Recent Health Care Legislature

Background to the Veterans Affair Law

The journey to enacting the veteran affairs law began as a response to challenges encountered by veterans while accessing healthcare at Veterans Health Administration hospitals (VHA). Issues regarding access to services and waiting time were a significant concern that reached the Congregational Committee. As such it resulted in the draft of the Veterans Access, Choice and Accountability Act of 2014. The law allowed veterans meeting specific criteria to seek medical attention at the closest veteran affair medical facility. After the legislation of this act, implementation challenges led to the improvement of the law, and other statutes were subsequently proposed as an enhancement of the existing law. Among the laws that were later established to cater for the health affairs of veterans is the VA Asset and Infrastructure Act of 2017, the VA Care in the Community Act, and the Caring for Our Veterans Act of 2017. The combination of provisions in these acts by the 115^th Congress introduced the Veteran Affairs Act of 2018 which was signed into law by President Donald Trump on 6^th June 2018 (Wagner, Almenoff, Francis, Jacobs, & Pal Chee, 2018).

The purpose of the act is to institute a veterans’ community care program that is permanent. It also seeks to set up a commission with the aim of making endorsement pertaining to the readjustments or modernization of the VHA’s facilities, to develop the infrastructure of the Department of Veterans Affairs (DVA) (Baughman et al., 2018). To make some amendments in the laws directed by the Secretary of Veterans Affairs regarding the DVA’s home loan program as well as for other reasons. The law has five titles which describe the scope of the legal instrument.

The veteran Affairs Law of 2018- Title I: Caring for Our Veterans

Title I provides the amendments to the law that offered authority to the secretary regarding care provision under any situation as follows: Care due to disability gained in service. Care due to disability for which a veteran was discharged from service. Care for a veteran who has a permanent disability due to disability related to military service,care for a disability linked to and said to be worsening a disability gained in service, care for a veteran with a disability and currently under rehabilitation, offering hospital care to women who are veterans, and offering certain veterans dental care.

Provisions under this title eliminate the current veteran affairs community care program and substitute it with the Veterans Community Care Program (VCCP) which adjusts the above care provisions and therefore offering increased flexibility in community health care access for all participating veterans, extended hospital care, medical services, and hospital care. Under the newly established program, the eligibility criteria for accessing healthcare services will not solely be dependent on service-connected disability but will cover a broader scope to include all veterans in the program (Wagner, Almenoff, Francis, Jacobs, & Pal Chee, 2018). Further, the provisions of this title will eventually dissolve the Veterans, Choice Program (VCP) within a year after the enactment of the law.

The veteran Affairs Law of 2018-Title II: VA Asset and Infrastructure Review

The Veterans Health Administration operates in numerous building some of which are leased. A review of the property of VHA was conducted under the CARES program. The objective of establishing the program was to assess the expected veterans’ healthcare needs for the following two decades and also manipulating the infrastructure of the VA to improve it so that it meets the required standards. Therefore, this title outlines the procedure for altering the VA’s infrastructure and realigning them to be modernized. Through the established procedure, the VA will create the process and criteria for determining which facilities need to be acquired, disposed or modernized with a focus of enhancing healthcare needs as required. The VA is then supposed to make recommendations based on their established standards and then submit the list to the commission.

The commission which is comprised of nine members is expected to review the list of recommendation given to them although it is not allowed to alter them unless the commission determines that there is a recommendation that is inconsistent with the created criteria. After review, the commission delivers the list to the president who is supposed to either approve or disapprove the list. The president should provide the reasons for disapproval when sending the recommendations back. When disapproved, the commission submits a subsequent report that factors in the reasons for disapproval. The president has the right to approve or disapprove the second list. If approved, then the presented recommendations must be implemented within three years.

The veteran Affairs Law of 2018- Title III: Improvements to Recruitment of Health Care Professionals

The focus of this title is to address the shortage of clinical workforce via modifying and developing new programs that offer loan repayments, scholarships and bonuses to personnel from fields that are difficult to recruit as decided by the inspector general who is mandated to publish staffing shortage reports annually (Baughman et al., 2018). One of the provisions in this title seeks to amend the scholarship program for VA’s health professional.  The purpose of the amendment is to make physician recruitment a priority and also to extend the program since it was set to terminate in about two years. The title has three other provisions which amend the Education Debt Reduction Program which offers loan repayment clinical workers in hard to train and hard to recruit fields. One of the three provision serves to increase the cumulative an annual limits, the other provision facilitates eligibility of new providers into the program, and the last provision increases Vet Centers to areas where they can be put to service. The title also has provisions that develop a new program that intends to enroll veterans into medical school and in return, the recruits commit to offering their clinical care services to the VHA.

