Over six decades, Mark Foreman has turned to the Department of Veterans Affairs to recover from the consequences of a bullet wound to the hip sustained fighting as a Marine in Vietnam. It took endlessly long, infectious days for him to get out of deep, cavernous mountains after getting shot, three weeks straight of surgeries in Japan, and years of medical care to try to move on from his wound.
Foreman was only 20 when he suffered the injury that would end his military career, and he was discharged after two years of service in 1968. Ever since, the VA has been providing the medical care he needs, as well as helping with the cost of art school that led to a career as a teacher.
"The VA was very supportive of that," said Foreman, who later taught art for 20 years in Milwaukee's public schools. "They knew that it would help me psychologically, emotionally."
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But Foreman is worried. A seismic shift is potentially underway in the way the VA provides medical care and support, accelerated during the first administration of President Donald Trump and potentially ready to expand over the next four years.
"There were so many psychological and physical emotional wounds, and now they've got departments to cover all of it," Foreman said. "But I feel very confident that that's all going to be taken away."
Veterans are increasingly getting care from private medical providers, who are then paid by the VA. It's an effort to create a parallel privatized care system, known by the phrase "community care," that is set to expand further as Congress looks to make it easier for veterans to skip VA facilities.
Before 2014, the Veterans Health Administration mostly operated in government facilities. That system was overloaded at times, such as in the wake of the Vietnam War.
"When I first started working at the VA, it was not a first-class health care system," said Bruce Carruthers, a Vietnam War veteran and a retired VA administrator living in Buffalo. "But later, significant changes started to be made; it became a much more modern health care system."
Between 1995 to 2005, the VA catapulted from 2.5 million to 5.3 million patients, according to the National Library of Medicine. The VA also transformed into a training ground for thousands of health care providers, Carruthers said.
As its patient load grew, so did the stress on the VA, as more and more veterans from the Global War on Terrorism began funneling into the system. Wait times skyrocketed, and old facilities, like the Walter Reed Army Medical Center, faced scandals tied to dilapidated conditions and patient neglect.
That helped lead to the 2014 Choice Act that started the VA on the path toward offering care outside of its own facilities, and was greatly expanded by the VA Mission Act signed by Trump in 2018 that created the community care network.
Today, the demand for private care is rapidly eating into the VA's budget. In fiscal 2023, roughly 40% of all veterans' health care appointments were handled by doctors outside of government facilities, but still funded by taxpayer money, according to VA officials. The agency now serves roughly 9 million patients.
" In the first Trump presidency, we've seen an increasingly larger percentage of our direct care budget spent on outsourced private care," said Mark Smith, an occupational therapist at a VA hospital in San Francisco.
But Smith said the redirection of funds perpetuated the VA's shortfalls, when lawmakers should focus the department's full energy on caring for veterans.
"What happens is the public pays for both," Smith added. "We pay for the public services that we provide at the VA, and then we also pay for the outside care. ... Pretty soon, you don't have the money to maintain your facilities, to keep your staff, to keep the lights on."
The contrast between VA capacity and private care could get much starker if Trump administration plans for VA cuts come to pass. A surge in demand after the passage of the PACT Act made more veterans eligible for VA health care was already stressing the system.
Months before Trump took office, the VA requested a $369.3 billion budget for fiscal 2025, a 9.8% increase from the previous year. That included funding for the agency's health care and benefits branches and the Toxic Exposures Fund, which covers benefits for service members affected by toxic exposures.
But Trump and his top campaign contributor Elon Musk, who has taken on a role seeking to prevent the federal government from spending money approved by Congress and slashing jobs, are looking at shrinking the size of the VA. Most of Musk's efforts are currently tied up in litigation as judges weigh the legality of ignoring civil service protections and rejecting previously signed law directing spending.
A memo released in March indicated that the Department of Veterans Affairs was planning a reorganization that would include cutting more than 80,000 jobs. VA Secretary Doug Collins promised that the layoffs would not impact veterans' care or benefits, though outside observers are skeptical of those claims.
"The average person, of course, doesn't understand it," said Jeff Roy, a U.S. Marine Corps veteran of the Vietnam War. "The veterans, when they're listening, when they're watching these actions and the consequences, they're starting to perk up."
Roy, 76, decided to seek VA care for the first time almost a decade ago in his 60s. After he was discharged from the military, he joined a group calling for the end of the Vietnam War. To him, that also meant boycotting the VA.
He started seeking the VA when he discovered from clinical tests his prostate was showing signs of cancer.
Prostate cancer has been linked to Agent Orange, and the VA presumes that the diagnosis in a veteran is connected to their service and therefore makes them eligible for care.
The VA's own specialized knowledge and services from working with veterans likely made diagnosing his health issues easier, according to Roy. With the VA covering all his treatment,
a hospital in Minnesota, where Roy lives, then performed a lifesaving prostatectomy on him.
He's skeptical that privatized care would have led to such a positive outcome.
"They talk about honoring veterans, supporting veterans and caring about veterans. The incredible term for all of that is that it's a clash of reality," Roy said.
In January, Republican leaders on the Senate and House Veterans' Affairs Committees introduced a bill called the Veterans' Access Act, early drafts of which appeared to make it easier for veterans to access private care without consideration of wait times or VA facility proximity.
A specific section of the bill would direct a three-year pilot program to allow enrolled veterans to access private mental health treatment and substance use services through the community care network. The program would not require a referral or preauthorization from VA doctors, essentially bypassing the VA, experts said.
"It is changing the VA primarily into an insurance carrier," said Russell Lemle, a senior policy advisor for the Veterans Healthcare Policy Institute, a nonpartisan think tank focused on veterans' health care and benefits.
A spokesperson from the House Veterans Affairs Committee denied that claim and instead said the provision is intended "to allow veterans to access residential rehabilitation treatment programs closer to their homes when VA is either too far away, or not available at all, to bridge the gap that exists in mental health care and rehab access."
Project 2025, a conservative think tank's blueprint for governance that Trump has closely followed since taking office, proposed to completely privatize VA care in the long term, Lemle said.
Carruthers, the former VA administrator, received gallbladder surgery and prostate treatment from the VA because of his years serving in Vietnam. For him, efforts by the Trump administration to cut VA care count as a direct rebuke to veterans.
"To me, 'Thank you for your service' is a meaningless trope if they're not going to support that," he said.
-- Jerry Wu covers national security and veterans' affairs in Washington, D.C., for Medill on the Hill. The San Diego native is a sophomore at Northwestern University studying journalism and international studies.
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