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On January 30, Robert Wilkie, the secretary of the Department of Veterans Affairs unveiled a plan that could push millions of veterans out of VA care and into the private sector. Wilkie's announcement follows the passage of the VA MISSION Act of 2018, legislation that gives Wilkie broad latitude to develop guidelines allowing far more veterans to get private-sector care at taxpayer expense. Critics, including veterans organizations and Democratic members of Congress, have warned the plan could seriously weaken veteran health care and move the VA perilously close to privatization.
As my colleague Jasper Craven and I predicted, Wilkie's plan is to expand private-sector access for veterans currently at the VHA. But instead of basing this access on the needs of individual patients or the quality of private providers, Wilkie focuses exclusively on wait times. Under his proposal, any VHA patient who has to drive for more than 30 minutes for a primary care or mental health appointment or 60 minutes for a specialty appointment will have access to private doctors and hospitals if they so choose. If a veteran has to wait more than 20 days for mental health or primary care or 28 days for specialty care he or she could also seek care outside the VHA (a stipulation that may shrink to 14 days in the future). But these parameters are needlessly broad: In many heavily trafficked urban, as well as scantly populated rural areas, drive times can easily exceed 30 or 60 minutes. According to internal VA estimates, the rule change could channel up to 63 percent of VHA patients into the private sector. What's worse, every dollar spent on outsourcing would come out of the VHA medical care budget. This could quickly drain resources from VHA facilities and programs, which are already understaffed and over-stretched.
Despite its insufficient budget, the VA has time and again shown itself to be far better equipped at caring for veterans than private-sector providers—a fact the administration readily acknowledges. Two days before his announcement, Wilkie issued another press release, lauding the care the VHA provides, citing studies that document that VHA wait times are shorter than those in the private sector, with care often superior to that provided by private doctors and hospitals. Nonetheless, he vowed to “revolutionize VA health care” by giving veterans greater choice.
Democratic legislators, many of whom supported the law, are now expressing buyers' remorse. On January 28, 29 senators, including Senator Jon Tester, who sponsored the MISSION Act, and Senator Bernie Sanders, who voted against it, sent Wilkie a letter warning against pushing veterans outside of the VHA. The quality of private-sector care, they said, is often inferior to that provided by the VHA, while the cost to taxpayers was not “adequately assessed,” ranging from $1 billion to $21.4 billion over five years. And according to the VA Commission on Care, the cost could be higher still, ballooning as high as $179 billion per year—all for what could be lower quality care. In their letter, all 29 senators agreed that administration’s refusal to increase federal spending, combined with escalating costs for private-sector care, “would likely come at the expense of VA’s direct system of care … something we cannot support.”
Veterans' service organizations who lobbied for the bill are now equally concerned. In their Independent Budget for the 116th Congress, the Disabled American Veterans (DAV), Veterans of Foreign Wars (VFW), and Paralyzed Veterans of America (PVA) warned that the MISSION Act's obsession with drive and wait times came at the expense of the individual needs of patients and the quality of private providers. In addition, these groups rightly fear that too much money for private-sector care will be siphoned from the VA budget. Finally, they argue that competency standards for private-sector providers should be “equivalent” to the high standards imposed on the VA. None of these recommendations were incorporated into the secretary's new guidelines. As such, the groups cautioned that the MISSION Act could have “devastating consequences for veterans who rely on VA for their care” if poorly implemented.
For his part, Wilkie denied that his plan would negatively impact care. Most Americans, he wrote, “can already choose the health-care providers that they trust, and President Trump promised that veterans would be able to do the same.” Wilkie further denied that any of this “represents a first step to privatizing” veterans' health care.
The administration's commitment to funnel veterans toward private providers reflects its close relationship with the Koch brothers-funded Concerned Veterans for America, an astroturf group with few actual members. The CVA has been persistent promoter of VHA privatization. Tellingly, the Trump administration has made CVA representative Darin Selnick a VA advisor on the MISSION Act implementation. As one VA official told the Prospect, the proposedstandards were written “in the secretary’s office with close scrutiny of Darin Selnick.”
For now, the future of veterans' health care now lies with members of the new Congress.
Wilkie's proposed standards will be finalized after a public comment period during which parties can register further objections. But any challenge to the standards will be problematic because Congress did, in fact, authorize the secretary to develop a mechanism for expanding veteran access to what's euphemistically called “community care.” Legislators and VSOs may dispute that the secretary failed to follow the intent of the law and didn't not adequately consult with them. But the language of the MISSION Act is so vague that Wilkie could credibly claim that he“consulted” with VSOs and other critical stakeholders (even if he didn't take their advice).
Yet Congress can still intervene to save the VHA through the appropriations process and by enacting amendments to the law itself. Currently, the VA budget contains separate allocations for the cost of outsourced care and treatment provided by the VHA itself. If, as President Trump and the VA secretary have proposed, these two accounts are merged into one, every federal dollar spent on reimbursing outside doctors and hospitals will be one dollar not available for direct VHA care. By thwarting this consolidation, Congress could stop the impending cannibalization of the VHA budget. The process of privatization could be further slowed down if the new Democratic House majority took the lead in amending the MISSION Act in a way that banned outsourcing based on drive and wait times rather than on quality and medical necessity. As recommended by Veteran Service Organizations as well as the Veterans Healthcare Policy Institute, all private-sector providers should also be required by law to match the VHA's own standards on quality and wait times.
But this kind of bold legislative counterattack on the Trump administration's not-so-stealthy privatization of the VHA will require a break with the misbegotten “bipartisanship” that saddled us with the MISSION Act in the first place.
