Hospital Access for all Veterans

A veterans’ hospital system was never deliberately legislated, but its roots were planted with the creation of the VB. In April 1922, the Public Health Service formally transferred facilities treating former service members to the new bureau.

Local representatives of different stripes—legislators, Chambers of Commerce, private citizens—eagerly approached the federal government about building hospitals for former service members in their communities.

In 1924, once a network of more than 40 veterans’ hospitals existed across the country, VB Director Frank Hines told Congress that all former members of the military—regardless of whether their injuries or illnesses were connected to service—should have free access to the facilities.

In the 1920s, like today, the idea of unfettered, universal access—even when practically justified for a select group of citizens—was greeted with hostility.

“You do not recommend that every man who walks up to a hospital with a discharge in his hand … regardless of his financial standing, shall be admitted to that hospital?” asked an incredulous Alfred L. Bulwinkle (D-NC).

Providing federal assistance so all veterans could access medical care would cost “billions of dollars,” said James H. MacLafferty (R-CA).

“If we establish the principle of free hospitalization for all veterans,” noted Robert Luce (R-MA), “it would then be incumbent upon us to furnish the facilities.”

Luce was ideologically opposed to the whole idea, which, he asserted, “involves an immeasurable expense over 50 to 75 years, but also involves a long step toward that centralization of activities which some people call socialism.”

By granting millions of former service members access to government hospitals, Luce suggested, communities would no longer be encouraged to collectively provide for themselves. “You are throwing away ... the idea of local responsibility,” he said.

Again, advocates and bureaucrats countered with arguments about efficiency.

“We believe, rather than go through all the administrative work of investigating and segregating, (that the VB should) take care of the man as he comes knocking at your door,” Edwin Bettelheim, of the Veterans of Foreign Wars, told members of Congress. Bettelheim noted that the reviews of records necessary in order to prove service connection were time-consuming and costly. Treating all veterans who sought care, as opposed to only some, Bettelheim and others asserted, would help alleviate wastefulness.

Wasn’t it worth spending four or five million dollars per year, Bettelheim asked, “to take care of these men that will become a charge on some community?”

By focusing on these and other practical benefits of expanding access, bureaucrats and advocates overpowered legislators’ ideological concerns about socialism. Congress passed the World War Veterans’ Act on June 7, 1924 stipulating that the director of the VB could provide hospitalization to all honorably discharged veterans who had served since 1897.

But the notion that a system of preference should exist was—and is—central to the shape of veterans’ health care.

According to the World War Veterans’ Act, former service members could be treated through the VB “without regard to the nature or origin of their disabilities,” but only if “existing Government facilities (permitted).” Preference for care would be granted to those with service-connected disabilities and individuals who were “financially unable to pay for hospitalization” otherwise.

As a result of the passage of the World War Veterans’ Act and increasingly lenient rules regarding disability ratings and service-connection for various conditions, the number of patients under hospital treatment sponsored by the VB grew from approximately 18,000 in 1924 to more than 30,000 in 1930. By that point, 46 percent of bureau patients were receiving hospital care for non-line-of-duty injuries or illnesses.

According to the 1930 Veterans Bureau annual report, the “hospitalization of veterans of the world and other wars, and the necessity for the expansion of government facilities” constituted a “growing problem.”

An Adaptable, Lasting, Selective System of “Socialized Medicine”

The legacy of postwar policy surrounding medical care for soldiers and veterans is not simply one of unyielding growth and generosity. Throughout the twentieth and twenty-first centuries, the U.S. government has backtracked and vacillated in its willingness to fulfill promises made to those who served, and the veterans’ health system has experienced both challenges and successes.

Still, legislation passed during and after the Great War was crucial. It established the fundamental principle that medical care should be offered as a federally sponsored entitlement to former service members.

As headlines abound regarding the rough rollout of the Affordable Care Act, it is worth noting that, even in the early days of veterans’ hospitals, there was great confusion and controversy about eligibility, standards of care, and how the bureaucracy would work.

Throughout the interwar years, piecemeal legislation was passed in order to address some of the most glaring problems with the new medical program.

Even after the Veterans Bureau was consolidated with the Bureau of Pensions, and the National Home for Disabled Volunteer Soldiers to form the Veterans Administration (VA) in 1930, the hospital system remained a “backwater,” as scholar Paul Starr puts it.

After World War II, when public concern for former service members was reignited, veterans’ hospitals gained more federal attention and funding, and began affiliating with medical schools. By the mid-twentieth century, the system had grown exponentially—it consisted of hospitals, nursing homes, ambulatory care, and education and training for medical professionals—but it failed to shake its negative reputation among veterans and many others.

In the wake of the Vietnam War, the majority of veterans eligible for care through the VA opted not to access it.

