell, Mont., to talk about advancing Republican values.

Lynch says health care is a top issue for him. He hates the Affordable Care Act. He’s 63 and says his job provided good health insurance coverage throughout the Obama administration and continues to do so. But, he said, “there’s a lot of people in my shoes who aren’t that lucky. I do know, personally, that they’ve seen huge increases in health care costs, to the point that they don’t even have it anymore.”

Indeed, people who are 55 to 64 can be charged as much as three times what a younger person can be charged for ACA health insurance. Subsidies are available based on income, but older people may earn more than young people just starting their careers.

Under the GOP bill passed by the House, however, older people can be charged five times as much as younger people, and the .

“We are uninsurable as a couple, so we’re very grateful,” Galusha said.

Republican candidate Gianforte said he won’t vote for a health care bill that doesn’t work for Montana.

“I need to know that, in fact, it’ll bring premiums down, preserve rural access and protect people with preexisting conditions,” he said.

He also said he would have voted against the House health care bill if he’d already been in Congress, because there wasn’t enough time to read the bill and understand it before the House voted.

Democrats, however, accused Gianforte of being disingenuous. They point to a recording of a phone call he had with lobbyists on the day the House bill passed, which was  to The New York Times. On the tape he said, “Sounds like we just passed a health care thing, which I’m thankful for, that we’re starting to repeal and replace.”

Quist pounced on those words. Quist needs Republican votes to win, so he’s trying to convince Republicans that their candidate will sell out the state’s interests on health care.

“Montanans want a congressman who’ll shoot straight, not a dishonest politician who says one thing to Montanans and another to the millionaires behind closed doors,” he said. Quist said he wants to build on the ACA and thinks the country should eventually move to a single-payer health insurance system.

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(Update: Trump at a ceremony Wednesday at around 11:30 a.m.)

Veterans Choice is a $10 billion response to the 2014 scandal in which Veterans Affairs health facilities altered records to hide months-long waits for care in Phoenix and elsewhere. The pays for private-sector health care for veterans and was set to expire in August, but the VA and some of the program’s harshest critics in Congress have agreed to extend it, with a few changes, until January. They said that will give the VA time to propose a more comprehensive package of reforms — fixes for the fix.

Montana Democratic Sen. Jon Tester authored the extension bill, which won bipartisan support in the House and Senate this month. It will become law when Trump signs it.

Tester, the ranking Democrat on the Senate Veterans’ Affairs committee, said he hopes to have draft legislation incorporating private-sector reform proposals ready in the fall.

Tester said his goal is to “cut the red tape and make sure it’s easy to work with for the providers. And I think we’ll get more providers jumping on board, and we’ll get more veterans using it, if the time to set up those appointments is reduced dramatically.”

Tester says he’ll defend the VA from those who “don’t want the government involved in health care at all.”

“I think it’s idealism versus realism,” Tester said. “We have folks that have borne the wounds of battle, and I think the VA is best suited to take care of those folks. So that VA needs to be there, and then we need to have a private sector that fills in the gaps around that VA.”

That’s particularly important in rural states like Tester’s Montana, where VA facilities are an important part of a generally understaffed health care landscape. They provide vital services, but rely on partnerships with private-sector doctors, clinics and hospitals to provide specialty care, or appointments that don’t require hours of driving.

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In Montana, this is playing out at the Blackfeet Community Hospital. It’s the only hospital on the Blackfeet reservation, and has been mostly funded — and chronically underfunded — by the , which has been in charge of Native American health care since its founding in the 1950s. But now, many Native Americans have been able to afford health insurance on the Obamacare exchange, and last year, Montana expanded Medicaid. Now, about one in seven reservation residents gets Medicaid.

Blackfeet Community Hospital needed to build an infrastructure to deal with the byzantine bureaucracy that comes with taking Medicaid and private insurance. The tribe’s community college started a new curriculum to help meet the growing demand for people in Indian country to process insurance claims.

“To me, there’s opportunity there to not only build health care, but to build your entire community and build jobs,” said Billy-Old Coyote.

Unemployment on most of Montana’s Indian reservations is the rest of the state. And people who are working don’t always get health insurance with their jobs. So ACA subsidies that bring down the cost of insurance premiums are a big deal, Billy-Old Coyote said. Most Montanans, Native or not, can now get policies for about $75 a month. It is a big change for the reservation communities where people are accustomed to the underfunded IHS, which often didn’t pay for care unless someone was in immediate danger of losing life or limb.

