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Pending Legislation Puts VA Health Care at Risk
“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.
The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.
Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long. 
Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”
Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.
The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:
(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.
This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.
Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.
(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.
On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.
(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.
In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.
Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.
In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”
The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.
“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.
The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.
Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long.
Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”
Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.
The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:
(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.
This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.
Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.
(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.
On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.
(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.
In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.
Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.
In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”
The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.
“What if VA health care goes away?” That was the headline of a July 6, 2023, Disabled American Veterans news article to its members. The question was not hypothetical. Legislation currently under consideration by the US Congress may make it a strong probability.
The US Senate Committee on Veterans’ Affairs recently held a hearing to discuss 2 bills that would drastically reshape the provision of private health care services through the Veterans Community Care Program. An unprecedented coalition of 10 organizations—made up of US Department of Veterans Affairs (VA) nurses, psychologists, physicians, dentists, social workers, optometrists, physician assistants, and nurse anesthetists, as well as the American Psychological Association, the Military and Veterans Committee of the Group for the Advancement of Psychiatry and the Veterans Healthcare Policy Institute—came together in a unified statement for the record highlighting how these proposed policies would open a Pandora’s box that could forever eliminate the Veterans Health Administration as we know it.
Over the past decade—and especially following the passage of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act—there has been a surge of veterans gaining eligibility for private care if a VA medical facility is too far away, does not offer the needed care, or the wait time for an appointment is too long.
Testifying before the House Committee on Veterans’ Affairs hearing last year, Miguel LaPuz, MD, MBA, then the acting Deputy Under Secretary for Health at the VA, warned that “VA is rapidly approaching a point where half of all care available in both settings is provided through community care.” He cautioned that leaders were bracing for “the potential of a spiral effect.”
Care that is rendered to veterans in the community must, of course, be paid for. When those community costs began to soar at the start of the Community Care program, Congress bailed out the VA by allocating extra funds. Today, escalating costs are drawn from local VA facility budgets. And to guarantee that private sector care is paid for out of VA facility funds, legislators are introducing language, such as in the Veterans Healthcare Freedom Act, which states: “No additional funds are authorized to be appropriated to carry out this section and the amendments made by this section, and this section and the amendments made by this section shall be carried out using amounts otherwise made available to the Veterans Health Administration.” The anticipated vicious cycle looms. More money pouring into the private sector will force reductions and closures of in-house VA staff, programs, clinics, and units. This will cause more veterans to obtain care in the community, which will further drain more money out of VA facilities, leading to more reductions, etc. Rural areas will likely be hit hardest.
The VA is nearing the tipping point of this ever-descending spiral. And that is even without expanding eligibility further. Three provisions in this pair of bills could, on their own, drastically open eligibility, eliminate remaining guardrails, and push VA over the edge:
(1) Veteran preference. Tucked into the HEALTH Act, introduced by the ranking Republican Member, Jerry Moran of Kansas, is language which would require VA to consider a “veteran’s preference” for obtaining their health care in the private sector.
This stipulation violates the intent of the VA MISSION Act. When MISSION passed, there was bipartisan agreement that the Community Care Program was meant, in numerous Senators’ words, to “supplement, not supplant” VA health care. A veteran would be offered the option of receiving health care outside of the VA under 6 narrowly defined criteria. Legislators understood that veterans would get the option to choose whether to receive care in the private sector or the VA if, and only if, they qualified under the 6 eligibility rules. As a well-researched document coauthored by Disabled American Veterans, Paralyzed Veterans of America, and the Veterans of Foreign Wars stated, “veteran convenience or preference” should never be used as a sole reason for referral.
Explicitly adding preference for the first time will create the expectation among veterans and lawmakers of a new allowance. Were this to pass, every veteran—100%—would become eligible for referral to the private sector, kicking off an unstoppable drainage of VA budget resources and threatening its viability. Hopefully, the Senate will follow the lead of the US House Committee on Veterans’ Affairs which, last week, amended its its own community care bill by deleting “veteran preference” as a possible new eligibility criterion.
(2) Self-referral. Also being deliberated is the Making Community Care Work for Veterans Act, a draft bill authored by the US Senate Committee on Veterans’ Affairs Democratic Chairman Senator Jon Tester of Montana. It calls for allowing self-initiated routine vaccinations and routine vision/hearing services in the community.
On the surface, Tester’s bill focuses on only a tiny sliver of care. But once self-referral is permitted for a few services, private sector interests will, in no time, push the door wide open and add more services to which veterans can self-refer. Testimony at the hearing confirmed that prediction, as the Veterans of Foreign Wars and America’s Warrior Partnership stated there is no reason to limit self-referral to only eye and ear examinations. They proposed that self-referral should extend to mental health, substance use, podiatry, prosthetics, laboratory services, dermatology, and diabetes. Like other perilous sections of these bills, seemingly innocuous language would quickly lead to crippling impacts.
(3) Pilot program for unfettered access. The HEALTH Act contains another provision in which veterans would be allowed to receive outpatient care without VA referral, authorization, or oversight. An enrolled veteran could simply make an appointment with any Veterans Community Care Program mental health or substance use disorder practitioner for care for any duration of time. VA’s only role would be to pay the invoice. Private sector interests have been pressing this sort of program for years, and when it was carefully studied by the Commission on Care, the costs were estimated to be 2 to 3 times the existing system. That would come from a combination of fee-for-service reimbursement structures that abet overuse and higher overall costs in the private sector. Were the pilot to pass, VA would convert from its primary role as a system providing health care to an insurance carrier.
In the name of offering more choices, health care options will diminish for veterans. When VA programs/clinics/facilities close, veterans—especially service-connected veterans who depend on VA for high-quality care tailored to their needs—will lose those choices. Moreover, a downsized VA will make it nearly impossible for the VA to continue to research veterans’ complex health conditions, educate future health care professionals (the majority of whom train at VA medical centers), or fulfill its Fourth Mission as a backup for national emergencies.
Senate Committee members indicated their intention to combine provisions of the Moran and Tester bills into a larger compromise bill in September. Legislators must slow down, contemplate the ramifications, and set aside the stipulations noted above. What is needed first is a projection of future veterans’ authorizations for community care (under current eligibility criteria and also with these new allowances), how much money would that pull out of VA facilities, and what is the tipping point of a doom cycle.
In the meantime, there are smart solutions to ensure veterans can access high-quality care, as Disabled American Veterans testified at the hearing: By “investing in VA's health care infrastructure and staffing… this is particularly true for veterans who live in rural and remote areas where VA is most likely to be a stable, long-term health care option for veterans.”
The VA administers the most successful health care system in the country. As a recent summary of research confirmed yet again, the quality of care delivered by the VA is as good as or better than the care veterans receive from VA-paid community care or the general public obtains through private care. There will always be a supplemental role for the community to play when VA cannot provide care in a timely or convenient manner. But community care must be fixed in ways that never starves VA facilities of essential funding. If there ever were a time to stand up for the sake of our veterans and the long-term viability of the VA, it is now.