What Is Happening at Louisville’s Veterans Hospital?

hearing-crowd-11-15-16-750pxA public hearing to present the results and hear comments about the draft Environmental Impact Statement for the proposed Replacement VA Medical Center in Louisville was held on November 15 at Christ Church United Methodist on Brownsboro Road. This is just down the road from the favored site on a vacant former farm on the southeast corner of the intersections of the I-264/Waterson Expressway and Route 42/22/Brownsboro Road. Two separate sessions were held: at noon and 6 pm. I attended the earlier session which lasted just shy of three hours. I did not count heads, but I estimate that something fewer than 100 people were in attendance including VA staff, consultants, and reporters. I learned about the hearing earlier from the newspaper. When I got home that afternoon, I found my personal notice in the mail delivered after the fact by the VA to all those who signed up as interested persons.  I do not know if more people would have attended had more timely notice been given in this manner.  The people who did show up were clearly already engaged, seemed to be largely neighbors of the project, and almost uniformly against locating the project at Brownsboro for multiple reasons. I do not know how the evening session went and will limit my comments to the midday session.

A bit of background.
The Robley Rex VA Medical Center replacement process has been a long, contentious, and multiply drawn out process. It is not becoming less so.  I first became engaged in the late 1990s when I began service as a government affairs officer for the University of Louisville. The VA was, and still is an important part of UofL’s clinical, teaching, and research missions.  An alternative was broached at that time that instead of building a separate hospital, that a VA hospital-within-a-hospital could be fashioned as part of University of Louisville Hospital. This concept represented too big a deviation from the tradition and mindset of both the Veterans Administration and its patients to get off the ground. The issue of whether an entirely separate medical system to meet the general medical needs of veterans remains open for discussion– indeed it was brought up at Wednesday’s session! I have written often and at length about the planning process and hearings held to date.

The final selection of possible locations.
Following a typical by-the-book methodical government process, three new potential sites were identified on which to build a new VA Medical Center: downtown near the existing academic medical center, a location referred to as the St. Joseph’s site near the intersection of Old Henry Road and the Jefferson Expressway in far-east Jefferson County, and the ultimately favored Brownsboro Rd. site.  Surveys of and meetings with veterans overwhelmingly favored remaining at the present Zorn Avenue site but were equally overwhelmingly against building a new hospital downtown.  For a variety of other reasons including difficulty and cost of land acquisition and construction, time to occupancy, flood plains, and travel distances for patients and University physicians and trainees alike, the Brownsboro Rd site was chosen and the land purchased.

Not everyone was happy. Was that even ever possible?
From the beginning, there was opposition to the government’s choice. Downtown officials and boosters, and the University pressed strongly for a downtown location for both economic development and convenience reasons. Although the downtown site was eliminated for a variety of reasons, note that convenience for UofL was one of many factors that tilted the site decision to Brownsboro, Additionally, a major factor was that the veterans themselves were very much against a downtown location.  Residents in neighborhoods surrounding the site were and are adamant that the Brownsboro site is improper for the same reasons that residents of any previously predominantly residential neighborhood would likely raise.  I have detailed these before but they include traffic, noise, air and water pollution, construction inconvenience, and any other reason that might be conceived of– some relevant and some not. In the unavoidable tension that arises in these situations the opponents of change are often unkindly characterized as mounting the ‘not-in-my backyard” defense.  The root of this difficult situation requires solving the equation of balancing the interests of the project’s neighbors with a broader community interest in meeting its obligations to the interests of our veterans. I suppose if it didn’t hurt a little in the process, we wouldn’t be doing it right.

Was the meeting held simply to check off the boxes?
There is a legal procedural purpose that the meeting had to fulfill. To build on land, especially federal land, certain requirements must be met including compliance with environmental laws.  Previous surveys of the potential sites did not unearth any deal-breaking findings. However, even people or businesses that claim to dislike government regulations know that one of the very best ways to kill or delay a federal project is to use the government’s own regulatory processes against it. This is how our Ohio River Bridge project was delayed for so long, and why to build the eastern-most bridge, a tunnel had to be built under a “historic” house that no one seems to want to buy or take care of.  So it came to be that in addition to the previous reasonable surveys, the VA was pressed into conducting a more extensive and expensive full-bore Environmental Impact Study (EIS) to look for any potential physical, environmental, cultural, or socioeconomic impacts of building on either the Brownsboro or St. Joseph sites, or of continuing to operate using the existing Zorn Ave site.  The purpose of Wednesday’s meetings was to present the draft form of the EIS to the public and to collect feedback from the public. The VA’s internal conclusion following its full EIS continues to favor building on the Brownsboro site. An executive summary of the Draft EIS is available here, and the complete document is available on the VA’s website.  An audio recording and copies of the presenter’s slides are available.

