In an overwhelmingly bipartisan vote last Wednesday, the House passed The VA Mission Act. The Senate is expected to pass companion legislation Wednesday, and President Trump quite likely will sign it into law on Memorial Day.
The objective of the VA Mission Act is clear: further privatization of key services inside the Department of Veterans’ Affairs. It has been plotted out behind closed doors by a bipartisan group of lawmakers, powerful business interests, and savvy conservative veterans’ groups who find themselves newly influential in Trump’s Washington.
The first strike in this war over privatization occurred in 2014, when Republicans blocked a bill introduced by Bernie Sanders that would have provided the VA with much-needed funds and expanded services to veterans. A compromise measure, the 2014 VA Choice Act, gave the VA a fraction of the funds it needed while allocating $10 billion for care in the private sector. (More than one-third of all VA-funded medical appointments last year took place in the private sector.)
The Choice Act, cast initially as a temporary measure, has been extended repeatedly. The Mission Act will make permanent its privatizing principles by allowing and even encouraging more veterans to seek care outside the VA. The Congressional Budget Office estimates that the act would result in 640,000 additional veterans seeking private care in the first few years after its passage, and that the agency’s current annual allocation of $9 billion for private care would increase substantially.
The act’s drafting has taken more than a year, and traditional veterans service organizations (VSOs) and Democratic lawmakers have successfully fought to remove some provisions that would have made the law even worse. But the act as currently composed creates new pathways to private care, without meaningfully addressing longstanding budget and staff shortages throughout the agency.
Despite this, Washington’s most influential lawmakers and 38 veteran groups have lined up in support of the bill. They run the gamut from the American Legion to Concerned Veterans for America, a conservative group backed by the Koch brothers. Interim VA Secretary Robert Wilkie, who last week was nominated by President Trump to permanently replace former secretary David Shulkin, is also in favor of the comprehensive package, claiming it will patch up agency problems while making care more accessible in rural areas.
The act includes a massive expansion of the VA’s caregiver program, a benefit veterans’ advocates have long sought. The program, which provides family caregivers of severely disabled veterans with a modest stipend, health insurance, and training, currently applies exclusively to veterans who served after 9/11; the Mission Act would extend benefits to millions more caregivers.
Yet while expanding this program is a good idea in principle, the Mission Act doesn’t actually provide funding for it. Meanwhile, the expansion can easily distract from the bill’s more ideological provisions, which will further fuse the VA with private health care networks. Even as they voted for the Act, a number of Democratic lawmakers expressed reservations about it. That’s because the bill contains a number of provisions that would channel more and more veterans into private sector care, deplete the Veterans Health Administration of billions of dollars, and, potentially, lead to closings of VA facilities across the nation. The bill’s $47 billion price tag over five years will also quickly trigger agency budget caps, which could result in cuts to other crucial agency services, including direct patient care. (The agency is already in need of emergency funding to fill 36,000 vacancies and make infrastructure repairs.)
The bill is essentially a Trojan Horse, and the provisions tucked inside it will further usher in privatization without meaningfully addressing core agency challenges. According to a detailed analysis by the Veterans Healthcare Action Campaign, a veterans advocacy group that opposes the law, the bill imposes stringent new quality metrics that are untested and fail to consider key health outcomes such as symptom reduction. Moreover, if a VA hospital is found to be underperforming in a certain area, a huge swath of patients can be pushed into the private sector. The act loosens other restrictions that determine a veterans’ eligibility to seek care from a private doctor or hospital.
Without providing the funding to hire extra staff, the law also imposes new time-consuming bureaucratic challenges on the VA (or, potentially, a contractor), including setting up appointments with private providers, coordinating care, processing payments to private providers and making sure they provide documentation of the care delivered. The law would also require VA employees to develop and deliver training materials for the private sector.
The bill does require that private-sector providers follow VA opioid-prescription guidelines. But, crucially, it doesn’t require training around military-related PTSD, Agent Orange and burn pit-related diseases, military sexual trauma, and other veteran-specific problems. Studies have documented that most private-sector providers know little or nothing about these complex conditions. Because of lack of knowledge, veterans may receive substandard care. The next PTSD or toxic exposure may go unrecognized and treatments and compensation for these problems may not be developed or provided.
Another wide-ranging provision allows veterans to seek unfettered care from private walk in-clinics. (The VA has already established pilot projects with CVS Minute Clinics in two locations.) While the walk-in program was pitched as a solution to simple problems, like pink eye or a cough, the language is so vague that it could allow private clinics to offer treatment for complex issues, like depression, PTSD or anxiety. This provision threatens to fragment a model of integrated model primary care, one that has helped the VA deliver care that is typically superior to that in the private sector.
Finally, the bill would establish a nine-person commission, beginning in 2021, to assess the VA’s future infrastructure needs. The commission will make recommendations of facility closures based on utilization. The upshot is that if the push to shift veterans into private-sector care continues, the corresponding decline in utilization of VA facilities could be used to justify closing those facilities permanently—regardless of who’s providing the highest-quality care.
The commission wouldn’t be created until 2021, and recommendations to Congress would come a year later. The body will be composed of various stakeholders, including veterans advocates and healthcare executives. Depending on the political makeup of Washington at the time, it could lead to the shuttering of VA hospitals. The entire act, like most bills, is frustratingly vague in certain sections, and VA bureaucrats and the agency secretary will wield incredible power over the details (in which the devils always lie) of its implementation.
This privatization push comes on the heels of numerous studies that have documented that private sector providers lack the expertise to provide veteran-centric care. As the bill moved through Congress, lobbyists for national health care companies—including CVS, Centene Corporation, Quality Health Strategies, and Ascension Health—worked to influence the legislation. So did regional health networks that are eager to offer up their services to VA patients. Other contractors that may take on some of the VA’s new bureaucratic tasks also lobbied, including TriWest Healthcare Alliance, which is under investigation from the VA’s Inspector General for contract work received through the Choice Act.
Given the potential power change in Congress after November’s election, Republicans seem eager to pass legislation that will fast-track VA privatization and make for a good talking point on the campaign trail. But the Senate still has a chance to protect the nation’s veterans by blocking this legislation. Yes, veterans need a caregiver program. They also need a more rational system of coordinating and managing care in the private sector to supplement, not replace, VA care. This legislation, however, is not the answer.