By Lauren Clason

CQ-Roll Call

WASHINGTON, D.C. — The Department of Veterans Affairs will face heavy scrutiny as it implements a major overhaul to its health care programs that President Donald Trump is expected to sign into law this week.

The bill, which moved through both chambers by wide bipartisan margins, would combine the VA’s seven programs for private medical care into one to streamline and simplify costs and access for veterans. The legislation would also extend the so-called Veterans Choice Program for one year, allowing veterans to seek care outside the VA under certain circumstances in the meantime.

That gives the VA a lot of work to complete in a short amount of time, and without a permanent leader in place. The troubled department has lacked a permanent secretary since March, when David Shulkin departed amid ethics questions over his taxpayer-paid travel expenses. Trump recently nominated acting Secretary Robert Wilkie to lead the department after Ronny Jackson, the president’s official physician and his first pick to replace Shulkin, withdrew from consideration over allegations of inappropriate conduct. The VA also lacks a permanent undersecretary for health.

The bill was a rare show of bipartisanship thanks to its expansion of access to private care and increase in recruitment funding for VA providers, but disagreements could resurface as the department begins drafting regulations.

“The regulatory fight is going to be an even bigger fight than the legislative fight,” Bob Carey, director of policy and advocacy for veterans service organization The Independence Fund, said at a panel recently. “And it’s not going to be nearly as sexy, but it’s going to be far more important.”

The bill would give the VA 120 days to draft new access and quality standards for the program — which will help determine when a veteran can seek care from a private doctor — and 270 days to give Congress a final report.

The measure would initiate a review of VA infrastructure to modernize, realign and potentially close some of its facilities, which could invite controversy. It would also expand caregiver assistance to veterans who served prior to the 9/11 terrorist attacks.

“All of those insidious unintended incentives that we have set up in the federal government are going to show themselves in the regulatory process,” Carey said at the event. “Those people that write regulations are not going to be writing regulations that get rid of their own jobs. They’re not going to be writing regulations that get rid of their own authority.”

Veterans’ access to private providers is a point of contention among advocacy groups. While Carey hopes the department will strengthen private care access when the VA falls short of its own standards, other advocates worry the department might lift restrictions on private care altogether.

An overhaul of this size is concerning for “even your strongest of institutions,” let alone the VA, said Melissa Bryant, chief policy officer for the Iraq and Afghanistan Veterans of America.

“There’s always opportunity for providers to take advantage of an ailing system,” she said.

Carlos Fuentes, legislative director for Veterans of Foreign Wars, is more optimistic. He’s confident the VA can meet the timeline for drafting access and quality standards to allow more private care, but hopes they will be flexible without rigid barriers for veterans.

“What we want to make sure happens is, one, that veterans who need care are able to receive care when they need it,” Fuentes said.

The expansion of the caregiver program is also cause for concern for some. Rep. Julia Brownley of California, the ranking Democrat on the Veterans’ Affairs Health Subcommittee, said a persistent hiring backlog at the VA could stymie the program as more people are phased in under the expanded eligibility conditions.

“Many VA social workers already manage large caseloads,” Brownley said in a statement. “With more veterans joining the program, the VA will need to move quickly to ensure it has the personnel to provide our veterans and their caregivers with the training and support they need for the program to be successful.”

The bill would also authorize a department center to test new payment and delivery models, just as a division of the Centers for Medicare and Medicaid Services does. The new center would be key to reimagining how the department performs tasks such as collecting payments and paying for care, said Darin Selnick, senior adviser for Concerned Veterans for America.

“This is the mechanism to do that,” he said at the panel.

Veterans’ groups expect to be included in the rule-making process. Louis Celli, director of veterans affairs for the American Legion, said Carolyn Clancy, who is temporarily leading the Veterans Health Administration within the VA, promised to include the largest veterans groups as the department drafts the regulations.

“That gives us some levels of comfort we need,” Celli said.