Jennifer Steinhauer

Under a new law, known as the Mission Act, veterans who need to drive for at least 30 minutes to a government-operated veterans hospital — rather than 40 miles under old standards — can receive primary care and mental health services outside the department’s traditional system. The switch for the 9 million enrollees in the program for veterans was the biggest shift in U.S. health care since the passage of the Affordable Care Act under President Barack Obama, potentially moving tens of thousands from government services to private care.

Officials at Optum Public Sector Solutions, the third-party administrator for the new health plan for veterans across a large portion of the United States, recently told congressional aides that they were unable to guarantee a health care network large enough to accommodate all the veterans who might seek care under the new system. They suggested that more money — perhaps as much as $75 million — would be needed to help build a larger network. The contracts for their region, complete with seven renewable one-year options through 2026, were worth a potential total of $55.2 billion. Their region includes 36 states in the eastern half of the United States, as well as the District of Columbia, Puerto Rico and the Virgin Islands.

“The $75 million figure is an early estimate based on nothing more than guesswork,” said Christina Mandreucci, a spokeswoman for the veterans department. “While there are almost always costs involved in contract modification, both VA and Optum believe they will be a fraction of that total, with future estimates driven by network utilization data.”

Two people with knowledge of the contracts said that Optum, a subsidiary of insurance giant UnitedHealth Group, was chosen in part because it was the lowest bidder for the regions, perhaps because its network was smaller than other companies.

Before the Mission Act was passed, the Department of Veterans Affairs had contracted with Optum Public Sector Solutions to manage veterans’ health care, replacing TriWest Healthcare Alliance, a popular system that maintains control of veteran private health care in the west. But officials at the company have told aides to lawmakers on Capitol Hill that under the new rules for care outside the department, they are unable to guarantee a network large enough to accommodate all those who subsequently may seek that care.

“The VA is now working to make modifications that will optimize the contracts for compatibility with the Mission Act,” Mandreucci said. “There is nothing unusual about this process, which is often required on various VA contracts in response to other legislative and regulatory developments.”

She added, “This issue is not affecting patient care in any way, as VA and Optum have mechanisms in place to ensure that high quality and safe care and services can be coordinated when needed.”

Since June, when the act officially took effect, Trump has repeatedly portrayed the transition as a mission accomplished.

“People said it couldn’t be done, ‘VA Choice,’ ” Trump said last week during a rally in Tupelo, Mississippi. “Our veterans were waiting on line for days and weeks sometimes.”

Now, under the new program, Trump said, veterans have the option to “go out, get a doctor, we pay the bill, and they don’t have to wait six weeks, four weeks, two weeks. We have people waiting in line, they weren’t very sick, by the time they saw the doctor, they were terminally ill. Now, they go on, and they go, and they go outside and they find a doctor, and we take care of our great veterans.”

That characterization of the problems in the federal veterans health system before the new standards is overstated, and the president has presented the new program as further along than it is.

Both the veterans department and Optum seem to be assessing in real time the market for care outside the traditional system and are not certain how many veterans will be choosing the system under the new standards. Veterans have long sought options to federal system in rural areas far from the hospital centers. However, those are also areas lacking in community-based health care providers, and that is where Optum is said to be most challenged, both in terms of doctors and the urgent care clinics that are also part of new menu of options for veterans who want to go outside the traditional network.

The percentage of veterans now eligible for what officials refer to as “community care” — about 8% of the 7 million treated annually — will rise to 20% to 30% under the new standards in the Mission Act, according to Department of Veterans Affairs officials.

“Optum is committed to ensuring our nation’s veterans can access the quality care they need, when and where they need it,” said Aaron Albright, a spokesman for Optum. “We are successfully building out a broad, high-performance care provider network and will continue to collaborate with the VA to expand on this critical work in full support of the Mission Act.”

Officials from Optum came to Capitol Hill several weeks ago to update staff members, who were startled to hear that the network as envisioned under the original contract would unlikely be able to meet the needs of a major influx of new veterans. A few weeks later, officials from the veterans department traveled to Capitol Hill to discuss the Mission Act and its progress, and it became clear that Optum did not have enough providers in the right locations, said one Senate official, surprising many in the room.

“Veterans aren’t getting the care the Trump administration promised to them under its access standards because VA and Optum can’t agree on contracting issues that should have been settled months ago,” said Sen. Jon Tester, the senior Democrat on the Senate Veterans’ Affairs Committee. “Optum needed to dot the I’s and cross the T’s before — not after — outbidding other networks to serve veterans. VA made promises to veterans when it developed these new access standards, and now it needs to follow through.”

This article originally appeared in

Early Problems as Trump's Signature Veterans' Health Plan Rolls Out

WASHINGTON — A health program for veterans that President Donald Trump heralds as a triumphant success is struggling to make its network of doctors as large as required to meet an aggressive expansion of care outside the Department of Veterans Affairs health facilities, officials said. The company managing the new program in a majority of the states said it would probably need millions of dollars more to meet the plan’s coverage goals.

Now, Pete Buttigieg, a former Navy intelligence officer who served in Afghanistan, is taking a notably more modulated and targeted approach as he seeks his party’s nomination, reflecting both the experiences of a post-9/11 generation of veterans and the sensibilities of a nation that largely reveres them, even as it is increasingly wary of military adventures abroad.

In the Democratic debate Tuesday night, Buttigieg, the mayor of South Bend, Indiana, did not so much brag about his military experience as leverage it to outflank his rivals in a heated exchange over President Donald Trump’s decision to abandon the Kurds in northern Syria. He listened as Beto O’Rourke praised his military service, and later told the former Texas congressman not to lecture him on gun control.

“I don’t need lessons from you on courage, political or personal,” Buttigieg said.

The strong showing in the Ohio debate was in no small part reliant on Buttigieg’s background as a service member and his ability to unpack questions about foreign policy and military intervention better than his opponents that night. His experience as a veteran, paired with his criticism of American conflicts over the last two decades, has the potential to appeal to a broad cross section of moderates and liberals alike.

