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Military Officers Association of America

STATEMENT

of the

MILITARY OFFICERS ASSOCIATION OF AMERICA

  on

VA Community Care Eligibility Requirements

2nd Session, 114th Congress

before the

HOUSE VETERANS’ AFFAIRS COMMITTEE

Subcommittee on Health

February 2, 2016

Presented by

 CDR René A. Campos, USN (Ret.)

Deputy Director, Government Relations

CHAIRMAN Benishek, RANKING MEMBER Brownley, and Members of the Subcommittee, on behalf of the more than 390,000 members of the Military Officers Association of America (MOAA), I am grateful for the opportunity to present MOAA’s views on the Department of Veterans Affairs (VA) eligibility requirements as outlined in its proposed Plan for Consolidating Community Care.

MOAA does not receive any grants or contracts from the federal government.

MOAA is grateful for the Subcommittee’s steadfast commitment and exceptional support to our nation’s veterans and their families.  Notably, the passage of the two key bills, the Veterans Access, Choice and Accountability Act of 2014 (VACAA P.L. 113-146, or the Choice Act) and the Title IV of the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act), as well as additional funding to address shortfalls in several Veterans Affairs Health Administration (VHA) accounts.  These bills and funding are foundational steps to reforming VA to better serve our veterans and their families.

The Secretary of VA, Bob McDonald, and his leadership team have also committed significant resources and attention to not only fixing current access problems, but are also moving swiftly to implement reform through a major effort called MyVA.  We applaud the Secretary’s vision and determination to get MyVA implemented and institutionalized as much as possible before leaving office.

EXECUTIVE SUMMARY

The guiding question before the Subcommittee today is, “Will the eligibility requirements outlined in the Department of Veterans Affairs’ (VA) plan to Consolidate Community Care Programs be sufficient to increase access to care among veteran patients?”

The Military Officers Association of America (MOAA) appreciates the opportunity to explore the question with the Subcommittee and to share our thoughts on the Secretary’s proposed New Veterans Choice Program (VCP) Plan, congressionally mandated in Title IV, Surface Transportation and Veterans Health Care Choice Improvement Act of 2015.

Generally, MOAA supports the plan to consolidate VA’s multiple and disparate purchased care programs into one New VCP.  We believe it has the potential to improve and expand veterans’ access to health care.  Much depends, however, on the Department’s success in working with its employees, Congress, the VA Commission on Care, veterans and military service organizations (VSOs/MSOs), and other stakeholders as the agency moves forward in developing and implementing the plan. 

MOAA commends VA Secretary Bob McDonald for his MyVA vision and tenacious leadership as he leads the largest and most complex integrated health system in America in a new direction, seeking to transform the Department into a veteran-centric organization by “modernizing VA’s culture, processes, and capabilities in order to meet the needs, expectations, and interests of Veterans and their families first.”  We are also pleased to see the New VCP aligns with the Secretary’s MyVA transformation efforts. 

VA established a strong communications channel and process to engage stakeholders.  This unprecedented collaborative process included frequent and ongoing dialog and feedback which continues today as VA moves forward in further developing and implementing the plan.  Such effort indicates VA’s sincere commitment to putting veterans and families first and is at the center of its plans for consolidating community care.

While MOAA is very encouraged by the Secretary’s transformation efforts, we respectfully urge Congress, the Commission on Care and the VA to:

  • Adopt The Independent Budget’s (IB) recent concept paper, a Framework for Veterans Health Care, incorporating the Disabled American Veterans (DAV), Paralyzed Veterans of America (PVA) and the Veterans of Foreign Wars (VFW) recommendations for transforming the VHA into a more robust system of health care for veterans. 
  • Eliminate the current arbitrary federal access standards (based on wait times, distance to a VA facility, or availability of services) and consider establishing a new clinically-based standard for both in-house and community care, where decision-making involves the veteran (including family/caregivers) and physician or medical professional in the process (per the IB VSOs) to provide a less complicated standard for accessing care.
  • Support VA’s plan for expanding access to emergency treatment and urgent care services, but oppose the copay requirement for veterans accessing such care, particularly those with service-connected conditions.
  • Direct resources and funding at modernizing the VA human resources system and requiring VA to implement a workforce management and succession planning strategy for attracting, training, retaining, and sustaining high quality personnel.

The ultimate test of any successful reform is whether VA is able to deliver the things veterans and their families value most—high quality, accessible, comprehensive, and culturally competent medical care and services that will meet their unique needs and circumstances.

