Health Policy

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

The U.S. Senate confirmed former Georgia congressman Doug Collins as the Secretary for the US Department of Veterans Affairs (VA) on Feb. 4 in a comfortable 77 to 23 vote. Collins received votes from every Republican Senator and 23 Democratic Senators.

“The MISSION Act, the VA Accountability and Whistleblower Protection Act and the PACT Act are 3 of the most important veterans laws in recent history,” Collins said during his confirmation hearing. “They received widespread bipartisan support because their focus is exactly where VA’s focus should be: on veteran convenience and accountability for the department.” 

Collins pledged to keep the VA strong but also to expand community care, noting: “I believe you can have both, you can have a strong VA as it currently exists, and you can have the community care aspect.”

Sen. Richard Blumenthal (D-CT), who voted to confirm Collins, urged the secretary to exempt all VA employees from the Trump Administration’s recent hiring freeze; ensure that financial assistance programs for veterans are exempt from funding pauses; work with President Trump to reappoint VA Inspector General Mike Missal, who was removed from office by the President in January; and to ensure all VA employees receive due process amid recent directives from the Office of Personnel Management.

The VA also announced a number of new political appointees, including Chris Syrek, who set to serve as chief of staff; Cheryl Mason is slated to serve as senior advisory to Secretary Collins; and Lynda Davis is set to serve as the chief officer with VA's Veterans Experience Office. No nominations have been made for the Undersecretary of Health to date.

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

Nearly 96,000 US Department of Veterans Affairs (VA) employees—about 20% of the workforce—will be required to return to in-office work by the end of February. The announcement follows a Jan. 20 presidential memorandum, which states agency heads must “take all necessary steps to terminate remote work arrangements and require employees to return to work in-person at their respective duty stations on a full-time basis.” According to a Jan. 28 email sent from the Office of Personnel Management but without a signature, federal employees who refuse will be offered “dignified, fair departure from the federal government utilizing a deferred resignation program.”

The revised VA work policy states “eligible employees must work full-time at their respective duty stations (agency worksites) unless excused due to a disability, qualifying medical condition or other compelling reason.” All nonbargaining unit employees and supervisors who are within 50 miles of their office have until Feb. 24 to return. The VA stated that further guidance is coming for those who live > 50 miles from a facility. 

“VA’s policy allows exceptions for arrangements approved for employees as a reasonable accommodation due to a disability or a qualifying medical condition. Exceptions may also be allowed for military spouses with permanent change of station orders,” according to a VA press release.

“This is a commonsense step toward treating all VA employees equally,” acting VA Secretary Todd Hunter said. “Most VA clinical staff don’t have the luxury of working remotely, and we believe the performance, collaboration and productivity of the department will improve if all VA employees are held to the same standard.” 

The impact on Veterans Health Administration operations remains difficult to determine. The order appears to include personnel providing telehealth care from remote locations, including those at the Clinical Resource Hub (CRH) program. CRH uses a hub and spoke model for limited time primary care and mental health care staffing to cover local clinician vacancies. CRH clinicians have provided > 500,000 veterans with care, averaging > 25,000 encounters in the program’s first year. Started during fiscal year 2020 amid the COVID-19 pandemic, CRH employed 636 clinicians, but more recent data are not available. The VA provided > 28 million telehealth sessions to veterans across all of its telehealth modalities in 2023. Details on how many CRH clinicians and other telehealth practitioners work remotely are also not available.

On Feb. 3, the Office of Personnel Management issued a memo to federal agency heads arguing that any collective bargaining agreements that include teleworking may “conflict with management rights” and therefore may be “unlawful and cannot be enforced.”

The American Federation of Government Employees (AFGE), which represents 800,000 federal employees, disputed the memo. “Federal employees should know that approved union contracts are enforceable by law, and the President does not have the authority to make unilateral changes to those agreements,” AFGE President Everett Kelley said. “AFGE members will not be intimidated. If our contracts are violated, we will aggressively defend them.”

The VA must decide where to put the more than 47,000 workers who may be coming back. According to the Government Accountability Office, “Federal agencies have long struggled to determine how much office space they needed to fulfill their missions efficiently.” The VA has reduced its office space by > 290,000 ft² over the last few years in the National Capital Region alone. 

In his confirmation hearing last month, VA Secretary nominee Doug Collins told lawmakers that, if confirmed, he would “encourage employees to come back to work,” but he also said he would ensure the department was following the White House’s remote work limits. “We’re going to make sure that we get people in there,” he said, “because at the end of the day, it’s about veterans.”

The US Department of Veterans Affairs (VA) has outlined > 300,000 exemptions to the federal hiring freeze to fill essential benefits and health positions. The exempted positions are primarily medical support staff. While the exemptions include pharmacists, physicians and nurses were not included. The day after taking office for the second time, President Trump signed an Executive Order implementing a “freeze on the hiring of Federal civilian employees, to be applied throughout the executive branch” but left many of the details to individual agencies.

Set to last 90 days, the hiring freeze forced Federal agencies to develop plans to reduce the size of their workforces through efficiencies and attrition, Trump said. These agencies would also not be able to hire contractors.

Three days later, however, the VA responded “Following successful implementation of President Trump’s federal hiring freeze, the Department of Veterans Affairs announced several exemptions to the policy. These exemptions clarify the department’s ability to continue filling essential positions that provide health care and other vital services to Veterans and VA beneficiaries.”

