The VA MISSION Act Let Veterans See Private Doctors, What It Changed

A government health system that makes sick people wait, and then hides how long they waited, has two problems. The first is the wait. The second is the hiding. Phoenix, in 2014, showed both, and the reform that followed is one of the rare cases in which Washington responded to a scandal by giving the customers a choice.

This post explains how that reform works: what the 2014 Choice Act did, how the 2018 MISSION Act replaced it, the access standards that decide whether a veteran can see a private doctor at government expense, the votes, the cost fights since, and the best argument of the critics. It is an explainer, so the terms come first and the argument follows.

The terms

The VA is the Department of Veterans Affairs, which runs the Veterans Health Administration, the largest integrated health system in the country, with its own hospitals and clinics. Community care is care delivered to a veteran by a private provider outside the VA, paid for by the VA. Eligibility is the set of conditions that entitle a veteran to community care. Access standards are the measures, such as drive time and wait time, that determine whether the VA's own offering is adequate.

A veteran does not become eligible for VA health care just by serving. Enrollment depends on service history, disability rating and income, and the VA sorts enrolled veterans into priority groups. That system is the background to everything that follows: the question at issue is not who gets care but where those already enrolled may receive it.

Phoenix

In April 2014 allegations surfaced that staff at the Phoenix medical center had kept a secret list to hide long waits for appointments, and that veterans had died while waiting. The accusations spread through national news. The VA's Office of Inspector General investigated and, in an interim report at the end of May 2014, found that veterans had waited far longer than the official data showed. The inspector general reported about 1,700 veterans seeking care who were not on the official electronic waiting list, and found that scheduling data had been manipulated at Phoenix and elsewhere to meet performance targets. Part of the reason was that managers' bonuses and ratings were tied to meeting the targets, so there was a reward for making the numbers look good rather than the care better.

Secretary Eric Shinseki resigned on May 30, 2014. And Congress, which rarely moves fast, moved.

The 2014 Choice Act

The Veterans Access, Choice, and Accountability Act of 2014 passed with large bipartisan majorities, 91 to 3 in the Senate and 420 to 5 in the House, after a conference negotiation led by Senator Bernie Sanders and Representative Jeff Miller, and President Obama signed it on August 7, 2014. It authorized about ten billion dollars to let veterans who faced long waits or long drives get care from private providers. The two triggers were simple, and they were the right kind of rule, a number a veteran could check: a wait of more than 30 days for an appointment, or a residence more than 40 miles from a VA facility.

The act also gave the Secretary more authority to remove senior executives for poor performance, a provision that was later struck down in part by a federal court, and it funded the hiring of doctors and the lease of new clinics.

The Choice program worked unevenly. At first the 40-mile rule measured straight-line distance rather than actual driving distance, which meant that a veteran living across a river or a mountain might not qualify even though the real trip was long. VA changed the measure to driving distance in March 2015. The program was run through two outside contractors and was hard to navigate for veterans and for the private providers who were supposed to be paid. Payments were slow, and many doctors found it was not worth the trouble to take part. Veterans reported being bounced between the contractors and the VA. The temporary money ran down faster than expected, and Congress had to pass extensions.

Those problems were a good illustration of a general rule: a good idea executed through a bad process is still a bad process. But the idea itself, that the veteran should be able to choose, had worked well enough to build on.

The 2018 MISSION Act

The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, the MISSION Act, was written to fix the process and make the choice permanent. It passed the House 347 to 70 and the Senate 92 to 5, and President Trump signed it on June 6, 2018. The community care provisions took effect on June 6, 2019, a year later, to give the VA time to build the system.

It did several things. It consolidated the VA's various community care programs, including Choice, into a single Veterans Community Care Program. It replaced the 30-day and 40-mile tests with new access standards. It created a new urgent care benefit that lets eligible veterans visit a network urgent care clinic for minor conditions without prior approval. It expanded a caregiver support program to cover veterans of earlier eras. It set up a process for reviewing the VA's facilities, leading to the Asset and Infrastructure Review commission that Congress then had to consider. And it protected the VA's own system by requiring a process to ensure that quality and cost were measured.

How a veteran qualifies

Under the MISSION Act a veteran is eligible for community care if any one of six conditions applies. These are worth knowing, since many veterans do not realize they qualify:

1. The VA does not offer the care or service the veteran needs.
2. The veteran lives in a state or territory without a full-service VA medical facility.
3. The veteran met the Choice program's 40-mile distance requirement as of June 6, 2018, and still lives in a place that qualifies; this is a grandfather clause.
4. The VA cannot provide the care within its access standards.
5. The veteran and the referring VA clinician agree that community care is in the veteran's best medical interest, a decision that must meet the VA's criteria.
6. A VA service line does not meet the VA's quality standards.

The access standards in point four are the heart of it. For primary care, mental health care and non-institutional extended care, the standard is an average drive time of 30 minutes and an appointment within 20 days. For specialty care, the standard is a drive time of 60 minutes and an appointment within 28 days. If the VA cannot meet the standard, the veteran may elect to see a private provider in the VA's network.

The drive-time test fixed the flaw of the Choice Act's straight-line mileage. It counts time, which is what a veteran with a bad knee or a long rural road actually experiences. The wait-time standard measures what the veteran cares about most, which is how long it takes to be seen.