“Now you’ve got an opportunity for American Indian people to truly have access to private insurance,” she said. “You have access to greater networks of providers and specialists, and all the things we generally don’t see you have access to.”

Medicaid expansion had a lot to do with the number of health care jobs in Montana growing by 3 percent last year, according to state statistics. And schools in Montana, including tribal colleges, are offering more classes in health care fields.

At Blackfeet Community College, 23-year-old Leroy Bearmedicine is working toward certification as an emergency medical technician.

“I’d like to become a registered nurse at some point, maybe even work my way up to flight nurse — something to get the adrenaline going,” he says.

Native American leaders have seen the Affordable Care Act as a means to remedy a series of broken promises by the federal government to care for them. They now fear that promise, too, will fade. One estimate suggests Montana will if the Affordable Care Act is repealed.

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“We didn’t want to implement a plan that was another entitlement that just had a bunch of people signing up to get free or cheap or subsidized health care,” Buttrey said. “We wanted a plan that said, ‘We’re going to get you on. We’re going to get you healthy. We’re going to identify your barriers to employment or better employment, and then we’re going to move you off the plan.’”

So Buttrey wrote a Medicaid expansion bill for Montana that linked the health coverage to a job training program. He wanted everyone getting benefits to have to meet with a labor specialist who would help them figure out how to get a job or to get a better paying job.

The goal is to “make them healthier, get them off social programs, get them off dependence on government, get them into higher wage jobs that have a future that possibly pay benefits. That’s a great benefit for the state,” he said.

But so far, federal officials said states can’t make participation in a work program mandatory for Medicaid recipients. Montana, instead, had to make its job training component voluntary.

The feds’ rejection of mandatory job training meant Buttrey was barely able to win enough votes in Montana’s Republican majority legislature to  last April. How’s it working?

“I think it’s a success story. I love this. I’m the poster child,” says Ruth McCafferty. She is a 53-year-old single mom from Kalispell, with three kids at home. She lost her job with a lending company last spring, and she had no idea there was a new job training program available when she signed up for Medicaid. She was just focused on finding a way to afford the drugs she needs to control her diabetes and asthma.

“One inhaler that I do is $647,” she says, bringing her medication costs to about $1,000 a month. “My plan was not to get them, only, like, a couple of them that were affordable, like $60, and the rest of them I was like, I guess I’ll just be called ‘Wheezy’ from now on!”

McCafferty instead got Medicaid, filled her prescriptions, and she got free online training to become a mortgage broker. The state even paid for her 400-mile roundtrip to Helena to take the certification exam. And now they’re paying part of her salary at a local business as part of an apprenticeship to make her easier to hire.

“It’s awesome!” she said.

Of the 53,000 Montanans who’ve signed up for expanded Medicaid, only about 3,000 have signed up for help getting a job. That’s in part because the federal government won’t allow states to use Medicaid money for it. To set it up here, Buttrey had to cobble together funding from other jobs programs and squeeze $1 million out of a reluctant state legislature.

Giving states the flexibility to tie their Medicaid programs to work requirements is an idea that’s likely to be popular with the new Congress and Trump administration. But health policy researcher , who runs the Center for Children and Families at Georgetown University, warns that it could backfire.

“I think it’s great and well worth doing to link people who might not be aware of existing job training programs or other kinds of work supports that can help them work. What I think is problematic is when this becomes a stick and not a support,” she said.

Alker said many people on Medicaid already have jobs, often low-paying ones that don’t offer health insurance, and they have little time for new training. In Montana, about two-thirds of those on Medicaid are already working. She said if people fail to meet a work requirement and then lose health benefits as a result, they’ll likely just get sicker and become less able to work.

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To meet the need, roughly have opened across the country. Patients go several times a week and undergoing the life-sustaining procedure. Medicare is now taking steps to make it easier for people to do their own dialysis at home.

That sounds like great news to , a nephrologist in Helena, Mont., who has an unusually high percentage of patients who do their dialysis at home: 40 percent versus the national rate of about 10 percent. That’s largely because LaClair is no fan of how dialysis has traditionally been done in America. He says his patients do better if they’re more active participants in their care, rather than passive receivers.

“The way we do dialysis in this country, no one would be saying, ‘This is the way we should be doing things,'” LaClair said.

