A Conversation with VA Secretary McDonough on the Department's Recommendations to the Asset and Infrastructure Review Commission

by Denis R. McDonough, Jennifer Steinhauer

The MISSION Act of 2018 required the U.S. Department of Veterans Affairs (VA) to conduct a nationwide study and issue recommendations for future investments in VA health care facilities. In advance of the study's scheduled release to the Asset and Infrastructure Review Commission, Secretary Denis R. McDonough discussed VA's current infrastructure, the approach taken in examining VA's 95 health care market areas, and VA's recommendations. Those recommendations included the construction of new VA health care facilities, modernization of existing facilities, and the closure of some facilities in certain markets. The study also recommended VA partnerships with organizations that supplement VA health care delivery, such as the U.S. Department of Defense, Indian Health Service, academic institutions, and community providers. If implemented, the recommendations would collectively represent the largest change to VA's health care footprint since World War II.


Rajeev Ramchand

Good afternoon, and welcome to today's discussion with the Secretary of Veterans Affairs, Mr. Denis McDonough, hosted by the RAND Epstein Family Veterans Policy Research Institute. My name is Rajeev Ramchand, and I codirect the institute along with my colleague Carrie Farmer. I want to start by letting you know that today's event is being recorded and will be posted to the RAND website in the next few days.

The RAND Epstein Veterans Policy Research Institute was founded in March of 2021—so just one year ago—with a generous gift from Dan Epstein. Housed at the RAND Corporation, the institute is dedicated to conducting innovative, interdisciplinary, evidence-based research to improve the lives of those who have served in the U.S. military. Through a range of partnerships, the institute prioritizes creative, equitable, and inclusive analysis and evaluation to meet the needs of diverse veteran populations while engaging and empowering those who support them. Visit us at veterans.rand.org to learn more about the institute and to sign up for our distribution list, where you will be the first to know about our new research and events like today's.

Today's conversation between Secretary McDonough and Jennifer Steinhauer will last approximately 30 minutes. Immediately after the conversation, Dr. Carrie Farmer will provide commentary on the conversation. Carrie codirects the Veterans Institute with me, and in 2014 was the lead of RAND's comprehensive assessment of the Veteran Health Administration required by the Veterans Access, Choice, and Accountability Act of 2014. Carrie has been closely following the AIR Commission and I am certain will provide thoughtful and concise commentary on today's discussion. But before we get to today's main event, it gives me great pleasure to introduce the president and CEO of RAND, Michael Rich.

Michael Rich

Thank you, Dr. Ramchand. One of the building blocks of the RAND Epstein Institute is RAND's long history of research and analysis aimed at ensuring that the men and women who have served in the United States military have access to high-quality health care, whether delivered by the VA or by community-based providers. Back in 2014, RAND led three independent assessments of VA health care required by the Veterans Choice Act, finding, among other things, that by 2019, demand for VA care would outpace the supply of available care before leveling off.

In 2018, President Trump signed into law the VA MISSION Act, which sought to expand health care options for veterans. That law established the Asset in Infrastructure Review Commission—the AIR Commission—to review current VA health care facilities and identify opportunities for realignment and modernization. The Department of Veterans Affairs is responsible for making recommendations to the AIR Commission, and that is what brings us all here today.

To preview those recommendations, we're joined by the 11th Secretary of Veterans Affairs, the honorable Dennis R. McDonough. Secretary McDonough has had an extensive career of public service before being nominated and confirmed for this cabinet post. Chief of Staff to President Obama from 2013 to 2017, where he helped lead the Obama-Biden administration's work on behalf of military families and veterans. Before that, he held several positions on the National Security Council staff, including Principal Deputy National Security Advisor, and several posts on Capitol Hill on both the House and the Senate sides.

Welcome to Secretary McDonough, and welcome as well to Jennifer Steinhauer. Ms. Steinhauer worked for 25 years as a reporter at the New York Times on the Metro Desk, Business, and National desks, also as City Hall Bureau Chief and Los Angeles Bureau Chief. She currently is Director of Speaker Series and Strategic Initiatives at the University of Chicago's Institute of Politics. She's also an accomplished novelist and cookbook author and has an upcoming book entitled "The Firsts" that will document the story of the women of the 116th Congress, the one elected in 2018.

Secretary McDonough and Miss Steinhauer, RAND is honored to host you and the many people who have tuned in to hear the discussion. Secretary McDonough, over to you.

