Broken promises: Veteran health care is being replaced by the private sector

In 2018, Congress passed then-President Trump’s signature veterans’ legislation, the VA MISSION Act, which was designed to shift many more patients from the Veterans Health Administration (VHA) to the private sector through a newly formed Veterans Community Care Program (VCCP). Lawmakers assured wary stakeholders that the VCCP would “supplement, not supplant” the VHA. This law was about options, they were told, not privatization.

Three years on, it’s clear that those were empty promises. VHA services are being rapidly replaced by private-sector care, even as studies continue to confirm that non-VA care generally is of lower quality and higher costs. 

A recent study reveals the situation has become dire. Between April 2019 and December 2020, VHA’s total monthly encounters shrank by 25 percent. Over that same period, VCCP continued its non-stop expansion, rising to 34 percent of all care delivered to veterans at taxpayer expense. That cost, too, is dramatically growing, doubling over the last four years and currently consuming 20 percent of the VHA’s health care budget, with no upper limit in sight.    

If the hemorrhaging of patients and funds out of the VHA isn’t stemmed promptly, it will likely be forced to lay off staff, cut programs and close facilities, especially if an impending Asset and Infrastructure Review Commission falls prey to politicization. These moves will cause further outsourcing, leading to an ever-downward spiral. Veterans may also face new restrictions over their eligibility for health care services. As a new VCCP study concluded, “without larger budgets, the VA may struggle to sustain its current infrastructure of hospitals and outpatient clinics while also providing more community care.” 

Veterans who were assured that the MISSION Act would offer them a choice between the VHA and the private sector may soon discover that the VHA option is unavailable. Instead, they will be thrust into a private system that lacks expertise in veteran-specific illnesses (especially for the unique wounds of war, such as posttraumatic stress disorder, traumatic brain injury and complex musculoskeletal conditions). Private sector care is also dangerously fragmented, which contributes to poor health outcomes.

Veterans aren’t the only ones who will lose, because the VHA serves us all through its training of 70 percent of America’s physicians and most other health care professionals, and its cutting-edge research. VHA has also been dependably serving as a national emergency backup during the COVID-19 pandemic, including direct support to 122 private hospitals and 980 community nursing homes.    

The hollowing out of the VHA is a direct result of MISSION Act provisions that were then exploited by the Trump administration in developing eligibility regulations for private sector care. When the VCCP was implemented in 2019, one-third of all veteran patients suddenly became automatically eligible for non-VA care if driving to a VHA facility takes more than a half-hour. A referral is offered even if a VHA clinic/hospital is geographically closer than a non-VA one, which is often the case.   

Although wait times in the VHA are typically shorter than those in the private sector, regulations nonetheless cause massive numbers of veterans to be sent to the private sector if the VHA cannot schedule an appointment within 20 or 28 days. That’s occurring in labor-intensive specialties like mental health, where failure to hire enough staff guarantees that veterans will be sent to the VCCP. Once in the VCCP, which has no wait time requirement, veterans often languish for months to be seen.

MISSION Act loopholes also grant referrals to non-VA telehealth services, even when the VHA has capacity to furnish them faster. This outsourcing is all-the-more inexcusable given that the VHA is the recognized world leader in the provision of telehealth.   

And as if the schemes weren’t harmful enough, VCCP eligibility standards — which are based on medical need, distance and timeliness — aren’t even being reliably applied. We are aware of widespread occasions in which veterans are referred for non-VA care who meet none of the specified eligibility criteria.

What can be done to remedy the situation? First, VHA and VCCP must be held to identical access and quality standards. It is the only clinically and administratively responsible thing to do. Second, VHA must revise regulatory language so that both telehealth and in-person care satisfy the standard for VHA access to treatment. Third, lawmakers must ensure that all VHA facilities have sufficient professional and support staff to meet demand. Finally, VHA must educate its schedulers of what are — and are not — eligibility criteria for VCCP.  

Policymakers who proclaim that they want to protect veterans’ health and well-being should do everything they can to maintain the integrity of a system that provides veterans with higher quality care faster and at lower cost than the private sector, and is central to training the nation’s healthcare professionals, conduct cutting-edge research, and navigate emergencies like the COVID-19 pandemic. Our veterans — and country — deserve no less.

Russell Lemle is a senior policy analyst at the Veterans Healthcare Policy Institute and was formerly chief psychologist at the San Francisco VA Health Care System

Suzanne Gordon is author of “Wounds of War” and is a senior policy analyst at the Veterans Healthcare Policy Institute.