A caution is in order, and I will state it as plainly as I can. Eligibility rules are detailed and the VA updates its guidance, so a family should check the current standards on the VA's website or by calling the VA, instead of relying on any summary, including this one. The numbers I have given are the standards as the statute and the VA regulations set them at the start of the program.

The steelman and the objection

Now the argument against. It comes mainly from public-sector unions, which represent VA employees, and from some veterans' groups and members of Congress, and it deserves a fair hearing.

One. The VA, they say, is not simply a health plan. It is an integrated system that specializes in the particular needs of veterans: combat injuries, prosthetics, post-traumatic stress, toxic exposure. Private doctors do not see many such cases and may not know how to treat them. Two. Community care is expensive. Every dollar that follows the veteran to a private provider is a dollar that does not go to the VA's own hospitals, and as volumes shift, the VA's fixed costs are spread over fewer patients, so the system hollows out. Three. Private care is not necessarily better. Studies have found that the VA's quality compares well with private care on some measures. Four. The real fix is to hire more VA staff, not to send patients elsewhere.

Those are serious points. The first is a real strength of the VA: it does certain things better than any private system, and a veteran with a complex service-connected condition may well do best in the VA. The second is a real budgeting problem, and the cost of community care has grown as a share of VA health spending since the program began, a development that has produced fights in Congress about how to pay for it and how to keep the department's own capacity healthy.

The answer

Here is the point-by-point response.

One. Nothing in the MISSION Act forces a veteran out of the VA. It gives him a choice when the VA cannot meet its own standard. A veteran who prefers VA care, and who is seen within the standard, stays. The argument that private doctors cannot treat veterans does not justify making a veteran wait weeks for a VA appointment that a private doctor could provide next week.

Two. On cost: the cost of community care is partly the cost of the VA's failure to meet demand. If the department had the capacity to see every veteran within the standard, the veterans would not need to go elsewhere. The money that follows the veteran is the money the department needed in order to meet its obligation, and the real question is why the demand was not met. Competition has a cost, and competition is also the only mechanism that has ever disciplined a monopoly. A government provider that loses patients when it fails them has a reason to improve. A government provider that holds a captive clientele does not. Phoenix is what captivity produced.

Three. On quality: the right comparison is not between the best of the VA and the worst of private care. It is between care available on time and care that arrives late. A good appointment in six weeks may be worse than an adequate one in six days for a condition that is getting worse.

Four. On staffing: more staff is part of the answer, and the VA has been hiring. But money and hiring are what the department already had when Phoenix happened. A system that rations care by wait time and measures itself, with managers rewarded for the measure, needs an outside check. Choice is that check.

I think this is the conservative principle in miniature: a person who has earned a benefit should be able to take it where it serves him best. That principle is the same one that underlies school choice, and the same objection is made against it, that money following the patient or the student drains the public institution. In both cases the answer is that the institution exists for the people, not the people for the institution. For the broader argument about government monopolies and accountability, see The Pentagon Has Never Passed an Audit, and Conservatives Should Mind, and for the health-policy roots of the way Americans get insurance in the first place, How World War II Wage Controls Tied Your Health Insurance to Your Job.

What conservatives should defend, and what they should demand

I would argue conservatives should defend the choice and also demand four things.

First, honest counting. The Phoenix scandal was a scandal of data. Any system that measures wait times must do so in a way that managers cannot manipulate, and the inspector general must have access. Second, simple rules. Veterans should be able to learn their eligibility in one phone call. Third, prompt payment of private providers, since a program in which doctors are not paid will lose its doctors. Fourth, a plan for the cost. Community care growth should be budgeted openly, with Congress deciding what the department needs, and the cost fights should be had in the light, as part of the appropriations process. For the arithmetic of how the government pays for what it promises, see the national debt clock.

The Constitution gives Congress the power to "raise and support Armies" and to make rules for the government of the forces, and the nation's duty to those who served is a long-standing obligation. The MISSION Act is an exercise of that power. It is also a good example of what Congress can do when it does not wait for the executive branch, and the bipartisan votes show that the principle of choice for veterans commanded a broad coalition. A reform that passed 347 to 70 and 92 to 5 has a mandate that a partisan measure lacks.

For the larger picture of how a veteran fits into the story of the country, including the myths that distort the debate, see Seven Myths About Veterans That Shape Bad Policy, and the Facts.

The case in brief

1. The Phoenix scandal of 2014 revealed that the VA's wait-time data had been manipulated, and the Choice Act of 2014 responded by letting veterans with long waits or long drives see private doctors.
2. The MISSION Act of 2018, which passed 347 to 70 in the House and 92 to 5 in the Senate, replaced it with a permanent Veterans Community Care Program, with access standards of 30 minutes' drive and 20 days' wait for primary and mental health care, and 60 minutes and 28 days for specialty care.
3. The best objections, that the VA specializes in veterans' needs and that community care drains it, are partly right about the value of the VA and wrong about the remedy, because choice is the only discipline a monopoly responds to.
4. Conservatives should defend choice and insist on honest data, simple rules, prompt payment and open budgeting.

What you can do: If you are a veteran or know one, check the current community care eligibility rules on the VA's website or by calling the VA, and ask your representative at the my-representatives page how the next VA appropriations bill funds community care.