Denis McDonough

Good afternoon, everybody. Thanks, Michael, for the very nice, generous introduction. Thanks to RAND for hosting us. Rajeev, thank you for the nice opening. Thanks as well to Jennifer for guiding our conversation today. And to everybody who's joined us this afternoon, thank you very, very much.

I want to just briefly— I have about seven or eight minutes here to start. I want to briefly recap how we got here. Michael just referred to it a little bit. It goes back to the MISSION Act of 2018. The process began with us at VA conducting market assessments across the country: studies of facilities, conditions, local partnerships, and, most importantly, the makeup of the veterans by health care needs, age, race, gender, era they served, and where they live. From those market assessments, we've developed recommendations for the future of VA's health care infrastructure—our medical centers, our hospitals, clinics, et cetera—which we'll be discussing in broad terms today and then submitting to the Federal Register on Monday. And then over the next year, these recommendations will be reviewed by the AIR Commission, the president, and then Congress to determine whether they become the pathway forward for VA.

Now, I know Jennifer has a lot of good questions and hard questions. So I want to be brief here. But let me just give you a sense of how we came to these recommendations, which was by asking ourselves one question: What's best for the vets we serve?

Result of asking that question over and over again, in markets across the country, is a set of recommendations that will cement VA as the primary world-class provider, integrator, and coordinator of veterans' health care for generations to come. That will build a health care network with the right facilities in the right places to provide the right care for vets in every part of the country, making sure that the facilities are where the veterans are. That will ensure the infrastructure that makes up the Department of Veterans Affairs reflects the needs of 21st-century veterans, not the needs and challenges of veterans in a health care system built 80 years ago. And that will strengthen—importantly, strengthen our leading role as health care researchers in America and as a leading health care training institution in America. That's not just for research and training of veteran care providers or in the veteran system, but across the whole health care system.

And I completely get that people have concerns about these recommendations and the whole AIR process. That's why, for the last several weeks and months, we've been communicating about this with VA employees, union partners, state partners, Veterans Service Organizations, Congress, and more. And that's why, right now, I'm continuing to consult with our unions, and will do so moving forward. Because I so appreciate that partnership we have with them, and because they, like the rest of the VA workforce, are the most important piece of our infrastructure.

But in addition to these conversations, I also want to say now, to anyone who is concerned about the process, that VA is here to stay. This is an investment in VA, not a retreat. It's a doubling down, a strengthening of our ability to deliver world-class health care. And it's true there will be changes in markets, but we are staying in every market. Between outpatient care, strategic collaborations, and referrals to the community, we'll continue to deliver timely access to world-class care to every vet in every corner of the country. And in the places where there are changes, we will be shifting toward new infrastructure or different infrastructure that accounts for how health care has changed, matches the needs of that market, and strengthens our research and education missions that, most of all, ensures that veterans who live in that location have access to the world-class care they need when they need it.

Couple of examples. One market in the Southwest, the number of vets is projected to increase by 25 percent. Demand for long-term care is projected to increase by 87 percent. So we're recommending the building of a brand-new VA medical center to meet that rapidly increasing demand.

In one Northeast market, where we have an old, outdated, and underutilized medical center, the opposite is happening. The veteran population has been declining for decades and is going to decline by an additional 18 percent in the next ten years. But even there, we're adding facilities to better address the needs of vets who do live there. Specifically, we'll recommend new facilities—including a community-based outpatient clinic—in parts of the market where most of the vets are concentrated. Meaning that those vets who currently go to the old medical center will continue to get the care they need, and it will actually be closer to them than it was before.

Now, the vets in this area are older, so we're also recommending a new community living center, or CLC—which is our long-term care facility—and other services, so those vets can get care where they want it: at home or near home. We're entering into a new strategic partnership there with VA clinicians embedded into a community hospital so vets can get care in a modern, high-quality setting rather than a VA hospital that only serves five or six patients per day. And then, when all of that new infrastructure is in place and the need for the old medical center is gone, we'll recommend closing it so we can focus on investing in the new facilities rather than pouring limited dollars into a facility that opened just after World War I.

In other markets, we're adding new facilities and new places based on projected demand for specific issues—like the number of vets struggling with homelessness or substance use disorder—to make sure those vets have access to care when they need it.

But we didn't just consider demand as we made these decisions. For example, there's markets in the Southeast and Midwest where topline demand numbers suggested we should close medical centers. But when I took a closer look, we realized that veterans in those areas were historically underserved minority vets and rural vets, and that if we reduced our presence in those markets, there wouldn't be enough good options in the community. So instead of downsizing those markets, we're doubling down on them, because that's the only way to guarantee that vets who live there will get the care they need.

