House considers major changes to VA health care

VA Secretary David Shulkin and Veterans Health Administration Executive in Charge Carolyn Clancy go over their notes before a House Veterans' Affairs Committee hearing on Capitol Hill, Oct. 24, 2017.


By NIKKI WENTLING | STARS AND STRIPES Published: October 24, 2017

WASHINGTON – Department of Veterans Affairs Secretary David Shulkin argued Tuesday that a House plan for veterans’ health care was too restrictive and wouldn’t offer enough veterans the choice of private-sector care.

House lawmakers and VA officials hashed out details Tuesday of two proposals outlining major changes to the VA’s community care programs. Both would effectively end the Veterans Choice Program that was created in 2014 following the VA wait-time scandal to extend VA care into the private sector. The plans do away with a rule that allows veterans to seek private sector care when they are forced to wait more than 30 days for an appointment or live more than 40 miles driving distance from a VA facility.

But critics of the House proposal, including Shulkin, said it wouldn’t allow enough veterans to go to private-sector doctors. With some exceptions, the House bill would require veterans to stay within the VA system unless the VA determines it couldn’t provide them with a health care team.

“We are concerned that this approach is narrow and relies on administrative, rather than clinical, criteria,” Shulkin said.

Instead, Shulkin’s plan leaves the decision to veterans and their VA doctors. He presented his plan to the House Committee on Veterans’ Affairs and described it as a simplification of the current Choice program, which has been widely criticized as complex and bureaucratic. It’s titled the Veterans Coordinated Access & Rewarding Experiences Act, or CARE.

“What we’re signaling in this is to start doing what we should’ve been doing more, which is giving the veteran more choice in the say of their care,” Shulkin said. “We want the provider and the patient making the best decision for the patient.”

Rep. Phil Roe, R-Tenn., chairman of the House committee, lauded the hearing as an “incredibly important meeting that’s going to shape the future of the VA.”

VA CARE plan

Shulkin was a holdover from former President Barack Obama’s administration and helped lead implementation of the Choice program as the VA’s undersecretary of health. He has promised since his first public address as secretary in February that he would end the 30-day, 40-mile rule and allow veterans to have greater autonomy in their health care decisions.

His long-awaited CARE plan would permit veterans to go into the private sector for medical care if the VA doesn’t offer what they need or can’t provide care in a “clinically acceptable time period.” Veterans would also be able to seek private-sector care when the VA secretary decides a facility isn’t meeting quality or access standards. Those specific standards were not outlined in the plan.

Veterans who think the VA wrongly denied access to private-sector doctors could appeal those decisions.

The proposal would have the VA enter into “Veteran Care Agreements” with private medical providers that the agency would reimburse at rates equal to or less than what Medicare pays. The plan calls for consolidating the VA’s multiple community care accounts into one, increasing the use of telemedicine and improving veterans’ access to non-VA walk-in clinics for minor illnesses and injuries.

CARE also attempts to address ongoing recruitment and retention challenges within the agency.

According to the latest VA data, there were 34,000 open positions as of June. Shulkin said Tuesday that the VA hired 900 mental health professionals in the past year but another 945 left the agency.

CARE gives the VA secretary more hiring authority. It allows for 1,500 more medical education residency positions in the VA and would create a reimbursement program for nurses, physicians and dentists pursuing continuing education, for up to $1,000 per employee each year. It also repeals limitations on the VA from handing out more than $360 million in employee performance awards each year.

“The VA CARE bill is more than purchasing care,” Shulkin said. “Much of the bill would strengthen and improve VA care.”

House proposal

The House bill would allow veterans to seek private-sector medical care if the VA determines it couldn’t provide them a health care team. Veterans would be able to get treatment through a network of private-sector providers that would be established in each VA region.

As with CARE, the House proposal orders the VA to enter into Veteran Care Agreements and pay private providers at Medicare rates. The rates could be negotiated higher in “highly rural areas,” where there’s little access to medical care, the bill states.

Many of the details of those agreements – and the criteria that determines which veterans are eligible to go into the private sector – are decisions the proposal mostly leaves to the discretion of the VA secretary.

When deciding whether a veteran can go into the private sector, the VA would be asked to consider if they face an “excessive burden” in accessing a VA facility. The legislation states that could mean a veteran lives too far from a facility, or there are poor road conditions, hazardous weather or the veteran is unable to travel because of a medical condition. The proposal leaves the criteria open-ended and the VA secretary could determine other factors that make it permissible for a veteran to seek private-sector care.

Each year, after a veteran chooses a private-sector doctor, the VA would be required to review the situation and switch them to a VA provider, if possible.

Money for private-sector health care would come from a new medical community care account – a consolidation of multiple, existing community care accounts. The bill states one year after its enactment, the Choice program would end and any remaining money would go into the account.

Shulkin’s plan would end the Choice program on Sept. 30, 2018, and he’s seeking $4 billion to fund the program until then. In August, Congress approved $2.1 billion in emergency funding for the program to keep it going until February 2018. The VA has recently projected the money will only last until the end of the year. A Choice overhaul needs to be approved by December, Shulkin said.

Funding fight

Neither proposal presented Tuesday included cost estimates.

