This story, part of a series of investigative reporting projects by Military.com on service member and veteran health, was supported by the Pulitzer Center.
The former Army medic sat, staring at his computer screen, waiting for a VA therapist to hop on the video call. He had spent months trying to get the appointment, months of his wife pushing him to get help, and he was alone.
Five minutes late.
The vivid nightmares had started again. The bouts of rage over the soldiers he tried to save and those he couldn't. It had been nine years -- really nine years? -- since he'd tried to end his life with a loaded pistol that jammed, and he knew he was slipping back to a dark place. Maybe the doctor wouldn't show up and he wouldn't have to go through with the conversation.
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Ten minutes late.
Marcus Bagwell had been receiving medical care at the Oklahoma City Veterans Affairs Medical Center when he worked up the courage to start looking for a mental health appointment. It wasn't easy to acknowledge he needed the help in late 2021, that he couldn't white-knuckle it anymore.
Fifteen minutes late.
And then he got a notice. The appointment had been canceled. All the nerves, all the bucking-up to get the help he needed, and then nothing.
Two months later in 2022, he managed to book another appointment, and the same thing occurred: Bagwell dialed in for the appointment; the VA canceled. Then it happened a third time.
The reasons given varied, but the results were the same, meaning Bagwell went six months without treatment.
"When they started canceling appointments on me, it made me feel like, 'Hey, listen, they don't give a s**t. Why should I?'" Bagwell said in an interview. "My wife [said], 'No, we're not going down this rabbit hole again. We're doing mental health.'"
Her support led him to the online therapy service BetterHelp, and Bagwell now pays out of pocket for the care he needs.
The Department of Veterans Affairs actively encourages veterans to enroll in VA health care, and officials, including VA Secretary Denis McDonough, voice pride in the department's expertise treating combat-related mental health conditions. In 2023 alone, nearly 11% of the nation's 18.1 million veterans sought mental health services at the VA, having 19.6 million behavioral health "encounters" with the VA, including appointments, walk-ins and emergency room visits.
But veterans say they often can't get individual therapy appointments to accompany psychiatric medical care, and when they do connect, the treatment often is derailed by appointment cancellations and scheduling problems, according to more than a dozen veterans and current and former VA employees interviewed by Military.com.
They shared remarkably similar stories of working up the courage to seek help -- something that historically has not been easy in a community skeptical of mental health treatment -- and waiting months for sessions as multiple appointments were canceled, either at the start of a telehealth session or on arrival at a medical center or clinic.
Sometimes they'd be blamed, accused of failing to show up for appointments they didn't know about, or told they'd canceled the appointments themselves.
In the past 18 months, a former Army sergeant seeking mental health treatment at the VA Puget Sound Health System has had seven of 16 behavioral health appointments canceled, according to records provided by his mother to Military.com.
According to the records, the former soldier's appointments were canceled every month from July through November 2023.
"He keeps trying to go back in to school. He is having difficulty. He just wants to know what is wrong," his mom, Meredith, said. "He felt like he was not being taken seriously [and] is just frustrated by the delay."
Data provided by the VA showed that from 2020 through 2023, the cancellation rate for mental health appointments across facilities averaged 10.6%, with a high of 12.1% in 2020 early in the COVID-19 pandemic to 9.2% in 2023.
But individual medical centers may have bigger issues. Data obtained by the Americans for Prosperity Foundation through an ongoing Freedom of Information Act lawsuit showed that at 14 representative facilities across the U.S., from January 2020 to late May 2021, the cancellation rate was nearly double the VA provided figures, at 21%, although the time frame coincided with the height of the COVID-19 pandemic restrictions on non-urgent care.
The foundation funds training, education and policy research for libertarian and conservative causes, including Concerned Veterans, an affiliated advocacy group that supports broader access for veterans to private health care.
Any cancellation can affect continuity of care and have a negative impact on a veteran's health, however. They may even contribute to suicide among veterans, although exactly how many is unknown. The number is not zero, however, according to families.
