The Veteran Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 provided a monumental shift in health care coverage for veterans of the United States. The VA MISSION Act expands health coverage for veterans through improved community care programs, improvements in VA healthcare delivery, and expands caregiver programs. Georgia Senator Johnny Isakson introduced the Act in February 2018 and signed by the president and became Public Law no: 115-182 on June 6, 2018. This paper analyzes bill S.2372 using Malone’s (2005) healthcare policy analysis and discusses ethical considerations as they relate to healthcare that veterans receive from the VA.
Background
In 2017, there was a total of 18,263,035 living veterans in the United States. Of those 18.2 million veterans, only 6.1 utilized healthcare from the Veterans Health Administration (VHA). The VHA is the largest integrated healthcare system in the United States, consisting of 1,255 health care facilities and 1,074 outpatient facilities available to all formerly active military members discharged under any condition other than dishonorable. (Veteran Affairs, 2019).
In 2014, a whistleblower gained media attention by exposing a VA Hospital in Phoenix, Arizona for having significantly long wait times for patients seeking care through the VHA, causing the deaths of 40 people. An Inspector General Report stated that the VA hospital in Phoenix had unacceptable lapses in follow-up, coordination, quality, and continuation of care (Griffin, 2014).
In 2015, the Inspector General released a report involving the Health Eligibility Center (HEC). The report expressed concerns about the competency of the HEC, including:(1) a backlog of 889,000 pending health care applications, (2) 47,000 veterans dying with a pending healthcare application, (3) the possible purging or deleting of 10,000 veteran health records, (4)the discovery of 40,000 unprocessed applications spanning a 3-year time period (Halliday, 2015).
The report found that the HEC had not correctly sent out correspondence to applicants seeking additional information, employed a new software that purged over 10,000 duplicate applications, and overlooked that 35% of all unprocessed applications were for deceased individuals (Halliday, 2015).
These reports and media attention showed how difficult it is for veterans to gain eligibility for healthcare under the VHA. Additionally, the VHA was discovered to have substantially long wait times to receive care. Veterans who do not have other forms of insurance are at risk of increasingly complicated and progressing health ailments due to extended delays in establishing care eligibility and even longer waits to receive medical attention from the VHA.
History of S. 2372 in Legislature
After the inspector general findings of how the VHA was treating veterans, it was apparent that something needed to be done to allow veterans to utilize this entitlement for serving our country effectively. Two identical bills were introduced to solve the VHA’s problems. Senator Johnny Isakson sponsors S. 2372 and introduced the bill to the chambers of Congress on February 5, 2018. H.R. 5674 and was sponsored by U.S. Representative Phil Roe and was introduced to the chambers of Congress on May 3, 2018, and incorporated into S. 2372 on May 16, 2018 (Govtrack, 2018).
In 2017-2018 the 115th Congress signed 25 bills into law that supported veterans (Isakson, 2018). S. 544 is The Veterans Choice Program Improvement Act and was one of the bills the 115th Congress signed into law. This act allowed veterans to receive care outside of the VHA promptly. S.544 was signed on April 19, 2017, and amended H.R. 3230 The Veterans Access, Choice, and Accountability Act of 2014 (S. 544).
H.R. 3230 provided three years of funding for veterans to receive care outside of the VHA if a veteran is unable to be seen within 30 days at a VHA. H.R. 3230 did not provide care outside of the VHA if veterans lived far away from a VHA facility (Veterans Affairs, 2014). S. 544 renewed the funding that H.R. 3230 no longer had after its sunset date. S. 544 also provided funding to veterans who lived more than 40 miles away to be eligible to be seen at a non-VA facility. S. 2372 took the flaws that H.R. 3230 and S.544 had and created a bill that better met the veteran’s needs.
Opposers of S. 2372
Senator Bernie Sanders supported and opposed S. 2372. Senator Sanders saw how important it is for veterans to receive healthcare through the VA after all of the sacrifices veterans made for our country. He understood how important it is to find solutions to the various problems that the VHA had. Senator Sander’s concern was the solution to allow veterans to receive community care could put the VHA at risk of becoming privatized. S. 2372 did little to solve the vacancies the VHA had. If the VHA had funding to fill healthcare worker vacancies within their facilities, more veterans would be able to be seen within the VHA instead of seeking care from the community (Sanders, 2018).
