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VA Choice reform becomes more complex as deadline looms

Republican Sens. John McCain and Jerry Moran on Monday introduced a new plan to overhaul the program that veterans use to receive private-sector medical care – tossing another option into an already complex debate that’s about to reach a crucial deadline.

The bill, the Veterans Community Care and Access Act of 2017, is one of three in Congress that proposes to overhaul the controversial Choice program and create a network of community medical providers that veterans could use at taxpayers’ expense. Each bill offers its own version of the new program, with differing rules for when veterans can seek health care outside of the Department of Veterans Affairs.

Republicans and Democrats agree on the need for reform. Since the Choice program was created in 2014, veterans have criticized it as being bureaucratic and complex. In his first address as VA secretary, David Shulkin announced he wanted to eliminate the rules that allow veterans to seek care in the private sector only if they’ve had to wait more than 30 days for an appointment or if they live more than 40 miles driving distance from a VA facility.

Disagreements over how to reform the program have focused on costs, concerns from Democrats over privatization and fears from Republicans about veterans remaining trapped inside the VA system. After nearly a year of debates and negotiations, a deadline is looming.

Preventing a funding crisis

Each of the Choice overhaul bills includes money — an amount ranging from $2.1 billion to $4 billion — to keep the program functioning while a new program is implemented. The VA is set to exhaust its funding for Choice by the end of the year and Shulkin has urged Congress to pass an overhaul bill before then, to prevent a crisis.

When the Choice program nearly ran out of money in mid-August, some veterans were prevented from scheduling private-sector appointments through the VA. At the time, Congress passed an 11th-hour bill providing $2.1 billion in emergency funding to keep the program operating for an estimated six months.

Congress is scheduled to recess Dec. 15 for the rest of 2017.

Louis Celli, who has been part of Choice reform negotiations on behalf of the American Legion, is doubtful lawmakers can come to an agreement in the next eight days.

“These are three completely different bills, all competing against each other, that have very little hope of reconciliation, especially before the holidays,” Celli said. “What has to happen is an infusion of cash into the Choice program in order to buoy that program.”

Lawmakers could introduce another emergency funding bill or include Choice funding as part of larger budget negotiations before lawmakers leave for recess, and return later to tackle even larger reform efforts. As of Tuesday, neither of those possibilities had happened.

Joe Chenelly, executive director of AMVETS, was more optimistic an overhaul of the Choice program could get done.

“We don’t want to keep kicking the can without real reform,” Chenelly said.

Nuanced debate

Legislation introduced Monday by McCain and Moran is one of two Choice reform bills in the Senate.

The Senate Veterans’ Affairs Committee voted last week to send their bipartisan bill, the Caring for Our Veterans Act of 2017, to the Senate floor. The bill passed through committee on a vote of 14-1, with Moran being the only member to oppose it. He stood against the measure after the rest of the committee voted down his amendments, which he then used to form the basis for his new bill.

“We have worked closely with Sen. Moran and his office trying to find common ground,” Committee chairman Sen. Johnny Isakson, R-Ga., said during a hearing last week. “We have not found it, and as chairman I’m going to be opposed to the amendment.”

Moran said it was a “missed opportunity” to “do this better than what we’re doing.”

There are several nuanced differences between the two bills, Celli said, but the biggest hang-up is over one section of Moran’s legislation that states veterans could go into the private sector if they can’t receive treatment at their VA health care facility. There are concerns that means veterans would be sent to the private sector, even if there’s another VA facility close by where they could receive care.

“There’s a lot of debate over how the ‘health care facility’ language could open a magic gateway to unfettered access to Choice,” Celli said. “We don’t think that’s the case, but that’s the foundation of the major source of contention between the two bills.”

Vets groups issue support

The American Legion has issued its support for both bills, and Celli said they approve of aspects of each. If the nonpartisan Congressional Budget Office states Moran’s bill would allow veterans unfettered choice, though, the organization would rescind that support, he said.

It’s uncertain when the CBO will issue a cost estimate for the bill. Preliminary estimates put the other Senate bill at $54 billion for 10 years. The House bill, which is still at the committee level, was estimated to cost $39 billion for 10 years.

There are other differences.

The McCain-Moran bill creates an innovation center at the VA where the agency can test new models of health care. The Senate Veterans’ Affairs Committee bill does not. The committee bill includes a measure popular among veterans organizations to expand caregiver benefits to veterans injured before 9/11, which comes at a cost of $3.4 billion and is not included in Moran’s legislation.

While the McCain-Moran bill outlines criteria for when veterans can receive private-sector care, the committee legislation is vague and leaves the criteria to the VA secretary, said Dan Caldwell, executive director of the conservative group Concerned Veterans for America.

“It more clearly defines what standards the VA should be using, which will help ensure veterans have a better understanding of when they can make the choice to access community care,” Caldwell said of the McCain-Moran bill. “If it’s too vague and there’s not a clear set of standards, then even though we trust Shulkin to be fair, future VA secretaries might exploit that vagueness to undermine choice and undermine the ability to access community care.”

CVA, part of the Koch brothers’ political network, has urged lawmakers to change the other two bills to allow veterans more autonomy to make health care decisions. Other groups, such as AMVETS, think unfettered access to the private sector would create escalating costs and lead to the erosion of the VA health care system.

Both groups issued their support for the McCain-Moran bill.

“We haven’t typically agreed with some of the things CVA has in a while,” Chenelly said. “We’re not exactly sure why they do, and to be honest, it’s caused us some concern.”

Jordan Langdon, deputy communications director for Moran, said the bill would maintain the VA as the gatekeeper to private-sector treatment.

As of Tuesday, eight veterans organizations issued their support for the bipartisan Senate committee bill. It’s uncertain when Senate leaders will schedule it for a vote.

A committee vote on the House bill was delayed in November after Rep. Phil Roe, R-Tenn., chairman of the House Committee on Veterans’ Affairs, said he wanted to review the CBO’s cost estimate more closely. A committee vote on that bill had not been scheduled as of Tuesday.

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