Background

The MyVA initiative was launched soon after Secretary McDonald’s confirmation and the passage of the Choice Act.  MyVA is an enterprise-wide transformation initiative. According to the Secretary, the initiative will modernize VA’s culture, processes, and capabilities to put the needs, expectations, and interests of Veterans and their families first.

Issues related to access to medical care have long plagued the system.  After news broke of secret waiting lists at the Phoenix, Arizona VA medical hospital in the early 2014, MOAA wrote a letter to the President and leaders of the House and Senate Veterans Affairs Committees to say bureaucratic red tape and gross inefficiencies were preventing veterans from accessing care and required immediate attention.

MOAA urged the President to establish an independent, high-level commission to examine the VHA to better understand the challenges that lie ahead so the VA is prepared to meet the long-term needs of millions of veterans who have served our nation.  Lawmakers heard our message and passed the Veterans Choice Act on August 7, 2014, which included establishing a VA Commission on Care.

The Commission was established on August 7, 2015 to examine the access of veterans to health care from VA and how best to organize VHA, locate health care resources, and deliver health care to veterans over the next 20 years.  It is expected to submit its findings and recommendations to the VA and Congress early this year.

The Choice Act also directed an independent study to look at the delivery systems and management processes of VHA in order to provide a holistic view of the system and its relationship within the VA.  The Independent Assessment was completed on September 1, 2015.

Within three months of the passage of the Choice Act, VA implemented the Choice Program on November 5, 2014.  The program allows eligible veterans to receive health care in their local communities from private or non-VA providers.  But VA struggled from the beginning to transition to the Choice Program.  Accessing the program was problematic and eligibility requirements were confusing and frustrating not only to veterans, but also to VA employees and providers trying to implement the program.  As a result, veterans continued to experience long wait times for care.

At the urging of MOAA and several partners in The Military Coalition, VA expanded the Choice Program rules on December 1, 2015.  VA changed the eligibility rules to measure distance from a veteran’s home of record to the closest VA facility using the more reasonable driving distance criteria rather than the former straight-line method. The change increased patient eligibility so more veterans could get care at private hospitals and clinics closer to home, more than doubling the number of veterans eligible for the program. 

Even with the change and more individuals eligible for the program, veterans continued complaining about having trouble accessing medical care through the Choice Program.

On July 31, 2015, Congress took bold action by passing the VA Budget and Choice Improvement Act to address lingering Choice Program problems and to fix a major budget crisis that had been brewing in VA because of increased demand from veterans for health care services. 

The law provided for important modifications and enhancements to the Choice Program, such as:

  • Eliminating the prior enrollment date requirement of August 1, 2014 for veterans to have been enrolled  in the VA health care system, allowing all veterans enrolled in VA health care to be eligible;
  • Allowing the agency to waive the 30-day wait time for veterans needing care;
  • Increasing the number of providers in the program; and,
  • Changing the distance requirement, allowing veterans seeking primary care who live within 40 miles of a VA medical facility, including a community-based outpatient clinic that does not have a full-time physician to use Choice for that care.

Additionally, the bill also provided some significant reforms to improve health service delivery and access in the future, including directing the Secretary to submit a plan to Congress by November 1, 2015, on how it will consolidate all non-VA care programs under one, the Choice Program. 

VA submitted its Plan to Consolidate Community Care Programs October 30, 2015.  The plan proposes consolidation of all seven purchased care programs into one New Veterans Choice Program called the New VCP.

Current Status of the Choice Program

Despite frustrations with the Choice Program implementation, most agree there has been significant progress in improving access in a relatively short period of time.  Though access to care is improving, VA continues to experience multiple systemic issues across the agency, impacting current mission as well as its ability to modernize to meet the growing demand and changing veteran population. 

In fact, the 2015 Independent Assessment Report required by the VACAA cited four systemic findings that impact VHA’s ability to execute its mission (Page xii):

  • A disconnect in alignment of demand, resources and authority.
  • Uneven bureaucratic operations and processes.
  • Non-integrated variations in clinical and business data tools.
  • Leaders are not fully empowered due to a lack of clear authority, priorities and goals.

Although the veteran population is expected to decline over the next decade, a unique mixture of demographic factors is leading to increased demand for VA services and is expected to continue for the foreseeable future. 