Peritoneal dialysis is less common than , in which a machine filters the blood itself. Most people who dialyze at home use the peritoneal technique, although it is possible for some patients to perform hemodialysis at home, too.

Shanahan says he often sleeps through most of the fluid cycling, getting about six hours of sleep a night. If there’s a problem, he says, his machine, which is about the size of a toaster oven, “has a squawker on it, so I could be sleeping and this thing wakes me up and tells me I’ve got to fix the line.”

But the routine he’s now familiar with requires a lot of up-front training. Medicare is  to more than double the payment it offers dialysis providers to teach patients how to do it — from the current $50.16 for 1.5 hours of a nurse’s time, to $95.57 for 2.66 hours.

Still, that may not be enough to cover actual training costs, says Dr. Frank Maddux, chief medical officer for , a large dialysis company. He said the number of Fresenius’ patients who dialyze at home has increased from 7 to 11 percent over the last five years.

“I don’t know that [the increased payment] will create all the fundamental changes that need to occur, but I think it sets a good, clear direction,” Maddux said.

Neither Medicare nor Maddux will say how many more dialysis patients should do the procedure at home. They say that is both a personal and medical choice that isn’t right for everyone, and they don’t want patients who are happy using dialysis centers to feel pressure to change.

Medicare officials declined to be interviewed for this story, but Maddux said he sees the agency’s proposed bump in payment for in-home dialysis training as part of its bigger “triple aim” goal of improving patients’ experience while also improving their health and lowering medical costs.

“There are many patients I think that could be much more engaged in their therapy,” Maddux said, which he thinks would likely lead to them feeling better. At least one  found that patients who dialyze more frequently feel better and are hospitalized less than those who do it less frequently.

Nephrologist LaClair practices at St. Peter’s Hospital in Helena, Mont. He said his patients who switch from the largely passive experience of a center to taking responsibility for their own care at home never want to go back, “even when we’ve had people having significant problems and issues” doing it themselves.

At St. Peter’s, LaClair said, they have had the opportunity to “model dialysis the way think we would want dialysis if we were sick, and that’s what we do.”

Neither LaClair nor Maddux sees home dialysis as a threat to the viability of the thousands of dialysis centers nationwide. Providers get the same base-level payments for caring for patients whether they do their dialysis at home or in centers. LaClair said maintaining patients on in-home dialysis is cheaper long term, but requires a significant investment up front in training, and he said it’s crucial that there is always medical staff on call to help with challenges, including infection control.

Information technology is improving the viability of home dialysis, too. Patients used to have to keep pen-and-paper logs of important health data about their treatments, logs that nurses say were notoriously inaccurate and that they only saw once a month. New machines track patients vital signs in real time and send the data back to providers via the Internet, allowing them to track and even adjust treatments on their computers or smart phones on the fly.

Medicare hopes to implement the payment increase by Jan. 1, 2017.

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State figures say enrollment as of July is nearly double initial projections, at 47,399 of the 25,000 who were expected to enroll by now.

And there’s still room to grow: to be eligible for Medicaid expansion, according to state officials.

Recipients have used their benefits to get $75 million worth of health care, 100 percent paid for by the federal government. That’s a big windfall in this state with slightly more than 1 million residents.

The state health department says Montana also saved $5.3 million by shifting 8,458 people from traditional Medicaid, where the state paid 34 percent of their costs, into the expansion population. States are allowed to shift a limited number of previous Medicaid recipients into the expansion pool if they meet certain conditions. Uncle Sam pays 100 percent of the Medicaid costs of the expansion population through next year, ramping down gradually to 90 percent by 2020.

“Perhaps the most compelling story that can be told about Medicaid expansion is the reduction it’s had on the uninsured,” Jessica Rhoades, policy director for the state health department said Wednesday.

Montana’s insurance commissioner in the state’s uninsured rate, from 15 percent in 2015 to 7.4 percent today, crediting Medicaid expansion for most of the drop.

One-fifth of Montanans lacked health insurance in 2012.

The state’s uninsured rate ticked down a couple of percentage points each year since the Affordable Care Act rolled out. But state lawmakers here rejected Medicaid expansion upon first consideration in 2013.

Montana’s legislature meets only every other year. It joined Pennsylvania, Iowa and Alaska in passing or implementing Medicaid expansion in 2015. Louisiana implemented it in 2016. A June by the Kaiser Family Foundation found that states that expanded Medicaid “experienced large reductions in uninsured rates and that these reductions significantly exceed those in non-expansion states.” (KHN is an editorially independent program of KFF.)

