The Trump administration has issued its plan to streamline and expand its programs allowing veterans to receive health care from the private sector, igniting the first spark in an upcoming fight on the future of the government’s role in providing care to former military personnel.
The Veterans Affairs Department wants to “merge and modernize” the array of programs allowing patients to receive care outside of VA providers, according to a framework of the Veterans Coordinated Access and Rewarding Experiences (CARE) Act department officials presented to Congress this week. The measure would eliminate rules for the Veterans Choice Program that require a veteran to live 40 miles from a VA facility or face a 30-day wait to receive care at one in order to become eligible for private care on the department’s dime. That program, created by a law President Obama signed in 2014, got off to a rocky start but has since gained popularity.
VA said its measure would also shore up VA facilities by improving buildings and boosting staffing levels where large numbers of vacancies persist. Secretary David Shulkin said earlier this year the department had 49,000 unfilled positions, but the number has since decreased.
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Still, opponents of expanding private care were quick to denounce VA’s plan, saying loosening eligibility restrictions for private coverage robs the department of resources for its own facilities and begins a slippery slope toward privatization. Many Democrats have said they can support expanding the choice program only if Congress invests equally in VA’s internal care. President Trump extended the shelf life of the choice program in August by signing a stopgap measure.
“I think the choice program is here to stay,” Rep. Julia Brownley, D-Calif., said at a forum on the future of VA health care earlier this month, “but many like myself are advocating very hard in any of these debates if we’re going to invest in choice we have to invest at least as much in VA.”
Rep. Mark Takano, D-Calif., the vice ranking member of the House Veterans' Affairs Committee, warned at the same forum that private care for veterans was “not a panacea.”
“Community care has always been part of care vets receive and it will continue to be,” Takano said. “But we can’t let it supplant VA care.”
VA Secretary David Shulkin has repeatedly pledged not to privatize his department’s health care mission and said VA’s legislative proposal honors that promise.
“We want veterans to work with their VA physicians to make informed decisions that are best for their clinical needs, whether in the VA or in the community,” Shulkin said, “and this bill does just that, while strengthening VA services at the same time.”
This is not the first time VA and lawmakers have added sweeteners to assuage potential opponents to private care expansion. Congress initially rejected the choice program extension bill this summer before the administration and detractors reached an agreement to boost Veterans Health Administration funding by $1.8 billion. A key co-author of the legislation creating the choice act, Sen. Bernie Sanders, I-Vt., did not sign on until provisions were added to authorize VA to build 26 new facilities.
Lawmakers, veterans service organizations and other advocacy groups have expressed concern about the approach the Trump administration would take as it sought to remake the choice program and consolidate its private care offerings. The 2014 law that created the choice program also chartered the Commission on Care to come up with proposals for the future of VA, but Obama rejected many of its main conclusions. The commission’s plan, Obama said last year, would force “untenable resource tradeoffs that would limit the ability of VA to carry out other parts of its mission on behalf of veterans.”
Meanwhile, three of the commissioners on that panel refused to sign off on the final report they said was far too mild. The leader of that cotingent, Darin Selnick, spent the opening months of the Trump administration as a senior adviser to Shulkin and now sits on the White House Domestic Policy Council as a veterans affairs adviser. Shulkin, who is an Obama administration holdover, has not pursued the drastic changes some have feared. Concerned Veterans for America, for example, a conservative group funded by libertarian-minded Koch brothers network that used to count Selnick among its advisers and whose former CEO Trump interviewed for VA secretary, has backed shifting VHA into a government-chartered nonprofit corporation. CVA said VA’s Veterans CARE Act offered some “positive reform,” but did not go far enough.
Lawmakers offered a tepidly positive response to VA’s new proposal.
“Secretary Shulkin’s proposal is a good starting point that takes into account months of our bipartisan conversations about the future of community care,” said Sen. Jon Tester, D-Mont, the ranking member of the Senate Veterans' Affairs Committee. “I’m pleased that the VA has prioritized putting veterans and their doctors at the center of medical decisions and getting rid of a one-size-fits-all system that doesn’t work for our nation’s veterans.”
Sen. Johnny Isakson, R-Ga., that panel’s chairman, praised the bill without offering his full endorsement, saying he will work with VA, VSOs and his colleagues in the House and Senate to come up with a final legislative proposal.
“Secretary Shulkin’s proposal for continuing efficient and timely veterans’ care in the community is very thoughtful and balanced,” Isakson said. “The VA’s proposal is the result of continued collaboration with veterans groups and Congress, and I will carefully evaluate its contents.”
The House Veterans' Affairs Committee, led by Chairman Phil Roe, R-Tenn., is pursuing its own path on reforming VA’s choice program and relationship with the private sector. A draft bill Roe is still ironing out with input from colleagues and VSOs would allow any veteran VA determines it cannot support with a care team or a dedicated primary care provider to seek treatment in the private sector through a network of providers it establishes in each of its regions.
“Chairman Roe and committee staff are reviewing VA’s community care proposal and will take it and stakeholder feedback into consideration as the legislative process moves forward,” said Tiffany Havely, a spokeswoman for Roe.
Roe is also leading the charge on another controversial measure to put VA through a process similar to the Defense Department’s Base Realignment and Closure Commission. The department must assess which facilities are underutilized and either consolidate or closure them, Roe and his supporters argue. The Commission on Care included a VA BRAC proposal in its final recommendations. Some of the savings would be reinvested back into the VA system, closure proponents have said, though the bill is intentionally being coupled with choice reform to offset some of the costs that will inevitably stem from expanding that program.
The VA reformers will face an uphill battle, despite some signs of bipartisan agreement. The American Federation of Government Employees, which represents about 230,000 VA employees, has held 36 rallies in 22 states across the country to fight against what it views as privatization efforts. Those rallies will continue, said AFGE President J. David Cox, adding groups such as the American Legion, Disabled American Veterans and Veterans of Foreign Wars are all collaborating to oppose choice expansion (for its part, the Legion applauded VA's efforts and promised to work with Shulkin to develop "improved healthcare options and outcomes to our nation’s veterans.")
“We’re definitely ratcheting up,” Cox said on Tuesday. The union chief called Shulkin’s proposal a “total dismantling of VA, taking resources out of VA and shifting it to private sector.”
Roe will hold a hearing on his bill and efforts to boost private sector care next week.