WASHINGTON — The Senate gave final passage on Wednesday to a multibillion-dollar revamp of the veterans health care system, consolidating seven Veterans Affairs Department health programs into one and making it far easier for veterans to take their benefits to private doctors for care.
The legislation, which passed 92 to 5, also expands popular stipends to family caregivers of veterans who served during the Vietnam War era or after. And it establishes a nine-member commission to study the department’s current infrastructure to determine where its health system should expand and contract.
The comprehensive bill had been a year in the making, and ultimately won the support of Republicans and most Democrats. The House passed it last week, 347 to 70, and President Trump plans to sign it into law.
The bill rounds out an ambitious legislative agenda on veterans issues that has bridged the administrations of President Barack Obama and Mr. Trump, and largely united moderates in both parties who set out to make major changes to the department after a 2014 scandal over the manipulation of data on patient wait times. Mr. Trump has already signed laws that make it easier for the department to remove and fire employees and for veterans to appeal benefits decisions, as well as a rewrite of the G.I. Bill for post-9/11 veterans.
Wednesday’s vote is “the last piece of a great mosaic to reform the benefits for our veterans to make them contemporary with the 21st century,” said Senator Johnny Isakson of Georgia, the chairman of the Senate Veterans’ Affairs Committee. Dozens of military and veterans groups, including the largest congressionally chartered organizations, such as the American Legion and Veterans of Foreign Wars, also touted the changes.
But beneath the surface, deep mistrust remains over the Trump administration’s mission to increase the use of private care. Many of the largest veterans groups, as well as Democrats and some moderate Republicans, fear that the White House’s push to unfetter veterans’ ability to choose their care is a backdoor effort to tip the scales in favor of private medicine and to starve the federal government’s second-largest department and its vast government-run health system.
Liberals, including the Democratic Party’s top lawmaker on the House Veterans’ Affairs Committee and a former chairman of the Senate committee, warned that because the bill lacks a long-term funding source, the cost of the program — estimated to be roughly $50 billion over five years — could end up cannibalizing other pieces of the department’s budget.
“It provides nothing to fill the vacancies at the V.A. That is wrong,” said Senator Bernie Sanders, independent of Vermont, who ran the committee in the aftermath of the wait-time scandal, when lawmakers first created the so-called Veterans Choice Program to relieve pressure on the system. “My fear is that this bill will open the door to the draining, year after year, of much-needed resources from the V.A.”
With veterans organizations supporting the measure, labor groups, including the American Federation of Government Employees, which represents 260,000 department employees, have led the opposition, arguing that it will allow the outsourcing of key department health services without addressing the department’s staffing shortages.
“Too much is at stake for veterans, their families and everyone who benefits from the V.A.’s extraordinary accomplishments to succumb to political pressures to hurriedly pass potentially damaging changes with many unknown consequences,” the groups wrote Tuesday in a joint letter.
But advocates of the bill, including Democrats and groups like the Legion and the V.F.W. that are staunchly opposed to privatization, say they have merely arrived at a sensible and much-needed compromise. The Choice program, they say, was designed with good intentions but has turned into a bureaucratic tangle, burdening department doctors, straining its balance sheets and delivering little of the relief it was meant to provide for veterans. They point out that earlier legislation had already made large investments in improving the department’s own health system.
“The Choice program has been a wreck,” said Senator Jon Tester of Montana, the top Democrat on the Senate committee. “Every veteran up here will tell you that.”
But, he added, “The best defense against any effort to privatize the V.A. or send veterans in a wholesale factor to the private sector is to make sure the V.A. is living up to its promise.”
Concerned Veterans for America, an advocacy group backed by the billionaire conservative activists Charles G. and David H. Koch, has led the push for veterans to have complete control over where they use their benefits, and it celebrated the vote. Its executive director, Dan Caldwell, called it “a big win for those who want to see the V.A. better integrate with the private sector.”
The new, combined program, called the Veterans Community Care Program, attempts to integrate the department’s 1,300 hospitals and clinics with credentialed private doctors. It also expands the circumstances under which veterans can elect to go to a private doctor at government expense.
The current Choice program allows patients facing a wait of at least 30 days to receive treatment to seek private care funded by the government. Veterans who must travel at least 40 miles can also seek private care. The new bill scraps those standards.
Instead, eligibility is determined by a mix of factors, including wait times, distance, the service ratings of government facilities and the availability of specialists. Veterans will be expected to consult with their Veterans Affairs Department primary care doctor about the best course of treatment.
Veterans who have used the department’s health system within two years will also be allowed walk-in visits to private clinics, in some cases without co-payments.
The department currently sends more than one-third of appointments to private providers, and the numbers have been ticking up over the past year. It will have substantial leeway in carrying out the new program over the next year.
The expansion of caregiver benefits has been a long-term priority of veterans advocates. The department currently only pays stipends to family caregivers of veterans who served after Sept. 11, 2001.
The creation of a commission to study the department’s physical footprint and distribution of resources is more divisive. Conservatives have long fought for the commission as a way to cut what they suspect are unneeded or redundant facilities. But Democrats and some veterans advocates fear the panel, in conjunction with the new private care program, could be used to justify a downsizing of the federal health system.
The bill includes a long list of other, smaller provisions meant to improve access to care. It eases some restrictions of the department’s use of telemedicine and establishes a pilot program to test the use of mobile care teams who will travel to rural or otherwise underserved areas.
The legislation includes modest incentives to try to build up the department’s work force, including loan repayment and recruitment and retention bonuses. There are currently more than 30,000 unfilled positions in a work force of more than 360,000.
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