VA Is at a Crossroads As It Kicks Off BRAC-Style Review of Medical Facilities

When Congress first considered legislation to require a comprehensive review of the Veterans Affairs Department's health care facilities in an effort to identify those that were underutilized for closure, even the strongest proponents of the reform thought it was a pipedream. 

“The deck is stacked against the [bill],” then-Rep. Phil Roe, R-Tenn., who wrote the measure, said at a hearing in 2017. “Moving forward will require a significant amount of political courage and let’s face it, members are not known specifically for that.”

Despite that skepticism, VA officials are, nearly four years later, in the midst of conducting 50 “listening sessions” with veterans across the country to ask about their future needs and identify where facilities may have become obsolete.

Lawmakers did ultimately find the courage to pass the requirement, albeit by tucking it into a much larger measure that gained far greater attention for its expansion of private sector health care options for veterans. Nearly three years after President Trump signed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act into law, VA is kicking off the multi-year process that could culminate in a transformative reshaping of the department’s physical footprint. 

As required under the statute, VA issued proposed criteria decision makers will use in determining the future of department facilities. As it awaits public comments on those guidelines, VA is also holding the listening sessions to solicit feedback from veterans on their current and future needs and requests for care through the department. 

Early next year, VA Secretary Denis McDonough will submit recommendations on the “modernization and realignment” of department facilities to a commission made up of individuals nominated by President Biden in consultation with leadership in both parties. The commission will then have a year to review that plan, conduct its own hearings and investigations, make its own proposals and send them to the White House. Biden can then reject the plan or sign off on it and send it to Congress. Similar to previous Base Realignment and Closure efforts at the Defense Department, Congress will have to accept all of the recommendations or none of them. Lawmakers must proactively vote down the proposals to void them, however, as inaction would allow them to take effect. 

In making recommendations, VA and the commission will consider whether a site is meeting VA standards, the potential cost savings from a closure, when those savings would occur, if it would harm VA’s ability to carry out its mission and input from local stakeholders.

An Evolving Debate

The MISSION Act won broad bipartisan support and backing from most veteran service organizations, despite some hesitancy over the Asset and Infrastructure Review (AIR) commission. The groups and lawmakers saw a need for expanding VA’s capacity to send veterans to the private sector for care and to refocus the department’s resources after a nationwide scandal of secret waitlists that came to light in 2014. The AIR commission has the potential to reignite a fight over the role government should play in providing health care to veterans, the flames of which raged five years ago but have since been suppressed into embers. 

“The debate about privatizing VA has changed,” said a VSO official who requested anonymity to openly discuss private discussions with VA. “It’s fizzled out.” The official, who fought against the inclusion of the commission in the MISSION Act, said he no longer expects “dramatic change” and it would now be “inconceivable” to see something like 20 medical facilities close. 

While observers expect the recommendations could shift resources away from select rural facilities in favor of community care, they also see opportunities to further grow VA’s footprint. Richard Stone, who continues to lead the Veterans Health Administration as he did under Trump, said in recent Senate testimony he is viewing the commission differently after witnessing the critical role VA played in responding to the COVID-19 pandemic. 

“We are the safety net to this system,” Stone said of the U.S. health care network writ large. “Therefore what I thought was a review looking at where veterans truly were has expanded now to acknowledge the fact that we will need small facilities in remote areas of this country in order to serve a potential future pandemic as well as to serve America’s veterans.”

Pat Murray, legislative director at Veterans of Foreign Wars, said his concerns from the earliest parts of the process have been largely alleviated. He too highlighted the pandemic, noting it demonstrated the strains placed on the U.S. health care system and the role VA can play as a backstop to it. 

“We are cautiously optimistic about the results,” Murray said. “We believe this could be a good thing for VA because we believe it will highlight the need for VA to continue providing critical care the way they are, and to expand it.” 

Still, there are concerns outstanding. In the last Congress, Sens. Joe Manchin, D-W.Va., and Mike Rounds, R-S.D., introduced a bill to eliminate the AIR commission altogether, warning closures could threaten the “livelihood and wealth of our rural veterans.” A congressional staffer not connected to that bill said there is still significant uncertainty about how the review will unfold. 

