President Donald Trump signed a massive Department of Veterans Affairs reform bill into law Wednesday, marking the start of a long implementation process and a likely fight over how to fund it.
Trump, who considered the moment a major political victory, signed the VA Mission Act during a ceremony at the White House, surrounded by some of the lawmakers and veterans groups who brokered the deal to get it through Congress. During his presidential campaign, Trump described the VA as the most corrupt federal agency and promised veterans increased access to private doctors.
“In the campaign, I also promised that we would fight for Veterans Choice. And before I knew that much about it, it just seemed to be common sense,” Trump said prior to signing the bill. “I’ll be signing landmark legislation to provide health care choice – what a beautiful word that is, “choice,” – and freedom to our amazing veterans.”
The signing ceremony finalized the end of a contentious legislative fight. Now, VA officials will initiate a rulemaking process, getting down to the nitty-gritty of deciding when veterans will be eligible to go outside the department for medical treatment.
More urgently, Congress must find a way to fund it.
Approximately one-third of all medical appointments made through the VA were outsourced last year to the private sector. Changes in the Mission Act would increase that, resulting in 640,000 more veterans being referred to outside doctors each year at an average cost of $8,600 per patient, according to the nonpartisan Congressional Budget Office.
The budget office estimated the Mission Act will cost $52 billion over the next five years, but lawmakers didn’t include a dedicated source of funding.
Funding questions
Questions arose Wednesday about whether money for the Mission Act could be stripped from existing VA services or other parts of the federal budget.
House Democrats predicted the funding issues. Rep. Tim Walz, D-Minn., the ranking Democrat on the House Committee on Veterans’ Affairs, helped draft the bill but voted against it because he worried that increased spending for the bill could trigger potential cuts to other VA programs.
When asked about funding concerns before the Senate vote on the Mission Act, key lawmakers who helped pass the bill claimed it wouldn’t be a challenge.
“We can work through this…There’s nobody up here who wants to short change any other program on behalf of veterans,” Sen. Jon Tester, D-Mont., said in a news conference the day before Congress passed the bill.
But on Wednesday, there were signs of a brewing fight. The White House distributed a memorandum to some House and Senate offices, attempting to stymy an effort in Congress to increase spending caps each year in order to pay for the Mission Act. Sens. Richard Shelby, R-Ala., and Patrick Leahy, D-Vt., the chairman and ranking Democrat of the Senate Appropriations Committee, are behind the push to get new funding approved for the bill.
Instead, Trump’s administration wants the money to come from somewhere in the existing federal budget. The memo, a copy of which was obtained by Stars and Stripes, warned that allowing the VA to break through spending caps could lead to unlimited spending on private doctors.
“Without subjecting the program to any budgetary constraint, there is no incentive to continue to serve veterans with innovative, streamlined and efficient quality of care,” the memo reads. “In addition, because this amendment would allow for virtually unlimited increases for community care, it could have the unintended effect of making community care more attractive than care provided in VA facilities and could eventually erode VA’s ability to provide care in its facilities.”
Administration officials wrote the situation would put the VA “one step closer” to privatization, which the White House said it “adamantly opposes.”
Walz, who predicted the debate over funding, said if Congress doesn’t approve new money for the Mission Act, the VA could “cannibalize itself.”
“Time and again, House Democrats have raised the alarm on the VA Mission Act’s lack of a sustainable funding source,” Walz said in a prepared statement. “This means current programs investing in VA infrastructure, direct patient care, suicide prevention, medical research, job training, and many more vital veterans programs could face cuts in funding in order to pay for care in the community under this new plan.”
The funding fight could culminate in Congress as early as this week, as lawmakers consider a nearly $196 billion VA spending bill for the 2019 fiscal year.
New rules for private care
The VA Mission Act upends the Veterans Access, Choice and Accountability Act, which was approved by Congress in response to the 2014 VA wait-time scandal. Four years ago, the bill created the Veterans Choice Program, allowing veterans to receive private-sector health care in an effort to ease demand on VA services.
The Choice program was implemented hastily, and many veterans thought the rules were too rigid. The program allows veterans to seek private-sector care only when they live more than 40 miles driving distance from a VA facility or it is estimated their wait for a VA appointment is more than 30 days.
