WASHINGTON — A health program for veterans that President Trump heralds as a triumphant success is struggling to make its network of doctors as large as required to meet an aggressive expansion of care outside the Department of Veterans Affairs health facilities, officials said. The company managing the new program in a majority of the states said it would probably need millions of dollars more to meet the plan’s coverage goals.
Under a new law, known as the Mission Act, veterans who need to drive for at least 30 minutes to a government-operated veterans hospital — rather than 40 miles under old standards — can receive primary care and mental health services outside the department’s traditional system. The switch for the nine million enrollees in the program for veterans was the biggest shift in American health care since the passage of the Affordable Care Act under President Barack Obama, potentially moving tens of thousands from government services to private care.
Officials at Optum Public Sector Solutions, the third-party administrator for the new health plan for veterans across a large portion of the United States, recently told congressional aides that they were unable to guarantee a health care network large enough to accommodate all the veterans who might seek care under the new system. They suggested that more money — perhaps as much as $75 million — would be needed to help build a larger network. The contracts for their region, complete with seven renewable one-year options through 2026, were worth a potential total of $55.2 billion. Their region includes 36 states in the eastern half of the United States, as well as the District of Columbia, Puerto Rico and the Virgin Islands.
“The $75 million figure is an early estimate based on nothing more than guesswork,” said Christina Mandreucci, a spokeswoman for the veterans department. “While there are almost always costs involved in contract modification, both V.A. and Optum believe they will be a fraction of that total, with future estimates driven by network utilization data.”
Two people with knowledge of the contracts said that Optum, a subsidiary of the insurance giant UnitedHealth Group, was chosen in part because it was the lowest bidder for the regions, perhaps because its network was smaller than other companies.
Before the Mission Act was passed, the Department of Veterans Affairs had contracted with Optum Public Sector Solutions to manage veterans’ health care, replacing TriWest Healthcare Alliance, a popular system that maintains control of veteran private health care in the west. But officials at the company have told aides to lawmakers on Capitol Hill that under the new rules for care outside the department, they are unable to guarantee a network large enough to accommodate all those who subsequently may seek that care.
“The V.A. is now working to make modifications that will optimize the contracts for compatibility with the Mission Act,” Ms. Mandreucci said. “There is nothing unusual about this process, which is often required on various V.A. contracts in response to other legislative and regulatory developments.”
She added, “This issue is not affecting patient care in any way, as V.A. and Optum have mechanisms in place to ensure that high quality and safe care and services can be coordinated when needed.”
Since June, when the act officially took effect, Mr. Trump has repeatedly portrayed the transition as a mission accomplished.
“People said it couldn’t be done, “V.A. Choice,’ ” Mr. Trump said last week during a rally in Tupelo, Miss. “Our veterans were waiting on line for days and weeks sometimes.”
Now, under the new program, Mr. Trump said, veterans have the option to “go out, get a doctor, we pay the bill, and they don’t have to wait six weeks, four weeks, two weeks. We have people waiting in line, they weren’t very sick, by the time they saw the doctor, they were terminally ill. Now, they go on and they go and they go outside and they find a doctor and we take care of our great veterans.”
That characterization of the problems in the federal veterans health system before the new standards is overstated, and the president has presented the new program as further along than it is.
Both the veterans department and Optum seem to be assessing in real time the market for care outside the traditional system and are not certain how many veterans will be choosing the system under the new standards. Veterans have long sought options to federal system in rural areas far from the hospital centers. However, those are also areas lacking in community-based health care providers, and that is where Optum is said to be most challenged, both in terms of doctors and the urgent care clinics that are also part of new menu of options for veterans who want to go outside the traditional network.
The percentage of veterans now eligible for what officials refer to as “community care” — about 8 percent of the seven million treated annually — will rise to 20 to 30 percent under the new standards in the Mission Act, according to Department of Veterans Affairs officials.
“Optum is committed to ensuring our nation’s veterans can access the quality care they need, when and where they need it,” said Aaron Albright, a spokesman for Optum. “We are successfully building out a broad, high-performance care provider network, and will continue to collaborate with the V.A. to expand on this critical work in full support of the Mission Act.”
Officials from Optum came to Capitol Hill several weeks ago to update staff members, who were startled to hear that the network as envisioned under the original contract would unlikely be able to meet the needs of a major influx of new veterans. A few weeks later, officials from the veterans department traveled to Capitol Hill to discuss the Mission Act and its progress, and it became clear that Optum did not have enough providers in the right locations, said one Senate official, surprising many in the room.
“Veterans aren’t getting the care the Trump administration promised to them under its access standards because V.A. and Optum can’t agree on contracting issues that should have been settled months ago,” said Senator Jon Tester, the senior Democrat on the Senate Veterans’ Affairs Committee. “Optum needed to dot the I’s and cross the T’s before — not after — outbidding other networks to serve veterans. V.A. made promises to veterans when it developed these new access standards and now it needs to follow through.”