Sloan Gibson, Veterans Administration acting secretary, speaks Tuesday, June 17, 2014, at the Baltimore VA Medical Center, where he promised to reduce wait times and improve health care quality for veterans.

The ambitious push by Congress and its veteran affairs committees to swiftly solve a health care wait-time crisis for tens of thousands of veterans by granting access to private-sector care appears to have run hard aground.

After four weeks, House-Senate conferees, working through their staffs to iron out differences in separate veteran health reform bills, need some major breakthroughs, according to lawmakers and staff.

“I am very concerned that this conference committee will end up taking a step backward for veterans’ health care in this country,” said Sen. Jon Tester (D-Mont.).

“That cannot happen. Veterans deserve better.”

Worries center on the showpiece of both bills: that VA for two years will make private sector care available to veterans if they face waits for VA care longer than 30 days or live more than 40 miles from a VA care facility.

The trouble goes beyond costs, though they are considerable. Lawmakers negotiating a final deal appear only now to be learning the challenges for veterans to access civilian care, and the need for VA to have the resources to monitor and coordinate expansion of purchased care.

The unease among lawmakers surfaced during a Wednesday hearing of the Senate Veterans Affairs Committee where acting VA Secretary Sloan Gibson presented the VA’s longer-term plan to improve access to care.

Sen. Patty Murray (D-Wash.), for example, asked about difficulties VA has in getting medical records returned from civilian providers, and monitoring the quality of care veterans receive in the private sector.

“One of the biggest challenges we have with purchased care in the community is maintaining continuity of care for the veteran,” Gibson said. “The ability to get medical record information back and forth is a vital part of this, [to] ensure the quality of care. I will tell you, if the floodgates open, it will present the department with challenges.”

The Congressional Budget Office dropped an anvil of hefty cost estimates on both bills, to the shock of fiscal conservative among supporters.

The Senate voted to treat its bill as emergency legislation, which means not appropriating billions of dollars needed to pay for it; the costs simply would be added to the nation’s debt. House Republicans want the final bill paid for, but need to find budget offsets that colleagues will accept.

With Sen. Bernie Sanders (I-Vt.), chairman of the Senate Veterans Affairs Committee, insisting on emergency funding only, the search is on for ways to lower costs enough to entice House conferees to compromise.

One idea is to cut, from two years to one, the window for easy access to private sector care for veterans facing long waits or long trips to get care. Another idea is to limit eligibility to current VA care enrollees, eliminating the threat of an enrollment rush and yet addressing the current care backlog.

After discussions with committee staffs, the Congressional Budget Office did lower its cost estimate for the Senate bill (HR 3230) to $35 billion in direct spending over 10 years. But CBO cautioned this new estimate ignores any costs from higher usage of VA care after October 2017, even if triggered by the bill’s design. In an earlier cost estimate, CBO said VA health costs could spike by $50 billion a year if as many as two million veterans are enticed to drop current health plans to seek VA-paid care from local docs.

The VA’s new plan to address the wait-time crisis includes expanding VA medical staff by 10,000 personnel, including 1500 physicians, over the next three years. That sounds like a lot, Gibson said, but it’s only a three percent hike to the Veterans Health Administration current staff of 300,000.

VA’s audit of wait times at health facilities, he said, found that the “number-one cause for scheduling difficulties” was a shortage of doctors.

“We have not historically managed to requirements. We have managed to a budget number” regardless of actual need. “And the veterans wound up being the shock absorbers in that process,” Gibson said.

VA also wants more facility space to provide direct care, so VA is asking Congress to fund eight large medical facilities from VA’s construction backlog list, support leases for 77 more outpatient clinics, and cover minor construction and maintenance projects that would open even more space.Those projects combined would allow eight million more VA health appointments annually, Gibson said. The entire plan would cost $17.6 billion over three years. Gibson hinted it’s a better plan than some lawmakers seek.

“I believe the greatest risk to veterans over the intermediate-to-long-term is that additional resources are provided only to support increased purchase care in the community and not to materially remedy the historic shortfall in internal VA capacity. Such an outcome would leave VA even more poorly positioned to meet future demand,” Gibson said.

More VA facilities and staff, however, are precisely what Tea Party conservatives in Congress vehemently oppose. And their view is said to be influencing debate among House-Senate conferees.

Sen. Mike Johanns (R-Neb.), a Tea Party favorite who will retire from the Senate in December, told Gibson that what VA needs is competition from private sector health care providers and not more billions of dollars to spend.

“If somebody were biting at your backside because they were providing better care, faster care, honest waiting lists, [VA leaders] would go, ‘Holy smoke! If we don’t get our act together [and] if we don’t see more patients during the day, we’re going to lose out,” Johanns said.

Gibson countered that many veterans like and depend on VA care.

“But at the end of the day,” Johanns interrupted, “these veterans fight for our freedoms. Why don’t they have the freedom to make their own choice about their health care? And maybe they say…‘That hospital 20 minutes down the road is simply a better situation for me than the [VA] hospital that’s 250 miles from where I’m at, with a long waiting list.’ ”

To a question from Tester, Philip Matkovsky, assistant deputy under secretary for health administrative operations, said purchasing care in the private sector generally costs taxpayers more than care in VA facilities.

Sanders expressed confidence that conferees will reach a deal in time to get a final bill passed before Congress goes on its August break.

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