In a sign of increasing pressure on safety-net providers, Department of Veterans Affairs Secretary Anthony Principi last week stood behind a July 18 memo ordering a halt to VA outreach efforts despite criticism from some members of Congress.
The memo, written by Undersecretary Laura Miller, instructed VA regional directors to stop activities aimed at attracting new enrollees, including health fairs, open houses and displays at veterans' service organizations. She cited "a growing crisis related to the continued demand for healthcare services that exceeds our resources," including wait times at clinics that exceed the VA's 30-day standard.
The VA is among many providers of publicly funded care who have recently tried to stem their volumes. Some state Medicaid programs have similarly tempered outreach efforts in the last 18 months in order to address budget shortfalls, according to policy analysts. And this month, a California hospital imposed limits on care to indigents (See related story, this page).
The VA's medical care budget increased 25% in five years, to $20.9 billion in fiscal 2001 from $16.7 billion in fiscal 1996, said spokeswoman Jo Schuda. Meanwhile, she said, the number of patients treated increased by nearly half, to 4.2 million from 2.9 million.
The VA won't deny benefits, but it's "not going out and putting sign-up cards in front of people," another spokesman, Jim Benson, said. He said the agency will "pull in horns a little on enrolling new vets into the system until we can attack the backlog" of current enrollees who are awaiting care. "The ones there are already frustrated enough," he said.
VA officials blamed several factors, including a 1995 law that expanded eligibility to middle-income veterans who lacked service-related disabilities. At the time, it was thought VA facilities would have excess capacity because of a declining population of World War II veterans.
In addition, the VA expanded access by opening 400 community-based clinics, Schuda said. She said rising drug costs also have been a burden.
Two years ago, the General Accounting Office criticized the VA for wasting money by delaying facility closures (April 10, 2000, p. 10). Cynthia Bascetta, the GAO's director of veterans' health and benefits issues, said that although the VA still could be more efficient, eligibility reform did open the floodgates. "We are hearing more and more that increasing demand and waiting time is a significant problem, so I think the agency really is between a rock and a hard place when it comes to meeting demand with current resources," she said.
Nevertheless, several members of Congress lambasted VA leadership, accusing it of attempting to cut off care. Sens. Max Cleland (D-Ga.), John Kerry (D-Mass.) and John McCain (R-Ariz.) called for President Bush to fire Miller or "whoever is responsible" for the decision to halt outreach.
However, the VA could have taken even stricter measures. Last fall, Principi decided to alleviate a $400 million budget shortfall by cutting off enrollment of veterans who did not have service-related injuries and had incomes of $24,000 or more. They are the VA's fastest-growing yet lowest priority category of enrollees.
But at the last minute, the White House instructed Principi to back off, and said somehow money would be found. Only last week, President Bush signed legislation that will provide the VA with supplemental funding of $142 million, Schuda said.
Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured, said the VA is an "important source of healthcare" for many people who might otherwise be uninsured. She said based on the experience of Medicaid programs, absence of outreach could lower participation, especially if veterans' groups don't pick up the slack with their own educational efforts.
If that happens, other healthcare facilities might have to fill the gap.
The American Hospital Association has not taken a position on whether the VA needs more funding, said spokesman Rick Wade. But he said the VA's decision to stop outreach could add a "modest amount of pressure" to address the problem of the uninsured.
-With Jeff Tieman