House Democrats block VA Choice reforms from spending bill

An attempt to get long-stalled reforms to VA Choice in the spending omnibus this week broke down because of opposition from House Minority Leader Nancy Pelosi (D-Calif.), once again putting on hold legislation that would substantially open up private care to veterans.

VA Choice is currently limited to veterans who live more than 40 miles away from the nearest VA medical center or who would have to wait more than 30 days before they can get an appointment. Under the proposed reforms, veterans would not have to "enroll" in a community care program like with previous programs. All veterans would be able to work with their provider to determine the best way for them to get care based on their clinical need.

The reforms to the Choice program, which would hold VA clinics to certain codified care standards and let private and VA providers decide where veterans should seek treatment, were ultimately combined with a mandatory infrastructure review of VA clinics and expansion of home caregiving options for veterans.

Congressional leaders are in final negotiations over the $1.2 trillion appropriations deal that must pass by Friday at midnight to avert a government shutdown. The VA legislation, which was rapidly finalized over the weekend and has not yet been released, was dropped from the omnibus on Monday due to strong opposition from Pelosi, according to several aides from the White House, Senate and House.

"What we are after is getting patients to care, period." House VA Committee's health chair Rep. Brad Wenstrup (R-Ohio) said. "And if it's within the walls of the VA, and available, and the best thing for the patient, good. But one of the things I've been fighting for, my preference, is that primary care doctor who has a patient makes the decision on specialty care."

But a Democratic aide said on Tuesday the proposal failed to meet the House Democrats' goal of consolidating the "VA's multiple care-in-the-community programs into one seamless, understandable and easy-to-use program that safeguards VA's role as veterans' chief advocate, partner and coordinator of care."

"This proposal fails that test by removing congressional oversight on VA's inadequate infrastructure, creating uncertainty with VA's budget and opening the floodgates to privatizing VA's mental health services and beyond," the aide said. "It won't reduce wait times and won't make the VA easier to use."

House VA Committee Chair Phil Roe (R-Tenn.) spoke with Pelosi late Tuesday afternoon in a last-ditch effort to win her support for the overall package. He argued that for real reform, the infrastructure review and caregiving provisions needed to pass along with the Choice reforms.

Negotiations had reached a pitch over the weekend, Roe said, but House Democrats didn't come on board with the compromise that had finally been hammered out between the House, Senate and the White House.

On Monday, a coalition of veterans service organizations came out with their endorsement of the package, including the VA Choice reforms that have fueled controversy over the past few months as the Senate, White House and VA wrangled over how they would decide when VA clinics should release veterans to care.

Pelosi's opposition is the latest roadblock to VA Choice reforms that have been subject to months of policy negotiations and political wrangling since December.

Sen. Jerry Moran (R-Kan.), an appropriator for the VA, had not only come out against the Senate VA Committee's own legislation, he also issued his own alternative bill along with Sen. John McCain (R-Ariz.). As negotiators worked to work through the differences between the competing bills, Moran demanded statutory clarification of the standards VA clinics must meet in order to provide the care for veterans.

The White House backed Moran's demands on access to care standards. Moran and the Senate VA Committee reached a compromise agreement, even as House Democrats worried that it might hasten privatization of the VA health system.

But at least some veterans service organizations have endorsed the final legislative package backed by both parties of the Senate VA Committee, the Trump administration and House Republicans.

In their Monday letter to congressional leadership urging passage of the legislation, eight veterans service organization executive directors said they support the bill's "proposed creation of a new, consolidated community care program based on integrated networks of VA and community providers" as a "balanced approach to ensuring timely access to all enrolled veterans, while continuing to strengthen the VA health care system that millions of veterans choose and rely on."

Moran also endorsed the legislation.

"The Choice bill as it came out of the veterans committee was amended in ways that we had recommended, that I support, and when that occurred I became a supporter of Choice and community care, and I am anxious for the bill to be enacted into law," Moran told Modern Healthcare on Tuesday.

Moran's office issued a statement expressing disappointment from "the idea that the minority in the House would obstruct meaningful legislation to support our nation's veterans by refusing to include bipartisan reforms to the VA" in the omnibus.

House Democrats hit back.

"If Republicans and the White House really wanted an agreement, they would have asked House Democrats for our priorities before Saturday night at the 11th hour," the Democratic aide said.

Senate lawmakers on Wednesday were still at odds over how much the VA should invest in Choice rather than the existing health system.

"I am not in favor of privatization, I have heard from every (veterans service organization) but one that they are not in favor of privatization, but I see privatization written all over this budget," the Senate VA committee's ranking member Jon Tester (D-Mont.) said during a hearing Wedneday.

VA Secretary Dr. David Shulkin testified at the hearing and was blunt about the challenge in the task to build up the VA health system while also expanding Choice.

"We are trying to balance an investment in VA to make it stronger system, and at same time we're trying to give vets a choice for another system," Shulkin said.

The secretary also acknowledged the problems Choice providers have had getting reimbursed from various third-party payers, and said that he is fast-tracking payments to providers owed the most by the VA.