Aging Vietnam veterans are using more services at increased costs.  Successful marketing of the Choice Program to increase awareness has led veterans to seek care who may previously have decided not to use the VA.  The conclusion of conflicts in Iraq and Afghanistan is bringing in a new generation of Post-9/11 veterans to the system.  A growing number of women veterans, now 10 percent of the military, are seeking VA treatment at higher rates than their male counterparts. 

Aging infrastructure; antiquated financial, human resource, and technology systems; and budget shortfalls further limit VA’s ability to make much-needed change and improvements on its own. 

Today’s VA health system is more complex and access requirements more complicated than ever, even after decades of reform efforts and enhancements like the Choice Program.  Veterans must contend with a multiplicity of access points, eligibility criteria and gatekeepers in trying to access health care and services.  The experiences of veterans using VA health care vary widely across the country.  The inconsistencies and complexities across the health system erode the trust and confidence veterans have in their system, particularly when they are told that new programs like Choice will help them get the care they need sooner, rather than later.    

MOAA members reflect some of the mixed experiences and feelings veterans have with VA health care, including accessing the Choice Program.  Some of their comments include:

  • 90 Year Old Male WWII Veteran“I’ve always had a great experience with my audiology care and responsive service at the VAMC in Phoenix, Arizona.”
  • 70+ Year Old Female Vietnam Veteran—“I did not intend to use the Choice Program. I have always been satisfied with the responsive on- and off-site services offered at the Sheridan, Wyoming VAMC. However, I was advised that I “have no choice” with the inaccurately named VETERANS CHOICE PROGRAM.   I must acquiesce in the new procedures for off-site services or pay for those services myself…The vets on the bottom of this avalanche of bureaucratic insanity are worse off than ever in their access to timely healthcare.”
  • 40+ Year Old Male OIF/OEF Veteran—“Thank goodness the VAMC in Los Angeles, California stepped in and helped me get my benefits and medical care I desperately needed.”  This wounded warrior was forced out of the military with no assistance in helping him with his transition.  He ended up being rated 100% unemployable, and the VAMC helped him get immediate medical care and services, giving him and his family the longer term security they needed.
  • 32 Year Old Male OEF Veteran—“I’ll never go back to the Washington, DC VAMC again.”  This veteran was in a very unstable condition when coming to MOAA for help.  He was suffering with chronic pain and post-traumatic stress from combat and had been sexually assaulted post-deployment before leaving active duty.  The system was unresponsive in helping him move up his appointment to see his primary care provider, directing him instead to seek care in the emergency room if he thought he needed immediate mental health attention—the ER would then send him to the clinic to see a behavioral health provider.

Implementing the Choice Program has brought to light many of the systemic issues mentioned earlier and with it the perfect opportunity to consider a new vision for VA health care that might otherwise have been missed. 

VA has certainly embraced the opportunity for a new vision for reform in its New VCP concept.  The plan is a step in the right direction to simplify community care and integrate the entire system to enhance the veterans’ experience and health outcomes.

The New Veterans Choice Program (New VCP)

The Secretary and his staff deserve great credit for the work undertaken to coordinate and produce the New VCP, particularly given the tight time constraints for producing the end product.  The proposed plan to consolidate community care provides a good foundation for Congress, the Commission on Care, the VA, and other stakeholders to consider in the process of deliberating the future of VHA.

MOAA, like many of our VSO and MSO colleagues working with VA to develop the New VCP concept, believes the plan offers the potential for expanding and improving access to care, particularly for veterans in need of emergency services and urgent care.  Regardless of what the system of care in the future will look like, the nation has a responsibility to ensure veterans have access to the care, benefits and services they have earned, deserve and value. 

The key elements of a health system veterans and their families/caregivers value most include high quality, accessible, comprehensive, and veteran-centric care—a system that is simple, easy to understand and navigate, and is seamless whether the care is delivered in-house or in the community. 

VA’s intent in its plan for consolidating community care program is to have “clear eligibility criteria, streamline referral and authorization processes, make customer support available when needed, and eliminate ambiguity around eligibility and personal financial obligations for care.” 

VA states the New VCP criteria will also be flexible enough to respond to the unique needs of veterans and eligibility requirements.  This will be evaluated over time depending on health care innovations and changes to the veteran population.

However, VA’s plan for hospital and medical services continues to base eligibility on wait times, geographic access to care and availability of services.  That is, the same confusing and inconsistently applied eligibility criteria used in the current Choice Program.   