This allowed > 304,000 jobs to be exempt from the freeze. Almost 92% of the VA’s 450,000 employees work in health care and health administration and support services. Most of the exemptions involve support staff. No physicians, mental health professionals or nursing positions are on the list. However, it does include 12,622 pharmacists and 5,975 pharmacy technicians. 

The VA worked in accordance with the White House and Office of Personnel Management to develop the updated guidance, Acting Veterans Affairs Secretary Todd Hunter said. In a Jan. 21 memo, Hunter wrote: "Positions critical to delivering care to veterans in the Veteran[s] Health Administration ... are exempted under the category of public safety.”

According to Hunter's memo, no other vacancies that existed as of midday Monday will be filled. Candidates who received job offers before noon on Jan. 20 and have a start date on or before Feb. 8 will be onboarded, while those with a start date after Feb. 8—or one that is undetermined—will have their offers rescinded.

The first Trump Administration began the same way in 2017, initiating a freeze on Federal hiring and receiving a similar response from the VA. In 2017, the hiring of doctors and nurses continued while that freeze was in effect, but onboarding of new support and administrative staff was not. Then-Secretary of Veterans Affairs Dr. David J. Shulkin said, “VA is committed to serving veterans, but at the same time improving efficiency and reducing bureaucracy.” 

The current Executive Order states it “shall not adversely impact veterans’ benefits and does not apply to positions related to public safety” (or military personnel, immigration enforcement, and national security). It also says it does not adversely impact the provision of Social Security, Medicare, or Veterans’ benefits. 

“Under President Trump’s leadership, VA will always do what is necessary to provide America’s Veterans with the benefits and services they have earned. The targeted hiring-freeze exemptions announced today underscore that fact,” said VA Director of Media Affairs Morgan Ackley.  

Some in Congress feel the VA should be doing more, though, and are pushing for an exemption of all VA employees. On Friday, Senate Veterans’ Affairs Committee Ranking Member Richard Blumenthal (D-CT) released a statement on the exemptions. “The latest Administration hiring freeze announcement still falls short. While I’m encouraged the President responded to our concerns by exempting certain VA personnel, only a clear, unequivocal statement to exempt all VA employees from the hiring freeze will reassure me—and veterans—they will receive the care and benefits they need and deserve. The exemptions listed yesterday provide more questions than answers and fail to include key personnel, including Veterans Benefits Administration employees. The Trump Administration is going to try to confuse the issue with a lot of vague assurances. We need a clear commitment every VA employee is exempt—effective immediately. Moreover, the Trump Administration must address the offers it has already rescinded that are now exempt.”

Blumenthal and 24 Democratic Senators also signed a letter to that effect, stressing concerns about the negative impact the hiring freeze will have on the delivery of veterans’ health care and benefits nationwide “if not quickly reversed.” Blumenthal also pressed Doug Collins (R-GA), Trump’s nominee for VA Secretary, to push back against a hiring freeze at VA, if his nomination is confirmed: “This is going to be a first test of your leadership.”

“We’ll take a look at the current levels of employees that we have and where they’re properly located,” Collins said, adding that he was “still examining” the freeze’s impact on the VA. “We will work under the Executive Order [Trump] has given us.” 

Blumenthal argued that the new exemptions exclude a number of critical positions at VA. Among them include all positions at the Veterans Benefits Administration and National Cemetery Administration, which provide veterans’ claims processing, survivor benefits, GI Bill education benefits, and burial scheduling and operations; many nonclinical positions critical to VA hospital functioning, including patient advocates, food service workers, and chaplains; and positions relating to construction project management for new hospitals and clinics, new nursing homes, new cemetery construction, leases, and repairs to existing VA facilities.

The US Department of Veterans Affairs (VA) has outlined > 300,000 exemptions to the federal hiring freeze to fill essential benefits and health positions. The exempted positions are primarily medical support staff. While the exemptions include pharmacists, physicians and nurses were not included. The day after taking office for the second time, President Trump signed an Executive Order implementing a “freeze on the hiring of Federal civilian employees, to be applied throughout the executive branch” but left many of the details to individual agencies.

Set to last 90 days, the hiring freeze forced Federal agencies to develop plans to reduce the size of their workforces through efficiencies and attrition, Trump said. These agencies would also not be able to hire contractors.

Three days later, however, the VA responded “Following successful implementation of President Trump’s federal hiring freeze, the Department of Veterans Affairs announced several exemptions to the policy. These exemptions clarify the department’s ability to continue filling essential positions that provide health care and other vital services to Veterans and VA beneficiaries.”

This allowed > 304,000 jobs to be exempt from the freeze. Almost 92% of the VA’s 450,000 employees work in health care and health administration and support services. Most of the exemptions involve support staff. No physicians, mental health professionals or nursing positions are on the list. However, it does include 12,622 pharmacists and 5,975 pharmacy technicians. 

The VA worked in accordance with the White House and Office of Personnel Management to develop the updated guidance, Acting Veterans Affairs Secretary Todd Hunter said. In a Jan. 21 memo, Hunter wrote: "Positions critical to delivering care to veterans in the Veteran[s] Health Administration ... are exempted under the category of public safety.”

According to Hunter's memo, no other vacancies that existed as of midday Monday will be filled. Candidates who received job offers before noon on Jan. 20 and have a start date on or before Feb. 8 will be onboarded, while those with a start date after Feb. 8—or one that is undetermined—will have their offers rescinded.

