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History of Veterans Healthcare
The United States has the most comprehensive system of assistance for veterans of
any nation in the world, tracing back to 1636, when the Pilgrims of Plymouth Colony fought
against the Pequot Indians. The Pilgrims passed a law stating that disabled soldiers would
be supported by the colony. More than 100 years later, the Continental Congress of 1776
encouraged enlistments for the Revolutionary War by providing pensions for disabled
soldiers. Direct medical and hospital care given to veterans in the early days of the
republic was provided by the individual states and communities. In 1811, the first
domiciliary and medical facility for veterans was authorized by the federal government.
But most people associate a federal veterans system with President Lincoln. In the
moving conclusion of his second inaugural address, Lincoln said, "With malice toward
none; with charity for all; with firmness in the right, as God gives us to see the right;
let us strive on to finish the work we are in; to bind up the nation's wounds; to
care for him who shall have borne the battle and for his widow, and his orphan -- to do
all which may achieve and cherish a just and a lasting peace, among ourselves, and with
all nations."
In 1865, just six weeks before his assassination, Lincoln signed legislation creating
the National Asylum for Disabled Volunteer Soldiers and Sailors, renamed the National Home
for Disabled Volunteer Soldiers in 1873. A direct antecedent for VA, it was incorporated
into the Veterans Administration in 1930. Eventually, there were 11 National Home branches
across the country. The first was located at Togus, Maine, at the site of the current VA
medical center. Initially, the National Homes were intended only for union veterans who
suffered economic distress from disabilities incurred in the Civil War. Later, it was
opened to all veterans suffering from disability from any war. The medical care offered in
the National Homes was largely infirmary level, but by 1930 it had risen to an accredited
hospital level. Ironically, or perhaps prophetically, the Board of Managers for the
National Homes would often hold its Washington D.C. meetings in the then-fashionable
Arlington Hotel, on the site of the present VA headquarters building.
Despite the care provided by the National Homes, by the end of WWI, a majority of
disabled veterans were receiving their hospital care and treatment from the Public Health
Service (PHS), with reimbursement by the Bureau of War Risk Insurance. At that time, five
difference agencies handled different parts of veterans issues, and processing of claims
was agonizingly slow. The Old Pension Bureau, for example, continued to handle pensions of
veterans from previous wars while the Federal Board for Vocational Education handled
schooling and rehabilitation benefits for the returning WWI veterans. As the flood of
soldiers returned from Europe, pressures for veterans assistance grew. In an attempt to
speed up its activities, the PHS decentralized its examining and outpatient functions to
14 district offices, but crisis still reigned. Finally, in 1919, public law transferred a
number of hospitals to the PHS for use for veterans, and several new hospitals were
authorized. Some contracting out to private hospitals occurred as well to ease the need
for care. In June 1920, the PHS had 11,639 beds in 52 hospitals. It still was not enough.
Tuberculosis was becoming a major health factor. Patients required isolation, good
climates, and healing settings for extended recuperation. Over a 35 year period starting
about 1919, over 35 properties were used (some were leased) to treat TB patients. When TB
was cured by drugs, many hospitals closed. Leases were terminated and property was sold.
Among the first acts of the Harding Administration was to appoint two committees to
look at the problem. Both committees, acting independently, came up with reports that
recommended a new agency to deal with veterans hospitalization and rehabilitation. Though
each offered slightly different names for the new agency and recommended different
hierarchies (one advocated that the new agency report to the president, the other to a
cabinet official) the proposals were similar. Wrote the Dawes committee in its quickly
drafted report, "no emergency of war itself is greater than is the emergency which
confronts the nation in its duty to care for those disabled in its service and now
neglected." The other committee, the White Committee, took longer to make a report,
but it was more comprehensive. One of the items they tackled, not be arise again for 25
years, was the idea of affiliating with medical schools.
The committee's recommendations were realized in 1921, when the Veterans Bureau
was established. Col. Charles R. Forbes, former director of the Bureau of War Risk
Insurance, was the director. Scandal and controversy plagued him, as it did the Harding
administration, and he soon resigned. Following him was General Frank Hines, who faced
such early difficulties as shifting physicians from PHS to the Veterans' Bureau and
figuring out their salaries and civil service status. Some physicians resigned and others
went back to PHS. The position of Medical Director was created in 1923. Dr. Lester B.
Rogers was the first. He lasted eight months. In 1924, Hines petitioned Congress to pass
legislation authorizing a Veterans Bureau Medical Corps with salaries that were equitable
and uniform. Between then and 1930, when the Veterans Bureau became the Veterans
Administration, nine bills were introduced. None passed. Twelve similar bills calling for
a Medical Corps were considered during the '30s and early '40s, and they too
were unsuccessful.
