The future of the Veterans Affairs Department’s health care programs is still up in the air, as the Senate debates either a major overhaul or permanent extension to current legislation that lets veterans access private providers for care.

The VA has long argued it needs the authority to consolidate the seven different ways veterans can currently access health care.

The Veterans First Act, which the Senate Veterans Affairs Committee quietly passed without amendment last week, contains some provisions that would give the VA more flexibility to develop agreements with private providers and consolidate veterans’ current options. But the bill’s main author, committee Chairman Johnny Isakson (R-Ga.), acknowledged there was more work to do.

“Please help us get the remaining few holes we have on that bill in the Senate off our bill so we can get it to the floor and pass it,” he said during a May 24 legislative hearing on the VA Choice Program and appeals process.

But a recent bill from Sen. John McCain (R-Ariz.) would make the current Veterans Choice Program permanent. The Care Veterans Deserve Act would also let all qualified veterans use the Choice card to receive care from community providers if they choose, regardless of where they live.

“I strongly believe the best way to improve veterans health care is to enable all eligible veterans to access the Choice Card,” McCain said in his testimony before the committee.

Under the current program, veterans who live more than 40 miles from a VA medical center or who have waited more than 30 days for an appointment can opt to receive care from a private provider.

The current Choice Program will expire next summer without congressional action.

But for VA, expanding the current Choice Program could have irreparable damage on the department’s mission.

“If this bill is enacted, we believe it would inevitably transform VA largely into an insurance provider and greatly erode our strengths as a health care provider centered on a continuifng relationship with veterans and their entire spectrum of health care needs,” Deputy VA Secretary Sloan Gibson said before the committee. “We’re not against care delivered outside the VA. Long before Veterans Choice, we were purchasing billions of dollars of care in the community because it was the right thing for veterans.”

VA will continue to purchase private care for veterans as the demand rises, Gibson said, but the costs of expanding the current Choice Program will be “truly staggering.”

Sen. Thom Tillus (R-N.C.), who co-sponsored McCain’s legislation, said he sees aspects of the bill that can be tweaked to better align with the VA’s point of view. But he insisted: he’s not interested in trying to privatize VA health care.

“But more than anything else, I’m not going to speak for Senator McCain … but there’s never been an attempt to privatize the VA for the reasons I’ve said before,” Tillus said. “It doesn’t make sense. If you’ve gone as I have, gone to all your VA hospitals, all your health care centers, all the places where care is provided to veterans, when veterans come together in a group, there’s a value to that that even goes beyond the medical treatment they receive in this facility.”

Isakson agreed, adding that no member of his committee has expressed a desire to privatize the department’s health care.

The conversation comes more than a month after a “strawman” proposal emerged from the congressionally appointed VA Commission on Care. The document suggested a major expansion of VA community care providers and a reorganization of the Veterans Health Administration, with a push to close 10-15 agency medical centers in the next two decades.

Ultimately, the department and committee agreed: future legislation must consider the lessons VA learned since Congress passed the original Choice Act in 2014.

Baligh Yehia, assistant deputy undersecretary for health for community care at the Veterans Health Administration, said the VA has learned that veterans in rural parts of the country have different needs than veterans who live in more urban areas. The future program, he said, must accommodate those needs.

“We need to make sure we don’t have a cookie cutter approach to community care, but we tailor it to different geographies and populations,” Yehia said.

Sen. Joe Manchin (D-W.V.) said the committee is trying to help the department find the “right blend” of community and VA care for the right populations of veterans.

“At the end of the day, what we’re looking to do is to get the best of both worlds,” Yehia said. “How do play off the strengths of the VA and then play off the strengths of the private sector? In some areas, in Alaska [for example], we’re probably going to purchase more care than make. In other areas, we might be making more care than buying. It’s really getting to an integrated health care network.”

Close on appeals reform?

In collaboration with the several different veterans service organizations, the VA drafted a legislative proposal that would reform the appeals process for veterans’ compensation claims. But the committee is looking for more details on the department’s plan.

Some veterans services organizations have their concerns too.

Leaders from Veterans of Foreign Wars (VFW) were active members in the VA’s series of meetings to develop a new appeals process.

“But participation does not imply consent or approval of a new process,” said Carlos Fuentes, senior legislative associate for VFW, who said the VA’s proposal had some major gaps that the department still needs to address.

According to the VA’s proposal, new veterans’ appeals would get processed within roughly one year, Gibson told the committee.

“The costs associated with implementing the new legislation is essentially zero,” he said. “The additional funds that we hope Congress will provide year by year to reduce the inventory in the current system is separate from the legislation to modernize the process.”

Under current law, which is nearly 80-years-old, it takes the VA nearly three years on average to process a veteran’s disability claim. If the claim moves to the Board of Veterans Appeals, the process takes roughly five years.

One veteran has waited nearly 27 years for a final decision, Gibson said, and the Board has issued decisions on that claim 25 different times.

Without action from the VA and Congress, veterans will wait 10 years on average before they get a decision on a claim, Gibson warned.

But the committee, as well as some veterans service organizations, are concerned that the new system doesn’t have the ability to resolve the current backlog of 450,000 unresolved appeals, nor the funding and personnel it needs to be successful.

The Congressional Budget Office is in the process of determining its score for the VA’s new plan, which Isakson said is a must-have before the committee can move forward.

“We need the exact language and we need a score, and we need to know what we need what we do with the 450,000 that are waiting,” he said. “Because if we change the appeals process prospectively, which we want to do to make it shorter and better and more responsive to our veterans, what happens to those 450,000, some of whom have been waiting 27 years for a determination of disability?”

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