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VA Recommendations to the AIR Commission


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Frequently Asked Questions

What is AIR?

When Congress passed the MISSION Act in 2018, it required that VA undertake AIR – an initiative to study the current and future health care needs of Veterans across America, and to evaluate VA’s health care infrastructure to ensure VA is ready and able to continue to provide Veterans with world-class access and outcomes.

As part of the congressionally mandated AIR process, VA will submit recommendations to the AIR Commission that will:

Cement VA as the primary, world-class provider and coordinator of Veterans health care for generations to come.

Build a health care network with the right facilities, in the right places, to provide the right care for all Veterans, including underserved and at-risk Veteran populations in every part of the country—making sure that our facilities and services are where the Veterans are.

Ensure that the infrastructure that makes up the Department of Veterans Affairs in the decades ahead reflects the needs of the 21st century Veterans—not the needs and challenges of a health care system that was built, in many cases, 80 years ago.

And strengthen our roles as the leading health care researchers in America and with our academic partnerships to remain the leading health care training institution in America.

This is a three-step process:

First, VA conducted market assessments – studies of every VA market across the country designed to understand the makeup of our Veterans by health care needs, age, race, gender, era they served, and where they live.

Second, VA used those market assessments to inform recommendations for the future of VA’s health care infrastructure. The Secretary announced the recommendations on March 14, and they are available at

Third, the AIR Commission (a bipartisan, presidentially appointed and congressionally approved group), the President, and Congress will review those recommendations and determine whether or not they will be accepted and implemented.

During the AIR Commission’s review, the Commission will hold public hearings, visit VA facilities, meet with employees and partners—and most importantly, listen to Veterans—to assess those recommendations. At the conclusion of that work, the AIR Commission will transmit the recommendations, with any changes it deems necessary, to the President.

The President will then determine whether or not he wants to submit those recommendations to Congress. If he does submit them, Congress can then accept those recommendations as a whole by inaction or reject those recommendations as a whole by passing a joint resolution of disapproval.

What does this mean for Veterans?

There will be changes in markets across the country, but VA is not leaving any market. Between outpatient care, strategic collaborations, and referrals to the community, VA will continue to deliver timely access to world-class care to every Veteran, in the community and in rural areas, in every corner of the country.

Will the AIR Process require me to get a new mental health or primary care provider?

There will be no immediate changes. Through the AIR Process, VA intends to increase access and improve outcomes for Veterans, not to direct Veterans away from providers they trust. Veterans will always be at the center of VA decision-making, and throughout the development of the AIR recommendations has sought to propose changes that will make a positive impact on Veterans now and into the future.

Did Veterans/VSOs get to contribute as part of this process?

Yes. From March to June 2021, VA hosted virtual listening sessions across the country to hear from the Veterans and the communities VA serves. Sessions were focused on hearing about Veterans’ experiences with VA health care and their vision for its future. Feedback from the listening sessions were considered when developing recommendations that the Secretary will submit to the AIR Commission. The Commission will hold public hearings, visit VA facilities, meet with our partners, and listen to Veterans to assess those recommendations. VA has engaged with VSOs throughout the entire process, updating them on progress and considering their feedback on methodology and data sources. In addition, VA sought Veteran and VSO feedback when developing the decision criteria that will be used in the AIR Commission recommendations.

Why is the AIR process necessary?

The median age of VA’s hospitals is 58 years old, and much of VA’s health care infrastructure was built in the 1940s and 1950s to meet the needs of World War II Veterans. The AIR process will ensure that the infrastructure that makes up VA in the decades ahead reflects the needs of the 21st century Veterans—not the needs and challenges of a health care system that was built, in many cases, 80 years ago.

What does this mean for VA employees?

In the short run, AIR will have no major impact on VA employees. In the long run, AIR recommendations could indeed impact VHA facilities and staff, but it’s too early to know exactly what or where those impacts might be. VA recognizes that it is not its infrastructure that cares for Veterans or saves their lives—it is the VA Workforce, VA’s incredible public servants. Through this process, VA is not only looking to invest in its physical infrastructure, but VA is also actively looking to invest in the VA Workforce, because they are a critical part of VA’s future.

What is the AIR Commission’s process for consideration of the AIR Report recommendations?

The MISSION Act requires the AIR Commission to conduct public hearings on the recommendations in regions affected by any of the Secretary’s recommendations to close a VHA facility. Hearings may also be held in regions where the Secretary recommends modernization or realignment. The MISSION Act requires that the public hearings have witnesses, including a Veteran and local public official.

In making its recommendations, the Commission may change any recommendation made by the Secretary if the Commission determines that the Secretary deviated substantially from the final criteria. The Commission may then change the recommendation to be consistent with the final criteria. They must also publish a notice of the change to the Federal Register and conduct public hearings on the proposed change.

By January 31, 2023, the Commission must submit its recommendations to the President and must justify any recommendation that is different from the recommendations made by the Secretary.

What is the difference between a recommendation and complementary strategy?

Recommendations are specific opportunities for modernization and realignment of VHA facilities in each market that the Secretary submitted for consideration by the AIR Commission. If approved, recommendations are mandatory actions.

Complementary strategies supplement VA’s recommendations to the AIR Commission and support a high-performing integrated delivery network in each market. Complementary strategies are additional discretionary actions VA anticipates taking to enhance the recommendations.