"We don’t know what this process will look like,” the staffer said. “Will they say we need to modify a [community-based outpatient clinic] here or close this hospital? It could be a range of things or none of those things." The staffer emphasized that Congress should continue to fund pressing VA infrastructure projects in the meantime. 

While the Trump administration ultimately showed little interest in shifting sizable portions of VA functions to the private sector, instead proposing and overseeing massive increases to the department’s budget, some stakeholders are also breathing a sigh of relief knowing the Biden administration will issue initial recommendations and decide whether to send the commission’s proposal to Congress. 

“This administration is much much less likely, this VA secretary and this VA, to come out with an aggressive closure strategy,” the VSO official said. 

The congressional staffer agreed. 

"I think we would be having a different conversation if Donald Trump were president,” the staffer said. 

Should closures occur, veterans groups are hopeful access to care will not significantly change due to the MISSION Act expanding availability of private sector clinicians. For VA employees, however, that knowledge offers little solace as such “realignments” would put them out of a job. 

“Our general fear is whenever these types of commissions or panels get implemented, the end result or end recommendations tend to be closures, something we’re super concerned about,” said Matt Sowards, a senior legislative representative for the VA council at the American Federation of Government Employees, which represents 230,000 department workers. While the conversation surrounding VA’s role has shifted in recent years, Sowards said the commission’s momentum could swing toward “harming the existing VA apparatus rather than building it up.” 

Soliciting Input

In a recent listening session for veterans in New England, VA officials told participants the department was looking for the human element of “predict[ing] demand in the future.” Regional leaders had already examined thousands of pages of data, one official said, but “data only provide part of the story.” 

“We can’t do this important work without your input,” said Tammy Krueger, the network strategic planner for the New England health care system. 

Callers spent the next two hours describing their concerns, both the parochial and the existential. They repeatedly suggested they preferred to receive care from VA directly, but were open to private sector options when wait times were too long or specific procedures were not available at the government facility. Some veterans implored VA to make more routine procedures available at their local facilities. All the while, VA conducted polls through its virtual portal on questions gauging veterans' satisfaction with the quality of their care, condition of their facilities and access to community care.  

Terrence Hayes, a VA spokesman, said feedback from the sessions will inform McDonough’s recommendations “to create high-performing networks of care.” VA plans to conduct 50 of the sessions through June. 

“VA is committed to ensuring listening sessions include all interested veterans in order to learn about the diverse experiences of veterans across the country,” Hayes said. 

The department has since 2018 engaged in market assessments as it seeks to fully understand what and where services are available through its own facilities, other government centers (such as the Defense Department and Indian Health Services) and in the private sector. VA has held “collaboration sessions” with VSOs and kept congressional offices apprised of its efforts, Hayes said. A congressional staffer confirmed Congress has requested and received regular briefings from VA on the AIR process and anticipates lawmakers will provide oversight to ensure veterans' voices are heard, that VA is consulting with VSOs, that it is using good data and it is taking into account the lessons learned from the pandemic. 

VFW’s Murray said his biggest outstanding concern is that VA will fail to ask the right questions or include the right data. If Congress looks at the product the commission produces and determines it is incomplete or incorrect, the whole undertaking “was just a waste of time,” Murray said. 

“You can’t, I believe, argue with numbers, data and facts,” he said. “We want a very complete set of numbers and data.” Murray added if decision makers “let the numbers do the talking,” they will clearly illustrate the VA system needs to be preserved, and in some areas, expanded. 

The next milestone stakeholders are monitoring is the nominations for the commission, which are due by the end of May. The Trump administration faced pushback after it briefly sought to identify nominees last year, an effort it abandoned after lawmakers and stakeholders publicized their understanding that only the president on Jan. 21, 2021 would make those appointments. 

Sowards said AFGE does not plan to advocate for specific individuals, but instead ensure the commission is not made up of individuals who are "out to just cannibalize the VA system."

The VSO official said his organization is optimistic the Biden administration and the commission it appoints will not take such an approach. He does not expect winners and losers like military communities faced under BRACs—aside from potentially impacted employees—as the goal is to ensure veterans have access to some form of care well into the future. 

“Our focus is whether any veteran will lose access to health care,” he said.