In 2021 -- the most recent year for which data is available -- veterans died by suicide at a rate twice the general, non-veteran U.S. population, with 6,392 taking their own lives that year, including Rico Marles, a former Marine who died by suicide after trying to get care at the West Palm Beach, Florida, VA. His family has filed a wrongful-death suit against the facility that cites problematic appointments as a contributing factor.
An investigation in 2022 at the Columbus, Ohio, VA hospital found appointment cancellations and missed follow-ups relating to the department's new electronic health records system disrupted care for a patient who died by suicide.
And cancellations and confusion over referrals for mental health care contributed to the suicide of a patient at the Memphis VA medical center in 2019, according to the department's Office of Inspector General.
While suicide is a complex issue that is tied to many factors, including mental illness, life circumstances and genetics, experts say consistent medical care with a trusted provider is a key component for prevention. Canceling appointments, often with little notice, on those who know they need help and have worked up the courage to seek it, only reinforces harmful thoughts that veterans aren't worth the effort.
According to the Cohen Veterans Network, a nonprofit group of clinics that provides behavioral health treatment to service members, veterans and their families, trust and connection between patients and therapists are key components to creating an environment where patients can share their experiences with suicidal thoughts and attempts.
"There's too many veterans who just give up. They're sick of fighting the system, they're sick of changing doctors," a VA scheduler who works at a Missouri medical center told Military.com. "And for us, there's no good guidance and no real plan to fix it."
System Overload or Performance Pressure?
Theories on the causes of cancellations vary. VA employees who spoke with Military.com said provider shortages are the root cause, while others point to the lack of a centralized scheduling system or pressure to keep veteran care inside the walls of a VA facility.
The VA has 32,199 mental health workers, including psychiatrists, psychologists, licensed professional mental health counselors, marriage and family therapists, peer support specialists, nurses and physician assistants, on staff, and officials say they are hiring more.
But the VA struggles to recruit clinicians, especially to rural locales and areas with underserved populations, and it competes with the private sector, where, in many places, quality care commands cash-only payments. According to the VA Inspector General in September, 66 of the VA's 140 health systems reported severe shortages of psychiatric providers.
Dr. Shereef Elnahal, the VA under secretary for health, said late last year that while the Veterans Health Administration was pulling back on overall hiring, it would continue to recruit mental health professionals and ambulatory care providers.
"We already have been working to increase our mental health workforce. But we know we're still not yet at what the evidence says should be the mental health staffing level at all our medical centers," Elnahal said in a call with reporters on Dec. 20.
Several VA employees who spoke to Military.com described a strained system that can't handle the demand. The scheduler in Missouri, who requested anonymity so they could speak freely on the issue, said many of the cancellations stem from staff taking leave without backup, high turnover and vacancies.
"A doctor leaves, and the whole clinic is canceled," said the scheduler. "They don't build a vacation schedule or build in holidays. Providers just don't cover each other like nurses are able to do."
Michelle Gradnigo, a retired Army lieutenant colonel and former site manager at the Chico, California, VA Clinic, said provider shortages and the lack of a centralized scheduling system contribute to appointment cancellations.
"In the Army, we had one big patient scheduler in the sky [me] with three people under me, the only people who could schedule, block out, appointments," Gradnigo said. "At the VA, [scheduling] is at the lowest level ... it's mismanagement. They have nothing centralized, they don't care to have anything centralized because there's no repercussions."
Others say the appointment cancellations are tied to the VA's desire to show it is meeting wait-time metrics and standards set by Congress to ensure it serves veterans in a timely fashion -- and avoid referrals to community care.
The wait-time metrics are important, because Congress set standards for such referrals. When a VA facility cancels an appointment, the clock continues to tick on the wait-time measures codified by the 2018 Mission Act, which expanded care for veterans in the private sector if they can't get an appointment at the VA.
If the veteran cancels an appointment, however, the wait-time clock resets, a change that would shorten the wait-time metric and allow the facility to reschedule the appointment, thus avoiding a referral.
Multiple veterans described being told about appointment no-shows when they'd never scheduled a session, or having VA employees insist the veteran had canceled. They described feeling "gaslit" by employees, a particularly troubling series of interactions for a veteran suffering through mental health issues.