The compromise expansion bill Montana  was sponsored by moderate Republican Sen. Ed Buttrey of Great Falls. It includes waivers that require higher-income recipients to pay premiums and sets up a workforce training program aimed at helping people get jobs that provide health coverage or boost incomes enough for them to buy marketplace policies.

This week the state health department told the special legislative committee that oversees Medicaid expansion that 61 percent of those enrolled already have jobs.

It also told the committee that Montana has collected $1.1 million in Medicaid premiums so far, and that the average premium, which are assessed based on income, is $26 a month.

Montana’s law also allows it to unenroll recipients who make 100 percent of the federal poverty level or more and fail to pay premiums for 90 days or more.

As of June, 379 people had been dropped for failure to pay.

The enrollment and financial data was released two days after three Republican state lawmakers for being too slow to release income data for Medicaid recipients.

The health care providers that lobbied hard for expansion in Montana generally said it’s still too early to have definitive data on how expansion is impacting them. But John Goodnow, CEO of Benefis Health System, which operates one of the state’s largest hospitals, said, compared to last year, it saw a 50 percent reduction in the number of uninsured patients, “which is amazing.”

Benefis is projecting a 43 percent reduction in bad debt this year compared to last based on figures from the first half of 2016.

Goodnow says he expects expansion to be a “big, big help” to Montana’s critical access hospitals, which have 25 or fewer beds and make up the majority of the state’s hospitals.

Also pleased are advocates for Native Americans, Montana’s largest minority population, which had an last year. Native Americans have a life expectancy 20 years shorter than that of whites here, and use significantly fewer health care services.

The state health department says 12 percent of Montana Medicaid expansion enrollees are Native American, about a quarter of that population that is eligible to enroll.

“We’ve benefitted substantially,” said Kevin Howlett, health director for the Confederated Salish and Kootenai Tribes. He said expansion has increased both access to care for tribal members, and revenue to tribal clinics, allowing the tribe to provide more services.

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Congress and the VA came up with a fix: , a $10 billion program. Veterans received a card that was supposed to allow them to see a non-VA doctor if they were either more than 40 miles away from a VA facility or they were going to have to wait longer than 30 days for a VA provider to see them.

The problem was, Congress gave them only 90 days to set up the system. Facing that deadline, the VA turned to two private companies to administer the program — helping veterans get an appointment with a doctor and then working with the VA to pay that doctor.

The VA claims there has been a massive increase in demand for care, but the problem has more to do with the way Veterans Choice was set up. It is confusing and complicated. Vets don’t understand it, doctors don’t understand it and even VA administrators admit they can’t always figure it out.

Veterans Face Delays And Worry

This is playing out in a big way in Montana. That state has more veterans per capita than any state besides Alaska. This winter Montana sent his staff to meet with veterans across the state. Bobby Wilson showed up to a meeting in Superior. He’s a Navy vet who served in Vietnam and is trying to get his hearing aids fixed. Wilson is mired in bureaucracy.

“The VA can’t do it in seven months, eight months? Something’s wrong,” he said. “Three hours on the phone,” trying to make an appointment. “Not waiting,” he said, “talking for three hours trying to get this thing set up for my new hearing aids.”

Tony Lapinski, a former aircraft mechanic, has also spent his time on the phone, with Health Net, one of the two contractors the VA selected to help Veterans Choice patients.

“You guys all know the Health Net piano?” he said. “They haven’t changed the damn elevator music in over a year!” That elicits knowing chuckles from the audience. Later during an interview, he said when he gets through to a person, “They are the nicest boiler room telemarketers you have ever spoken to. But that doesn’t get your medical procedure taken care of.”

Lapinski has an undiagnosed spinal growth and he’s worried. “Some days I wake up and go, ‘Am I wasting time, when I could be on chemotherapy or getting a surgery?’ ” he said. “Or six months from now when I still haven’t gotten it looked at and I start having weird symptoms and they say, ‘Boy, that’s cancer! If you had come in here six months ago, we probably could have done something for ya, but it’s too late now!’ ”

Lapinski finally got to a neurosurgeon, but he didn’t exactly feel like his Choice card was carte blanche. Doctors, it turns out, are waiting, too — for payment, he said.

