All across America and around the world, this
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day. I'm Jim Fossone. I'm the Officer of the
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.com. We want to welcome to Veterans Radio today,
Russell B. Lemley. Russell, welcome to Veterans
Radio. Thanks so much for having me, Jen. Now,
Russ is a senior policy analyst for the Veterans
Health Care Policy Institute. Looks like 20,
30 years. at the San Francisco VA healthcare
system, and he was the chief psychologist there
in that system for 25 years, so he knows what
he's talking about. Dr. Lemley, why don't you
give us a little bit more of your background.
Yeah, and that's right. I did work for 38 years
for the VA all at the San Francisco VA healthcare
system. And as you mentioned, two thirds of that
as the chief psychologist. I'm a clinical psychologist
by background and I retired from the VA six years
ago and worked full time in the nonprofit that
we'll talk about in a moment in the interim.
Well it certainly gave you a long career where
you got exposed to a lot of things and there's
a lot happening in the VA world, VA Medical Center
world these days and we want to talk about that.
But let's explain to our veteran radio listeners
what the Veterans Healthcare Policy Institute
is about. Happy to do so. So the Veterans Healthcare
Policy Institute is a non -partisan, non -profit
policy organization. focused exclusively on Veterans
health care issues in the U .S. and we're led
by Veterans health care policy experts and journalists.
And we produce policy reports, analyses, education
materials, all aimed at informing these issues.
Well, it's kind of interesting that this think
tank came about in 2016. So it's been around
a while. And it was founded by veterans, health
care providers, and journalists. Really kind
of gives you a mix of professionals you're working
with, with maybe a larger scope of how they look
at issues. You've probably found that interesting
since you've been there. Absolutely. And I hope
we get more into that as we talk further. That's
right. Absolutely. So one of the things that
caught my eye recently was an article that you
wrote in military .com in late February, talking
about a, I guess a bill that's in Congress I
really hadn't heard much about, which is called
the Veterans Access Act. Can you explain to us,
Doc, what that's about? I can let me just give
a little bit of context and see if that works.
You know what that opinion piece was about has
to do with the impact that the legislation should
have passed and at this point. it has been considered
in both the Senate and the House Veterans Affairs
Committees, but is on hold in part waiting for
a Congressional Budget Office scoring of how
expensive it will be. It's in a holding pattern
at this point, but we can get more into that
act in a moment. But the context of the whole
opinion piece is to lay bare what the future
of the VA would look like if this particular
act passes other similar legislation on the future
of the VA as a healthcare system. You know, since
2014, when there were plenty of kind of media
coverage of wait lists across many VAs, particularly
at the Phoenix VA, there has been a very steady
expansion of options for veterans. to receive
their health care in the community. And the expansion,
because it actually started back right after
World War I, that veterans began getting options
for care in the community. It started out at
a much smaller scale, but we've had nearly 100
years of community options for veterans when
their local VA facilities at that point were
just generally too far away from where they lived.
Once the 2014 Phoenix crisis happened at the
VA there with long wait lists, a choice act was
passed and that was 2014 was implemented 15 and
actually gave rise to my nonprofit. because it
was beginning to change the nature of the balance
between VA care and caring the community. And
that balance has continued to shift, particularly
with this one bill that, again, we'll get into
in a moment. But the context has to do with the
balance between these two systems and what could
potentially happen in the future if that's not
addressed. you know, ironically, at this point
in time, community care is the one system that's
never going to go away. But there's some danger
in which the VA healthcare system internally
could be reduced to a very small size and not
look at all like what it is currently. And so
that's the larger frame for talking about that
particular legislation. Having this conversation
in general is that you know, contrary to the
way in which it's sometimes addressed in the
media, community care is the one thing we know
is never gonna go away. The danger is what could
happen to the VHA. It's back to that old issue,
right? Russell, like, does the exception eat
the rule? The rule was, you know, if you're entitled
to it, you should be able to go to a VA hospital
or clinic and get your care. The government owes
you that. Right. But when they couldn't, you
know, out of the spotlight on the Phoenix crisis
and wait lines in 2014, community care now has
expanded and continues to expand. Does the exception
eat the rule? Isn't that kind of a bit of the
concern? Well, even before we talk about the
Access Act, there was a independent review a
year ago. known as a red team report, which was
looking at just what you just said. And that
is that community care referrals have been growing
at 15 to 20 % a year since what was called the
Mission Act in 2018. And at this point is approaching
half of all the care that veterans receive. And
the budget is over a third of the entire VA healthcare
budget. And it's nonstop. So what you were saying
about the exception overtaking the standard,
that's exactly right, is that it's an unabated
increase year by year by year, and it will overtake
the VA and this red team report indicated exactly
how that could happen to such an extent that
within a kind of limited pie, with limited funds,
the larger the slice of the pie that goes to
community care, ultimately, the less it's going
to go to the VA and it will overtake it. That's
right. I don't think, don't get me wrong, don't
get Russell wrong here. We're not saying that
there isn't areas of community care that are
necessary and appropriate, and a good one that
he and I talked about before we got on air was,
you know, women veterans can't always get the
care they need in a VA and have to go into the
community, even for such simple things as mammograms.
