Since this article was written and as of Wednesday April 14, there are 4,400 cases of coronavirus among the patients at the nation’s Veterans Affairs health centers, with 272 deaths—up from 53 deaths on April 1. VA facilities have been hit hard, particularly among “cluster cities” in New York (Brooklyn is the worst), New Jersey, Louisiana and Michigan. According to this report the death rate for those tested and confirmed with the virus is 6 percent (mostly older and infirm). As of April 8, seven VA health care workers had died from the virus. As of Sunday 1600 VA health care workers across the country have been tested positive. Other reports indicate that despite officials’ insistence, not all VA facilities are fully equipped to fight the pandemic, raising the usual questions about the system’s readiness to respond to crises, whether a public health emergency or an influx of veterans during nearly 20 years of war.

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Gary Pressley wasn’t the first veteran to shoot and kill himself in a Veterans Administration hospital parking lot and likely won’t be the last. According to the VA, there were 19 such suicides across the country from 2017 to 2018. Pressley’s particular cry for help—and what some observers have called a grim form of protest—was a bit unique, however, because it not only raised questions about VA’s ability to give veterans timely, quality care, but also cast doubt on the success of recent congressional plans to redirect veterans to private care when necessary.

Pressley’s death in Georgia in April 2019 (his was one of three on a VA property in a five-day period) and his mother’s subsequent lawsuit against the VA system for negligence, casts light on an ongoing debate over why the VA cannot seem to crawl out of its massive bureaucratic problems. But the 28-year-old Navy veteran didn’t just kill himself because he couldn’t get an appointment. According to his mother, he began going through pain medication withdrawals after his private doctor stopped taking veterans in February 2019 because the VA owed the practice thousands of dollars in unpaid reimbursements. According to his family, after he was dropped, Pressley tried repeatedly to get an appointment with the VA (he was a patient there before they referred him to the private sector), to no avail.

Family members warned the VA police on April 5 that Pressley was making the two-hour drive from Forsyth to the VA in Dublin, Georgia. There, he made five desperate, reportedly unheeded calls to the main switchboard. He was found slumped over the car’s console that evening, at 5 p.m.

His sister “Lisa told the operator exactly where he was located based on his GPS signal,” the lawsuit reads. “No one from the VA attempted to locate or assist Gary, who was on the brink of death.”

A spokeswoman at the VA headquarters in Washington would not comment directly about Pressley’s case. 

So, five years after Congress passed the Veterans Choice Program to deal with the influx of over 1.5 million Iraq and Afghanistan veterans coming into the system since 2001 (not to mention the scandals over wait times and poor access to care), it seems that no one is satisfied with how it’s turning out. The biggest problem, as highlighted in Pressley’s case, is the 2.5 million backlogged reimbursement claims from private providers, representing hundreds of millions of dollars of unpaid bills. To get a sense of how much this is, consider that as of February, New Hampshire alone said its providers were waiting for repayments of $134 million.

‘New and Improved’?

Doubts are already circling around the second “new and improved” incarnation of the choice program—the Mission Act—which began in select regions last June and is rolling out fully this year. The new program consolidates the network of doctors and streamlines the rules. Veterans can go to any urgent care without prior authorization (but still need pre-authorization for primary and specialty care). Those with more than 20-day wait times for mental health and primary care at the VA (and 28 days for specialty care) can access a doctor in the private network. Those who are more than 30 minutes away from a VA (60 minutes for specialty care) are automatically eligible.

There are already bumps: in November, one of the two third-party private companies administering the new, more consolidated choice program said it would probably need upwards of $75 million more to build out the network to accommodate the increase of patients under the new Mission Act (about 2.1 million eligible vets total). The contracts for three regions in the U.S. were awarded to Optum Public Sector Solutions Inc., in December and are worth $55.6 billion through 2026.

Senators, too, have recently voiced skepticism that the new system can accommodate the strain.

