Michael Macor/San Francisco Chronicle via AP
Biden’s VA secretary has dragged his feet on reversing Trump-era administrative rules determining veteran eligibility for private-sector care.
During a recent campaign speech in North Carolina, former President Donald Trump claimed that, when he first entered the White House seven years ago, there were “sadists” working at the VA who “would beat up old wonderful soldiers. Beat the hell out of them … and we weren’t allowed to fire them.” In a meeting with New Hampshire veterans, Trump urged them to support his re-election effort so, next year, he can fire “every corrupt VA bureaucrat who Joe Biden has outrageously refused to remove from the job or put back in the job.”
Such threats are not MAGA rally rhetoric. They constitute Trump’s plan of action for the Department of Veterans Affairs (VA), which has the second-largest workforce and third-largest budget of any federal agency.
As the Prospect and other media outlets have warned, Trump and his supporters will be much better prepared next January to seize the levers of power than they were in 2017. According to one former Trump official, their collective mission will be to act as a “wrecking ball” aimed at “the administrative state [from] Day One.”
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Right-wing policy wonks, who are part of a Heritage Foundation–sponsored group called Project 2025, have developed a detailed agenda to slash federal spending and cut taxes, dismantle key agencies, strip 50,000 workers of civil service protections, renegotiate union contracts, and privatize even more government functions, like providing medical care to nine million patients of the VA-run Veterans Health Administration (VHA).
Their blueprint for next year and beyond—if Republicans win in November—can be found in a 920-page document called Mandate for Leadership: The Conservative Promise, released by the Heritage Foundation last summer. The chapter devoted to veterans affairs was penned by Brooks D. Tucker, who served as chief of staff for Trump’s second VA secretary Robert Wilkie. Tucker’s acknowledged helpers include Darin Selnick, a leading alumnus of the Koch brothers–funded Concerned Veterans for America (CVA) and advocate of dismantling the VA when he served on a presidential commission in 2016.
The challenge facing concerned veterans and their caregivers is how to mobilize to prevent a much better-coordinated Republican return to the White House, when the current administration does not offer enough of an alternative to Trump’s own VA agenda, past and future. Biden’s VA leaders continue to ignore the elephant in the room: the already swinging wrecking ball of privatization. One sign of this is the rare Project 2025 praise of Biden appointees, for “adopt[ing] some of their predecessors’ governance processes” at the VA.
The Dilemma of VA Defenders
As previously reported in the Prospect, Biden’s VA secretary Denis McDonough has dragged his feet on reversing Trump-era administrative rules determining veteran eligibility for private-sector care. The Veterans Community Care Program (VCCP), launched by his Republican predecessor and authorized by the MISSION Act, has been expanded to include 1.6 million outside medical care vendors. VCCP utilization is growing by 17 percent a year, 42 percent of VA patients are now channeled into the private sector, and the program is consuming over 30 percent of the VHA’s clinical care budget. That has, of course, weakened the VA’s direct-care capacity, strained its finances, and made working conditions worse for frontline caregivers.
As a result of this and other management decisions, the VHA is now facing a $4 to $5 billion budget deficit and will have to curtail new hiring. In response to this situation, VA officials authorized a “Red Team Review,” led by Kenneth W. Kizer, under secretary for health at the VA during the Clinton administration and a widely respected health care reformer. Team members were asked to offer ideas to deal with the rising costs of the community care program and what insiders believe is an “existential threat” to the VHA’s continued existence. Participants in the meeting, held in early January, included current high-level VA officials, plus representatives of the military and private-sector health systems. Their report and recommendations are due to be released in the near future.
VA headquarters has already informed local and regional medical center leaders that they must maintain “neutral FTE’s.” Dr. Shereef Elnahal, the VA’s current under secretary for health, has repeatedly acknowledged that the resulting workload increases will add to job stress and burnout. But he is already contributing to that with his drive to increase patient loads for clinicians via a much-disliked system of “bookable hours,” a productivity measurement of the sort favored by Project 2025.
Prospect interviews with VHA facility managers around the country reveal that they are warning VA headquarters that local program cuts and staff layoffs will be necessary soon, if outsourcing costs continue to drain local budgets. As one VA medical center chief of staff predicted, “If the Secretary does not revise the access standards to community care so we are actually able to meet them, in five years, we won’t be able to deliver care, we’ll be just another insurance company.”
Not Reversing Course
Rather than reversing course, McDonough and Elnahal are moving full steam ahead on nearly $40 billion in outside contracting, which threatens to further entangle the VHA in some of the worst practices of the private health care industry. As previously reported by the Prospect, the Biden administration plans to spend $23.5 billion over the next decade on an “Integrated Critical Staffing Program” (ICSP), a gravy train for HR outsourcing firms that will fill VA jobs by hiring non-union temps. Another just-announced initiative allocates $14 billion to hire “commercial health care consultants” and other vendors who will advise the agency on modernization of its service provision. The VA will be adding many more contractors to its roster even though its own Office of Inspector General has just released a report documenting that the agency isn’t adequately vetting and monitoring those already on the payroll.
