I have often been struck by a symbolic device frequently invoked by television reporters when they cover an event at a Department of Veterans Affairs (VA) medical center. They will show introductory foot-age of an unkempt elderly individual on crutches or in a wheelchair, obviously not in the prime of life, and not the picture of career success. At best, this image (along with its newspaper and radio variants) conveys the romantic picture of an agency that serves fading heroes, down on their luck, in need of respect for service to their country, some medical care, and, perhaps, shelter from the perversity of a modern world. But it often fuels a more cynical view connoting an agency with a narrow yet expensive mission better accomplished in the private sector. In truth, whether interpreted romantically or cynically, the image does the VA and the nation a disservice. There is far more to what the VA, through its medical arm, the Veterans Health Administration, does—not just for veterans but for all Americans.
The VA is indeed a treasure unknown to the vast majority of the American public. Its vital influence is felt throughout the spectrum of health care. Whether the concern be geriatric care, homelessness, spinal cord injury, prosthetics, or primary care, the VA's impact is evidenced by groundbreaking health care innovation, research, and teaching. Yet, most of what the agency does is virtually unknown or, at best, taken for granted by those who benefit. With a political system that is less and less responsive to the traditional rationale surrounding our debt to our nation's veterans, there is an ever-growing need to cast more light on this valuable national asset.
Figure. Ed Thorsland...Image Tools
It is not uncommon for me, as a VA Medical Center director, to encounter the questions, “Why do we need a VA medical system? Isn't it awfully expensive? Why don't we just close down the VA and give all the vets vouchers to go anywhere they want for medical care?” Questions like these come from both the general public and their elected leaders and cry out for a closer examination of VA expenditures and what they buy.
In Fiscal Year 1999, the medical care component of the VA budget was $17.3 billion, most of which provided 3.4 million individual veteran patients with a wide range of inpatient, outpatient, and extended care, as well as a variety of social services, including readjustment counseling to Viet Nam veterans and services to the homeless. The coverage was all-inclusive: doctors, nurses, facilities, medications, prostheses, etc. There was no limit to the level and complexity of care; it included every conceivable specialty, some of which are rare outside the VA. This would translate to $5,100 per active patient and $4,100 per enrollee (i.e., a person enrolled in the system but not necessarily using it), supplemented very modestly by third-party payments and user co-payments. To put these figures in perspective, two years earlier (1997), Medicare expenditures for Parts A and B were $5,900 per active patient and $5,400 per enrollee. As I discuss further below, patient care was not the only use to which this money was put. But, even if it had been, the cost would appear to be well within reason if not a down-right bargain.
As indicated above, this so-called patient care funding supports a whole lot more than strictly patient care. One prominent example is health care education. Fully 105 medical schools have formal affiliations with VA medical centers. Most of these affiliations represent very extensive VA commitments to the education and postgraduate training of our nation's physicians. At the Denver VA Medical Center, for instance, our affiliation with the University of Colorado Health Sciences Center translates to funding for 116 residents, 25% of the third- and fourth-year training for 250 medical students, and faculty appointments for nearly every VA physician.
Throughout the nation there are numerous schools of nursing, pharmacy, psychology, social work, physical therapy, occupational therapy, and others that depend upon the VA for a rich training experience and the teaching skills of multitalented VA providers. During the past year at the Denver VAMC alone, nearly 400 nursing students as well as 35 trainees in other disciplines had training time at the facility. All training that takes place in VA Medical Centers is supported with the same appropriation that pays for patient care.
VA research is similarly positioned as an important national asset. In 1999, 13,000 VA researchers worked on over 22,000 research projects, 1,300 of which were VA-funded. At the Denver VA Medical Center we have 71 investigators involved in 338 different projects. Although VA research protocols are funded by a separate appropriation, the lion's share of the investigators' salaries comes out of medical care appropriations. Some VA research is enhanced by its ability to do multiple-site investigations via its Co-operative Studies program. With two Nobel Prize winners and a long list of impressive accomplishments over the years, VA research has been extremely productive. Its yield has included the cardiac pacemaker, hepatitis vaccine, radioimmunoassay techniques, and theory leading to the development of computerized axial tomography (CAT) and magnetic resonance imaging (MRI). The upfront research work necessary to perform the world's first kidney and liver transplants was all done at the Denver VA Medical Center. Currently, among our many research endeavors, we are leading the way in investigating the genetic origin of schizophrenia.
Returning now to the original questions about the expense of the VA and whether we really need it, the immediate answers are that it's a bargain and we do indeed need it. However, I would pose a different question: Where would we be without the VA and its medical arm, the Veterans Health Administration? My answer is that our nation would lose a substantial part of its health care education capacity. Postgraduate residencies would be harder to come by, valuable training ground would be lost, and the cost of medical education would rise even faster. Likewise, the incredibly productive research at VA medical centers would be gone. Break-throughs such as those we have experienced in the past might be rarer, and they certainly would be more expensive. Our veterans would not only lose access to world-class treatment at sophisticated teaching hospitals that understand veterans' needs, but would have greater difficulty accessing specialized care for such things as posttraumatic stress disorder. The VA's expertise in prosthetics, geriatric care, spinal cord injury, rehabilitation, blind rehabilitation, and others would be lost to veterans and medical education.
There is another, more subtle, implication of a world without VA medicine. By this, I am suggesting that the agency functions not only as a safety net but as a pressure stabilizer for the nation's health care costs. By providing all-encompassing health care services to all eligible comers (whose numbers have increased every year), and doing so on a fixed budget while meeting the highest quality standards, it pressures others in the national health care arena to keep up. For example, the Health Care Financing Administration has found itself challenged to explain why it pays more than the VA does for certain goods and services. The VA has shown that quality can be sustained—actually raised—within such an environment. The agency has scored consistently higher grades than the average of all hospitals with the Joint Commission on Accreditation of Healthcare Organizations, exceeded the performances of most managed care operators on a wide array of quality markers, and performed well on patient satisfaction surveys.
Where would we as a nation be without the VA? We would be without a leader: a leader in health care education, a leader in medical research, and a leader in health care quality and economy. The loss would start a domino effect, felt first by our veterans and our medical schools, later by all Americans. The hidden treasure would become the lost treasure. Hopefully, the nation will not have to wait for that to happen before we realize there is more to health care in the Department of Veterans Affairs than that ill-informed stereotypical vision of a veteran who could just as easily get his or her care somewhere else.