Honoring the service and sacrifice of America's veterans on Veterans Day, 2025.

— 641 — 20 DEPARTMENT OF VETERANS AFFAIRS Brooks D. Tucker MISSION STATEMENT The Department of Veterans Affairs (VA) is the primary provider of health care, benefits, and memorial affairs for America’s veterans and their families. The VA has the noble responsibility to render exceptional and timely support and services with respect, compassion, and competence. The veteran is at the forefront of every VA process and interaction. The VA must continually strive to be recognized as a “best in class,” “Veteran-centric”1 system with an organizational ethos inspired by and accountable to the needs and problems of veterans, not subservient to the parochial preferences of a bureaucracy. OVERVIEW At the end of the Obama Administration, the VA was held in low esteem both by the veterans it served and by the employees who served these former warriors. Eroding morale caused by the downstream effects of a health care access crisis in 2014 led to the resignation of Secretary Eric Shinseki and extensive oversight investigations by Congress from 2015–2016. By 2020, however, the VA had become one of the most respected U.S. agencies. This significant progress was due in part to the leadership of Secretary Robert Wilkie (2018–2021) and his team of political appointees and career senior executives, many of them veterans, who led the effort to ensure that the VA became “Veteran-centric” in its governance decisions and fostered a more positive work environment. This mindset translated into a department that was better attuned to employees’ and veterans’ needs and experiences in the daily operations of health care, benefits, — 642 — Mandate for Leadership: The Conservative Promise and memorial affairs. During that period, the VA received the largest number of watershed congressional authorizations to reform its health care and benefits that it had received since the post–Vietnam War years along with historic increases in annual appropriations, which have tripled since the last full year of the George W. Bush Administration. The current VA leadership team of Biden appointees has adopted some of their predecessors’ governance processes. However, they have not sustained the previous Administration’s commitment to a genuine “Veteran-centric” philosophy, most nota- bly with respect to the delivery of health care, and harbor a bias toward expanding the unionized federal employee workforce that has not always been aligned with a focus on “Veteran-centric” care. There also is growing concern in Congress and the veteran community that the VA is poorly managing and in some cases disregarding provisions of the VA MISSION [Maintaining Internal Systems and Strengthening Integrated Out- side Networks] Act of 20182 that codify broad access for veterans to non-VA health care providers. Efforts to expand disability benefits to large populations without adequate planning have caused an erosion of veterans’ trust in the VA enterprise. Additionally, the current VA leadership is focusing very publicly on “social equity and inclusion” within departmental policy discussions toward ends that will affect only a small minority of the veterans who use the VA. For the first time, the VA is allowing access to abortion services, a medical procedure unrelated to military service that the VA lacks the legal authority and clinical proficiency to perform. In addition to continuing the grotesque culture of violence against the child in the womb, these sociopolitical initiatives and ideological indoctrinations distract from the department’s core missions. DEPARTMENTAL HISTORY Following the Civil War, state veterans homes were established to provide med- ical and hospital treatment for all injuries and diseases. When the United States entered World War I in 1917, “Congress established a new system of Veterans benefits, including programs for disability compensation, insurance for service personnel and Veterans, and vocational rehabilitation for the disabled”3 that was overseen by three different federal programs: the Veterans Bureau, the Department of the Interior’s Bureau of Pensions, and the National Home for Disabled Volunteer Soldiers. In 1921, Congress combined those programs into the Veterans Bureau. Following World War II, a national VA hospital system, much of which remains operational today, was established to care for millions of returning veterans. Following the Vietnam War, the VA’s federally owned and operated hospital network expanded again to meet the needs of the volunteer and draftee population. In the past two decades, the VA has purposely transitioned to leasing medical prop- erties rather than building expensive new facilities that can take years to complete and often experience budget overruns. As the nature of health care has evolved

