Republicans’ Latest Gambit to Deny Rural Veterans Health Care

To qualify as one of America’s 1,337 Critical Access Hospitals, such a facility must be located at least 35 miles from the nearest hospital (or 15 miles in mountainous terrain), maintain an emergency room, and house up to 25 beds with patients staying an average of 96 hours or less. This special designation, established in 1997, helps hospitals achieve greater financially stability and offers rural Americans a lifeline by maintaining essential health care.

These lifelines are now in danger of closing or drastically reducing their services, due to President Trump’s “One Big Beautiful Bill Act” (OBBBA). The bill slashes $911 billion in Medicaid funding over the next decade, potentially leaving entire communities stranded. According the Kaiser Family Foundation, rural areas stand to lose $87 billion, even after accounting for the $50 billion supplemental “Rural Health Transformation Fund” embedded in the legislation.

Instead of fixing a problem of their own making, leaders in Congress are now using Critical Access Hospitals as a red herring to siphon public funding away from veterans’ health care.

Two Republican Senators who sit on the Senate Committee on Veterans’ Affairs—Kevin Cramer of North Dakota and Tim Sheehy of Montana—have rightfully expressed concerns about the fragility of rural health care. To address the crisis, they have introduced the “Critical Access for Veterans Care Act,” legislation they claim will help rescue the nation’s rural hospitals and clinics. In their press release announcing the bill, they state: “As a country, we have prioritized the preservation of Critical Access Hospitals to ensure rural America has readily available care.”

Unfortunately, their proposed solution will likely do far more harm than good. Rather than protecting rural veterans from further decimation, the bill would gravely interfere with the health care access that most veterans depend on.

The mechanics of the Senators’ proposal reveal its fundamental flaw. Cramer and Sheehy argue it will preserve rural hospitals by automatically allowing veterans enrolled in the Department of Veterans Affairs (VA) health care system to obtain care at CAH hospitals and affiliated outpatient clinics and medical offices within 35 miles of where they live. Under this proposal, veterans could simply call to make an appointment, or walk in, without first obtaining authorization from the VA.

The Senators strenuously oppose VA’s authorization-based system. Instead, they promote the ability for veterans to “freely pursue care that is paid by VA.” Cramer makes no bones about his motive to abolish the prior authorization process in its entirety, declaring, “We can’t let the VA itself determine whether a veteran is qualified to receive local care,” adding, “I don’t believe we have an obligation to sustain the bureaucracy.”

The VA’s prior authorization system—a routine feature of any insurance payer that foots the bill, such as Medicare or United Healthcare—is absolutely necessary. It offers critical protections to veterans who might otherwise receive unnecessary or duplicative tests and procedures, or care that isn’t based on scientific evidence. VA scrutiny also assures that outside contractors are not bilking the taxpayer through the kind of fraudulent billing practices that are rife in America’s profit driven health care system. Without pre-authorization, for example, it would be difficult for the VA to verify that a veteran treated by a CAH lives within the 35-mile radius.

The Cramer-Sheehy legislation claims to give veterans quicker access to services. It argues that rural veterans are being left “without timely access to the high-quality care,” and the bill “offers veterans new options for health care in rural areas where there might not be a VA health facility nearby.” These “timely access,” “new options” and “no facility nearby” assertions do not hold much water.

First, the VA MISSION Act of 2018 created a private sector network, the Veterans Community Care Program (VCCP), which guarantees veterans emergency medical and psychiatric care, as well as walk-in urgent care, anywhere. Veterans can access private sector outpatient care if they need to wait more than 20-28 days for an appointment or drive more than 30-60 minutes to a VA medical center or clinic. Whenever that’s the case, the VA offers the option for private care, including at CAHs and their outpatient services.

Second, a vast number of CAHs are well within a 35-mile radius of VA hospitals. In Jamestown and Devils Lake, VA community clinics are located on the same premises as the CAH. In Grand Junction, Colorado, the full-service Grand Junction VA Medical Center, serving 37,000 veterans, sits only 13 miles from Family Health West Hospital. The Altoona Pennsylvania VA Medical Center, serving 26,000 veterans, is 17 and 24 miles from Penn Highlands Healthcare and Conemaugh Miners Medical Center. Ohio has 32 and Michigan has 28 Critical Access Hospitals proximate to VA clinics. Hundreds of similar cases exist across the country. 

