June 17, 2014

Chairman Sanders, Chairman Miller, Ranking Member Burr, Ranking Member Michaud:

As leaders of the veterans community and on behalf of our memberships, we write to offer some common views regarding legislation recently passed in the Senate and the House in response to the Department of Veterans Affairs (VA) health care access crisis. We applaud the bipartisan manner in which you have worked to move legislation designed to expand access for veterans currently waiting for VA health care. Although we have had only a few days to review the legislative language contained in H.R. 4810, passed by the House on June 10, and S. 2450, passed as an amendment incorporated into H.R. 3230 on June 11, after discussion among ourselves, we have arrived at some common views, which we ask you to take into consideration during any negotiations or formal conferences conducted to achieve compromise legislation.

Although the organizations we represent have different origins, bylaws and missions, and while we do not agree on every policy position, there are certain fundamental principles and critical policy positions that we all share. One principle central to the current crisis is that no veteran who is eligible for health care services from VA should be forced to wait too long or travel too far to get medical treatment and services they have earned through their service. Unfortunately, there is no longer any doubt that far too many veterans who sought care at VA facilities waited too long to receive it or continue to wait for it; such delays must end immediately. Over the past several weeks, there has been a flurry of activity by Congress to examine the extent and causes of the current crisis and to develop short- and long-term solutions. While we appreciate the speed with which you have moved, the opportunity for veterans organizations and other key stakeholders to provide substantive input to the process has been limited. Given the critical nature of the challenges before us, we offer the following joint comments on key elements of pending legislation to address VA’s access crisis.


The first priority for both Congress and for VA must be to ensure that all veterans currently waiting for treatment, and those who would be forced to wait for care in the near future, are provided access to timely, convenient health care as quickly as medically indicated. We understand that VA has undertaken a number of initiatives to immediately schedule appointments for veterans waiting for care, both within and outside of the VA system, and therefore any legislation that is enacted by Congress must not interfere with that ongoing process. In addition, as Congress negotiates a compromise bill that contains provisions to strengthen and restructure VA to avoid future access problems, it must ensure that any debates or disagreements over such future-oriented policies do not impede, slow down or in any way interfere with the enactment of legislation whose primary goal should be providing immediate access for all veterans currently waiting for care.


Whenever VA is unable to directly provide enrolled veterans with access to care that is medically necessary within reasonable waiting time or travel distance standards, VA must be involved in the timely coordination of and fully responsible for prompt payment for all authorized non-VA care. The Senate bill contains provisions that reflect part of this principle and should be retained, but should also be amended to allow VA to use all available means at its disposal, including the Non-VA Care Coordination Program, to coordinate such care to ensure veterans are treated within reasonable access standards. The House bill contains a provision authorizing follow-up care, an important element of care coordination; however, the length of time for completion of such care should remain a clinical determination. Both the Senate and House bills specify access standards for timeliness; however, the Senate provision set at 30 days is the better option at this time. The Senate bill also contains a provision regarding prompt payment to providers that should be retained; however, it is more important that the final version of the legislation contain clear requirements to guarantee that VA remains wholly responsible for making payments to non-VA providers. Veterans must not be billed directly by providers for care coordinated by VA and any copayments that may be required of veterans must be collected only by VA. Finally, neither existing nor new administrative requirements concerning coordination of care should impede or further delay access to care for veterans currently waiting.


As Congress considers legislation mandating the expansion of VA’s purchased care authority, VA must accurately estimate the additional costs that will be incurred and request sufficient supplemental funding. In turn, Congress must then fully fund such costs with new appropriations, separate from funding required to operate VA’s hospitals, clinics and other health care facilities and programs. Unless additional funding is provided specifically for the expansion of purchased care, needed care will remain delayed and VA facilities will be forced to continue making tradeoffs between providing additional access now through purchased care, versus expanding internal capacity for the future through additional hiring of clinicians, purchase of equipment or expansion of infrastructure.

For the current fiscal year, VA should use all unobligated balances first, then request sufficient supplemental appropriations to fulfill its planned access initiatives, which Congress must immediately appropriate. Furthermore, the FY 2015 VA appropriations bill currently pending before Congress, which includes the FY 2016 advance appropriations request, must be increased prior to final passage to reflect VA’s new estimates for purchased care for both years. It must also be increased to reflect the additional costs for expanded access in the final enacted legislation as estimated by the Congressional Budget Office, currently estimated at $35 billion for Title 3 of the Senate bill. Most importantly, in passing legislation to expand veterans’ access to health care, Congress and VA must not rely on budgetary gimmicks, such as unrealistic estimates of operational improvements, efficiencies, collections, carryovers and contingencies. These undocumented “savings” have rarely materialized and have contributed significantly to funding shortfalls that have plagued VA for more than a decade.


