Veterans Access, Choice, and Accountability Act of 2014

Veterans Access, Choice, and Accountability Act of 2014 (113th Congress; HR3230; S2424).
The pervasive problems of access to health care for veterans in the VA health system precipitated new Congressional action. While the VA leadership has been working to correct problems with access to health care, they have been unable to put this crisis in care and loss of trust behind them. In 2014, Kizer (former VA Undersecretary for Health) and Jha recommended specific strategies to move the VA forward. Just this year, the current VA Undersecretary for Health published his perspective and plans in the New England Journal of Medicine. Notwithstanding hard work at the VA over the past 2 years, a recent Wall Street Journal (WSJ) editorial castigates what it calls “the ‘corrosive culture’ at Veterans Affairs”. Clearly, problems with access to health care persist at the VA!
Before passage of the Veterans Access, Choice, and Accountability Act (VACA), veterans had several other choices for receiving health care from non-VA sources. All veterans who are over age 65 years (especially Vietnam veterans) are eligible for all components of Medicare. These veterans are dually eligible and can receive care simultaneously from a private provider through Medicare and from a VA provider. Other veterans have access to health care through VA’s fee-basis system —veterans meeting certain criteria get a “fee-basis card” allowing them to access private health care providers — or through the Department of Defense Tricare program (military personnel, military retirees and their dependents).
Components of the VACA
VACA is a new attempt to improve further veterans access to health care. There are a few criteria veterans must meet to be eligible for this enhanced access. First, there must be no medical appointment available within 30 days of a veterans preferred date or the date determined as medically necessary by their provider. Second, veterans must reside more than 40 miles from the closest VA medical facility. In addition to these two criteria, a veteran must meet one of the following criteria. 1.) The veteran must enroll with the VA by August 1, 2014 and have contacted the VA for a medical appointment. 2.) The veteran must be a combat-theater veteran discharged or released from active duty 5 years prior to VA enrollment.
The new law has several key components (I discuss only a few).
Improving access
Veterans who meet the criteria and elect to seek care from an eligible non-VA health care provider are able to do so once the VA confirms their eligibility and vets the non-VA provider–those veterans receive a “Veterans Choice Card”. By law, this program operates for only 3 years or until funding in the “Veterans Choice Fund” is exhausted. The WSJ editorial observes, “The law allows veterans to see outside doctors, but only for 60 days. Then it’s back to the VA queue”. One wonders if VACA actually provides veterans new choices for non-VA care or merely provides time for the VA to resolve its health care access problems.
Health care staffing
This part of VACA directs the VA to increase its Graduate Medical Education (GME) residency positions up to 1,500, emphasizing residency positions that improve veteran’s access to primary care, mental health, and other specialties that the VA deems appropriate. Furthermore, VACA extends the VA’s existing Health Professionals Educational Assistance Program until 2020 and increases the maximum reimbursement ceiling for education debt reduction from $60,000 to $120,000. In addition to these GME enhancements, there are provisions to recruit and appoint qualified personnel to fill occupations within the VA with the largest staffing shortages. These provisions in the new law should help the VA recruit additional medical professionals, and by increasing staffing, improve access to services for veterans.
There are many other components of the VACA, including provisions affecting health care related to sexual trauma; provision of additional veteran’s educational benefits; and VA personnel authorities and disciplinary procedures. While the VA continues to experience serious problems with access to health care, one might question whether Congress has provided the VA all the tools needed to improve performance. This is most obvious in the case of so-called personnel authorities and the ability to reward high performing employees while disciplining or terminating poor performers. The initial results reported in the WSJ editorial are discouraging!
Also see:
Kizer KW and Jha AK. Restoring trust in VA healthcare, N Eng J Med 2014;371:295-297.
Shulkin DJ. Beyond the VA crisis—becoming a high-performance network. N Eng J Med 2016; 374:1003-1005.
K M Rotunda. The “corrosive culture” at Veterans Affairs. WSJ editorial April 11, 2016; A11.