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COVID-19: Beyond Tomorrow
August 18, 2020

Maximizing the US Department of Veterans Affairs' Reserve Role in National Health Care Emergency Preparedness—The Fourth Mission

Author Affiliations
  • 1Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
  • 2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
  • 3VA Boston Health Care System, Boston, Massachusetts
  • 4Boston University Medical School, Boston, Massachusetts
  • 5Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 6Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Surg. 2020;155(10):913-914. doi:10.1001/jamasurg.2020.4153

The US Department of Veterans Affairs (VA) delivers 3 primary services for veterans: (1) health care through the Veterans Health Administration (VHA), (2) civilian benefits (eg, education, home loans, life insurance), and (3) burial services.1 However, in 1982, Congress enacted the VA/Department of Defense Health Resources Sharing and Emergency Operation Act,2 which created a lesser-known fourth mission. The intent was to use the VA’s extensive health care network and resources as a reserve for the Department of Defense in times of armed conflict and to bolster US preparedness for and its ability to respond to war, terrorism, national emergencies, and natural disasters.

The novel coronavirus disease 2019 (COVID-19) pandemic has clearly illustrated the need for this type of surge capacity for both health care equipment and personnel. In this regard, there are 3 primary resources the VA can provide when US health care needs exceed the system’s capacity: (1) clinical workforce, (2) medical supplies, and (3) national infrastructure. Given the possibility of future pandemics, understanding how the VA can best provide these resources will maximize its ability to fulfill its fourth mission.

Clinical Workforce

The VHA employs more than 320 000 full-time health professionals and support staff working across 170 medical centers (one in nearly every state).3 Furthermore, the VA has well-developed information technology infrastructure to support broad use of telemedicine. This large workforce could help provide care to patients and support to clinicians across the nation, primarily through use of telemedicine. This would also maintain a healthy clinician workforce while caring for patients with infectious disease. Alternatively, because of federal supremacy over state licensing, practitioners credentialed by the VA have flexibility in terms of where they can practice. In fact, VA military reserve and civilian staff from less affected parts of the country were deployed to COVID-19 hot spots during the pandemic (Table).4,5 Voluntary redeployment of VA clinicians to areas where need exceeds capacity could be beneficial for patients and community clinicians, who have been overwhelmed in some major cities during this pandemic.

Table.  Support Provided to States and Territories by the US Department of Veterans Affairs (VA) as Part of its Fourth Mission Since the Beginning of the Coronavirus Disease 2019 (COVID-19) Pandemic
Support Provided to States and Territories by the US Department of Veterans Affairs (VA) as Part of its Fourth Mission Since the Beginning of the Coronavirus Disease 2019 (COVID-19) Pandemic

Medical Supplies

One of the biggest challenges during the COVID-19 pandemic has been access to medical supplies.6 This was compounded by a lack of publicly available information about the size and location of the national stockpile. By comparison, the VHA maintains a reserve of medical supplies that it immediately accessed and deployed to both VA and non-VA facilities in need (Table). Moving forward, part of the national emergency preparedness plan should include the creation of a national database of medical supplies, staffing, and clinical expertise (eg, extracorporeal membrane oxygenation) across federal and nonfederal hospitals and the development of a robust stockpile of personal protective equipment and ventilators within the VA that can be made available to both VA and community hospitals.

The integrated nature of the VHA also presents an opportunity for centralized accounting of local, regional, and national supply levels, which could help with efficient mobilization of equipment to areas in need. As an example, some VA facilities contributed medical supplies and equipment to community partners who experienced shortages at the onset of the COVID-19 pandemic.5 While similar resource-sharing models could be used in other parts of the country, this will require all VA facilities be supplied with not only resources to provide veterans with health care under normal circumstances but also an additional reserve stockpile—the size of which could be informed by data from the current COVID-19 pandemic.

National Infrastructure

A notable strength of the VHA is its national infrastructure spread across regionally integrated networks. As part of the federal response to the COVID-19 pandemic, approximately $17 billion was appropriated as emergency funds to the VHA to ensure adequate personnel and resources are available for disaster response.7 The VA could be used as a national integrated command center to help coordinate response efforts and data collection with local, regional, and national public health agencies to ensure such resources are used to full advantage. Also, the VA’s patient outreach and research infrastructure has already assisted with basic research and large clinical trials related to the COVID-19 pandemic. Its collaborative trial network should be further strengthened in preparation of future pandemics.

Current Barriers

Cooperation between the VA and community hospitals will require methods for fluid, 2-way information sharing. Such efforts are already ongoing as part of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act and in the future will hopefully result in the required information technology infrastructure to facilitate efficient data sharing between VA and private sector hospitals and clinicians. Additionally, the VA provides health care services to veterans on a fixed budget. The Congressional Budget Office has estimated implementation of the MISSION Act over the next 5 years will cost approximately $50 billion; therefore, it is unclear how resources and funds dedicated to care under the MISSION Act will affect the VA’s future ability to maintain supplies and staffing.8 This issue would most readily be addressed by appropriating separate budgets for each of these distinct activities: (1) usual care for veterans, (2) outsourcing of veteran care to the community, and (3) national emergency preparedness. A final barrier is knowing how and when to prioritize the care of veterans at times when there is a national need for overflow capacity for civilian patients at VA facilities. Most VA facilities have existing affiliations with major medical centers. These relationships should be leveraged and used to develop contingency plans addressing circumstances in which civilian patients should receive care at VA hospitals. Similar agreements could also be created between nonaffiliated medical centers with nearby VA facilities. Negotiating such agreements locally rather than implementing a national policy would provide needed flexibility that considers differences in local needs and resources.

Given the recent resurgence of the COVID-19 pandemic, it is imperative the US health care system maintains its readiness for this and future natural disasters. While the VA has traditionally been associated solely with services for veterans, it has the resources, personnel, and infrastructure to help bolster current and future national disaster planning. The VA can be a critical resource for the US health care system by making sure it is always well supplied and ready for an organized response at times that may be unanticipated but most needed.

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Article Information

Corresponding Author: Nader N. Massarweh, MD, MPH, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, OCL 112, Houston, TX 77030 (massarwe@bcm.edu).

Published Online: August 18, 2020. doi:10.1001/jamasurg.2020.4153

Conflict of Interest Disclosures: Dr Itani has received grants from Pfizer. Dr Tsai has received personal fees from Sigilon Therapeutics and Seamless Mobile Health. No other disclosures were reported.

Funding/Support: This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness, and Safety award CIN 13-413 (Dr Massarweh).

Role of the Funder/Sponsor: The funders had no role in the preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.

Disclaimer: The opinions expressed in this article are those of the authors and are not in any way intended to reflect the position or policy of the Department of Veterans Affairs, the US government, Baylor College of Medicine, Boston University, or Harvard Medical School.

US Department of Veterans Affairs. About VA. Accessed April 15, 2020. https://www.va.gov/about_va/
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US Department of Veterans Affairs. VA Fourth Mission summary. Accessed July 29, 2020. https://www.va.gov/health/coronavirus/statesupport.asp
US Department of Veterans Affairs. Department of Veterans Affairs COVID-19 national summary. Accessed July 29, 2020. https://www.accesstocare.va.gov/Healthcare/COVID19NationalSummary
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