So, but I always get worried when I come back
to... These bills in Congress always have these
names that are sort of developed somehow in some
basement dungeon, I suppose. Let's find a cool
name that will hide the real meaning. So when
I read something like Veterans Access Act, well,
that's got to be good. People like access for
their health care. But I also know that that's
part of the game. Let's name it something that
everybody will get a little bit fooled by. What's
really in this proposed act? Well, let me just
say that I completely agree with what you just
said, and I want to reiterate that having care
options in the community is an important feature
of the entire system. For some of the examples
that you just gave, the conversation isn't whether
it's a necessary ingredient, because it is. And
that's especially true for rural veterans in
which a VA facility and particularly a VA medical
center itself is not conveniently located. So
we do absolutely need the community to supplement
VA care when it's at some distance. And then,
of course, when the weights are way too long
for the care, even if you may want care at a
VA, but the weights are too long that you may
then have the option of going to a community
provider. So the first thing that you said, totally
agree with. This is not a conversation about
whether it's an important ingredient or whether
it should be scaled back. the question is really
the reverse. And as you're alluding to, there
are various bills and they do come up with acronyms.
It is the way that kind of bills are often named
and it sometimes becomes easier to remember them
because of that, or as you said, imply something.
So if we pivot here and just talk about this
one particular bill, in the Access Act, there
is a component of it that creates a new way in
which veterans would be able to access care in
the community. Up until now, really, for the
last hundred years, the way that the VA system,
the health care that's provided by the VA is
set up is that the VA will be the authorizer
of caring community when the VA can't provide
it in a very timely way or in a very kind of
close in distance convenient way. And there are
few other exceptions as well to that, but basically
it's it's it's it's too long or it's too far.
Then the VA says sure, if you want to go to the
community, we will give you authorization to
do so. And here's here's a list and there's over
one and a half million providers. who are in
the community who see veterans on the VA's dime
if the veteran qualifies and then exercises the
option to get care in the community. The Access
Act actually would change that for the first
time. And it basically says that the VA would
no longer need to be the authorizer care. It
is presumed that if you are enrolled veteran,
you already are authorized so you can bypass
and skip asking the VA for referral and just
go get the care yourself and send the VA the
bill. So it's a completely different system that
is proposed in the Access Act. And if that passes,
And as I said earlier, it's still in the pipeline
that it might if that passes, there will be a
further. kind of outsourcing of care, the funds
follow the veterans care and under the way in
which Congress is thinking about funding for
veterans healthcare, the dollars will flow from
VA facilities to the community and inevitably
will have to reduce the scope of what they provide.
Well, you know, just in that simple explanation,
I think most of us would say, There's a there's
a value in the gatekeeper role of saying yes,
you can go to community care or no You can't
hey, you know, we already have those services
and yours appointment for next week Why would
we send you off to the to the community for that
thing? I? Can't imagine any kind of set of services
where there was should be no gatekeeper and that
that's kind of sounds like what they're doing
here is Removing the gatekeeper on where referrals
if you will should go You know, that's exactly
right. And in removing the gatekeeper, the funds
then become less easy to manage. If you qualify
for healthcare, you're going to get the healthcare.
And if more of that healthcare then is outsourced
and the money follows it, as you said, without
the kind of gatekeeping, there's just less available
to maintain the services at the local. kind of
VA facility. And really what we're talking about
here is for those veterans who depend on the
VA and the VA medical centers and facilities
who prefer that, we're talking about those veterans
will in time not have that option. Yeah, they'll
get squeezed out monetarily. The budget will
be eaten up and you'll see the thing you can
control is your number of employees, your number
of medical centers. But is this as currently
envisioned by somebody in Congress, I don't know
who's promoting this or what groups are promoting
this, but is this envisioned as only to apply
to one area of health care, like mental health
and addiction, or does it apply elsewhere? Well,
it's yes and yes. In this particular piece of
legislation, it starts with mental health and
substance use disorder care. So the first half
of your question is that's how it's written,
but it's also indicates that after a three year
pilot period of time, it then is open to all
areas and all medical conditions, all psychological
and so forth. So although it starts in a more
limited way in the legislation, it says that's
just the way to get it started because the intention
is for everything. That's where this caught me
as a seismic change and yeah caught me as as
you as you wrote It's transforming the VA's primary
role from a health care provider to an insurance
company writing checks And that really stopped
me in my tracks Is that where you think this
would head? Ultimately, I do think so it would
happen incrementally because you know After the
pilot's over and it expands to all medical conditions,
there would just be more money that's flowing
from the VA to the community. And once care is
provided in the community, the VA has to pay
for it. And where is it going to come from? It's
just going to come out of local budgets. And
so it would incrementally pull money out of VA
facilities. I mean, you wouldn't get the upgrades
that you need for infrastructure. You won't have
as many staff. You won't have as many programs.
