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The VA as a Patient (VA I)

In honor of Veterans Day, the in-Training staff would like to dedicate a few pieces in “Military Medicine” to the Veterans Administration (VA), an institution entrusted with serving those who served us. This article is a primer, perhaps more correctly a gross oversimplification, of the history of veterans’ health care in the United States. As with any medical student interpreting a history, there may be crucial details omitted and wholly unnecessary information retained. This is hardly definitive, but instead an introduction from an outsider’s perspective.

Medical students often encounter the phenomenon of two completely different recited stories: students hear one thing and attendings another, and I suppose the VA is no different. It works, but it doesn’t. It’s supportive, but flawed. Overall it’s that difficult but endearing patient you’ve seen in your clinic your whole career. I dare say that the VA realizes what the United States learned long ago: that any compensation for those who surrender all inevitably falls short.

Few references offer a unique VA perspective, and fewer still comment on its history. It’s a bit ironic, too; all the patients at even just one VA facility are probably filled with more knowledge, humor and wisdom than UpToDate and Cochrane shoved together. The entirety of the history in this article comes from the Department of Veterans Affairs PDF, “VA History in Brief.”

The VA that we know today, in its strictest sense, began only in 1930 with the fusion of the Veterans’ Bureau, the Bureau of Pensions and National Homes for Disabled Volunteer Soldiers. The sentiment, however, far precedes official status. As early as 1636, the Plymouth Colony vowed to pay those wounded in its defense. The Continental Congress offered “1/2 pay for life” to men severely wounded in the American Revolution though only about 3,000 availed themselves of the gesture. The first US Congress authorized a formal pension for veterans in 1789 and, by 1816, the list of veteran pensioners rose to 2,200. It included severely disabled veterans, their widows and orphans of both the Revolution and the War of 1812. Congress eventually favored ambiguity in 1818 when it offered pensions to not just the disabled but to all veterans “with need.”

The Civil War added 1.9 million veterans to the pension roster. Interestingly, pensions were only offered to Union Soldiers. Confederate soldiers never received Congressional recognition until an official pardon in 1958 when benefits were extended to the one Confederate soldier still living. The years following the Civil War brought the advent of the National Cemetery Service in 1862, the National Asylum (later, “Home”) for Disabled Volunteer Soldiers in 1865 and further expansion of pension eligibility. Abraham Lincoln’s resonant call in 1865, “to care for him who shall have borne the battle and for his widow, and his orphan,” eventually became the service’s motto.

The Sherwood Act of 1912 finally granted pensions to all veterans regardless of injury or disease status, an act which unknowingly readied for a massive pensioner expansion with the outbreak of World War I. Approximately 4.7 million Americans served in WWI and roughly 320,000 were wounded or killed. The Great War prompted vocational rehabilitation and soldier life insurance. Shortly following the armistice, in 1921 the Bureau of War Risk Insurance, the Public Health Service and the Federal Board for Vocational Education consolidated to form the comprehensive Veterans’ Bureau.

The early 20th century yielded the Great Depression which hurt indiscriminately. Those who served over a decade earlier missed the benefits of wartime industrialization and needed further aid. These servicemen were offered at least $1 per day served. The money, however, was written as a certificate not valid until 20 years after date of issue and thus hardly of help to anyone in immediate lack of necessities. The summer of 1932 saw the “Bonus March” in Washington D.C. advocate for early disbursement of these benefits. Marchers converged in sufficient numbers to overwhelm available sanitation, ignite a public health crisis and were forcibly removed. Their “bonuses” were cashed four years later in 1936. This calamity prompted most comprehensive veterans legislation: the GI Bill.

Formally the “Servicemen’s Readjustment Act of 1944,” the GI Bill was but one of many investments which helped readjust the country to peacetime life, affecting far more than just those who returned from war. It guaranteed servicemen and women the best integration possible: up to four years of educational benefits, guaranteed home, farm or business loans and assured unemployment compensation. The end of WWII brought a change in peacetime objectives, too. The VA opened residency and fellowship positions and, in 1946, first associated with medical schools. The first such partnership was between Hines Hospital in Chicago, Northwestern University and the University of Illinois. This exchange of course continues today; many students are required to rotate through VA facilities and some schools offer longitudinal clerkships for students passionate about serving the veteran population. It remains a center of learning known for both unique history and pathology.

The VA served dutifully even amidst the breakdown of national consensus throughout the Vietnam War. It continued to offer its resources to those who returned from war to face a nation that viewed their service with either apathy or anger. Widespread unemployment encouraged 76 percent of all eligible veterans to claim their education benefits and profit from VA follow-up programs. Unique challenges of Vietnam War veterans spurned the creation of health facilities, assistance centers, alcohol abuse counseling and substance dependence services.

Finally, as the independent federal agency with the largest budget and with roughly one-third of the US population eligible for benefits, President Ronald Reagan elevated the VA to cabinet status and appointed the first Secretary of Veterans Affairs in 1989.

As of 2005 the VA boasted a $63.5 billion-dollar budget to support almost 25,000,000 veterans. At the time of source authorship it was associated with 105 medical schools and 55 dental schools. Its (as of 2005) $1.5 billion-dollar research fund produces renowned innovations in prosthetics, blindness rehabilitation, spine injury, AIDS, PTSD, aging and amputee care. Its 300 grants for homeless veterans reduce the number of indigent servicemen every year.

Jason Bunn (3 Posts)

Medical Student Editor

University of Colorado School of Medicine

Jason is a member of the Class of 2020 at the University of Colorado School of Medicine. He graduated from UCLA with a bachelor's in molecular biology and a minor in French. He loves the med school science, the med school humanistic curriculum and, frankly, the med school naps. His other interests are running, writing, history and travel.