Inside The AIR Commission's Perilous Work

By Suzanne Gordon, Senior Policy Fellow



On March 14, VA Secretary Denis McDonough released recommendations mandated by the VA MISSION Act Asset and Infrastructure Review (AIR) process. Weeks earlier, VHPI had obtained the internal market assessments that informed McDonough’s decisions. In addition to analyzing these documents, our policy analysts have been speaking with experts and reporting out details on the flawed process and assumptions grounding the Secretary’s proposals. Here is a summation of our findings:


The AIR section of MISSION established a nine-member commission to determine the fate of Veterans Health Administration (VHA) facilities and services for decades to come. Trump’s second VA Secretary, Robert Wilkie, hired consultants to conduct the market assessments upon which McDonough has relied. The Secretary himself has acknowledged that much of the data collected by these Trump-era consultants is out of date, superficial, often unsourced, even inaccurate. Most problematically, it does not consider the myriad impacts of the Covid-19 pandemic on either the VA or other non-VA healthcare systems, healthcare workers and healthcare professionals. McDonough has promised that a new “red team” is busily amassing data to remedy these shortcomings, though there is no guarantee that this team will produce better information.


In spite of the Secretary’s stated reservations about the assessments, he nonetheless based his own recommendations on them. If adopted, they will degrade veterans’ healthcare, undermine the VA’s role in educating healthcare professionals, and hobble the VA’s ability to conduct research that benefits not only veterans but all Americans – indeed all patients across the globe. The recommendations will also impact the VA’s Fourth Mission to serve as a backup to the civilian sector healthcare system in times of local, regional, national, and even global emergencies. (VHPI has written extensivelyabout how the VA delivered healthcare to veterans and non-veterans alike during the pandemic.)


McDonough has launched a full-court campaign to promote the recommendations, which began with a “conversation” hosted by the RAND Corporation. The session was introduced – and concluded – by RAND experts, which left the impression that the well-respected think tank was endorsing the proposals, even as RAND experts raised serious concerns with them in the final few minutes. Former New York Times reporter Jennifer Steinhauer served as in-house journalist at the event. In what appeared to be a highly-scripted performance, she lobbed a series of soft-ball questions to the Secretary, allowing him to present his views about his plan without having to answer any probing follow-up queries.


As VHPI has noted in numerousarticles, the Secretary’s recommendations are misguided and ill-informed and, if implemented, would do exceptional harm to both veterans and civilians.


They would shutter vital facilities and programs and outsource vast swaths of VA care to ill-equipped private sector professionals. They do not even consider the private sector’s physical and operational capacity to care for complex veteran patients or its expertise in identifying and treating their military-related conditions. Nor do they consider private sector providers’ broad unwillingness to accept pay rates that the VHA could offer. The recommendations also do not consider how the disappearance of VA facilities would exacerbate, rather than remedy, a catastrophic crisis in rural healthcare.


The VA’s consultants and current VA leaders seem to conceptualize healthcare in the most narrow economic fashion — as essentially a series of disconnected physician visits and hospital admissions. The VA’s market assessments calculated only how many physicians of a particular kind were in each “market” and how many hospital beds were available. Even if one ignores the fact that these assessments were largely inaccurate, what can’t be ignored is the fact that all the other players involved in the delivery of healthcare – nurses, nursing assistants, pharmacists, mental health professionals, physical therapists, etc. – are apparently off the radar in the VA’s calculations.


If one considers the importance of just one of these groups — registered nurses — it becomes immediately clear how this omission skews the picture of how veterans would be cared for in the private market. In America today, hospitals are so short on nursing staff that they’ve had to curtail or cut services, even close their doors entirely. Yet the assessments fail to consider how nurse shortages will impact veterans’ private sector care. The plan also does not consider whether private sector hospitals have safe nurse-to-patient ratios. (Many don’t.)


There was also no attempt to calculate the number of other critical non-physician healthcare professionals that exist in each “market.” To cite only one example, the VA’s robust mental health programs rely not only on psychiatrists (the only mental health professionals the assessments assessed) but, among others, on psychologists, social workers, as well as peer counselors — veterans who have had mental health problems and who have been trained to help other vets. The market assessments simply don’t evaluate how many of those professionals or counselors are available in the private sector.


It’s also unclear how the VA’s critical suicide prevention programs would be replicated by the private sector. And what about the robust programs VA has developed to support the care of veterans who exhibit what is euphemistically referred to as “disruptive behavior”? In the VA you can’t fire patients. But the small cohort of vets who scream at a nurse or doctor or throw a chair or assault staff can be refused services in the private sector. In fact, private sector doctors are tutored in how to “fire” difficult patients.


The VA’s plans to embed their own physicians and other clinicians in private sector hospitals also reveals a startling failure to understand how healthcare works, and shows an ignorance about the positive influence of the VA’s system of coordinated care on patient outcomes. “This is a terrible idea,” one VA physician exclaimed to us in horror. “I’d be working next to private sector doctors in a system with totally different imperatives. I would no longer work alongside VA nurses, pharmacists, dieticians and other staff. And I might be working in hospitals with lower nurse-to-patient ratios and where employees might be treated abysmally. That is not a good idea and my patients would suffer.”


Perhaps the worst problem with the Secretary’s recommendations, is that they seem to view the VA as just another healthcare system competing for patients in the “free market” of healthcare. The recommendations construct complex VA patients as just another group of rational consumers seeking the best healthcare “choices.” According to this view, there isn’t much difference between a VA private sector clinic, operating room, or Emergency Department and those in the private sector. The recommendations not only assume that a patient is a patient is a patient but that a healthcare professional is a “provider,” a producer of a product – a knee replacement or PTSD treatment – also competing in the vast marketplace of American healthcare.


It’s unsurprising that Trump’s VA leaders were animated by this view of healthcare. It is tragic that Biden’s VA leaders seem to share the same narrow views. As Alan Sager, professor of health care policy and management at Boston University’s School of Public Health, reminds us, “there is no such thing as a free market in healthcare.”


Sager further explains that “the VA is not just any healthcare system. It’s actually a public good.” It has missions whose value is difficult to calculate when traditional economists or healthcare consultants conduct cost-benefit analyses. These missions, which are social goods, include the VA’s research, teaching, and Fourth Mission, as well as its care-coordination and integration. They also include the sense of community and shared purpose the VA creates.


Donald Cohen and Allen Mikaelian, authors of the recently published “The Privatization of Everything,” eloquently sum up the dangers of outsourcing: “privatization advocates depend on transforming citizens into consumers… Their sunny view of the free market obscures the rivalries and exclusions that markets create.”


Public goods on the other hand, “are things we all benefit from even if we personally don’t use them … They are things that recognize our interconnectedness and interdependence and make us a healthier, fairer, more compassionate, and more democratic nation.” Because the VA is one of those public goods, any decisions about the VHA’s future must consider not only how far vets want to drive to see a doctor, or how old a VA building is and how much it will cost to renovate it, but whether plans for the system connect us, make us healthier, more compassionate, and yes, more democratic.