“Kerry’s generation had difficulty in separating policies from the troops,” Buttigieg said in an interview this summer, referring to the 2004 Democratic nominee and Vietnam veteran. “He was an anti-war vet and in some ways I am too. For my generation, it makes total sense that he would be against that war and serve. For his generation, you had to choose a side.”

Buttigieg’s military record is only one facet of how he is increasingly trying to distinguish himself from liberal rivals like Sen. Elizabeth Warren and moderates like former Vice President Joe Biden.

At 37, roughly half the age of those other two Democrats, Buttigieg is running on a message of generational change and arguing that he would bring fresh thinking to economic problems facing middle-class and working-class people. He holds a mix of moderate and liberal views, making him harder to caricature as a leftist candidate. As a Midwesterner, he is trying to appeal to rural white Americans, voters who backed both Barack Obama and Donald Trump for president, and others in battlegrounds like Wisconsin and Iowa. And he would make history as the nation’s first openly gay president.

With significant financial resources due to robust fundraising, Buttigieg has the money for advertising to highlight his biography as he seeks to become better known among voters and improve his poll numbers, which are still modest.

His service as a Naval Reserve officer — he decided to join the military after a 2008 campaign trip to Iowa for Obama — is one part of that biography that he is weaving into a larger political narrative concerned broadly with public service, America’s inherent inequities and the toxic bifurcation of the nation’s politics.

In many ways, he is the supersized version of the veteran Democrats who prevailed in the 2018 midterm elections. They campaigned as sensible, moderate antidotes to both Republican incumbents and more liberal Democrats, unburdened by the past foreign policy mistakes of either party.

Democratic Reps. Mikie Sherrill of New Jersey, Jason Crow of Colorado, Chrissy Houlahan of Pennsylvania and Elaine Luria of Virginia — who were among the new veterans in Congress who wrote an influential op-ed in The Washington Post advocating the impeachment of Trump over Ukraine matters — all ran in part on their military history.

“We shared many of the same values,” Sherrill said in an interview, “since we worked in the same types of places and environments and we served the country in similar ways.”

While veterans voted disproportionately for Trump in 2016 and have generally approved of his performance more than the general population, some support from prominent Republican veterans has cracked in recent days over the Syria policy.

And in the debate Tuesday night, Buttigieg hammered Trump for pulling U.S. troops out of the country and exposing Kurdish allies to attack. “When I was deployed, I knew one of the things keeping me safe was the fact that the flag on my shoulder represented a country known to keep its word,” he said. “Our allies knew it and our enemies knew it. You take that away, you are taking away what makes America America.”

Former Sen. Bob Kerrey of Nebraska, a Democrat who served in Vietnam, said Buttigieg’s military service reinforced his credibility among veterans. “For vets, that he has experienced and understands that culture makes him one of us,” Kerrey said. “There must be millions of veterans who might disagree with everything he supports but might vote for him for that reason alone.”

Buttigieg’s military service has been a ballast for his candidacy, an essential addition to a biography that, in addition to training on assault weapons, includes a Harvard degree, a Rhodes Scholarship, a stint at a fancy consulting firm and marriage to another man.

It’s a part of his résumé he refers to often, casually but artfully dropping it into conservations on a wide range of policies, generally avoiding the battle bravado of previous veteran candidates and bristling at the suggestion that he had higher office in mind when he signed up.

“I began to feel that I was part of a problem if I didn’t serve,” said Buttigieg, who has frequently recounted how during his trip to Iowa, he became acutely aware that the burdens of military service were falling too heavily on too small a slice of the population. “It’s something that I want people to know. It’s an important part of my story and how I come at the world. I also don’t want people to think I am flogging it, presenting myself as a Navy SEAL or career war hero. My turn came and I did my part.”

Buttigieg was accepted into the Navy Reserve’s direct commission officer program in September 2009. The program, which was developed during the Cold War to attract applicants with special expertise, draws accomplished private-sector civilians who want to serve and keep their day jobs, and fast-tracks them to officer status.

“It was the most stable moment of my life to date,” said Buttigieg, who joined when he was working as a consultant for McKinsey &amp; Co. He was elected mayor of his hometown in 2011 while still in the Reserve, and took an unpaid seven-month leave in 2014 to deploy to Afghanistan, where he served as a counterintelligence officer.

“He felt guilty that communities were emptying out and he wasn’t doing anything at all,” said David W. Barno, a retired Army lieutenant general and former top commander in Afghanistan. “This was a catalytic moment for him. His deployment probably gave him a wake-up. It is a unique place in society where you have a white male who works for someone African-American 10 years older than you from a very different cultural background. He talks about the leveling experience of being in the military.”

It was a theme that would stick, even after Buttigieg was honorably discharged in 2017.

While in Afghanistan, Buttigieg spent many days gingerly making his way through Kabul on convoy security in a heavily armed Land Cruiser. “I thought I was sent to Kabul for my experience in bureaucratic politics,” he said, “but because I was rifle qualified, it was my ability to drive a vehicle with two long guns” that got him that assignment, he said. “At the end of the day my usefulness was as a driver more than an elected officer.”

Thomas Gary, a senior petty officer at Naval Station Great Lakes near Chicago, who worked with Buttigieg before he became mayor, said he kept his politics low key. “I didn’t even know he was a Democrat until he won his primary for mayor,” he said. “That wasn’t something he advertised. I do remember when he was sworn in, I wanted to make sure we from the unit showed a little love for this accomplishment.”

Buttigieg spent his down time in Kabul tooling around the base’s cigar club, playing in a joint division fantasy football league and visiting Afghan orphanages. He would retreat back to his barracks late at night to make calls back to South Bend. “I wanted to be a good enough officer so even my roommate had no idea what my day job was,” Buttigieg said.

Google made this wish unattainable. “When I got there, I may have had more to prove to demonstrate that I was there to get the job done,” he said.

As a candidate, Buttigieg does not lead with his veteran status, but rather sprinkles it through his conversation, a hint of flavor that is meant to be noticed, and the result of careful mental spade work meant to extrapolate his experiences into his political identity.

