A detailed proposal on the future of Veterans Affairs health care calls for creating a nationwide system of public and private health networks to care for veterans and closing poor or underutilized VA facilities.

After a nearly two-year review, the Commission on Care on Tuesday sent the White House a nearly 300-page assessment of the current VA health care system with 18 recommendations to improve quality and access to care as well as modernizing some VA hospitals and clinics.

Saying VA facilities still have "profound deficiencies" in delivering care, the panel proposed that veterans get medical care through a new Veterans Health Administration Care System, or VHA, System -- a series of networks that would include VA hospitals, Defense Department facilities and other federally funded providers along with civilian physicians credentialed by VA.

Under the VHA Care System, veterans would choose a credentialed primary care provider within the system and would see specialty care doctors, also in the system, after receiving a referral from their primary care doctor.

Read the report: Commission Care Final Report

According to the commission, all veterans who are eligible for VA health care would be managed under the system, with no restrictions placed on them, like the 40-mile distance rule or 30-day wait time requirement of the Veterans Choice program.

The panel emphasized, however, that veterans with service-connected conditions as well as impoverished veterans should have top priority within the proposed plan.

To manage the system, the Veterans Health Administration would have an 11-member board of directors appointed by the president, Congress and VA with expertise in health care, contracting, facilities management, budgeting and finance, according to the assessment.

Members of the commission said the board is needed to provide leadership continuity that is lacking in the current system.

"Recently, each under secretary for health has served for only a relatively short period, leaving office with a change in administration or sooner. This pattern has deprived VHA of vitally needed sustained leadership and has likely contributed to short-term decision making," they wrote.

Saying VA care still has "profound deficiencies," the panel said VA must transform to ensure it can provide high quality care for veterans, adding that "America's veterans deserve much better" and "VHA operations require urgent reform."

The commission was created in 2014 by the law that established the Veterans Choice program, a community care initiative designed to accelerate access to care in for veterans who live in areas where VA care is unavailable or appointment wait times were extensive.

The Veterans Choice program was a response to the scandal that found veterans at the Phoenix VA Medical Center and elsewhere waited months for care while managers manipulated appointment schedules to appear as if their facilities were meeting wait time standards.

In crafting their final report, commission members analyzed previous reports on VA health care, spoke with VA officials, employees and veterans organization representatives, conducted public meetings with veterans and consulted health care experts.

In its report, the commission also recommended that VA embark on a process similar to the Defense Department's Base Realignment and Closure effort to dispose of underutilized or excess property. Panel members also said VA should improve its workforce training and performance processes and transform its culture.

For more than 30,000 veterans who left military service with other-than-honorable discharges for behavior possibly related to a service-connected injury, such as brain damage, the panel also recommended that VA revise any regulations that prevent it from offering these veterans health services.

The commission, which met more than a dozen times in nearly two years, still failed to reach a complete consensus. Three of 11 members did not sign the final report, with two commissioners, including former VA employee and Concerned Veterans For America senior adviser Darin Selnick, and Stewart Hickey, a retired Marine Corps major and former national executive director of AMVETS, opposing the final report because they felt it didn't go far enough.

Commissioner Michael Blecker, executive director for Swords to Plowshares, also did not sign, saying the main recommendation, for the VHA Care System, went too far.

A spokesman for CVA said the final report contained "some good recommendations" but added that it the product did not produce a hoped-for blueprint for system-wide change that the organization expected the panel to craft.

"The bulk of the recommendations would leave most of the current system intact, particularly the recommendation to create VHA managed-care networks … this would leave VA bureaucrats in charge of veterans' health care, denying veterans the real health care choice they deserve," CVA spokesman Dan Caldwell said.

"One of the problems I saw early on with the commission is we spent more time listening to the VA and how they were fixing the problems, and the [veterans service organizations] coming in and telling us how the VA needs more money and more resources to fix their problems," Hickey said.

Commissioner Blecker said he thought the VHA Care System would "threaten the survival of our nation's veteran-centered health care system" and would be more costly than the current structure to implement.

"Key elements of the proposed new system will result in the degradation or atrophy of important health services that the VA provides with high quality, to high demand, at low unit cost, and with a unique degree of military and veteran competency," Blecker said.

After release of the report, veterans service organizations and lawmakers weighed in, with many parsing out the parts they like and dismissing others.

The Veterans of Foreign Wars said they it agreed with the majority of the recommendations except the proposal to create a board of directors for VHA. 

"We cannot support ... the proposal to establish a politically-appointed board of directors that would govern the VA health care system. The VA needs leadership, not management by committee," VFW National Commander John Biedrzycki said.

Iraq and Afghanistan Veterans of America released a statement saying it supports they support a public-private health care system but added that the "fight to fix VA is far from over."

"We are pleased that the Commission didn't buckle to partisan calls for privatization of the VA [but] we will continue to pressure Congress to fund a VA-led integrated care network that results in a dramatic new vision for a 21st-century VA," said IAVA founder and CEO Paul Rieckhoff.

Most of the proposals require congressional action, and the report is likely to spark renewed debate in Congress and within the administration on the future of VA care.

A spokesman for Rep. Cathy McMorris Rodgers, who has proposed her own draft legislation that would place placing all Veterans Affairs Department medical facilities under a nonprofit entity and give all new veterans access to private health care, said Tuesday that McMorris Rodgers will continue to pursue change at VA.

"She continues to hear from veterans who are concerned about the quality of care they are getting — or not getting — at VA and are looking for new choices. They want additional choices of the nature [that McMorris Rodgers] has proposed," the staff member said.

Sen. John McCain, R-Ariz., has floated legislation that would expand the Veterans Choice program to all veterans. On Wednesday, he praised the Commission on Care report for expanding access to veterans and demanding more accountability from VA, but he also took issue with its characterization of the Choice program, which commissioners said is inherently had a flawed design and was poorly executed.

"I am encouraged by many of the recommendations made in the Commission on Care report, which underscore many of the reforms for which I have been fighting for years to provide greater choice and flexibility in veterans' health care," McCain said. "I support any and all reforms that would provide veterans more freedom to choose when and where they can receive care."

House Veterans Affairs Committee chairman Rep. Jeff Miller said the document "makes it abundantly clear that the problems plaguing Department of Veterans Affairs medical care are severe," adding that fixing them "will require dramatic changes."

Commissioners estimated the potential cost of creating and implementing a VHA Care System to range from $65 billion to $85 billion in 2019. , with a middle estimate of $76 billion. The fiscal 2017 VA medical care budget is $65 billion.

VA Secretary Bob McDonald said Veterans Affairs officials will spend the coming weeks studying the report and crafting opinions on it. He added, however, that he was pleased to see recommendations that he said are in line with transformation currently underway at VA.

According to McDonald, VA set a record in March for completed appointments, 5.3 million at VA — 730,000 more than in March 2014 — and that 90 percent of veterans surveyed say they are "satisfied or completely satisfied" with the timeliness of their appointments.

"However, until all veterans say they are satisfied, I won't be satisfied. Nobody at VA will be satisfied, but our progress so far proves that VA's current leadership, direction and momentum can produce the necessary transformation," McDonald said.

Patricia Kime covers military and veterans health care and medicine for Military Times. She can be reached at pkime@militarytimes.com