There is, of course, finger-pointing on all sides, raising the age-old question of whether a government-run system tailored to their needs, or the private sector, better serves veterans looking for more efficient and accessible care.

“I voted against the Mission Act,” declared Senator Mike Rounds of South Dakota, in an interview with TAC. He was only one of five opposing votes last May and one of two Republicans (the other was Senator Bob Corker from Tennessee.) “I thought they were making promises they could not keep; they were offering services that they were not properly funded to do, and in doing so they were taking away the first set of guarantees we promised veterans for years.”

He said there were millions of dollars in unpaid private care in his state, “and the VA has not shown how they are going to fix it.”

To attempt to comprehend the blame game involved in the epic saga that is VA healthcare reform, we have to tease out the competing interests among veterans, advocates, and politicians. 

Defenders of the VA say that “privatization zealots” (particularly among Trump appointees who have been accused of undermining the institution) are pushing veterans into a private healthcare system that is wholly unprepared for the burden. Moreover, they do this at the expense of truly fixing what has been wrong with VA for decades (resources not meeting demand, bureaucratic morass, poor training, and a toxic culture).

Those in favor of more privatization said that the VA has proven unable to clean its own house. Until it is capable of providing the care promised to veterans, those who sacrificed should have choices. Meanwhile, they say, problems in the private system, like the reimbursement backlog, are directly caused by the usual red tape endemic to an over-regulated, flabby, inefficient federal system.

Why can’t the VA get it together?

Aside from the rosy view projected by the VA press office and the Trump administration, no one is fully confident in this hybrid system to date. And most agree that the VA is insufficient at a time when millions of new veterans are pumping into the system due to 18 years of endless wars overseas. A generation of older veterans are leaving the rolls, yes, but we know the VA wasn’t prepared to take on the myriad mental health and polytraumatic injuries that are emblematic of this post-9/11 cohort—including brain injuries, amputations, and toxic exposures—from the beginning.

Furthermore, the network of VA hospitals built in the 20th century is ill-fitted to today’s veteran demographic, which is more rural and concentrated in the southern and western parts of the country. Only 55 percent of veterans are within a 40-minute drive of a medical center, and only 26 percent are within a 40-minute drive of VA specialty care, like oncology and cardiology facilities. Those who are poor and rely on public transit are in even worse shape. Older, low-income vets tend to rely on the VA more.

Combine that with chronic issues and scandals involving hospital administrations hiding unacceptable wait times and accompanying mortality rates, huge backlogs of disability claims, and continued whistleblower retaliation across the country, and you have a system that has been fighting non-stop for the confidence of a nation, not to mention the veteran population, every year, through Democratic and Republican administrations alike.

And yes, the VA budget totals have increased every year since 9/11. The 2020 budget is $221 billion; the White House has proposed $240 billion for 2021. In 2001, before the Iraq and Afghanistan wars, the budget totaled around $45 billion. But the issue is not how much, but how it is being spent. As one veteran advocate who works for a law firm specializing in disability claims put it, the money gets spread around with no heed to changing demands. There are critical vacancies in the departments and hospitals that need it most, leading to poor training and implementation of constantly changing rules and mandates. Add that to inconsistent congressional oversight and the injection of privatization politics, and you end up with constant fragility.

What veterans say

When contacted by TAC, representatives of top veterans’ service organizations (VSOs) offered varying opinions of the new and previous choice programs, and of VA performance overall. A common thread: most veterans prefer the VA because their doctors are not only top-notch, but are also trained to appreciate the full scope of veterans’ unique injuries and experiences. But if they cannot get timely appointments within a reasonable distance from home, they want to have the option of seeking out non-VA care.

“We have been very strong advocates of the use of privatized care. But we don’t support a full privatization of the VA,” said Dan Caldwell, senior advisor to Concerned Veterans of America (CVA), a conservative advocacy group that has been accused by some of pushing full privatization. “That’s not what we support,” insisted Caldwell. “The VA must be a good choice but not the only choice. We believe in healthcare choice, which requires a community care (private) option, but it also requires a strong VA.”