Meanwhile, medical care for veterans was booming. Between 1931 and 1941 the number of
VA hospitals increased from 64 to 91, and bed capacity rose from 33,669 to 61,849. Special
training programs for physicians and nurses were active, and Dr. Charles Griffith, the
medical director from 1931 to 1945, believed in and supported active medical research.
By the time the country began gearing up for WWII, VA was both a respected member of
the medical community and a designated "defense agency." VA recommendations for
the physical examination of draft registrants were followed. VA also became a leader in
emphasizing mental health as an important factor in overall physical health, based on
their experience with WWI veterans.
WWII brought many problems to VA. Immediately after Pearl Harbor, VA from San Francisco
and Los Angeles were relocated to safer locations inland. About 7,000 VA employees left in
the first year to join the war effort in another capacity. Then came an important piece of
legislation: in 1943, Congress granted WWII veterans the same eligiblity for benefits as
WWI veterans. Previously, WWII veterans were only eligible for care for compensable
service connected disabilities. Now, they could get care if they couldn't afford it
and there were available beds. Though the legislation did not have an immediate impact --
there were few returning veterans at this stage -- it would come to overwhelm the system
at the end of the war.
Early in 1945, in a familiar scenario, national media began to attack VA healthcare.
"Veterans Hospitals Called Backwaters of Medicine" was one headline, "Third
Rate Medicine for First Rate Men" was another. Controversy and testimony ensued.
Appearing before Congress in 1945, VA Administrator Hines was asked, among other things,
what VA was doing for women veterans. The hearing also highlighted the unsuccessful
legislation creating a medical corps for VA. Shortly after, a congressional committee made
recommendations including the initiation of a VA Department of Medicine and Surgery headed
by a physician responsible only to the Administrator. Meanwhile, General Paul Ramsey
Halwey, a long-time military physician, became "Acting Surgeon General" for
veterans healthcare, responsible to Bradley. The problem was that Dr. Griffith remained as
Medical Director until he was reassigned to the VA hospital in Mt. Alto, in Washington,
D.C. While Congress debated the initiation of a medical corps, Hawley insisted veterans
should get care "second to none" and enlisted the help of the Association of
American Medical Colleges and the American Medical Association.
In January 3, 1946, Public Law 293 was signed, creating the VA's healthcare
administration. It was just in time. By May of 1946, VA was in a significant growth mode.
The average daily patient load was 86,272. Hospital construction was in progress at 31
locations, which would bring an additional 13,594 beds. After WWII demobilization, there
were 15.2 million veterans of whom 11.3 million were from WWII. Waiting lists for
admission grew. Beds were increased at existing hospitals and the construction projects
sped up. The Army Corps of Engineers was brought in to help. They ultimately built 44
hospitals for veterans, supplementing those built by VA. Bradley also instituted a
sweeping reorganization of the department, welcomed by most, but criticized by the
American Legion which had wanted a businessman -- not a General -- appointed as
Administrator. Demobilization of the military put a strain on VA budgets and in 1947
Bradley asked the House Appropriations committee for more money. He sent a telegram to VA
branches throughout the country asking them to freeze personnel at existing levels and
eliminate all but critical travel. The funds were approved.
In 1946, virtually days after the law creating the Department of Medicine and Surgery
was signed by President Truman, the first affiliation with medical schools was
established. The agreement was between Northwestern, University of Illinois and the
VA's Hines VA Hospital. Affiliations had an almost immediate effect in one
significant way -- they changed where VA medical centers were built. Until then, many were
located in beautiful, but isolated spots. "To hell with the scenery, I want the
finest doctors," Halway is quoted as saying. The medical affiliation program was
expanded during the 1960s when the nation faced a physician shortage.
From 1942 to 1950, the number of VA hospitals jumped from 97 to 151, but then
construction slowed during the '50s and the growth became more gradual. Early in May
1951, after a Korean War veteran was unable to get treatment at the Tucson VA Medical
Center because his condition was nonservice connected, eligibility changes gave Korean War
veterans the same rights as granted to WWI and WWII veterans, including hospitalization
for nonservice connected conditions.
In 1953, after more than a year of study by consultants Booz Allen and Hamilton, top VA
officials, service organizations and others, a major reorganization plan was authorized.