All across the board with these recommendations, we're embracing the idea that health care has evolved, so VA needs to evolve with it. And, in fact, lead the evolution. That means building facilities designed with veterans and VA employees in mind. Because VA employees will always be our number one asset, and they should have the modern tools they need to provide the best care possible for vets. Evolving also means new facilities designed for the specific care needs of today's more diverse group of veterans, including women vets, the fastest-growing cohort of veterans in our network. Evolving also means building facilities capable of delivering world-class telehealth and replacing old facilities that literally don't have enough space between floors to support cables and Wi-Fi. It means— evolving means moving the care to veterans, making VA more local for veterans, which will result in more vets seeing VA as an available option, more vets learning about VA, and, ultimately, more vets getting care from VA—care that's proven to provide the best outcomes for vets, by the way.

Evolving means that we don't need as many inpatient beds as we did 100 years ago, or 50, or even 10 years ago. Because vets want to recover at home, not in the hospital. And because modern health care has made it possible to do so. Hip replacements. One example. In the '90s, a hip replacement could leave you in a hospital bed for weeks. Today, the average hospital stay for hip replacement isn't even 24 hours. That evolution from inpatient care to outpatient care—to ambulatory services, as we call it—is happening across the health care landscape, and it's just one example where VA needs to evolve.

These recommendations are being made for many reasons and many different— many different reasons and many different markets. But the bottom line is that all of the recommendations, if approved, will add up to the one thing that matters most: more care and better care for the vets we serve. That doesn't mean we're doing a bad job at the moment; we're not. We're already providing more care to more vets than ever before in VA history, and our outpatient scores are at 90 percent—trust scores—the highest level in years. But if we implement these recommendations, nearly 150,000 more vets will have primary care nearby. Nearly 200,000 more vets will have mental health care nearby. Nearly 375,000 more vets will have access to outpatient specialty care nearby. And all of the care will be delivered in modern, state-of-the-art facilities, meaning increased access, better care, and, most of all, lives saved and improved.

Now, because Jen works in Chicago— Jennifer works in Chicago now, and because my wife is from Chicago, I have to tell a story about Chicago. Kari and I—my wife and I—went to the Hines Medical Center to deliver donuts on Christmas morning. We're walking down to say thanks to the people working on Christmas morning. We're walking down the hallway, and I started to sweat. And since it was at the height of Omicron, I thought, "oh, Lord, I'm spiking a fever." But before I got in too much of a panic, I asked others with me if they were feeling hot too. And they all said that they were. And the cop who was walking with us—the VA cop—said, "don't worry, sir. What happens is the heat breaks down here a lot. So in the cold winter months, we have to crank the heat way up, because when it breaks, and if it's quickly, reduces temperature, we're going to have burst pipes."

That's what we're dealing with right now when it comes to our infrastructure: spending extra money to maintain out-of-date facilities rather than building— rather than investing the too-few dollars we get in new, state-of-the-art facilities. And that's what our health care professionals deal with: sweating in a facility in Chicago on Christmas morning. Now, you all know when that facility was built? 1921. More than 100 years ago. It's time to replace that.

That's all I've got. Thanks again for having me. I think I'm turning it either over to Rajeev or to Jennifer, and I look forward to the questions. Thanks so much.

Jennifer Steinhauer

I think I'm picking it up, sir. Thank you very much, Mr. Secretary, for doing this. And thank you for all the people who've joined us today and really demonstrate such a strong interest in this topic.

Sir, you alluded to some of the things that we know about changing veteran population demographics. Lower, fewer.

Denis McDonough


Jennifer Steinhauer

Greater percentage women. Generally speaking, growth in the Southwest, less so in the Northeast. I'm curious, when you did these market assessments, outside of these things that we sort of know as givens about the veteran population, what things surprised you, and how did they inform some of these decisions? And particularly what you heard in the listening sessions, as well?

Denis McDonough

Great. Thank you very much, Jennifer. There's one thing to keep in mind, which is: I was skeptical of the market assessments when I first arrived. And here's why. The market assessments were started in 2019, before the pandemic started. And so the first thing to think about the market assessments is: Are they up to date? And is it good data on which to make an analytic— to serve as analytic basis for the judgment about facilities?

