The Battle over Veterans’ Health Care: How the Republican Majority Hopes to Reshape the VA

With the new Congress sworn in and President-elect Trump poised for his second inauguration, Republicans have queued up a number of bills that could widely expand veterans’ access to the private health care system, setting up the latest battle over VA’s reliance on what’s known as community care. 

Efforts to reform how the Department of Veterans Affairs provides health care to millions of veterans are heating up in 2025 as pressures to bring down costs and lower wait times for care mount. 

Republicans argue that VA is a bloated bureaucracy that is making a concerted effort to prevent veterans from accessing community care and forcing them to stick with the VA system to curb costs. Democrats, meanwhile, fear that the proposed legislation would strip VA of its ability to provide direct care, disrupting coordination and quality.

Hanging in the balance are nine million veterans enrolled in VA health care, many of whom have frustrations with both VA and community care, and simply want medical care without long wait times and bureaucratic hurdles.

 “We must keep the individual veteran as our North Star,” Cole Lyle, a Marine Corps veteran and director of Veterans Affairs and Rehabilitation for The American Legion, told the House Committee on Veterans Affairs during a December hearing.

The MISSION Act of 2018 aimed to strike a balance of modernizing and strengthening VA’s direct care service and offering community care, Lyle said, but the outcome so far has resulted in ballooning costs: The price tag for community care spiked from roughly $15 billion in 2018 to $28.5 billion in 2023. VA leaders worry that the level of spending will increasingly damage their ability to retain the staff, clinics, and hospitals needed to provide care. 

“VA would not be referring so many veterans out in the community if they had the capacity to serve those veterans in house,” Lyle says. “So at the end of the day, the veteran still needs to get the care they need when they need it.”

Some veterans advocates want to see more money funneled toward improving VA’s hospitals, clinics, scheduling systems, and health records, rather than continue to pour funds into the private sector. But a handful of bills that Republicans revived before the holiday is a shift in the opposite direction. They include:

• Securing Community Care’s Availability: Republican Congressman Mike Bost’s Complete the Mission Act 2024, in part, seeks to lock in distance and wait time standards that make veterans eligible for community care, rather than allowing VA to keep it as an internal policy that can be tinkered with every three years. The bill would also create a system for veterans to self-schedule community care appointments. Both Paralyzed Veterans of America and The American Legion acknowledge that this bill offers ideas worth exploring. 
• Health Savings Accounts: Texas Republican Rep. Chip Roy would allow VA to offer health savings accounts that veterans could use for direct primary care services outside the VA system.
• No VA preapproval required: Arizona Republican Rep. Andy Biggs’s bill would greenlight a pilot program for veterans who could seek care in the community without VA preapproval, an idea the organization Concerned Veterans for America eagerly supports and says would “truly revolutionize the way we deliver veterans’ health care.” 
• Opening up Tricare: A bill proposed by Florida Republican Rep. Greg Steube would launch a pilot program to open Tricare Select, a government-sponsored insurance for active-duty military and retirees, to veterans with service-connected disabilities. Steube says this would give veterans “true choice” to use their Tricare insurance to seek out care in the communities where they live and not rely solely on VA. 

Suzanne Gordon, with Veterans Healthcare Policy Institute, a research and policy nonprofit, blasted the proposals as “irrational policymaking” intended to damage VA. 

“The Hilton couldn’t exist if the guests came in and [the Hilton] said, ‘Oh, we’ll pay for you to stay in the Marriott.’” 

Some Democrats and advocates are convinced the wave of bills is only the beginning in a larger effort to change the way VA pays for veterans’ care. 

“Committee Republicans’ recent legislative hearing makes clear that they intend to fast-track legislation that would privatize more veterans’ health care in the next Congress,” Rep. Mark Takano, a Democrat from California, told The War Horse. “This is not what’s best for veterans.” 

