In Lake Charles, La., it’s not the condition of a clinic but the lack of one. It’s estimated that 6,000 veterans would enroll in VA health care if the community were to get a new clinic.

The Department of Veterans Affairs has cited these examples as it sought approval from Congress last year for a dozen new or expanded health clinics around the country.

Lawmakers anticipated that the cost for the current fiscal year would probably run into the tens of millions of dollars, but the estimate from the Congressional Budget Office came in at $1.2 billion. The nonpartisan CBO said that sound accounting principles require the full cost of the 20-year leases for the clinics be accounted for up front.

The huge jump in the clinics’ price tag left lawmakers scrambling, and in the face of the budget-cutting climate on Capitol Hill, the VA request stalled. Now the agency is warning that unless lawmakers act, some currently operating clinics may have to close after their old leases expire and other long-planned expansions will not go forward.

Since the mid-1990s, the VA has turned to outpatient clinics as a way to bring health care closer to where veterans live. The department has opened 821 clinics to supplement the care provided at 152 medical centers. The clinics vary in size and services offered but virtually all provide primary care and mental health counseling. In most cases, the VA enters into a lease with private building owners, which gives the department flexibility to meet changes in demand down the road.

“I know the VA itself had plans to go beyond these 12 in the next several years. It’s going to be difficult for that to happen at a time when we see veterans’ needs rising,” said Rep. Charles Boustany Jr., R-La., whose congressional district includes Lake Charles and Lafayette, where the expansion of another VA outpatient clinic was delayed. “This has thrown a wrench into the entire way we do things.”

Any lease costing more than $1 million a year requires congressional approval. That’s where the 12 proposed clinics come in. Lawmakers submitted the legislation to the Congressional Budget Office, which keeps score of how legislation fits with congressional spending targets.

When CBO took a closer look at the clinics, analysts determined that the leases generally involved the construction of new buildings that the VA would essentially finance through a 20-year lease. The CBO told lawmakers that the entire cost of the leases needed to be accounted for up front to show taxpayers the true cost associated with a 20-year obligation.

The Congressional Budget Office declined to discuss publicly the rational for its new treatment of VA leases. Instead, it forwarded a brief about financing arrangements akin to those being used by the VA. The brief said that treating long-term investments as annual operating expenses understates the size of the federal government and its obligations. Sound budgeting requires agencies to acknowledge the full cost of their investment up front, the brief said.

That left lawmakers with two options — find $1.2 billion in savings from other government programs or waive rules that require offsets to new spending. They decided to regroup and try again this year.

“Most Democrats and Republicans agree that these projects should move ahead, so the task at hand is simply finding a way forward in light of CBO’s new method of scoring lease authorizations,” said Rep. Jeff Miller, the Republican chairman of the House Committee on Veterans Affairs. “I’m confident we’ll find a solution that doesn’t involve cuts to veterans’ benefits to pay for these leases, an option that is not on the table and one that I would not support.”

The VA leases the buildings used for nearly two-thirds of its outpatient clinics. Most of the leases that Congress declined to take up last year involved expansions.

For example, in New Port Richey, Fla., the VA proposed to consolidate leases covering five different buildings into one lease that would more than double the amount of square footage now in use. The change would result in shorter wait times and more effective care, the VA said in its proposal. The proposal added that contracting out care was not a good alternative because “there are not sufficient, qualified, private-sector providers in the New Port Richey area to accommodate increasing veteran workload.” It said that constructing a new, VA-owned building would delay the expansion and “limits the ability to relocate services in the future to adapt to changes in veterans demographics.”

For veterans in Lake Charles, talk about building a new VA clinic has been going on for a decade now. Local veteran Jim Jackson said the project has been fraught with delays. A mobile RV is stationed there now, but Jackson said local vets want a more permanent solution. He said patients concerned about privacy, particularly female veterans or those seeking mental health care, are reluctant to seek care out of the RV.

“When you go to war, you come back different,” Jackson said. “We have to take care of our veterans.”

The Department of Veterans Affairs said in a statement that failure to move ahead with the leases would hurt access to health care with increased travel and wait times for veterans.

Veterans groups are starting to voice alarm as well. The group Disabled American Veterans sent an alert to its members in recent days saying that leases for nearly two dozen additional clinics could be in jeopardy over the next five years.

“Unless a change is made, VA will be forced to buy land and construct government-owned clinics, or more likely will require veterans who need VA care to travel longer distances to receive it,” the alert stated.