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VETERANS HEALTH ADMINISTRATION (VHA) Needed Reforms

Rescind all departmental clinical policy directives that are contrary to principles of conservative governance starting with abortion services and gender reassignment surgery. Neither aligns with service-connected conditions that would warrant VA’s providing this type of clinical care, and both follow the Left’s pernicious trend of abusing the role of government to further its own agenda.

Focus on the effects of shifting veteran demographics. At least during the next decade, the VA will experience a significant generational shift in its overall patient population. Of the approximately 18 million veterans alive today, roughly 9.1 million are enrolled for VA health care, and 6.4 million of these enrollees use VA health care consistently. These 6.4 million veterans are split almost evenly between those who are over age 65 and those who are under age 65, but the share of VA’s health care dollars is spent predominantly in the over-65 cohort. That share increases significantly as veterans live longer and use the VHA system at a higher rate. VHA enrollments of new users are increasingly at risk of being exceeded by the deaths of current enrollees, primarily because significant numbers of the Vietnam generation are reaching their life expectancy. The generational transition from Vietnam-era veterans to post-9/11 veterans will take several years to complete. The ongoing demographic transition is a catalyst for needed assessments of how the VA can improve the delivery of care to a numerically declining and differently dispersed national population of veterans—a population that is more active, reaching middle age or retirement age, and migrating for lifestyle and career reasons. At the center of the VHA’s evolution during this generational transition is an ongoing tension, some of it politically contrived, between Direct Care for Veterans provided from inside the VHA system and Community Care for Veterans who are referred to private providers participating in the VHA’s two Community Care Networks (CCNs). In recent years, the budget for Community Care has grown as demand from veterans has risen sharply, sometimes outpacing the budgets for Community Care at individual VAMCs.

First and foremost, a veterans bill of rights is needed so that veterans and VA staff know exactly what benefits veterans are entitled to receive, with a clear process for the adjudication of disputes, and so that staff ensure that all veterans are informed of their eligibility for Community Care. Currently, veterans are not routinely and consistently told that they are eligible for Community Care unless they request information or are given a referral.

To strengthen Community Care, the next Administration should create new Secretarial directives to implement the VA MISSION Act properly. Sections for consideration and areas for reform include the following: 1. Sections 101 and 103 (Community Care eligibility for access standards and the best medical interest of the veteran). 2. Section 104 (Community Care access standards and standards for quality of care).

The Trump Administration made Community Care part of its “Veteran-centric” approach to ensure that veterans would be able to participate more fully in their health care decisions and have options if or when the VHA was unable to meet their needs. The Biden Administration has watered down that effort, has sought various procedural ways to slow the rate of referrals to private doctors, and at some facilities is reportedly manipulating the Community Care access standards required by the VA MISSION Act of 2018. If the makeup of Congress is favorable in 2025, the next Administration should rapidly and explicitly codify VA MISSION Act access standards in legislation to prevent the VA from avoiding or watering down the requirements in the future.

3. Section 121 (developing and administering an education program that teaches veterans about their health care options available from the Department of Veterans Affairs).

Section 152 (returning the Office for Innovation of Care and Payment to the Office of Enterprise Integration with a joint governance process set up with the VHA). 5. Section 161 (overhauling Family Caregiver Program expansion, which has gone poorly, so that it focuses on consistency of eligibility and awareness that the most severely wounded or injured may require the program indefinitely).

Require the VHA to report publicly on all aspects of its operation, including quality, safety, patient experience, timeliness, and cost-effectiveness, using standards similar to those in the Medicare Accountable Care Organization program so that the government may monitor and achieve continuous improvement in the VA system more effectively. Encourage VA Medical Centers to seek out relevant academic and private- sector input in their communities to improve the overall patient experience. Budget

Conduct an independent audit of the VA similar to the 2018 Department of Defense (DOD) audit to identify IT, management, financial, contracting, and other deficiencies.

Assess the misalignment of VHA facilities and rising infrastructure costs. The VHA operates 172 inpatient medical facilities nationally that are an average of 60 years old. Some of these facilities are underutilized and inadequately staffed. Facilities in certain urban and rural areas are seeing significant declines in the veteran population and strong competition for fresh medical staff.

In 2018, Congress authorized an Asset Infrastructure Review (AIR) of national VHA medical markets to provide insight into where the VA health care budget should be responsibly allocated to serve veterans most effectively. However, the Senate Veterans Affairs Committee lacked the political will to act on the White House’s nominations of commission members, and this ultimately led to termination of the AIR process. The next Administration should seek out agile, creative, and politically acceptable operational solutions to this aging infrastructure status quo, reimagine the health care footprint in some locales, and spur a realignment of capacity through budgetary allocations. Specifically:

Embrace the expansion of Community Based Outpatient Clinics (CBOCs) as an avenue to maintain a VA footprint in challenging medical markets without investing further in obsolete and unaffordable VA health care campuses. 2. Explore the potential to pilot facility-sharing partnerships between the VA and strained local health care systems to reduce costs by leveraging limited talent and resources.

Personnel

Extend the term of the Under Secretary for Health (USH) to five years. Additionally, authority should be given to reappoint this individual for a second five-year term both to allow for continuity and to protect the USH from political transition. Establish a Senior Executive Service (SES) position of VHA Care System Chief Information Officer (CIO), selected by and reporting to the chief of the VHA Care System with a dotted line to the VA CIO.

Identify a workflow process to bring wait times in compliance with VA MISSION Act–required time frames wherever possible.

Assess the daily clinical appointment load for physicians and clinical staff in medical facilities where wait times for care are well outside of the time frames required by the VA MISSION Act. 2. Require VHA facilities to increase the number of patients seen each day to equal the number seen by DOD medical facilities: approximately 19 patients per provider per day. Currently, VA facilities may be seeing as few as six patients per provider per day. 3. Consider a pilot program to extend weekday appointment hours and offer Saturday appointment options to veterans if a facility continues to demonstrate that it has excess capacity and is experiencing delays in the delivery of care for veterans. 4. Identify clinical services that are consistently in high demand but require cost-prohibitive compensation to recruit and retain talent, and examine exceptions for higher competitive pay. — 647 — 5. Assess the medical facilities where Community Care is readily available but referrals for Community Care are below the averages in other similar markets, referrals expiring are above the average, and/ or canceled appointments are above the average. Identify reasons and factors and consider possible ways to improve timeliness and responsiveness for veterans. 6. Further explore how to leverage telehealth to reduce personnel costs across the enterprise and serve veterans. Continue to pursue expansion of broadband services to remote and rural areas. 7. Assess recruitment and retention in highly competitive medical markets to identify common limiting factors for attracting high-demand, specialized occupations. 8. Consider aggressively recruiting retired physicians who desire to serve veterans. Consider expanding VA tuition assistance in exchange for reciprocal service in rural or understaffed VAMCs.  9. 10. Examine the surpluses or deficits in mental health professionals throughout the enterprise, recognizing that the department needs a blend of social workers, therapists, psychologists, and psychiatrists with a focus on attracting high-quality talent. l Conduct a high-priority assessment of Electronic Health Record (EHR) transition delays and functionality problems. VA innovation in health care for the next 20 years and beyond will rest squarely on the timely implementation of the new VHA EHR in coordination with the DOD’s parallel pacing effort. The VA’s EHR rollout has been blocked by technical delays at local facilities where personnel have raised safety concerns and infrastructure has not been modernized to accept the new system.