Were specific metrics used to determine which facilities should be opened, closed, or modernized? If so, what metrics were used?

There is no single metric that is used to determine whether to open, close, or modernize VA facilities. VA’s aim is to deliver high quality care in locations that are accessible to Veterans. VA’s recommendations were developed pursuant to Section 203 of the MISSION Act, which required VA to establish specific criteria to use in the development of the recommendations. In May 2021, VA released criteria that specified the key sets of metrics used in the recommendations. VA engaged with multiple stakeholder groups, including Veterans and Veterans Service Organizations, to better understand their perspectives and used their input to develop the Section 203 criteria.

The decision criteria include Veterans' Need for Care & Services and the Market's Capacity to Provide Them (Demand), Accessibility of Care for Veterans (Access), Impact on Mission, Providing the Highest Quality Whole Health Care (Quality), Effective Use of Resources for Veteran Care (Cost Effectiveness), and Ensuring a Safe and Welcoming Health Care Environment of Care (Sustainability). All recommendations have been formulated to meet the criteria and the AIR Commission will evaluate the recommendations on the criteria.

In addition to the decision criteria, the recommendations were developed with consideration of each market’s unique needs to ensure Veterans have access to high quality care now and in the future. The recommendations are the result of years of research and analysis conducted to assess VA’s current infrastructure and determine how to invest resources to maintain and improve Veteran health care.

Does the AIR Report include recommendations to close VA facilities?

There have been no announcements or decisions regarding any VA facilities closing, anywhere. The report recommends modernizing VA’s health care system to get care closer to where Veterans live. In some cases that includes recommendations to close facilities and invest in modern facilities in locations in that market convenient to Veterans that look to maintain or improve their access to care.

VA recognizes that it’s not the infrastructure that cares for Veterans or saves their lives—it’s the VA Workforce, the incredible public servants. VA is not only looking to invest in physical infrastructure but also actively looking to invest in the VA Workforce, because they are a critical part of VA’s future. VA aims to build a health care network with the right facilities, in the right places, to provide the right care for all Veterans, including underserved and at-risk Veteran populations in every part of the country—making sure that facilities and services are where the Veterans are. Recommendations in the report to close a facility are based on multiple data points that may include a facility’s age, the existing and projected Veteran demand for health care services in the local area, and the potential to leverage local partnerships to deliver the best care to Veterans. Among the criteria used to develop recommendations is “access”—a requirement that all recommendations maintain or improve access to care. The AIR Commission’s review process will include determining if VA’s recommendations meet all criteria to include the access criteria.

How will VA prioritize and fund projects that result from the AIR Process?

If approved, the MISSION Act requires VA to begin implementing recommendations no later than three years after the date on which the President transmits the report to Congress. The MISSION Act also established an AIR account to support future appropriations for implementation of the recommendations. During the implementation, VA would develop a process for prioritization and funding of projects.

Why was the release of the AIR Commission recommendations postponed?

Spread of the Omicron variant impacted everyone’s work and lives, especially those who work in health care settings. VA’s staff needed to be focused on providing care to Veterans and keeping our staff safe. It was vitally important to the Secretary and VA leaders across the enterprise that market assessment findings and recommendations were discussed with staff before they were published in the Federal Register. In the context of staff’s ongoing, heroic response to the Omicron variant, more time was needed to communicate with staff about the recommendations before they were published.

What are the next steps after the AIR Commission's review?

After the AIR Commission completes its review and submits its recommendations to the President, the President has the opportunity to review the recommendations and transmit a report to the Commission and Congress containing approval or disapproval of the recommendations. 

If the President disapproves of the recommendations, the AIR Commission has an opportunity to respond and resubmit recommendations to the President for approval. If the President disapproves again, the process terminates. 

If the President approves of the recommendations, the President will submit them to Congress with certification of approval. Congress will have the opportunity to disapprove the recommendations by introducing and passing a joint resolution of disapproval on the recommendations as a whole. If no action is taken within a specified timeframe the recommendations will be considered approved.

Is the AIR Commission similar to a BRAC?

This is not a “stay or go” process. VA will remain in health care markets and look to strengthen the delivery of care to Veterans. The Base Realignment and Closure Commission (BRAC) focused on closure and realignment. In contrast, the AIR process is focused on increasing access and improving outcomes for Veterans regardless of care location and strengthening VA’s ability to provide health care in every market, with VA services remaining the preferred method of delivering care. In the places where there are changes, VA will be shifting toward new infrastructure, or different infrastructure that accounts for how health care has changed, that matches the needs of a market, that strengthens VA’s research and education missions, and that—most of all—ensures that the Veterans who live in that location will have access to the world-class care they need, when they need it.

What are market assessments?

Market assessments are an initiative for each of VA’s markets, providing analysis and insights that informed recommendations to the AIR Commission. Market assessments used a variety of data to inform the analysis, including but not limited to information regarding market geography and demographics, current and future market demand, Veteran access, quality of care, facility conditions, and health care resources—such as federal and community provider data—that exist in the broader market. Analysis is also significantly informed by input from local VA medical facilities, including site visits and more than 1,800 interviews with field staff.

VA developed a standardized methodology for the market assessments built on leading practices in federal and commercial health care strategic planning. The methodology was customized to reflect the unique elements of VA, including VA’s requirements to meet all four of its mandated missions (e.g., health care, education, research, and emergency preparedness).