According to the most recent US Census, an estimated 18.2 million veterans are living in the United States, with roughly 4.7 million veterans residing in rural areas. Veterans who live in rural areas often have less access to care as rural areas have fewer physician practices, hospitals, and other health delivery resources. The health care services provided by the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) have been under intense scrutiny for not meeting the needs of veterans, especially those residing in rural areas. In 2014, in response to Congressional hearings and highly publicized events about VA care and wait times, Congress created the Veterans Access, Choice, and Accountability Act (VACAA), which initiated a program called the Veterans Choice Program (VCP). The VCP allowed Veterans, who met certain criteria, to choose non-VA community care providers with the goal of remedying the issues surrounding appointment wait-times and healthcare accessibility.

On June 6, 2018, President Donald Trump signed the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Networks Act of 2018 (the MISSION Act). Among other things, this Act created a permanent choice program, Veterans Community Care Program (VCCP), ending the previous VCP on June 6, 2019.

Before the VCCP, there were seven different community care programs. The MISSION Act was created to streamline the VA’s community care programs through consolidation, in addition to improving VA Health care delivery and expanding the number of caregivers within the VA network. The Act establishes six new eligibility criteria for community care options, removes telehealth state boundaries for VA providers, adds a new urgent care benefit, increases funding for staffing vacancies, and creates a new mobile deployment pilot program. Therefore, veterans living in rural areas will likely see an increase in access to care under the MISSION Act.

WHO IS ELIGIBLE FOR COMMUNITY CARE?

To be eligible for the new community care program, veterans must be enrolled in VA health care and meet one of the six eligibility criteria. If a veteran meets any one of the criteria, they may then be referred to a non-VA community provider. The non-VA community provider will then bill the VA, not the veteran. In most circumstances, veterans must still receive approval from the VA before obtaining care from a community provider.

A veteran is eligible for non-VA community care if they need a service that is not available at a VA medical facility.

If a veteran lives in a state or territory without a full-service VA medical facility they are eligible for community care. This provision applies specifically to veterans living in Alaska, Hawaii, New Hampshire, and the U.S. Territories of Guam, American Samoa, the Northern Mariana Islands, and the U.S. Virgin Islands.

Veterans are eligible to receive community care under the “grandfather” provision related to the VCP’s distance eligibility. If a veteran lived more than 40 miles away from the nearest VA medical facility on June 6, 2018 (the day that the MISSION Act was enacted), and the veteran continues to reside in a location that would qualify, then they may be eligible to visit a non-VA community provider. In addition to meeting the 40-mile criterion, under the grandfather provision the veteran must either 1) live in one of the five states from the 2010 Census: North Dakota, South Dakota, Montana, Alaska, and Wyoming or 2) live in a different state, but received care from a VA approved community provider between June 6, 2017 and June 6, 2018 and require additional care before June 6, 2020.

A veteran is eligible for community care if the VA cannot provide care within its designated access standards. If a veteran’s drive time is 30 minutes or more for primary care, mental health, non-institutional extended care, or 60 minutes or more for specialty care, then the veteran is eligible to visit a non-VA community provider. The VA has determined that 30 minutes or more equates to the VA failing to furnish care within access standards. Drive times will be calculated by the VA’s geo-mapping software that incorporates factors such as traffic, a benefit for both veterans living in rural and urban areas. In addition to the drive time access standards, the VA has set designated access standards for appointment wait time. If a veteran has a wait time of 20 days or more for primary care, mental health, non-institutional extended care, or 28 days or more for specialty care, then they are also eligible to visit a non-VA community provider.

A veteran may be eligible if both the veteran and the referring clinician agree that it is in the veteran’s best medical interest to see a community provider. Some of the factors to be considered in evaluating whether it is in the veteran’s best medical interest are: 1) The distance between the Veteran and the facility or facilities that could provide the required care or services; 2) The nature of the care or services required by the veteran; 3) The frequency of visits the veteran requires for care or services; 4) The timeliness of available appointments for the required care or services; 5) The potential for improved continuity of care; 6) The quality of the care provided; and 7) Whether the veteran faces an unusual or excessive burden in accessing a VA facility.

A veteran may be eligible if a VA service line does not meet certain quality standards. Under this criterion, veterans can elect to receive care from a community provider, if the VA has identified that a medical service line is not meeting VA’s standards for quality based on specific conditions. However, the VA has yet to implement a clear guideline of quality standards that must be maintained.

The MISSION Act has expanded eligibility criteria to encompass preexisting community care eligibility requirements, while also attempting to make the criteria simpler and less arbitrary. With the expansion, veterans, especially those living in rural areas, will likely experience greater choice options and expect better access to care.

CAN VETERANS UTILIZE TELEHEALTH TECHNOLOGIES AND URGENT CARE FACILITIES?

Before the MISSION Act was implemented, there was ambiguity as to whether or not VA providers were allowed to treat veterans in states for which they were not licensed. The MISSION Act not only created a new community care program, but it also grants authorization for VA providers to use telehealth technologies to deliver care to veterans across state lines.

Now VA doctors, nurses, and other health-care providers may administer care to veterans regardless of where in the US the veteran resides, or where the provider is located.
Expanded access from the MISSION Act does not stop with telehealth. Veterans will also have access to urgent care providers that are in the VA’s network. Over a thousand locations have been added nationwide, allowing eligible veterans to visit urgent care providers for non-emergent symptoms. For veterans to utilize the VA’s new contracted network of urgent care facilities, they must be currently enrolled in the VA health care system and have received care through the VA or a VA community provider within the past 24 months. Although a veteran using this benefit will not have to pay at the time of use, the VA may later bill the veteran for the applicable copayment.