In a recent interview with Military Times, Sen. Jerry Moran, a Republican from Kansas, who will now chair the Senate Veterans’ Affairs committee, said he’s determined to ensure access to community care, particularly for rural veterans. 

And Trump’s nominee for VA Secretary agrees. Doug Collins, a former Republican Congressman from Georgia, is now scheduled to face his Senate confirmation hearing on Tuesday after a delayed background check thwarted his appearance this week. In a November interview, Collins told Fox News he strongly supports veterans choosing where they get medical care. 

“We’ve got to get back to a system that puts those veterans patients first, and if that means they want to go to their own doctors then so be it,” he said. “We give them that opportunity to do it.”

What’s become a political issue did not start out as one.  

In 2014, after an investigation uncovered the Phoenix VA hospital was concealing long wait times that led to the deaths of 40 veterans, Congress passed the Choice Act. It created access to community care if a veteran was unable to schedule a VA appointment within 30 days of their preferred date, or a veteran lived more than 40 miles away from a VA hospital or clinic.

Four years later, a new bill, the Mission Act, expanded the number of veterans who could seek care in the private health care system. It also swapped drive time for the 40-mile rule because driving 20 miles in a big city can sometimes take longer than 40 miles in rural areas. Wait time guidelines have also been shortened in recent years.

Since 2018, according to an internal VA report, community care referrals increased by an average of 15-20% every year, with a rising number of veterans seeking emergency care, geriatric care, and other forms of health care in the private sector. The report, generated by a panel of independent experts, also advised that VA focus on bringing veterans back into the VA system.

VA has made efforts to do just that. The department experienced a 10% increase in health care appointments last year and the agency reported it had reduced average wait times, cutting the average wait time for primary care by 11% and mental health care by 7%. Congress also addressed the issue of VA wait times as part of a sweeping bill signed into law earlier this month. It requires VA to develop a plan that ensures a veteran can schedule an appointment the same day they contact the agency with a health issue, and, when possible, even see a clinician that very day. 

Still, it’s not hard to find veterans who say VA is actively trying to prevent them from accessing private care in the community. Lyle, of the American Legion, says he hears from veterans who have appointments with doctors outside of VA authorized and then abruptly canceled, and there are stories of life-saving care that for a variety of reasons VA does not approve at all. 

But last week, in his final news conference before Trump returns to the White House, VA Secretary Denis McDonough bristled at the suggestion that the department is purposely denying veterans access to community care. “That’s patently, fundamentally, overwhelmingly inaccurate,” he said.

He did, however, express that community care can’t keep growing exponentially without settling a larger debate about the risks that go with that, including, losing VA’s ability to offer certain types of specialty care or nixing primary care services. “Each of those would end up creating a different scenario for veterans, and each of those has significant costs,” he said. 

Still, even supporters of expanded community care say their goal is not to completely wipe out VA, but rather shrink the massive bureaucracy, perhaps scale back VA’s direct care, and let veterans skip the VA authorization process and choose their providers and specialists, an argument that appeals to many in the veteran population who are aging and increasingly in rural areas. 

“If you live in Great Falls, Montana, and it’s a three-hour drive to the local VA, there are doctors in Great Falls, Montana. It might just be better for you,” says John Byrne, strategic director for Concerned Veterans for America, an advocacy organization. 

But Joy Ilem, national legislative director for Disabled American Veterans, says diverting more and more care away from VA risks weakening a health care system that’s made for veterans, many of whom have complex and layered health issues, like toxic exposures, high blood pressure, anxiety, and other ailments that she says are better served by clinicians and specialists under one umbrella. 

Without VA taking the lead on care, “you lose a lot of that coordination piece,” Ilem says, “you’re on your own.”

 This War Horse story was reported by Anne Marshall-Chalmers, edited by Mike Frankel, and copy-edited by Mitchell Hansen-Dewar. Hrisanthi Pickett wrote the headlines.

Editors Note: This article first appeared on The War Horse, an award-winning nonprofit news organization educating the public on military service. Subscribe to their newsletter.