The Purple Heart ceremony on Fort Richardson a week ago began with the usual formality. Lines of uniformed soldiers took seats in the mess hall before a podium and a row of official flags. We stood to welcome the VIPs -- including Maj. Gen. William Troy, head of the U.S. Army in Alaska, and U.S. Sen. Mark Begich -- and then we sat again when we were told.
Troy gave a short speech. And then Begich took the podium. The senator asked the soldiers to tell him what they needed so he could take the message back to Washington, D.C. He said he wanted to make sure they were taken care of, that they weren't nickel-and-dimed.
Then Sgt. 1st Class Michael Waszak was introduced. He had been sent from Alaska to Iraq in February 2004. His mission was to train Iraqi soldiers. He was injured in August of that year in the town of Al Habbaniyah, west of Baghdad. He had been with his men, chasing a target over rooftops. There was a violent explosion. He was thrown in the air, then smashed to the ground. The Iraqi soldiers with him were killed.
In front of the crowd, Waszak stood with his wife and 8-year-old son. Begich attached the medal to the pocket flap of his uniform with a binder clip. And then it was Waszak's turn to talk.
He looked out into the room, filled with members of the Warrior Transition Unit, all of them wounded. There were 100 or so, awash in gray-green. He said he didn't know many of them.
"I don't have any friends anymore," he said. "I don't go out. I don't leave my house."
And then he asked a few people to stand. They were military doctors and counselors. He thanked a civilian doctor who took care of him.
"If it weren't for these individuals, I would have eaten a bullet," he said. "A lot of you know what I mean."
And then he turned to Begich. There was something he needed the senator to know, he said. There weren't enough doctors in Anchorage who would take the military health plan called Tricare because the program pays doctors so little. He needed a surgery and had to fly Outside. There was only one doctor in the city who would take his insurance and help him manage his pain.
"Tricare will not help us. Doctors will not take Tricare," he said. "That's what I ask you take to Washington."
Waszak and I met later that day at a coffee shop on Muldoon Road. He ordered a Pepsi and used it to wash down the painkillers OxyContin and Dilaudid. He was also wearing a Fentanyl patch that dispensed medicine through his skin. He joked that if I took as much pain medicine as he was taking, it would probably kill me.
His hands shook slightly and the medication slowed his blinking. I noticed he limped a little when he walked. He told me he was 32 years old. It had been five years since he was in a war zone, but when he started talking, it was like he'd just come back. He described the feeling of flying through the air after the explosion. He described waking up in an Iraqi hospital afterward. He talked about getting the news that his men had been killed.
He has a long list of physical injuries. Spinal fractures, a blown knee, head trauma, detached ribs. He has stomach problems and near-constant nausea. There are psychological injuries too. He doesn't like all the hype around post-traumatic stress disorder, but he spent two months undergoing in-patient treatment for it in 2006 and has been hospitalized for it twice since, he said.
Leaving the house puts him on edge, he told me. He spends most of his time in bed. Frequently, he goes for days without sleeping and is prone to leaping to his feet in the middle of the night in a panic, startling his wife. He got to the restaurant early to check the place out, he told me later, and he wouldn't have sat down if anyone had been seated behind him.
Physical pain and guilt about the strain he has put on his family make him wonder sometimes if they would be better off without him, he said. If he weren't worried about what it would do to them, he might have shot himself a long time ago.
"I don't need my son and my wife coming home to a body on the floor," he said.
Ever since the explosion, Waszak has been on a medical odyssey. For years, because of his injury and his PTSD, he didn't think about a Purple Heart. But things have stabilized some recently. He decided to go through with it, he said, because he saw it as way to thank his doctors.
Waszak returned to Anchorage in November 2004 after dealing with his injuries for nearly two months in Iraq. He told me that while Tricare is a serious problem, the military health care system has improved a lot in the last five years, mostly because of the establishment of the Warrior Transition Units, which focus wholly on soldier health.
"Soldiers coming back now have a future," he said. "For me, coming back, it didn't feel that way."
Injured soldiers returning here are treated first within the military medical system. When they need specialists the system doesn't offer, they go to civilian doctors, using Tricare to pay. Tricare reimbursement rates are set by Congress and are similar to Medicare's. They are frequently far below the billed cost of care. Tricare is mainly for active-duty military, dependents and retirees. It's separate from the Veterans Affairs medical system, which also uses civilian doctors to fill gaps in care.
Waszak said he tried several pain management clinics in Anchorage and was refused because of his insurance. He was accepted by Leon Chandler, an anesthesiologist with an outpatient clinic.
Chandler determined that Waszak needed a rare, risky surgery to remove ribs that were detached and compromising his lungs. But, Chandler told me, the surgeons in Anchorage he called refused.
Some said the risks of the surgery outweighed the benefits. Tricare may also have been a factor, though it wasn't discussed, Chandler said.
It took a year and seven months before Chandler convinced a military doctor in Washington state to do the procedure. Meantime, Waszak's condition worsened. He made numerous visits to the emergency room for breathing problems. He had a bout with pneumonia, then meningitis.
Chandler told me Waszak was one of his most complex patients. He can take Tricare patients because his practice is large enough to absorb the low reimbursements. Most doctors want to treat all patients, no matter what they can pay, he said. But every practice must have a balance of patients to work economically. Some smaller clinics can't make it work with Tricare, he said.