Both initiatives are very much in the spirit of Project 2025’s encouragement of private-sector partnerships “to improve the overall patient experience,” which most studies confirm is better inside, rather than outside, the VHA. VA workers upset with these priorities have been forced to mobilize, not against the looming threat of Trump’s return, but against management policies and practices that differ little from the Trump era.
In Cincinnati, hospital staff represented by the American Federation of Government Employees (AFGE) held a picket for “Dignity, Fairness, and Respect” over unfair discipline and deteriorating labor-management relations. Members of National Nurses United (NNU) organized protests in Georgia, Colorado, and Illinois against what their union calls a “nurse staffing crisis throughout the VA,” exacerbated by local management resistance to flexible scheduling necessary to attract and retain RNs. (“It’s as if they don’t care if seasoned and well-trained VA nurses have left and will continue to leave,” says Atlanta RN Dana Horton.)
National Federation of Federal Employees (NFFE) Local 1 held the largest of these events, rallying more than 100 nurses and other staffers from the VA Medical Center in San Francisco against an unpopular change in RN work schedules that was imposed in November. This cost-cutting move was local management’s response to a $76 million budget deficit that resulted, in part, from McDonough’s refusal to rewrite his predecessor’s rules requiring costly and unnecessary patient referrals outside the VHA.
Rank-and-file concern about staffing—at a facility with nearly 100 vacancies—led to a tense exchange between union reps, several of whom are veterans, and McDonough when he came to San Francisco on January 25. The VA secretary lost his temper in response to a series of pointed questions. He strongly defended his $23 billion temp hiring scheme, would not discuss any timetable for returning $1 billion worth of outsourced telehealth work to the VA, and claimed he couldn’t restrain outsourcing via administrative rulemaking without Congress first amending the MISSION Act.
This is a position McDonough has never taken before, either with lawmakers or the press or in a September 2022 mandated report to Congress on “Access to Care Standards.” As Military.com reported in June 2022, he told the Senate Veterans’ Affairs Committee that “my hunch is that we should change access standards” to restrain the cost of outsourcing, then consuming 33 percent of the VHA’s total health care demand.
A Misleading Message
McDonough’s jousting with union members, who should be natural allies of Biden’s re-election effort, came just a month after a misleading directive to all 400,000 VA employees. In a New Year’s message, the VA secretary warned about “controversies and challenges … that will get accentuated during this presidential election year.” During this trying period, he wrote, “our noble mission, our singular purpose and our critical responsibility to always keep Veterans at the heart of everything we do … requires each of us to stay out of politics” (emphasis added).
McDonough’s mass email did include a link to the U.S. Office of Special Counsel (OSC) website providing guidance on what political activities by federal employees are limited and permitted under the Hatch Act. Yet that was hardly enough to make its impact less damaging, given the historic wariness of federal employees about the Hatch Act, which has long been invoked by managers for political demobilization purposes in the past. As one former AFGE official told us, “That message was threatening, dangerous, and factually wrong—something you’d expect of his Republican predecessor. The original intent of the Hatch Act was to protect federal workers from political pressure and patronage. It does not mean they should ‘stay out of politics.’”
As this McDonough critic noted, the act permits VA employees to register and vote; sign nominating petitions; donate to parties, campaigns, and partisan groups; attend political rallies and fundraisers; be members of politics clubs and parties; and aid campaigns for or against referendum questions and other public-policy issues—civic-minded behavior that most Americans would consider to be political engagement, rather than “staying out of politics.”
One VA worker reached out to Erica Hamrick, deputy chief of the OSC’s Hatch Act Unit to express concern about McDonough’s message being widely misinterpreted by his co-workers. On behalf of her office, Hamrick responded that “we understand your concern with the broad language” and will “reach out to the VA and explain our concerns.” When asked about the status of that message from the OSC earlier this month, VA Public Affairs Director Terrence Hayes told the Prospect that McDonough’s “comments were taken out of context.”
“The bottom line,” Hayes said, “is the Secretary welcomes all VA employees to be involved in the political process. We just can’t get involved in the noise of the election. We need to avoid the noise of the election season and stay focused on our mission of delivering high-quality care and timely access to benefits to all our veterans.”
This year’s general-election contest will indeed be noisy, but 2024 is not a year for political inaction by federal workers, either organizationally or individually. At the VA, where a third of the health care workforce consists of former service members like Hayes himself, nobody is better positioned to counter Trump’s demonization of “VA bureaucrats” as “sadistic” and “corrupt” than its frontline caregivers.
Only they can put a human face on who actually delivers “high-quality care” and helps veterans gain “timely access” to other service-related benefits. And if they fail to do that in sufficient numbers, particularly in key battleground states, just 11 months from now the keys to VA headquarters will be handed over to conservative promise-keepers from the Heritage Foundation. Their agenda has already proved disastrous, for VHA patients and providers, during Trump’s first term and, unfortunately, in its Biden-era iteration as well.
