The Illusion of Choice

At his confirmation hearing in January of 2025, Secretary of Veterans Affairs Doug Collins, a former congressman from Georgia, assured the Senate Veterans’ Affairs Committee of his commitment to provide specialized, high-quality medical care for the roughly nine million veterans enrolled in the nation’s largest and only truly integrated public health care system, the Veterans Health Administration (VHA).

But Collins, a chaplain in the Air Force Reserve, also explained that his mandate from President Trump is to make it “easier for veterans to get their health care when and where it’s most convenient for them,” by giving them greater choice between in-house and outsourced care. To do this, he planned to lean on the network of 1.7 million private-sector providers who are part of the Veterans Community Care Program (VCCP), created by the VA MISSION Act of 2018. Annual reimbursement of these non-VHA doctors, therapists, hospitals, and clinics now costs the federal government more than $30 billion per year, nearly one-third of the VA’s entire direct care budget.

Collins’s proposed budget for fiscal year 2026 calls for a 50 percent increase in VHA spending on private care and a 17 percent reduction in direct care funding. And Collins has taken other steps consistent with the goal of downsizing direct service provision and boosting the VHA’s reliance on outside vendors.

Republicans in Congress routinely assert that veterans can easily find better and faster treatment outside the VHA. That’s because they assume that we have enough hospitals, primary care providers, specialty physicians, and mental health therapists to care for the country’s current patient load of 330 million nonveteran Americans, let alone nine million more veterans.

To test the accuracy of these claims, the Veterans Healthcare Policy Institute (VHPI) partnered with the Prospect on a survey of the U.S. health care landscape in all 50 states. State by state, we looked at the data on the current available supply of primary care providers, mental health professionals, and hospitals, particularly in the rural (and remote rural) areas where about one-quarter of all veterans, or about 4.7 million, reside, with 2.8 million of them enrolled in the VHA.

This analysis reveals a system that cannot provide even basic medical and mental health services to nonveteran patients. Hundreds of hospitals in America’s rural counties and underserved areas have curtailed critical services or closed entirely. And thousands of counties across America are experiencing significant health provider shortages, according to federal data.

The dramatic shortfall in capacity in our nation’s health system will get even worse with the passage of President Trump’s One Big Beautiful Bill Act. On top of unilaterally imposed cuts that are already crippling the nation’s academic medical centers, the law, signed on July 4, will impose over a trillion dollars of cuts to Medicaid and the Affordable Care Act. Around 17 million people are expected to lose their health insurance due to Trump’s policies, guaranteeing increased uncompensated care at emergency rooms. States will also have less money to fund their Medicaid programs. All of this will lead to additional hospital closures and more shortages of health care personnel.

Yet, at precisely this moment, President Trump, VA Secretary Collins, and Republicans in Congress also want to send more veteran patients into an already troubled private-sector system, while depleting that system of the resources necessary to absorb this extra load. The idea that this will work well is shaped more by ideology than reality.

One longtime VA expert observed: “Imagining that you can add more complex VA patients into a private-sector system that will be reeling from, and contracting because of, funding cuts is nothing short of delusional.”