Waszak estimated he's had two dozen surgeries to deal with spine, rib and knee problems. Along with all of his medications, he has a nerve stimulator implanted in his spine to help manage pain. I asked Chandler if Waszak would ever get better. Chandler said his problems would grow worse with time.
"He's never going to be normal," Chandler told me. He was injured serving his country, and now his country should take care of him, he said.
"We did this to him. We owe him a lot."
TROUBLE WITH TRICARE
I called Begich to see what he thought of what Waszak said at the Purple Heart ceremony.
"The higher-up brass weren't sure if his presentation to me was offensive," he said. "It wasn't."
The issue with Tricare isn't just reimbursements, Begich said. There are paperwork issues too. And remoteness and the limited number of Alaska providers make everything more complicated. Rural patients have a more difficult time accessing care, he said. He said he wants to organize a forum with patients, physicians and Tricare officials to look at the issue sometime in the next three months.
Sen. Lisa Murkowski's office staff said they hear "routinely" from patients with experiences like Waszak's. Murkowski met with senior Tricare officials in September, to ask them to look into the situation in Alaska. Tricare had increased reimbursement rates somewhat in the state but it was still far behind.
"Unfortunately this is not the first time I've raised this point with senior Tricare leaders going back to 2007," Murkowski said in an e-mail.
I called Jerome List, a local ear, nose and throat specialist. He's president of the Anchorage Medical Society, which represents doctors. He told me he sees Medicare patients and even patients who can't pay at all, but he quit seeing Tricare patients in his office. He will only see them in the hospital.
He said he made the decision after he spent a month treating a critically ill girl who had been hospitalized in the intensive care unit for a tumor in her windpipe.
"When you have a really sick child, your whole life revolves around this," he said.
Then he received a reimbursement from TriWest, the company that administers the government's Tricare program in western states.
"For the amount of involvement, what I was reimbursed was offensive," he said. "I think the janitors made more money cleaning the ICU."
He voided the check and mailed it to then-Sen. Ted Stevens.
There have been times when he has seen Tricare patients in the hospital for free because the reimbursement is less than the cost of paying someone to bill them, he said. Later I talked to his billing person. She sent me a reimbursement form for a recent procedure List performed that involved putting tubes in the ears of a baby. The procedure was billed at $4,780. Tricare paid $430.82.
I called Fort Richardson to see if I could speak with Gen. Troy, but the public affairs office directed me to a medical public affairs officer in Fairbanks, who directed me to Lt. Col. D. Vince Gill, an Air Force health administrator in charge of the Alaska Tricare office. His job is to oversee the relationship with civilian doctors. He asked me to submit my questions in writing.
I asked what he says when patients tell him they can't get care in Anchorage because doctors won't accept Tricare. His answer was a paragraph long, but basically it said that those patients are sent Outside, either to military doctors or to doctors who will take Tricare.
I wondered whether military doctors thought Tricare was a problem for their patients. Col. Paul Friedrichs, commander at the Elmendorf hospital, and Ron Stephens, commander of Bassett Army Community Hospital at Fort Wainwright, agreed to a conference call.
They told me that their hospitals, the state's largest military health care hubs, serve about 130,000 active-duty military personnel, retirees, dependents and veterans. They've expanded their services as the military has grown in Alaska but they still depend on referrals for specialties like neurosurgery and oncology. The military also has no dialysis, pain management clinic or pediatric ICU.
I told them about the local doctors' concerns about reimbursement and asked them if they worried it compromised patient care. They said they couldn't answer that question and referred me to Gill.
Toward the end of the interview, Friedrichs said he didn't want me to write something that gave the impression that there weren't doctors in Anchorage who would take Tricare.
"We are so grateful for the docs who have agreed to see our patients," he said.
STRUGGLING TO FIT IN
The day after the Purple Heart ceremony, I met Waszak again, along with his wife, Karen. She works on the base in the financial office that pays soldiers. I asked them to tell me about a normal day at their house. Karen said Waszak gets his son ready for school, takes him there and goes home to bed.
I asked if I could visit them at home. Waszak said no. The only visitors over the last five years have been in-home nurses, one Army friend and his son's friend. But that only happened once.
After the interview, Waszak called me. He told me Karen had been generous. Usually he can't get his son to school, he said. He wishes he could. He wishes he could volunteer in his son's class, he said. Just for 30 minutes, even once a week.
"I feel safe there for some reason," he said. "I feel like I can help my son."
He has tried it. But the last time he came in, the second-graders were doing an activity where they had to circle even numbers on a page. His stared at the numbers. His brain felt jumbled up.
"I couldn't make sense of it," he said. "I couldn't understand anything anymore."
That humiliated him. Being in public is the same way, he said. Like he's constantly trying to keep people from noticing that he's damaged. If they knew, he said, they might be afraid of him.
"I do my best to fit in with everyone else," he said. "But inside I'm scared as hell."
He thinks about going back to the class. But lately he's only managed to drive into the parking lot and wait in the car for his son after school.
It's easiest to be at home, at the end of a road in Peters Creek, with nothing but mountains behind him. He's grateful for the support he's had from the military, he said. The doctors, nurses and counselors have kept him alive, he said. He'll retire from the military in February.
He told me he would like to sell their house and start over in Kentucky. He's been calling around down there, looking for a pain doctor. He estimates he's called 18 doctors, looking for one who will treat him.
But so far, none will take him on.
UPDATE 10/23: To read some responses to this column, click here.