In a January television interview shortly after dipping his toe in the 2020 waters, he referred to himself as “a millennial, Episcopalian Maltese-American gay veteran mayor.” Asked if he was worried about being targeted by conservatives over his sexual orientation, he responded: “I’ve been deployed in a war zone. I am used to dealing with attacks.”

At the end of one debate he summed himself up this way: “Nothing about politics is theoretical for me. I’ve had the experience of writing a letter to my family, putting it in an envelope, marking it ‘just in case,’ and leaving it where they would know where to find it in case I didn’t come back from Afghanistan.”

Buttigieg was discharged before the Clinton-era policy of “don’t ask don’t tell” was repealed and gay men and lesbians were allowed to serve openly in the armed forces. He refers to the experience of serving without telling as informing his views on the Trump administration’s current ban on transgender service members.

In a Democratic debate last month, Buttigieg said he had feared that coming out would be a “career-ending professional setback,” but that his deployment had reinforced the notion “that you only get to live one life, and I was not interested in not knowing what it was like to be in love any longer.”

“So, I just came out,” he said.

“A big part of being in the military is the social side,” he said. “Knowing that as we sat around talking about life off base, there was so much I had to filter with people I was learning to trust in some deep ways, there were times I wish I could have kicked back and talked about my personal life in a fuller way.”

“That, I think, creates a level of stress that service people don’t need,” he added.

Some of his policy positions stem directly from his time in the military, he has said. For example, his national service plan would expand voluntary public service programs like AmeriCorps and the Peace Corps, and add new ones focused on combating climate change, addressing mental health and addiction, and providing caregiving for older people, especially in low-income communities.

The proposal draws from his sense that serving in the military brought him closer to Americans of different backgrounds, and that young people should have those opportunities outside of war zones. “It shapes my take on service and policy,” he said of his time in the military, “but I think it’s important to let people know that’s part of my story without beating them over the head with it.”

He makes clear connections between his time in Afghanistan and his views on U.S. policy in the Middle East, which include support for pulling troops out of Afghanistan but criticism of Trump’s desire to withdraw from Syria.

His service background “lets us get out of this framework that one party is focused on national security,” Buttigieg said. “I think even progressive Democrats are excited about the idea of people who have served.”

At the same time, Buttigieg is well attuned to potential criticism that his service was not steeped enough in conflict. “He spent at least 100 trips outside the wire,” said Barno, the former top commander in Afghanistan. “He was not a guy who sat behind a computer. He was out of the vehicle. He took some pretty interesting lessons from that. You can say he was not in direct combat, but he was out there where 99% of Americans weren’t.”

A Post-9/11 Veteran as President? Pete Buttigieg Makes His Case

The last time a Democratic presidential nominee was trying to unseat a Republican incumbent, he arrived at the podium at the Democratic National Convention to tout his military service, his strongest credential: “I’m John Kerry and I’m reporting for duty.”

In the Democratic debate Tuesday night, Buttigieg, the mayor of South Bend, Indiana, did not so much brag about his military experience as leverage it to outflank his rivals in a heated exchange over President Donald Trump’s decision to abandon the Kurds in northern Syria. He listened as Beto O’Rourke praised his military service and later told the former Texas congressman not to lecture him on gun control, a subject he often discusses in the context of the weapons he carried in Afghanistan.

Buttigieg’s campaign seems to have these two generations — his and Kerry’s — in mind as he tries to distinguish himself from liberal rivals like Sen. Elizabeth Warren and moderates like former Vice President Joe Biden. His military record is just one facet of how he is drawing distinctions.

At 37, roughly half the age of those other two Democrats, Buttigieg is running on a message of generational change and arguing that he would bring fresh thinking to economic problems facing middle-class and working-class people. He holds a mix of moderate and liberal views, making him harder to caricature as a leftist candidate. As a Midwesterner, he is trying to appeal to rural white Americans, voters who backed both Barack Obama and Donald Trump for president. And he would make history as the nation’s first openly gay president.

And in the debate Tuesday night, Buttigieg hammered Trump for pulling U.S. troops out of the country and exposing America’s Kurdish allies to an attack by Turkey. “When I was deployed, I knew one of the things keeping me safe was the fact that the flag on my shoulder represented a country known to keep its word,” he said.

Buttigieg’s military service has been a ballast for his candidacy, an essential addition to a biography that, in addition to training on assault weapons, includes a Harvard degree, a Rhodes scholarship, a stint at a fancy consulting firm and marriage to another man.

It’s a part of his résumé he refers to often, casually but artfully dropping it into conversations on a wide range of policies, generally avoiding the battle bravado of previous veteran candidates and bristling at the suggestion that he had higher office in mind when he signed up.

“His deployment probably gave him a wake up,” said David W. Barno, a retired Army lieutenant general and former top commander in Afghanistan. “It is a unique place in society where you have a white male who works for someone African-American 10 years older than you from a very different cultural background. He talks about the leveling experience of being in the military.”

Buttigieg began his military service before the Clinton-era policy of “don’t ask don’t tell” was repealed and gay men and lesbians were allowed to serve openly in the armed forces. He refers to the experience of serving without telling as informing his views on the Trump administration’s current ban on transgender service members.

“A big part of being in the military is the social side,” he said in an interview. “Knowing that as we sat around talking about life off base, there was so much I had to filter with people I was learning to trust in some deep ways. There were times I wish I could have kicked back and talked about my personal life in a fuller way.”

Some of his policy positions stem directly from his time in the military. For example, his national service plan would expand voluntary public service programs like AmeriCorps and the Peace Corps, and add new ones focused on combating climate change, addressing mental health and addiction, and providing caregiving for older people, especially in low-income communities.

A View Outside the Wire Lifts Buttigieg Onstage

“You felt like you were a piece of meat,” said Foster, 34, who retired as a sergeant. “Standing in line at the registration desk, I was getting comments from the male patients behind me, looking me up and down. It was a major source of discomfort.”

