Veterans Should Carry Their Health Care Dollars the Way They Carry the GI Bill

We trust a twenty-two-year-old veteran to choose between Ohio State and a community college, but some officials do not trust him to choose a cardiologist. That is the contradiction at the center of veterans' health policy, and it has been there for eighty years.

The argument of this post is short. In 1944 America decided that the men and women returning from war should be handed the means to pursue an education and let them decide where to spend it. The country never regretted that decision. The same principle, applied to medical care, says that when the Department of Veterans Affairs cannot provide a service promptly, the veteran should carry the government's payment to any qualified doctor who can. That is not a repudiation of the VA. It is the natural extension of a policy that worked.

Define the terms

Three terms need to be clear, since the debate gets muddy without them.

Choice means that the veteran, not an administrator, decides where a covered service is received, within a set of qualified providers.

Community care is the department's term for care a veteran receives from a non-VA provider, paid for by the VA.

Access standards are the rules that say when a veteran qualifies for community care: how long a wait, how long a drive, what kind of service.

I will use these terms the way the law does. And I will separate three questions that are often blurred. Should the VA exist? Yes. Should it be good? Yes. Should a veteran be bound to it when it cannot meet his need in a reasonable time? No.

The model: the Servicemen's Readjustment Act of 1944

The statute that came to be called the GI Bill was signed by President Franklin Roosevelt on June 22, 1944, two weeks after D-Day. Its formal name was the Servicemen's Readjustment Act of 1944. It had several parts: unemployment benefits for a limited period, loan guarantees to help veterans buy homes, farms and businesses, money for more veterans' hospitals, and the part that made it famous, support for education and training.

The structure of the education benefit matters. The government did not build a single national veterans' university and order veterans to attend. It did not assign veterans to schools by a central committee. It paid tuition, up to a yearly cap, to the school the veteran chose from the approved list, which included private institutions, and it paid the veteran a modest monthly allowance. The money followed the person.

The results were striking enough that the numbers are worth looking up. The VA's own history says that in the peak year of 1947 veterans accounted for 49 percent of college admissions, and that 7.8 million of the 16 million World War II veterans took part in an education or training program before the original bill ended in 1956. The point does not depend on the decimals. Trust in the veteran's own judgment produced a generation of graduates, and it also forced colleges to compete for the veteran's tuition by improving what they offered.

Notice what the GI Bill did not do. It did not ask whether the veteran was "qualified" to choose. It treated the person who had spent years in service, making decisions with high stakes, as an adult. A country that had trusted him with a rifle, a ship or an aircraft was not going to pretend he could not pick a school. Imagine the alternative: a Bureau of Approved Majors, with a form for changing your mind about chemistry.

The current law: the MISSION Act of 2018

On June 6, 2018, President Trump signed the VA MISSION Act. Its name stands for Maintaining Internal Systems and Strengthening Integrated Outside Networks, and it built on the temporary program Congress had created after the 2014 wait-time scandal. Phoenix 2014 and the Secret Wait Lists That Changed Veterans' Health Care tells that story. The MISSION Act made community care a permanent program and set defined access standards.

Under the standards the VA put into effect in June 2019, a veteran may qualify for community care if the drive to a VA facility for primary care or mental health care exceeds thirty minutes, or the drive for specialty care exceeds sixty minutes, or the wait for primary care or mental health care exceeds twenty days, or the wait for specialty care exceeds twenty-eight days. There are other routes in: a service the VA does not offer, or a case where the veteran and his clinician agree that outside care is in the veteran's best interest. The VA MISSION Act Let Veterans See Private Doctors, What It Changed covers the details.

That is real progress, and I want to credit it. But look at the shape of it. The MISSION Act is a door with several locks, and the department keeps the keys, which is a little like asking the bakery whether you may buy bread elsewhere. The veteran must qualify under a rule, the rule is applied by the department, and the department that applies the rule is also the department that would lose a patient. The GI Bill's design was cleaner. It let the veteran choose where the benefit went.

The numbered argument

Here is the case in order.

1. A government that asks a person to serve owes him prompt care for the injuries of service. The promise is old. Lincoln stated it in 1865, in the Second Inaugural Address, as the nation's duty "to care for him who shall have borne the battle and for his widow and his orphan." The obligation is to the veteran, not to the department's buildings.

1. The obligation is met by care delivered, not by the capacity to deliver it. If a veteran waits months for a service that a doctor ten minutes away can provide next week, the nation has not kept its promise just because a VA hospital exists somewhere in the state.

1. We already trust veterans with a comparable choice. The GI Bill's education benefit proved that people who have served can be trusted to spend a public benefit wisely, and that the competition their choices create improves the providers.

1. A choice of provider is a check on the department. An institution that knows its patients can leave works harder to keep them. That is not an insult to the staff. It is how every other part of American life keeps service honest.

1. Therefore the veteran who cannot be served promptly should be able to carry the payment elsewhere, with standards that are simple, published and applied to his case without a second layer of approval.

If you accept the first two premises, as I think everyone does, the rest follows with some force. The disagreement is not about whether veterans deserve good care. It is about who should decide when the VA's care is not good enough, and what happens when it is not.

The opposing case, stated fairly

Now the other side, and I will state it in terms that its defenders would accept.

The case against broad choice goes like this. The VA is not a generic health insurer. It is an integrated system built around the particular needs of those who served: combat injuries, amputations and prosthetics, spinal cord injury, the wounds of war that many civilian practices rarely see, and mental health care shaped by military experience. Its clinicians know the culture and the exposures. Its records are unified, so a veteran's history travels with him. And because it is a single system, it can coordinate care that a patchwork of private providers cannot.

