The VA just expanded private care with a $5 billion spending bill
President Donald Trump signed a landmark bill on June 6, 2018, to replace the troubled Veterans Choice Program and expand private health care options amid a fight between the White House and Congress over how to pay for it.
The bill, the VA Mission Act, would also expand caregivers assistance to the families of disabled veterans and order an inventory of the Department of Veterans Affairs' more than 1,100 facilities with a long-term view to trimming excess.
"This is a very big day," said Trump, who made veterans care one of the signature issues of his run for the White House. "All during the campaign, I'd say, 'Why can't they just go out and see a doctor instead of standing on line?'
"This is truly a historic moment, a historic time for our country," he continued, before signing the bill at a White House Rose Garden ceremony. "We're allowing our veterans to get access to the best medical care available, whether it's at the VA or at a private provider."
In his remarks, Trump did not mention that funds to pay for the bill have yet to be identified, or that the White House and Congress are at odds on funding mechanisms. The bill's projected costs over five years are also in dispute.
At a Senate news conference in May 2018, Sen. Johnny Isakson, R-Georgia, chairman of the Senate Veterans Affairs Committee and a key sponsor of the bill, and Sen. Jon Tester, the ranking member of the committee, put the total costs at $55 billion, although other estimates have it at $52 billion.
Isakson acknowledged that the bill isn't paid for but said he is working with Sen. Richard Shelby, R-Alabama, chairman of the Senate Appropriations Committee, to add funding for the bill that would likely balloon the deficit. The White House has argued for funding the bill by cutting other programs.
A White House memo obtained by The Washington Post said that simply adding funding is "anathema to responsible spending" and would lead to "virtually unlimited increases" in spending on private health care for veterans.
Shelby said on June 5, 2018, that going along with the White House would result in cuts of $10 billion a year to existing programs, including some at the VA.
"If we don't get on it, we're going to have a hole of $10 billion in our [appropriations]," said Shelby, who predicted "some real trouble" in reaching agreement, according to a Washington Post report.
Critics of the bill have warned that over-reliance on private-care options could lead to the "privatization" of VA health care, but Trump said, "If the VA can't meet the needs of the veteran in a timely manner, that veteran will have the right to go right outside to a private doctor. It's so simple and yet so complicated."
In his remarks at the ceremony of less than 20 minutes, Trump also noted that it was the 74th anniversary of the D-Day landings in Normandy when U.S. troops "stormed into hell."
"They put everything on the line for us," he said and, like all veterans, "when they come home, we must do everything that we can possibly do for them, and that's what we're doing."
The issue of funding has plagued the existing Veterans Choice Program since it was enacted in response to the wait-times scandals of 2014 in which VA officials were caught doctoring records to show better performance.
The Choice program allowed veterans who lived more than 40 miles from a VA facility or had to wait more than 30 days for an appointment to have access to private care, but the program was time limited and Congress has struggled to come up with money for extensions.
The program was again due to run out of funding May 31, 2018, but the VA said there was enough money remaining to keep it in operation until Trump signed the VA Mission Act.
The new bill called for $5.2 billion in funding to keep the existing Choice program in operation for a year while the VA worked through reforms to consolidate the seven private-care options into one system while eliminating the 30-day, 40-mile restrictions.
However, a Government Accountability Office report on the Veterans Choice Program released June 4, 2018, cast doubt on the VA's ability to implement the reforms called for under the VA Mission Act.
The GAO said veterans could wait up to 70 days for private-care appointments under the Choice program because of poor communication between the VA and its facilities and "an insufficient number, mix, or geographic distribution of community providers."
Trump touts ridding VA of corruption, poor performers
Ahead of the signing ceremony, the White House put out a statement citing Trump's accomplishments in his first 500 days in office. Veterans programs topped the list.
Trump "worked with Congress to forge an overwhelming bipartisan vote of support" for the VA Mission Act, the statement said. The vote in the House was 347-70; the Senate vote was 92-5.
The VA Mission Act and other veterans legislation will "bring more accountability to the Department of Veterans Affairs and provide our veterans with more choice in the care they receive," the White House statement said.