The treatment was the same at the Veterans Affairs medical center in Murfreesboro, Tennessee, where Foster moved after living in Texas. At that point she gave up, and opted for her husband’s insurance outside the department. “They need to make the facilities not feel like an old soldier’s home,” Foster said.

An entrenched, sexist culture at many veterans hospitals is driving away female veterans and lags far behind the gains women have made in the military in recent years, veterans and lawmakers of both parties say. Although the Department of Veterans Affairs has scrambled to adjust to the rising population of female veterans and has made progress — including hiring more women’s health care providers, fixing basic privacy problems in the exam rooms and expanding service to women in rural areas — sexual harassment at department facilities remains a major problem.

Women say it is galling that such a demeaning atmosphere persists, especially for the roughly 30 percent of female veterans who have reported being harassed or assaulted while serving in the military. That number includes Sen. Martha McSally, R-Ariz., who spoke at a congressional hearing last week about being raped by a superior officer while serving in the Air Force.

“Changing the culture has been an ongoing, overarching goal,” said Dr. Patricia Hayes, chief consultant for Women’s Health Services at the veterans agency. “We want women veterans to feel respected and safe and secure.”

At a recent hearing with veterans agency officials on Capitol Hill, Rep. John Carter, R-Texas, described the treatment of female constituents trying to obtain VA health care. “It’s like a construction site,” he said.

Carter cited the same medical center in Texas that Foster had used — and noted that the Women’s Trauma Recovery Center within it was moved last year to a female-only facility in Waco so that women, who said they feared for their safety, could receive treatment without facing harassment.

Rep. Will Hurd, R-Texas, was visibly frustrated as he described women abandoning the center in his district because of harassment. “This is the biggest concern I hear from female veterans,” he said.

While the number of women using veteran health services has tripled since 2000 — to about 500,000 from 159,810 — they still make up only 8 percent of all users of health care at the VA. Officials expect that the number will increase. Two million women are in the U.S. veteran population, or about 10 percent, and yet they make up 16 percent of the active-duty military force.

“I believe that we still have a tsunami wave of women vets coming in,” Hayes said.

For now, many female veterans say they are made to feel as if they do not belong at the VA, as they describe front-desk employees asking for a husband’s Social Security number when they check in or being passed over for items like complimentary coffee, which employees say are “for vets.”

“It’s hard to walk into a place and feel like everyone is looking at you wondering why you are there,” said Kristen Rouse, 45, founding director of the NYC Veterans Alliance, who described a sense of loss every time she glanced at the department’s motto affixed to her center in New York City: “To care for him who shall have borne the battle and for his widow, and his orphan.” Her organization supports changing the motto.

“Over the 24 years I have served my country, I have never been any of those,” said Rouse, who remains a reservist in the Army. “And I never will be.” (That portion of the motto, coined by President Abraham Lincoln, is now the subject of legislation.)

Some centers, like the one in Washington, have removed benches from entryways so that men no longer have a place to linger and badger women, or have created separate facilities, like the one in Texas. Every center now has at least two providers focused on women’s health, and nearly 6,000 providers have been trained in the practice; about 98 percent of them are women.

While the VA is still trying to address the needs of pregnant veterans — the centers do not provide full obstetrics care on site — many of the centers across the country now have baby showers around Mother’s Day, offering diapers and other baby supplies.

Yet the culture remains an impediment for many.

Brandy Baxter, who served as a senior airman in the Air Force, loves the care she receives at the women’s health clinic through the Veterans Affairs center in Dallas. But she hates the elevator ride to get there.

“The male vets give me the once over with their eyes,” she said. “I look them right in the eye, just to tell them, ‘I’m checking your height, your weight, your skin color — just in case I need to report you.’ ”

This year, the House Veterans Affairs Committee will establish a task force to address women’s health care, and harassment issues are expected to be front and center. “This is about the physical transformation of our facilities,” said Rep. Mark Takano, D-Calif., the new chairman of the committee.

A model for what women’s health care can be is on display at the Jesse Brown VA Medical Center in Chicago, where the vast majority of doctors and staff members are women. The five exam rooms and waiting area are only for women, and beyond offering basic health care, the center offers women a number of programs like a golf team, a weight loss group and art therapy.

“I think women veterans really want programming that speaks to their entire identity,” said Jenny Sitzer, coordinator for women at the center.

Staff members wear badges that read, “My name is not ‘Hey baby,’ ” and banners all over the campus feature the faces of female veterans describing the pain of being harassed on their way through the broader VA.

Lori Brown, 58, is grateful for all these services, but most of all for the ability to walk into the medical center without facing harassment, and to have only women for her care. “I can allow myself to be who I am in front of the doctor or nurse and not be intimidated by men,” said Brown, who was an Army sergeant.

Many other challenges face the VA, like a shortage of providers for specialty services. Fertility treatments remain another area of complaint. Only women are eligible for treatment, and they must be married to men and have their infertility linked to an injury, exposure or other problem that occurred during their service.

Many women do not use the medical facilities because they lack child care, which the department is largely not able to provide. Another issue is reaching homeless female veterans, a serious problem that also affects the male population.

Women also have mental health care needs — over 40 percent of female veterans who use the VA are diagnosed with at least one mental health condition, compared with about 25 percent of men.

Bills touching on these issues are expected to come up in this Congress, and some veterans’ organizations have made services for women a top legislative priority, especially Iraq and Afghanistan Veterans of America, all in the name of making the VA a better place for women.

“One must be persistent,” Hayes said. “Culture change does not happen overnight. We want to continue to get the message to women that we want you here.”

This article originally appeared in <a href="https://www.nytimes.com/2019/03/12/us/politics/women-veterans-harassment.html" id="8eff68fa-810f-3ab1-a4f6-0a995464673d">The New York Times</a>.

Treated Like a 'Piece of Meat': Female Veterans Endure Harassment at the VA

Corey Foster spent her Army career caring for wounded troops, both as a flight medic in the Iraq War and at Walter Reed hospital, so she looked forward to one of the most celebrated benefits of military service — health care for life from the Department of Veterans Affairs. Then she walked through the door at a VA medical center in Temple, Texas.