Registered nurses that work within the VHA have the same concern that Senator Sanders has with regards to vacancies within the VHA. VHAs provide care that meets the unique needs of veterans. Having veterans go out into the community can put them at risk of receiving care from healthcare providers that do not have experience and/or training to meet their unique needs. Nurses opposed the H.R. 5674’s version of the VA MISSION Act due to these concerns (Burger & Ross, 2018).
S. 2372 acknowledges that community care physicians could lack understanding on how to meet the unique needs of veterans. S. 2372 therefore provides funding to educate physicians in community care settings on how to meet these unique needs (S. 2372. 2018). Community care physicians can get knowledge on how to meet these needs but lack experience. Physicians at VHAs can meet veteran needs more effectively based on their experience seeing veterans every day. S. 2372, unfortunately, has no mention of how the VHA will fill vacancies within their facilities. Veterans will have to seek community care instead of receiving care within the VHA due to the lack of staffing, which is still a primary concern for nurses.
Policy Analysis
Malone’s (2009) framework for analyzing a policy can be used to determine if a policy will be effective. S. 2372 acknowledged there was a problem with how veterans were receiving care through the VHA and that previous bills such as S. 544 and H.R. 3230 provide some assistance for veterans, but more could be done. Any veteran waiting to establish care with the VHA or waiting for an appointment were affected by the problems with the VHA that S. 2372 attempts to solve.
S. 2372 found solutions to the problems the VHA has and allows veterans to no longer to be affected negatively. One of the solutions S. 2372 has is that veterans now have more opportunities to be seen outside of the VHA than before. If a veteran has to wait over 20 days or drive over 30 minutes for primary care, or 28 days or drive over 60 minutes for specialty care, they are qualified for healthcare in the community. Veterans are now eligible to utilize urgent care and walk-in clinics for immediate health care needs instead of waiting for an appointment at the VHA (Veterans Affairs, 2019).
Senators like Johnny Isakson are in positions to allow S. 2372 to make a difference in the veteran community. Senator Isakson is a veteran himself and understands the struggles that veterans go through every day after they transition out of the military. He uses his knowledge, experience, and political power to sponsor S. 2372, so he can make a difference in the veteran’s life that seeks out healthcare through the VHA.
The main obstacle that S. 2372 has is that it lacks assistance and funding to provide manning to VHAs to meet veterans’ healthcare needs. Instead, S. 2372 provides funding to pay for community care to meet veterans’ healthcare needs. Nurses can be involved in S. 2372 by finding out if the healthcare facility they work in will provide community care to veterans in need. If a nurse is at one of these facilities, they can utilize S. 2372 education funding to educate themselves and other healthcare workers on the unique needs of veterans. Getting this education sets the veteran and healthcare facility up for success by being prepared to meet the veteran’s unique needs and allows the veteran to have a higher quality of life after receiving care from the nurse’s healthcare facility.
Ethical Discussion
The VA MISSION Act was signed into law on June 6, 2018, and went into effect on June 6, 2019. This law allows veterans better access to community care and gives healthcare providers access to training to understand better the unique needs veterans need at the end of their military contract. This law needs to have ethical considerations and discussions to make sure veterans receive the best possible care after risking their lives to serve our country. First, one must apply the principle of nonmaleficence to keep the veterans’ welfare intact by treating them autonomously and to not harm those seeking care from the VHA. Second, the principle of justice is discussed to evaluate the bill’s intentions of solving injustices veterans previously received from the VHA.
Nonmaleficence
The Hippocratic Oath states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.” This statement falls under the ethical principle of nonmaleficence; it is defined as the obligation to abstain from causing harm to others (Beauchamp & Childress, 2013, p. 150). Frankena (1973) divided the principle of nonmaleficence into obligations such as “one ought not to inflict evil or harm.”
Before S. 2372 was signed into law, veterans were harmed in various ways. The backlog of unprocessed applications and improperly sending out correspondence when additional information was needed caused veterans harm. This poor communication between the VHA and veterans trying to receive care causes veterans harms due to a lack of medical attention that reduces their quality of life.
