The recent increase in COVID-19 cases is straining some parts of the U.S. health system due in part to the limited availability of hospital beds in hard hit communities and the simultaneous return of certain services that were delayed at the onset of the pandemic. Some hospitals already lack the resources to handle an influx of COVID-19 patients.
In searching for solutions to the lack of beds, equipment, and personnel to treat patients with COVID-19 and other conditions, cities and states have turned to a variety options, including the Veterans Health Administration (VHA). The VHA, which operates the largest integrated health system in the country, is statutorily required to back-up the nation’s health system in times of public emergencies. Within the context of the coronavirus pandemic, this brief examines the role of the VHA during public health emergencies and its capacity to support the broader community if called upon. We find that the VHA offered additional hospital capacity to a small number of strained communities during the first months of the pandemic, but that VHA support to the non-Veteran community has become increasingly more widespread and varied as the pandemic has progressed and placed sustained pressure on local health systems.
Veterans Health Administration and COVID-19
The Department of Veterans Affairs (VA) operates the country’s largest integrated healthcare system, the Veterans Health Administration (VHA), which includes more than 150 hospitals and over 1,000 outpatient clinics across the country. Combined, these hospitals have a total of over 13,000 acute care beds, 1,800 of which are intensive care beds. According to the VA Secretary’s office, the VHA began working to expand capacity during the early days of the pandemic, resulting in the creation of 1,000 additional ICU beds in the system. Compared to many community hospitals, VHA hospitals have additional equipment and specialized care facilities, such as negative pressure rooms used for treatment of patients with infectious diseases like COVID-19. The VA has diagnosed over 33,000 COVID-19 cases among veterans and VA employees, but inpatient admission rates at VA medical centers are significantly lower than their pre-pandemic levels due to patients generally avoiding hospitals out of fears of contracting the virus and the VAs efforts to transition many services to telehealth.
A majority of VA Hospitals are located on the East Coast and in metropolitan areas
VA efforts to support COVID-19 capacity in the community
The operations of the VA fall within the scope of four “missions.” The first three relate to services provided directly to veterans and their families. The “Fourth Mission,” as it is known, deals with improving the nation’s preparedness to respond to national emergencies, disasters, and war. The VA has previously acted under this mission to provide medical resources to Puerto Rico after Hurricane Irma, for example, and to supply mobile care units in Orlando after the 2016 mass shooting at Pulse nightclub.
The VA’s “Fourth Mission” directs the VHA to act as a safety net for the nation’s private healthcare system, providing extra capacity and resources should community hospitals become overwhelmed. Under the National Response Framework, an interagency plan coordinating the federal response to emergencies, the VA can be tasked with two Essential Support Functions that can support the response to COVID-19: sharing healthcare resources with the community and/or providing care to non-enrolled veterans or non-veterans. Under the National Response Framework, federal, state, or local officials can request that HHS operationalize the VHA to provide these community and non-veteran services. Typical requests include a lack of needed supplies of personal protective equipment (PPE), hospital beds, or medications. Importantly, veteran enrollees still take priority and the VA can only provide these support services if it can first handle the strain from veterans with COVID-19 and ensure continuity of care for non-infected veterans.
In response to the COVID-19 pandemic, the VA is executing these support functions in several ways. As of July 20, the VA was supporting 46 states and the District of Columbia in their COVID-19 responses, including providing additional tests and/or equipment in 17 states, opening beds to care for non-veteran patients in 14 states, and providing additional staff in several more states. In April, the Secretary of the VA indicated to FEMA that the VHA could provide up to 1,500 beds for missions in the community, including 500 ICU beds. So far, 279 non-veteran COVID-19 patients have been admitted to VHA facilities.
The first instance where the VHA bolstered local hospital capacity came in late March when, after a request from the state of New York, the VHA opened 50 hospital beds (35 acute care and 15 intensive care unit beds) to non-veteran, non-COVID-19 patients. In the time since, VHA facilities in 13 other states have made hospital beds available for some non-veteran patients (Arizona, California, Illinois, Iowa, Louisiana, Michigan, Mississippi, New Jersey, New Mexico, Oregon, Texas, Utah, and Washington). During the recent surge in COVID-19 cases, VA medical centers in coronavirus hotspots, like Phoenix and South Texas, have reported transferring non-COVID patients to different VA medical centers in preparation for increasing COVID-hospitalizations from veterans and potentially non-veteran patients. The VHA has also dispatched more than 750 doctors, nurses, or other staff to aid non-VA facilities in Florida, New Jersey, Alabama, California, New Hampshire, Massachusetts, and Tennessee.
The VHA could be a resource to expand capacity in states and localities strained by the recent resurgence in COVID-19 cases, as shown by the VHA’s current support of some affected areas. However, the VHA may face limitations that could challenge their ability to successfully activate the “Fourth Mission” and provide capacity and support across different communities.
Like other hospitals during the pandemic, VHA facilities may face their own workforce and resource shortages. However, the VHA has made progress towards filling positions since the start of the pandemic, reporting that 5,285 registered nurses have been hired and onboarded since March.
VA medical centers are also primarily concentrated in metropolitan centers and the Northeast. As of 2015, only 25 VA medical centers were designated as rural, and while the VHA has outpatient clinics and other smaller facilities to care for veterans in rural areas, these facilities lack the beds and equipment to care for critically ill COVID-19 patients. Consequently, although VA resources could improve overall capacity, rural communities may benefit less, particularly outside of the Northeast. This disparity is especially important because the number of COVID-19 cases and deaths in rural communities have grown more quickly than in urban communities since April, and rural hospitals have less capacity and fewer alternatives to adapt if they become overwhelmed.