The first Trump Administration began the same way in 2017, initiating a freeze on Federal hiring and receiving a similar response from the VA. In 2017, the hiring of doctors and nurses continued while that freeze was in effect, but onboarding of new support and administrative staff was not. Then-Secretary of Veterans Affairs Dr. David J. Shulkin said, “VA is committed to serving veterans, but at the same time improving efficiency and reducing bureaucracy.” 

The current Executive Order states it “shall not adversely impact veterans’ benefits and does not apply to positions related to public safety” (or military personnel, immigration enforcement, and national security). It also says it does not adversely impact the provision of Social Security, Medicare, or Veterans’ benefits. 

“Under President Trump’s leadership, VA will always do what is necessary to provide America’s Veterans with the benefits and services they have earned. The targeted hiring-freeze exemptions announced today underscore that fact,” said VA Director of Media Affairs Morgan Ackley.  

Some in Congress feel the VA should be doing more, though, and are pushing for an exemption of all VA employees. On Friday, Senate Veterans’ Affairs Committee Ranking Member Richard Blumenthal (D-CT) released a statement on the exemptions. “The latest Administration hiring freeze announcement still falls short. While I’m encouraged the President responded to our concerns by exempting certain VA personnel, only a clear, unequivocal statement to exempt all VA employees from the hiring freeze will reassure me—and veterans—they will receive the care and benefits they need and deserve. The exemptions listed yesterday provide more questions than answers and fail to include key personnel, including Veterans Benefits Administration employees. The Trump Administration is going to try to confuse the issue with a lot of vague assurances. We need a clear commitment every VA employee is exempt—effective immediately. Moreover, the Trump Administration must address the offers it has already rescinded that are now exempt.”

Blumenthal and 24 Democratic Senators also signed a letter to that effect, stressing concerns about the negative impact the hiring freeze will have on the delivery of veterans’ health care and benefits nationwide “if not quickly reversed.” Blumenthal also pressed Doug Collins (R-GA), Trump’s nominee for VA Secretary, to push back against a hiring freeze at VA, if his nomination is confirmed: “This is going to be a first test of your leadership.”

“We’ll take a look at the current levels of employees that we have and where they’re properly located,” Collins said, adding that he was “still examining” the freeze’s impact on the VA. “We will work under the Executive Order [Trump] has given us.” 

Blumenthal argued that the new exemptions exclude a number of critical positions at VA. Among them include all positions at the Veterans Benefits Administration and National Cemetery Administration, which provide veterans’ claims processing, survivor benefits, GI Bill education benefits, and burial scheduling and operations; many nonclinical positions critical to VA hospital functioning, including patient advocates, food service workers, and chaplains; and positions relating to construction project management for new hospitals and clinics, new nursing homes, new cemetery construction, leases, and repairs to existing VA facilities.

The US Department of Veterans Affairs (VA) has outlined > 300,000 exemptions to the federal hiring freeze to fill essential benefits and health positions. The exempted positions are primarily medical support staff. While the exemptions include pharmacists, physicians and nurses were not included. The day after taking office for the second time, President Trump signed an Executive Order implementing a “freeze on the hiring of Federal civilian employees, to be applied throughout the executive branch” but left many of the details to individual agencies.

Set to last 90 days, the hiring freeze forced Federal agencies to develop plans to reduce the size of their workforces through efficiencies and attrition, Trump said. These agencies would also not be able to hire contractors.

Three days later, however, the VA responded “Following successful implementation of President Trump’s federal hiring freeze, the Department of Veterans Affairs announced several exemptions to the policy. These exemptions clarify the department’s ability to continue filling essential positions that provide health care and other vital services to Veterans and VA beneficiaries.”

This allowed > 304,000 jobs to be exempt from the freeze. Almost 92% of the VA’s 450,000 employees work in health care and health administration and support services. Most of the exemptions involve support staff. No physicians, mental health professionals or nursing positions are on the list. However, it does include 12,622 pharmacists and 5,975 pharmacy technicians. 

The VA worked in accordance with the White House and Office of Personnel Management to develop the updated guidance, Acting Veterans Affairs Secretary Todd Hunter said. In a Jan. 21 memo, Hunter wrote: "Positions critical to delivering care to veterans in the Veteran[s] Health Administration ... are exempted under the category of public safety.”

According to Hunter's memo, no other vacancies that existed as of midday Monday will be filled. Candidates who received job offers before noon on Jan. 20 and have a start date on or before Feb. 8 will be onboarded, while those with a start date after Feb. 8—or one that is undetermined—will have their offers rescinded.

The first Trump Administration began the same way in 2017, initiating a freeze on Federal hiring and receiving a similar response from the VA. In 2017, the hiring of doctors and nurses continued while that freeze was in effect, but onboarding of new support and administrative staff was not. Then-Secretary of Veterans Affairs Dr. David J. Shulkin said, “VA is committed to serving veterans, but at the same time improving efficiency and reducing bureaucracy.” 

The current Executive Order states it “shall not adversely impact veterans’ benefits and does not apply to positions related to public safety” (or military personnel, immigration enforcement, and national security). It also says it does not adversely impact the provision of Social Security, Medicare, or Veterans’ benefits. 

“Under President Trump’s leadership, VA will always do what is necessary to provide America’s Veterans with the benefits and services they have earned. The targeted hiring-freeze exemptions announced today underscore that fact,” said VA Director of Media Affairs Morgan Ackley.  

