Ideas

The VA: Trouble from the start

Created to save money, the agency has only ended up illuminating the human cost of war

At Wadsworth VA Hospital in West Los Angeles in 1981, Vietnam veterans camped out after the suicide of a disabled Marine who had rammed the front door with a Jeep and sprayed gunfire to protest lack of treatment.

Nick Ut/Associated press/1981

At Wadsworth VA Hospital in West Los Angeles in 1981, Vietnam veterans camped out after the suicide of a disabled Marine who had rammed the front door with a Jeep and sprayed gunfire to protest lack of treatment.

This summer’s revelations about the Veterans Administration have tarnished the image of a cherished national institution. One of the nation’s largest health care systems, the VA provides a lifetime of medical services at no personal expense to military veterans. But recent events suggest the system is broken. Reports from Phoenix exposed an organization rife with negligence and mismanagement, where sick veterans waited three months or more to be seen by a doctor, and administrators falsified these wait times to earn incentives for complying with timeliness mandates. Many have suffered from the latest VA debacle: ailing veterans in need of care, grieving family members who have reportedly lost loved ones because of delays; and Eric Shinseki, the four-star Army general who was forced to resign from his position as secretary of veterans affairs this past May.

Given the profound importance of veterans and their contributions, trouble at the VA is the rare issue that can move those on both sides of the political aisle. Appalled conservatives like Representative Jeff Miller have spoken out against the “selfish bureaucrats” and governmental bloat that are hurting veterans. The left and center-right seem to agree that the problem is resources: An unlikely combination of Senators Bernie Sanders and John McCain got a Senate emergency funding bill passed, with the goal of building additional facilities and hiring more doctors and nurses to meet ever increasing veteran demand on the system.

National museum of health and medicine

The VA grew from efforts to help rehabilitate WWI soldiers, like the private seen here.

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Behind all the political posturing is a shared sense of dismay that the VA is in practice a complicated, messy, underfunded bureaucracy, shortchanging the people who gave themselves to the service of the country. There is a great deal of shock at this latest revelation, but there shouldn’t be. From its inception during the First World War nearly a century ago, the VA was specifically designed to save the government money by eliminating prohibitively expensive veterans’ pensions. And though the VA was supposed to produce savings, from the very beginning the opposite was true. From the time it opened its doors, it instantly became tangled in red tape and scandal, and, in the years since, the VA health care system has proven to be incredibly costly, especially as more and more veterans from the wars of the 20th century have developed long-term disabilities.

Few observers of today’s VA scandals are aware of the institution’s long and fraught history, or that the troubles in the news are only the most recent example of a national reluctance to admit what a massive undertaking veteran care is. A look at the VA’s history forces us to acknowledge that war has a human cost that far outlasts the conflict itself—and that as a nation, we have long been reluctant to shoulder it.

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While it is tempting to blame the VA’s woes on the advent of more harmful modern warfare or more expensive modern medicine, the troubles date back to an earlier time and to an even earlier conflict. The VA, in a sense, is an artifact of the Civil War, which accounted for more US deaths and casualties than any other we have fought. By 1916—the year before the United States officially entered the Great War—disability payments to Civil War veterans had accounted for over $5 billion in US government spending, a cumulative amount that exceeded the price of the actual war. Although the Civil War should have been a distant memory by the time of the First World War, the “boys of ’65” had become elderly men who continued to drain the Treasury’s coffers by drawing triennial pension checks. Looking across the Atlantic at the human toll of the First World War, Americans feared that this military engagement—a war that was consuming Europe—would lead to a heavier economic burden than all of the nation’s previous conflicts combined.

Although the Civil War veteran had long been revered for his courage, honor, and masculinity, turn-of-the-century reformers began to recast him as a “parasite” on the country, a man on the dole, always looking for handouts. Seen this way, economic dependency—often linked overtly and metaphorically to womanliness—came to be understood as the real handicap thwarting the post-war recovery of the veteran and the fiscal strength of the nation. The shorthand term used at the time was “war’s waste,” which referred to not only excess spending on military conflict, but also the human wreckage that it caused.

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To prevent this waste the next time around, certain Progressive Era US policy makers proposed a new type of veterans’ welfare system focused on individual recovery and rehabilitation. The idea was to encourage veterans to become fully independent again. The framers of the new legislation, known as War Risk Insurance, had expertise in family protection and the actuarial sciences and believed that the “problem” of veterans who were dependent on federal handouts could be solved through some well thought-out social engineering.

