The Veterans Choice program was born of scandal two years ago, as news of veterans dying while on secret waiting lists for medical appointments at Department of Veterans Affairs facilities exploded into public view.

The concept: Give veterans who couldn’t get prompt care or lived too far from a VA facility a plastic card that they could use to see a private doctor instead.

But the temporary fix quickly became a tangled mess. Veterans have in many cases waited even longer for appointments than they did before. They complain of constant back-and-forth phone calls with private contractors hired to administer the program and of getting stuck with bills that should be covered. Medical providers have soured on the program, too, citing late payments and burdensome paperwork requirements.

In its recent report, the Commission on Care – empaneled by Congress to recommend broad reforms at the Veterans Health Administration – called the $10 billion program flawed in “design and implementation.”

So, with Veterans Choice set to expire next August – or earlier if the $10 billion is exhausted sooner – why not just go back to the way things were before?

The answer: 1 million veterans now rely on it, according to the VA, many with little choice in the matter.

The VA for years has bought private care for veterans at its own discretion. But the Veterans Access, Choice, and Accountability Act made getting that care a right for a significant number of veterans. And, after a slow start, top VA officials last year told local health care systems that they had to use it.

That wreaked havoc on local VA facilities that already were relying heavily on the private sector to treat veterans – without the complications of going through a middleman.

In Alaska, for example, which was buying outside medical care at about three times the national rate, an investigation by Reveal from The Center for Investigative Reporting found that the mandate took a working system and made it worse, triggering delays in care. And the program did not increase access to private doctors, as Congress intended.

Nationally, the volume of private care did climb after the program became mandatory. The commission report found that the VA now buys about a third of veteran medical care from the private sector, up from 10 percent before the wait-time scandal.

Now, as Veterans Choice edges toward its sunset date, Congress must agree on what comes next. But philosophical differences persist on the very role of private care for veterans. Some want it used only as a stop-gap for those veterans who cannot get prompt or proximate care through the VA, while others see it as a right that all veterans should be able to enjoy at their choosing.

Meanwhile, Congress has yet to act on key reforms to the Choice program laid out in bipartisan legislation called the Veterans First Act. And concerns over steep costs stalled a separate bipartisan compromise in the works in the spring by Sens. Jon Tester (D-Mont.) and Richard Burr (R-N.C.) that offered a legislative road map for the VA’s own vision for its future.

That vision, unveiled by VA officials last October, would consolidate and simplify the way the department buys private care while keeping a reformed Choice program at its core.

Under what the VA is calling “New Veterans Choice Program,” eligibility requirements for veterans and rate structures for medical providers would be standardized across all methods of purchasing care. Veterans no longer would have to go through private call centers to get appointments – that responsibility returns to the VA. And local VA facilities would regain some of the flexibility they lost with the one-size-fits-all Choice program.

VA Secretary Robert McDonald showed visible frustration over the stalemates at a recent Senate Veterans’ Affairs Committee hearing.

“We’ve submitted over 100 proposals for legislative changes that we put in the president’s 2017 budget,” he said at the hearing. “No results yet.”

On Wednesday, the VA saw a small breakthrough when the Senate approved a stop-gap spending bill to avert a government shutdown. Included was full funding for veterans programs for the coming fiscal year. A spokesman for Tester said the senator included language that creates a single pot of funding for all VA community care programs. Once Choice dollars dry up, that will eliminate the incentive that has driven the VA to push the complex program over other ways of buying private care.

“Congress will still have some work to do, but it’s a big step in the right direction,” said spokesman Dave Kuntz.

Still, with the election looming, it appears that Congress might not tackle the details of just what will follow Choice until next year, raising the possibility that legislation could once again be crafted in crisis.

“The future is unclear, and that really concerns us because, ultimately, congressional inaction will harm veterans,” Carlos Fuentes, deputy legislative director of Veterans of Foreign Wars, said in an interview.

“Something’s going to give,” he added. “Either the Choice program expires and all these tens of thousands of veterans receiving care through the program every month, all of a sudden that stops, or Congress acts. We can see an eleventh-hour fix, but the fix is still to be determined.”

McDonald defended the Choice program to the Senate committee, saying four legislative fixes and other adjustments have helped drive up its use. He noted that 5 million appointments have been held since the program’s inception. He pleaded with the committee to renew it promptly so veterans don’t lose their right to private care in the midst of treatment.

He also pressed for passage of the stalled Veterans First Act – which cleared the Senate committee in the spring and now boasts 44 co-sponsors. It would solve some of the thorniest issues with the Choice program: It makes the VA pay first for care in all circumstances, eliminating the requirement that veterans being seen for conditions that aren’t service related initially use their own private insurance. That has delayed payment to medical providers and landed many veterans in collections. The bill also would allow the VA to buy care from medical providers under agreements that are far less onerous than the federal contracts now required. Lawmakers in rural states say the change is particularly necessary for small providers with low veteran caseloads.

The omnibus bill also gives the VA new power to fire employees due to poor performance or misconduct. Concerns with that and other provisions unrelated to the Choice program led to a block on the bill reaching the Senate floor. Fuentes said many of those concerns have been addressed.

Still, wildly competing visions for the future persist, clouding the path forward.

Sen. John McCain (R-Ariz.), the chief architect of Veterans Choice, in the spring introduced the Care Veterans Deserve Act, which would make Veterans Choice permanent and expand it so all veterans enrolled in VA health care could use it without preauthorization.

The VA, along with nearly all veteran service organizations, has opposed such broadened access, saying it would drain resources away from VA facilities and particularly from critical programs to treat traumatic brain injury, post-traumatic stress disorder and other ailments with which veterans struggle.

The Commission on Care’s own recommendation calls for a compromise – a tightly integrated network of VA and private doctors delivering care that is coordinated by the VA. The size of those networks would vary depending on regional needs. It would eliminate the Choice program altogether.

Yet even that proposal goes too far for most veteran service groups by allowing veterans to see private primary care doctors without prior VA approval and tasking those doctors with coordinating their specialty care.

Meanwhile, there is the looming question of cost. Every plan put forward would cost significantly more than the Choice program did, with the commission proposal coming in as high as $35 billion a year in the scenario that most broadly expands access to private-sector care. (If use of private care doesn’t grow further, however, the commission suggests a cost savings.)

The VA is pressing ahead anyway. Earlier this year, the department quietly moved to let its local health care systems directly schedule veteran appointments using Choice dollars if the program’s private administrators – Health Net Federal Services and TriWest Healthcare Alliance – couldn’t do so promptly, correctly or conveniently.

And next month, the department expects to put out a call for proposals from private industry to run the next iteration of Choice – with hopes that congressional action will follow. With key components still unresolved, however, the move could be risky.

Adrian Atizado, assistant national legislative director of Disabled American Veterans, said securing enough funding will be tough.

“It took a national crisis whipped up by every member, by every media outlet, by every veteran, for Congress to authorize only $10 billion over three years,” Atizado said of the Veterans Choice program. “Imagine them trying to come up with $35 billion.”

This story was edited by Fernando Diaz and copy edited by Nadia Wynter and Nikki Frick.

Lee Romney can be reached at leoraromney@gmail.com. Follow her on Twitter: @leeromney.

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