‘Choice’ reform, Agent Orange ailments could raise VA costs

by Tom Philpott

VA Secretary David J. Shulkin announced this week that his priorities for improving services to veterans include expanding their access to private sector health care in part by asking Congress to remove two irksome cost controls.

Under the oft-criticized Choice program, enacted in 2014 in response to a wait-time scandal across the VA health system, veterans can seek private sector care at VA expense only if they face wait times longer than 30 days for a VA appointment or they live more than 40 miles from a VA health care facility.

Congress set these restrictions to limit the exodus of patients to private sector care during what was seen as temporary crisis. Without them, the Congressional Budget Office predicted, Choice users would burn through the $10 billion set aside for a three-year emergency program in less than a year.

The Trump administration now wants Choice extended and expanded, as do key congressional leaders, despite warnings from veteran service organizations that shifting too many patients and too much funding to private sector care could begin a slide toward full privatization of VA health care.

Shulkin told a conference of the American Legion on Tuesday that he wants Congress to extend authority for Choice past its Aug. 7 sunset date “because we need those resources to be able to provide the care for veterans that they deserve.”

More surprisingly, Shulkin said the VA will seek authority to redesign Choice to provide faster access to private sector care, which “means we’re going to need to eliminate the 40-mile/30-day rule.” Trump, he added, is committed to such moves to ensure more timely care.

VA policymakers made those early cost projections by congressional auditors look wildly high. They did so by continuing to serve as gatekeepers on access to non-VA care, referring patients whenever possible to approved networks of civilian providers, and leaving veterans frustrated, angry and complaining to Congress.

By early 2016, the VA had revised the 40-mile-rule twice to broaden eligibility, first by replacing “as-the-crow flies” distance with driving distance to the nearest VA hospital or clinic, and later mandating that a VA facility must have at least one primary care physician to be counted in the 40-mile rule.

Rep. Phil Roe, R-Tennessee, a physician who now chairs the House Veterans Affairs Committee, noted that the VA health budget has climbed from $97 billion in 2009 to almost $180 billion this year while the VA hired 100,000 more health care employees, he told Legionnaires. Still, Roe said, he wants to see access to private sector care expanded and veterans put “in charge of health care decisions.”

“If you feel like you’re not getting the care you need at the VA hospital, then you should have the choice to go where you want,” Roe said. Veterans deserve “the absolute best health care that can be provided by anybody in the world,” he added.

Sen. John McCain, R-Arizona, an architect of the Choice program, also wants it expanded. He said the VA “does the best job of anybody on PTSD, traumatic brain injury, prostheses” and other select health services. But veterans shouldn’t have to wait to get routine medical care, McCain told the Legion conferees. They should have the same access to local physicians and hospitals as do Medicare patients.

Shulkin listed nine other priorities, some with significant price tags including modernizing the VA’s electronic medical records. But one pending issue he didn’t discuss could increase VA costs by more than many of his other priorities combined.

Shulkin is said to be weeks away from deciding if hundreds of thousands more Vietnam War veterans will be eligible for VA compensation and health care for new illnesses linked Agent Orange and other herbicides used in the war.

Among ailments under final review is hypertension (high blood pressure), which afflicts two-thirds of elderly American to include Vietnam War-era veterans.

Other conditions that might be added to the list of 17 ailments that the VA presumes were caused by wartime herbicide exposure are bladder cancer, hypothyroidism and conditions with Parkinson’s-like symptoms.

A year ago, the National Academy of Medicine, formerly known as the Institute of Medicine of the National Academy of Sciences, delivered to the VA the last of a series of reviews of scientific studies on ailments possibly linked to chemicals used in Vietnam to defoliate jungles where the enemy could hide.

The National Academy concluded that recent research strengthens the association to herbicide exposure of bladder cancer and hypothyroidism, finding “limited or suggestive” evidence of a link. That was an upgrade from “inadequate or insufficient” evidence found earlier. The report also affirmed limited or suggestive evidence that herbicides could cause hypertension. And it found “no rational basis” not to add conditions that cause Parkinson’s-like symptoms from the limited or suggestive evidence category too.

Dr. Ralph Loren Erickson, chief consultant of post-deployment health services for the Veterans Health Administration, said the Academy findings were reviewed for months by a VA technical work group that included experts in disability compensation, environmental medicine, public health, toxicology, epidemiology and legal requirements of relevant statutes. That work then was reviewed by a strategic work group and finally a task force of senior VA leaders. Shulkin received their final packet of recommendations Feb. 17, three days after he was sworn into office.

“It doesn’t take much imagination to realize how broad it would be and the costs involved” if Shulkin, backed by staff work, decides high blood pressure is a service-connected condition for Vietnam veterans, said Rep. Tim Walz (Minn.), ranking Democrat on the House Veterans Affairs Committee.

“I trust the secretary. I know he’ll do what’s best for veterans,” Walz said. “But I think we put him in a very difficult position” where a decision to add high blood pressure to the list of presumptive conditions would also force him to ask for billions of dollars more to process claims, award compensation and provide care for a condition common in any adult population, or else cut back on other VA services.

The Defense Department estimates that 3.4 million service members deployed to Southeast Asia from 1964 through 1975. If 75 percent are still alive and, based on age, two-thirds have high blood pressure, that’s almost 1.7 million more veterans potentially filing new compensation claims.

Asked if the VA takes cost into account for such decisions, Dr. Erickson said no.

“I suppose at some later date someone who is paid to count beans and to cost things out will probably come up with a number,” he said. “But as it relates to the decision for presumption, cost is not a factor. What we are guided by is if the scientific evidence in the peer review literature sufficient to support presumption.”

Erickson said the drafting of new rules following the secretary’s decision on possible new presumptions would take several months because other federal agencies, including the Office of Management and Budget, would be involved.

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