Some in Congress feel the VA should be doing more, though, and are pushing for an exemption of all VA employees. On Friday, Senate Veterans’ Affairs Committee Ranking Member Richard Blumenthal (D-CT) released a statement on the exemptions. “The latest Administration hiring freeze announcement still falls short. While I’m encouraged the President responded to our concerns by exempting certain VA personnel, only a clear, unequivocal statement to exempt all VA employees from the hiring freeze will reassure me—and veterans—they will receive the care and benefits they need and deserve. The exemptions listed yesterday provide more questions than answers and fail to include key personnel, including Veterans Benefits Administration employees. The Trump Administration is going to try to confuse the issue with a lot of vague assurances. We need a clear commitment every VA employee is exempt—effective immediately. Moreover, the Trump Administration must address the offers it has already rescinded that are now exempt.”

Blumenthal and 24 Democratic Senators also signed a letter to that effect, stressing concerns about the negative impact the hiring freeze will have on the delivery of veterans’ health care and benefits nationwide “if not quickly reversed.” Blumenthal also pressed Doug Collins (R-GA), Trump’s nominee for VA Secretary, to push back against a hiring freeze at VA, if his nomination is confirmed: “This is going to be a first test of your leadership.”

“We’ll take a look at the current levels of employees that we have and where they’re properly located,” Collins said, adding that he was “still examining” the freeze’s impact on the VA. “We will work under the Executive Order [Trump] has given us.” 

Blumenthal argued that the new exemptions exclude a number of critical positions at VA. Among them include all positions at the Veterans Benefits Administration and National Cemetery Administration, which provide veterans’ claims processing, survivor benefits, GI Bill education benefits, and burial scheduling and operations; many nonclinical positions critical to VA hospital functioning, including patient advocates, food service workers, and chaplains; and positions relating to construction project management for new hospitals and clinics, new nursing homes, new cemetery construction, leases, and repairs to existing VA facilities.

Veterans living in rural areas are often too far away from health care institutions to easily travel to their appointments. Even if they can drive, the cost of gas and other related travel expenses may be too much for some. Telehealth was meant to help relieve that problem, but poor internet access can mitigate its convenience and accessibility for those patients. Two proposals offer solutions. 

In February, Sens. Jon Ossoff (D-GA), Susan Collins (R-ME), and John Thune (R-SD) introduced the Rural Veterans Transportation to Care Act, a bill that would expand eligibility to the US Department of Veterans Affairs (VA) Highly Rural Transportation Grants, a program currently only available to counties with < 7 people per square mile.

“As I’ve sat down with veterans in rural areas across Georgia, one of their key concerns is lack of transportation,” Sen. Ossoff said. “That’s why I’m introducing this bipartisan bill to ensure veterans have more access to transportation services that can bring them to VA clinics and medical centers to get the care they need.”

Amanda Flener and her husband, John, a veteran wounded while serving in Iraq, were driving as long as 3 hours from Fitzgerald, Georgia (population 8900) to attend his medical appointments. In the last 2 years, Flener told the Daily Yonder she had put nearly 72,000 miles on her vehicle. Following hurricane Helene, she said, "We had been driving 30 miles just to get gas to power our generator … and we were fortunate to be able to do that.” 

Telehealth appointments can help fill coverage gaps, Flener said. But even while paying for the most expensive internet plan available in her county, the signal isn't always strong enough. Telehealth care is "progress, for sure," Flener said. "So, we pay for the best Wi-Fi we can get in our area, but it isn't always reliable enough to take the video calls from the VA." 

As a result, veterans and their caregivers could benefit not only from the bipartisan transportation proposal, but also from a decision announced in November. The VA is proposing to eliminate copayments for all VA telehealth services and establish a grant program to fund designated VA telehealth access points in non-VA facilities, with a focus on rural and medically underserved communities.

The program, called Accessing Telehealth through Local Area Stations (ATLAS), would provide funding to organizations — including nonprofits and private businesses — to offer veterans comfortable, private spaces equipped with high-speed internet access and the technology to remotely meet with VA clinicians. Grants would also provide designated funding to train on-site personnel to support the program.

These proposed changes would advance the VA’s and the Biden-Harris Administration’s ongoing efforts to lower costs and expand access to care for veterans. They also could make a life-changing difference for the 2.7 million rural veterans enrolled in VA health care.

According to a 2024 RAND study, just under half of military and veteran caregivers live in a county without a VA facility, and nearly half live in a primary care physician shortage area. For military/veteran caregivers in particular, the survey found, reduced access to support related to the more complicated care some patients require, greater distances to reach opportunities (eg, retail, economic, or social), and even differences in Wi-Fi/broadband internet access may create “unique needs.” The survey found that 24% of rural military/veteran caregivers did not have reliable broadband internet. 

“Waiving copays for telehealth services and launching this grant program are both major steps forward in ensuring veterans can access health care where and when they need it,” said VA Secretary Denis McDonough. “VA is the best and most affordable care in America for veterans — with these steps, we can make it easier for veterans to access their earned VA health care.”

 The rulemaking can be viewed in the Federal Register under public inspection, and is open for comment. The VA anticipates a notice of funding opportunity for this grant program following publication of the final rule.

Veterans living in rural areas are often too far away from health care institutions to easily travel to their appointments. Even if they can drive, the cost of gas and other related travel expenses may be too much for some. Telehealth was meant to help relieve that problem, but poor internet access can mitigate its convenience and accessibility for those patients. Two proposals offer solutions. 

In February, Sens. Jon Ossoff (D-GA), Susan Collins (R-ME), and John Thune (R-SD) introduced the Rural Veterans Transportation to Care Act, a bill that would expand eligibility to the US Department of Veterans Affairs (VA) Highly Rural Transportation Grants, a program currently only available to counties with < 7 people per square mile.

