Is this the last word?
The Record of Decision dated May 30, 2017 and signed by the Secretary of the U.S. Department of Veterans Affairs on October 12 makes it sound like an easy decision. The 23-page document contains only three words or phrases in the text highlighted by the VA to draw attention to the central logic of the decision.
Page 1. “The purpose of the proposed project is to provide Louisville area Veterans with facilities of sufficient capability (functional) and capacity to meet their current and projected future health care needs.”
“The proposed project is needed because the current hospital and CBOCs [outpatient clinics] are operating at maximum capacity and are unable to accommodate the projected increase in the regional Veteran population. The configuration and condition of the existing 63•year-old Louisville VAMC facility offers limited options to expand to meet these needs, and parking at the Zorn Avenue VAMC is insufficient.”
Page 7. “For these reasons, VA does not view the general locations or sites suggested in public comments as reasonable alternatives warranting additional investigation and detailed evaluation in the EIS [Environmental Impact Statement]. Chapter 2 of the Final EIS includes a detailed description of the site selection process, as well as the reasons for eliminating the Fegenbush and Downtown sites, and for not reconfiguring the existing VAMC on Zorn Avenue.”
It has not been a straight path!
Easy or not, the path to this decision to replace the Robley Rex VA Hospital beginning in the late 1990s to the present has been acrimoniously disputed and successfully delayed. I and others have written about the selection process extensively. My own series of some 25 articles beginning in 2011 can be accessed here, and I offer links to recent coverage by others at the end of this article. My perspective is shaped by my VA Hospital experiences as a medical student; resident; VA-employed physician; senior ward- and teaching attending; and both local and national lobbyist for medical schools and teaching hospitals. (The current VA Secretary, David J. Shulkin, a physician, likely spent some of his training time in VA facilities also.)
The Record of Decision (ROD) summarizes the past process, referring often to the full Environmental Impact Study (EIS), and other required and requested evaluations that were performed. During the many hearings and other opportunities for public comment, many objections and recommendations were made. The ROD uses the bulk of its pages to describe plan alterations made to accommodate issues raised and to mitigate predictable issues that will arise during the construction phase and afterwards.
Considerable attention was given to traffic and transportation–the most often and perhaps most credible objection raised by opponents of the site. I made several field trips to the relevant intersections over the past few years and occasionally looked current traffic displays on Google Maps. I find traffic there comparable to other intersections along the Waterson Expressway, and unless there has been an accident, not the doomsday situation sometimes described. Traffic modeling studies do predict an increase in traffic after construction that would be most troubling at the evening rush hour compared to leaving the site undeveloped. However, these projections are not significantly different from what would have resulted if the multi-use Midlands development had gone forward before the VA bought the land. Continued development along the I-71 and Route 42 corridors eastward will also put additional stresses on these intersections no matter what happens on the former Brownsboro farm. Indeed, additional major road changes had been considered before the VA was even in the picture. According to the ROD, these were not built because of the successful traffic relief afforded by the new intersection at Westport Road and the slip exit from the Waterson to Route 22, and because of objection from the adjacent neighborhoods now protesting the location of the Hospital. Change is going to happen and a variety of the possible road improvements will be needed in any event. Several examples are suggested in the report.
Scope of project downsized.
For reasons that are not given, the plan to place a separate building on the site for a Veterans Benefit Authority regional office building was removed from the overall project. This will decrease potential traffic to the site and require a smaller parking facility. More frequent public transportation to the hospital and its outpatient clinics will be needed which should also decrease individual car traffic.
Time and money squandered.
Much was made by opponents of the Brownsboro site was the (irrelevant?) claim that the government paid $3 million more for the land than it was worth. This claim is subject to different interpretation or significance. In any event, that sum is a pittance compared to the many $millions of excess expenditure and years lost due to the same kind of successful organized opposition used to delay the building of the new East End Bridge, and by those hoping to profit from economic development in a different location.
Who is happy and who is not?
There is no place to build a new VA hospital that would have made everyone happy. This was always going to be a trade-off of competing interests. Most disappointed in the decision are the immediate neighbors of the Brownsboro site in Crossgate, Northgate, other nearby developments, and those who have to commute through the intersection. While some of these folks may genuinely have the best interest of veterans in mind, a driving factor is almost certainly of the “not in my backyard” variety for both the building and its patients. Also unhappy are those who hoped to cash in on the economic development or social justice that could accrue to a different party of the county, or for that matter at least one adjacent county. These latter include downtown boosters and the University of Louisville. Disappointed too are vets who would have liked to have the new hospital built on its current Zorn Avenue location. That latter possibility was never in the cards.
Those who are probably the most happy are vets who wanted to see a new hospital in their lifetimes, those in the large majority who wanted anywhere except downtown Louisville, and vets who have to drive in from adjacent counties or Indiana. It is made clear in the ROD that a major factor for the placement of the new hospital was for the overall convenience of the veterans themselves, the employees who take care of them, and the University of Louisville which uses the hospital for teaching, training, and research purposes. Those are not bad motivations. No doubt our local and federal elected leadership is also happy to get this matter off their plates.
What will happen now?
The hospital is not built yet. Some expect organized local opponents such as the single-issue, non-profit, Grow Smart Louisville to bring a lawsuit. Congress actually has to come up the money. It will be several years– 2024 if we are lucky– before the hospital opens its doors. An entire generation of veterans will never see it. A lot can happen before then. If I were King, and because the majority of patients served in VA hospitals are being treated for the same aliments as the rest of us, I would blend the medical care of veterans into a well-coordinated healthcare system that serves all. There would still be a need for some highly specialized services to deal with more specific war-related issues, but even they might benefit from being more centralized rather than in smaller, more widely distributed centers. I do not see this dream coming true any time soon.
What must happen now.
Nonetheless, the VA system needs to evolve in parallel with the rest of our national health system. We must have more openness and accountability in measures related to quality and utilization. At the very least we can require the VA hospital system to be subject to the same reporting systems as civil hospitals to assure that our veterans– who often do not have any other option– have access to safe, effective and efficient medical care. If it must be separate, it must be equal or better.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
Oct 24, 2017