“Changing the culture has been an ongoing, overarching goal,” said Dr. Patricia Hayes, chief consultant for Women’s Health Services at the veterans agency.

“Changing the culture has been an ongoing, overarching goal,” said Dr. Patricia Hayes, chief consultant for women’s health services at the veterans agency.

“Changing the culture has been an ongoing, overarching goal,” said Dr. Patricia Hayes, chief consultant for women’s health services at the veterans agency. “We want women veterans to feel respected and safe and secure.”

“It’s hard to walk into a place and feel like everyone is looking at you wondering why you are there,” said Kristen Rouse, 45, who described a sense of loss every time she glanced at the department’s motto affixed to her center in New York City: “To care for him who shall have borne the battle and for his widow, and his orphan.”

“One must be persistent,” Hayes said. “Culture changes does not happen overnight. We want to continue to get message to women that we want you here.”

Now, nearly a generation after the Sept. 11, 2001, attacks, the oldest and largest veterans’ service organizations — known colloquially as “the Big Six” — are seeing their influence diluted, as newer, smaller organizations focused on post-9/11 veterans compete for money, political influence and relevance.

The newer organizations reflect cultural shifts in a smaller community of younger and increasingly diverse veterans who are replacing the older, predominantly male veterans — many of them having served because of a draft for now long-ago wars.

The scores of upstarts include Student Veterans of America, which advocates on education and job issues; Team Red, White and Blue, which promotes service and “camaraderie” events; and Iraq and Afghanistan Veterans of America, which focuses on the specific health and employment challenges those who served in those two wars face.

Leaner and more financially efficient than their predecessors, these newer veterans’ organizations focus on issues such as education and job training rather than on brick-and-mortar meeting spaces for veterans to gather or on resources spent lobbying in Washington.

In addition, many officials of the newer organizations say, their goals are to integrate veterans back into civilian communities where they feel misunderstood and have lost ties, while helping civilians who have had little contact with veterans — active-duty troops make up less than 1 percent of the U.S. population — understand their experiences.

As older veterans die, so, too, do the VFW halls, scores of which have shuttered in recent years. While accurate membership numbers are hard to ascertain because many veterans pay dues to several organizations, a shrinking veteran population overall has caused memberships to fall and some groups to restructure.

“The young vets are saying we need to do things differently with a different emphasis,” said Chuck Hagel, a former defense secretary and Vietnam veteran who is associated with a small organization, HillVets, that helps veterans find staff jobs on Capitol Hill. “The Vietnam vet is a different kind of vet than Afghan or Iraq War vets; they were draft vets and they wanted in and out. Most veterans today are married with families, and that means new demands, new interests and new pressures.”

At times, the politically progressive leaders of some of the organizations — many from the Vietnam era — take positions that appear out of step with more socially conservative members from previous wars. This has irritated Robert Wilkie, the Veterans Affairs secretary, who views these as unwelcome partisan positions, said several agency and veterans’ group officials.

Last April, Wilkie hosted a breakfast for veterans’ service organizations that included representatives not just of the traditional Big Six, but also the Independence Fund and Concerned Veterans for America, which is financed by Charles and David Koch, who have backed conservative causes.

The Koch-supported group was instrumental in ousting the last head of the department. It has also been pushing for more health care to take place outside the VA system, with the first step beginning soon under a sweeping new law. Their voices were welcomed by House Republicans as they passed the measure this year.

At a hearing last month on Capitol Hill, some Democrats suggested that Wilkie was ignoring the opinions of traditional organizations on this law. “A lot of VSOs have talked to me about the communication within the VA,” said Sen. Jon Tester of Montana, the ranking Democrat on the Senate veteran committee. “It’s not where it needs to be.”

Wilkie made his position clear. “Half of our veterans are now under the age of 65,” he said, “which means they have different cares, they have different interests. What I have done in my short time is actually open the aperture to the table at the Department of Veterans Affairs to bring in veterans who are not traditionally part of the system.”

The shifts, while perhaps inevitable, leave some worrying that the hard work of pressing for the complicated and expensive health care needs, and other issues, will lack a generation of new leaders.

“These smaller groups don’t do policy advocacy while the Big Six have been carrying all the water,” said Kristofer Goldsmith, an assistant director for policy and government affairs at the Vietnam Veterans of America. “The average vet has no idea what these groups are doing on their behalf. They have a free T-shirt from Red, White and Blue but don’t realize my 72-year-old boss with emphysema walks around Capitol Hill advocating for them on the GI Bill.”

The first large veterans’ service organizations, the Grand Army of the Republic and the United Confederate Veterans, arose after the Civil War, with new ones forming after each conflict to serve veterans lacking services.

While there are thousands of nonprofit veterans’ organizations registered with the IRS, the majority of power has been consolidated among the Big Six: Disabled American Veterans; Veterans of Foreign Wars; American Legion; Paralyzed Veterans of America; AMVETS; and Vietnam Veterans of America, which was developed after Vietnam veterans were turned away from other organizations.

According to a study this year by the Center for a New American Security, a nonpartisan policy research center in Washington, nonprofits that serve veterans generate about $3.6 billion in annual revenue.

While the older organizations control roughly 68 percent of total income in this market, the recent growth has been dominated by large post-9/11 organizations, which have grown in excess of 15 percent per year, compared with the 2 percent income growth of the Big Six. The study also found that post-9/11 organizations save their money at a rate almost 2.5 times greater than pre-9/11 organizations.

A relatively new entry, the Wounded Warrior Project, has set a new model for advocacy organizations, raising money from outside the veterans’ community and funding research and services rather than infrastructure. The group is widely viewed as having finally recovered from a major spending scandal in 2016.

“They figured out how to raise money from outside the vets’ community better than anyone else,” said Emma Moore, one of the authors of the Center for a New American Security report. “The Big Six are struggling with overhead. As the veteran population shrinks, how they end up dealing with the overhead of maintaining buildings and their structures is yet to be determined.”

Through grants, the Wounded Warrior Project also marries legacy Big Six organizations with newcomers to build coalitions around issues like toxic exposure, which brings post-9/11 veterans into advocacy, and legacy groups into the future.

