WASHINGTON — The fight over privatizing Veterans Affairs health care is about to escalate.
On Wednesday, department officials released their first public draft of new rules regarding which veterans will be eligible for private-sector medical appointments covered by taxpayer funds. The rules amount to a massive expansion of those outside care options, potentially adding more than 1 million more patients to community care programs.
Almost immediately, critics attacked the plan as an overreach by President Donald Trump’s administration to shift patients and funding from the federal veterans medical system to the private sector, in an attempt to undermine government backed health care. House Veterans’ Affairs Committee Chairman Mark Takano, D-Calif., has promised a public hearing on the issue in coming weeks.
“Rather than working to find an equilibrium within the system by building up VA’s ability to deliver high quality care, … today’s announcement places VA on a pathway to privatization and leads Congress to assume the worst,” he said in a statement after the rules release.
But VA officials are calling those reactions nothing more than hyperbolic partisanship, and they said the new rules are designed to give veterans more options, not undermine the existing system.
They also insist that the changes won’t significantly alter how the majority of veterans in America get their care, since many are satisfied with their current care plans. The small percentage who aren’t will now enjoy more choices, with the government picking up the bill.
“Most Americans can already choose the health care providers that they trust, and President (Donald) Trump promised that veterans would be able to do the same,” said VA Secretary Robert Wilkie.
“With VA’s new access standards, the future of the VA health care system will lie in the hands of veterans, exactly where it should be.”
The rules release is the culmination of nearly two years of debate within veterans community over how to balance promised health care with program reforms — and whether Trump supporters have pushed that line too far. Now, the disagreements are likely to get even more attention, as outside groups view the fight as a proxy for broader arguments over whether the president is interested in improving federal agencies or dismantling them.
** The new rules
Currently, VA community care options are a collection of at least seven separate programs, each with different eligibility and payment rules. The most well-known is the VA Choice program, put in place after the department’s 2014 wait time scandal that forced the resignation of multiple top VA officials, including former Secretary Eric Shinseki.
The Choice program allows veterans who live 40 miles away from a VA medical facility or face a 30-day wait for care there to receive funding for medical appointments in their local community. Those standards have been attacked from both sides of the political aisle, as either too loose or too restrictive.
Last summer, Congress passed (with overwhelming bipartisan support) the VA Mission Act, mandating that department officials consolidate the existing community care programs and come up with new eligibility rules.
Many Democrats who had warned that Trump officials were pushing for too much private-sector funding still went along with the legislation, arguing that reforms were needed regardless of the potential pitfalls.
The draft rules unveiled by Wilkie this week would echo the VA Choice limits but ease them significantly.
For primary care and mental health medical appointments, the department is proposing a 30-minute average drive time standard and a wait-time standard at closer VA facilities of 20 days. For specialty care, the drive-time standard would increase to 60 minutes and the wait-time standard would increase to 28 days.
Drive times would be calculated according to a private-sector program based on Microsoft’s Bing search engine maps.
About 600,000 veterans enrolled in VA health care are eligible for the existing community care programs. The proposed expanded standards will raise that number to between 1.5 million and 2.1 million patients, according to the department.
But VA officials are quick to note that eligibility doesn’t mean guaranteed use. Last year, of all the veterans eligible for the VA Choice program, only about 36 percent used it. Less than 1 percent used those outside care appointments to cover all their medical appointment needs.
Usage of all community care programs dropped about 2 percent from 2016. As a result, VA officials are saying they don’t expect a significant rise even if the expanded rules are put in place.
** Patients’ choice or bureaucratic attack?
But critics don’t buy that, saying the new rules could easily amount to a rapid expansion of the program.
“My concern is if (the standards) are too broad, it’s going to hollow out the VA, and we’re not going to be able to foot the bill,” said Senate Veterans’ Affairs Committee ranking member Jon Tester, D-Mont.
“A 30-minute drive, if you’re in Scobey, Montana, that seems reasonable. But if you’re in the middle of Chicago caught in traffic, does that work? We need a lot more information.”
