Thom Bridge/Independent Record via AP
Veterans Affairs Secretary Denis McDonough addresses a roundtable discussion with veterans and other community members, April 7, 2021, at Fort Harrison in Helena, Montana.
On May 31st, President Joe Biden is required, by law, to submit the names of his candidates for a nine-member commission that will decide the fate of many Veterans Health Administration (VHA) facilities and services across the country. This commission, similar to the Defense Department’s Base Realignment and Closure (BRAC) process for the shuttering of U.S. military bases, was the brainchild of right-wing proponents of VA privatization, like the Koch brothers–funded Concerned Veterans for America. During the Trump administration, CVA staffer Darin Selnick helped craft the VA MISSION Act of 2018, which established an Asset and Infrastructure Review (AIR) Commission that would provide a list of VA facilities to close, consolidate, repurpose, or improve. The list would have to be approved by the president and voted on—up or down—by Congress, denying legislators effective input into decisions on the future of almost 1,300 facilities and hundreds of programs upon which veterans’ lives depend.
Trump and his supporters clearly hoped that he, not a Democrat, would be in charge of appointing the members of this critical commission, as well as determining the criteria that would be used to evaluate which VA programs and facilities would continue, and which would be sold off to real estate developers or other hospitals. Rather than addressing the long-standing congressional failure to allocate enough funds (currently estimated between $70 and $80 billion) to maintain, renovate, or construct new VHA facilities to meet current and future needs, the privatizers’ solution is to, well, privatize care.
Now that Democrats are in charge, the critical question is this: Will the Biden administration implement a Trump initiative designed to weaken the VHA, or will it appoint proper commissioners and staff as well as provide accurate information to the commission, so it can genuinely address veterans’ complex health care and social needs, particularly during and after the COVID-19 pandemic in which millions of veterans have lost their health care and will turn to the VHA for help?
The section of the law establishing the AIR Commission was clearly written to ensure that it would be composed of health care industry insiders with a big stake in VA privatization, and little knowledge of how the nation’s largest fully integrated health care system actually works and who it serves. One slot on the commission, for example, is reserved for a representative of the private-sector health care industry. One member must have experience with federal capital asset management and construction, architecture, and “strategic partnerships”—a euphemism for outsourcing veteran care to the private sector. This guarantees that at least one, if not two, members of the nine-member commission will be pro-privatization.
Three members of the commission must be representatives of congressionally chartered veterans service organizations (VSOs). This is not reassuring, since all the federally chartered VSOs have lobbied strongly for outsourcing, and some, like the American Legion and AMVETS, are very conservative. Since the Republican leadership in the House and Senate get to weigh in on Biden’s picks, they could push for the most conservative VSO representation. Not a single slot on the commission has been reserved for anyone with experience in population and/or public health, or rural health, even though more than 20 percent of veterans live in rural areas. No labor representation is mandated, even though closures would impact thousands of employees.
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Nor is anyone on the commission required to have knowledge of the economic, social, and medical impact of hospital closings on a community. Alan Sager, professor of health care finance and management at the Boston University School of Public Health, has studied the impact of hospital closings since the 1930s. Sager told the Prospect that “for decades, there’s this idea that a closed hospital is a good hospital and that hospital closures save money. Nothing could be further from the truth.” He explained the “multiplier” effect of having a VA hospital in a particular community. “If you have a $100 million VA hospital, it generates another $110 million in economic activity in the surrounding region,” Sager said. “The nurses pay rent, the property owner fixes the roof, that means the roofer can buy a new car, and so on.”
All this is lost when a hospital closes. Plus, patients also suffer. “In the short run, the estimate is that 30 percent of inpatients stop seeking care,” Sager notes. “I think for the VA the rate may be higher because the VA offers such a familiar and all-embracing environment. If you’re 78 and you lose your hospital and your doctor, where are you going to go.” This is particularly true for veterans in rural areas, which lost 176 hospitals between 2005 and 2014 and are expected to lose even more because of the pandemic.
The section of the law establishing the AIR Commission was clearly written to ensure that it would be composed of health care industry insiders with a big stake in VA privatization.
To provide commission members with accurate information, the MISSION Act mandated that the VA conduct market assessments of the VA’s as well as the private sector’s capacity to care for veterans. The VA has also held a series of “listening sessions” around the country, where veterans can express their concerns about and preferences for VA or private-sector care. According to many observers, the listening sessions have been poorly attended and have included only vague, closed questions like “Does VA provide the healthcare services veterans need?” Arlys Herem, who was an Army nurse during the Vietnam War and is a member of the Save Our VA campaign of Veterans for Peace, told the Prospect that the listening session he attended featured “few people actually commenting to questions that were too general and didn’t really elicit responses that seemed pertinent to the AIR Commission’s goals.”
As for the market assessments, documents leaked to the Prospect indicate that the data collected are not validated. “The commercial market capacity assessment considers only reported physical capacity,” reads one document, “and does not incorporate: 1) ability to staff patient care services or accept VA patients; 2) length of time to change facilities to accommodate Veteran demand; and 3) any negotiations for specific rates for care provided in the community.” Another issue, according to several VA clinicians who preferred to remain anonymous, is that the process has been shrouded in secrecy. “I have worked at the VA for decades,” one longtime VA leader currently working in the VA Central Office told the Prospect. “There is no discussion in meetings, which is very weird because this is a very big deal, but there is nothing but silence.”
In comments to the Federal Register, the Disabled American Veterans pointed out that the market assessments have primarily relied on “static databases of local medical capacity, rather than engaging in real-time consultations with the private providers.” In-person discussions would reveal, for example, whether psychiatrists in a particular location accept insurance of any kind, or whether psychologists are adequately schooled in gold-standard treatments for PTSD, like cognitive processing therapy or prolonged exposure therapy. Studies have confirmed that only 55 percent of American psychiatrists accept insurance of any kind, and most mental-health practitioners don’t provide evidence-based treatment for PTSD and other disorders from which veterans suffer.
The Biden administration can make sure that knowledgeable commissioners are appointed to serve on the AIR Commission and that the information they are provided is up-to-date and accurate. It can demand that very detailed criteria are used to evaluate VA facilities as well as private-sector providers’ ability and capacity to absorb millions of veteran patients.
The administration has made many positive moves when it comes to the VHA, including by allocating $18 billion in its proposed American Jobs Plan to VA infrastructure improvement and new construction. But much more attention is needed to assure that the Biden administration does not implement a Trump plan to effectively cripple the VA.