Any legislative, regulatory or administrative changes designed to respond to the VA health access crisis, whether temporary or permanent, must protect, preserve and strengthen the VA health care system so that it remains capable of providing a full continuum of high-quality, timely health care to all enrolled veterans. Both the Senate and House bills include sunset provisions as part of their expanded access provisions designed to fill in gaps resulting from VA’s current lack of capacity to treat veterans within the VA health care system, and a sunset provision should remain part of the final bill. However, unless the legislation simultaneously sets VA on a path to intelligently strengthen health care delivery, expand access and capacity, reallocate resources and ensure that overall VA funding matches its mission, the current problems confronting VA and veterans will inevitably recur.

Both the Senate and House bills contain provisions creating new commissions, studies and reporting requirements designed to examine the root causes of VA’s capacity and access problems, and some version of these should remain part of the final compromise. In addition, it is essential that such commissions look holistically at the interrelated issues of access, capacity, infrastructure and funding in order to ensure that VA in the future has sufficient resources to match its mission.

Recent legislation approved in the House, H.R. 813, and a Senate companion bill marked up in Committee, S. 932, could provide a proven framework (advance appropriations) to improve VA’s ability to better plan and manage its funding, especially in relation to infrastructure and IT projects, two areas contributing to VA’s access problems. In addition, H.R. 813 contains important provisions to increase VA’s budgetary transparency and accountability, which is critical to the success of expanding VA’s access to care. H.R. 813 would create a new strategic planning framework comprised of a Quadrennial Veterans Review, a Future Years Veterans Program, and a Planning, Programming, Budgeting and Execution (PPBE) process, similar to what is used by the Department of Defense. H.R. 813 also contains relevant provisions regarding studies about how to reorganize VA and management accountability. For all of these reasons, we strongly encourage Congress to include both H.R. 813 and S. 932 within the scope of any negotiations or conference committee on improving access to care for all veterans.

In addition, while developing final legislation designed to expand access to care outside VA, Congress must never lose sight of the continuing need to increase VA’s internal capacity to provide specialized care to veterans who rely heavily or entirely on the VA system, such as catastrophically disabled veterans. Veterans with spinal cord injury or dysfunction, amputation, blindness, PTSD and polytrauma, cannot receive the holistic specialized care they need in the private sector and will always require a robust, fully funded VA system to provide cutting edge services they deserve. These men and women have also earned the right to rely on a VA system capable of providing all of their primary health care needs as well, which is how the current system was designed and must continue to operate.

Finally, both the Senate and the House bills contain provisions designed to increase accountability for senior employees in the VA, and in negotiating a final compromise we would encourage you to retain provisions that provide at least some minimum due process protections.


As Congress and the Administration develop, debate, negotiate, enact and implement new policies and procedures, they must do so in an open and transparent manner that allows meaningful input from VSOs, veterans and other key stakeholders. The failure to share and communicate information inside and outside of VA contributed to the current waiting list crisis and both the Senate and House bills include important provisions regarding public and congressional reporting requirements that should remain part of the final legislation. Valid reporting data on access, quality, health outcomes and other metrics can provide invaluable information to help guide improvements to the health care system. In a similar spirit of openness and transparency, we would strongly urge Congress to ensure that a conference committee or other negotiations related to this legislation be open and transparent to the public and particularly to veteran stakeholders. Furthermore, we would hope that as you continue moving towards a final compromise, that you will reach out to us for our input regarding this legislation that will have long lasting effects on the VA health care system for millions of veterans. Similarly, as you move legislation that will require VA to develop implementing regulations, we ask that you also require VA to consult with and solicit comment from veteran stakeholders prior to regulations being promulgated, even for interim final rules.

Messrs. Chairmen and Ranking Members, although this has been a very difficult few months for veterans and the VA, there remain reasons to be optimistic. We are encouraged that Congress has begun to show signs of returning to a bicameral, bipartisan approach to veterans issues, and we hope that you will continue working in this manner to address other pressing veterans matters that remain unfinished this year. We also hope that you and VA officials will continue to reach out to veteran stakeholders to hear our views, learn from our experiences and benefit from our expertise as you develop new policies, regulations and laws designed to improve the delivery of health care to the men and women who served. Thank you for your consideration of our comments.

The American Legion

DAV (Disabled American Veterans)

Paralyzed Veterans of America

Veterans of Foreign Wars of the United States

Vietnam Veterans of America

Military Officers Association of America

U.S. Coast Guard Chief Petty Officers Association

Jewish War Veterans of the USA

Association of the U.S. Public Health Service

United States Army Warrant Officers Association

Air Force Sergeants Association

Marine Corps Reserve Association

Association of the U.S. Army

Fleet Reserve Association

Reserve Officers Association

VetsFirst, a program of United Spinal Association

Iraq and Afghanistan Veterans of America (IAVA)

Association of the U.S. Navy (AUSN)

Military Chaplain Association of the United States

Marine Corps League