S. 2372 works to provide the right care, at the right time and the right place. This allows veterans to not be at risk for harm. S. 2372 provides more options for veterans to receive healthcare outside of the VHA through community care and coverage of urgent/walk-in care facilities.
The VHA has an ethical quality improvement tool called the ISSUES approach. Nonmaleficence can be practiced effectively utilizing ISSUES by producing measurable and sustainable changes to ethical concerns within the organization. The steps of the ISSUES approach are (1) Identify an issue, (2) Study the issue, (3) Select a strategy, (4) Undertake a plan, (5) Evaluate and adjust, (6) Sustain and spread (VHA, 2018, p. 6). S. 2372 worked to have this approach utilized within the VHA to allow ethical principles such as nonmaleficence to prevent harm to veterans.
Utilizing ISSUES, the VHA gave S. 2372 the groundwork to be able to be signed into law. The VHA identified the issue of long wait times for veterans to receive care and studied what can be done to improve wait times. Finding ways to receive funding to allow veterans to utilize community care and urgent care facilities was their strategy. Creating a bill to allow for funding was the plan. After the bill passed in 2018, the VHA took a year to evaluate and adjust how veterans would receive these new benefits and in June 2019, they put the MISSION Act into action for veterans to use. Through correspondence to veterans through postal letters and electronic mail, the information about these benefits has spread.
ISSUES and S. 2372 allowed for nonmaleficence to be adequately practiced. Instead of a veteran having to wait weeks and/or months to receive the care, they can go to an urgent care facility for minor injuries and illnesses. Urgent care facilities typically have same-day appointments and can allow a veteran with a minor injury such as a sprained ankle to receive care the same day the injury occurred instead of waiting weeks to receive care from a VHA facility or waiting for hours at VHA emergency rooms. If a sprained ankle does not receive care from a medical professional promptly, the injury can become worse and cause the patient more harm. Urgent care facilities allow veterans to get care for a sprained ankle and reduce the potential of them receiving harm through the same-day or next-day appointments.
Justice
Beauchamp and Childress (2013) interpret justice as fair, equitable, and appropriate treatment in light of what is due or owed to persons. When someone decides to enlist in one of the branches of the military, they are putting their life at risk in order for every American to have the freedoms and rights our country is founded upon. Assisting veterans can be traced back to 1636 when Pilgrims passed a law that disabled soldiers would be supported by the colony (Veterans Affairs, 2018).
As our country grew into what the United States is today the VA grew as well. It is common knowledge that veterans need support after they transition from their time in the military and the VA strives to provide that support to them. The VA provides benefits to veterans for serving our country such as payments for education, home loans, burial services and healthcare.
Based on the ethical principle of justice, veterans should receive healthcare that is fair, equitable and appropriate because they risked their lives in order for Americans to have freedom. Unfortunately, veterans are not receiving justice with regard to the VHA. The VA has 1,255 healthcare facilities and 1,074 outpatient clinics. Not every veteran is receiving equal care from the VA even though it is their right. Some veterans live too far away from these facilities or clinics, and it is not feasible for them to travel to receive care. Other veterans were never given proper resources on how to apply for this benefit or their application was lost in the backlog of 40,000 unprocessed applications.
S. 2372 looked to bridge the gap in the lack of proper healthcare that veterans were receiving and allow them to receive the justice they deserve for serving our country. Under the VA MISSION Act veterans receive more opportunities to receive care and improve their quality-of-life. Veterans that live in Alaska, Hawaii, and New Hampshire are now eligible for community care since these states do not have a full-service VA medical facility (Veterans Affairs, 2019). This allows veterans to have equality with regards to healthcare compared to veterans that live near a VA medical facility.
Another way S. 2372 gives veterans justice is by providing community care to veterans that have to drive more than 30 minutes or wait more than 20 days to receive primary care and mental health services. Veterans that have to drive more than 60 minutes or wait 28 days for a specialty care appointment are eligible for community care as well (Veterans Affairs, 2019). Giving veterans equality to healthcare through community care opportunities gives them the justice they deserve through fair, equal, and appropriate treatment that is owed to them for their sacrifices to our country.