By law, the VA must refer veterans to community care if the wait time for primary or mental health care appointment at a VA facility is more than 20 days or the drive time is longer than 30 minutes.
"We've been told you're going to live within your budget, you're going to control community care costs, you're going to improve efficiency internally and [the VA] is not going back to Congress to ask for money," said the director of a southern VA medical center in an interview with Military.com, just before the VA asked Congress for $12 billion more to fund health care in fiscal 2025.
The medical center director added that hiring new mental health professionals is problematic, because while the VA Central Office has encouraged facilities to add staff, they also are being told that based on their budgets, they really shouldn't be hiring.
"I just feel like I'm in a death spiral," he said.
Community care -- treatment paid by the VA to non-VA providers -- now accounts for 42% of the medical services provided by the department to veterans, up from 26% in 2021. VA Secretary Denis McDonough has warned that the rising cost of outsourcing care could undercut the VA's ability to provide treatment directly to veterans in its own facilities.
An internal VA report generated by a panel of experts this spring recommended that the VA double its efforts to bring patients back to the VA, expanding mental health offerings, monitoring referrals more closely and revisiting access standards to community care.
Schedulers say they are feeling the pressure of the recommendations in the report, a copy of which was obtained by Military.com, to ensure that veterans remain as VA facility patients regardless of disruption to their care. According to them, they are encouraged to refer veterans to another VA facility, often miles away from the veteran's home, rather than close-by community care. Or they make appointments with VA providers knowing they may get canceled and rescheduled.
"We really don't want [veterans] to go to community care, because it's costing too much money," the Missouri scheduler said.
Infrequent appointments and cancellations certainly weighed heavily on Marles, the former Marine sergeant who died by suicide after trying to get care at the West Palm Beach VA.
Marles' attorney, Peter Bertling, said the defense is using an argument that Marles was an unreliable patient, often canceling his own appointments or not showing up.
But Bertling said he has records of cancellations by the facility.
"Here's the record where you're saying he is scheduled to see a doctor, a mental health provider, a psychologist and he gets the notification, 'Oh sorry, buddy, we have to cancel your appointment,'" Bertling said. "People who have mental health issues [who] are going through stress, anxiety, having hallucinations, flashbacks and [they] are told you gotta wait."
An Army veteran who served as a Black Hawk crew chief in the mid-1990s told Military.com that after moving to Charleston, South Carolina, he had numerous appointments canceled at the VA medical center in late 2023, a pattern he also experienced in 2021 at the Martinsburg VA Medical Center in West Virginia.
When he asked whether he could get a consult for community care, he was told he could pay out of pocket for a civilian therapist.
He has stopped pursuing therapy. "[The VA] won't do it, and they won't give referrals out. The only thing I do mental health-wise with the VA is have an appointment every three months with my psychiatrist for a meds review," said the veteran, who asked that his name not be used because he worried about retaliation from the VA.
Escalating Demand
VA officials said patient requests for mental health care have grown steadily in the past 10 years at a rate that far exceeds demand for overall health services, and they have shifted toward a more proactive approach that includes case management, outreach and "stepped-care," meaning it may begin a patient with group therapy, self-help or brief sessions and proceed to more intensive treatment as needed.
The VA also has hired more mental health providers -- including 4,106 last year.
"There is nothing more important to us at VA than providing veterans with the mental health care they need, whenever and wherever they need it," VA Press Secretary Terrence Hayes said in an email on Sept. 19.
"Over the past few years, veteran mental health appointments have increased, the number of veterans receiving support for mental health has increased, wait times have decreased, and cancellations are down -- meaning that veterans are getting the care they need when they need it," Hayes said.
He said trust in the system has risen among veterans and wait times for mental health care declined an average of 7% from April 2023 to April 2024, "at a time when VA is delivering more care to more veterans than ever before."
Earlier this year, the department held "Access Sprints" at certain facilities, offering appointments in primary care, mental health and other specialties during night and weekend hours.
According to Veterans Health Administration spokesman Mark Ledesma, the Access Sprints helped VA facilities increase the volume of new patient appointments and decrease wait times.