“As I’ve sat down with veterans in rural areas across Georgia, one of their key concerns is lack of transportation,” Sen. Ossoff said. “That’s why I’m introducing this bipartisan bill to ensure veterans have more access to transportation services that can bring them to VA clinics and medical centers to get the care they need.”

Amanda Flener and her husband, John, a veteran wounded while serving in Iraq, were driving as long as 3 hours from Fitzgerald, Georgia (population 8900) to attend his medical appointments. In the last 2 years, Flener told the Daily Yonder she had put nearly 72,000 miles on her vehicle. Following hurricane Helene, she said, "We had been driving 30 miles just to get gas to power our generator … and we were fortunate to be able to do that.” 

Telehealth appointments can help fill coverage gaps, Flener said. But even while paying for the most expensive internet plan available in her county, the signal isn't always strong enough. Telehealth care is "progress, for sure," Flener said. "So, we pay for the best Wi-Fi we can get in our area, but it isn't always reliable enough to take the video calls from the VA." 

As a result, veterans and their caregivers could benefit not only from the bipartisan transportation proposal, but also from a decision announced in November. The VA is proposing to eliminate copayments for all VA telehealth services and establish a grant program to fund designated VA telehealth access points in non-VA facilities, with a focus on rural and medically underserved communities.

The program, called Accessing Telehealth through Local Area Stations (ATLAS), would provide funding to organizations — including nonprofits and private businesses — to offer veterans comfortable, private spaces equipped with high-speed internet access and the technology to remotely meet with VA clinicians. Grants would also provide designated funding to train on-site personnel to support the program.

These proposed changes would advance the VA’s and the Biden-Harris Administration’s ongoing efforts to lower costs and expand access to care for veterans. They also could make a life-changing difference for the 2.7 million rural veterans enrolled in VA health care.

According to a 2024 RAND study, just under half of military and veteran caregivers live in a county without a VA facility, and nearly half live in a primary care physician shortage area. For military/veteran caregivers in particular, the survey found, reduced access to support related to the more complicated care some patients require, greater distances to reach opportunities (eg, retail, economic, or social), and even differences in Wi-Fi/broadband internet access may create “unique needs.” The survey found that 24% of rural military/veteran caregivers did not have reliable broadband internet. 

“Waiving copays for telehealth services and launching this grant program are both major steps forward in ensuring veterans can access health care where and when they need it,” said VA Secretary Denis McDonough. “VA is the best and most affordable care in America for veterans — with these steps, we can make it easier for veterans to access their earned VA health care.”

 The rulemaking can be viewed in the Federal Register under public inspection, and is open for comment. The VA anticipates a notice of funding opportunity for this grant program following publication of the final rule.

Veterans living in rural areas are often too far away from health care institutions to easily travel to their appointments. Even if they can drive, the cost of gas and other related travel expenses may be too much for some. Telehealth was meant to help relieve that problem, but poor internet access can mitigate its convenience and accessibility for those patients. Two proposals offer solutions. 

In February, Sens. Jon Ossoff (D-GA), Susan Collins (R-ME), and John Thune (R-SD) introduced the Rural Veterans Transportation to Care Act, a bill that would expand eligibility to the US Department of Veterans Affairs (VA) Highly Rural Transportation Grants, a program currently only available to counties with < 7 people per square mile.

“As I’ve sat down with veterans in rural areas across Georgia, one of their key concerns is lack of transportation,” Sen. Ossoff said. “That’s why I’m introducing this bipartisan bill to ensure veterans have more access to transportation services that can bring them to VA clinics and medical centers to get the care they need.”

Amanda Flener and her husband, John, a veteran wounded while serving in Iraq, were driving as long as 3 hours from Fitzgerald, Georgia (population 8900) to attend his medical appointments. In the last 2 years, Flener told the Daily Yonder she had put nearly 72,000 miles on her vehicle. Following hurricane Helene, she said, "We had been driving 30 miles just to get gas to power our generator … and we were fortunate to be able to do that.” 

Telehealth appointments can help fill coverage gaps, Flener said. But even while paying for the most expensive internet plan available in her county, the signal isn't always strong enough. Telehealth care is "progress, for sure," Flener said. "So, we pay for the best Wi-Fi we can get in our area, but it isn't always reliable enough to take the video calls from the VA." 

As a result, veterans and their caregivers could benefit not only from the bipartisan transportation proposal, but also from a decision announced in November. The VA is proposing to eliminate copayments for all VA telehealth services and establish a grant program to fund designated VA telehealth access points in non-VA facilities, with a focus on rural and medically underserved communities.

The program, called Accessing Telehealth through Local Area Stations (ATLAS), would provide funding to organizations — including nonprofits and private businesses — to offer veterans comfortable, private spaces equipped with high-speed internet access and the technology to remotely meet with VA clinicians. Grants would also provide designated funding to train on-site personnel to support the program.

These proposed changes would advance the VA’s and the Biden-Harris Administration’s ongoing efforts to lower costs and expand access to care for veterans. They also could make a life-changing difference for the 2.7 million rural veterans enrolled in VA health care.

According to a 2024 RAND study, just under half of military and veteran caregivers live in a county without a VA facility, and nearly half live in a primary care physician shortage area. For military/veteran caregivers in particular, the survey found, reduced access to support related to the more complicated care some patients require, greater distances to reach opportunities (eg, retail, economic, or social), and even differences in Wi-Fi/broadband internet access may create “unique needs.” The survey found that 24% of rural military/veteran caregivers did not have reliable broadband internet. 