“Congress still listens to them,” said Phillip Carter, a senior policy researcher at the RAND Corp. who specializes in military and veterans’ issues, describing the continuing clout of the Big Six. “Members and staff understand the political throw weight of veterans’ groups based on their large membership and the degree to which they command public respect.”

But when it comes to forming laws, some groups are clearly on the rise, like Student Veterans of America, which played a significant role in drafting a new GI Bill. These groups, lacking the large governance structures of the old veterans’ service organizations, tend to be faster on their advocacy feet.

Outside Washington, the contrasts between the groups is stark. Many of the old VFW halls remain outposts of fellowship over beer, while younger veterans prefer community centers with healthier and more practical assets, like Wi-Fi, child care and yoga classes. In many cases, social media has replaced physical spaces as a place where veterans congregate.

Many of the new groups steer away from lobbying on Capitol Hill, and have turned instead to community services, running races and other activities meant not to connect veterans to one another as much as to the rest of the communities they have rejoined.

“The epidemic of alienation and loneliness in society writ large is magnified in the vets’ community,” said Bana Miller, a spokeswoman for Team Red, White and Blue, which engages veterans in community service and physical activities.

“Many post-9/11 vets served five, 10, 15 years, and they are looking for connection and community and support,” she said. “We are key to getting people out into their communities and taking what they learned from their service, doing things together shoulder to shoulder to build deep bonds with other people.

“Our organization is not necessarily in the advocacy space,” she added. “We work toward mental health solutions via physical and social activity.”

Traditional veterans’ organizations say this new focus does not replace theirs.

“We get bills passed,” said Kayda Keleher, associate director of national legislative service for the Veterans of Foreign Wars of the United States. “We provide financial assistance to cover bills for veterans who were attending a college that shut down. We provide scholarships and fellowship opportunities, our National Home for Children, and so much more. Those are our strengths and our legacy that will keep us around.”

The greatest demonstration of the power across the spectrum from old and new groups, as well as the Koch-backed organization that has the Trump administration’s collective ear, will be on display next year as Congress carefully examines major changes to health care services for veterans stemming from a large bill passed last year.

“Veteran organizations can be like Sears, using the same business model with diminishing returns,” Carter said. “Or, they can reinvent themselves and their business models to remain viable, and focus on issues that appeal to all generations to remain relevant.”

This article originally appeared in <a href="https://www.nytimes.com/2019/01/04/us/politics/veterans-service-organizations.html" id="b39aa740-fee4-32d0-a75c-e76c4dffd592">The New York Times</a>.

Veterans' Groups Compete With Each Other, and Struggle With the VA

WASHINGTON — For generations, Veterans of Foreign Wars and American Legion posts have been as integral to American political culture as pancake breakfasts, town squares and state fairs. In advocating for veterans — among the country’s most revered and coveted voters — the groups have wielded unquestioned power on Capitol Hill and inside the White House.

WASHINGTON — Has no one told these people about the free candy?

When former Gov. John Hickenlooper of Colorado dropped out of the presidential race Thursday, he made a point of noting that people were all but begging him to run for the Senate. Hickenlooper, who had previously dismissed a Senate run, said he would now give the idea “some serious thought,” evincing all the enthusiasm of a bride mulling boiled versus baked potatoes for the reception.

The fact that a currently underemployed Democrat who was at 0% to 1% in the polls is now treating a chance to serve in the most elite legislative body in the country as a massive booby prize is a remarkable statement about the institution.

There are reasons to be turned off: The lack of a substantive legislative agenda. Gruesome and unending partisanship. The death of earmarks that, for so many years, fueled projects on the home front. The eroding power of the Senate committees.

But in the words of former Rep. Beto O’Rourke on Thursday, has the Senate really become not “good enough”?

O’Rourke, a Democrat who came fairly close to edging out Sen. Ted Cruz of Texas in 2018, was arguing that running for Senate again in 2020 would not be as good for his hometown El Paso or for the country as running for president — even though his candidacy is struggling.

Steve Bullock, the popular governor of Montana and perhaps his party’s only chance at grabbing a Senate seat in that state in 2020, is also choosing to hang on to his low-polling White House bid. This week, too, Stacey Abrams, a Democratic star who ran unsuccessfully for governor of Georgia in 2018, said she would spend 2020 working to prevent voter suppression instead of seeking the presidency or challenging Sen. David Perdue in his first reelection campaign.

“Being a senator isn’t the job it used to be,” said Jennifer Duffy, a senior editor for The Cook Political Report. “Little is ever accomplished, despite the acknowledgment that there is much to do. These days, the Senate is a great job for someone who enjoys banging his or her head against a wall.”

Yes but. It’s. Still. The. Senate. Where else can you roll into work in an SUV that someone else is driving, stop by the conveniently located barber or private gym down the hall from the office, enjoy reasonably tasty prepared lunch three times a week and amble into hearings and meetings while someone else carries your briefing notes? You get to bypass airport security to catch a flight that someone other than yourself has spent the last hour on the phone securing for you. On the Senate floor there is that deep, aforementioned desk full of candy, which members get to gnaw on while chewing over the latest judicial nominee. And all this for $174,000 per year, plus benefits.

And unlike representatives in the House, individual senators can still wield enormous power — perhaps not to get things done, but at least to prevent them. Ask Sen. Rand Paul, R-Ky., who has built an entire Senate career out of single-handedly preventing his colleagues from passing even basic legislation by standing against the unanimous consent rules that grease the wheels of the Senate.

In 2020, Republicans also face a hard time finding top-tier candidates for the Senate. The party so far hasn’t lured Gov. Chris Sununu of New Hampshire to run against Sen. Jeanne Shaheen; President Donald Trump has talked up his former campaign manager, Corey Lewandowski, but he is not precisely Everett Dirksen. Even in open Republican seats, the interest is minimal. Secretary of State Mike Pompeo has so far remained unconvinced that the seat in Kansas of Pat Roberts, who is retiring, would be a better gig than his current one. That has left Republicans contending with conservative gadfly turned perpetual candidate Kris Kobach, who last year did the impossible, losing the Kansas governorship to a Democrat.