You'll close units. And then, you know, facility
by facility, there will be closures. Uh, so that
ultimately, so this isn't going to happen in
just a couple of years, but this could easily
happen in a decade where you just see closures.
And then the only care available is in the community
for veterans. And, and the sad part is that there
are many veterans who get all of their care at
the VA and that's by choice. And they will no
longer have the freedom to exercise that option
because the option will be gone. If I think about
this more, and obviously that's what your article
op -ed piece did for me, made me think about
it, you could see them saying, well, we don't
need to buy the latest machine for MRIs or CAT
scans or blood work or whatever, cancer diagnosis.
We're not going to make that capital investment
in the VA system because we're going to let you
go to the community. And you can sort of see
that kind of thinking if it creeps in, it will
be ultimately the erosion of a VA healthcare
system as we know it. And I think that's kind
of what you're predicting, how this, over time,
the exception could eat the rule. Yes, yeah.
You know, for veterans who do not want to go
to the VA for whatever their reason, and they
qualify for care in the community, that option
is just going to expand independent of this particular
piece of legislation. That's just not going to
be threatened. It is for the veterans who really
do prefer the VA, that is what they exercise
in terms of the options. of where they get their
care, those are the veterans who should, and
I said so in my article, make their voices known
because if we wait too long, then they're gonna
lose an option and it will not come back. And
for those who want community care, most of what
you and I are talking about is not that relevant,
because that option is just going to be there
for them always. We're really talking about the
veterans who depend on the VA. Well, and you
point out, I guess I didn't know this, that there's
a huge shortage of primary care and psychiatrists.
in the United States and in rural communities,
kind of explain how the VA, because it's set
up to deal with those kind of issues, fills that
gap. That's correct in a couple ways that you're
implying, which is when VA's shutdown units and
shutdown services, there isn't necessarily something
available in the community to pick up the slack.
And so it's not inconceivable that there are
just going to be much longer waits when the VA
closes down different aspects of. what it now
offers. There aren't enough primary care providers.
There aren't enough psychiatrists. There aren't
enough health care providers in general that
are available in the community, especially in
rural areas. And I talk a tiny bit about this
in the article, including the fact that many
of the rural hospitals are on the brink of financial
collapse and closing. So the services aren't
necessarily going to be there when the VA closes
down. I don't think that is of major concern
to those who are writing the legislation because
the intention as it appears is to just keep expanding
more options into the private sector. You know,
it's philosophically based on other things that
we're now seeing as well coming straight from
the administration, which is that philosophically,
the notion of government sponsored health care
is something that is out of favor right now.
And so whether the weights are longer, whether
the quality is lower, which actually research
shows that it is. that still is in favor at this
point as a model of providing the healthcare
for veterans. We're talking to Russell Lemley,
PhD, who is with the, and this is what kind of
caught my attention, he's with the Veterans Healthcare
Policy Institute and has written on this issue,
is the Veterans Access Act something, veterans
should be writing their congress folks on, or
is this so far not gonna, you know, so much stuff
starts in Washington as an idea but dies in Washington
because it's a bad idea. Where do you put this
and what is your call to the veteran world based
on your, you know, 40 years of being in the VA
medical healthcare system? Right, I think if
you're a veteran and you really would like the
VA to go out of business, you could write to
your member of Congress and say you're a big
supporter of this because it will kind of increase
the probability that the VA will downscale incrementally
over time. So if you're somebody who has no interest
in the VA, you could write and say you're in
favor of this bill. If you're a veteran who really
is generally pleased with the VA, Actually, the
surveys indicate that the vast majority of veterans
are generally pleased with their VA care and
they would like the VA to remain the primary
provider of healthcare systemically. Then you're
a veteran who should think about writing your
member of Congress and indicating that because
the Access Act, unless it is significantly modified,
is going to, I think, ultimately reduce an option
that for those veterans you really want to see
continued indefinitely. And this piece of legislation
puts that in jeopardy. Well, it's a very interesting
topic. I'm glad we're able to bring it to our
veteran radio listeners early on before we wake
up one day and go, well, this is now the law.
I didn't even know what was going on and I wanted
to give a chance to voice my opinion. Well, now
you can. You know it's out there. You should
voice your opinion, whichever way it is. And
if you want to follow more about Russell's writing
and what the Policy Institute is doing, the website
is veteranspolicy .org. And this Military Times
article and others that you've written on similar
topics are there. Russell, I really appreciate
the time that you've given to Veterans Radio
today. Well, Jim, I appreciate the time to do
this, because as you and I started, this is an
opportunity to weigh in before it's too late,
and I'm glad that you and I had a chance to talk
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