Less than executive summary of the EIS.
A consultant from the company that did the EIS walked through the various findings under headings required by law including: Need for a Hospital, Aesthetics, Air Quality, Cultural Resources, Geology and Soil, Hydrology and Water Quality, Wildlife and Habitat, Noise, Land Use, Floodplains and Wetlands, Socioeconomics, Community Services, Solid Waste and Hazardous Materials, Transportation and Traffic, Utilities, and Environmental Justice.  In this sense, he was checking off the boxes.  I will not repeat the findings here.  Suffice it to say that no threatened wildlife or plants were found, nor ancient graveyards.  Such impacts as were identified were minor or the same as those that would be relevant no matter what form of multi-use development ultimately occurs on the property.  [A multi-story office building is already immediately adjacent to the site.  It is likely that the land at the site’s entrance where the Goodwill Industries building once stood will see some sort of commercial development.  Aerial photos document the extent of existing commercial development typical of what springs up around major intersections.]  The potential impacts identified were termed minimal or could be reasonably mitigated.  Significantly, there were no meaningful differences in impact between the Brownsboro and the St. Joseph sites except for traffic which would be impacted to a greater extent at the latter.  The difference between the two sites seems moot now because the St. Joseph land is reported to be no longer available. There will of course be unavoidable local disruptions during construction from any development. The effect on aesthetics will depend on the individual observer and range from negligible to major.

Will anything change the minds of opponents?
Suffice it to say that the audience, composed nearly entirely by site neighbors or their allies, was having none of it.  Most of their old arguments against locating a hospital at Brownsboro were raised again with a few new ones I had not heard before. Small-particle air pollution from car exhaust was a new one that seems to have caught on. Threats that doctors would not come out to a Brownsboro hospital was another. Most the concerns that have been raised in this process have been legitimate.  I would likely raise them too if I lived there. Some objections seemed irrelevant.

Care must be taken.
A handful of comments were ill-advised to raise.  I would not have pointed out, as more than one person did, that the VA will not pay taxes on this valuable piece of land, and that the neighbors would be better served by managing the real-estate differently to generate better income so as not to have to pay correspondingly higher taxes themselves. Some developments are presumably thought better than others.  I would not have trivialized the report because it surveyed many Native-American tribes to enquire about possible ancient uses of the land but did no surveying of their undesignated “clientele.”  I would not have made the blanket statement that “no one thinks [Brownsboro] is the appropriate place for this hospital” which allowed one potential client in the audience to interject: “This veteran does.”  I would not have assumed that the single African-American in the room would represent a potential client of the Hospital to be consulted, or who would benefit economically if the replacement hospital was built west of 9th Street.

I am willing to grant that the juxtaposition of references to race and property values by the same speaker were accidental, but I found them inappropriate if not insensitive.  It remains true however, that controlling who can live where, or how land can be developed has been a factor that perpetuates structural racism to this day. Even as I write this, there is opposition to an affordable housing development at Norton Commons. Additionally in Prospect up the road, the city is fighting a proposed affordable living complex for seniors reportedly raising concerns about crime, traffic, and decline in property values.  It may be true that some clients of a Brownsboro VA hospital will not look or dress like the individuals in the neighborhoods surrounding it.  Many will have medical conditions and share the non-medical determinants of health associated with disadvantaged populations.  We can never know what is in a given individual’s heart, and I would like to assume the best, but opponents of locating a VA hospital in their neighborhood must be sensitive to how others might interpret their concerns. An element of social justice unavoidably overlies this matter.

“It’s the traffic, stupid!”
… was a phrase used a few times on Wednesday.  I agree that a worsening in traffic is a valid concern– perhaps even the most justifiable one.  Will traffic be so bad that the hospital cannot be approached by emergency vehicles, patients, or visitors? Will people be able to get to work in an acceptable manner?   Will busses be able to get to the schools in the area?  Paradoxically, the issue of traffic is the both the major one offered and yet the one most amenable to empiric examination and forecasting.

