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The VA Mission Act passed into law with broad bipartisan support last year, but that unity began to wane immediately, when President Trump signaled after signing it that he wouldn't give it an additional stream of funding.
The law expands a popular caregiver program and will examine VA's aging infrastructure.
But the most controversial plank is a drastic increase in the number of veterans who will be eligible to use a private health care provider and bill the VA, in what's known as the Veterans Choice Program.
The VA has been defensive about the program ever since; last month, VA Secretary Robert Wilkie pre-empted the release of new regulations for private care with a statement.
"Although these new standards represent an important win for America's Veterans, they will not be without controversy. Some will claim falsely and predictably that they represent a first step toward privatizing the department," Wilkie said.
As predicted, the union representing VA workers did just that.
"The Adminstration is setting us up to fail," said American Federation of Government Employees National Veterans Affairs Council President Alma Lee. "We believe that this push for further privatization cannot be allowed to happen, and the MISSION Act should not be implemented under the current schedule because the VA needs to do a thorough analysis of the huge impact it will have on veterans their receiving care here."
VA has been sending patients to outside specialists for years — but mostly that was VA doctors doing it for clinical reasons. VCP, which started in 2014, gave vets the option of choosing a private doctor if VA care was too slow or too far away.
It has had mixed results, says Iraq vet Kayla Williams, who has been waiting for an appointment with a specialist.
"I was notified recently that they have not been able to find any providers in the D.C. metro region who are willing to accept the Medicare rates that Choice uses," she said.
VCP has gotten a reputation for paying providers late and confusing everyone with red tape. Williams' experience has been frustrating, even though she knows the ropes: She's not only a vet, but she's also a former official at VA and currently directs a program on veterans at the Center for a New American Security.
Williams says that when the new expanded version of VCP goes into effect this June, there might not be so much choice to choose from, because health care is in heavy demand nationwide.
"A lot of folks seem to believe that the capacity exists in the community, that providers are equally good. But that's not the data that I've seen," she says.
VA defends its performance
Studies show that VA care is on par or better than private care for speed and quality, in most regions. So even as it's about to expand private care, VA officials like Dr. Richard Stone, acting head of VA health, have been stressing that vets who try outside care usually return.
"They have had a choice for years about where to go for health care. Ninety percent chose to stay with us. Of the 10 percent that go out to commercial health care providers, the vast majority go once and then come back to us," he said in a VA webcast last month.
But expanding the Veterans Choice Program could prove that wrong, says Dan Caldwell, an Iraq vet with the conservative advocacy group Concerned Veterans for America.
"When you give veterans the ability to vote with their feet, you're going to see really how VA is performing and how veterans perceive the VA," said Caldwell.
Caldwell's group, which is backed by billionaire conservative Charles Koch, advocates for all vets to have a choice between private care and the VA. He calls the new rules a good step in that direction.
"We want to get to a place where veterans have the ability to access a private provider without prior authorization from the VA," said Caldwell.
But critics say that would amount to privatizing much of the VA and, because private care is more expensive, would also bleed resources away from the department.
What it will cost is still an open question.
House Veterans Affairs Committee Chairman Mark Takano, D-Calif., says the Trump administration hasn't been telling Congress how it intends to pay for it.
"We don't know the cost, we don't know how they're going to pay for all those [patients]," said Takano, who says the VA has given "highly specious arguments about why they couldn't be more transparent with Congress."
Takano signed on to a letter from Democratic and Republican committee chairs this month asking VA to collaborate more with Congress. Two days later, the VA put out a press release proclaiming "a new and unprecedented level of transparency to lawmakers in Congress." But the lawmakers are still waiting for the information they requested.
For all the alarm about the new rules, they are something of a compromise, said Amy Fahrenkopf, former VA official in charge of the Veterans Choice Program.
"My first impression is that this is not the giant step toward privatization that many were worried about or many were pushing for," she said.
Fahrenkopf is a Republican who left the VA last year among an exodus of high-ranking officials during a period of leadership turmoil. She says she thinks the new rules could introduce an element of competition with VA, which could be good for the department.
But Fahrenkopf also points out that by eliminating any need for co-pays, the new program could entice millions of veterans who currently get private health care from their employer to switch to VA. It could cost the department billions, at the same time as private providers are required to accept Medicare rates for their services.
"It's almost a Medicare-for-all type program," Fahrenkopf said, adding that she can't imagine why any fiscal conservative Republican would support it.
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