VA: the Sagging Survivor

DANIEL S. GREENBERG

September 30, 1993|By DANIEL S. GREENBERG

WASHINGTON. — Washington -- Antiquated and long overdue for termination, the hospital system of the Department of Veterans Affairs has again demonstrated its political untouchability by coming through unscathed from the Clinton-Gore plan for reinventing government.

The blueprint for remaking the federal bureaucracy merely asks the department to consider the president's health-care proposals ''and take actions to restructure the VA health-care system.'' No surprise in that mild, non-specific prescription, given the electoral retribution that veterans organizations grimly vow against legislators who tinker with their favorite government program.

So much for the VA and the reinvention scheme. However, under the Clinton health plan, the veterans-hospital system would be routed from its insulated emplacements on the medical landscape and subjected to the rigors of competition in service and price. Since the presidential redesign of American health care faces many months of politicking and deliberations on Capitol Hill, there's no telling what the outcome will be for VA health care or any other part of the effort to revolutionize the medical system. But as spelled out in the heavily leaked ''working-group draft'' of the Clinton plan, the intent is to push the VA hospital system into a sink-or-swim environment.

At present, the VA medical system draws some $15 billion a year from the U.S. Treasury, and the money keeps coming, regardless of the quality and cost-efficiency of the medical service provided by the VA. Unfortunately, virtually every review of VA health care -- except those carried out by the VA itself -- deplores the system's performance as inadequate and sometimes needlessly dangerous to health.

Nonetheless, the VA seems to have achieved bureaucratic immortality. Though only 2.6 million of the nation's 27 million veterans avail themselves of any kind of health care VA style, the VA hospital empire has stood steady for many years at 171 separate institutions, making it the largest hospital system in the country.

The VA's hospital-building program evolved after World War I, when hospital space for veterans was in short supply. By 1930 it consisted of 54 hospitals. After World War II, it just kept growing, despite a huge surge in federal assistance for building non-government community hospitals.

In addition to the hospitals, the VA operates 350 outpatient clinics, 128 nursing homes, and 35 domiciliaries. Any attempt to close a VA hospital evokes a Stalingrad defense by veterans groups and local beneficiaries of the VA payroll.

In the waning days of the Bush administration, a proposal to open underutilized VA facilities to non-veterans in rural areas set off political explosions in Congress and were promptly rescinded. As a sop to the irate veterans lobbyists, VA chief Edward J. Derwinski was forced to walk the plank. Though the American hospital system remains over-bedded, the VA has recently built several new medical centers, including one in Baltimore. In the never-never land of guaranteed federal appropriations, the system just rolls on.

The Clinton health plan is prudently low key about the place of VA health care in the highly orchestrated national system proposed by the president. Rather than declaring a clear-cut goal, the plan states: ''The Department of Veterans Affairs may organize its health centers and hospitals into health plans or allow them to function as health providers contracting with health plans or other providers to deliver services.'' To which are added the key words that could make or break the VA health-care system: ''Health plans organized with the VA system [must] conform to the requirements and standards for all other health plans.''

In the arcane language of health policy, what that means is that the VA hospitals would have to meet the quality and cost standards established in their region, or they wouldn't be permitted to treat patients. In addition, the VA hospitals could open their doors to non-veterans enrolled in the national health-insurance system.

But don't count on any radical changes in what is surely America's most coddled and incompetent health-care system. Vets who need medical care, for whatever reason, deserve better than this broken-down product of long-ago wars and enduring pork-barrel politics. However, Bill Clinton has characteristically pledged that the details of his health plan are negotiable. The vets' organizations have no doubt already called for an appointment.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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