Lack of Federal Understanding of Agency’s ‘Fourth Mission’

Bridget Fisher, a nurse practitioner from China, Maine, has her identification checked before boarding a DoD aircraft for a flight to New York to begin COVID-19 response operations at VAMCs in New York City. More than 120 health care providers from the VA New England Healthcare System have deployed to New York City and the greater Boston area. Photo from April 30, 2020, VAntage Point blog

WASHINGTON — VA was initially left out of strategic decisions made by the U.S. Coronavirus Task Force, the group ostensibly coordinating the nation’s response to the pandemic, the agency revealed in a recent report. 

The 557-page “COVID 19 Response Report” picks apart how VA has responded to the pandemic and describes how the absence of VA’s voice at the table resulted in early fumbling of the federal response. Complicating matters was a general ignorance by other members on the task force of VA’s capabilities or a solid understanding of the department’s “fourth mission” of supporting the nation’s healthcare system during times of emergency.

According to the report released last month, VA had to request to be included in the conversation in late March when it became clear that miscommunications and mishandling of resources would continue otherwise.

In addition, the report describes how weak coordination at the federal level continues to affect VA’s ability to respond to the pandemic at the state and local scale.

The Coronavirus Task Force was officially formed on Jan. 29 under the leadership of Health and Human Services Secretary Alex Azar. It included representation from HHS, the national Centers for Disease Control and Prevention, Medicare, the Department of Homeland Security and the Department of State, among others. On Feb. 26, President Donald Trump assigned leadership of the task force to Vice President Mike Pence. At that time, VA was still absent from the conversation. 

The department was continuing with its own pandemic response preparation, and, during those first two months, VA was analyzing data from outbreaks in other nations. It became increasingly clear to VA leadership that the department would play a large role in the nation’s response and might be asked to take the pressure off civilian hospitals. As it ran pandemic models, VA prepared to be called on by the Federal Emergency Management Agency to support hard-hit areas. 

That opportunity came in late March when the virus spiked in New York City, threatening to overrun the city’s hospitals. 

On March 26, VA was finally allowed a seat at the table, and VHA Chief of Staff Lawrence Connell was appointed as the agency’s representative on FEMA’s National Response Coordination Center (NRCC). 

“He began updating the NRCC on VHA’s activities to expand ICU and [medical/surgical] bed capacity by 3,000 beds nationwide with intent to offer bed capacity in locations where healthcare systems were approaching capacity,” the report states. “However, VHA’s fourth mission was not generally understood and much of the focus on federal health assets for response to NYC was on DOD.”

That DoD response consisted of creating an alternate site of care at the Jacob Javits convention Center and the USNS Comfort, which had docked in NY Harbor. The Comfort has originally been fitted to treat up to 1,000 non-COVID patients, but in early April was refitted to handle 500 COVID 19 patients. 

Yet, neither space saw the volume of patients that had been expected. The use of the Comfort especially was treated with skepticism, if not actual mockery. by local health officials, who viewed the ship’s deployment as more show than substance. The Comfort would eventually leave New York City at the end of April, having served fewer than 200 patients during that time.

At the same time as the deployments at the Comfort and Javits Center, VHA opened up its medical centers for community COVID-19 patients, specifically offering to accept critical care patients. VAMCS in the area received 111 patients, mostly receiving critical care.

According to the report, VA and DoD had been in the midst of discussing how they could coordinate their pandemic response in New York City when they were essentially overridden. 

“Parallel discussions at a national level led to commitment of extensive DOD assets before a coordinated VHA-DOD response could be proposed,” the report declares. “VHA then also mounted an extensive response focused on critical care capacity in VAMCs for COVID-19 victims.”

This misuse of resources caused DoD to later “moderate its commitment of medical forces to civil support” out of concern for the healthcare requirements of its servicemembers and beneficiaries, the report states.

VA, DoD Coordination

According to the report, DoD officials see VA as the primary healthcare response option during a national or regional emergency with DoD’s contributions limited to areas where it is uniquely capable, such as aeromedical evacuation and the rapid deployment of field hospitals. 

VHA leadership agreed with that assessment but noted that more coordination between the two agencies is needed for an “agile, efficient response.” Specifically, VHA senior leaders have expressed renewed interest in a partnership with the Commissioned Corps of the Public Health Service. They believe such a partnership would boost VHA’s deployment capability while providing a career track in VA for PHS members.

New York City was not the last city that required support from VA. As the numbers of COVID-19 patients rose across the United States, more and more localities were looking to the agency to provide relief but were confused about VA’s capabilities and how to access them.

“As the pandemic progressed and localities experienced sustained periods of accelerated spread of COVID-19, state governments and community health systems were generally unfamiliar with VHA’s response capabilities under its Fourth Mission,” the report explains. “They were also generally unaware of the process for requesting VHA assistance.”

The lack of communication and understanding of VA’s capabilities at the Task Force had essentially trickled down to the local level. Consequently, it was put on VA to create ad-hoc lines of communication with state governments to determine when and how assistance could be given. 

“The Secretary of VA sustained frequent and regular contact with governors throughout the response, with discussions focused on concerns about stress on community health systems, support to state veteran populations and areas where VA response could be helpful,” the report states. “According to the VHA liaison to FEMA NRCC, the Secretary of VA’s direct engagement with governors expedited requests and VA response to crises in several instances.”

The report includes a number of recommendations to improve the nation’s pandemic response going forward. Many of them are directed at improving communication and strengthening VA’s role in emergency preparedness. These include establishing a permanent VA liaison with FEMA’s NRCC, making VA the lead in integrating federal medical data and national biosurveillance capabilities, and performing a postmortem of the interagency COVID-19 response to see what the federal government can do better.