President Trump is preparing to sign a sweeping new law Wednesday aimed at expanding veterans' access to private-sector healthcare. But behind the scenes his administration is fighting a bipartisan Senate effort to fund the legislation.
The VA Mission Act authorizes new healthcare programs for veterans, but the bill does not reserve federal money to pay for those programs. A group of powerful Senate committee chairmen aims to remedy that by amending a separate measure to pay for the new $50-billion law, saying that adding the funds is the best way to ensure the new programs give veterans access to medical care.
But the White House has engaged in a quiet effort to thwart the senators' plan, encouraging lawmakers to vote it down and instead asking Congress to pay for the veterans programs by cutting spending elsewhere.
White House officials are circulating a memo on Capitol Hill this week that slams the senators' proposal as "anathema to responsible spending" and predicts it would lead to ballooning costs and "virtually unlimited increases" in veterans' spending on private healthcare.
"Without subjecting the program to any budgetary constraint, there is no incentive to continue to serve veterans with innovative, streamlined and efficient quality of care," the administration says in the memo, which was obtained by the Washington Post.
Sen. Richard Shelby (R-Ala.), chairman of the Senate Appropriations Committee, argued that if Congress does not ratify his proposal, the alternative could be to cut $10 billion a year for five years from existing programs, including initiatives within the Veterans Affairs Department.
"If we don't get on it we're going to have a hole of $10 billion in our approps," Shelby said Tuesday, predicting "some real trouble."
Shelby is joined in his effort by the top Appropriations Committee Democrat, Patrick J. Leahy of Vermont, as well as the leaders of the Veterans Affairs Committee, Chairman Johnny Isakson (R-Ga.) and Sen. Jon Tester (D-Mont.). Their coalition reflects a renewed commitment in the Senate to completing spending bills on a bipartisan basis after years of budget dysfunction.
Their effort has run into stringent opposition from a White House still reeling from conservative backlash to the $1.3-trillion government-wide spending bill Trump signed in March. The deal broke through previous spending caps with huge increases in domestic spending Democrats demanded in exchange for military spending sought by Republicans.
Conservatives, including close Trump allies, publicly slammed the spending package and criticized Trump for signing it, and the administration has subsequently dug in against new spending and worked to claw existing spending back.
Trump frequently touts his support of veterans and members of the armed services, promising during the campaign to fix the VA and give more veterans access to private healthcare. Aiming to keep those promises, veterans programs are one of the few areas aside from the military where Trump has encouraged new spending.
But the White House says it won't accept new spending on the veterans' bill above the agency budget levels already negotiated with Congress, arguing enough money can be found to fund it within existing budget limits.
"We have a responsibility to provide our Veterans with the care they deserve, while also being good stewards of the taxpayer dollar," the administration said in a statement.
The VA spending fight could come to a head as soon as this week, as lawmakers prepare to take up a military construction and VA appropriations bill that the bipartisan group of chairmen want to use to fund the VA Mission Act's program.
It could be a preview of spending fights to come, with the next government shutdown deadline looming on Sept. 30, just ahead of the November midterm elections. Trump has already issued demands for more money for his border wall, something likely to meet resistance in the Senate and setting up the possibility of a shutdown showdown weeks before elections that will decide control of Congress.
The tension over how to pay for the legislation is part of a larger debate over private care for veterans. The Mission Act revamps a private-care program Congress approved in 2014 after a scandal over fudged patient wait lists for medical appointments. The new, bipartisan measure consolidates numerous private-care programs that were fragmented and inefficient and drew support from disparate veterans groups that often disagree. It also expands stipends for a popular program that pays family caregivers of veterans who served in Vietnam and later wars, for example, a priority for advocates.
The legislation's biggest costs, though, will come in new doctor's appointments outside the VA system, which now sends roughly a third of veterans to private doctors. The Congressional Budget Office estimated the increase at 640,000 veterans each year, particularly with new authorization for VA to negotiate a contract for care at private walk-in clinics.
But the shift to greater outsourcing - arguably the top White House priority for veterans - has been controversial. It was a key reason the president fired former VA Secretary David Shulkin in March after the White House suspected that he was not pushing so-called "Choice" aggressively enough. Many Democrats, traditional veterans' service organizations and federal employee unions adamantly oppose the goal of giving veterans unfettered options to choose private doctors, arguing that such a change would starve VA's vast system of government healthcare, the country's largest.
Another sticking point is cost. There is no reliable estimate and little research to determine how much taxpayers pay for a private medical appointment versus one inside the VA's system of 1,300 clinics and hospitals. Conservatives and liberals agree that outsourcing tends to cost more because VA care has economies of scale, but how much more is a question that will affect the spending debate between the senators and the White House.
"The Congressional Budget Office has not done a good job projecting how much private care costs because VA doesn't share its data and often doesn't collect it, so you can't make an accurate prediction," acknowledged Dan Caldwell, executive director of Concerned Veterans for America, a White House-allied group backed by the conservative industrialists Charles and David Koch that has led the push for veterans to decide where to get their medical care and from whom.
Caldwell said, however, that the White House is right to oppose lifting the budget caps to cover the Mission Act. He said that consolidating the multiple private care programs that exist now should control the new bill's costs.
"I think they can pay for this program without raising the caps," Caldwell said.
But traditional veterans groups, which oppose what they suspect is a White House strategy to privatize VA, were adamant Tuesday that if the spending caps aren't raised, the agency could be forced to take money from other valuable veterans' benefits to ensure that veterans have access to healthcare.
"Some degree of community care is necessary, because no one should have to wait three months or drive 200 miles to get a flu shot," said John Hoellworth, communications director for AMVETS. "But it is not the most cost effective way to take care of our veterans."
He added, "You shouldn't have to ask Congress every year for money to take care of veterans."
Philip Carter, a senior researcher at the Rand Corp., a nonprofit think tank, said the bill could push up the demand for medical care at VA hospitals as the pressure on them eases with more outside appointments.