The veteran Affairs Law of 2018- Title IV: Health Care in Underserved Areas

Provisions under this title focus on increasing the provision of clinical services in underserved areas. These are locations that veterans face challenges in accessing healthcare or where there is a shortage of healthcare providers. It achieves this by creating a process to declare the facilities of VA underserved and submitting necessities around that development. There are two provisions under this title that aim at addressing workers shortage in the facilities located in the areas designated as underserved. The first provision addresses the issue by creating a mobile healthcare providers team that can be sent to offer services at these facilities. The second provision manages the problem by setting up a training program for medical residents at some VA facilities and other not owned by the VA.

Before the Veterans Affairs Law was enacted in 2018, the department lacked a practice for entitling its facilities as underserved and hence to direct capitals to facilities that are in greater need of resources. On the contrary, the Department of Health and Human Services (HHS) declares facilities that serve prisoners, Indian tribes, and the public as the underserved facilities if they meet certain conditions. Some of the conditions required to meet the criteria for eligibility as an underserved facility include a high rate of a particular health condition and a high ratio of service providers to the served population. The department employs this criterion to direct resources such as greater reimbursement rates, and loan repayment for healthcare providers. The HHS does not entitle the department of veteran affairs facilities as underserved.

The Veteran Affairs Law of 2018- Title V: Other Matters

The fifth and the final title of the law is dedicated to addressing other matters that fall within a broad category. It mandates that the secretary annually submits a report that indicates the performance bonuses and awards given to senior executives in the department (Wagner, Almenoff, Francis, Jacobs, & Pal Chee, 2018). Specific laws are also amended under this title where a podiatrist is authorized to serve in any supervisory position similar to any doctor with a doctor of medicine qualification as long as they have a doctor of podiatric medicine. Additionally, the title also requires the department to publish vacancies on its website

Literature Review Regarding the Issue

Kupfer, Witmer and Do (2018) critically evaluate the implications of the paradigm shift in healthcare delivery as set by Veterans affairs law and Do (2018). The researchers note that among the provisions of the act, the substitution of the Choice Program with a new healthcare model that seeks to offer veterans with more healthcare choices is very significant. The new healthcare model intends to rely on a network of community providers. Even if access to external healthcare providers was catered for under the Choice Program, referral approvals to outside providers were chiefly determined under certain circumstances by the VA. Providing greater choices as the Act provides is considered a positive factor and proponents argue that increased choices are economical and leads to better healthcare outcomes since it improves accessibility and increased healthcare quality. Therefore, Kupfer, Witmer and Do (2018) assert that the new healthcare model provided in the law is better since it creates more value to both the veterans and the taxpayers.

Additionally, it is noted that VA care faces many challenges in the accessibility of services due to organizational and structural deficits that slow down healthcare access for veterans. Hence the new structural changes that allow the use of external networks will improve the health status of veterans, however, the research paper positions that this will be dependent on the tradeoff among access, quality, and costs with care offered by VA. It is identified that high-quality care is at the core of VA care program (Hale, Haverhals, Manheim, & Levy, 2018). Additionally, VA facilities are found to outperform other facilities in the commercial US health care system in many measures of excellent inpatient care. In comparison, veterans with cancer have a greater survival rate in VA facilities than in non-VA facilities. Also, VA centers provide more equitable care with fewer quality variations and reduced economic barriers. Therefore, the researchers argue that the dependence on community providers will result in an increase in the number of people who use both the VA and private sector care which is linked to poor health outcomes.

The provision of greater health care choice in the enacted law implies that the quality of care and costs in non-VA facilities is similar to those in VA care. However, Kupfer, Witmer, and Do (2018) position that their analysis suggests otherwise and they conclude that quality is expected to decrease as the cost increase. The reason for this implication is that healthcare in the private sector is faced with significant health inequities and lack uniformity in performance which implies that veterans seeking care in these facilities will face tradeoff among access, autonomy, and quality.

