Congress is trying to solve a real problem in veterans’ health care — long wait times for appointments
No veteran should wait months for needed care. But for veterans with spinal cord injuries and disorders (SCI/D), the solution lawmakers have increasingly relied on — expanded use of the Department of Veterans Affairs’ (VA) Community Care program — can create a different problem.
The idea behind community care is straightforward. If the VA cannot provide timely care, veterans are referred to private-sector providers instead. Lawmakers often describe this as “choice.” For veterans with paralysis, it can feel more like being pushed out of the specialized system designed specifically for our conditions.
That distinction matters because for SCI/D patients, access alone isn’t enough. What matters is access to the right care. A missed symptom, delayed response or lack of clinical experience with paralysis can quickly turn a manageable condition into a medical emergency. When complications arise, you need clinicians who understand the realities of paralysis. That’s not a preference — it can be life-sustaining.
I experienced this firsthand. After worsening neuropathic pain in my arm, my VA physician referred me to a pain specialist. Because of staffing shortages and long wait times, I was routed into community care at a local university medical center.
The providers were competent and well-intentioned, but they had limited experience treating patients with SCI. Instead of receiving care informed by SCI/D expertise, I spent much of the visit explaining basic aspects of paralysis and its complications.
That experience highlighted a growing flaw in veterans’ health care policy. Congress has expanded community care eligibility in response to legitimate concerns about access. But in solving wait-time problems, policymakers are also creating a different risk for veterans with complex disabilities — access to care that lacks the necessary specialization.
For someone with paralysis, an appointment is only part of the equation. Providers must understand pressure injuries, autonomic dysreflexia, neurogenic bladder complications, wheelchair seating and positioning, caregiver coordination and other issues that are rarely central in general medical practice.
This is precisely why the VA built its specialized SCI/D system. Over eight decades, it has developed the nation’s largest integrated SCI care network, including 25 regional SCI/D centers and specialized outpatient teams nationwide. These clinicians treat veterans with paralysis every day. They recognize warning signs early, understand the complications and know how to prevent small problems from becoming life-threatening crises. Most community providers don’t have that level of experience.
I’ve seen the practical differences. I’ve arrived at facilities where my wheelchair couldn’t fit through a bathroom doorway. The proposed workaround was a bedpan. Equipment standard in VA SCI/D centers, such as ceiling lifts for safe transfers, is often missing in private facilities. Without it, even routine transfers can become unsafe for both patients and staff. These aren’t minor inconveniences, they’re basic issues of safety, accessibility and dignity.
The gaps extend beyond physical infrastructure. Caregivers, who are essential to the health and independence of SCI/D patients, are often treated as visitors rather than members of the care team. Within the VA SCI/D system, their role is integrated into care planning because continuity doesn’t stop at discharge or clinic doors. These issues directly affect patient safety. For someone living with paralysis, a pressure injury can lead to months of hospitalization. A urinary tract infection can escalate into sepsis. A sudden spike in blood pressure may indicate autonomic dysreflexia, a potentially life-threatening emergency that requires a rapid, informed response.
Experience matters in these situations. Yet, federal policy increasingly treats specialized SCI/D care as interchangeable with general community-based care. Since the passage of the 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, community care spending has grown significantly and referrals outside the VA have increased. The intent was to improve access, but for veterans with catastrophic disabilities, the result can be a system that prioritizes speed over expertise.
That trade-off deserves closer scrutiny than it currently receives. Community care does have an important role. Veterans who live far from VA facilities or require services that are unavailable within the VA should have access to local providers. But that system was designed to supplement the VA’s system, not replace its specialized capabilities. Today, however, policy increasingly treats outside referrals as the default solution to VA capacity problems. Every veteran sent out of the system due to staffing shortages or long waits reflects not success, but a gap in investment and planning.
The answer to access problems shouldn’t be to weaken the very system that provides highly specialized care for complex conditions. For veterans with SCI/D, the “choice” is often framed as either accepting care from providers with little experience in paralysis or waiting indefinitely for VA specialists. That’s not a meaningful choice. If specialized care becomes unavailable because Congress fails to invest in the workforce and infrastructure required to sustain it, veterans haven’t gained options — we’ve lost one.
Congress is right to focus on long wait times. But in addressing that problem, lawmakers risk creating another if they steer veterans with paralysis into systems unprepared for their needs. Veterans with SCI/D don’t simply need faster care. We need appropriate care. That means strengthening the VA’s SCI/D system, investing in trained clinicians and staff and ensuring community care remains a supplement to specialized VA services, not a substitute. Because when something goes wrong, the solution isn’t more options on paper. It’s a provider who understands paralysis.
If Congress continues addressing delays primarily by shifting care outside the VA system, it may end up trading one access problem for another safety problem. And for veterans whose health depends on specialized expertise, that’s a trade-off the system cannot afford.
As always, please share your thoughts with me at al@pvamag.com.