Congress’ next big health care fight has already begun, and this time it’s in the Department of Veterans Affairs.

After months of unsuccessful efforts to repeal the Affordable Care Act, critics of government-backed health care efforts are now turning their focus to VA health programs as a battleground for broader issues of government bureaucracy and federal overreach.

And ground zero for that fight was set to be this Wednesday’s mark up of VA health care reforms, a lengthy list of technical changes closely followed by the veteran community but largely ignored by the rest of the country.

The issue has been delayed for a few days, over last-minute concerns about unclear costs surrounding the proposal. The bill — introduced by House Veterans’ Affairs Committee Chairman Phil Roe, R-Tenn., late last week — would create a permanent program for veterans to seek medical care outside the VA system at the government’s expense.

Nearly one-third of all VA-funded appointments last year were with private-sector doctors, but management and reimbursement of those programs is currently handled by a patchwork of different authorities.

The new legislation would simplify that by expanding partnerships with outside health systems and loosening restrictions on when veterans could see local doctors for care. But it also keeps VA physicians as the primary care coordinator for veterans, one way to monitor the quality of the care they get outside the traditional veterans system.

The measure has the support of every Republican and Democrat on the committee. Outside that panel, however, critics have already begun picking apart the measure.

“The (bill) contains some positive reforms but still falls short of delivering real health care choice to our veterans,” said Dan Caldwell, executive director for Concerned Veterans for America.

“Under this legislation, the VA will still retain almost complete control over when a veteran can access private health care, which could undermine the better aspects of this legislation.”

At issue is a fundamental political debate over whether sending more federal dollars to private-sector businesses can create better, cheaper results for taxpayers. U.S. President Donald Trump has repeatedly promised to increase veterans’ access to private-sector physicians, arguing that often they’ll get better care in their communities than at VA locations.

CVA and a coalition of conservative groups — several new to veterans’ issues — have pushed VA (and Congress) to relax rules surrounding that outside care, arguing that veterans should be able to choose where to receive their government-funded medical appointments.

In their view, that would mean more “competition” for a VA system they have criticized as overcrowded and inefficient. If department hospitals improve, more veterans will want to go there. If they don’t, veterans won’t be forced into failing facilities.

But mainstream veterans groups have attacked that view as privatization of core VA missions. They insist that many civilian health systems aren’t familiar with battlefield injuries like traumatic brain injury or limb amputations and will end up pulling away money needed to improve VA facilities to provide the best care possible for veterans.

“Our goal is to strike a balance between access to care and access to veteran-centric care,” Adrian Atizado, deputy national legislative director at Disabled American Veterans, told committee members at a hearing last month.

“This really deals with the creation of local veteran-centric integrated networks to ensure that veterans do not fall victim to fragmented care that is rampant in the private sector,” Atizado said.

A 2014 Rand study found only 13 percent of private-sector mental health care providers have met readiness criteria for patients with military backgrounds, a figure that the veterans groups note when private-sector appointments are mentioned.

Late last month, a coalition of nine veterans groups trampled down a legislative proposal to allow some veterans to access private-sector mental health care at government expense without prior VA approval.

Supporters had said the move was needed “to address the suicide crisis” among veterans. Veterans groups called it a stealth attempt to shift millions from VA medical centers to private clinics. The better solution, they argued, is boosting VA funding to build better facilities and more small-clinic offerings.

Critics of the department say the VA budget is already bloated and that throwing more money at the problem is unlikely to improve outcomes for veterans.

Amid the debate, leaders of the American Federation of Government Employees — the largest union representing VA workers — have accused Republican lawmakers and outside conservative activists of working to undermine VA medical programs to sow doubt about the efficacy of any federal health care programs.

CVA and its supporters have countered that the unions are more interested in protecting low-income employees than helping veterans.

Meanwhile, VA officials have offered their own plan to shift more responsibilities outside their medical center doors, one that is more expansive than the House plan.

Three weeks ago, VA Secretary David Shulkin unveiled his proposed Coordinated Access & Rewarding Experiences (CARE) Act, which would allow veterans to get community medical appointments without VA oversight if they are seeking specialty care not provided by VA or face a wait longer than “a clinically acceptable period.”

VA officials could also authorize additional outside care when “the veteran and the veteran’s primary care provider agree that furnishing care and services through a nondepartment entity or provider would be in the best medical interest of the veteran.”

That open-ended language has raised concerns among critics, both because of the potential cost — still not officially announced — and the long-term impact it might have on veterans services.

In testimony before the committee late last month, Shulkin said he supported the framework of the House plan but wanted to see changes as the legislative process unfolds to bring it closer to the VA version.

Critics on boths sides want to see that as well. For now, no major changes are expected to the legislation as it moves out of committee. But activists on both sides are hopeful they can shift the measure closer to their positions as it winds through the full House and Senate in the weeks to come.

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.

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