The program was expected to decrease wait times, but a government watchdog released findings Monday revealing that veterans often had to wait between 51 and 64 days for appointments with private doctors. Some of them waited as long as 70 days.
The Government Accountability Office reviewed a sample of appointments from 2016 to determine the average wait times. Auditors blamed inefficiency, unreliable data and understaffing for problems with the program. Multiple changes in policies and procedures within the program created a “tremendous amount of confusion” among VA and private providers, said Sharon Silas, who helped lead the GAO study.
“What we found was that, contrary to the Choice Act’s 30-day, wait-time requirement, VA had designed a process that could actually take up to 70 days for a veteran to receive care from a Choice provider,” Silas said. “The Choice program referral and appointment scheduling processes were quite complex.”
In a written statement Tuesday, the VA didn’t dispute the GAO’s findings. VA Press Secretary Curt Cashour said the Mission Act would “streamline and make many improvements” to the agency’s private-sector care programs.
Under the Mission Act, the VA secretary now has broad authority to wipe out rules under the Choice program and implement new regulations for when veterans can go to private doctors.
With funding from the VA Mission Act, the Choice program will operate as usual for another full year before it expires. The new law mandates the VA draft new access and quality standards for its private-sector care programs within 120 days. The agency is required to send a final report to Congress after 270 days.
It’s the intention of Congress that once the new rules are put into effect, veterans will be able to decide with their VA doctors whether they should seek private medical care. A host of issues could be taken into consideration, including whether a veteran faces an “unusual or excessive burden to accessing a VA facility.”
Some major veterans organizations plan to oversee the rulemaking process closely. Melissa Bryant, chief policy officer for Iraq and Afghanistan Veterans of America, said she maintains a “healthy skepticism.” IAVA, along with other groups, has voiced concerns in the past that an aggressive expansion of veterans’ care into the private sector could erode VA resources and eventually dismantle the agency.
“We’re obviously skeptical of any type of overhaul of this scale,” Bryant said. “We’ll be part of regular talks at the VA and ensure the VA has all it needs. That’s been our main concern – ensuring that investment goes into the VA and into community care.”
IAVA founder Paul Rieckhoff said the group wasn’t invited to the signing ceremony, though they supported the bill.
Concerned Veterans of America, part of the Koch brothers’ conservative political network, had a spot on the stage Wednesday. CVA Director Dan Caldwell said he intends to work closely with the VA and White House on implementing the bill.
“We have faith this administration will properly execute on the regulatory process,” Caldwell said. “We’re going to be monitoring that process, and hopefully we can get a good set of regulations that will ultimately increase choice for veterans and are going to be difficult to undermine by bureaucracy.”
It’s expected that Robert Wilkie will lead implementation of the Mission Act. Wilkie works as the undersecretary of personnel and readiness for the Defense Department and was acting VA secretary for two months after former VA Secretary David Shulkin was fired in March.
Trump announced plans last month to nominate Wilkie as VA secretary on a permanent basis, but Wilkie hadn’t officially been nominated as of Wednesday. The Senate was still waiting on paperwork from the White House before continuing the confirmation process.
Rep. Cathy McMorris Rodgers, R-Wash., chairwoman of the House Republican Conference, called on the Senate to quickly confirm Wilkie.
“This law will certainly help rebuild the trust that’s been broken by a bureaucratic system that has failed our veterans, but there’s more work that must be done. We need a permanent Veterans Affairs secretary,” McMorris Rodgers said. “We need to have the right people in place so that this work can continue.”
In addition to overhauling the agency’s private-sector care programs, the Mission Act extends benefits such as monthly stipends, health insurance, medical training and access to home health aides to more veteran caregivers.
Through a VA caregiver program implemented in 2010, those benefits are available only to caregivers of veterans injured after the 9/11 terrorist attacks. The legislation extends them to veterans injured before May 7, 1975. Two years after the law is enacted, veterans injured between 1975 and 2001 will be eligible.
The new law also has the potential to change where VA facilities are located. The Mission Act creates an asset-review commission tasked with inspecting VA buildings and recommending which facilities to close and where the VA should invest. Under the terms of the law, the commission will conduct its work in 2022 and 2023.
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