The vet connects program part of a more significant effort aimed at improving the quality of care to veterans receiving who are under long-term care. Elderly veterans that reside in community nursing homes often seek special services from VA centers although they receive primary care in the homes where they reside. Hale, Haverhals, Manheim, and Levy (2018) evaluates the quality improvement program for veterans residing in VA contracted nursing homes. Since the veteran affairs law seeks to improve care in underserved locations such as rural areas, the vet connects program assists in improving care where there is a greater need. The use of video technology by the program supports healthcare access to veterans who require special care. Veterans who cannot travel to VA care facilities or those who live in rural areas.

Veterans receiving services through the telehealth program experience increased efficiency and access to care while at the same time decreasing travelling time and costs. The researchers point out that evidence demonstrates the program suits VA care for elderly patients with depression since it can substitute face to face visits.

VA facilities are among those hospitals that are under comparison by policymakers, purchasers and consumers who need to gauge performance metrics between hospitals for purposed of decision making. Comparison of hospitals is essential for boosting competition and transparency within healthcare facilities and as such, publishing information on important hospital performance metrics is very important. For VA facilities, this coincides with the recently passed law which aims at giving veterans a more excellent choice of services by contracting private sector providers. Therefore it is crucial that this information is availed so that they can make an informed decision. Scholars argue that increasing competition among hospitals and increasing transparency will help veterans and other patients, however, others suggest that VA facilities do not adequately compare with other non-VA hospitals because of the predominant patients they serve (Hale, Haverhals, Manheim, & Levy, 2018). Nevertheless, the Commission on Care suggested that VA facilities need to modernize their operation so that they serve as a healthcare system for learning. Again this is consistent with the newly passed law the veteran’s affairs law 2018 which has provisions that seek to improve and modernize the infrastructure of the VA facilities.

The researchers Wagner, Almenoff, Francis, Jacobs and Pal Chee (2018) assessed the usefulness of utilizing the Medicare risk adjustment model for comparing commercial hospital facilities with VA facilities. The researchers decided to use the VA because it now has a provision that seeks to improve transparency and access to quality care by offering greater choices (Kupfer, Witmer, & Do, 2018). Thus, the safety-net institution can be assessed to determine if it is comparable to commercial facilities and whether it meets the expectation of increased transparency and better access. The researchers assert that it is found that veterans seeking medical care at VA facilities are at more critical conditions than those who seek treatment from non-VA facilities. Therefore, this highlights the value of a suitable risk adjustment model considering that the VA facilities serve patient under greater need and therefore placing more pressure on the facilities. The results of the assessment indicated that the current risk adjustment model employed to compare commercial and VA hospitals is flawed and hence the results are unreliable for making decisions. The cause of flaw is the fact that these algorithms do not control for mental health problems. Therefore it is suggested that it is necessary to update the comparison model to take into account mental health issues.

Fulton and Brooks, (2018) present a paper that seeks to invoke thoughtful solutions for offering accessible quality care in VA facilities and non-VA hospitals. The researchers arrive at this decision after evaluating the state of care provided to veterans in hospitals. Given that the newly enacted law allows veterans to seek healthcare in commercial hospitals, there is a need to resolve accessibility problems (Kupfer, Witmer, & Do, 2018). It is already identified that the most significant challenge facing veterans is the accessibility of care services and it is already reported that many have died while waiting for treatment. Fulton and Brooks position that there are accessibility and quality problems within the VA. However, they assert that it is the responsibility of the government to provide quality healthcare access to veterans and now that the systems are failing it is essential to provide lasting solutions through the veterans Affairs law which has provisions that cater for quality and accessibility issues. They support the VA act that was recently enacted and state that it is the best way forward to solving the current problems. However, given that the implementation of the Act depends on the VHA which is repeatedly involved in scandals, it may still be a challenge to resolve the problems faced by veterans. In the long-run, veterans are the ones who suffer when the law fails to be enacted appropriately due to organizational or issues of leadership within the VHA. The researcher questions whether the public and more so veterans should place their hope in the organization especially with regards to efficient implementation of the enacted law.

