Department of Veterans Affairs' Choice Program and the Future of VA Community Care Programs, Authorities and Budget

Mr. Chairman, Ranking Member Walz and distinguished members of this critical, veteran-serving committee, The American Legion believes in a strong, robust veterans’ healthcare system that is designed to treat the unique needs of those men and women who have served their country. However, even in the best of circumstances there are situations where the system cannot keep up with the health care needs of the growing veteran population requiring VA services, and the veteran must seek care in the community. Rather than treating this situation as an afterthought, an add-on to the existing system, The American Legion has called for the VA to “develop a well-defined and consistent non-VA care coordination program, policy and procedure that includes a patient centered care strategy which takes veterans’ unique medical injuries and illnesses as well as their travel and distance into account.”^[1]

As congress is now discovering and as The American Legion predicted, costs are skyrocketing beyond all budget predictions because congress failed to implement established cost control measures that had been used by VA for years, and instead opted to open access using the Choice act which encouraged virtual uncontrolled spending.  By committing $10 billion to this new procurement vehicle congress removed all established contracting control measures used in VA’s other community care programs; instituted third party administrators, additional eligibility criteria, higher and inconsistent reimbursement rates, and a disconnected billing authority; in addition, the Choice act required VA to issue physical Choice cards to every enrolled veteran that were essentially worthless, wasting millions and millions of dollars on designing and procuring millions of these cards in 90 days or less.

The one thing the Choice act did do effectively was expose VA’s practice of managing to budget as opposed to managing to need.  While the Choice act set a restrictive access boundary of 30 days of wait time, and 40 driving distance miles by presenting it as increasing access, the truth is, VA already had the authority to contract those patients out they just rarely used the authority because their budget could serve twice as many veterans if redirected toward campus or established community care contracts. 

Every year VA would send their budget request to the Office of Management and Budget (OMB) as calculated by the number of veterans they projected would require medical care from VA in the upcoming fiscal year, and every year OMB would recommend less money than VA had requested for the president’s annual budget request.  To congress’ credit, each year congress would fund VA at an amount greater than what the president would request, but still lower than what VA had predicted their needs would be.  This budgetary tug-o-war continued for years while returning injured veterans became new patients of VA, aging Vietnam and Korean War veterans consumed more medical services, congress opened free access to all returning combat vets regardless of whether or not they had a service connected disability, and The Affordable Healthcare Act pushed veterans into VA who were eligible for VA care but never used VA because they had access to private care, but who’s private care didn’t qualify for Obamacare.  It was this combination of events in tandem with the national shortage of primary care doctors that contributed to the backlog of patients that erupted in 2014.

Over the years, VA has implemented a number of non-VA care programs to manage veterans’ health care when such care is not available at a VA facility, could not be provided in a timely manner, or is more cost effective through contracting vehicles.  Programs such as Fee-Basis, Project Access Received Closer to Home (ARCH), Patient-Centered Community Care (PC3), and the Veterans Choice Program (VCP) were enacted by Congress to ensure eligible veterans could be referred outside the VA for needed, and timely, health care services.

Congress created the VCP after learning in 2014 that VA facilities were falsifying appointment logs to disguise delays in patient care. However, it quickly became apparent that layering yet another program on top of the numerous existing non-VA care programs, each with their own unique set of requirements, resulted in a complex and confusing landscape for veterans and community providers, as well as the VA employees that serve and support them.

Last year Congress passed the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act) after VA sought to consolidate its multiple care in the community authorities and programs. This legislation required VA to develop a plan to consolidate existing community care programs.

On October 30, 2015, VA delivered to Congress the department’s Plan to Consolidate Community Care Programs, its vision for the future outlining improvements for how VA will deliver health care to veterans. The plan sought to consolidate and streamline existing community care programs into an integrated care delivery system and enhance the way VA partners with other federal health care providers, academic affiliates and community providers. It promised to simplify community care and gives more veterans access to the best care anywhere through a high performing network that keeps veterans at the center of care.  That legislation was never enacted.