— 644 — Mandate for Leadership: The Conservative Promise In sum, the VA for the foreseeable future will experience significant fiscal, human capital, and infrastructure crosswinds and risks. Budgets are at historic highs, and with a workforce now above 400,000, the VA is contending with a lack of new veteran enrollees to offset the declining population of older veterans. Recruitment of medical and benefits personnel has become more challenging. Veterans are migrating from the northern states to the southern and western states for retirement and employment. Meanwhile, VA information technol- ogy (IT) is struggling to keep pace with the evolution of patient care and record keeping. Consequently, VA leaders in the next Administration must be wise and courageous political strategists, experienced managers to run day-to-day oper- ations more effectively, innovators to address the changing veteran landscape, and agile “fixers” to mitigate and repair systemic problems created or ignored by the present leadership team. VETERANS HEALTH ADMINISTRATION (VHA) Needed Reforms l Rescind all departmental clinical policy directives that are contrary to principles of conservative governance starting with abortion services and gender reassignment surgery. Neither aligns with service-connected conditions that would warrant VA’s providing this type of clinical care, and both follow the Left’s pernicious trend of abusing the role of government to further its own agenda. l Focus on the effects of shifting veteran demographics. At least during the next decade, the VA will experience a significant generational shift in its overall patient population. Of the approximately 18 million veterans alive today, roughly 9.1 million are enrolled for VA health care, and 6.4 million of these enrollees use VA health care consistently. These 6.4 million veterans are split almost evenly between those who are over age 65 and those who are under age 65, but the share of VA’s health care dollars is spent predominantly in the over-65 cohort. That share increases significantly as veterans live longer and use the VHA system at a higher rate. VHA enrollments of new users are increasingly at risk of being exceeded by the deaths of current enrollees, primarily because significant numbers of the Vietnam generation are reaching their life expectancy. The generational transition from Vietnam-era veterans to post-9/11 veterans will take several years to complete. The ongoing demographic transition is a catalyst for needed assessments of how the VA can improve the delivery of care to a numerically declining and differently dispersed national population — 645 — Department of Veterans Affairs of veterans—a population that is more active, reaching middle age or retirement age, and migrating for lifestyle and career reasons. At the center of the VHA’s evolution during this generational transition is an ongoing tension, some of it politically contrived, between Direct Care for Veterans provided from inside the VHA system and Community Care for Veterans who are referred to private providers participating in the VHA’s two Community Care Networks (CCNs). In recent years, the budget for Community Care has grown as demand from veterans has risen sharply, sometimes outpacing the budgets for Community Care at individual VAMCs. The Trump Administration made Community Care part of its “Veteran- centric” approach to ensure that veterans would be able to participate more fully in their health care decisions and have options if or when the VHA was unable to meet their needs. The Biden Administration has watered down that effort, has sought various procedural ways to slow the rate of referrals to private doctors, and at some facilities is reportedly manipulating the Community Care access standards required by the VA MISSION Act of 2018. If the makeup of Congress is favorable in 2025, the next Administration should rapidly and explicitly codify VA MISSION Act access standards in legislation to prevent the VA from avoiding or watering down the requirements in the future. First and foremost, a veterans bill of rights is needed so that veterans and VA staff know exactly what benefits veterans are entitled to receive, with a clear process for the adjudication of disputes, and so that staff ensure that all veterans are informed of their eligibility for Community Care. Currently, veterans are not routinely and consistently told that they are eligible for Community Care unless they request information or are given a referral. l To strengthen Community Care, the next Administration should create new Secretarial directives to implement the VA MISSION Act properly. Sections for consideration and areas for reform include the following: 1. Sections 101 and 103 (Community Care eligibility for access standards and the best medical interest of the veteran). 2. Section 104 (Community Care access standards and standards for quality of care).

— 655 — Department of Veterans Affairs ENDNOTES 1. U.S. Department of Veterans Affairs, Veterans Health Division, VHA Directive 1003, “VHA Veteran Patient Experience,” April 14, 2020, pp. 1 and B-1. 2. S. 2372, VA Mission Act of 2018, Public Law No. 115-182, 115th Congress, June 6, 2018, https://www.congress. gov/115/plaws/publ182/PLAW-115publ182.pdf (accessed January 30, 2023). 3. U.S. Department of Veterans Affairs, VA History Office, “VA History,” last updated May 27, 2021, https://www. va.gov/HISTORY/VA_History/Overview.asp (accessed January 28, 2023). 4. 38 U.S. Code § 1116, https://www.law.cornell.edu/uscode/text/38/1116 (accessed January 28, 2023). 5. S. 3373, Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act of 2022 (Honoring Our PACT Act of 2022), Public Law No. 117-168, 117th Congress, August 10, 2022, https://www. congress.gov/117/plaws/publ168/PLAW-117publ168.pdf (accessed January 28, 2023). 6. H.R. 2471, Consolidated Appropriations Act, 2022, Public Law No. 117-103, 117th Congress, March 15, 2022, Division S, Title I, https://www.congress.gov/117/plaws/publ103/PLAW-117publ103.pdf (accessed March 18, 2023). Known variously as the Department of Veterans Affairs Nurse and Physician Assistant Retention and Income Security Enhancement Act and the VA Nurse and Physician Assistant RAISE Act. 7. See note 5, supra. — 657 — Section Four THE ECONOMY The next Administration must prioritize the economic prosperity of ordi- nary Americans. For several decades, establishment “elites” have failed the citizenry by refusing to secure the border, outsourcing manufacturing to China and elsewhere, spending recklessly, regulating constantly, and generally controlling the country from the top down rather than letting it flourish from the bottom up. The proper role of government, as was articulated nearly 250 years ago, is to secure our God-given, unalienable rights in order that we might enjoy the pursuit of happiness, the benefits of free enterprise, and the blessings of liberty. Finding the right approach to trade policy is key to the fortunes of everyday Americans. In Chapter 26, president of the Competitive Enterprise Institute Kent Lassman and former White House director of trade and manufacturing policy Peter Navarro debate what an effective conservative trade policy would look like. Lass- man argues that the best trade policy is a humble, limited-government approach that would encourage free trade with all nations. He maintains that aggressive trade policies involve an increased government role that future leftist Administra- tions will utilize to push “climate change” and “equity”-based activism. Focusing more on gross domestic product (GDP) growth than on median income, he writes that “people mistakenly believe that U.S. manufacturing and the U.S. economy are in decline” when in truth “American manufacturing output is currently at an all-time high.” Meanwhile, we continue to experience “record-setting real GDP” despite our “long-run decline in manufacturing employment.” Lassman does not think that an aggressive U.S. trade policy would lead to more manufacturing jobs. Rather, he writes, “Federal Reserve research shows” that the