“Waiving copays for telehealth services and launching this grant program are both major steps forward in ensuring veterans can access health care where and when they need it,” said VA Secretary Denis McDonough. “VA is the best and most affordable care in America for veterans — with these steps, we can make it easier for veterans to access their earned VA health care.”

 The rulemaking can be viewed in the Federal Register under public inspection, and is open for comment. The VA anticipates a notice of funding opportunity for this grant program following publication of the final rule.

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴

As Veterans Day approaches, stores and restaurants will offer discounts and free meals to veterans. Children will write thank you letters, and citizens nationwide will raise flags to honor and thank veterans. We can never repay those who lost their life, health, or livelihood in defense of the nation. Since the American Revolution, and in gratitude for that incalculable debt, the US government, on behalf of the American public, has seen fit to grant a host of benefits and services to those who wore the uniform.^2,3 Among the best known are health care, burial services, compensation and pensions, home loans, and the GI Bill.

Less recognized yet arguably essential for the fair and consistent provision of these entitlements is a legal principle: the veteran’s canon. A canon is a system of rules or maxims used to interpret legal instruments, such as statutes. They are not rules but serve as a “principle that guides the interpretation of the text.”⁴ Since I am not a lawyer, I will undoubtedly oversimplify this legal principle, but I hope to get enough right to explain why the veteran’s canon should matter to federal health care professionals.

At its core, the veteran’s canon means that when the US Department of Veterans Affairs (VA) and a veteran have a legal dispute about VA benefits, the courts will give deference to the veteran. Underscoring that any ambiguity in the statute is resolved in the veteran’s favor, the canon is known in legal circles as the Gardner deference. This is a reference to a 1994 case in which a Korean War veteran underwent surgery in a VA facility for a herniated disc he alleged caused pain and weakness in his left lower extremity.⁵ Gardner argued that federal statutes 38 USC § 1151 underlying corresponding VA regulation 38 CFR § 3.358(c)(3) granted disability benefits to veterans injured during VA treatment. The VA denied the disability claim, contending the regulation restricted compensation to veterans whose injury was the fault of the VA; thus, the disability had to have been the result of negligent treatment or an unforeseen therapeutic accident.⁵

The case wound its way through various appeals boards and courts until the Supreme Court of the United States (SCOTUS) ruled that the statute’s context left no ambiguity, and that any care provided under VA auspices was covered under the statute. What is important for this column is that the justices opined that had ambiguity been present, it would have legally necessitated, “applying the rule that interpretive doubt is to be resolved in the veteran’s favor.”⁵ In Gardner’s case, the courts reaffirmed nearly 80 years of judicial precedent upholding the veteran’s canon.

Thirty years later, Rudisill v McDonough again questioned the veteran’s canon.⁶ Educational benefits, namely the GI Bill, were the issue in this case. Rudisill served during 3 different periods in the US Army, totaling 8 years. Two educational programs overlapped during Rudisill’s tenure in the military: the Montgomery GI Bill and Post-9/11 Veterans Educational Assistance Act. Rudisill had used a portion of his Montgomery benefits to fund his undergraduate education and now wished to use the more extensive Post-9/11 assistance to finance his graduate degree. Rudisill and the VA disagreed about when his combined benefits would be capped, either at 36 or 48 months. After working its way through appeals courts, SCOTUS was again called upon for judgment.

The justices found that Rudisill qualified under both programs and could use them in any order he wished up to the cap. The majority found no ambiguity in the statute; however, if interpretation was required, the majority of justices indicated that the veteran’s canon would have supported Rudisill. While this sounds like good news for veterans, 2 justices authored a dissenting opinion that questioned the constitutional grounding of the veteran’s canon, noting that the “canon appears to have developed almost by accident.”⁶ The minority opinion suggested that when the veteran’s canon allocates resources to pay for specific veteran benefits, other interests and groups are deprived of those same resources, resulting in potential inequity.⁷

The potential ethical import and clinical impact of striking down the veteran’s canon is serious. It is especially concerning given that in a recent case, the SCOTUS ruling struck down another legal interpretation that also benefited the VA and ultimately veterans: the Chevron deference.⁸ This precedent held that when a legal dispute arises about the meaning of a specific federal agency regulation or policy, the courts should defer to the federal agency’s presumably superior understanding of the matter. The principle places the locus of decision-making with the subject-matter experts of the respective agency rather than the courts.

Ironically, given the legislative purposes of both interpretive principles, their overturning would likely introduce much more uncertainty, variation, and unpredictability in cases involving veteran benefits. This is bad news for both veterans and the VA. Veterans might not prevail as often in court when they have a reasonable claim, leading to more aggressive challenges. In response, the VA would have a heavier and more costly burden of administrative proof to defend sound decisions.⁹ Recently, the VA has tried to reduce the backlog of claims. The inability to have legal recourse to Chevron or Gardener could result in even more delay in adjudicating veterans’ claims that enable them to access benefits and services, already an object of congressional pressure.¹⁰

Courts will continue to debate the issue with another judicial test of the canon on the current SCOTUS docket (Bufkin v McDonough).¹¹ The veteran’s canon was put in place to equalize the power differential between the VA and the veteran: in administrative language, to make it more likely than not that the veteran would prevail when regulations were ambiguous. There are many legal and political rationales for veteran’s canon, including enabling veterans to file claims for service-connected illnesses. The veteran’s cannon helped Vietnam War-era veterans receive VA care while researchers were still studying the sequela of Agent Orange exposure. ¹² The legislative purpose of the veteran’s canon is the same as that of all VA benefits and services commemorated on Veterans Day. As expressed by SCOTUS justices in the wake of World War II, the benefit statutes should be “liberally construed for the benefit of those who left private life to serve their country in its hour of greatest need.”¹³