There is no question that traffic on Brownsboro Rd/Rt. 42 is heavy in the early morning and late afternoon.  That is why these times are called rush hours. Thirty years ago, I commuted downtown from Prospect, often more than once a day.  It wasn’t that bad!  River Road was wide open as a quick alternative and there were few traffic lights.  Predictably, with the extensive commercial and residential development of eastern Jefferson and adjacent counties, traffic got worse– not just at Brownsboro, but at Breckenridge, Shelbyville, Taylorsville, Bardstown, and all the other choke points defined by our two circumferential interstate rings.  As I followed the VA site-location discussions, I began to pay attention to traffic. I would drive both early and late through the intersection.  I stood on corners at rush hours and noted that the off ramps mostly cleared with each cycle of the light.  I pulled up Google maps showing traffic at different times of the day. I still use that intersection often. I must confess that there is a disconnect between what I hear from opponents of a hospital there, and what I perceive.   Of course traffic can be a pain there at rush hours, but I do not know if it is worse than what the rest of us endure every day all over the city. I am confident that during most of the day, traffic around the proposed hospital site is pretty reasonable if not clear.

We should not judge current traffic to be the baseline.  The bridge and other construction projects have thrown a monkey wrench into traffic all over the county. The widening of the I-75 exit from the Waterson played havoc with traffic for many months as is the ongoing widening of I-71 approaching the Jefferson Expressway.  A bridge on Rt. 22 was washed out for many months, and that road is blocked for construction even now.  The construction on Rt. 42 further up the road at the site of the tunnel at I-265 has forced people to modify their commuting routes.  I disagree very much with statements that recent modifications to the Brownsboro intersections and their traffic lights, and the addition of the intersection at Westport Road have not improved traffic. Finally, Kentucky’s Department of Transportation has plans on the book to make additional substantial modifications at the Waterson/Brownsboro bridge which were on display at the meeting.

Traffic is an issue, certainly, but even so, does that mean we should put a hold on all future growth in the county? An important take-away from the models exhibited Wednesday is that there is little difference in predicted transit times whether the site is filled with a hospital, or with the other non-hospital, mixed-use development that is certain to happen.  (Tables with projected transit times were made available.)

It is not in the interest of the opponents to overstate the severity of traffic in the area.  On the other hand, our entire community deserves to be convinced by empiric data, properly collected, that the hospital neighbors are not being asked to assume more than their share of an undue or unfair burden.

There are important concerns to agree with.
I share some of the concerns of the neighbors.  Closing and consolidating three community primary care outpatient clinics seems a step away from the concept of primary care provided close to home.  The Brownsboro site is convenient to out-of-towners, but not so much for urban Louisvillians. I tend to agree with one speaker that we should be moving away from a separate healthcare system for veterans and including them in a single payer system with the rest of us.  A smaller number of VA facilities for specific issues related to service and combat can still be made available on a regional basis. Just as with schools, when there is more than one healthcare system and one group is funneled into one of them, it becomes difficult to say they are both equal.

I also agree with some of the speakers that control of veteran healthcare is not a provider entitlement for economic development purposes– not for a downtown medical center or a medical school.  Veterans are not a reward to prop up otherwise failing healthcare providers.  Perhaps it would have been nice, as some suggested, to have put the hospital in West Louisville.  Recent planning for other development projects there have not come to fruition.  I do not remember if in the early stages of the site selection process that any acceptable locations were identified. Neither can I recall that any town meetings were held in that half of the city.  I hope my memory is wrong.  Regardless of where our VA Hospital ended up, frequent access by public transportation is essential.  Not all will arrive from surrounding suburbs or counties.

No one is listening to us!
I cannot agree with all the comments that “no one is listening.” Participants complained bitterly that they were not being listened to, or that their questions were not being responded to usefully.  Since I was not in those loops, I cannot comment on responses to individual queries.  Not being listened to is different animal than not liking the answers being returned. There have been quite a few public forums where plans for the replacement hospital were presented at which there was a lot of action.  It certainly appeared to me, at the very least, that the design and placement of the new hospital was modified to respond to issues raised by the local community.  Modifications were not what was wanted however.  The commenters on Wednesday afternoon aimed the same criticism of not listening on senior federal and local elected officials who represent a larger constituency and who did not adopt the neighbors’ favored positions. The single exception mentioned was Councilwoman Angela Leet, the District 7 official who represents the neighborhoods around the Brownsboro site and who has championed their concerns.