We actually hired a red team to look at that question. They came back and said the data's too old. GAO, it turns out, was looking at the data, too. They said the same thing. So one thing we'll be doing, coterminous with the commission meeting this year, is updating that information and feeding it into the commission to make sure that we have the best, pandemic-informed data about what to expect market by market. So the picture itself, the analytic basis for the recommendations themselves will be being updated coterminous with the deliberation on the recommendations. That's the first thing.

But big findings are, I think— the really interesting thing is the geographic differentiation of the demands for veterans. Older veterans in the Northeast. Younger, more ethnically- and gender-diverse veterans in the South, Southeast, Southwest. More delivery of telehealth, as a result of the pandemic, than we would have anticipated. And then more complications with mental health and acute substance use disorder than I would have expected. So much so that I think, like, something we're dog-earing is, what do the updated market assessments tell us about mental health needs, especially coming out of the— so, over the course of this next year, coming, as we are, out of the pandemic, and the complications there from?

But, you know, one of the— one last word on this. One of our biggest problems with homelessness right now are older vets suffering acute mental health disorder with nowhere else to go. Because they're not welcome, or it's not available to them to get to Medicaid-funded nursing homes. So we are seeing more and more acute mental health disorder among elderly vets, among the homeless. So when you see the recommendations overall, you'll see investment in what we call RRTP—residential treatment facilities—for both substance use disorder and mental health disorder, and seeing that in parts of the country, say in southeast Ohio, where we know that the opioid use disorder is particularly acute.

Jennifer Steinhauer

Well, I thank you for addressing the mental health component of that, because I can tell you as a reporter, there is nothing I got more emails about than veterans and their families suffering from mental health issues and concerns about access. And by the way, mental health access is not limited to the VA. That's obviously a national health care problem that we have. So thank you for addressing that; I was going to bring that up.

So I'm sure you've gotten some pushback already from stakeholders in terms of inpatient facilities that you might be closing. I would say, in probably smaller numbers, there'll be some folks who think that closing the number of major medical centers that you're doing are too few, given the physical condition of many of them and some of the demographic trends that we've just discussed. Can you unpack a bit how you thread that? Because I'm sure you've heard both.

Denis McDonough

Yes. So if you take a step back, I think overall in net, if you take inpatient facilities, hospitals. We start right now with 171. We get to the other side with 168. So that's a net reduction of three. But there's places that we— you know, Buffalo, for example. A dated facility, but which needs to be updated, and especially in an area like Buffalo, where the census of veterans we had will, you know, will continue quite high. And so our view was, as I said in the opening remarks, to get the care where the vets are. And so that means that, inevitably, there is going to be changes. And I think there is, as you say, there's people who think it's too few. There's going to be people who think it's too many.

I think the better indicator is going to be, you know, proximity to care and availability of services and a recognition that VA is not unique in terms of needs for veterans—even though our vets have more intense health care needs—than what's happening in the rest of the health care system, where more and more health care systems are going to outpatient care. So if you take an example of Hot Springs in South Dakota, which has been talked about. We will reduce the inpatient services— we'll stop inpatient services there. In its place will be what we call a multi-service, multi-specialty CBOC, or outpatient clinic. We assess—it's obviously difficult because it's assessment, not hard intel, but—we assess that actually, the provision of care and services at that MS-CBOC will actually generate more veteran appearances there than maintenance of the inpatient system. Because the kind of care we'll be providing over this period is going to be of that makeup. And so, like, I go from wondering if I did, if we were too aggressive or whether we were insufficiently aggressive any day of the week.

I think this adds up, but this is the last thing I'll say: That's the strength of this process, which is, the commission will have the year out in the field talking to veterans. Talking to our partners. Making sure that they're comfortable with our recommendations. And if they're not, then they'll urge us to change them, and we'll send them back.

Jennifer Steinhauer

This seems like a good segue to talk about how this will interact with the MISSION Act, and specifically with the access standards. And I know you were pretty candid that you weren't a superfan necessarily of every component of that. How do these two, how do these two things interact?

Denis McDonough

It's a really good question. So we're—right now, we're in the midst of, as I've talked to you about, with the rest of our press corps about—we've spent this calendar year in a deep dive, looking at what is happening in our referrals to the community, what is happening, and trying to get some results-based data on what's happening with our vets who go to care in the community. What are similarly-structured occurrences when they stay in the direct care system? And how do we assess that apple for apple? And what does that say about how we should think about access to the community going forward?

Under the MISSION Act, we need to report to Congress–I forget if it's in June or July; I use those interchangeably, but it's one of those two—this year about the experience of three years with these access standards. We're finalizing that report now actually, and— we're finalizing our first draft of that report now. We'll be talking to Congress about it, culminating with the report to Congress in June or July.

