Stuck On Hold Act

— 647 — Department of Veterans Affairs reimagine the health care footprint in some locales, and spur a realignment of capacity through budgetary allocations. Specifically: 1. Embrace the expansion of Community Based Outpatient Clinics (CBOCs) as an avenue to maintain a VA footprint in challenging medical markets without investing further in obsolete and unaffordable VA health care campuses. 2. Explore the potential to pilot facility-sharing partnerships between the VA and strained local health care systems to reduce costs by leveraging limited talent and resources. Personnel l Extend the term of the Under Secretary for Health (USH) to five years. Additionally, authority should be given to reappoint this individual for a second five-year term both to allow for continuity and to protect the USH from political transition. l Establish a Senior Executive Service (SES) position of VHA Care System Chief Information Officer (CIO), selected by and reporting to the chief of the VHA Care System with a dotted line to the VA CIO. l Identify a workflow process to bring wait times in compliance with VA MISSION Act–required time frames wherever possible. 1. Assess the daily clinical appointment load for physicians and clinical staff in medical facilities where wait times for care are well outside of the time frames required by the VA MISSION Act. 2. Require VHA facilities to increase the number of patients seen each day to equal the number seen by DOD medical facilities: approximately 19 patients per provider per day. Currently, VA facilities may be seeing as few as six patients per provider per day. 3. Consider a pilot program to extend weekday appointment hours and offer Saturday appointment options to veterans if a facility continues to demonstrate that it has excess capacity and is experiencing delays in the delivery of care for veterans. 4. Identify clinical services that are consistently in high demand but require cost-prohibitive compensation to recruit and retain talent, and examine exceptions for higher competitive pay. — 648 — Mandate for Leadership: The Conservative Promise 5. Assess the medical facilities where Community Care is readily available but referrals for Community Care are below the averages in other similar markets, referrals expiring are above the average, and/ or canceled appointments are above the average. Identify reasons and factors and consider possible ways to improve timeliness and responsiveness for veterans. 6. Further explore how to leverage telehealth to reduce personnel costs across the enterprise and serve veterans. Continue to pursue expansion of broadband services to remote and rural areas. 7. Assess recruitment and retention in highly competitive medical markets to identify common limiting factors for attracting high-demand, specialized occupations. 8. Consider aggressively recruiting retired physicians who desire to serve veterans. 9. Consider expanding VA tuition assistance in exchange for reciprocal service in rural or understaffed VAMCs. 10. Examine the surpluses or deficits in mental health professionals throughout the enterprise, recognizing that the department needs a blend of social workers, therapists, psychologists, and psychiatrists with a focus on attracting high-quality talent. l Conduct a high-priority assessment of Electronic Health Record (EHR) transition delays and functionality problems. VA innovation in health care for the next 20 years and beyond will rest squarely on the timely implementation of the new VHA EHR in coordination with the DOD’s parallel pacing effort. The VA’s EHR rollout has been blocked by technical delays at local facilities where personnel have raised safety concerns and infrastructure has not been modernized to accept the new system. VETERANS BENEFITS ADMINISTRATION (VBA) Needed Reforms The most evident and ongoing concern is the complexity of benefits, which can lead to confusion for the veteran and, if not mitigated early in the veteran’s interactions, long-term distrust of and animosity toward the VA. Wholesale ben- efits reform is unnecessary and politically a “third rail,” but effective managerial

— 644 — Mandate for Leadership: The Conservative Promise In sum, the VA for the foreseeable future will experience significant fiscal, human capital, and infrastructure crosswinds and risks. Budgets are at historic highs, and with a workforce now above 400,000, the VA is contending with a lack of new veteran enrollees to offset the declining population of older veterans. Recruitment of medical and benefits personnel has become more challenging. Veterans are migrating from the northern states to the southern and western states for retirement and employment. Meanwhile, VA information technol- ogy (IT) is struggling to keep pace with the evolution of patient care and record keeping. Consequently, VA leaders in the next Administration must be wise and courageous political strategists, experienced managers to run day-to-day oper- ations more effectively, innovators to address the changing veteran landscape, and agile “fixers” to mitigate and repair systemic problems created or ignored by the present leadership team. VETERANS HEALTH ADMINISTRATION (VHA) Needed Reforms l Rescind all departmental clinical policy directives that are contrary to principles of conservative governance starting with abortion services and gender reassignment surgery. Neither aligns with service-connected conditions that would warrant VA’s providing this type of clinical care, and both follow the Left’s pernicious trend of abusing the role of government to further its own agenda. l Focus on the effects of shifting veteran demographics. At least during the next decade, the VA will experience a significant generational shift in its overall patient population. Of the approximately 18 million veterans alive today, roughly 9.1 million are enrolled for VA health care, and 6.4 million of these enrollees use VA health care consistently. These 6.4 million veterans are split almost evenly between those who are over age 65 and those who are under age 65, but the share of VA’s health care dollars is spent predominantly in the over-65 cohort. That share increases significantly as veterans live longer and use the VHA system at a higher rate. VHA enrollments of new users are increasingly at risk of being exceeded by the deaths of current enrollees, primarily because significant numbers of the Vietnam generation are reaching their life expectancy. The generational transition from Vietnam-era veterans to post-9/11 veterans will take several years to complete. The ongoing demographic transition is a catalyst for needed assessments of how the VA can improve the delivery of care to a numerically declining and differently dispersed national population — 645 — Department of Veterans Affairs of veterans—a population that is more active, reaching middle age or retirement age, and migrating for lifestyle and career reasons. At the center of the VHA’s evolution during this generational transition is an ongoing tension, some of it politically contrived, between Direct Care for Veterans provided from inside the VHA system and Community Care for Veterans who are referred to private providers participating in the VHA’s two Community Care Networks (CCNs). In recent years, the budget for Community Care has grown as demand from veterans has risen sharply, sometimes outpacing the budgets for Community Care at individual VAMCs. The Trump Administration made Community Care part of its “Veteran- centric” approach to ensure that veterans would be able to participate more fully in their health care decisions and have options if or when the VHA was unable to meet their needs. The Biden Administration has watered down that effort, has sought various procedural ways to slow the rate of referrals to private doctors, and at some facilities is reportedly manipulating the Community Care access standards required by the VA MISSION Act of 2018. If the makeup of Congress is favorable in 2025, the next Administration should rapidly and explicitly codify VA MISSION Act access standards in legislation to prevent the VA from avoiding or watering down the requirements in the future. First and foremost, a veterans bill of rights is needed so that veterans and VA staff know exactly what benefits veterans are entitled to receive, with a clear process for the adjudication of disputes, and so that staff ensure that all veterans are informed of their eligibility for Community Care. Currently, veterans are not routinely and consistently told that they are eligible for Community Care unless they request information or are given a referral. l To strengthen Community Care, the next Administration should create new Secretarial directives to implement the VA MISSION Act properly. Sections for consideration and areas for reform include the following: 1. Sections 101 and 103 (Community Care eligibility for access standards and the best medical interest of the veteran). 2. Section 104 (Community Care access standards and standards for quality of care).

