By Tony Leys, KFF Health News
WATERLOO, Iowa — John-Paul Sager appreciates the care he has received at Department of Veterans Affairs hospitals and clinics, but he thinks it should be easier for veterans like him to use their benefits elsewhere.
Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. “It seems like it takes entirely too long,” he said.
Many veterans live hours from VA facilities, or they need health services that aren’t readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.
John-Paul Sager, a veteran of the Marine Corps and Army, is treated for chronic back and shoulder pain by chiropractor Matt Gronewold in Waterloo, Iowa, on June 20, 2025. (Tony Leys/KFF Health News/TNS)
Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.
Two Republican senators have introduced legislation that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump’s first term.
Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn’t be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.
“My main concern is for veterans, not for the VA,” Sen. Kevin Cramer, R-N.D., told KFF Health News. “I don’t believe we have an obligation to sustain the bureaucracy.”
About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.
Cramer co-sponsored a bill that would allow veterans who live within 35 miles of a rural, “critical access” hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.
Related Articles
DC Mayor Bowser walks delicate line with Trump, reflecting the city’s precarious position
Social Security has existed for 90 years. Why it may be more threatened than ever
European leaders praise Trump for offering US military support for future peace force in Ukraine
As Canada wildfires choke US with smoke, Republicans demand action. But not on climate change
Melania Trump demands Hunter Biden retract ‘extremely salacious’ Epstein comments
Cramer, who serves on the Senate Veterans’ Affairs Committee, noted his state has just one VA hospital. It’s in Fargo, on the state’s eastern border, which is more than 400 miles by car from parts of western North Dakota.
Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. “I kept thinking to myself, ‘This doesn’t make any sense at all,’” Cramer said.
Cramer said previous laws, including the VA Mission Act, made it easier for veterans to use their benefits to cover care at community hospitals and clinics.
But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.
“We can’t let the VA itself determine whether a veteran is qualified to receive local care,” he said.
U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans’ Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department’s money to support private health care facilities.
The VA provides specialized care that responds to veterans’ needs and experiences, he argues.
“We must prevent funds from being siphoned away from veterans’ hospitals and clinics, or VA will crumble,” Takano said in a statement released by his office. “Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community.”
Some veterans’ advocacy groups have also expressed concerns.
Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn’t want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.
Retzer said it’s true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. “This is a national crisis.”
Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. “We want to ensure that the VA is the primary provider of that care,” he said.
Veterans Affairs Secretary Doug Collins has pledged to improve the community care program while maintaining the strength of the department’s hospitals and clinics. The department declined a KFF Health News request to interview Collins.
Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer’s bill. Lewis is a Navy veteran who uses the VA’s community care option to pay for treatment of a back injury stemming from his military service.
Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. “It’s frustrating.”
Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they’re entitled to receive locally.
“I think a lot of folks just don’t want to fight the system,” he said. “They don’t want to go through the extra hoops, and so they’ll jump in the van, and they’ll ride along.”
Rep. Mike Bost (R-Ill.), chairman of the House Veterans’ Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.
Bost helped gain the House’s approval for Trump’s request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that passed Aug. 1.
Bost also co-sponsored a House bill that would spell out requirements for the VA to pay for community care.
John-Paul Sager developed chronic back and shoulder pain during his military service, including his role as an Army drill sergeant at Fort Sill, Oklahoma, where he took this photo in 2014.. (John-Paul Sager/KFF Health News/TNS)
Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.
Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency’s mission, including its employment of many veterans. “You just feel like you’re being taken care of by your own,” he said.
He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can’t promptly provide.
The local VA doesn’t offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.
Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.
Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn’t have to jump through so many hoops to obtain convenient care.
“After what they’ve done for us? Please,” she said.
©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.
