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Office of Public and Intergovernmental Affairs

Remarks by Secretary Denis R. McDonough

AIR Commission Speech at RAND Corporation
Washington, DC
March 10, 2022

Good afternoon, everyone! Thanks Michael [Rich] for that kind introduction, and to RAND for hosting. Thanks, as well, to Jennifer [Steinhauer] for guiding our conversation today—and to everyone who’s joined us this afternoon to talk about VA’s AIR commission recommendations.

Just to briefly recap how we got here, these recommendations are a critical step in a long process set off by the MISSION Act in 2018.

The process began with us at VA conducting market assessments across the country—studies of facility conditions, local partnerships, and most importantly, the makeup of our nation’s Veterans by health care needs, age, race, gender, era they served, and where they live.

From those market assessments, we developed recommendations for the future of VA’s health care infrastructure—our medical centers, hospitals, clinics, etc.—which we’ll be discussing in broad terms today and then submitting to the federal register on Monday.

And then, over the next year, those recommendations will be reviewed by the AIR Commission, the President, and Congress to determine the path forward.

Now, I know that Jennifer has a lot of questions for me, so I’ll be brief in my opening remarks here. Really, I just want to focus on how we came to the recommendations that you’ll see on Monday, and—more importantly—why we made those recommendations.

And the answer is quite simple. We came to these recommendations by asking ourselves one question above all else: what’s best for the Veterans we serve?

The result of asking ourselves 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 Veterans in every part of the country—making sure that our facilities are where the Veterans are.

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

and that will strengthen our roles as the leading health care researchers in America, and the leading health care training institution in America.

And look, I completely understand that people may have concerns about these recommendations and the whole AIR process. 

That’s why we’ve spent the last several weeks and months 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 the strong partnership we have with them, and because they—like the rest of the VA’s workforce—are the most important part of our infrastructure.

But in addition to those conversations, I also want to say now—to anyone who is concerned about this process—that VA is here to stay.

This is an investment in VA health care, not a retreat.

This is VA doubling down, strengthening our ability to deliver the world-class health care that Vets have earned and deserve.

Now, there will be changes in markets across the country, but we are staying in every market. 

Between outpatient care, strategic collaborations, and referrals to the community, we will 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, that matches the needs of a market, that strengthens our 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.

Let me give you a few examples.

In one market in the Southwest, the number of Vets is projected to increase by 25% and demand for long-term care is projected to increase by 87%. So, we’re recommending building a brand-new VA medical center to meet that rapidly increasing demand.

In one Northeast market where we have an old, outdated, and under-utilized medical center, the opposite is happening: the Veteran population has been declining for decades and is going to decline by an additional 18% in the next ten years.  

But even there, we’re adding facilities to better address the needs of the Vets who do live there. Specifically, we’re recommending opening new facilities—including a Community-Based Outpatient Clinic—in the parts of this 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’ll be closer to them than it was before.

Also, the Vets in this area are older, so we’re recommending adding a new community living center and other services so those older Vets can age where they want to: at home or near home.

And we’re entering into a new strategic partnership, with VA clinicians embedded in a community hospital, so Vets can get their care in a modern, high-quality setting rather than a VA hospital that serves only 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 new facilities rather than pouring money into a facility that opened just after World War I.

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

But it’s important to note that when making these decisions, we didn’t only consider demand.

For example, there are markets in the Southeast and Midwest where topline demand numbers suggested we should close medical centers. But, when we took a closer look, we realized that the 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 for care in the community. So, instead of downsizing in those markets, we’re doubling down on them—because that’s the only way to guarantee that the Vets who live there will get the care they deserve.

And, all across the board with these recommendations, we’re embracing the idea that health care has evolved—so VA needs to evolve with it.

Evolving means building facilities designed with Veterans and VA employees in mind. Because VA employees are and always will be our number one asset, and they should have the modern tools they need to provide the best possible care for Vets.

Evolving means building new facilities designed for the specific care needs of today’s diverse group of Veterans—including Women Vets, the fastest growing category of Veterans in our network.

Evolving means building facilities that are capable of delivering world-class telehealth to Veterans... replacing old facilities that literally don’t have enough space between floors to support cables for fast Wi-Fi.

Evolving means moving care to the Veteran—making VA local for the Veteran—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 is proven to provide the best outcomes for Vets. 

And evolving means that we don’t need as many inpatient beds as we did 100, 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. 

Take hip replacements, for example. In the early 90s, a hip replacement could leave you in a hospital bed for weeks. Today, the average hospital stay for a hip replacement isn’t even 24 hours.

That evolution from inpatient care to outpatient care is happening across the health care landscape, and it’s just one example of how VA’s infrastructure needs to evolve with the times.

So, these recommendations are being made for many reasons in many markets across the country. But the bottom line is that all of the recommended changes—if approved—will add up to the one thing that matters most: more care, and better care, for the Veterans we serve.

Don’t get me wrong—we’re already delivering excellent, world-class health care to Veterans at VA. In fact, we’re providing more care to more Vets than ever before in VA’s history—and our outpatient trust scores are up to 90%, the highest level in years.

But if we implement these AIR recommendations, nearly 150,000 more Veterans will have primary care nearby; nearly 200,000 more Veterans will have mental health care nearby; nearly 375,000 more Veterans will have access to outpatient specialty care nearby; and all of that care will be delivered in modern, state-of-the-art facilities.

That’ll mean increased access. It’ll mean better care. And—most of all—it will mean even more Veterans’ lives saved, and improved, by the work we do.

And that’s what these recommendations are all about.

Now, before I close, let me just tell one story that underlines why these recommendations are so important for Vets. My wife Kari and I went to the VA Medical Center in Chicago on Christmas morning to deliver donuts to the folks working that day.

And when I was walking down the hallway that morning, I started to feel hot... really hot.

Keep in mind, this is at the height of Omicron, so I began to worry—do I have a fever? am I getting sick? But before I got too worked up, I asked the folks I was with if anyone else was feeling the same thing. 

Turns out, they were all hot.

Fortunately, the VA cop I was with, who works in that facility every day, chimed in with an explanation, saying, “Oh, don’t worry about that. When it gets cold in Chicago, the heat breaks down in the hospital, and we have to worry about water pipes bursting—so we crank the heat way up to avoid that happening.”

That’s what we’re dealing with right now when it comes to infrastructure: spending extra money to maintain out-of-date facilities rather than building new, state-of-the-art facilities.

That’s what our Vets are dealing with when they come to those old facilities.

And that’s what our health care professionals are dealing with when they’re busy trying to save lives... sweating, in a facility in Chicago, on a freezing-cold Christmas morning.

You know when that facility was built? 1921, more than a hundred years ago.

That’s not good enough.

Vets deserve better—and with these AIR recommendations, we’re going to give it to them.

That’s all I’ve got! Thanks again for having me today.

Rajeev [Ramchand], over to you.