With their abiding faith in the new medical sciences, Progressive reformers turned to physicians and other health experts to make this happen. At first, disabled soldiers received medical and rehabilitative care in military hospitals. Walter Reed Hospital in Washington, D.C., for example, was transformed from an acute-care to a long-term care facility, with infectious disease wards converted into “curative workshops,” where disabled soldiers would recover both their bodily integrity and employability by learning industrial trade work. The new legislation mandated that injured and sick soldiers would receive care until they had reached “maximum improvement.” Economic and bodily recovery were expected to happen simultaneously and fairly swiftly, so that after war’s end, the cost of military engagement could be quickly stanched.

But for all the planning involved, the War Risk Bureau (a direct predecessor to the VA) was caught unprepared with the signing of the Armistice in November 1918, with no real infrastructure to care for the hundreds of thousands of soldiers who became veterans overnight. There was no nonmilitary generalized hospital program for veterans, no plan for medical screening or for rating disabilities, no staff. In an ad hoc effort to cope with America’s demobilization, the bureau transferred about 300,000 hospitalized veterans over to US Public Health Service hospitals, an existing network of facilities in America’s major port cities that took care of immigrants and merchant seamen affected by epidemic diseases.

By the middle of 1919, complaints about overcrowding were already starting to emerge. A congressional study showed that less than a year after war’s end, there was a huge backlog of pending cases and not enough hospital beds to service the growing number of disabled veterans. One of Woodrow Wilson’s last presidential acts was to appropriate $18.6 million to the building of hospitals for veterans and to create a separate agency that would become the Veterans Bureau.

It was supposed to save money, but by 1924, the Veterans Bureau was becoming a costly and entrenched government agency.

Library of Congress

It was supposed to save money, but by 1924, the Veterans Bureau was becoming a costly and entrenched government agency.

Despite the money and political support, the Veterans Bureau quickly became mired in bureaucracy, inefficiency, confusion, and neglect. Investigative reports told of shell-shocked veterans being sent to hospitals for disabled children, where grown men had to endure the indignity of sitting in infant chairs. The first director of the Veterans Bureau, Charles R. Forbes, possessed little knowledge of how to operate a hospital system and showed little concern for the medical needs of disabled veterans. In 1923 Forbes was indicted for bribery and fraud, having sold millions of dollars’ worth of Veterans Bureau hospital mattresses, sheets, and towels at a profit to a private Boston firm, and went to prison for his crimes. Comparing the newspaper coverage from the 1920s to today’s, one cannot help thinking of George Santayana’s warning that those who cannot remember the past are doomed to repeat it.

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By 1924 the Veterans Bureau’s total annual budget was reported to be $400 million, and it had become clear that the agency could no longer be promoted as a cost-saving measure. One social commentator pointed out that the cost of this one agency was “what it took to run the whole United States Government in 1895.” During the 1930s, the newly named Veterans Administration became ever more entrenched, a bureaucracy just as ingrained into the fabric of governance as the Civil War Pensions Bureau had been. Federal hospitals for veterans became, in the words of historian Rosemary A. Stevens, “just the way things were.”

In many ways, the VA was an improvement over the system of Civil War-era pension payments. Disabled soldiers from the First World War received health care and vocational training that they would have never gotten otherwise. Most veterans, then and now, want to move back into the workforce and not be forever reliant on federal funds. But war creates complex physical and mental disabilities, many of which are beyond the scope of medical cures. Moreover, the rather lofty and ill-defined goal of providing care until a veteran reaches “maximum improvement” proved to be a perennial sticking point. From the beginning of the VA’s history, many disabled soldiers felt that they needed much more time to recover—months and even years—before they were ready to seek out employment. VA officials and doctors, meanwhile, under constant threat of budgetary constraints, have been motivated to cut corners, refusing to classify certain impairments as disabilities (such as post-traumatic stress disorder, until recently), and shortening the durations of treatment.

The guiding philosophy of today’s VA has remained virtually unchanged since its founding. Its mission statement—words chiseled into the edifice of the US Department of Veterans Affairs’ federal building near the National Mall—come from President Abraham Lincoln: “To care for him who shall have borne the battle.” What constitutes “care”—whether in the form of pension payments, medical treatment, housing benefits, or a free education—changes over time. What stays the same, however, is a general reluctance in the public sphere to admit to the monumental costs that come with honoring the commitment of caring for our veterans.

The latest reports coming from current VA scandals and investigations suggest that the inherent paradox of the system still lies at the heart of many of the problems that plague it. The VA was born as an experiment in fiscal conservation by means of governmentally funded health care. The cost of military engagement is inseparable from the long, slow, and massively expensive process of helping those who suffer battle wounds. For a nation that prides itself on military preparedness, frank and honest discussions about the aftermath of war are in short supply.

Beth Linker is an associate professor in the History and Sociology of Science at the University of Pennsylvania and the author of “War’s Waste: Rehabilitation in World War I America.”
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