As a veteran, I trusted the Department of Veterans Affairs Community Care program to ensure my safety when care was provided outside the VA system. Unfortunately, my experience revealed a serious gap in oversight that could affect countless veterans across the country.

On January 3, 2025, during a VA-authorized outpatient procedure at a community medical facility, I experienced a documented hypoxic event where my oxygen saturation dropped to approximately 22%. Emergency airway intervention was required. Despite the severity of this medical emergency, I was discharged the same day with paperwork stating that there were “no complications,” and neither I nor my emergency contact were informed that the event had occurred.

Months later, I began experiencing neurological symptoms including persistent headaches, cognitive difficulties, balance issues, and sensory changes. When these symptoms were later evaluated, it raised serious concerns about whether the hypoxic event may have caused lasting injury. However, because the incident was not clearly reported or documented as a complication at the time of care, it created significant challenges in ensuring proper follow-up, accountability, and continuity of care.

The VA Community Care program exists so veterans can receive care from community providers when VA facilities are unavailable or when specialized care is needed. While this program expands access to healthcare, it also creates a dangerous gap in oversight when adverse medical events occur outside the VA system.

A key issue is the lack of a clear accountability bridge between the VA and community medical providers. When care is delivered through Community Care, responsibility for documenting and reporting serious medical events can become unclear. Community providers may assume the VA will handle follow-up care, while the VA may rely on the external provider’s documentation. When no formal reporting requirement exists to connect these two systems, serious medical events can fall into an accountability gap where neither system takes clear responsibility.

If serious complications are not consistently reported back to the VA, veterans may leave a procedure without knowing a life-threatening event occurred, and the VA may never receive the information needed to properly monitor the veteran’s health or provide appropriate follow-up care.

Reports from the Government Accountability Office (GAO) and other oversight bodies have already identified concerns about accountability and coordination in the Community Care program. When critical medical events go unreported, it undermines patient safety, damages trust in the system, and leaves veterans vulnerable to long-term health consequences.

Veterans deserve transparency and accountability in their healthcare. No veteran should discover months later that a serious medical emergency occurred during a procedure that was supposed to be routine.

This petition calls for the Department of Veterans Affairs to establish a mandatory reporting requirement for all Community Care providers. Any serious medical event — including hypoxia, emergency airway intervention, cardiac events, or other complications — must be immediately reported to the VA and documented in the veteran’s official VA medical record. Veterans and their designated emergency contacts must also be informed before discharge when such events occur.

By closing this accountability and reporting gap between community providers and the VA, we can strengthen oversight, protect veterans, and ensure that the VA has the complete medical information necessary to provide proper follow-up care.

Our veterans put their lives on the line for this country. The least we can do is ensure transparency, accountability, and safety in the healthcare they receive.

Sign this petition to call on the Department of Veterans Affairs to require mandatory reporting of serious medical events in the Community Care program.