VA planners have put a price tag of more than $21 billion over five years on the new standards. But critics have also questioned that, saying it will fall short of actual costs, especially if administration officials push the new options as preferred.
“We are witnessing a deliberate attempt to drain the coffers that feed the VA and to force our veterans into the fragmented and chaotic private sector, a system that is costly, inefficient and unprepared to meet the needs of our veterans,” said National Nurses United Co-president Jean Ross, in a statement.
“Nurses are concerned that veterans returning from combat will find it harder to find specialized care or advocates to help them navigate through the maze of private-sector providers. If we fail to provide for our veterans, we are failing to live up the promise we made when they took the oath to serve.”
The group, along with federal union officials, have warned that years of bad-mouthing VA services combined with loosening eligibility rules for outside care options will lead to worse care for veterans.
Since his presidential campaign, Trump has repeatedly suggested that many veterans face onerous wait times when turning to VA for medical care, showing the need for more outside options.
But earlier this month, a study published in the Journal of the American Medical Association found that in most cases veterans’ waits for appointments with VA clinics are shorter than in the private sector. In 2017, the average wait time for VA doctors was just under 18 days, compared to nearly 30 days for private sector care.
In addition, veterans groups have long argued that private-sector doctors aren’t always prepared to deal with combat injuries like post-traumatic stress and traumatic brain injury. They worry that the push for more outside appointments takes focus away from building up VA services and resources.
“It will not be acceptable to veterans like our members, who use VA health care almost exclusively, to cannibalize the existing system in order to fund the expansion of this new community care program,” said Carl Blake, executive director for Paralyzed Veterans of America.
** What is privatization?
When Takano holds his planned hearing on the new standards, the primary question will become whether tripling the number of veterans eligible for outside care amounts to privatizing VA’s core mission to provide care for veterans.
Wilkie has already argued that it does not. In his statement before Wednesday’s release, he offered an early rebuttal to the privatization claims, arguing that allowing veterans more choices for their care will force VA hospitals to strive for even better service, in turn providing better care to veterans.
“Our medical services must meet our veterans’ needs and reinforce the trust that forms the basis for every interaction with VA,” he said. “We will constantly innovate, upgrade, and pursue ways to serve our nation’s heroes as best we can. Our new access standards are a vital part of this effort.”
But opponents say the new community care program won’t hold outside providers to the same wait-time or quality standards that VA physicians must meet. That puts VA at a disadvantage as they try to explain to veterans why their breadth of experience and associated support resources many outweigh a slightly-shorter car drive for check-ups.
“The standards turn a blind eye to the quality of care veterans would receive in the private sector,” said Russell Lemle, a senior policy analyst at the Veterans Healthcare Policy Institute, a frequent critic of the administration’s VA reform plans.
“These standards will privatize veterans’ health care, plain and simple. They open up the floodgates for veterans to receive vouchers for private sector services. Now for the first time, dollars will follow veterans into the private sector, leaving less money and less staff available for VA facilities.”
Veterans groups have offered a mixed assessment of the rules thus far.
Officials at the Veterans of Foreign Wars, like PVA, expressed serious concerns about the rules as written now. Officials at Disabled American Veterans said they have numerous unanswered questions about “whether sufficient new funding will be provided, without diverting resources from existing VA programs or modernization plans.”
But AMVETS National Executive Director Joe Chenelly praised the initial draft.
“The reality is VA-funded care is being placed in the hands of the veteran, and that is the right thing to do,” he said. “Many of those veterans will choose to go to a VA medical facility, while others want more freedom of choice.”
But Chenelly — along with officials from Wounded Warrior Project and several other organizations — said they still have questions about the implementation, many of which were not explained to key community stakeholders before the Wednesday announcement.
Republicans on the House and Senate Veterans’ Affairs Committee have largely offered support for the community care changes thus far, potentially giving VA support when their officials are summoned before those panels on Capitol Hill in coming weeks.
Under rules laid out the Mission Act, VA officials must finalize the new community care rules by the beginning of March. They’ll go into effect in June, unless lawmakers opt to block them.
Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.