As Veterans Day approaches, stores and restaurants will offer discounts and free meals to veterans. Children will write thank you letters, and citizens nationwide will raise flags to honor and thank veterans. We can never repay those who lost their life, health, or livelihood in defense of the nation. Since the American Revolution, and in gratitude for that incalculable debt, the US government, on behalf of the American public, has seen fit to grant a host of benefits and services to those who wore the uniform.^2,3 Among the best known are health care, burial services, compensation and pensions, home loans, and the GI Bill.

Less recognized yet arguably essential for the fair and consistent provision of these entitlements is a legal principle: the veteran’s canon. A canon is a system of rules or maxims used to interpret legal instruments, such as statutes. They are not rules but serve as a “principle that guides the interpretation of the text.”⁴ Since I am not a lawyer, I will undoubtedly oversimplify this legal principle, but I hope to get enough right to explain why the veteran’s canon should matter to federal health care professionals.

At its core, the veteran’s canon means that when the US Department of Veterans Affairs (VA) and a veteran have a legal dispute about VA benefits, the courts will give deference to the veteran. Underscoring that any ambiguity in the statute is resolved in the veteran’s favor, the canon is known in legal circles as the Gardner deference. This is a reference to a 1994 case in which a Korean War veteran underwent surgery in a VA facility for a herniated disc he alleged caused pain and weakness in his left lower extremity.⁵ Gardner argued that federal statutes 38 USC § 1151 underlying corresponding VA regulation 38 CFR § 3.358(c)(3) granted disability benefits to veterans injured during VA treatment. The VA denied the disability claim, contending the regulation restricted compensation to veterans whose injury was the fault of the VA; thus, the disability had to have been the result of negligent treatment or an unforeseen therapeutic accident.⁵

The case wound its way through various appeals boards and courts until the Supreme Court of the United States (SCOTUS) ruled that the statute’s context left no ambiguity, and that any care provided under VA auspices was covered under the statute. What is important for this column is that the justices opined that had ambiguity been present, it would have legally necessitated, “applying the rule that interpretive doubt is to be resolved in the veteran’s favor.”⁵ In Gardner’s case, the courts reaffirmed nearly 80 years of judicial precedent upholding the veteran’s canon.

Thirty years later, Rudisill v McDonough again questioned the veteran’s canon.⁶ Educational benefits, namely the GI Bill, were the issue in this case. Rudisill served during 3 different periods in the US Army, totaling 8 years. Two educational programs overlapped during Rudisill’s tenure in the military: the Montgomery GI Bill and Post-9/11 Veterans Educational Assistance Act. Rudisill had used a portion of his Montgomery benefits to fund his undergraduate education and now wished to use the more extensive Post-9/11 assistance to finance his graduate degree. Rudisill and the VA disagreed about when his combined benefits would be capped, either at 36 or 48 months. After working its way through appeals courts, SCOTUS was again called upon for judgment.

The justices found that Rudisill qualified under both programs and could use them in any order he wished up to the cap. The majority found no ambiguity in the statute; however, if interpretation was required, the majority of justices indicated that the veteran’s canon would have supported Rudisill. While this sounds like good news for veterans, 2 justices authored a dissenting opinion that questioned the constitutional grounding of the veteran’s canon, noting that the “canon appears to have developed almost by accident.”⁶ The minority opinion suggested that when the veteran’s canon allocates resources to pay for specific veteran benefits, other interests and groups are deprived of those same resources, resulting in potential inequity.⁷

The potential ethical import and clinical impact of striking down the veteran’s canon is serious. It is especially concerning given that in a recent case, the SCOTUS ruling struck down another legal interpretation that also benefited the VA and ultimately veterans: the Chevron deference.⁸ This precedent held that when a legal dispute arises about the meaning of a specific federal agency regulation or policy, the courts should defer to the federal agency’s presumably superior understanding of the matter. The principle places the locus of decision-making with the subject-matter experts of the respective agency rather than the courts.

Ironically, given the legislative purposes of both interpretive principles, their overturning would likely introduce much more uncertainty, variation, and unpredictability in cases involving veteran benefits. This is bad news for both veterans and the VA. Veterans might not prevail as often in court when they have a reasonable claim, leading to more aggressive challenges. In response, the VA would have a heavier and more costly burden of administrative proof to defend sound decisions.⁹ Recently, the VA has tried to reduce the backlog of claims. The inability to have legal recourse to Chevron or Gardener could result in even more delay in adjudicating veterans’ claims that enable them to access benefits and services, already an object of congressional pressure.¹⁰

Courts will continue to debate the issue with another judicial test of the canon on the current SCOTUS docket (Bufkin v McDonough).¹¹ The veteran’s canon was put in place to equalize the power differential between the VA and the veteran: in administrative language, to make it more likely than not that the veteran would prevail when regulations were ambiguous. There are many legal and political rationales for veteran’s canon, including enabling veterans to file claims for service-connected illnesses. The veteran’s cannon helped Vietnam War-era veterans receive VA care while researchers were still studying the sequela of Agent Orange exposure. ¹² The legislative purpose of the veteran’s canon is the same as that of all VA benefits and services commemorated on Veterans Day. As expressed by SCOTUS justices in the wake of World War II, the benefit statutes should be “liberally construed for the benefit of those who left private life to serve their country in its hour of greatest need.”¹³

As Veterans Day approaches, stores and restaurants will offer discounts and free meals to veterans. Children will write thank you letters, and citizens nationwide will raise flags to honor and thank veterans. We can never repay those who lost their life, health, or livelihood in defense of the nation. Since the American Revolution, and in gratitude for that incalculable debt, the US government, on behalf of the American public, has seen fit to grant a host of benefits and services to those who wore the uniform.^2,3 Among the best known are health care, burial services, compensation and pensions, home loans, and the GI Bill.

