The VA Mission Act hopes to improve upon the Choice program, which ran over budget and didn't do much to reduce wait times for many veterans.
As often as she can, Judi Robinson raises an American flag outside her rambler-style house in Long Beach, Cal. She doesn't keep it up overnight, and she's careful about storage and handling of the national emblem.
"I'm a real stickler for flag etiquette," she said as she unfurled the stars and stripes. "I was a Girl Scout, I was a Marine, and now I'm a member of the Daughters of the American Revolution."
The veteran lives near the Long Beach VA hospital and says she "loves" her primary care doctor there. She says she has defended the VA many times, even when scandals at the agency took over the headlines.
"Because I think some members of the media can blow up stories to get their ratings," Robinson said.
That's why a rocky experience last year came as a surprise.
Robinson had a swollen toe, but after sending some photos to her primary doctor, she was told the wait to see a VA podiatrist was at least 60 days.
"Meanwhile my toe is swelling more and more each day," she recalled.
The VA has a solution designed for just this situation: the Veterans Choice program, launched in 2014 after a scandal over falsified wait times first discovered at the Phoenix VA.
Choice gives patients the option to see a private doctor if they face longer than a 30-day wait for VA care or have to drive 40 miles or more to a VA facility.
"I was thrilled when they offered me the sheet that said, 'okay, you qualify for Choice 30," Robinson said. "I went home and started making calls."
But for Robinson, that's where things stalled. She faced delay after delay in getting a Choice referral.
First, the agency said a VA podiatrist couldn't get her a referral to private care for a couple of weeks, because it would take that long to review her file.
Then, Robinson was told she needed to be seen by an in-house VA podiatrist. Later she was referred to the vascular clinic, but once again had to wait a couple weeks to make an appointment while the doctor reviewed her file.
"I was incredulous," Robinson said.
By the time the vascular department called to get her in, she had given up and taken matters into her own hands. A month-and-a-half after contacting the agency, she was fed up with her beloved VA.
"My response to them was 'thanks but no thanks. It's taken care of itself, I'm tired of this system,'" Robinson said.
She instead used her Medicare coverage to have the swelling treated by a private specialist.
The Long Beach VA says Robinson may have been mistaken -- or was given misleading information -- about her eligibility for the Choice program. The agency confirmed that the wait for a VA podiatry appointment was greater than 60 days, but said Robinson was recommended to make that appointment as a follow-up, not for her initial treatment.
"The Choice Act has been a great tool for VA Long Beach to support our veterans getting access to care when we could not provide it in a timely manner," said VA Long Beach Health Care System spokesman Richard Beam. "However, the communication and frequent changes to the program criteria has at times been confusing to both our staff and our veterans."
A hurried solution
According to a 2018 government study, many VA patients have shared Robinson's experience. It found an average 51 day-wait time for care under the Choice program.
The VA now admits Choice was a rush job -- a temporary fix with unrealistic timelines driven by enormous public pressure. It repeatedly ran over budget and cost taxpayers billions in overhead. There were also issues with paying providers on time, making it hard to keep them in the network.
Enter the new solution: The VA MISSION Act, signed by President Trump last June. (The official name is the "Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.")
The law represents an expansion and streamlining of private healthcare for veterans. But there's uncertainty about what new eligibility rules mean for patients, and critics are worried the new program will undermine VA care.
"All we're doing is getting our veterans on the same playing field as their fellow citizens," said VA Secretary Robert Wilkie. "We're giving them the opportunity to choose what is important to them."
The Mission Act simplifies the current jumble of seven different VA "community care" programs into one system, and it initiates new standards for vets to use networks of outside doctors.
The rules are loosened: Now veterans who have to wait 20 days or drive more than 30 minutes for VA primary care or mental health appointments will get the green light to see private doctors. Specialty care has an average 60-minute drive time or 28-day appointment wait threshold.
The VA expects that will more than double the number of vets eligible, according to a briefing document for members of Congress and their staff obtained by ProPublica. Over a third of VA medical appointments are currently handled in the private sector.
But some veterans groups and members of congress are sounding the alarm about the new rules and what they consider a creeping privatization of VA healthcare.
"We're at a crossroads here," said California Congressman Mark Takano, the Chairman of the House Veterans Affairs Committee.
He was one of 55 Democrats who signed a letter in March asking the VA to re-evaluate the Mission Act's access standards and price tag.
"That's just going to drive up costs, but not necessarily better care, not necessarily more timely access," Takano said. "And we'll see a withering away of VA medical centers."
Wilkie rejects that prediction. Far from withering, he points out, the VA's budget has increased under the Trump Administration. He also cites recent studies showing shrinking wait times and better health outcomes in the VA system, which -- the Secretary says -- will encourage many veterans to stick with their VA doctors.
"If we're privatizing VA, we're going about it in a very strange way," Wilkie said.
The technology underpinning the Mission Act rollout has also come under scrutiny.
The U.S. Digital Service conducted an independent review of the software tool that will determine eligibility for private care. It found serious problems -- glitches, slow run speeds -- that would potentially add extra time to each veteran appointment. Overall, the software problems could mean 75,000 fewer veterans seen at the VA every day.
But Wilkie objects to the idea that the Mission Act is being rushed and vulnerable to similar problems Choice faced.
"Even if -- for some strange reason -- IT didn't work, we have the tools available to make sure people can choose to take advantage of [the Mission Act]," he said.
Some veterans optimistic, but questions linger
With a big transition ahead, many VA patients don't know what to make of the new rules.
"There are some confusing things in there," said Army vet Dean Brown, the president of the Antelope Valley Veterans Community Action Coalition in Palmdale, Cal.
Brown is optimistic about some changes. For example, for minor ailments, patients will be able to walk into participating urgent care clinics without having to get pre-approval from the VA. The Mission Act also does away with an existing process involving triage nurses who, Brown said, have left veterans with medical problems waiting more than 24 hours for referrals to local clinics.
But Brown wants more information -- like what does a 30-minute drive time standard really mean in Southern California's legendary traffic?
"Just from my house to the clinic in Lancaster, I can usually make it there in 20 minutes," he said. "But it also depends on what time of day. I can go past that 30 minutes real quick."
Judi Robinson says she likes the idea of more choices, but also worries about a future where the VA is farming more and more care out to private doctors.
"I would like to be able to maintain the VA as a one-stop-shop," Robinson said. "I would like to maintain most all of my medical care within one system."
Despite all the changes coming down the line, the VA will remain the coordinator for veteran care. The agency has to sign off on veterans seeing private doctors and will keep centralized medical records.
"VA will be the central node no matter what that veteran decides to do," Wilkie said in December at a joint House and Senate hearing on Mission Act implementation.
The new Mission Act rules are scheduled to launch June 6.
This story was produced by the American Homefront Project, a public media collaboration that reports on American military life and veterans. Funding comes from the Corporation for Public Broadcasting.
