The Department of Veterans Affairs has just completed a major step in the congressionally-mandated Asset and Infrastructure Review, or AIR, process — a process designed to ensure VA’s infrastructure in the next few years reflects the needs of 21st century veterans, not those of the previous century.
On March 14, VA recommended 35 of its 171 hospitals be closed or completely rebuilt; 14 new hospitals constructed; and 140 community-based outpatients opened. Altogether, it will cost approximately $2 trillion to modernize the department’s facilities under this proposal.
I understand the role of members and others to advocate for their interests, but we must be mindful that without comprehensive infrastructure reform, VA’s health care system will perish. Those who have already called VA’s recommendations “dead on arrival,” or “a massive mistake,” because they represent affected communities should understand what is at stake and keep an open mind.
VA, like other providers, faces many challenges in meeting the needs of its patients in the 21st century. All health care organizations must adopt to the seismic changes in medicine now underway. These include advances in medical technology, such as telehealth; an increasingly aging population; nurse shortages and scarcities in other health professions; and increasing numbers of people suffering from multiple conditions and serious mental illnesses.
To its credit, VA has recently been in the forefront of health care change. In the 1990s and early 2000s, the department transformed itself, with remarkable speed, from a collection of inpatient hospitals characterized by a limited number of specialized facilities often far from a veteran’s home to a system based on an outpatient model and telehealth with over 1,300 sites of care.
However, VA faces the unique obstacle of continuing to modernize its care despite an enormous legacy health care system costing billions of dollars annually to maintain. The department has been trying to build a 21st century health care system on a foundation of an antiquated infrastructure.
Many VA hospitals were constructed in the aftermath of World War II. The average age of a VA hospital is nearly 60 years, compared to just 8.5 years in the private sector. These older hospitals were built before women were a significant presence in the military and have insufficient facilities for their care; are too old to sustain the strong internet connections required for telehealth; and were built at a time when inpatient care, not outpatient care, predominated — resulting in floors, even entire buildings, sitting unused.
VA is spending billions on bricks and mortar, instead of doctors and nurses. In 2004, the last full year I was Secretary, VA health care received $28.3 billion in funding from Congress. This fiscal year, the department will receive $101.5 billion — more than a 350% increase. Meanwhile, the number of living American veterans has decreased from 24.5 million to 19.2 million.
At some point, if things do not change, Americans will question the need to maintain a system that provides care in antiquated facilities that costs far more than other alternatives. Then the well of funding is going to run dry, marking the end of a system that has made historic contributions to the health of veterans and all Americans.
This dystopic future is what VA’s current recommendations are designed to address. I commend VA Secretary Denis McDonough and his staff for what The American Legion called a “careful and thoughtful approach” to the process.
The department’s recommendations will now be reviewed by a commission of experts, whose members were nominated by President Joe Biden on March 9 and are now awaiting Senate confirmation.
The commission will review VA’s recommendations and conduct public hearings before submitting any changes it deems necessary to the president within a year. The president can then determine whether or not to submit those recommendations to Congress. If the president does submit them, Congress can then accept those recommendations as a whole by not acting, or reject them as a whole by passing a joint resolution of disapproval. If the recommendations are accepted, VA must begin implementing them within three years.
Politicians and communities will use the review process to debate the pros and cons of individual recommendations. But let us turn away from arguments that question the value of the entire process because of any single recommendation, or seek to hold nominations up over parochial concerns. We must keep our eyes on the ball, and understand this once-in-a-lifetime chance to transform a cabinet department cannot be squandered.
We have an opportunity to help VA build a health care network with the right facilities, in the right places, to provide the right care for veterans in all parts of the nation. If we fail, we will surely destroy an invaluable national resource.
Anthony J. Principi served as the Secretary of Veterans Affairs from January 2001-January 2005. Mr. Principi is a 1967 graduate of the Naval Academy at Annapolis, Md., and served aboard the USS Joseph P. Kennedy. He commanded a River Patrol Unit in Vietnam’s Mekong Delta.
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