VA chief to recommend hospital closures and expansions in restructuring of the country’s largest health-care system

In addition, 174 outpatient clinics would close, according to the Veterans of Foreign Wars, which was briefed on the plan. But VA would replace some of the shuttered facilities with 140 clinics offering specialty care, two dozen nursing homes and about a dozen residential facilities specializing in substance abuse issues.

The effort aims to address a massive shift in the population of veterans from the Northeast, Midwest and parts of the rural West into warmer locales in the Sun Belt and Southwest. It also is meant to advance a realignment long sought by some VA leaders and conservatives that would dramatically reshape a health-care system that serves 9 million veterans but has failed to modernize alongside its private-sector counterparts.

But the plan also is expected to set off a politically explosive battle over which of the closures are ultimately approved and where expansions are allowed, akin to fights over military base closures in the 1990s that devolved into power skirmishes. Rep. Nicole Malliotakis (R-N.Y.) organized a rally Sunday in front of the Brooklyn medical center, which under the plan would consolidate services with the Manhattan hospital and eventually contract with private providers, the congresswoman’s office said.

South Dakota’s Republican congressional delegation promised a fight to save three sparsely used clinics that, if the plan is approved, would close or have services reduced.

“I’ll fight like hell to make sure veterans in South Dakota receive the care they’ve earned,” Sen. Mike Rounds said in a statement issued with two other South Dakota Republicans, Sen. John Thune and Rep. Dusty Johnson. Former VA secretary Bob McDonald had moved to close one of the clinics, in Hot Springs, but the Trump administration rescinded the decision.

Details of the plan, some of which were first reported by the Military Times, will be formally released Monday in the Federal Register. Any closures and new construction would be years away and must be approved or modified by a new, congressionally mandated commission that will hold hearings in affected communities over the next year.

VA has come under sustained pressure in recent years for relying for generations on a costly model of inpatient care while private hospitals turned toward much more outpatient treatment as medical advances reduced the need for hospital stays.

In some places, VA hospital wards have empty beds and more staff than patients on a given night, and many buildings are so old that repairing them would cost more than replacing them. The heating system at the Chicago VA hospital is so old and poorly regulated that during a visit in December, McDonough said, he was so hot he thought he had contracted the coronavirus. A vacant historic building on the Chillicothe campus has a sapling growing through the walls.

VA officials acknowledge that while the medical needs of older veterans will grow in coming years, much of the system’s health care is offered in the wrong places. Veterans are leaving New England, for example, where their population is projected to drop by 18 percent over the next decade. At the same time, their presence in the Southwest is projected to surge by 25 percent, without enough facilities to treat them.

Part of the push to realign how and where the government-run system cares for veterans is ideological. The agency already has redirected billions of dollars from veterans’ hospitals to private health-care providers in a controversial transformation that accelerated during the Trump administration; about a third of the veterans enrolled in the system now are seen by private doctors. The proposals released Monday are likely to inflame tensions between advocates for more private care and wary unions that fear that care at some facilities that close would be provided instead by non-VA doctors, with the government paying the bills — at a cost to federal jobs.

McDonough, previewing his plan late this week at a Rand Corp. veterans policy center, said the shifts would meet the “needs of 21st-century veterans, not the needs of a health-care system built 80 years ago.” He called the proposals “an investment in VA, not a retreat” and said 150,000 more veterans would have closer access to primary care and 370,000 more to specialty care than they have now.

“All across the board, we’re embracing the idea that health care has evolved,” McDonough said, “and VA needs to lead the evolution.” He pledged that his leadership team is “actively working” to keep health-care jobs and predicted that “we’re looking at more jobs over time, not fewer.”

The plans carry political risk for President Biden and McDonough, who acknowledged this week that he was deeply uneasy when, shortly after taking office, he launched the year-long hospital review, mandated by a 2018 law. Already opposition to the plan has come from lawmakers in both parties, many of whom voted for the law, known as the Mission Act, which included the review as part of a broad expansion of veterans’ access to private doctors. The law passed Congress by wide margins in both parties, but that has not prevented lawmakers whose districts could lose service from gearing up for a long battle.

“These are sacred cows,” said Louis Celli, a former executive director of the American Legion who now co-hosts a podcast focusing on veterans’ issues with former VA secretary David Shulkin. “Every lawmaker prides themselves on having a great big shiny veterans hospital in their district.”

The American Federation of Government Employees, which represents 280,000 health-care employees from doctors to physical therapists, decried what it said would be a dangerous shift to more private care.

“Closing VA facilities will force veterans to rely on uncoordinated, private, for-profit care, where they will suffer from long wait times and be without the unique expertise and integrated services that only the VA provides,” the union’s national president, Everett Kelley, said in a statement.

Some veterans groups said they were keeping an open mind about the proposed changes

“A lot of people view this as a way to shrink VA,” said Patrick Murray, legislative director of the Veterans of Foreign Wars. “We knew there were going to be closures, but we also think this is going to be a net gain.”

Jeremy Butler, chief executive of Iraq and Afghanistan Veterans of America and a New York City resident, said that while the city has a large population of veterans, its VA hospitals are not widely used in part because they face fierce competition from world-class private hospitals.

“It’s a long process, and we need to think holistically,” Butler said of the restructuring proposals. “And we need to stay away from the ‘This is my city and keeping the hospital open because it’s my city is the only thing I care about’” mentality.

McDonough has rejected comparisons of his plan to the fiercely contested base closures of the 1990s, saying the VA process would add care, not shrink it overall. “There will be changes, but we are staying in every market,” he said.

“The veterans health system has always had ancient facilities that were falling apart,” said Darin Selnick, now a senior advisor for CVA who led efforts at VA and later the Trump White House to muscle the commission into the legislation. “You’re wasting money keeping empty beds in empty hallways. The advantage now is you’ll have newer facilities closer to where the veteran is, with equal or better service” — including in the private sector.

McDonough, aware of the sensitivities of the review for VA’s vast workforce, postponed its release in January, citing the disruptions it would cause as the agency battled a surge in coronavirus cases.

The secretary invited several former VA secretaries to a luncheon in his office this week in advance of the release to inform them of his plans. It was only last week that the White House released a list of nominees to the commission that must consider the proposal.

The nine members of the panel, known as the Asset and Infrastructure Review commission, once confirmed by the Senate, will have a year to review the plan, hold hearings around the country in affected communities and send its proposals to the White House. Biden can sign off on them and send them to Congress, or reject them. As with the military base closures led by the Defense Department, Congress must accept all of the changes or none. Lawmakers would have to vote to deny the proposals to stop them; no action means they would take effect.

VA and the commission must consider whether an existing hospital or clinic serves enough veterans, the projected demand for care in the coming years, the cost savings that would result from closing it or reducing service, and whether alternatives exist to allow VA to continue to carry out its mission in the area. The market assessments have been ongoing for more than a year, as a private contractor solicited opinions from local officials and veterans groups.