For Democrats, this is a high-stakes exercise. To retake control of the Senate, Democrats will need to pick up either three or four seats in 2020, depending on which party wins the White House. There are currently 34 Senate seats up for grabs, 22 of them held by Republicans. In every imaginable scenario — Trump wins or loses, Democrats hold the House or lose it — taking back the Senate would be a boon for the party and its policy agenda, even if that is simply stopping Sen. Mitch McConnell of Kentucky, the majority leader, from continuing to reshape the entire American judiciary.

“The two most important things about running for the Senate and winning, far more important than any others, are the Supreme Court and closing Mitch McConnell’s legislative graveyard,” said Sen. Chuck Schumer of New York, the minority leader.

Democrats are quick to point out that the party has attracted strong contenders already for a few races.

The speaker of the House in Maine, Sara Gideon, will take on Sen. Susan Collins, the Republican from that state. Mark Kelly, the former astronaut and gun control advocate, is running against Sen. Martha McSally in Arizona, who was appointed last year to fill Sen. John McCain’s seat; McSally has already lost once to Sen. Kyrsten Sinema, the Democratic freshman. Setting up a bit of farm-kid-on-farm-kid electoral violence, there is also Theresa Greenfield, a businesswoman, who is taking on Sen. Joni Ernst, R-Iowa.

For some Democrats, the fact that Ben Ray Luján gave up a top House leadership post to run for a Senate seat in New Mexico (albeit a relatively safe one) is further evidence that the Senate is still considered awesome. And, again, Hickenlooper is considering it.

But Democrats know that their only shot at unseating Sen. Steve Daines, R-Mont., most likely lies in Bullock, and Hickenlooper is by far and away their best chance at picking off Sen. Cory Gardner in Colorado, a swing state. Georgia and North Carolina both lack high-velocity candidates.

Texas is a long shot for their party, but with the purple hue intensifying in various parts of the state — and O’Rourke’s increasingly higher profile from his response to the crisis at the border and a mass shooting in El Paso — he would seem to have the best chance of anyone who would dare take on Sen. John Cornyn. (The Democrats’ current candidate, M.J. Hegar, an Air Force veteran who sued the government to lift the ban on women flying combat missions, lost a House campaign last year.)

If O’Rourke and Abrams fear that losing twice in statewide races would taint their future political careers, history shows that such losses have seldom daunted politicians who make multiple runs at the White House.

Still, the personal choice of what, when and where to run seems to perpetually vex everyone who has served in public life.

“In general,” said former Sen. Bob Kerrey of Nebraska, whose comeback bid to return to the Senate fell short in 2012, “all of us who have made decisions about becoming candidates are just a little more delusional than people like you who have to understand what we are doing and why we are doing it.”

This article originally appeared in <a href="https://www.nytimes.com/2019/08/16/us/politics/senate-hickenlooper-beto-abrams-bullock.html" id="9308eae7-a2b7-3fde-a41d-b9a41fea2845">The New York Times</a>.

(Political Memo)

Is the Senate Really Not 'Good Enough'?

Conspicuously missing from that list: gun control, an issue that has defined him since his wife, former Rep. Gabrielle Giffords, was critically injured in an assassination attempt in 2011.

Kelly’s Senate campaign in a state with some of the least restrictive gun laws in the nation could be a test of the enduring potency of the gun control debate, which for years proved toxic for Democrats, especially in states with large rural swaths.

Even after the horrific shooting that nearly killed Giffords and left six others dead, gun policy falls below health care, immigration and education as front-of-mind issues for voters here, the candidates and political experts agree, presenting more pitfalls than opportunities.

“I’m going to focus on the things that both Arizonans need and issues where I feel like, based on my personal experience, I can really help,” Kelly said after a recent round-table discussion with older voters.

The race in Arizona is currently seen as a tossup, with both parties viewing it as critical to control of the Senate in 2021, and with unpredictable political factors like the impeachment inquiry of President Donald Trump and the role of Arizona as an Electoral College battleground that could influence the outcome.

McSally finds herself caught between trying to appeal to both primary voters on the right and increasingly moderate general election voters. Kelly is trying to position himself as a centrist in the mold of Sen. Kyrsten Sinema, who last year became the first Democrat to win statewide here in a generation.

But as the White House and the Republican-controlled Senate contemplate new laws in response to a series of high-profile mass shootings this summer, and as Democrats running for president continue to advocate for gun restrictions, the issue of gun control is one Kelly and McSally will not be able to escape.

Democratic presidential candidates will participate in a gun safety forum Wednesday hosted by advocacy groups Giffords, founded by Giffords and Kelly, and March for Our Lives, demonstrating the potency of gun control as a campaign issue.

Sen. Mitch McConnell of Kentucky, the majority leader, has suggested he could bring a gun control bill to the Senate floor, though the House Democrats’ move toward impeachment has slowed the momentum, for now. “Given the multiple horrendous shootings in August,” McConnell said last month, “we owe it to the American people to act.” This would force McSally to get on the record over an issue she has largely been able to avoid for years.

With many Democrats running for president talking openly about gun control after years of retreat on the issue, Kelly often finds himself fielding questions about their positions on the campaign trail.

His role as a high-profile gun control advocate with an intensely personal connection to the issue rivals his status as a former astronaut and combat veteran as his primary identity in the state, even as he tries mightily to broaden the aperture of his biography. He and Giffords co-founded Americans for Responsible Solutions, now called Giffords, a nonprofit and super PAC that promotes gun safety.

Recently, the head of the Arizona Republican Party, Kelli Ward, sent out a fundraising note saying supporters needed to stop Kelly “dead in his tracks,” which stirred criticism. (Kelly sent his own fundraising message to supporters highlighting the attack.)

“The fact that Mark Kelly’s wife is one of the most famous shooting victims here plays a role,” said Paul Bentz, a pollster and consultant here. But, Bentz added, “I just don’t think he wants to be defined by the issue.”