I think we should not go through this whole effort and just report on what's happening. I think we should have an answer to, what do we think about what this means on how we should treat access standards going forward? Which we will do. And that will be happening as the debate about the commission is ongoing. And so, if there's relevant findings, we'll make sure that the commission understands that. But that's point one.

Second point is: The market assessments did a deep-dive look also at the health of the community infrastructure for community care options for the vets. That's uneven across the country, too. And that's going to be something that we're going to have to update over time. Fact is, we're increasingly a large payer into the community, and so we should leverage those large payments on expectations about quality and also on timely referral back to us of the records generated by the health care.

Last thing: A similar thing that we ought to be thinking about is our ongoing work on the caregiver program, which is innovative among the federal health care providers. In fact, it's the most robust health caregiver program anywhere in the country. And it would be a mistake for us to not make sure that, as we're building that really innovative program—an exciting program—we're also thinking about the fact that a lot of our vets want to age in place. That's one of the key tenets of the assessments that inform the recommendations. Each of these things ought to be considered in where those silos cross with one another. Not separately. I think we're structured to do that. But it'll be one of the challenges.

Jennifer Steinhauer

So just, not to belabor that, but are you suggesting that the MISSION Act— the access standards could evolve with this process?

Denis McDonough

Yes. I am.

Jennifer Steinhauer

Okay. That's interesting.

Denis McDonough

But again, just so people aren't wondering about that. If access standards were to evolve, that's a rule, that's a public rulemaking effort. So, this would be something that would happen in the light of day; we'd consult with Congress. I've been telling Congress that these ideas are coming. And by the way, they're coming because they've required us to send them. So nobody should be surprised by that.

Jennifer Steinhauer

I'd like to talk a little bit more about women veterans. You have— you are no doubt highly informed about the complaints that many female veterans have had about their experiences in some of the VAs.

Denis McDonough

I am.

Jennifer Steinhauer

And obviously, with this a growing percentage—I think it's the largest-growing group, if I'm not mistaken, of veterans is females. So can you perhaps illuminate a little bit more about how are– how women are being considered in this program?

Denis McDonough

Yeah. So when we think about, you know— so a very basic way is how we structure the facilities in which we provide care. So we have a model now where, for example, in any of our new CBOCs, the clinicians sit in the middle of the facility. And they have independent entryway into the exam rooms. And so the veteran patient stays in the exam room, and members of the care team enter into her facility rather than making her move around the facility, which is best practice in terms of making sure that the care itself is integrated. But it's also best practice in making sure that somebody who may feel vulnerable in a health care setting is not forced to leave a private setting. So that's a very basic example of making sure that the needs of our vets are considered in something as basic as, how many different rooms do they need to enter during one set of— during one visit? One.

Two. We also just have to have facilities—and this is why the proliferation of outpatient clinics, or CBOCs—we just have to get better at the provision of gender-specific care. And that's, you know, everything from gynecological requirements to mammography to mental health. And making sure that we have in mind the fact that the needs of our veterans–including the fast-growing cohort now of women veterans—hopefully we convince them to stay with us so they're going to age with us. And so we have to have not only gender-specific care, but gender-specific care for each of our age cohort of veterans.

The last thing I'll say about this is: we— the MISSION Act has put us in a position where it's now apples to apples for us to compete with the community-based and private-sector providers. The data says we actually do pretty well. Vets in our care, on outcomes, do better. That means we have to just get vets in our care. And so when we get a shot at them, we got to keep 'em. And so what I've talked about with our providers, and with RAISE and VHA leadership, is that, let's think about the AIR Commission recommendations as another place where we are able to demonstrate our excellence. So that we can get, and keep, women vets. So that they continue to be the fastest-growing cohort of our patients. Because if we don't keep them, then we won't have patients. Right? And if we don't have patients, we're not going to have a budget, and there's no reason for us. So this is a survival thing for us. The best way we survive is that we perform.

Jennifer Steinhauer

OK. I'm sure people will be holding you to that.

You alluded to the role of the pandemic in some of your thinking on this. With telehealth, and obviously evolving data. Can you say some more about that?

Denis McDonough

Yeah, I mean, you know, it, as a general matter, put a premium on several of the things that VA really excels at. Right? One is research. Another is preventative care. And this is why, when we think about—and you'll see this, I think, in the recommendations when they go live on Monday—when we think about the recommendations, we have to think about timely delivery of world-class care, for sure. But we have to also think about the other three missions: research, training, and, importantly, the fourth mission. I've already talked a little bit about the research and training. But I'll give you an example of this.

