The Once and Future Veterans Health Administration

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.