McSally, a retired fighter pilot and former House member who was appointed last year to fill out the late Sen. John McCain’s term, has been evolving on her gun positions since the summer’s shootings and as Trump has called vaguely for tougher gun laws.

A longtime gun rights advocate who has enjoyed heavy support from the National Rifle Association, McSally said in an interview that she was “looking for meaningful legislation that can actually be turned into law.”

She said she was in “many conversations with the White House and fellow senators,” but she would not provide specifics about any potential bills beyond her own, which would make domestic terrorism a distinct federal crime.

One complication for her is an emergent Republican primary opponent, Daniel McCarthy, a cosmetics executive who says he believes gun rights is “the most important topic of this election.” He has tried to elevate the issue even as Republican primary voters in a recent meeting in Mesa, a solidly conservative city, seemed more interested in talking with him about the filibuster (he loves it), the 10th Amendment (Google it) and how much money he can raise (“I don’t know, and I don’t care,” he said).

McCarthy somewhat ostentatiously canceled a meeting with Gov. Doug Ducey, a fellow Republican, last month because of Ducey’s support for so-called red-flag laws, which permit law enforcement officials to temporarily remove firearms from people deemed dangerous.

“McCarthy wants to run to the right on guns,” Bentz said, “but I don’t believe that is where the electorate is at. Every time we have tested gun control issues, the Arizona electorate has been fairly supportive of increased limitations.” McSally has already been endorsed by Trump and the entire Republican establishment, which tried and failed to get McCarthy to go away.

Years of mass shootings, a sharp increase in suicides, increased attention to links between domestic violence and gun crimes, and other factors have blurred the lines on gun control, especially among suburban voters. Myriad polls show ample support for congressional action on guns and expanded background check laws.

Kelly “has not spent much time talking about the issue, but if he does, it will not hurt him as much as Republicans think,” Bentz said. McSally, he predicted, “would be fine” if she opted to vote for a bill that would expand background checks for gun buyers.

The 2018 midterm elections demonstrated that voters in districts previously held by Republicans were open to Democrats who supported gun control, like Reps. Lucy McBath of Georgia, Max Rose of New York, Angie Craig of Minnesota and Jason Crow of Colorado.

“It has turned out to be a winning issue,” said Crow, whose state has been the site of numerous mass shootings. “Not a week goes by where a parent or student or teacher doesn’t come to me in tears and tell me they are scared to go to school. When balloons pop at pep rallies, kids jump out of their seats. That’s the environment we have created. Four or five years ago, it was a very different environment.”

Kelly is nowhere near as aggressive about gun control as, say, former Rep. Beto O’Rourke, a presidential candidate who has talked openly about confiscating certain automatic weapons. “I do not support that,” Kelly said. “I think we need to approach this with what most of us agree on,” such as expanded background checks.

“I own a bunch of firearms,” he said. “I don’t hunt a lot now, but I used to. I’m a strong supporter of the Second Amendment. But we can’t ever get to the point where we think a bunch of kids getting shot in the classroom is something that is just normal.”

McSally, who is trying to raise her profile with voters around the state who know her best for her loss last year to Sinema, said she wanted “to do something that is actually going to make a difference” and that she thought red-flag laws were promising as long as they involved due process for offenders.

Still, she said, her main focus is her current Senate term. “I look at every day as if these are the last days of my life, thinking about what I can do and giving every ounce of energy to make things better.”

Is Arizona Shifting on Gun Control? Senate Race May Offer an Answer

PHOENIX — Mark Kelly, a former astronaut turned Democratic Senate candidate, checked off the policy issues he expects to focus on as he campaigns to unseat the Republican Sen. Martha McSally here: energy, health care, education and a strong national defense, in that order.

The woman, Andrea Goldstein, a reserve Navy intelligence officer and a lead staff member for the Women Veterans Task Force on the House Veterans Affairs Committee, was waiting for a smoothie at a cafe in the busy center, which has one of the most celebrated women’s clinics in the Department of Veterans Affairs health system.

A man slammed her below the waist and told her that “you look like you could use a good time,” Goldstein said in an interview. “He pressed his entire body against mine.”

Goldstein said she had just come from a meeting on Capitol Hill and was carrying in her purse the draft of a bill designed to curb sexual assault and harassment when she became a victim of it. She said that she was able to extricate herself and then complained to several center employees but that only when she got to her doctor were police called.

The incident underscores an intractable problem for many VA hospitals across the nation as they scramble to provide better health care for the rising number of women in the system.

Many female veterans praise the care they get at the hospitals but describe a difficult journey walking through them, in which they may be harassed or assaulted by male veterans or have their own status as veterans questioned.

WASHINGTON — A senior policy adviser on female veterans issues for the House said she was assaulted last week at the VA Medical Center in Washington by a man who slammed his body against hers and then pressed himself against her in the center’s cafe.

Jennifer Steinhauer

Articles written by the author

Early Problems as Trump's Signature Veterans' Health Plan Rolls Out

A Post-9/11 Veteran as President? Pete Buttigieg Makes His Case

A View Outside the Wire Lifts Buttigieg Onstage

Treated Like a 'Piece of Meat': Female Veterans Endure Harassment at the VA

Treated Like a 'Piece of Meat': Female Veterans Endure Harassment at the VA

Treated Like a 'Piece of Meat': Female Veterans Endure Harassment at the VA

Treated Like a 'Piece of Meat': Female Veterans Endure Harassment at the VA

Veterans' Groups Compete With Each Other, and Struggle With the VA

Veterans' Groups Compete With Each Other, and Struggle With the VA

Is the Senate Really Not 'Good Enough'?

Is Arizona Shifting on Gun Control? Senate Race May Offer an Answer

Woman Trying to End Sexual Assault at VA Centers Says She Is Attacked in One

Program to Prevent Veterans Suicide Earns Bipartisan Support

2019 belongs to Shirley Chisholm

Women and minorities make gains if they opt to run, a study shows

Treated like a 'piece of meat': Female veterans endure harassment at the VA

When 'your commanding officer is your breath'