Durham, North Carolina. There was some discussion about whether we would move our hospital in Durham. You know, south and east, closer to Camp Lejeune, where there's a lot more vets. And by the same token, we have a deep, collaborative relationship with Duke University. In fact, we train 700 doctors a year there. So we said, wait a minute, we better not make any decisions about this in the recommendations until we've talked to Duke. It turns out Duke sees things much the same way we do, so we actually will continue planning this future presence together. That's the kind of decision that I mean, when I sought assurance from our team and got it, that research and training under the recommendations will be at least as good, in the worst case. Or, in the best case, improve our training and research functions.

Second thing out of the pandemic. Take Manhattan. Brooklyn— sorry, Brooklyn and Manhattan. Both those VAs supported our fourth mission, which is care for non-vets in crisis. So they both supported the fourth mission during the height of the pandemic. And early, Brooklyn became a COVID-specific hospital. And they saw 111 civilian patients in those early days of the pandemic because there was no— there wasn't excess capacity in the rest of the system to manage that many COVID patients. Civilians, non-vet patients. So we have to think about our future with Manhattan and Brooklyn. How do we, on top of everything else, maintain the great research they do there? Maintain the great expertise we have there in mental health care, which frankly fans out across the country supporting veterans? But then also, how do we ensure that we can maintain a presence for the fourth mission, which was very front and center in the context of the pandemic? So it's a long answer, Jennifer. I hope that's responsive.

Jennifer Steinhauer

I saw some information about current and projected impact on the labor force. I'm sure that's something that is front and center for all your folks throughout the country when considering these changes. What can you kind of give us as an overview in that front?

Denis McDonough

Yeah. So the workforce is something we're talking about all the time and thinking about all the time. In fact, we started this year with a particular focus on the human infrastructure at VA, which I continue to say is the most important piece of our infrastructure. We set out— because we're currently at a 15-year high for nurse turnover, we made our number one legislative priority for this first part of the year enactment of new flexibilities to allow us to increase nurse pay, as well as nursing assistants and nurse practitioners. That bill, called the RAISE Act, is included in the omnibus passed out of the House last night. We're hopeful to see it enacted, passed out of the Senate and then signed by the President soon. That's the kind of investment, frankly, that comes from our constant looking at our human infrastructure. Point one.

Point two. We have not done the job-by-job assessment yet, Jennifer, but the model undergirding the recommendations is moving care to the veteran. Making the care—the VA option–thus a more local, more visible option. Thus making it likelier that greater numbers of the veterans in those local communities take us up on care. And just the overall number of facilities and the type of care that we anticipate from the market assessments we will need, it stands to reason that we will not lose billets, but that we'll be doing what we're doing today, which is actively working to maintain the billets and fill new required billets. Meaning that—I don't have the spreadsheet yet that shows me this—I assess that, in that net, we're looking at more jobs over time, not fewer.

Jennifer Steinhauer

Interesting. Well, let's talk a little bit about the politics and the process of this. This is obviously going to be caught up in both. I know there's been some difficulty even getting Congress to act on the commissioners. I think the entire process, I believe, is a bit behind schedule.

Denis McDonough

It is.

Jennifer Steinhauer

So, do you actually, candidly, feel this can even be seen to fruition? What are you anticipating in terms of political pushback, process difficulties, all the good stuff that happens when you interact with Congress and frankly, the Executive Branch, too?

Denis McDonough

Yeah. Well, thanks. It's a fair question. Day before yesterday, or maybe it was yesterday, we submitted eight of the commissioners for the commission. The commission is to have nine commissioners. We provide five names for the commission. We, the Executive Branch; the President provides five names. And then each of the four leaders. Republican leader in the House and Senate, Democratic leader—majority leader—in the Senate, speaker in the House. They each get one. We've been waiting— those were supposed to have been submitted in May of last year. So we're now, what is that, 10 months over? We still don't have both the Republican nominees. We just have one, which is better than where we were. And so that's the first big challenge we have, is we have to get all nine nominees.

Then we have to get those nominees confirmed through the Senate. Chairman Tester and Senator Moran, the chairman and ranking member of the Veterans Affairs Committee, are very focused on this. They've been readying for this. I think they'll get them through the committee as quickly as they can. Then the question is, can we get them through the floor? And your guess is as good as mine. It sounds like— you know, we were just having a conversation off camera with Michael about some of the challenges with State Department and Department of Defense nominees. You know, all we can do is try. I don't want to handicap the situation. But that's our first big challenge: Get the commissioners.