Less recognized yet arguably essential for the fair and consistent provision of these entitlements is a legal principle: the veteran’s canon. A canon is a system of rules or maxims used to interpret legal instruments, such as statutes. They are not rules but serve as a “principle that guides the interpretation of the text.”⁴ Since I am not a lawyer, I will undoubtedly oversimplify this legal principle, but I hope to get enough right to explain why the veteran’s canon should matter to federal health care professionals.

At its core, the veteran’s canon means that when the US Department of Veterans Affairs (VA) and a veteran have a legal dispute about VA benefits, the courts will give deference to the veteran. Underscoring that any ambiguity in the statute is resolved in the veteran’s favor, the canon is known in legal circles as the Gardner deference. This is a reference to a 1994 case in which a Korean War veteran underwent surgery in a VA facility for a herniated disc he alleged caused pain and weakness in his left lower extremity.⁵ Gardner argued that federal statutes 38 USC § 1151 underlying corresponding VA regulation 38 CFR § 3.358(c)(3) granted disability benefits to veterans injured during VA treatment. The VA denied the disability claim, contending the regulation restricted compensation to veterans whose injury was the fault of the VA; thus, the disability had to have been the result of negligent treatment or an unforeseen therapeutic accident.⁵

The case wound its way through various appeals boards and courts until the Supreme Court of the United States (SCOTUS) ruled that the statute’s context left no ambiguity, and that any care provided under VA auspices was covered under the statute. What is important for this column is that the justices opined that had ambiguity been present, it would have legally necessitated, “applying the rule that interpretive doubt is to be resolved in the veteran’s favor.”⁵ In Gardner’s case, the courts reaffirmed nearly 80 years of judicial precedent upholding the veteran’s canon.

Thirty years later, Rudisill v McDonough again questioned the veteran’s canon.⁶ Educational benefits, namely the GI Bill, were the issue in this case. Rudisill served during 3 different periods in the US Army, totaling 8 years. Two educational programs overlapped during Rudisill’s tenure in the military: the Montgomery GI Bill and Post-9/11 Veterans Educational Assistance Act. Rudisill had used a portion of his Montgomery benefits to fund his undergraduate education and now wished to use the more extensive Post-9/11 assistance to finance his graduate degree. Rudisill and the VA disagreed about when his combined benefits would be capped, either at 36 or 48 months. After working its way through appeals courts, SCOTUS was again called upon for judgment.

The justices found that Rudisill qualified under both programs and could use them in any order he wished up to the cap. The majority found no ambiguity in the statute; however, if interpretation was required, the majority of justices indicated that the veteran’s canon would have supported Rudisill. While this sounds like good news for veterans, 2 justices authored a dissenting opinion that questioned the constitutional grounding of the veteran’s canon, noting that the “canon appears to have developed almost by accident.”⁶ The minority opinion suggested that when the veteran’s canon allocates resources to pay for specific veteran benefits, other interests and groups are deprived of those same resources, resulting in potential inequity.⁷

The potential ethical import and clinical impact of striking down the veteran’s canon is serious. It is especially concerning given that in a recent case, the SCOTUS ruling struck down another legal interpretation that also benefited the VA and ultimately veterans: the Chevron deference.⁸ This precedent held that when a legal dispute arises about the meaning of a specific federal agency regulation or policy, the courts should defer to the federal agency’s presumably superior understanding of the matter. The principle places the locus of decision-making with the subject-matter experts of the respective agency rather than the courts.

Ironically, given the legislative purposes of both interpretive principles, their overturning would likely introduce much more uncertainty, variation, and unpredictability in cases involving veteran benefits. This is bad news for both veterans and the VA. Veterans might not prevail as often in court when they have a reasonable claim, leading to more aggressive challenges. In response, the VA would have a heavier and more costly burden of administrative proof to defend sound decisions.⁹ Recently, the VA has tried to reduce the backlog of claims. The inability to have legal recourse to Chevron or Gardener could result in even more delay in adjudicating veterans’ claims that enable them to access benefits and services, already an object of congressional pressure.¹⁰

Courts will continue to debate the issue with another judicial test of the canon on the current SCOTUS docket (Bufkin v McDonough).¹¹ The veteran’s canon was put in place to equalize the power differential between the VA and the veteran: in administrative language, to make it more likely than not that the veteran would prevail when regulations were ambiguous. There are many legal and political rationales for veteran’s canon, including enabling veterans to file claims for service-connected illnesses. The veteran’s cannon helped Vietnam War-era veterans receive VA care while researchers were still studying the sequela of Agent Orange exposure. ¹² The legislative purpose of the veteran’s canon is the same as that of all VA benefits and services commemorated on Veterans Day. As expressed by SCOTUS justices in the wake of World War II, the benefit statutes should be “liberally construed for the benefit of those who left private life to serve their country in its hour of greatest need.”¹³