In his remarks, Trump hailed passage of the VA Accountability Act, which is aimed at getting rid of poor performers, and lashed out at civil service unions for opposing reform.
"Four years ago, our entire nation was shocked and outraged by stories of the VA system plagued by neglect, abuse, fraud and mistreatment of our veterans," he said in a reference to the wait-times scandals.
"And there was nothing they could do about it. Good people that worked there, they couldn't take care of the bad people — meaning 'You're fired, get the hell out of here,' " Trump said.
More accountability "made so much sense but it was hard," he said. "You have civil service, you have unions. Of course, they'd never do anything to stop anything, but they had a very great deal of power.
"So we passed something that hasn't been that recognized, and yet I would put it almost in the class with Choice. Almost in the class with Choice. VA Accountability — passed. And now, if people don't do a great job, they can't work with our vets anymore. They're gone," Trump said.
The VA has more than 360,000 employees serving the health care needs of about nine million veterans annually. Most of them are represented by the American Federation of Government Employees, which opposed the VA Mission Act.
The AFGE said that the act amounts to "opening the door to privatization of the country's largest health care system."
The major veterans service organizations (VSOs) also initially feared privatization but came round to backing the VA Mission Act as a catalyst for improving care while preserving the VA's role as the main provider of health care.
In a statement after the signing ceremony, Keith Harman, national commander of the 1.7 million-member Veterans of Foreign Wars, said, "The VFW and other veterans service organizations worked closely with Congress and the White House to help create a carefully negotiated bipartisan deal with the fingerprints of veterans who rely on the VA all over it."
Bill also addresses caregivers, excess VA facilities
In addition to expanding private-care options, the bill would also address long-time concerns of the VSOs on the restrictions in the current program to provide small stipends to family members who care for severely disabled veterans.
The program has been limited to post-9/11 veterans, but the bill was aimed at expanding caregivers assistance over two years to veterans of all eras.
Advocates had argued that caregivers assistance saves the VA money by allowing disabled veterans to remain at home rather than relying on more expensive in-patient treatment.
"The more veterans and their caregivers who are eligible for support, the closer we are to fulfilling our promise to care for those who've sacrificed so much on our behalf," Sen. Patty Murray, D-Washington, a chief sponsor, said in a statement.
The Congressional Budget Office has estimated that more than 41,000 caregivers could be added to the rolls under the new bill over the next five years at a cost of nearly $7 billion.
In reference to the caregivers section of the bill, Trump said, "If you wore that uniform, if at some point you work that uniform, you deserve the absolute best and that's what we're doing."
In a statement, Delphine Metcalf-Foster, national commander of the Disabled American Veterans and herself a former caregiver to her late husband, said in a statement:
"This new law will not only extend support to thousands more deserving family caregivers that severely injured veterans rely on, but also make a number of reforms and improvements to strengthen the VA health care system and improve veterans' access to care."
The bill also ordered up a VA asset review in which the president would set up a nine-member Asset and Infrastructure Review (AIR) Commission, with representatives from VSOs, the health care industry, and federal facility managers.
Opponents have likened the commission to the Base Realignment and Closure Commission (BRAC) at the Pentagon on the hot-button issue of base closings.
The panel would meet in 2022 and 2023 to issue recommendations on "the modernization or realignment of Veterans Health Administration facilities."
At a Senate news conference in May 2018, Carlos Fuentes, the VFW's National Legislative Services director, said comparing AIR to BRAC is misleading.
"Under BRAC, DoD moves its assets, including service members and their families. VA can't force veterans to move," Fuentes said.
At a panel discussion last month in the House, Rep. Phil Roe, R-Tennessee, chairman of the House Veterans Affairs Committee, said that the average age of a building at the VA is more than 50 years.
He said the VA has more than 6,000 buildings in its inventory, and about 1,100 "are not even utilized. So we're paying millions of dollars to keep up empty buildings — makes no sense."
This article originally appeared on Military.com. Follow @military.com on Twitter.