And then I expect challenges. You know, that commission's got to get to work and take a look at this. I think the process is straightforward. The commission has until about next February to make some determinations about our recommendations. They send them to the president. He has a couple of months to look at them, then he sends them to the House—sorry, to the Congress. The Congress can only vote them down. Meaning they have one option, which is to disapprove. If they don't disapprove, they're enacted. And I assume that, if the president submits them to the Senate and the House, that if they were to disapprove of them, he would veto their disapproval. So if they're going to disapprove of it, they would have to disapprove of it at veto level, assert veto-proof–level margins. All of that means that there's a lot of momentum on the side of the president if what we get to him through the commission is a meritorious project. I believe it will be. But we have a year to prove ourselves on that.

Jennifer Steinhauer

And that does always bring up parallels with BRAC, which was obviously the look at military bases around the country. You reject that as a as a parallel analogy, correct?

Denis McDonough

I do. The BRAC was designed to close facilities and to get— to reduce the DoD footprint. This is designed to maintain VA as the premier health care provider in every market in the country. So we're not— we're staying in every market in the country. We're not closing ourselves off from any individual market. Which, at the end of the day, that's the definition of a BRAC, right? Well, what this is, is a modernization effort to upgrade the effectiveness of our facilities by moving away from aged and dated facilities into modern facilities that reflect the needs of our 21st-century vets.

Jennifer Steinhauer

You opened up with a very interesting anecdote about Chicago—I think I've been in that VA—to illustrate your facilities, your infrastructure issues. Did you interact personally with any veterans or hear report, or read the transcripts with listening towards the veterans, that really stuck— that were one or two people, or any particular anecdote really stuck in your mind that sort of illustrates the need for this? The hope of the outcome? Why you think that, why you're convinced this is in the best interest of veterans?

Denis McDonough

Well, I mean, I have so many anecdotes, you know. As you were asking about women veterans, I was reminded of one of the first facilities I visited, where one of our women veteran patients would have been expected to move among rooms in a highly-trafficked part of the facility. Where, you know, as unfortunately, as we know, too often, women veterans are—let's just say, not treated hospitably when they are in our facilities for care. Often they're asked, well, are you here with your husband, or with your father, or with your brother? Or worse, they're harassed. And here, at this moment when you're at the doctor, among your most vulnerable moments, you're expected then to walk through a busy facility, to go from room to room to be seen by an expert. And that's an experience that I've heard from far too many of our women veterans is still happening.

You know, we have one facility that has a tree growing through the building. But because it's an historic building, we can't do anything about that. That's not clinical best practice, the tree in the facility. I'm not a doc, but it's not great. It's time to get the stuff done.

Jennifer Steinhauer

I'm trying to decide if I would like a tree growing in the middle of my workplace. I might; I don't know. I definitely see your point as a clinical matter.

I think I have just time to ask you two really good quick questions. The last one will be quite straightforward. But if this one, too, just if you could kind of summarize this in brief: If you could kind of just say, what is your number one goal? What was the number— I know what your driving goal was in the beginning of this process. As you see this through, what do you, what would you say is your number one goal to come out of this process?

Denis McDonough

Look, I see all of our, all of what I do at VA to flow from our two core missions: Timely provision of world-class benefits, timely provision of world-class health care. So this is squarely in that second one, timely delivery of world-class health care. Timely and world-class. I want what comes out of this to be something that allows us to advance that fundamental goal. And there are two really important audiences. Obviously, most important, our vet patients. But two is our clinicians.

There is so much tightness in the labor market for health care providers right now. That— any individual factor that decreases our competitiveness in that market troubles me. And our facilities increasingly are part of that. Because we have docs and nurses who can walk across the street and make 50, 200 thousand dollars more working in a different facility. Most of them still stay, though, because of the mission. But if they can't do the things that they know they need to do for our veterans because of the age of our facilities, we're going to lose those people, and we're going to lose bad. We're going to decrease outcomes for our vets, and that's— we just can't do that anymore. So that's what I want out of this, is, how does this help us advance core principle number two, which is timely access to world-class healthcare?

Jennifer Steinhauer

OK. And I'm just going to ask you one final question. This is mostly aimed for our audience. Where should people go to learn more about the specific recommendations? And when, precisely, are those going to be available?