The effort also led to a decrease in the number of patients who received community care referrals as a result of prolonged wait times at the VA.
"Access Sprints have ended; however, VA continues to optimize best practices and lessons learned across the enterprise," Ledesma said in an email.
Regardless, any cancellation for mental health treatment can disrupt care and frustrate patients. Duane France, a therapist and Army veteran who served in Iraq and Afghanistan, said for veterans, building trust with a clinician is a key component of treatment and cancellations can destroy that faith.
"It's really necessary to build trust and have trust, especially with mental health care providers, and being able to have consistent appointments with the same provider can definitely be beneficial for sharing a lot of those things that may be difficult to talk about," France said during an interview with Military.com.
Disruptions to mental health treatment can have horrific consequences for patients who struggle for care, like Julia Larsen, a former Navy firefighter who sought care at the Chico, California, VA clinic in late 2021.
Larsen had served on an aircraft carrier and later earned accolades for a response to a fire on the flight deck of the amphibious assault ship Kearsarge. Her father Marty Larsen, also a Navy veteran, was proud of his daughter following him into service.
But shortly after Julia left the Navy, Marty and Candy Larsen noticed changes in their daughter. They learned she had been sexually harassed and physically assaulted on the Theodore Roosevelt while it was in the shipyard, and that experience, along with the stress of the fire response, triggered mental health problems, Marty Larsen told Military.com.
Larsen's appointments at the Chico clinic had been spotty, and the care inconsistent. While Julia was able to obtain medications for her condition, she received little psychotherapy. Her dad estimates that roughly half her appointments were canceled.
On Jan. 3, 2022, Candy Larsen took a "highly agitated" Julia to the clinic to see whether she could get a same-day appointment. Julia was sent home with sleeping meds and scheduled for an appointment 11 days later. That night, while staying with her parents, she had what appeared to be prescription drug-related psychosis and picked up a gun, according to the VA Office of Inspector General. The incident was also at the center of an investigation by ProPublica published earlier this year.
She fired off several rounds and, while fighting with her father for control of the weapon, shot Candy dead. She struck Marty with the pistol and nearly killed him as well.
"She wanted to be normal so bad -- she went to college, got a job, and she was trying to not be that person that had mental problems," Marty Larsen said. "She wanted a proper counselor."
Gradnigo, who later was fired from her job for alleged comments she made to co-workers but said her status as whistleblower at the clinic contributed, believes the chaotic scheduling system is purposeful at individual facilities. "I definitely think it is a practice ... it's piss-poor management and a combination of three things -- no policy, no leadership and no repercussions. And nobody cares."
Julia Larsen was found not guilty of her mother's death by reason of insanity and is finally getting the help she "desperately needed" at a California state hospital, according to her father, who has spoken with her on the phone but can't bring himself to visit.
Marty Larsen chokes up when he discusses the failures of his daughter's VA care, saying he wants a "sea change" at the VA.
"Instead of screwing up and having people like me file lawsuits against them, wouldn't it be better to focus on doing it right from the beginning?" he said.
Some veterans are able to persevere in the VA system and find help.
A former Navy cryptologic technician told Military.com that after roughly five appointment cancellations from a therapist with whom she clashed, she stopped trying and stopped taking her medication. After trying again at VA, she eventually found suitable treatment.
"So they got a new person recently, and she seems to be pretty good," the former sailor said.
Others, like Bagwell, managed to get care when they finally gave up on the VA.
Bagwell said BetterHelp provides the weekly support he wants and gladly pays for.
The Army veteran in Charleston said he stopped getting VA treatment after the cancellations and scheduling problems with a therapist who, once they connected, spent the appointment singing the praises of remote work with her cat draped around her neck.
"It was, pardon my French, a f***ing disaster ... so now I'm just on my meds doing my best," he said.
If you are a service member or veteran who needs help, it is available 24/7 at the Veterans and Military Crisis Line. Dial 988 Press 1, text 838255 or use the online chat function at www.veteranscrisisline.net.
-- Military.com reporter Drew Lawrence contributed to this report.