He said CVA was probably the most aggressive VSO in support of the Mission Act, though he concedes there are a “lot of moving parts and a lot of ways the Mission Act could be implemented improperly.” The group is in favor of a BRAC-style realignment (included in the Mission Act), which would entail closing or downsizing underused, older facilities in favor of shifting VA resources to where they are needed. Caldwell would also like to see something like the military’s Tricare system, where veterans do not need pre-authorizations for every primary and specialty care visit.

“The VA needs to move forward in empowering vets over the bureaucracy,” he noted. “Too often you hear that veterans and some veterans’ groups unfortunately feel this way—that the interest of veterans is not always aligned with the interests of a 400,000-person bureaucracy.”

Much of the problem is also mistrust and a lack of communication, said Tom Porter, spokesman for the Iraq and Afghanistan Veterans of America (IAVA), which today has about 425,000 members. In recent surveys, according to Porter, the group found that only 16 percent of its members have used the community choice program, and only 36 percent have even heard of the Mission Act. In the meantime, high numbers—86 percent—say VA care is average or above, though experiences vary. “As they say, you see one VA, you’ve seen one.”

“We support the Mission Act, but we need to keep a watchful eye on the implementation,” Porter said. Members have complained about confusion with authorizations and how the program has worked in the past. Also, the VA has “not been particularly transparent” with VSOs about how things are going. Meanwhile, Porter agrees that funding to the VA is scattershot and not effectively targeted, pointing to unspent funding for mental health/suicide prevention outreach and unequal resources for women-specific healthcare.

Senator Rounds admits he is more cynical about the VA’s systemic problems. There is a reason this culture punishes, not rewards, whistleblowers who call out cover-ups and mismanagement: the bureaucracy is designed to protect itself first. “With a bureaucracy as large as the VA I think they see any money going outside to the private sector as money they cannot use for their own operations. I really do see that as part of the problem”—a problem that contributes to huge backlogs in the payment system, confusion, and veterans waiting for authorizations to seek care in the private network.

That is just not true, says Christina Mandreucci, a VA spokesperson, in a recent email exchange with TAC. “Many of the older claims you reference are from before the implementation of the Mission Act, and either have to do with unauthorized emergency care claims or community care programs that no longer exist.” She also said the VA plans to have those 2.5 million unpaid claims completed by the end of the year.

As for the new program, Mandreucci says it is designed to be more streamlined than the previous incarnation, which required pre-authorization even for urgent care. She notes there were already some 200,000 urgent care visits “completed” since June 6. “The Mission Act has greatly expanded the choices veterans have when it comes to their healthcare,” she charged.

The American Legion, too, is cautiously optimistic. “We’re in a wait-and-see phase,” said Chanin Nuntavong, director of government affairs for the American Legion and its nearly two million members.

Paul Harris, media director for the organization, is a veteran and has used private care under the new system, as well as the VA, while working in Denver. “It was nice having both available.”

However, in their own survey, “our members preferred to use VA care. We support that. I personally use VA—they understand me, they understand my ailments, and how I got them,” he said. “We believe the VA care is the best care because civilian providers don’t understand.”

This brings us back to the beginning. VA care may be “the best care”—when it is working. The private sector offers choice to veterans who cannot access that superior care. What can Congress do? If they are honest about reforming the system, they can start by better targeting the resources, listening to regional directors, and demanding straight answers from Washington bureaucrats.

They can also provide a streamlined private alternative that is not encumbered by the VA’s notorious red tape and inefficiency. This may perhaps take some of the pressure off the VA while it gets its house in order, and keep veterans like Gary Pressley from killing themselves in the parking lot.  

Kelley Beaucar Vlahos is Executive Editor of The American Conservative.