When Joe Biden ran for president in 2020, he marketed himself as a pragmatist, eager to collaborate with Republicans and capable of bridging divides because of his long experience in the Senate and as vice president.
Despite this résumé, in late June Biden was rebuked by Senate colleagues on both sides of the aisle. They came together, unexpectedly, to block his nominations to a presidential commission that no one at the White House or the Department of Veterans Affairs (VA) thought would be that controversial.
The Asset and Infrastructure Review (AIR) Commission was created by the 2018 VA MISSION Act to help shape the future of veterans’ health care delivery. Rather than breaking with Trump’s agenda of downsizing VA hospitals and clinics and privatizing their services, Biden remained on the same path. As the Washington Monthly reported in April, his picks for the nine-member AIR Commission were not confidence inspiring. There were few staunch defenders of the VA-run Veterans Health Administration (VHA). Instead, the well-connected nominees included past advocates of outsourcing medical care for veterans, active-duty servicemembers, and others with past or present ties to the health care industry, which has a significant stake in privatizing services the VHA provides to nine million veterans.
On June 27, five members of the Senate Veterans Affairs Committee, Chair Jon Tester, and 11 colleagues announced their “collective opposition to the AIR Commission process moving forward.”
This was a sharp rebuke to VA Secretary Denis McDonough. Four months ago, as part of that AIR process, McDonough proposed that dozens of VHA facilities be closed or downsized and that more care be outsourced to private providers. He offered little guarantee of funding for infrastructure improvements, like building new hospitals in places like North Carolina and supersized outpatient clinics on Staten Island. McDonough’s recommendations unleashed a torrent of objections from stakeholders, including patients, unions, and the politicians whose states and cities would suffer from the closure of their VA facilities. Opposition came from a diverse group, including the American Federation of Government Employees, which represents about 300,000 VHA employees, and the Republican governors of South Dakota and West Virginia.
In response to this growing grassroots dissent, Tester, Joe Manchin, and other senators, most of whom supported the VA MISSION Act, which created the AIR Commission, expressed dismay that McDonough’s recommendations would “put veterans in both rural and urban areas at a disadvantage.” They wisely concluded that this legacy of the MISSION Act was “not necessary for our continued push to invest in VA health infrastructure” to provide the agency with “the resources, and tools it needs to continue delivering quality care … now and into the future.” Their decision effectively shuttered the commission, and no one seemed interested in reviving it.
Befitting the tangled politics of veterans’ health care—which we explore in a new book available this month—AIR Commission boosters, who had wanted the panel to champion privatization, were disappointed. “This decision is short-sighted and will hurt veterans by keeping them trapped in a broken and outdated system,” said former Trump adviser Darin Selnick, a key figure in the Koch brothers-backed Concerned Veterans for America, which favors VHA privatization.
“Dissolving the commission does not help,” agreed Robert Wilkie, Trump’s second VA secretary and a CVA favorite. Bob McDonald, the West Point graduate and former Procter & Gamble CEO who headed the VA under President Barack Obama, said that the lawmakers displayed “a total lack of courage.” And McDonough himself, speaking through a deputy, vowed that he would continue to pursue VHA facility modernization so “our Veterans in the 21st century” are “not forced to receive care in early 20th century buildings.”
While the senators who deep-sixed the commission were motivated, in part, by the threat of hospital closures in their states, they were also reacting to McDonough’s disastrous rollout of infrastructure “realignment” in general. Biden’s VA secretary tried to make a case for this by denigrating his own cabinet department in a manner reminiscent of Republicans Wilkie and Selnick during the Trump years.
McDonough’s public presentations about AIR this spring painted a distorted picture of the VHA as hopelessly antiquated and often malfunctioning with crumbling facilities. The thousands of frontline VHA caregivers did not appreciate this flagellation. Before, during, and after the worst of the COVID-19 pandemic, the VHA far outperformed its counterparts in private-sector hospitals and nursing homes. At one press briefing, McDonough highlighted a tree growing inside an old building at the VA Medical Center in Chillicothe, Ohio. AFGE Local 1631 President Jessica Fee explains that the building hadn’t been used in decades. Top VA officials have never provided the funds to demolish it. They’d rather shutter the whole center.
By designating numerous VHA facilities as shutdown targets, McDonough undermined his agency’s still lagging efforts to fill thousands of staff vacancies left open by Wilkie, who favored outsourcing over direct care. In Coatesville, Pennsylvania, one local union rep reported, “We have a big sign outside our facility saying, ‘Now Hiring,’ and then people are reading news in the paper that our facility is about to be shut down. Why would anyone come and work here?”
Some of the VHA’s 1,200 facilities are indeed aging—just like hundreds of private-sector hospitals. But many of the oldest are being renovated, and all must pass accreditation and licensing provisions, or they would have been shut down. In addition, VHA outpatient clinics are often located in modern office building spaces that are leased from private landlords.
Meanwhile, veterans and their families continue to express gratitude for the specialized treatment available at the VHA that has saved many lives and is not easily accessible elsewhere. Speaking on behalf of his son, a disabled Air Force veteran who has experienced care in both the private sector and the VHA, Joseph Riotta told a New York City Council hearing that “veterans receive compassion, respect, and outstanding medical care” in the nation’s largest public health care system.
Even without the AIR Commission, McDonough must still decide how to improve the VHA, including closing or refurbishing old facilities or building new ones. To do this, Obama’s White House chief of staff should seek advice from experts in structural engineering, hospital architecture, and health care delivery, not privatization advocates.
No VHA facility should be shuttered if it could serve a nation plagued by shortages of mental health and primary care providers, particularly in rural areas, where the VHA is often the only option for veterans. Any decisions about underutilized VHA facilities should anticipate the influx of tens of thousands of veterans suffering from illnesses caused by post-9/11 burn pit exposure. Their myriad “service-related conditions” will hopefully become easier to prove when, as expected, Biden signs the Honoring Our PACT Act this month. One of those conditions is glioblastoma—the cancer that killed Biden’s late son, Beau, after his service in Iraq.
If VA leaders want to cut waste, they should use their rule-making authority to curb the diversion of resources to outside providers. According to McDonough, private hospitals, doctors, and other vendors receive about 33 percent of the VHA’s total health care budget, up from about 26 percent last year. Rather than privatizing, the VA could maintain or renovate its existing hospitals and construct new ones. Doing so would require $70 to $80 billion. Yet, in the Biden administration’s initial infrastructure spending proposal in 2021, $18 billion was earmarked for the modernization of these facilities. By the end of last year, the president’s Build Back Better Act—still not enacted– contained just $5 billion for that purpose. If the 12 senators who just declared their “commitment to expanding and strengthening modern VA infrastructure” want to aid veterans again, they should persuade their Capitol Hill colleagues to strengthen a VHA system that is working.