— 483 — Department of Health and Human Services l Readdress the National Strategy to Support Family Caregivers. While in theory the strategy aims to support family members with duties to care for older family members, the plan is overly focused on racial and “LGBTQ+ equity.” The strategy should be examined to establish an efficient plan to support caregivers and their families. There should also be a review of its COVID-19 policies. HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) l Congress should allow CMS to use the 340B data that HRSA collects rather than having CMS conduct its own survey, especially in view of the U.S. Supreme Court’s American Hospital Association v. Becerra decision.69 The legislation should also create penalties for those who do not respond to HRSA’s data collection. l Legally define the locus of service as where the provider is located during the telehealth visit rather than where the patient is. With such a definition, states could continue to reserve their powers to establish the standards for licensure and scope of practice. The providers could ensure continuity and consistency of care no matter where their patients might move while maintaining the licenses that make the most sense for them. Americans are far more mobile and technologically advanced today than they were when most health care laws were written. Telehealth has become increasingly important, particularly during the height of the COVID-19 pandemic. It also has great potential in rural and other areas where there are shortages of health care providers. HRSA’s Office for the Advancement of Telehealth includes a program known as the Licensure Portability Grant Program, which bolsters state efforts to reform licensing laws to maximize telehealth flexibility. HRSA does not have the authority through this office to dictate licensure laws; that power has typically been reserved to the states. However, telehealth across state lines, when permitted, is interstate commerce, which can be regulated by the federal government according to the Constitution. l Restore Trump religious and moral exemptions to the contraceptive mandate (also a CMS rule). HHS should rescind, if finalized, the regulation titled “Coverage of Certain Preventive Services Under the Affordable Care Act,” proposed jointly by HHS, Treasury, and Labor.70 This rule proposes to amend Trump-era final rules regarding religious and moral exemptions and accommodations for coverage of certain preventive services under the ACA. Preventive services include contraception, and — 484 — Mandate for Leadership: The Conservative Promise it appears the proposed rule would change the existing regulations for religious and moral exemptions to the ACA’s contraception mandate. There is no need for further rulemaking that curtails existing exemptions and accommodations. l Require HRSA to use rulemaking to update the women’s preventive services mandate. The contraceptive mandate issued under Obamacare has been the source of years of egregious attacks on many Americans’ religious and moral beliefs. The mandate was issued as part of the women’s preventive services guidelines, which were issued without any rulemaking that involved public notice and an opportunity to comment. Instead, HRSA issued and changed the mandate by simply posting changes to its website. HRSA also started off not requiring coverage of fertility awareness–based methods of family planning, then requiring them, and then removing the requirement without notifying the public. A federal judge recently ruled that this failure to undergo notice and comment in issuing the mandate is unlawful. HRSA should be required to repromulgate any women’s preventive services mandates through the notice and comment process that is compliant with the Administrative Procedures Act. Moreover, since the Obama Administration HRSA entered into long- term contracts with the pro-abortion American College of Obstetricians and Gynecologists (ACOG) and related entities to serve as an exclusive adviser with respect to the content of this mandate, HRSA has used this arrangement to ignore comments that members of the public were sometimes able to submit in the process, and ACOG has abused its position to attack HHS’s allowance of religious and moral exemptions to the contraceptive mandate. HHS should rescind these contracts and establish an advisory committee that is compliant with the Federal Advisory Committee Act and has members that are committed to women’s preventive services and are not pro-abortion ideologues. l Expand inclusion of fertility awareness–based methods and supplies to family planning in the women’s preventive services mandate. The ACA requires coverage of and prevents insurance plans from imposing any cost-sharing requirements on women who obtain preventive care and screenings as defined by HRSA. In 2016, HHS included “instruction in fertility awareness-based methods” as part of this requirement. However, in December 2021, HHS removed that language from its list without using the notice-and-comment process or giving any rationale, both of which are mandated by the Administrative Procedures Act. In August