“You get your procedure done, and you find out that two months later the people haven’t been paid. They have got $10 billion that they have to spend, and they are stiffing doctors for 90 days, 180 days, maybe a year!” said Lapinski. “No wonder I can’t get anyone to take me seriously on this program.”

He said he gets it. He used to do part-time work fixing cars, and he would still take jobs from people who had taken more than 90 days to pay him or bounced a check. But he did so reluctantly.

“I had a list of slow-pay customers,” he said. “I might work for them again, but everybody else came before them. So why would it be any different with these health care professionals?”

Hospitals, clinics and doctors across the country have complained about not getting paid, or only paid very slowly. Some have just stopped taking Veterans Choice patients altogether, and Montana’s largest health care network, Billings Clinic, doesn’t accept any VA Choice patients.

Not cool, said Montana Sen. Jon Tester, of Health Net and other contractors.

“The payment to the providers is just laziness,” Tester said. “I’m telling you, it’s just flat laziness. These folks turn in their bills, and if they’re not paid in a timely manner, that’s a business model that’ll cause you to go broke pretty quick.”

The VA now admits the rushed timeframe led to decisions that resulted in a nightmare for some patients.

Health Net declined to be interviewed for this story. But in a statement, the company said that VA has recently made some beneficial changes that are helping streamline Veterans Choice. For example, the VA no longer demands a patient’s medical records be returned to VA before they pay.

Meanwhile, though, veterans continue to wait. “If I knew half of what I knew now back then when I was just a kid, I would’ve never went in the military,” said Bobby Wilson. “I see how they treat their veterans when they come home.”

Scheduling Lags Also Irk The Doctors’ Offices And The VA

And there’s another whole side to the coin. Doctors are frustrated in dealing with another government health care bureaucracy.

In Gastonia, North Carolina, Kelly Coward dials yet another veteran with bad news.

“I’m just calling to let you know that I still have not received your authorization for Health Net federal. As soon as I get it, I will give you a call and let you know that we have it and we can go over some surgery dates,” she told a veteran.

Coward works at Carolina Orthopaedic & Sports Medicine Center, a practice that sees about 200 veterans. Dealing with Health Net has become a consuming part of her job.

“I have to fax and re-fax, and call and re-call. And they tell us that they don’t receive the notes. And that’s just every day. And I’m not the only one here that deals with it,” she said.

Carolina Orthopaedic’s business operations manager, Toscha Willis, is used to administrative headaches — that’s part of the deal with health care — but she’s never seen something like this.

She said it takes, “multiple phone calls, multiple re-faxing of documentation, being on hold one to two hours at a time to be told we don’t have anything on file. But the last time we called about it they had it, but it was in review. You know, that’s the frustration.”

It can take three to four months just to line up an office visit.

The delays have become a frustration within the VA, too. Tymalyn James is a nurse care manager at the VA clinic in Wilmington, North Carolina. She said Choice has made the original problem worse. When she and her colleagues are swamped and refer someone outside the VA, it’s supposed to help the veteran get care more quickly. But James said the opposite is happening.

“The fact is that people are waiting months and months, and it’s like a, we call it the black hole,” she said. “As long as the Choice program has gone on, we’ve had progressively longer and longer wait times for Choice to provide the service, and we’ve had progressively less and less follow through on the Choice end with what was supposed to be their managing of the steps.”

The follow-through is lacking in two ways. The first is the lengthy delay in approving care. And after that’s finally resolved, there’s a long delay in getting paid for the care.

At least 30 doctors’ offices across North Carolina are dealing with payment problems, some that have lasted more than a year.

Carolina Orthopaedic’s CEO Chad Ghorley said his practice is getting paid after it provides the care. It’s the lengthy delay on the front end that burdens his staff and, he worries, puts veterans at risk. He’s a veteran himself.

“The federal government has put the Band-Aid on it when there’s such a public outcry to how the veterans are taking care of, all right?” he said. “Well, they’ve got the Band-Aid on it to get the national media off their backs. But the wound is still open, the wound is still there.”

Those experiences for both veterans and providers are typical. Congress is now working on a solution to the original solution, a bill is expected to clear Congress by the end of the month.

This story is part of a partnership that includes , , NPR’s Back at Base project and Kaiser Health News.

CORRECTION: A previous version of this story misstated how many veterans were waiting at least a month for an appointment this year. The 70,000 figure applies to the number of appointments in which it took vets at least a month to be seen. The story has been corrected to reflect this difference.

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