VA does propose expanding eligibility for emergency treatment and urgent care services.  MOAA is very supportive of the expansion but opposed to requiring veterans to pay a cost share to access these services.  VA’s plan would require copays of $100 for emergency treatment and $50 for urgent care services for veterans with or without a service-connected condition.  We believe this is a major departure from current eligibility requirements and will negatively impact veterans and their families.  Such a requirement presents yet another set of criteria for VA to manage and another impediment to veterans accessing care.

The new VCP is an ambitious plan.  Any significant reform of VHA will require strong, sustained leadership at all levels of the Department.  Ten of the top 16 VHA executives are new since the Secretary took office, and VA is facing some of the most troubling human resource challenges of its time in recruiting, training, retaining, and developing a viable workforce for the future. 

Clearly, VA must reform.  What remains to be seen is whether VA will have the strong, consistent leadership, vision and commitment at all levels of the organization necessary to drive the real, cultural and transformative changes needed across the entire VA Health Administration (VHA)—one that remains focused on veterans and is agile enough in adapting to the changing veteran population and advances in American medicine.

At its January 2016 VA Commission on Care meeting, Dr. Kenneth Kizer, the former Under Secretary of Health Administration from 1994-1999, told commissioners the issues facing VA today aren’t much different from earlier times when he led the last major reformation.

When commissioners asked him what needs to be done to fix VA, Kizer said, “These are all fixable issues with the right leadership and commitment.” He went on to say, “VA’s biggest challenge is leadership—the culture is driven by the right leadership in the right places at all levels, including Congress.”

Multiple ideas and solutions to reform VHA have come forward in recent months, providing a unique opportunity to take a fresh look at health care. 

One such idea MOAA believes should be seriously considered is the Independent Budget’s (IB)  VSO concept.  The IB’s Framework for Veterans Health Care approach builds upon VA’s progress in transforming VHA, but goes beyond the legislative, regulatory and bureaucratic constraints confining the system today. 

For example, the IB recommends moving away from arbitrary federal access standards to a clinically-based decision made between a veteran (to include family/caregivers) and their physician or health care professional, offering great potential for simplifying eligibility requirements and expanding access across the system, beyond just community care.    

The IB framework starts with the idea of what a veterans’ health care system should look like, rather than what VHA should look like.  MOAA believes this is an important distinction for the Commission on Care to consider when making its recommendations to Congress.

MOAA Recommendations

While MOAA is very encouraged by the Secretary’s transformation efforts, we urge Congress, the Commission on Care and the VA to:

  • Adopt the Independent Budget’s (IB) Framework for Veterans Health Care approach by incorporating the concept recommendations in any plans for transforming the VHA. 
  • Eliminate the current arbitrary federal access standards and establish a new clinically-based standard for both in-house and community care, to include veterans (and family/caregivers) and their physician or medical professional in the decision-making process to yield a less complicated standard for accessing care.
  • Support VA’s plan for expanding access to emergency treatment and urgent care services, but oppose the copay requirement for veterans accessing such care, particularly those with service-connected conditions.
  • Direct resources and funding at modernizing the VA human resources system, requiring VA to implement a workforce management and succession planning strategy for attracting, training, retaining, and sustaining high quality personnel.

Conclusion

MOAA is grateful to the Members of the Subcommittee for your leadership in supporting our veterans, their families and caregivers. 

We look forward to working with Congress, the Commission on Care and the VA as we seek to reform VHA into a world-class system that puts veterans and their families/caregivers at the center of their health care.

Biography of René Campos, CDR, USN (Ret.)

Deputy Director, Government Relations

Commander René Campos rejoined the MOAA staff in February 2015 as the Deputy Director, Government Relations, managing matters related to military and veterans’ health care, wounded, ill and injured, and caregivers.  She previously helped establish a military family program at MOAA, working on defense and military quality of life programs and policy issues.  In September 2007, she joined the MOAA health care team, specializing in Departments of Defense and Veterans Affairs health care systems, as well as advocating for seamless transition programs and women in the military issues.

She began her 30-year career as a photographer’s mate, enlisting in 1973 and was later commissioned a naval officer in 1982.  Her last assignment was at the Pentagon as the Associate Director, Office of Family Policy in the Office of the Deputy Under Secretary of Defense for Military Personnel and Family Policy.

Commander Campos serves as a member of The Military Coalition (TMC) — a consortium of nationally prominent uniformed services and veterans’ organizations, representing approximately 5.5 million current and former members of the seven uniformed services, including their families and survivors, serving on the Health Care; Morale, Welfare & Recreation and Military Construction, and Base Realignment & Closure; Veterans; and Personnel, Compensation and Commissary Committees.