But during the last decades of the twentieth century, there were signs of progress. In the late 1970s, VA doctors pioneered an electronic health record system that continues to serve as a model for private sector institutions.

In 1989, the VA became the Department of Veterans Affairs, as it gained cabinet status and the administration of health services was placed under a reorganized branch—the Veterans Health Administration.

Soon after, in the mid-1990s, VHA administrators undertook efforts to make services more accessible to non-indigent veterans and those with non-service-connected disabilities. At that time, 23 regional “integrated service networks” consisting of a variety of types of in- and out-patient facilities replaced hospitals as the focal points of care.

Following those organizational improvements, battles about the righteousness and conditions of federal intervention have raged on. As the U.S. engaged in two lengthy wars in Iraq and Afghanistan, the number of veterans eligible for treatment rose sharply, much to the chagrin of conservative legislators who argued—as some did in the 1920s—that access to publicly sponsored medical care should be strictly limited.

The Cato Institute’s Michael F. Cannon maintained in March 2006 that the Veterans Health Administration was hardly a model system since it was forced to “play politics with people’s health” and cope with decreases in federal funding by “freezing enrollment, increasing waiting times, and rationing access to the latest prescription drugs.”

In November 2011, when presidential candidate Mitt Romney told a gathering of veterans in a South Carolina barbeque shop that he wondered “if there would be some way to introduce private sector competition” to the VHA, New York Times columnist and economist Paul Krugman joined a chorus of skeptical veterans’ advocacy groups.

“What Mr. Romney and everyone else should know is that the VHA is a huge policy success story,” Krugman argued, pointing out that it has achieved “rising quality and successful cost control.” That is true, he added, because it is an “integrated” system, meaning it both provides and pays for health care. “Yes,” Krugman noted, “this is ‘socialized medicine’ … but it works.”

Today, more than eight million former service members receive health care through the VHA.

Echoes of the Past

Justifications offered during the post-World War I years for the necessity of publicly sponsored veterans’ health services were echoed nearly a century later during debates over the ACA: government intervention was not only laudable in a humanitarian sense, advocates maintained, but it would cut costs, increase efficiency, and protect the public’s health.

“This bill creates four million jobs,” House Democratic Leader Nancy Pelosi said in a July 2012 congressional floor speech in opposition to Republican efforts to repeal the ACA. “It reduces the deficit, it enables our society to have the vitality of everyone rising to their aspirations without being job locked … let us move forward together to strengthen the economy and to strengthen the great middle class, which is the backbone of our democracy.”

President Obama, too, reiterated arguments focused on economic efficiency. “Each time an uninsured American steps foot into an emergency room with no way to reimburse the hospital for care,” he told attendees of the American Medical Association convention in Chicago in 2009, “the cost is handed over to every American family as a bill of about $1,000.”

Likewise, opponents of the ACA have cited concerns similar to those who questioned the expansion of the VA system: cost, government largesse, and the squashing of individual rights and initiative.

In August 2012, when Republican Representative and Vice Presidential candidate Paul Ryan addressed the Republican National Convention, he invoked Robert Luce’s ideals regarding “local responsibility” and gave voice to a timeless argument against federal involvement in health care: “We do not each face the world alone,” Ryan said. “And the greatest of all responsibilities, is that of the strong to protect the weak.” But, Ryan argued, “our rights come from nature and God, and not from government.”

An October 2009 report by Matt Peterson of the National Center for Public Policy Research made a related point, referring specifically to the ACA’s requirement that every citizen purchase insurance. The so-called individual mandate, Peterson said, “would constitute a gross abuse of governmental power and a violation of every American's right to decide what is best for themselves and his or her family.”

Perhaps the most stunning similarity between the formation of a veterans’ health program and the ACA is that in both cases conceptions about dependency—the creation of a “dependent class” as Mark Steyn put it in the National Review in 2009—shaped opinions.

Some, including Public Health Service Surgeon General Rupert Blue, Robert Marx of the Disabled American Veterans, and Democratic Leader Nancy Pelosi, viewed federal intervention as a means of promoting self-reliance.

Others—Utah Republican Reed Smoot, his Massachusetts counterpart, Robert Luce, and Paul Ryan—tended to see it in the opposite light: government aid was something to be earned, a potential threat to community, and frighteningly paternalistic.

In a variety of ways, early proponents of veterans’ health care faced less of a challenge than the Obama administration and its supporters. They represented a limited and, they argued, worthy constituency.

The ACA, on the other hand, was designed with the ambition of making health insurance available to virtually every citizen—not least of all to those left behind by state- and employer-sponsored programs established in the twentieth century. Today’s “underserved” are the working poor, the young, and people with previously existing conditions; they do not form a cohesive and powerful constituency.

Time will tell if the legislation intended to cover those populations, like its twentieth-century predecessor aimed at veterans, will prove enduring.