When then-President Trump’s Veterans Affairs (VA) Secretary Robert Wilkie established rules in 2019 under the VA MISSION Act allowing veterans to swiftly bypass the Veterans Health Administration (VHA) for the private sector, he violated the intent of the law, as well as the wishes of important stakeholders, chief among them veterans service organizations.
Specifically, Wilkie’s standards channeled veterans to private sector providers if they faced a 30- to 60-minute drive to a VHA facility or a 20- to 28-day wait-time for an appointment. Troublingly, these unrealistic standards apply only to VHA, while private sector providers are let off the hook for meeting any standards at all.
Fortunately, the MISSION Act requires a three-year evaluation of its access and quality standards, one the VHA is now undertaking by collecting comments through the Federal Register and seeking other data on the new Veterans Community Care Program (VCCP). This much-needed reassessment offers President Biden’s VHA leaders an opportunity to revisit and rewrite the rules to protect veterans and the health system they overwhelmingly support.
In survey after survey, veterans recognize that the VA health care system is the only one that specializes in treating their complex, service-related health care conditions. That’s why they say they want it to be strengthened and improved, not privatized. Wilkie’s standards made this mission impossible. His drive and wait-time standards guaranteed a massive outsourcing of veteran care to the private sector, regardless of timeliness or quality of private sector services or whether VHA could deliver higher-quality services more quickly and at lower cost.
A recent study of veterans obtaining private cataract surgery confirmed that the Wilkie standards lead to unnecessary referrals with more than one-quarter of those procedures occurring in facilities further than the closest VHA facility. Another study found that veterans who receive private sector emergency room care have higher mortality at higher costs than VHA care. A report from the Congressional Budget Office (CBO) stated unequivocally that the quality of private veteran care was not only “unknown,” but unknowable since “no single national system of quality reporting exists in the United States.”
Paying for private-sector care of “unknown” and unknowable quality is cannibalizing the VHA budget, making it impossible to improve and strengthen the system. As the CBO report highlights, “VHA’s costs for community care grew from $7.9 billion in 2014 to $17.6 billion in 2021.” That’s a more than 100 percent increase.
The new health care realities created by the COVID-19 pandemic also make changing these standards imperative. When it was written, MISSION Act supporters assumed that care would be rapidly available from private-sector providers. This assumption ignored long-standing shortages in multiple health care professions, from primary care to mental health, to nursing. COVID-19 has transformed what had been considered shortages into catastrophes. It is now almost impossible to find a primary care provider accepting new patients in either urban and rural America. Private sector hospitals are reeling from nursing shortages and can’t discharge patients and quickly free up beds because of lack of staff in nursing homes and rehabilitation facilities. In New York — a state with the fifth-largest veteran population — the governor has recently deployed National Guard troops to help staff in nursing homes.
The problems in mental health capacity are equally severe: 37 percent of Americans live in areas with severe mental health provider shortages, and 60 percent of American counties have no psychiatrists at all. Even in supposedly well-resourced urban areas, it’s difficult to find a therapist because so many people are suffering from anxiety and depression. A recent New York Times article on therapist overload bluntly stated the facts, “Nobody Has Openings.”
Whatever mental health care that veterans do receive via the VCCP may also be compromised by the fact that private sector providers aren’t held to any rigorous quality standards. In his comments to the Federal Register, Rick Staggenborg, a retired VA psychiatrist, highlighted this problem, “I saw far too much non-evidence-based psychotherapy practices when I was in community care to feel at all comfortable with referring the most vulnerable of our veterans to inadequately trained providers,” Staggenborg wrote.
As VHA leaders review VCCP access standards, they must follow the letter and intent of the law, utilizing private-sector care only when clinically necessary and when VA cannot provide needed care to veterans. They must assure that there are uniform access standards that apply not just to VHA but to VCCP providers as well. Bob Carey, executive vice president of The Independence Fund, concurred with this last suggestion during the recent VA meeting reviewing VCCP access standards. During public comment period, Carey affirmed he was philosophically in accord with having universal standards.
Given the COVID-19 pandemic, it would also be reckless not to rigorously assess whether a private sector system stretched to the max can accommodate millions of veteran patients when it can’t even take care of desperately ill non-veterans.
Finally, as Peter Dickinson, senior adviser to the Disabled American Veterans, eloquently stated in the access standards meeting, VA must remain the primary provider and coordinator of veteran care. This can only be done, Dickinson astutely noted, if VA has the resources to end the kind of staffing shortages that lead to delays in care.
Suzanne Gordon is author of “Wounds of War” and is a senior policy analyst at the Veterans Healthcare Policy Institute
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