Another Threat to VA Health Care 

A provision in pending Congressional legislation—the Veterans’ ACCESS Act of 2025—threatens to undermine veterans’ health care and saddle taxpayers with staggering costs. At issue is a proposed pilot program allowing veterans with mental health and substance use disorders unlimited private-sector provider appointments without VA authorization. After three years, such unrestricted access would expand across the entire VA system. As I’ve written extensively, and the Washington Monthly has shown, VA’s high-quality health care remains preferred by those who served, and rash privatization imperils it.  

This proposal represents a dangerous miscalculation that could burden taxpayers with tens—or hundreds—of billions of dollars annually. Yet the fiscal recklessness is only part of the problem. The ACCESS Act pilot amounts to a dismantling of VA health care disguised as a small-scale experiment. By granting veterans unfettered access to the private sector, it accelerates the shift of both veterans’ care and dollars from VA facilities to community providers, steadily gutting the VA system from within. 

This trajectory aligns with the Heritage Foundation’s blueprint for VA transformation. As costs spiral upward, non-service-connected veterans lose eligibility for VA-paid care, and coverage for veterans with service-connected health conditions diminishes. What seems like expanded choice would actually result in fewer options for many veterans—and none whatsoever for some. 

The reason for alarm is clear-cut. In 2016, the congressional Commission on Care directed its analysts to estimate the cost of allowing veterans to use private-sector health care without requiring VA authorization or referral—precisely what the ACCESS Act proposes. They examined veteran demographics, health care utilization surveys, and research on how cost-sharing influences medical consumption.  

The Commission identified four cost drivers: 

First, there would be an enrollment surge from veterans not in the system. Veterans now receiving care in the private sector with private insurance for reimbursement would have a strong incentive to switch to VA coverage. The appeal is irresistible: the VA’s minimal co-payments would reduce their out-of-pocket expenses compared to private insurance.  

Second, veterans who hadn’t previously qualified would self-refer to private-sector providers, no longer requiring VA authorization. This includes intensive outpatient care offered at over 6,500 programs in the United States, which are also pipelines for residential rehabilitation treatment, averaging an exorbitant $124,470 for a 45-day stay.  

Third, the fee-for-service model drives costs upward. Multiple studies and the VA Office of Inspector General conclude that private providers often use unnecessary and costly tests, procedures, and extra appointments.  

Fourth, implementing a new referral and reimbursement system would entail substantial costs. An education campaign would be necessary to inform veterans in targeted areas about the new referral procedures and to train community providers on billing protocols for services that are exempt from pre-authorization. These implementation costs could easily reach tens of millions of dollars.  

The commission’s estimated impact: $124 billion annually by year five and $152 billion annually by year ten. As the Washington Monthly’s Phillip Longman, a commission member, emphasized: “Make no mistake—those amounts represent massive new spending on top of existing VA health care costs.” 

Late in 2025, the Congressional Budget Office (CBO) released its own estimates, suggesting the pilot would cost next to nothing. The CBO predicted that only 1,000 out of the 1.9 million veterans receiving VA mental health services would use the new option annually. This minuscule prediction seemingly ignored the financial and other incentives for veterans to opt for VA coverage that the commission recognized. The CBO scoring also failed to account for the costs of fee-for-service arrangements. Even worse, the CBO assumed that veterans outside of the pilot regions would not be given the new option, despite the bill instructing the VA to begin “mitigating any barriers to extending the pilot program across the entire Veterans Health Administration.” 

Further, these calculations don’t capture the legislation’s collateral damage, starting with the erosion of quality. Dozens of peer-reviewed studies demonstrate that VA health care delivers results equal to or better than those of private alternatives. The VA’s own testimony on the legislation warns that “it is not clear how VA could coordinate the care of such Veterans, or even if VA would know that such care was being sought until after it was received.” The VA’s teaching and research missions, as well as its emergency preparedness capabilities, would also decline. 

What about mental health—the pilot’s initial focus? In August, two senior advisors from Concerned Veterans for America, an influential group promoting massive outsourcing of veterans’ health care, urged Congress to fast-track the ACCESS Act because “veterans in crisis can wait weeks (or worst case, longer) for treatment that should be available in hours.” But thanks to the COMPACT Act of 2020, which afforded veterans in crisis immediate access to mental health evaluation and treatment at any VA or non-VA facility—with no co-pays —there are no delays during crises. Curiously, they never mentioned the projections by the Commission on Care (on which one of the authors served). 

For routine mental health care, community providers treating veterans for PTSD routinely fail to complete diagnostic assessments, conduct suicide risk evaluations, or use evidence-based treatments. Fewer than 5 percent of the veterans they treat show improvement in PTSD symptoms. Is this what taxpayers should be promoting?  

Congress must thoroughly consider the Commission on Care’s analysis before advancing the pilot program. The American people are owed an honest reckoning before committing to a program that could consume billions in taxpayer dollars. 

Moreover, Congress should mandate that community providers meet VA-level training standards before expanding private-sector access. Veterans deserve the same quality of care regardless of where they receive it. Without these safeguards, expanding access simply means greater exposure to inferior care. 

Despite its freedom-friendly rhetoric, the pilot is a budgetary time bomb that threatens veterans’ health care. Congress can defuse it.