What should we make of these objections?
I do not know how to respond to criticism that the site is too small to house a hospital, or that the site allows little room for future expansion such as “should we have three Vietnam Wars at the same time.”  I have to defer to people who build hospitals and healthcare systems about whether the site is big enough, but the planners should be able to convince an unbiased and unemotional 3d party that their conclusions are reasonable.  I am puzzled at the persistence of about statements assuming a conspiracy to improperly inflate the purchase price of the Brownsboro land by “$3 million,” or in plans to hand over the Zorn Ave. land to a favored developer on which to build McMansions and make big-bucks.  I tried to estimate a time-value of money on the the land transaction some time ago. If the property was first purchased in July 2004 for $7.9 M and sold 8 years later on July 2012 for $12.9 M, the annual rate of return would be a little less than 7%.  This is what I used to hope for in my University retirement accounts. In any event, the transaction was investigated by experts and no illegality was found.  Vague accusations of financial misdoings should not be continued in the “birther” mode.  Advance the claims in court if they are real or stop making them.  I do admit I would be pissed off too if there was a backroom deal that turned the old Zorn site over to the private benefit of some insider. If someone has something, out with it!

Another continuing objection is still being pushed of which I do not understand the relevance to our local matter.  It is pointed out that in recent years, some new VA Hospitals have not been completed on time or on budget– some failing badly.  What else is new about government projects?  The Veterans Administration is rightly under intense scrutiny in Washington and elsewhere.  It deserves to have its feet held to the fire for a host of reasons including access and quality. If the VA and its contractors cannot manage and finance major construction projects in a satisfactory manner, I suggest they fold-up shop altogether and provide vets healthcare in the same manner and places as the rest of us.  Until that happens, I do not see how this objection is relevant to us in Louisville where a new VA hospital is currently needed. I would also turn up the heat on our federal officials to get on the job.  It’s not just at VA hospitals where our tax dollars are being wasted.

The arguments about better quality downtown are specious.
I cannot agree with the oft-mentioned justification for putting a new hospital downtown because the quality of care is better there, or that doctors and facilities there will work well together to provide care to the our Veterans.  As a lifelong academic physician, I would like to make those assumptions too, but at present they are unwarranted if not demonstrably incorrect. The three hospital systems downtown do not play well together. Objective determinations of safety and quality made by both government and private organizations– flawed as they may be– put two of the downtown hospitals at the bottom of the list for both Louisville and Kentucky. I would like to believe this status will change– perhaps even in the time it will take to build a new hospital.  I should point out that quality ratings of our VA have been very good to excellent.

The way VA hospitals staff their hospitals nowadays is different from the times when I was a VA trainee, employee, and physician. The staffing practices of VA hospitals and medical schools has changed.  For example, our medical school could not provide enough primary care physicians or hospitalists to serve its needs so the VA hired these healthcare professionals on its own.  I understand that it has begun to hire some of its own specialists as well.  The Louisville VA contracts for specialty services such as cardiology with other Louisville hospitals. There are excellent hospitals and medical centers which could potentially serve VA patients that are closer to the Brownsboro site than are the downtown hospitals.  A little competition may not be bad in our to provide the best possible care to VA patients.

This objection got under my skin.
I reject categorically the several comments which warned that “physicians,” presumably University Physicians, will not come out to a Brownsboro hospital.  As an albeit retired member of the executive faculty, I felt obliged to make a comment of my own on this matter.  Of course they will come– no matter where the hospital is.  The Veterans Hospital is important to the University of Louisville’s clinical, teaching, and research missions.  Its patients comprise an increasingly important piece of its student and housestaff training programs.  Faculty  physicians who currently serve at the VA will come because it is their duty, their calling. On a more practical basis, they will also come because they or their departments are being paid for clinical services under contracts that require salaried physicians to be on VA hospital grounds. Google Maps tells me that driving time to the Brownsboro site is barely longer that to the Zorn site, and if time finding parking and walking to the hospital are taken into account, door-to-door time from University to Brownsboro is probably shorter!