Shulkin was adamant the new process would require cuts to other areas of VA spending. But he argued CARE would be cheaper than Choice in the long term because it would streamline complex processes that create large administrative expenses.

To pay for Choice, Shulkin proposed rounding down cost-of-living adjustments to all veterans who receive disability compensation from 2018 through 2027. The practice was standard until 2013.

The plan also calls for cutting federal funding given to veterans who attend flight training programs. At a House hearing earlier this month, representatives from the VA, American Legion and Student Veterans of America accused some flight schools of charging disproportionate amounts of money to students who use the GI Bill to pay for their educations. At the time, congressmen were considering legislation to impose a spending cap on flight schools.

Other cost-saving measures put into CARE would further extend pension reductions for Medicaid-eligible veterans in nursing facilities and extend fees on VA-guaranteed home loans.

The American Legion, Disabled American Veterans and Veterans of Foreign Wars spoke out strongly Tuesday against rounding down cost-of-living adjustments. The measure would cost each veteran an average of $12 annually.

“The Legion is appalled that either Congress or the administration would recommend that veterans disability checks be debited, even one dime, to cover the costs of other veterans benefits,” said Legion member Roscoe Butler. “Veterans’ health care should not be subjected to offsets or pay-fors.”

Rep. Tim Walz, D-Minn., the ranking Democrat on the House committee, also opposed the round-downs. He said Tuesday’s discussion might have been premature without cost estimates.

“I think most of us agree on principle that getting vets timely access to health care as near to home as possible – that’s what we should do,” Walz said. “You can’t have the concept and not talk about the money.”

Parts of the VA plan are still under review by the Office of Management and Budget, Shulkin said. Roe’s proposal won’t be reviewed by the Congressional Budget Office or receive a CBO score with cost projections until the bill is officially introduced.

“My bill is a work in progress,” Roe said. “We still need to figure out how to pay for these improvements, which will be no easy or pleasant feat for any of us.”

Stakeholders weigh in

In recent days, the progressive advocacy group VoteVets, the Veterans Healthcare Action Campaign and the American Federation of Government Employees – a union representing about 230,000 VA workers – have accused President Donald Trump’s administration of using Choice reform as a cover for privatizing the department.

Addressing concerns of privatization, Shulkin and Roe reiterated they are not attempting to privatize the VA. Shulkin said his focus is to “strengthen the VA, but at the same time ensure veterans aren’t waiting.”

“This effort is in no way, shape or form intended to create a pipeline to privatize the VA,” Roe said of his bill. “Under the draft bill, the VA retains the right of first refusal. If VA medical facilities can provide care, it will be provided in that facility. But when the VA can’t do that, my bill would ensure veterans aren’t left out to dry.”

Major veterans service organizations didn’t have those same concerns about privatization but some of them – including Paralyzed Veterans of America and AMVETS -- argued the VA’s CARE plan lacks details that could lead to veterans’ health care sliding too far into the private sector.

“Allowing large numbers of veterans into the private sector while not fixing long-term recruitment, hiring and retention of necessary staff, which would in essence solve many access-to-care issues, is a very slow and painful way to bleed the VA health care system dry of funds while lining the pockets of the private sector,” AMVETS policy adviser Amy Webb said in a written statement.

While those groups criticized the VA plan for being too open-ended, other, conservative groups said the House proposal didn’t go far enough.

The conservative Concerned Veterans for America is calling on lawmakers to create a bill allowing veterans to choose a private-sector doctor, even if there’s one available for them at the VA. CVA also wants Congress to create an appeals process for veterans who think they were wrongly restricted from accessing private providers, as in Shulkin’s CARE plan.

“Keeping the VA, and not the veteran, at the center of the VA health care system will perpetuate the issues that prevent many veterans from accessing the care they need,” CVA Policy Director Dan Caldwell said in a written statement.

The group wants the legislation tied to another committee proposal -- the Asset and Infrastructure Review Act -- which would create a commission to review VA facilities and choose which ones to close and where to modernize. During a hearing on the proposal earlier this month, major veterans service organizations acknowledged the necessity of an effort to “right-size” the VA, but they opposed the commission-style process, comparing it to the Defense Department’s unpopular Base Realignment and Closure program.

Some veterans groups were successful earlier this year at killing VA funding legislation in the House that would’ve incorporated a BRAC-style process for the department. Roe conceded a BRAC program for VA would be difficult to approve in Congress.

CVA was part of a coalition of conservative groups, some of them with ties to the Koch brothers’ political network, that sent a letter to lawmakers Monday asking them to create a system in which all veterans could choose a primary-care doctor inside or outside of the VA. Only that type of system would fall in line with Trump’s promise of increased choice for veterans, the groups wrote. Groups that endorsed the letter include Americans for Prosperity, Tea Party Nation and Heritage Action for America, a sister organization to the conservative think-tank Heritage Foundation.

Most groups that weighed in Tuesday acknowledged the two proposals represented a first step. Roe said the committee would take the feedback and make changes.

It was uncertain Tuesday when legislation would be officially introduced.

Twitter: @nikkiwentling

House Veterans' Affairs Committee Chairman Phil Roe, R-Tenn., right, confers with Ranking Member Tim Walz, D-Minn., at a hearing on Capitol Hill, Oct. 24, 2017.

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