The Department of Veterans Affairs is meant to be America's backup healthcare system in times of crisis. But VA was largely left out of early United States coronavirus planning and strategy at the highest levels, according to a newly released report.
The U.S. Coronavirus Task Force was established on Jan. 29, without VA -- the largest single healthcare system in the country and the second-largest federal agency, according to the department's 557-page COVID-19 Response Report released Monday, which analyzes VA's response to the pandemic from January through June 30.
In February, as "concern mountain in the U.S. regarding the threat posed by COVID-19, the president appointed the vice president as lead of the (task force) on Feb. 26 and the task force was still absent VA representation," the report said.
In March 2020, VA Secretary Robert Wilkie had to recommend "VA's inclusion on the U.S. Coronavirus Task Force due to VA's 'Fourth Mission' to respond to public health emergencies within the U.S.," according to the report.
Wilkie's recommendation was accepted and VA joined the task force in late March after VA already recorded its first veteran death from the coronavirus.
The report detailed several issues with communication between federal agencies and VA leaders on pandemic response, including for VA's Fourth Mission, which was activated at the "greatest scale and scope in VA's history" in 2020.
VA is expected to play a critical role in national emergency medical response, including pandemics. That role is one of VA's four core missions as a federal agency. VA's large national reach and federal authority give it the ability to respond in ways private healthcare systems can't match.
Beginning in 1982, VA was chosen as “a backup to the Department of Defense medical care system and the Public Health Service and the National Disaster Medical System in times of natural and technological disasters,” according to a National Health Policy Forum (NHPF) report in 1998. That includes outbreaks of disease such as COVID-19.
In the event of national emergencies, VA essential functions and funding are guaranteed by the federal government -- even in a shutdown -- and VA and its medical facilities are tasked with supporting “our nation’s communities affected by nationally-declared disasters,” according to VA’s emergency management plan. That includes assisting FEMA and HHS in response to emergencies, such as pandemics.
VA is one of four federal partners in the National Disaster Medical System (NDMS), along with Homeland Security, the Defense Department and HHS. The NDMS is intended to establish a national medical response to help state and local authorities respond to public health crises, including national disasters or disease outbreaks, or to help the military medical system care for casualties of war, “from the smallest incident to the largest catastrophe.”
That responsibility includes the Disaster Emergency Medical Personnel System (DEMPS) which deploys clinical and other staff to respond to emergencies or disasters, as well as mobile medical units.
“For all intents and purposes (VA is) the federal government’s only direct response capability,” former VA Undersecretary for Health Ken Kizer said in the 1998 report. “The U.S. Public Health Services no longer has any resources with which to respond to a disaster or national emergency.”
U.S. law allows the secretary of the VA "to provide hospital care and medical services to non-VA beneficiaries responding to, involved in or otherwise affected by a disaster or emergency.”
Only one of VA’s core missions is to provide care to veterans, or those “who shall have borne the battle” and their families. The other three are to train medical professionals, conduct medical research and to be a last line of defense in national health emergencies.
At the start of the pandemic, though, the extent of the help VA could offer wasn't clear. The most recent publicly released VA pandemic plan in March was 14 years old and covered how VA would respond to a flu pandemic. And the most recently updated public information on the number of hospital beds available at VA for emergencies was specifically not publicly available.
VA also has an Emergency Cache Program for medical supplies and medicines, meant to serve as a backup in times of crisis and built to support thousands.
But as it turns out, federal and state government leaders didn't have a consistent understanding of VA's role in national emergencies.
"VHA’s Fourth Mission was not generally understood and much of the focus on Federal health assets for response to NYC was on (the Department of Defense)," the report reads.
DoD mounted a major response at the Javits Center and the USNS Comfort docked in New York harbor, but neither saw the volume anticipated.
"Discussions at a national level led to commitment of extensive DoD assets before a coordinated VHA-DoD response could be proposed," according to VA's report.
In March, the FEMA National Response Coordination Center (NRCC) "encountered a major challenge" in supplying states and VA with "critical supplies and equipment" such as masks and other personal protective equipment (PPE).
When the president invoked authorities within the Defense Production Act for the distribution of health and medical resources for pandemic response including PPE and ventilators, VA's report said "initial distribution prioritization under Defense Production Act did not give priority to VHA's requirements for PPE, threatening to impede community response under VHA's Fourth Mission."
Supply chain issues within and outside VA "were major," the report said, though VA leadership earlier in the pandemic repeatedly denied staff and veteran reports of major supply shortages and rationing. VA's "mitigating actions" were successful in eventually providing enough supplies and equipment to meet "all demand for care and Fourth Mission responses," the report said.
National shortages of testing supplies also "impeded VHA capacity to fully utilize testing devices" to detect the virus, but VA later managed and adapted testing to meet demand as availability grew, according to the report.
Wilkie's push to remind other federal agencies about VA's need and communities' need for VA to be fully equipped led to a higher priority for VA, according to the report.
"VA and VHA were assertive in making their capabilities’ readiness known to those leading the national response as they recognized the importance of VHA capabilities to the effort," the report said.
States were also "generally unfamiliar" and "generally unaware" of VA's Fourth Mission, and that they could request help from VA through FEMA for overwhelmed hospitals and other medical needs during the pandemic. Wilkie was in regular contact with governors about the stress on their own healthcare systems, veterans in state nursing homes and how VA could assist.
According to Veterans Health Administration Executive in Charge Dr. Richard Stone, "the support actions in response to FEMA Mission Assignments of the two large federal healthcare systems, VHA and the Military Health System, have not been coordinated during this response," the report said.
While the federal government called on DoD in the early weeks of the pandemic, Pentagon leaders said they considered VA, coupled with FEMA, "as the primary healthcare response options for a national or regional public health emergency," with DoD assisting as necessary. But military leaders did not consider DoD to be a primary responder to such crises.
Early incorporation of VA into the planning and execution of federal pandemic response could have helped in the first months of the pandemic, according to the report.
"It is recommended that VHA expand its presence and relationships with selected federal agencies and organizations," the report said in its list of recommended actions, a nod to the communication breakdowns detailed in the report.
VA's report recommended that the department pursue relationships with other federal agencies and standing processes for "a coordinated interagency response to public health crises ... to enhance national readiness."
Now, as America enters what appears to be its third major spike of in virus cases, VA has exceeded record levels of patients and staff actively sick from the coronavirus, echoing increases nationwide as reports begin to emerge again of hospitals filling up with patients, a need VA is meant to fill through its Fourth Mission.