The use of the urgent care benefit is not without its limits. The VA will only pay for urgent care visits if the provider is part of the VA’s contracted network. Thus, if veterans go to an out-of-network urgent care provider, they may be required to pay the full cost of care. Also, the VA is clear that the new urgent care benefit is not a replacement for preventive care. The VA has stated that if a veteran goes to an urgent care provider for preventative services, the veteran could pay the full cost of care. However, the VA will pay for or fill prescriptions for authorized urgent care visits.

WHAT DOES THE ACT CHANGE FOR THE 4.7 MILLION VETERANS RESIDING IN RURAL AREAS?

Under the VCP, 87.9% of eligible veterans lived in rural counties, with a majority of the veterans in counties with no psychiatrists, specialists, or mental health centers. Under the new VCCP, it is predicted that a majority of the eligible veterans will likely be veterans who live in rural areas where there is a scarcity of VA providers and non-VA providers. Therefore, although the VCCP may give greater choice to veterans living in rural areas, it does not solve access discrepancies. Rural veterans may still have to travel long distances to receive care for certain specialties.

While the VCCP might not completely solve the access issue for veterans residing in rural areas with provider shortages, the MISSION Act takes additional steps to reach veterans and break barriers to access. The removal of telehealth restrictions allows veterans to receive care from VA providers without leaving their homes. This is an immense benefit to veterans living in rural areas without access to appropriate providers, especially for those veterans receiving treatment requiring frequent appointments. According to VA Secretary Robert Wilkie, “Telehealth is a critical tool to ensure veterans, especially rural veterans, can access health care when and where they need it.”

The MISSION Act also establishes funds to hire and retain VA health care professionals. There are an estimated 40,000 vacancies within the VHA, with many of those vacancies in rural states. A large portion of the vacancies within the VHA are mental health professionals. To address this problem, the MISSION Act increases discretionary funding that will provide the VA with an opportunity to recruit additional medical professionals through more competitive pay and higher student loan forgiveness amounts.
Additionally, the MISSION Act establishes a pilot program to furnish mobile deployment teams to underserved and rural facilities, providing both specialized and routine health care. These programs will increase medical choices for veterans living in rural communities while decreasing barriers to access. Under the MISSION Act, Veterans will access care from avenues that were previously unavailable.

ARE WE WITNESSING THE PRIVATIZATION OF THE VA? SHOULD WE BE CONCERNED?

The VA Office of Inspector General reviewed the VCP and found that of the veterans who opted into the VCP, 53% waited an average of 45 days to receive care, and 13% of veterans returned to the VA without having received any care.
The VCP fell short of the mark in implementing and delivering its charter, sparking bipartisan agreement that the program needed reform. VA Secretary Wilkie stated that the VA MISSION Act is the appropriate reformation as it will finally “put Veterans at the center of their care and offer options . . . so they can find the balance in the system that is right for them.”

However, not everyone is sure that choice expansion is the direction that the VA should move towards. About 600,000 veterans enrolled in VA health care were eligible under the VCP to obtain care by non-VA providers. Under the MISSION Act, the number of veterans eligible for community care will likely increase anywhere from 1.5 million to 2.1 million, according to the Department of VA. Critics of the act are worried that the expanded choice options are going to harm the VA’s medical facilities as it will redirect billions of dollars to the private sector each year. Will Fischer, the Director of Government Relations for VoteVets.org, stated that “Each time you’re taking resources out and putting them into the private sector, you’re leaving VA dying on the vine.” Carlos Fuentes, Director of the National Legislative Service at Veterans of Foreign Wars, one of the largest Veteran serviced organization, also expressed hesitation: “Our view is that Congress and the administration must fix what is wrong with the VA health care system — improve hiring authorities, expand and fix its aging infrastructure, improve access, customer service — and not just simply turn to the private sector when VA facilities are having problems.” Many groups fear that while the VCCP expands benefits to veterans, it may ultimately lead to a diminished VA health care system.

Not only are critics concerned with the monetary implications of the new community care program, but many are also worried that there will be a variance in the standard of care between the VA and non-VA providers. The VA hospitals have expertise in service-connected injuries such as PTSD, spinal cord injury care, and amputee care, expertise that may not be shared with non-VA providers. In an article published in the Federal Practitioner, after analyzing the VA’s latest study on veteran suicide, Dr. Lemle warned of the harm the choice program might have on veteran suicide prevention. In his conclusions, he stated that “[f]urnishing vouchers to veterans that bypass VA preauthorization will weaken veterans’ mental health care and suicide prevention efforts.” He continued and stated that “once mental health services are privatized, the remainder of VHA services, whose overall quality also has been determined to be equal or better than that delivered in the community, would follow in quick succession.” Dr. Lemle believes that the VA is best equipped to provide the care to veterans. Some critics believe, like Dr. Lemle, that veterans might be inadvertently substituting accessibility for quality under the VCCP.

Secretary Wilkie has responded to privatization claims by referencing the new record-high $6.8 billion funding increase for the VA’s discretion and an overall budget of $220 billion. He stated that “if we’re going about privatizing this, we’re going about it in a very strange way.” Additionally, Secretary Wilkie believes that Veterans will ultimately still choose to use the VA to provide their healthcare needs, as the VA has “made great strides since 2014, and now compares favorably to the private sector for access and quality of care – and in many cases exceeds it.” Ultimately he states that with the MISSION Act, “the future of the VA healthcare system will lie in the hands of Veterans – precisely where it should be.”

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Agneta Hendershot
Agneta Hendershot is a current JD candidate at Penn State Law. She worked as a legal summer intern at the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center. She is now interning at the Veterans and Servicemembers legal clinic in State College, Pennsylvania.