WASHINGTON—Over the course of the next year, the House Veterans Affairs Committee will host a number of field hearings around the country inviting veterans to comment on what they see as the pressing needs within the Department of Veterans Affairs’ healthcare system. Committee chair Rep. Bob Filner, D.-Calif., told reporters at a press briefing last month that the committee and VA leaders plan to take a hard look at how care is distributed to veterans, especially underserved populations and those living in rural areas.

A New Way to Serve Rural Veterans

According to Rep. Filner, VA has the authority to help veterans who live far from VA facilities get easier access to care, but that local VA administrators are reluctant to use it. “It looks to me that there is a sense of inflexibility or a refusal to use the authority they already have in terms of contracting out. They don’t use that in a policy-driven way,” Rep. Filner said.

For example, it is within a VISN administrator’s power to allow any veteran living 300 miles from the nearest VA medical center to see a private physician for mental health services with the VA contracting out to that physician. But, according to Rep. Filner, it is rare that any such region-wide policies are instituted. “None of the local guys want to make policy in that way, but they have the power to do it,” he said.

One reason might be the cost. Contracting out services is usually considerably more expensive than using physicians employed at VA facilities. “Too many directors look at it as how it’s going to affect their bottom line. They’re judged by the amount of money they save, not by the veterans they serve, so they don’t use the authority they have,” Rep. Filner said. “It seems to me that each person is making a decision, and decentralized decision making I guess is good. But they’re looking at it from their bottom line.”

While it is understandable that VA not contract out services at every opportunity, the department must find a middle ground where the needs of veterans who do not have easy access to healthcare services, particularly specialty care, are met.

“I have a very rural part of my district, and a very urban one. In the rural part, after much debate, they put in a community-based outpatient clinic. They purposefully located it in a place where there are other medical [services] around. But then they won’t let them use [the other medical facilities],” Rep. Filner said. “There’s an optometrist next door. Let them use it. There was a radiology clinic two doors down, but they make them come 200 miles to the medical center for [advanced imaging services].”

If VA administrators do not begin to use the authority already given to them to help serve rural veterans, the committee will have to do it for them by making it policy, he said.

Is CARES Defunct?

Five years ago, an independent commission of healthcare experts and former VA leaders released the final draft of the CARES (Capital Asset Realignment for Enhanced Services) report, a landmark study commissioned by VA that produced specific recommendations on how to change the structure of the VA healthcare system to improve services. The proposed realignment drew large amounts of controversy from legislators angered by some of the recommendations, which included the building of three new hospitals, dozens of clinics and the shutting down of at least seven VA medical centers. One of the major goals of the process was to redistribute VA resources to better provide care for underserved and rural veterans.

But are the results of an evaluation that began years before the report’s publication still valid?

“I never had much confidence in it myself. And I think most of my committee—most of them are newer members, and even the older members—don’t really understand it,” Rep. Filner admitted. “It just doesn’t seem to meet the needs of what I hear from my colleagues.”

“We’ll be looking at it very closely this year, especially in regard to rural vets. In fact, we’re going to have a series of field hearings around the country,” he added. “And I know [Secretary] Shinseki is looking at it, too.”

But while any reevaluation of the CARES process should focus on rural veterans, there are other populations that need to be looked at as well, Rep. Filner said. “We’re going to evaluate it from a rural perspective, and also [look at] traditional unmet needs that somehow are not part of that so-called objective process [that went into CARES]. There is, for example, South Texas with a heavily Hispanic population. The CARES process looked at that in some numbers way, but here’s a group of people who have been left out of a lot of stuff. And they feel that they’ve been left out, not because there’s not enough veterans [in that region] but because they’re Mexican-Americans. And you have to take [the regional population] into account. You have to say whether that prejudice has gotten into our process, and we have to look at those different issues.”

Regardless of how the report is reevaluated, the amount of time that has passed means that it almost certainly needs to be updated, he said. “Things have changed. The process began a decade ago. So we’re going to update that, but look at it from the perspective of special needs,” Rep. Filner said.