The federal Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans hospitals to private health care providers in an effort to improve veterans’ access to health care. The VA Mission Act of 2018, costing $55 billion over five years, would divert substantial support from our excellent VHA system of 1,300 hospitals and clinics, with negative consequences for veterans.
Veterans hospitals, which treat 7 million patients annually, have been challenged by both the influx of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 motivated Congress to begin a search for a resolution. The “Choice Program” legislation of 2014 enabled some outsourcing of VA care to private physicians.
Congressional concern culminated in the bipartisan VA Mission Act of 2018, signed by President Trump June 6. It will expand the Choice Program, with an additional 640,000 veterans projected to move into private health care annually in its early years.
A modification of the Mission Act would specify a much greater utilization of community health centers (CHCs) for veterans' outsourced primary care. This would ensure high-quality comprehensive primary care and control cost, with most subspecialty care remaining within VHA facilities.
The Choice Program, which is receiving $5.2 billion in its final year, and which handles one-third of all veterans' medical appointments, has been fragmented and unwieldy. Private doctors have complained about slow and nonexistent payments, and veterans have encountered insurmountable red tape.
It is likely that substantial obstacles will be encountered as the Mission Act is implemented, including insufficient access to private physicians (especially in rural areas), continued conflict with private physicians regarding reimbursement, and an uncertain quality of care from a diverse group of private physicians not necessarily focused on unique veterans’ health issues.
The Mission Act does not provide federal money to pay for it. A bipartisan congressional effort has tried to address that problem by developing a separate measure to fund the new $55 billion law. However, the president has insisted on cutting spending elsewhere in the VHA system in view of the growing budget deficit.
Without passage of an alternative, tradeoffs will likely be encountered about which veterans programs receive funding. Given the new legislation’s substantial cost, a disturbing scenario is that the VHA could be forced to cannibalize itself to ensure access to outsourced health care services. Many in Congress and some veterans service organizations adamantly oppose giving veterans unlimited options to choose private doctors, contending that such a change would starve the VHA’s excellent, vast system of government health care. There is no reliable estimate and little research that compares the cost of care inside and outside the VHA’s system.
The aforementioned hazard particularly applies to Wisconsin. We have superb VHA facilities in Madison and Milwaukee that provide world-class subspecialty care and medical research, as well as being closely integrated with the mission and operation of our two state medical schools.
Community health centers are a better solution for enhancing VA health care via outsourcing. The established efficacy of CHC care for Medicaid patients applies equally to veterans. CHCs would provide our veterans with high-quality, cost-effective care, with VHA care funds strengthening the fiscal viability of CHCs rather than private hospitals and physicians.
The CHC program, now over 50 years old, includes nearly 1,400 health centers serving more than 27 million patients at over 9,000 community sites. CHCs provide provide comprehensive services, including dental, vision and behavioral health care as well as pharmaceuticals. CHC integration of mental health professionals is particularly effective in managing post-traumatic stress disorders and substance abuse disorders. Also, excellent dental care is usually available with reduced fees for those with limited income.
Another important factor is the need to better address the health care of the 25 percent of veterans who live in rural communities. The more sparsely populated a community is, the greater the challenge in providing primary care. Funding preferences historically have been provided to rural communities seeking to address geographic and other barriers to care. Today, 44 percent of all CHCs are located in rural communities, while only 19 percent of the U.S. population lives in these areas.
Between 2008 and 2016, the number of veterans served by CHCs increased 54 percent, to over 300,000. Of those CHCs serving veterans, approximately 87 percent provide mental health care and 80 percent provide dental health services. Significant increases in the number of CHCs providing substance use disorder treatment services are anticipated to result from recent federal initiatives that will invest $350 million to expand access to substance use disorder and mental health services.
The VA Mission Act involves a $55 billion, five-year commitment of VHA funds to expand the frustrating bureaucratic and legal burdens of using private providers. As a minimum, our Wisconsin congressional delegates should request the Congressional Budget Office to conduct a study comparing cost and accessibility of CHC with private practice outsourced care. In the absence of developing an incremental, cost-effective alternative, we believe that the private practice outsourcing provision of the Mission Act represents a threat to future viability of our excellent VHA system and the outstanding care it provides for our veterans.
Richard Rieselbach is professor emeritus of medicine, University of Wisconsin School of Medicine and Public Health.
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