Millions of Americans live in nursing homes, and this includes over 46,000 veterans (Baughman et al., 2018). The VA operates many nursing homes that cater to veterans who need special care. It also has skilled nursing facilities (SNFs) which are referred to as Community Living Centers (CLCs). Quality care and accessibility of services are some of the fundamental issues raised in the Veteran Affairs law, as such; the VA is challenged by the need to improve patient transfers to hospitals from the skilled nursing facilities. The transfer of patients is based on making priorities. A model for improvement is evaluated by (Baughman et al., 2018) to develop process improvement under the new law which seeks to give veterans greater choices in healthcare. In the study, several interventions were used as improvement models, and they aimed at automation, standardization, and streamlining.

Statistical Data Related to the Issue

VA funding is now discretionary, and no longer is mandatory, however, the funds allocated to VA for 2019 very high, $86.5 million is approved by the committee to fund VA for 2019. The passing of the recent bill in 2018 saw the department incur additional costs in catering for community care; therefore, the department is to receive an additional 1.75 billion dollars as agreed by Congress. The amount of money VA is set to receive as funding exceeds their initial request by 500 million. The reason for the additional cost is because the VA is expected to incur other unexpected costs in its community programs. As per the enacted law, the department is expected to start streamlining and consolidating these programs in mid of 2019. VA funding is an issue of great concern considering that Congress has not stipulated the terms of long-term financing of the enacted law. Therefore, as much as funds for the year 2019 have been decided, the issue of funding will certainly need to be addressed by lawmakers in the future.

Budget caps in the future are expected to be less specific meaning that lawmakers will strain more in making decisions for funding in the absence of a long-term budget program. In the past, the VA has experienced difficulties in estimating how much funds it requires for its choice program. Consequently, this has often forced Congress to make abrupt financial solutions to fund the program. Hence, failing to make a plan as to how the Act will be funded in the future is likely to lead to a similar problem. Additionally, 1.1 billion is allocated as funds for VA so that it finances the electronic health record modernization.

Significant data pertaining the legislation related to its funding since it is an area that has not been well covered. Now that the department is set to expand to private care, additional costs are set to be incurred. An estimation given to Congress by the department’s officials indicates that at least 32.1 billion is needed to cover the expansion cost for five years. Some policymakers assert that the move will affect the VA system since overall government spending is still in place. The resultant costs of the VA’s systems are said to defy the purpose of passing the legislation. The legislation of the law also seems like an act to privatize the system since significant healthcare services are in the hands of the private sectors. In 2014, the number of healthcare services delivered in commercial facilities increased from 22% to 32%. At the moment, policy evaluations are being done by the administration which seeks to increase the number of services delivered in the private sector to 55% (Fulton & Brooks, 2018). It, therefore, means that more veterans will receive care in commercial hospitals as opposed to VA facilities.

The funds received by the VA are definitely limited, and this means that the department has to limit access to care based on certain criteria. Some veterans may not be enrolled in a program because the resources are inadequate if they do not meet a certain military threshold. Veterans who are enrolled in the program account for less than half of the veteran population. They are divided into several groups which are categorized by income, disability, and special status. Enrolled individuals with a service-connected disability or those with particular honors account for 1.4 million people. Those with low income, are part of a particular population or are housebound make up a total of 2.6 million and the number of veterans with a high income and lack service-connected disability amount to 2.1 million.

Source: (Fulton & Brooks, 2018)

As indicated in the graph below, the cost of medical care continues to increase despite the decline in the number of veterans who benefit from the services. The rate of cost increase exceeds the rate of inflation, and this makes the operational costs of eh department a point of concern.

Source: (Fulton & Brooks, 2018).

Nursing Role in Passing the Legislature

Nurses play a critical role in passing the legislature since they are at the forefront of medical care and they understand the significant issues facing care delivery. They are well positioned to understand the implications of the provisions contained in the law and can react accordingly (Wagner, Almenoff, Francis, Jacobs, & Pal Chee, 2018). In this legislature, nurses have already shown discontent with some of the provisions which they feel that they compromise the quality of care given to veterans. As such, their role in passing the legislation may include proposing recommendations to the bill or asking for a vote against it.