Nurses and S. 2372
With over 18 million veterans in the United States, nurses will take care of veterans on numerous occasions during their career. The American Nurses Association’s (ANA) code of ethics holds nurses to a high standard when providing care to patients. Provision two and provision five of the code of ethics show support for S. 2372.
Provision two of the nurse Code of Ethics states, “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population,” (Fowler & American Nurses Association [ANA], 2015, p. 25). The negligence of the VHA affects not only the veteran as a patient, but also, through the continued suffering of the veteran, loved ones and the population as a whole. In 2016 the VA released a ruling to allow full practice authority to Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs) and Certified Nurse Midwives (CNMs). The ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN was supportive of this ruling and now allows 6,000 Advanced Practice Registered Nurses (APRNs) to provide care to veterans within their full scope of practice (Byrd, 2016). Having APRNs provide care to veterans can reduce the suffering veterans and their loved ones experience by being able to be seen sooner and receive quality care.
Provision five shows nurses support for S. 2372. Veterans seeking medical care can receive care from APRN’s when a physician is unavailable or has a long waiting time for an appointment. Veterans are eligible to receive community care outside of the VA if specific criteria is met. APRN’s can be the solution for veterans who are eligible for this community care. When a veteran’s healthcare needs are met this can release a burden upon the veteran and their family. When these burdens have been uplifted the nurse’s commitment to quality care has been met.
Veterans have unique healthcare needs and nurses can meet those specific needs through ethics. Provision five states, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth,” (Fowler & ANA, 2015, p 73). The nursing profession involves life-long learning. When nurses educate themselves on unique healthcare needs that veterans can have, they can promote health and safety in the veteran’s life. This can keep the veteran’s integrity intact. This can promote the nurse’s professional growth within their career and give them a sense of purpose and give them personal growth when they know they are knowledgeable in these veteran unique needs and give the nurse a sense of purpose within their career and in veteran’s lives.
One of the unique needs that veterans have when they transition out of the military is a lack of mental health coping skills and resources. Provision five shows support for S. 2372 by giving veterans better access to mental health services. Jeremiah wrote in Jeremiah 29:11, “”For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope and a future.” Nurses can assist veterans in their future endeavors by giving them the mental health care they need and deserve, and S. 2372 can make this all possible.
Personal Reflection
As a third-generation veteran this bill was very personal to me. When I reflected upon this bill for the first time, I saw that this bill and law that went into effect showed that the US government acknowledged that there are a lot of problems within the VHA and something needed to be done to fix these problems. After the Vietnam War every veteran who served our country volunteered to do so and sacrificed so much during their time in the military so each and every single American can enjoy freedom. The VHA is a benefit that veterans have earned and if the administration has these many flaws, something needs to be done to fix it which S. 2372 strived to do. As a veteran myself, a daughter and granddaughter to veterans and a wife to a veteran I am satisfied that this bill was signed into law.
As a future registered nurse seeing that S. 2372 wants to expand education opportunities to healthcare providers, I am excited to see what education opportunities will be provided. With serving in the Navy, people lack understanding what it means to be on a ship deployment for 6-9 months and provided little time off the ship during the deployment and what this can do to you from a mental and physical level. My transition out of the military and becoming a veteran has been difficult as with most veterans. I am hopeful that the funding S. 2372 gives to educating healthcare providers can give them a better understanding of what I and other veterans have experienced during our time in the military and why the transition into becoming a veteran is difficult and we can receive better care based on our unique needs as veterans.
Conclusion
S. 2372 made history when this bill was made into law. After the whistleblower reports in 2014 that showed the lack of care veterans were receiving from VHA that caused the untimely deaths of 40 veterans it was apparent that something needed to be done. Previous bills attempted to meet the healthcare needs of veterans and did some improvement, S. 2372 meets more veterans needs and gives them a better quality of life. S. 2372 provides justice to veterans through fair, equitable and appropriate care for veterans based on their right to VA healthcare benefits for their service and sacrifices to our country and nonmaleficence is practiced through the prevention of harm to veterans by providing timely appointments though the VHA or community care.
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