The draft standards the VA has announced detailing the circumstances under which veterans will be able to access health care in the community are inadequate and ill-designed. Congress should rigorously oversee implementation of the Mission Act to ensure that quality of care and fiscal responsibility are not sacrificed to the illusion that community choices are superior.
The VA Mission Act (Public Law 115-182), signed into law in June 2018, was crafted in the wake of the 2014 veterans’ health care access scandal and the resulting problem-plagued rollout of the Choice Act, hastily passed that same year. Incorporating input from the Commission on Care, veterans service organizations, and the Department of Veterans Affairs (VA), bipartisan leaders in Congress reached a compromise agreement that addresses multiple areas of veteran health care, including asset and infrastructure review and expansion of the caregiver support program. It also created the Veterans Community Care Program (VCCP), which will consolidate seven existing programs through which veterans access non-VA health care and change the circumstances under which veterans are authorized to get care outside VA.
Proposed Access Standards
To implement the Mission Act, the VA has developed and announced the following draft access standards:
“The VA is proposing new access standards, effective when the final regulations publish (expected in June 2019), to ensure Veterans have greater choice in receiving care. Eligibility criteria and final standards as follows were based on VA’s analysis of all of the best practices both in government and in the private sector and tailored to the needs of our Veteran patients:
- Access standards will be based on average drive time and appointment wait times.
- For primary care, mental health, and non-institutional extended care services, VA is proposing a 30-minute average drive time standard.
- For specialty care, VA is proposing a 60-minute average drive time standard.
- VA is proposing appointment wait-time standards of 20 days for primary care, mental health care, and non-institutional extended care services, and 28 days for specialty care from the date of request with certain exceptions.
Eligible Veterans who cannot access care within those standards would be able to choose between eligible community providers and care at a VA medical facility.”
Weaknesses of Proposed Standards
The VA’s press release states that these standards are specifically designed “to ensure Veterans have greater choice.” While seen by some as inherently good, choice alone is neither the highest priority for medical care, nor a desirable end in and of itself. The VA’s drive and wait-time based standards make no mention of ensuring veterans have access to the highest quality care, in the timeliest manner, or at optimal cost to taxpayers – all of which are more likely within a strong VA.
The draft standards also make no reference to what will be required for community providers to be considered eligible or how the department will ensure those providers can deliver high-quality, evidence-based, culturally competent care to veterans. This is unfortunate, given the multiple studies showing that the VA provides higher quality care on many measures, including mental health. In addition, mental health care providers who work in community settings are far less likely to have military cultural competence and training in evidence-based therapies for post-traumatic stress disorder or other conditions that are more prevalent in veteran populations.
Basing access standards on average drive times and wait times may not even improve access for veterans. Estimating drive times based on the closest VA Medical Center, rather than considering whether needed care can be accessed at one of the far more numerous Community-Based Outpatient Clinics, artificially harms the appearance of proximity to a VA facility. In addition, the assumption that community providers will exist may also be misplaced: while veterans live in all but one of the nation’s 3,142 counties, “fifty five percent of U.S. counties, all rural, have no practicing psychiatrists, psychologists, or social workers.” The mean wait time for new primary care appointments at the VA is exactly 20 days, meaning a high percentage of VA patients will be able to request referral to community care … where the mean wait time is over twice as high, at 40.7 days.
The drive to increase veterans’ choices is also based on the flawed underlying assumption that having more choices is inherently better. However, research does not support this assertion. Numerous studies have shown “not only that excessive choice can produce ‘choice paralysis’ but also that it can reduce people’s satisfaction with their decisions, even if they made good ones.” Crucially, the elderly and those with lower cognitive ability are less likely to make optimal decisions when navigating complicated health care landscapes replete with choices. Opening the aperture on choice for veterans struggling with heavy disease burdens, traumatic brain injuries, and mental health conditions puts these veterans and their families at increased risk of being targeted by unscrupulous private sector providers willing to prey on their desperation to profit from offering unproven “treatments,” repeating the same pattern we have already seen with for-profit colleges eager to leach federal dollars at the expense of wounded warriors.
Despite – or perhaps because of – providing higher quality, more integrated, more comprehensive care for the unique population it serves, the VA also does so at lower cost. Increasing the number of veterans eligible for community care could come at tremendous cost to taxpayers – in billions of dollars of added costs that are not going toward health care – while not improving veterans’ health outcomes.
What Congress Should Do
Secretary Wilkie’s statement about the draft access standards says that they are “based on what matters most: the convenience of our Veteran customers.” Convenience, however, should not be “what matters most” without consideration for quality or outcomes. VA patients tend to be older, sicker, and poorer: they have more complex needs than typical patients. Community providers will not be integrated into the VA’s efforts to screen for – and refer patients for assistance with – homelessness or housing instability, food insecurity, military sexual trauma, legal woes, intimate partner violence, and suicidality.
Congress must therefore rigorously oversee the VCCP implementation now underway to ensure the best outcomes for our nation’s veterans. Access standards should align with true congressional intent, rather than simply providing increased access to community care for the sake of offering greater choice.
It is imperative that Congress insist the VA provide additional details on the proposed regulations for implementing the VA Mission Act, rigorously uphold its oversight role, and ensure that the VA’s finalized standards meet the spirit and letter of the hard-fought consensus that led key stakeholders to support its passage. The Independent Budget Veterans Agenda for the 116th Congress contains carefully considered recommendations with thoughtful supporting rationales that should inform the aggressive oversight required to truly serve veterans in the long run. Crucial among these are holding non-VA community providers to the same standards and requirements as VA providers and ensuring the VA works swiftly and diligently to improve hiring of qualified personnel.
Veterans, particularly those wounded in service to our country, deserve a strong VA, one that continues to provide innovative, patient-centered care, particularly for issues that may disproportionately affect them such as traumatic brain injuries, post-traumatic stress disorders, amputations, spinal cord injuries, and blindness. Taxpayers also deserve a robust VA, one that continues to fulfill its missions not only of delivering clinical care to veterans but also supporting all Americans by conducting incomparable research, training medical residents, and supporting local communities in emergencies. Rather than being seduced by platitudes about choice and convenience, Congress must consider the extensive evidence about the quality, timeliness, and cost-effectiveness of VA care and insist that in-house care is strengthened, rather than allowing it to be diluted by diverting further funds to community care.
Kayla M. Williams is a Senior Fellow and Director of the Military, Veterans, and Society Program at the Center for a New American Security.
Read the policy brief.