Some of the issues raised by nurses concerning the legislation are the passing over of primary care to commercial hospitals. Nurses are against this provision since they claim that it will jeopardize the quality of medical care received by veterans. They assert that the VA is built on the premise of primary care. The core of the operations of VA facilities is based on giving primary care and so giving out this service to the private sector is a step towards dismantling the Veterans Health Department. The provision of primary care services by external providers leads to privatization of services which form the foundation of VA services. Therefore this will be weakening the VA system by denying it a chance to integrate care (Wagner, Almenoff, Francis, Jacobs, & Pal Chee, 2018). Thus, before passing the legislation, the voice of nurses is critical in evaluating if the law undermines one sector or whether the overall disadvantages of a system exceed its benefits.

The nurse also looks at the legislation as a process towards the privatization of the VA. Although this is not the objective of the law, it is essential to consider the perspective of nurses before passing the law. Nurses assert care for veterans will be adversely affected. Additionally, the private sector is not fully equipped to deal with healthcare concerns that mainly affect individuals that have been in combat. A comprehensive care system which offers all healthcare needs results in specialized high care standards according to nurses. Therefore, the decision to employ outside networks is not feasible according to nurses.

In passing the legislation, nurses play a critical role in evaluating some health implication of closing down some VA facilities. Altering the structure of the VA must consider the quality of care and taxpayers’ money. As such, nurses position that formulating a commission that oversees the closure of some facilities will lead to a decline in healthcare quality and loss of money. Additionally, familiarity with veterans and the impact of combat on their health is an essential aspect of providing care. Nurses work closely with patients who also include veterans and understand the needs of those who have served in the military. Thus nurses are best suited to recommend changes to the legislation to fit the healthcare needs of veterans. Policy makers may have the best interest of veterans but may fail to understand their healthcare needs. Also, nurses are more familiar with the operations of the VA than other service providers who are not medics. Therefore, they can present better judgment of the legislation by determining its effectiveness in solving the challenges facing the VA facilities.

Conclusion

The Veteran Affairs was signed into law in June by President Donald Trump. The central focus of the law is expanding healthcare services to the private sector which seems appears to make the choice program permanent. Under the provisions in the law, veterans will visit private physicians other than VA facilities. Therefore, the program is seen to increase healthcare choices which are assumed to correspond with increased satisfaction. However, researchers and critics argue that the new law will not reduce cost and neither will it improve the quality of care, but it will result in the opposite. Others find the law a move towards privatization of the services which will lead to increased costs for the taxpayer. A review of relevant literature identifies several thoughtful considerations about the Act. By availing several options to veterans, the healthcare model seems more suitable and therefore better. However, the department will likely face implementation challenges since deficits in organizational structure. Also, seeking external services are found to be less effective considering that studies indicate VA facilities outperform commercial hospitals in many performance metrics. Therefore, veterans will experience tradeoff between cost and quality of care. Other researchers positioned that the assumption that cost and quality of care in both VA and a private hospital is similar is not valid. Seeking care in the private sector is set to increase the costs and decrease the quality of care. Given that the healthcare sector is filled with health iniquities, veterans will face trade-offs in access autonomy and quality. Therefore despite the positive attributes associated with the enacted law, there are significant concerns that need to be addressed.

References

Baughman, A., Cain, G., Ruopp, M., Concepcion, C., Oliveira, C., & O’Toole, R. et al. (2018). Improving Access to Care by Admission Process Redesign in a Veterans Affairs Skilled Nursing Facility. The Joint Commission Journal On Quality And Patient Safety, 44(8), 454-462. doi: 10.1016/j.jcjq.2018.04.002

Fulton, L., & Brooks, M. (2018). An Evaluation of Alternatives for Providing Care to Veterans. Healthcare, 6(3), 92. doi: 10.3390/healthcare6030092

Hale, A., Haverhals, L., Manheim, C., & Levy, C. (2018). Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes. Geriatrics, 3(3), 57. doi: 10.3390/geriatrics3030057

Kupfer, J., Witmer, R., & Do, V. (2018). Caring for Those Who Serve: Potential Implications of the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018. Annals Of Internal Medicine, 169(7), 487. doi: 10.7326/m18-1539

Wagner, T., Almenoff, P., Francis, J., Jacobs, J., & Pal Chee, C. (2018). Assessment of the Medicare Advantage Risk Adjustment Model for Measuring Veterans Affairs Hospital Performance. JAMA Network Open, 1(8), e185993. doi: 10.1001/jamanetworkopen.2018.5993