Is a downtown site really the most convenient? Perhaps not for everyone, but an adjacent VA does not necessarily equate to more physicians spending time in the hospital. In fact, it makes it easier to stay away in a private office or lab.  From a training point of view, being located away from the mothership allows senior housestaff to assume a justifiable and necessary greater degree of independence. There are tradeoffs in these time and distance issues.

Project already delayed?
It occurs to me that one reason not mentioned that Louisville’s project might not be completed on time and within-budget is because of the well-organized opposition to it.  I do not see this opposition retreating.  Indeed, the Crossgate subdivision hired a lawyer who has already asked for a further delay and is rattling the oppositional tool of failure to follow federal regulation. The creation a few years ago of the single purpose advocacy organization “Grow Smart Louisville” has been effective in extracting a pro-downtown policy position from the medical society. Its activities were intended to allow former University President Ramsey an opportunity to reopen negotiations to return the favored site to downtown.  The success of this advocacy and lobbying group has been impressive. Maybe it’s a done-deal, maybe it is not. It seems to me that all interests have had an opportunity to make their cases.

The Vets themselves want to stay at their Zorn home.
Much was made of the well-documented preference of veterans to remain at the Zorn Avenue site. Equally valid is the well documented overwhelming preference of veterans not to have to go downtown. If it is true that hospital experts and engineers believe that the old hospital has exceeded its useful life; and that it is not possible to build a second structure on the site; then the most relevant question has not been put before the Veterans themselves. The choice to be considered is: if staying at Zorn is off the table, would you rather have your new Veterans Administration Medical Center downtown, or at the Brownsboro Road location?

It is probably too late at this point to start over, but in my opinion, based on my attendance at virtually every public forum held in the past 5 or more years, non-urban Louisville veterans would strongly prefer the Brownsboro location.  Since I am unaware that a public forum was ever held west of 9th street, and unaware of how many veterans live in urban Louisville, I have no reason to be confident of where they would prefer to go for their VA care.  I suspect it would be to primary care clinics near their homes or perhaps even to a VA hospital in urban Louisville itself.   If adequate public transportation is available, urban vets might not be unhappy at Brownsboro.  It is not that much further out than Zorn.  I doubt that urban veterans would choose to have to make the trip to the outer-most reaches of the county as at the St. Joseph site, nor should they have to.

What would I do if I were they?
This article was hard to write and is too long because this is not a simple matter.  I am personally unaware of any solution that will make all the players happy.  I believe the Veterans Administration and its consultants and contractors made their best good-faith effort in arriving at a decision to place a new hospital at the Brownsboro Road intersection.  I wish I could say that I would not feel differently if I lived in the Brownsboro neighborhoods, but to be honest with myself, I cannot.  Who would believe me no matter what I claimed?  It is impossible for everyone to be objective in this matter.  It appeared to me that the audience at the morning session last Wednesday was made entirely of residents and their backers who opposed locating a hospital at the site. Virtually all speakers prefaced their comments by claiming to be a veteran or to be a family member of a veteran– but none claimed to use a Veterans Hospital.  There were vanishingly few actual hospital-using veterans in the room.  Nonetheless, one of the last speakers from the audience at the noon session provided a different perspective.  After identifying himself as a Veteran, he offered what he termed a “simple statement: that …”not since I returned from Vietnam, [emotional pause] … not since then have I seen such disastrous non-support of veterans.”  He could not continue and no response from the audience was attempted or possible.  The decision of where to place a new Veterans Hospital is a decision that the community as a whole had to, or yet has to make.  Balancing fairness and justice for both those who live or work near the Brownsboro site, and veterans who have been promised and are due healthcare services requires a judgement worthy of Solomon.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
President, KHPI
19 November 2016


One thought on “What Is Happening at Louisville’s Veterans Hospital?”

  1. I wrote the above over-lengthly article without looking at any of the 24 other articles I wrote since 2011 covering the Veterans Hospital replacement project. I find that I have been saying the same things over and over, just as the proponents of “anywhere but Brownsboro” and “only downtown” been making the same arguments over and over. We seem as a community to be going round and round on the matter. How can we get off the dime?

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