The critics also make a financial argument. If the department pays private providers for more and more care, it must pay for the services twice: once for the private care, and again to keep the fixed costs of its own hospitals running, with fewer patients to spread them over. Over time, they say, the VA's specialized programs shrink, because they lose the volume they need to stay expert. Outside care may cost more per visit. It may be harder to coordinate. And in some communities there are not enough private providers to take the veteran anyway. For these reasons, advocates of this view want the department to be fixed from within and funded for the capacity it needs, with community care limited to genuine gaps.

That is a serious position, and I'll note with a straight face that it is the first time in recorded history anyone has argued that a hospital is too popular to be allowed competition. It is held in good faith by serious people, including many veterans. Parts of it are correct.

Why the answer does not defeat choice

I'll answer the objection in four points.

First, the specialized-services case is an argument for the VA's strengths, not for a monopoly. If the VA is the best place for a polytrauma patient, then the veteran with a polytrauma injury will choose it. A choice program that lets him go elsewhere for a knee replacement does not take him away from a spinal cord unit. The two coexist. The VA can concentrate on what it does uniquely well and let veterans take the routine services where they can get them promptly.

Second, the fixed-cost argument proves too much. It would justify forbidding any competition for any public service. If a school loses students it must be shut, if the post office loses letters it must be protected. A government institution is entitled to the veteran's loyalty only to the extent that it earns it. The test of whether an institution serves veterans well is whether veterans, when free to leave, stay.

Third, the problem of coordination is real, and it is solvable. A veteran's records can follow him, and a good community care program requires it. This is a design challenge, not a reason to lock the door. Anyone who has seen how medical records move between private systems knows the challenge exists everywhere. The answer is to fix the handoff, not to forbid the handoff.

Fourth, the capacity argument cuts against the status quo. Where there are not enough private providers, choice does little harm, because few will use it. Where there are many, the veteran who is waiting weeks for the VA has an alternative the VA's own funding could not supply. If anything, a world where veterans can leave pushes the department to staff up where the demand is, because empty chairs and long lines become visible.

I should say plainly what I am not claiming. I am not claiming the VA should be dismantled. I am not claiming private care is always better. And I am not offering any medical judgment about which kind of care is clinically superior in any case, because that is for a veteran and his clinician. I am claiming that the decision belongs to the veteran when the department cannot deliver.

The constitutional and historical frame

The Constitution gives Congress the power in Article I, Section 8 "to raise and support Armies," "to provide and maintain a Navy," and to provide for the common defence. A nation that raises armies by calling on citizens incurs a debt to them, and Congress, which controls the purse, has always chosen how to pay it: lifetime pensions and bounty land after the Revolution, and the GI Bill after World War II. Each generation chose a vehicle suited to its time. The vehicle in 1944 was a benefit that followed the veteran to the school he chose.

Madison, in Federalist 51, made the point that institutions have to be built for human beings as they are, with checks that do not depend on anyone's good intentions. An agency that is both the provider and the gatekeeper of a veteran's care has a built-in reason to keep its patients. A choice mechanism removes that conflict. For a fuller treatment of how the VA's performance has been measured and debated, Seven Myths About Veterans That Shape Bad Policy, and the Facts separates the claims from the facts.

What a better rule would look like

If I were drafting the rule, I would keep the following principles, and I invite you to read the MISSION Act and see which it already meets.

• Simple, published thresholds. A veteran should be able to read the rule and know whether he qualifies without calling a supervisor.
• A default that favors the veteran. When the VA cannot meet the standard, the veteran should not have to prove it. The department should have to offer the option.
• Money that follows the person. The payment should travel with the veteran to a qualified provider, with prompt payment of providers so that doctors will take the patient.
• Transparent reporting. Wait times and community care use should be published in a form that outsiders can audit, since an agency's own numbers are not enough. The Phoenix episode taught that lesson.
• A strong VA for those who choose it. Nothing in this list reduces the VA's funding for its core, specialized work. The point is to let each veteran use the system that serves him best.

For the larger conservative argument that people respond better to incentives and choices than to central planning, see Four Conservative Health Plans Side by Side, From Tax Credits to Block Grants, which compares the options on offer.

The values underneath

Let me close with a statement of values, since I think you should know which claims are facts and which are commitments.

The facts are in the statutes: the 1944 Act, the 2014 and 2018 laws, the standards the department adopted. The commitment is mine, and I hold it because of a moral tradition I believe in. A free society treats the individual as the bearer of dignity, and it trusts him with the decisions that govern his own life, especially when he has put his life at risk for the rest of us. The GI Bill was an expression of that dignity. It said to a generation: you earned this, and you decide how to use it.

It would be strange if that dignity extended to the choice of a college but stopped at the door of the doctor's office.

The case in brief

1. The GI Bill of 1944 paid the veteran and let him pick his school, and the approach worked.
2. The MISSION Act of 2018 created permanent community care with access standards, but the veteran still passes through the department's gate.
3. The nation's debt to veterans is met by care delivered promptly, not by the existence of a hospital.
4. The best case against choice, that outside care drains specialized VA services, is an argument for the VA's strengths, and it is answered by letting veterans choose the VA where it excels.
5. The principle is simple: when the VA cannot serve a veteran promptly, the veteran should carry the payment to a qualified doctor who can.

What you can do: read the community care eligibility standards on the VA's public website, then share them with a veteran you know and ask your representative's office how they track the program's wait times.