It included a revision along major-purpose lines rather than functional line and it
established three departments within VA -- the Department of Medicine and Surgery, the
Department of Insurance and the Department of Benefits. Also during that year, a survey of
the 166 VA hospitals showed that 47 installations, mostly in the South, continued to
practice some form of racial segregation, including separate canteens and toilet
facilities. Central Office management worked with those facility directors to administer
the agency policy abolishing all forms of racial segregation. Within a year, without
publicity or newspaper headlines, racial segregation was eliminated.
By the mid-50s, Congress cut down financial requests from VA even though the increasing
number of hospital and patients called for more money. Funds were cut so deeply that
layoffs were required in many hospitals and some stations closed beds and didn't open
newly constructed wards. One problem was extreme lengths of stays, by today's
standards. In a census taken in November 1954, 65 percent of patients had been in VA
hospitals for more than 90 days; 8 percent had been in the hospital for over 20 years!
In 1955, William S. Middleton, M.D., was Chief Medical Director. During his eight years
in that post, the president approved a ceiling of 125,000 beds for VA and stopped
designating hospitals for a particular type of treatment. The days of the TB hospital were
nearly over. During this time, medicine was changing and VA was changing as well. Under
Middleton, employment of the physically handicapped rose, and the concept of a seven-day
hospital was born. Previously, hospitals -- including private hospitals -- functioned five
days a week, with only a skeleton crew on the weekends. Changing this helped reduce
lengths of stay as under the old system patients who missed being discharged on a Friday
could not be discharged until Monday. Middleton also realized that chronic cases required
long hospitalization and research into geriatrics became of prime importance. The
VA's nursing home program began in 1963, when the President directed that 2,000
nursing home beds be created within VA through modification of existing facilities. A year
later, a law authorized 4,000 nursing home beds.
New programs began to sprout all over. In 1964, the first hemodialysis centers were
created at Hines and LA. In 1970, a hospital based home care program was initiated and
tested at six hospitals for two years. Between 1973 and 1974 25 more were established.
GRECCS began in 1975 to improve healthcare and treatment of older veterans. Ambulatory
care started an upward trajectory. In 1962 the average number of annual ambulatory patient
visits was only about 4 million. It jumped to more than 10 million in 1974 and 20 million
in 1986. It reached 26 million in 1995.
In 1979, VA began operating Vietnam Veteran Outreach Centers -- Vet Centers -- to
provide readjustment counseling services to Vietnam Era veterans, many of whom shunned VA
hospitals, as they had not returned as victorious national heroes and were not embraced by
sociey. There are more than 201 Vet Centers today with more than 1 million veterans using
them for counseling. Post Traumatic Stress Disorder programs are also initiated at medical
centers, and VA is now a leader is such treatment and research into the effects of
traumatic stress.
In 1982, VA was established as the primary back up to the DOD during war or national
emergency. VA was mobilized to provide support in the early '90s, during the Persian
Gulf War, but have spent most of their resources on domestic emergencies, including the
1995 bombing of the federal building in Oklahoma and Hurricane Marilyn in the Virgin
Islands. In 1996, VA is part of a federal team providing disaster back-up planning to the
Atlanta-based Olympics.
In 1989, the VA became a Cabinet level Department of Veterans Affairs headed by a
Secretary rather than an Administrator. Later legislation changed the Chief Medical
Director to the Under Secretary for Health and renamed the Veterans Health Service and
Research Administration as the Veterans Health Administration (VHA).
In 1995, VHA reorganized into 22 veterans integrated service networks and reorganized
and downsized headquarters. Under Secretary for Health Kenneth Kizer, M.D., M.P.H.
envisions a thriving veterans health system well into the next century, with VHA serving
as a model for healthcare delivery and quality. To meet that objective, sweeping cultural
changes are underway, with an emphasis on customer service and value. Other changes in tap
include revamping the residency and research programs, increased sharing and cooperating
agreements with the private and public sector, and eligibility changes that will allow a
greater focus on primary and ambulatory care.
Today, VHA deals with issues not even imagined 50 years ago: AIDS, Persian Gulf
illnesses, Agent Orange, telemedicine, computerized medical records, homelessness, to name
only a few. And the sheer size of VHA -- the largest integrated health system in this
country -- would not doubt stagger those early VA pioneers. Today, VA provides care
through 172 facilities, 126 nursing homes and 32 domiciliaries. It has 200,000 employees,
treats 1.1 million inpatients and has an average daily inpatient census of 87,504. The
newest VA medical center just opened its doors in Detroit in June 1996.
Some things never stop changing -- the state of medicine, standards of care,
technology, to name a few. But some things never change. For 50 years, employees of the
veterans healthcare system have cared for veterans with compassion and skill. That will
never change -- even in the next 50 years.
Primary reference: Medical Care of Veterans published by VA in 1967
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