Veterans who live within the established VA drive and wait standards already have everything from primary care to mental health care, as well as a pathway to more specialized hospital care at a major VA medical center or community clinic. These facilities may also operate nursing homes as well as residential treatment programs for a variety of mental health problems. The quality of VA care has been repeatedly shown to equal or exceed that of the private sector.

It becomes clear that the legislation neither offers rural veterans quick, nearby care, nor solves the increasingly dire rural health care crisis. Instead, it would accelerate the privatization of the nation’s largest integrated national health care system, depriving rural—and urban—veterans who depend on the VA. Most veterans would never want to leave the VA unless a lack of services forced them to.

The bill constructs an alternative referral system that would incrementally defund and dismantle rural VA services. This is not by accident—it is by design. When veterans move their care outside the VA, dollars follow them out the door. Declining patient volumes trigger budget cuts, forcing specialized programs and even entire facilities to be scaled back or eliminated. Veterans who depend on these programs are abandoned. Furthermore, once veterans can bypass the VA for the hospital or doctor’s practice down the corridor or across town, legislators committed to privatization will have a built-in excuse to transform the entire system.

Over the past decade, we have witnessed increasing outsourcing of veterans’ health care.  In 2014, Congress passed the Veterans Access, Choice and Accountability Act, which allowed veterans to seek private sector care under certain limited conditions. The program was supposed to sunset after three years. Instead, in 2018, President Trump signed the VA MISSION Act, which allowed far more veterans to seek private sector care through the creation of the Veterans Community Care Program (VCCP). What was explicitly intended to be a program that supplemented—not supplanted—VA care now has 1.7 million private sector providers, treats over 60% of veteran patients and consumes over a third of the VA’s clinical care budget. And it’s still expanding. For FY 2026, VA Secretary Doug Collins asked for a 54% increase over the prior year in funds for the private sector network.

A 2024 major evaluation of outsourcing of VA care done by prominent health care experts, including former VA Under Secretaries for Health under Democratic and Republican administrations Kenneth W. Kizer and Jonathan B. Perlin, concluded that the VCCP has not led to care that is more conveniently located or of higher quality. Instead, the evaluation found, “The increasing number of Veterans referred to community providers … threaten to materially erode the VA’s direct care system.” Without a course correction, the experts wrote, mass closures of VA clinics or certain services could ensue, “eliminating choice for the millions of Veterans who prefer to use the VHA direct care system for all or part of their healthcare needs.”

Cramer’s and Sheehy’s contention that their bill will help save rural hospitals similarly ignores the complex nature of the crisis, which as the Veterans Healthcare Policy Institute has reported, has many causes. Without major federal or regional subsidies, sparsely populated rural areas simply can’t supply hospitals with enough patients to maintain their existence. Plus, private and government (including the VA’s) reimbursement is often so low that it further compromises hospitals’ financial health. That’s why so many rural hospitals were in jeopardy even before the One Big Beautiful Bill Act cut close to a trillion dollars from the Medicaid program.

The way to save rural hospitals is not by downsizing VA facilities and thrusting veterans into a private sector facing severe shortages of physicians, mental health providers and hospital services. The solution is to rethink how rural hospitals are paid. It’s to expand VA facilities, hire more VA staff and offer VA services to all veterans.

With proper support, the VA can remain a stabilizing force in a crumbling rural health care environment—not become another casualty of it. Sens. Cramer and Sheehy should spend less time attacking the VA authorization process and more time fighting the Medicaid cuts that threaten the entire rural health care system. Rural veterans—and all rural Americans—deserve better.

Russell LemleMore by this author →

Russell Lemle is a Senior Policy Analyst for the nonprofit, non-partisan Veterans Healthcare Policy Institute. He’s authored numerous scientific publications and commentaries in a diverse range of outlets, including Task & Purpose, The Hill, The American Prospect, Washington Monthly, Federal Practitioner, Military.com and American Psychologist on the impact of the VA’s accelerated outsourcing of veterans’ health care and on the prevention of suicide.

Suzanne GordonMore by this author →

Suzanne Gordon is a journalist, author, and editor, who has written extensively about health care work and policy issues. She has published three books about the veterans’ healthcare system, including most recently Our Veterans: Winners, Losers, Friends and Enemies on the New Terrain of Veterans Affairs from Duke University Press (co-authored with Steve Early and Jasper Craven). Her work has appeared in the New York Times, Boston Globe, American Prospect, The Nation, Jacobin, Atlantic Monthly, and many other publications. She also lives in Richmond and works with the Bay Area-based Veterans Healthcare Policy Institute. She can be contacted via her website, suzannegordon.com.