The Washington PostDemocracy Dies in Darkness

Senators kill sweeping plan to reshape sprawling VA health-care system

The VA Hospital in Clarksburg, W.Va., seen in September 2019, was dedicated in 1950 and received an add-on in 1989. The median age of VA hospitals is nearly 60 years, a VA official noted. (Jeff Swensen for The Washington Post)

After years of inaction, lawmakers and advocates in 2018 rallied around an ambitious plan to modernize the sprawling, government-run health-care system for veterans, which still treats many patients in hospital wards built before World War II.

A commission, mandated that year by Congress, was tasked with weighing recommendations from the Department of Veterans Affairs for each of its 1,200 hospitals and clinics across the country and holding hearings in affected communities. The southward migration of veterans from the Northeast and Midwest, the shift from costly inpatient to outpatient care and the age of each building would factor into whether facilities would be urged to close, reduce service or shift patients into private care. VA would finally catch up to modern private hospitals, saving billions of dollars from it spends each year to shore up its aging health-care facilities, proponents of the plan argued.

But a long-sought realignment of the country’s largest health care system was killed this week by bipartisan political resistance through a short news release from 12 senators who said they would not approve the nine nominees up for confirmation to establish the Asset and Infrastructure Review (AIR) Commission. And a costly four-year effort to reposition VA in an increasingly competitive health care market fell victim to the principle that, just as all politics is local, so, apparently, is any decision to shift services for a constituency as crucial as veterans.

The lawmakers indicated that the politically explosive recommendations VA made in March made moving forward impractical.

“We share a commitment to expanding and strengthening modern VA infrastructure in a way that upholds our obligations to America’s veterans,” the senators, led by Senate Veterans’ Affairs Committee Chairman Jon Tester (D-Mont.), wrote in their release Monday. “We believe the recommendations put forth to the AIR Commission are not reflective of that goal, and would put veterans in both rural and urban areas at a disadvantage.” The release said lawmakers were committed to a “continued push” to help VA invest in “21st century [health-care] facilities” for veterans.

Lawmakers in both parties had expressed misgivings about a process they felt was flawed from the start. The data VA relied on to assess the hospitals was several years old and collected before the coronavirus pandemic, potentially skewing the number of patients and physicians in a community to appear lower than they really were.

The White House also was slow to nominate the nine-member commission, with the final member announced only last week. That left a too-tight window to complete its work by an early 2023 deadline, lawmakers argued, as well as uncertainty about whether a nominee would face pressure to weigh in on the recommendations in order to be confirmed.

But by halting the commission and the sweeping plan released by VA Secretary Denis McDonough with recommendations to build about 80 new clinics, hospitals and nursing homes of varying sizes and close a net of three major hospitals and dozens of clinics with unused inpatient beds, the lawmakers left the agency with no blueprint to modernize its aging system, current and former officials said.

“President Biden has insisted that our Veterans in the 21st century should not be forced to receive care in early 20th century buildings,” Melissa Bryant, VA’s acting assistant secretary for public and intergovernmental affairs, said in an email. She noted that the median age of VA hospitals is nearly 60 years. “Whatever Congress decides to do with the AIR Commission, we will continue to fight for the funding and modernization that our veterans deserve,” Bryant wrote.

VA leaders going back years have said they are burdened by the need to maintain as many as 1,000 underused clinics and hospitals, some of which have more staff than patients, at significant cost. Closing them would require approval from Congress.

When the commission was created as part of the larger Mission Act, conservatives said the government would reduce wasteful expenses and shift more veterans’ health care to the private sector. Democrats, including McDonough, embraced the possibility of caring for more veterans in communities where they’re moving.

“We saw it as an opportunity,” said one VA official, who spoke on the condition of anonymity to discuss a sensitive issue. In a commitment to new investment, Biden requested about $18 billion in new money for VA construction in an early version of his infrastructure plan, although the money was eventually left out of the law.

But even before McDonough released his recommendations, members of Congress who were briefed on possible reductions to service in their districts went on the offensive, some holding rallies in opposition, others issuing defiant statements that previewed the battle to stave off reductions.

The American Federation of Government Employees, the union representing more than 200,000 VA staff, pressured Democratic allies in Congress to oppose feared job losses. Republicans, most of whom voted for the Mission Act, became sensitive to local concerns that veterans would lose access to doctors, as the plan called for closing or rebuilding 35 large hospitals in 21 states.

“It’s a total lack of courage,” Robert McDonald said of the decision to kill the commission, citing the midterm elections in November. “It’s obvious what’s behind it. There’s an election coming up. Elections are local.”

McDonald, who was VA secretary for several years under President Barack Obama, had tried to close a sparsely used hospital in South Dakota, only to see the Trump administration cancel the plan soon after taking office following objections from Sen. Mike Rounds (R-S.D.)

Robert Wilkie, President Donald Trump’s second VA secretary, also expressed disappointment with this week’s decision. “We have to build a VA where the veterans live now, not where they lived in 1945,” he said in a text message. “The VA dollar is being stretched to the breaking point and dissolving the commission does not help.”

It’s unclear if lawmakers who still support the commission have any options. Rep. Mike Bost (R-Ill.), who with Sen. Jerry Moran (R-Kan.) opposed the decision, said in a statement Wednesday that he is “still assessing how to move forward “as the law requires.”

“The fact remains that there is a serious and growing mismatch between the VA health care system as we know it today and how, and where, it needs to evolve for the future,” Bost wrote.

Darin Selnick, a senior adviser for Concerned Veterans for America who led efforts at VA and later in the Trump White House to create the commission, said the Biden administration left VA to issue recommendations with no structure to vet them, opening the process to political resistance.

“Anytime a legislator hears they might close a facility in their district they go ballistic,” Selnick said, “but if you had had a commission in place that wouldn’t have mattered.” He emphasized that VA’s plan “was only a set of recommendations” that could have been changed.

An official with the American Legion predicted dire consequences of inaction.

“Veterans are going to lose,” said Chanin Nuntavong, the group’s executive director of government and veteran affairs. “Old infrastructure needs to be repaired or replaced. Veterans’ care will be degraded by a lack of technology and unsanitary conditions while construction costs go through the roof.”

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