Manchin, Rounds to President Biden: Absence of Rural Representation on VA AIR Commission is Concerning

Dear President Biden:

We write to you today with regard to your role in considering the recommendations to be made by the Asset and Infrastructure Review (AIR) Commission, as prescribed in Subtitle A of Title II of the VA MISSION Act. Specifically, we request that at least one of the nine commissioners appointed have a background working in or for rural health care systems. We also request you not act on recommendations from the Commission until verifying that they will not disadvantage rural communities with limited access to healthcare options.

Rural communities have historically suffered the most from initiatives such as the AIR Commission. We are concerned that history will repeat itself. The last time there was a similar asset review, the CARES Commission in the early 2000s recommended closing or moving critical medical services in a number of states including West Virginia, South Dakota, Pennsylvania, Missouri, Oklahoma, Washington, and Iowa. With the VA's expressed purpose on expanding private care through the MISSION Act, we must prevent the closing of existing facilities or relocation of services in areas that have no viable alternative.

Currently, there is no requirement for any of the nine-member AIR Commission appointees to have experience with rural health care systems. Additionally, none of the current nominees have any significant experience in rural health. A lack of representation for the over two million rural Veterans enrolled in VA healthcare places them at an acute disadvantage during the AIR process. With six established requirements for appointees, there are three remaining spots that we request be filled with at least one rural health expert.

Rural communities are home to a greater percentage of older Americans, with 17.5% of the rural population being 65 years and older, compared to 13.8% in urban areas. Rural communities also have higher rates of chronic illnesses. In addition to these challenges, health care staffing challenges in rural communities are particularly severe. Ensuring veterans in rural communities have access to care is vital.

In order to mitigate the risks to rural veterans and healthcare providers, the AIR Commission must consider the implications of moving or closing services at any rural VA facility. To do so, we request that you not implement any recommendation that hasn't been vetted by the Health Resources and Services Administration (HRSA) and the Rural Health Council within the Centers for Medicare & Medicaid Services. Third party verification will make certain that no substantial burden is placed on rural communities. Additionally, any recommendations should utilize the Health Professional Shortage Area metric, which is maintained by HRSA, and the Medically Underserved Area/Population metric to demonstrate that moving or closing VA health services will not result in making it more difficult for veterans or the general public to access healthcare.

COVID-19 highlighted that neither the VA nor other government agencies can always predict the health trends that will impact veterans and the care they need. As our Vietnam and post-9/11 veterans age and experience illness related to military service, the VA must proactively anticipate their needs as well as the burdens that future conflicts may place on the existing healthcare system. We encourage the AIR Commission to adopt our bipartisan, commonsense proposals that will ensure we do not close critical VA facilities today that leave our veterans, their friends, their families, and their communities underserved and unprepared for tomorrow.

Veterans have put their lives on the line to protect this country. They deserve consistent, accessible, quality care when they return. That's the promise we made to these brave men and women when they took their oath to serve, and that's the promise we intend to keep.

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