Amid the alarm over President Donald Trump’s cabinet nominees who are under-qualified and self-styled disrupters, Veterans Affairs Secretary Doug Collins has a more reassuring resume.
The former four-term member of Congress from Georgia is an Iraq war veteran with law and divinity school degrees. An Air Force Reserve colonel, Collins, the son of a Georgia state trooper, has ministered to fellow soldiers as a military chaplain. He also served stints in the Georgia State House and the U.S. House GOP leadership.
At his confirmation hearing last month, no one questioned Collins’s ability to manage the federal government’s second-largest workforce and third-largest agency budget ($300 billion). On the Senate Veterans Affairs Committee (SVAC), only one out of 19 Republicans, Democrats, and Independents voted against him in committee (due to concern about his views on VA patient access to abortion). However, some of those Democrats voted against him on the chamber floor.
The 77-23 vote to confirm the bespectacled 59-year-old was based partly on the nominee’s assurances that he would champion continuity rather than disrupt the nation’s most extensive public healthcare system. Senator Richard Blumenthal of Connecticut, the ranking member of SVAC, was one of many Democrats to vote for Collins.
Collins’s promise to stay the course at the Department of Veterans Affairs (VA) by offering its nine million patients a choice between direct care in 1,350 VA facilities and referrals to private-sector hospitals and providers bolstered the support.
But there’s still plenty of reason to worry about Collins. First, there’s the situation he inherits at the VA-run Veterans Health Administration (VHA), which is running out of money to fund further outsourcing of veterans’ care without inflicting fatal damage on its hospitals, clinics, and 300,000-person workforce (one-third of whom are veterans themselves).
Of course, the incremental privatization of the VA is not new. This costly and unnecessary experiment began a decade ago under Barack Obama with strong Democratic support. It was greatly expanded during President Trump’s first administration and continued under Joe Biden, despite his professed opposition to privatization as a 2020 presidential candidate.
But now the VA is back in the hands of hard-core Republican ideologues who favor wider implementation of the VA MISSION Act of 2018, one of Trump’s proudest first-term legislative achievements that Collins supported as a House member. The bill significantly accelerated the privatization of Veterans’ health care. On the campaign trail last year, Trump touted the MISSION Act-mandated outsourcing as a great system of “rapid service,” in which veterans “go to an outside doctor . . . get themselves fixed up, and we pay the bill.” Collins was a serious legislator, but he is also hard-core MAGA. He was Trump’s pick in the 2020 Republican U.S. Senate primary in Georgia, where he lost to Kelly Loeffler. He even penned a book about Democrats being obsessed with Trump.
Collins and other Republicans assure veterans they can have the best of both worlds. They can continue to receive specialized, high-quality in-house care and exercise virtually unlimited “healthcare freedom” by going outside the VA at tax-payer expense. “At the end of the day,” Collins told SVAC members, “the veteran is getting taken care of,” and “there will always be the VA healthcare system” as “backup.”
This last claim, though, is on a collision course with reality. Imagine how long Kaiser Permanente would remain in business if some 40 percent of its patients could freely seek “out-of-network” care while it pays the bill. Plus, VA hospitals and facilities need fresh funding just at a time when President Trump and Elon Musk are looking to slash budgets.
According to a bi-partisan panel of experts, who sent their assessment to Collins’ predecessor, Denis McDonough, nearly a year ago in a report entitled “The Urgent Need to Address VHA Community Care Spending and Access Strategies,” referrals outside the VA have grown 15 to 20 percent per year and now involve more than 40 percent of its patient population.
The cost of reimbursing for-profit vendors enrolled in the MISSION Act-created Veterans Community Care Program (VCCP) has also “dramatically increased—from $14.8 billion in FY 2018 to $28.5 billion in FY 2023.”
As a result, “some VA Medical Centers are incurring community care spending deficits in the hundreds of millions of dollars and…consuming more than half of their clinical care budgets.” This has created an “existential threat” to the VHA, which, absent “new funding…will likely be forced to consider eliminating direct care services or closing VA facilities.”
This review further noted that hospital closings would ” eliminate choice for the millions of Veterans who prefer to use the VHA direct care system for all or part of their healthcare needs.” Plus, the lesser-known but equally critical medical research, teaching, and emergency preparedness functions of the VHA, which benefit all Americans, would also be gutted.
None of the healthcare experts on this McDonough-appointed panel, whose recommendations he sadly ignored, was against sending vets to private doctors or hospitals “when needed services are not readily available in the VA’s direct care system.” They questioned outside referrals that don’t result in more timely, accessible, or better care.
The panel’s wake-up call has not stopped Congressional Republicans from ignoring problems with private-sector treatment. The journal Health Affairs just published the results of a new study showing that private sector medical services utilized by veterans are of “lower quality” than those offered at the VA.
Last month, the Republican chairs of the Senate and House Veterans Affairs Committees, Senator Jerry Moran of Kansas and Representative Mike Bost of Illinois, teamed up to introduce the ACCESS Act of 2025. It’s an acronym for Assuring Critical Care Expansions to Support Service Members Act.
According to Representative Bost, the ACCESS Act will “protect and preserve the intent of the MISSION Act and the VA community care program so that no bureaucrat can stand in the way of veterans accessing the healthcare they have earned—whether that is inside or outside the VA.”
The legislation codifies and loosens patient referral standards developed during the first Trump Administration, which triggered a surge in costly and unnecessary outsourcing. Senator Moran claims the result will be “great flexibility” for veterans.
Contrary to the claims of Republicans like Secretary Collins and the bill’s sponsors, veterans are not poised to enjoy the best of both worlds—VA direct care and private doctors. As the VA becomes more of a Medicare-style bill payer and less of a direct care provider, its latter function becomes increasingly unsustainable. That’s a problem Collins and the rest of Washington can’t easily square.