The American Legion commends this committee for recognizing the need to fix the Choice program. The American Legion supported passage of the Veterans Access, Choice and Accountability Act of 2014 as a temporary fix to help veterans get the health care they need, regardless of distance from VA facilities or appointment scheduling pressure. As congress now recognizes long-term solution requires consolidating all of VA’s authorities for outside care, including Choice, PC3, Project ARCH and others, under one authority to help veterans only when and where VA cannot meet demand. The American Legion supports a strong VA that ultimately relies less and less on outside care, rather than move toward vouchers and privatization.  An initial hope for the emergency Choice program was that whatever worked from that program, or previous programs such as ARCH and PC3 could be incorporated into a single program that learned best practices and lessons from the predecessors.

While many veterans initially clamored for “more Choice” as a solution to scheduling problems within the VA healthcare system, once this program was implemented, most have not found it to be a solution, indeed, they have found it to create as many problems as it solves.  The American Legion operates the System Worth Saving Task Force, which has annually traveled the country examining up close the delivery of healthcare to veterans for over a decade.  What we have found, directly interacting with veterans, is that many of the problems veterans encountered with scheduling appointments in VA are mirrored in the civilian community outside VA.  The solutions in many areas may not be out in the private sector, and opening unfettered access to that civilian healthcare system may create more problems than it solves.  National Public Radio recently noted that “thousands of veterans referred to the Choice program are returning to VA for care – sometimes because the program couldn’t find a doctor for them” or “because the private doctor they were told to see was too far away.”[2]

Additionally, we note that the $10 billion originally appropriated for the Choice Program which was expected to be depleted by May 2017 still has funding available, and The American Legion wants to make sure that VA retains access to those funds until fully depleted.

The American Legion has serious concerns about future years funding shortfalls for the VA. We urge this committee and Congress to take additional steps now to ensure VA has the tools and resources it needs to address the needs of America’s veterans next year and for years to come. The American Legion expects a fully funded VA from Congress. Since the access to care crisis, it was apparent that VA needed to expand its ability to provide care through its own facilities and by providing access for eligible veterans to private-sector health care. In short, VA needs enhanced capacity and that takes funding.

As predicted by The American Legion, sending patients off VA campuses to community providers absent well-crafted contracts such as those used for Project ARCH and PC3 has led to inadequate compliance by local physicians to return treatment records to VA following care provided by Choice. When the Choice legislation was being developed, The American Legion insisted that any doctor treating a referred veteran have access to the veteran’s medical records so that doctors would have a complete history of the veteran’s medical history and be able to provide a diagnosis based on a holistic understanding of the patients medical profile.  This is important for a litany of reasons, not the least of which includes the risk of harmful drug interaction, possible overmedication, and a better understanding of the patients previous military history – all important factors in wellness.

Also, The American Legion was adamant that any treating physician contracted through Choice had a responsibility to return treatment records to be included in the patients VA medical file so that VA could maintain a complete and up-to-date medical record on their patients.  We believed that safeguarding of the veterans medical records was so important, that we helped craft a provision that was included in the language that prevented VA from paying physicians until they turned over the treatment records to VA.  Sadly The American Legion was forced to acquiesce our position in favor of paying doctors whether they turned over the medical records or not, because doctors weren’t sending the records – it just wasn’t that important to them, and when VA refused to pay, they blamed VA for not paying them, ultimately billing the veterans and refusing to see any more VA-referred patients until they got paid.  Since it was more important that veterans had access to sufficient medical care and not have their credit damaged, The American Legion supported repealing the current provision.

Chairman Roe, this, among other reasons including unsustainable cost, is why Choice is not the answer.  The equation is simple; a dramatic increase in cost is guaranteed to result in an increased financial burden to veterans using VA care which will include higher co-pays, premiums, deductions, and other out-of-pocket expenses currently suffered by non-VA healthcare programs. 

Mr. Chairman, Ranking Member Walz, and  other committee members, The American Legion thanks you for your time, and urges you to take serious action to make access to quality care across this nation a priority of the 115^th Congress.