New Department of Veterans Affairs medical facilities in Fayetteville, Charlotte, and elsewhere have reduced wait times. But the VA concedes it must do more.
Much of the response to the VA medical system's nationwide wait time scandal has involved giving veterans access to private health care alternatives.
But in North Carolina, in addition to that approach, the Veterans Health Administration has succeeded in reducing wait times with bulldozers, shovels and hammers. Indeed, the department is undergoing a building boom in the state, constructing a wave of new clinics and hospital wings.
The VA's North Carolina and Virginia region has been the fastest growing in the country for years. It added more than 42 percent more patients in the decade ending last year, or nearly twice the national growth rate.
The Durham VA Medical Center – one of four VA hospitals in the state – has been adding new patients at a rate of more than 900 a month. Even with a tight, landlocked site, it has figured out ways to grow.
On a recent day, Heather Boaz, a project engineer for the hospital, stood inside a 10-bed hospice wing still under construction and went down a list.
"We have a lot of projects coming behind this," she said. "We'll add ORs, and we also are adding a radiation oncology wing, we're adding some primary care space, some dental care space ... and increasing our parking where we can, but that's one of the biggest challenges here."
Her hospital and the others around the state have not only grown new wings, they have come to anchor their own local networks of care. They've opened satellite clinics that help meet demand in major cities or help push care closer to veterans in smaller communities.
In just the past two years, the VA has built three new outpatient clinics that are so large they look like hospitals. They total nearly 1 million square feet in Charlotte, Fayetteville and Kernersville.
Mark Shelhorse, the interim director of the VA healthcare regional network that's mainly made up of North Carolina and Virginia, said the local networks around each hospital aren't exactly about decentralization.
"The hospitals are still in the same places they've been for tens of years," he said. "The clinics, however, have expanded dramatically. We have over 30 clinics now that have been spread all over the geography of both Carolina and Virginia."
That creates more capacity to serve the growing number of patients, puts less pressure on the hospitals, and pushes the most commonly needed kinds of care closer to the veterans, he said.
"The majority of care that any individual needs is just basic care," Shelhorse said. "You need to see your primary care doctor, your internist, your general practitioner, and they take care of the basic-care needs."
Since empty buildings can't take care of patients, the VA has hired hundreds of doctors, nurses and other workers to staff them. According to data compiled by NPR, staffing at the four North Carolina VA hospitals and their clinics has increased substantially since 2014. The Fayetteville VA has nearly 30 percent more employees, and Salisbury has about 11 percent more.
Data NPR collected also suggests that the new facilities and private care options have helped the VA push down most wait times across the state or at least hold them steady, despite the sharp rise in the number of patients.
The Fayetteville VA hospital in particular had become notorious for some of the worst wait times in the country, but the giant new clinic that opened in that city in late 2015 has helped.
"We had waiting times because we were out of space," Shelhorse said. "And we couldn't hire the providers to practice in facilities that didn't exist."
He said the Veterans Choice Program that lets VA patients use private care if they face long wait times or live far from VA care has begun helping a lot, too.
"I can't give you an actual number that it has reduced our wait times, but it has helped tremendously," he said. "We've been blessed in having veterans come to us in great numbers, and it did overwhelm our capacity to get care to them."
"Without the private sector and without the Choice option, I don't think we could have met that in this previous year and a half," Shelhorse said.
Wait times are still higher in Fayetteville than they should be, he said, but have improved.
"So, it's probably not solved, and I hate to be committing myself to that kind of a statement," he said. "I think it's well on the mend, though. We've gone from over a 30-day primary care wait time to a 5.5-day wait time, which is remarkable, and I think directly related to the opening of the new building and getting those people on board."
The VA expects the number of new patients to grow at nearly the same pace for years to come. And there's a proposal to build another giant hospital-sized clinic in Raleigh to help take pressure off the Durham VA.
Nationally, the VA's budget picture is murky. President Donald Trump has called for expanding it by 6 percent. But his VA secretary, David Shulkin, isn't taking larger budgets for granted. He has restricted new hiring for administrative positions at the national and regional levels and is expected to increase the use of private care for VA patients.
On a recent visit the Durham VA, Shulkin said the the agency might close more than 1,100 vacant and underused buildings around the country. He said that would free up funding so construction could continue where it's most needed.
He said that might mean more money for things like the proposed Raleigh clinic.
"That is our intent," Shulkin said. "Where we are seeing growth in veterans – and you’re seeing them here in North Carolina – we need to get more resources for capital here."
He also said that significant new hiring would continue in areas with fast-growing populations of patients like the Triangle.
Shelhorse, the interim regional director, said he expected the future of VA care in the state and the region to continue to include private care, and there may be more partnerships that allow veterans to be treated at military hospitals and clinics on base.
He hopes the proposed Raleigh clinic will get funding, but beyond that, there will probably be less VA construction in the near future, in part because there has been so much recently.
"We've had huge additions to infrastructure, maybe out of proportion to maybe other places in the United States, we're very grateful for that," he said.