Denis McDonough

Yes. Yeah, they should go to va.gov/aircommissionreport, all one word. And that's "air," A-I-R. So va.gov/aircommissionreport. That will be live as of Monday morning. So, we publish in the Federal Register. You'll, if you were to go to that website, that web address, tomorrow, you'll see, hey, you're at the right web address. Come back here on Monday; the whole thing will be here. So that's the way the Federal Register works. You get one day heads up that it's coming. It'll be out there on Monday morning. And then we'll be here to respond to any questions that people have along the way.

Jennifer Steinhauer

Great. Thank you so much, Mr. Secretary.

Denis McDonough

Thank you, Jennifer.

Rajeev Ramchand

Great. Thank you, Secretary McDonough. And thank you, Jennifer. This was really informative. We look forward to that report on Monday. And I'm going to turn it over real quickly to our RAND expert on all things Veteran Affairs, Carrie Farmer, who also codirects the Veterans Institute here at RAND. Carrie.

Carrie Farmer

Well, thank you, Rajeev. And thank you to Secretary McDonough and Ms. Steinhauer for starting this important conversation about the future of VA health care.

RAND's own analysis of how veteran demographics would change over time are consistent with what VA's analysis has shown. In 2015, our models suggested that over the following decade, the veteran population would shift from the Northeast and Upper Midwest to the South and Mountain regions and concentrate further in urban areas. We also found that demand for VA health care would increase from 2015—when we did this study—through 2019 and then level off or even decline. Planning for the future of VA health care must take these changing demographics and the associated changes in demand for care into account.

All models assume certain things. And in RAND's case, we assumed that there would be no new wars and therefore no new large influx of veterans. VA must do the same in its own models. So plan ahead for the expected population of veterans, including those currently serving. But no one can predict the future, and future wars or eligibility expansions could bring new demands.

I'm looking forward to reading the detailed recommendations on Monday. Based on what the secretary has said today, the department's recommendations appear to bolster access to high-quality mental health care for veterans by increasing both inpatient and outpatient mental health care. Across the country, as was discussed today, accessing private sector mental health care is incredibly challenging, which has been especially apparent during the pandemic. And the quality of that care varies considerably.

VA has long been a leader in delivering veteran-centered, evidence-based mental health care, and VA researchers have developed some of the most effective treatments for mental health conditions such as PTSD and depression—conditions which are more common among veterans. Increasing access to high-quality mental health care for veterans should be a priority. And based on this overview and what we've heard so far, it appears that VA's recommendations do just that.

VA's recommendations also include increased access to long-term care in some markets by expanding the number of residential rehabilitation facilities and community living centers. Both RAND's and VA's projections show that the average age of the U.S. veteran population will increase over time, and with that will come increased demand for long-term care.

As we've heard today, the recommended changes would shift more inpatient care to the community in some markets. Whether this will be good for veterans depends on the quality of that care. On the one hand, we know that quality improves with volume. For example, surgeons who only rarely perform a certain procedure have worse outcomes than surgeons who regularly perform that procedure. In certain parts of the country, VA hospitals may have a lot of these kind of low-volume procedures, and having veterans receive care from community hospitals with higher volumes should improve outcomes overall. However, there is consistent evidence that the quality of VA care and outcomes from care are better than non-VA care. And just this week, a new study found that veterans transported by ambulance to VA hospitals had a 20 percent lower mortality rate in the following month than veterans transported to non-VA hospitals.

One thing I'll be reading for when I see the report is how VA accounted for the quality of care in its market assessments. As noted by— in a GAO report last week, VA does not currently have good information on care provided by community providers to veterans. This includes data on access, such as the availability of appointments and whether private-sector providers are accepting new patients and could accommodate an influx of veterans, and data on quality. In the markets where VA recommends shifting more care to the private sector, VA currently has no or limited data on whether those providers currently provide high-quality, evidence-based care.

That said, no data is perfect, and with an analysis of this size and scope, there are certain to be flaws. So what I will be looking at is the extent to which these kinds of data limitations are acknowledged and how these limitations were taken into account in building the recommendations. As the AIR Commission begins its work, commission members should consider mechanisms for assessing the impact of implementing the recommendations, such as how VA will monitor the quality of care that has shifted to the community, to ensure that veterans continue to be well cared for.

Thank you again to Secretary McDonough and Ms. Steinhauer for this insightful conversation. We really appreciate your coming. And thank you to all of you for attending. This webinar has been recorded, and a recording will be available at veterans.rand.org in the next few days. Thanks again. And this concludes our webinar.

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