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DEPARTMENT OF VETERANS AFFAIRS Brooks D. Tucker

MISSION STATEMENT

OVERVIEW

At the end of the Obama Administration, the VA was held in low esteem both by the veterans it served and by the employees who served these former warriors. Eroding morale caused by the downstream effects of a health care access crisis in 2014 led to the resignation of Secretary Eric Shinseki and extensive oversight investigations by Congress from 2015–2016.

By 2020, however, the VA had become one of the most respected U.S. agencies. This significant progress was due in part to the leadership of Secretary Robert Wilkie (2018–2021) and his team of political appointees and career senior executives, many of them veterans, who led the effort to ensure that the VA became “Veteran-centric” in its governance decisions and fostered a more positive work environment. This mindset translated into a department that was better attuned to employees’ and veterans’ needs and experiences in the daily operations of health care, benefits,

The Department of Veterans Affairs (VA) is the primary provider of health care, benefits, and memorial affairs for America’s veterans and their families. The VA has the noble responsibility to render exceptional and timely support and services with respect, compassion, and competence. The veteran is at the forefront of every VA process and interaction. The VA must continually strive to be recognized as a “best in class,” “Veteran-centric”1 system with an organizational ethos inspired by and accountable to the needs and problems of veterans, not subservient to the parochial preferences of a bureaucracy.

and memorial affairs. During that period, the VA received the largest number of watershed congressional authorizations to reform its health care and benefits that it had received since the post–Vietnam War years along with historic increases in annual appropriations, which have tripled since the last full year of the George W. Bush Administration.

The current VA leadership team of Biden appointees has adopted some of their predecessors’ governance processes. However, they have not sustained the previous Administration’s commitment to a genuine “Veteran-centric” philosophy, most nota- bly with respect to the delivery of health care, and harbor a bias toward expanding the unionized federal employee workforce that has not always been aligned with a focus on “Veteran-centric” care. There also is growing concern in Congress and the veteran community that the VA is poorly managing and in some cases disregarding provisions of the VA MISSION [Maintaining Internal Systems and Strengthening Integrated Out- side Networks] Act of 20182 that codify broad access for veterans to non-VA health care providers. Efforts to expand disability benefits to large populations without adequate planning have caused an erosion of veterans’ trust in the VA enterprise.

Additionally, the current VA leadership is focusing very publicly on “social equity and inclusion” within departmental policy discussions toward ends that will affect only a small minority of the veterans who use the VA. For the first time, the VA is allowing access to abortion services, a medical procedure unrelated to military service that the VA lacks the legal authority and clinical proficiency to perform. In addition to continuing the grotesque culture of violence against the child in the womb, these sociopolitical initiatives and ideological indoctrinations distract from the department’s core missions.

DEPARTMENTAL HISTORY

Following the Civil War, state veterans homes were established to provide med- ical and hospital treatment for all injuries and diseases. When the United States entered World War I in 1917, “Congress established a new system of Veterans benefits, including programs for disability compensation, insurance for service personnel and Veterans, and vocational rehabilitation for the disabled”3 that was overseen by three different federal programs: the Veterans Bureau, the Department of the Interior’s Bureau of Pensions, and the National Home for Disabled Volunteer Soldiers. In 1921, Congress combined those programs into the Veterans Bureau. Following World War II, a national VA hospital system, much of which remains operational today, was established to care for millions of returning veterans.

Following the Vietnam War, the VA’s federally owned and operated hospital network expanded again to meet the needs of the volunteer and draftee population. In the past two decades, the VA has purposely transitioned to leasing medical prop- erties rather than building expensive new facilities that can take years to complete and often experience budget overruns. As the nature of health care has evolved

with a growth in same-day surgical procedures and outpatient care, so has the VA, and in 2018 Congress added access to private-sector urgent care outlets as one of the VA’s health care benefits.

Today, the VA operates 172 inpatient VA Medical Centers (VAMCs), which are an average of 60 years old, and 1,113 Community Based Outpatient Clinics (CBOCs), which are newer facilities designed to meet the needs of veterans closer to home. The VA also manages a Community Care Network (CCN) through contracts with Optum and TriWest, third-party health care administrators responsible for build- ing and maintaining a robust population of community providers to meet the needs of veterans referred for care outside of the VA system. Currently, approximately 6.4 million veterans out of 18 million nationally (and out of the 9.1 million who are enrolled) use the VA for health care; the remainder use employer-sponsored plans, Tricare, Medicare, and Medicaid.

The disability benefits system evolved significantly in the years between the Cold War era and the global war on terrorism, a period when the VA enrolled large numbers of veterans from World War II, Korea, and Vietnam who were seeking disability benefits and health care. Disability compensation is the largest VA benefit, but there also are dozens of others, the next largest of which are the GI Bill and the Home Loan Guaranty. These benefits are administered through 56 Regional Benefits Offices (RBOs) and hundreds of satellite sites around the country.

The Agent Orange Act of 19914 significantly expanded the scope of disability ben- efits for those who had deployed to Vietnam, and the cost of those benefits began to increase dramatically as the Vietnam generation of veterans aged and began to expe- rience adverse health conditions, some of which were presumed to have been caused by defoliant chemicals used in Southeast Asia. In 2016 and 2017, a burdensome backlog of appeals of denied disability claims from multiple wartime generations—a backlog numbering in the hundreds of thousands—led to a joint effort by the VA, Vet- eran Service Organizations (VSOs), and Congress to pass legislation that streamlined appeal processes. Implemented in 2017, this historic “good governance” success has helped the VA to reduce the number of these appeals dramatically.

The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 20225 addressed adverse health outcomes presumed to be the result of veterans’ exposure to airborne toxins during the global war on terrorism and further expanded disability benefits to the most recent gen- eration of veterans. These ambitious authorities, like the 1991 authorities, have the potential to overwhelm the VA’s ability to process new disability claims and adjudicate appeals. Currently, the VA is seeking to hire large numbers of personnel to process these claims while exploring the use of an automated process to accel- erate claims reviews and decisions. The ever-present lag in the hiring and training of new employees could result in major problems with the timely adjudication of benefits well into the next Administration in 2025.

In sum, the VA for the foreseeable future will experience significant fiscal, human capital, and infrastructure crosswinds and risks. Budgets are at historic highs, and with a workforce now above 400,000, the VA is contending with a lack of new veteran enrollees to offset the declining population of older veterans. Recruitment of medical and benefits personnel has become more challenging. Veterans are migrating from the northern states to the southern and western states for retirement and employment. Meanwhile, VA information technol- ogy (IT) is struggling to keep pace with the evolution of patient care and record keeping. Consequently, VA leaders in the next Administration must be wise and courageous political strategists, experienced managers to run day-to-day oper- ations more effectively, innovators to address the changing veteran landscape, and agile “fixers” to mitigate and repair systemic problems created or ignored by the present leadership team.