Talk to the patients in the hospital beds and waiting rooms at Department of Veterans Affairs hospitals today and you'll find the men and women who hit the beach at Normandy, fought on Pork Chop Hill and repelled the Tet Offensive.
But fast-forward 20 years: Most of the 10.3 million veterans of World War II and the Korean War will have died. And although the 8.2 million Vietnam veterans-by then in their 60s and 70s-will be using the system at rates similar to that of their elders, the only group behind them will be the 1.9 million Gulf War veterans.
Meanwhile, the smaller military conflicts predicted by the Pentagon decades earlier will have produced ever-smaller generations of veterans who suffer from the disabilities that entitle them to VA care.
These demographic trends undoubtedly will raise some uncomfortable questions for the VA and Congress: Who is served by the VA's system of 172 hospitals and hundreds of clinics, nursing homes and extended-care facilities? And does it make sense for American taxpayers to continue financing a government-owned and -operated healthcare system that spends $17.3 billion a year and serves a shrinking population, when the government could buy the same care in the private sector?
A small group of contrarians has an answer: Privatize the VA.
Persistent heresy. Although that solution is virtual heresy in Washington, where veterans groups are among the most powerful lobbies, it doesn't seem to go away.
"We have to get away from this fixation on facilities," says Carrie Gavora, a healthcare policy analyst with the conservative Heritage Foundation.
"You've got the VA sitting out there, and it's going to be more and more contentious because it (represents) a lot of money," says Robert Helms, director of health policy studies at the American Enterprise Institute, a free-market think tank.
But for now, Helms says, the political environment makes such a discussion difficult. "There aren't many brave people out there," he says.
Even VA officials concede that the system may be too large to treat the veterans of 2020.
"I would think that over time we would need fewer hospitals," says Deputy VA Health Undersecretary Thomas Garthwaite. "The demographics alone would lead you to conclude it."
The benefits. If the federal government privatized the VA, the reasoning goes, it would spend less to build and maintain its healthcare facilities and could spend more on veterans' healthcare.
The VA estimates that the replacement value of the system's capital assets is $33 billion. Its nonrecurring maintenance and repair costs will be $269.6 million in federal fiscal 1999, which began Oct. 1.
Furthermore, if the VA were privatized, veterans who lived far from VA hospitals or clinics would have greater access because they could use their benefits as Medicare beneficiaries do: at hospitals and doctors in their communities.
That, in turn, could help ease overcapacity in non-VA hospitals, where more than one-third of beds, on average, sat empty in 1996.
Carmela Coyle, senior vice president for advocacy and representation at the American Hospital Association, says the VA will continue to contribute to overcapacity because it is government funded and not subject to the market forces faced by privately owned hospitals.
"Because the VA is this walled-off entity funded in a different way . . . I think there is a tendency to create a separate solution for that," Coyle says. "Those organizations will continue so long as they're funded by the government."
But privatization means different things to different people. Some, like members of the conservative think tanks, believe the best way to privatize is to give vouchers to eligible veterans that they could use to buy private or public health coverage.
Not the first time. It's not a new idea. In 1975, for example, Helms' group, the American Enterprise Institute, published a report questioning the need for a separate VA healthcare system for a population that was better-educated, usually employed and covered by health insurance. It proposed providing veterans with insurance coverage rather than direct medical care.
Cotton Lindsay, then a professor at the University of California-Los Angeles, wrote the report for the institute. Later, in the early 1980s, the General Accounting Office, Congress' investigatory agency, asked Lindsay to meet with VA officials and other experts to discuss his research, he says.
But VA officials weren't interested in his research. "We were told to go study something else," says Lindsay, now a professor at Clemson (S.C.) University.
"(The VA officials) mentioned an earlier staff report (on privatization) that had been done internally. There had been a lot of people reassigned" because of it, Lindsay says.
But such resistance hasn't deterred others from proposing that veterans be given vouchers to buy healthcare coverage at facilities such as competing private-sector hospitals.
In the 1980s, the Maryland Hospital Association, then led by current American Hospital Association President Richard Davidson, proposed a three-year demonstration of healthcare vouchers in Maryland. The association was fighting the construction of a new facility next to University of Maryland Hospital in Baltimore.
At the time, the MHA objected to the building of a new VA hospital because the Baltimore area had at least 300 excess beds and because the VA could draw nurses from private hospitals in the midst of a nursing shortage.
The association claimed that with vouchers veterans would have better access to more medical service without costing the federal government $96 million to build the facility.
But the MHA lost that battle.
"We caused all hell to break loose," says Richard Wade, who had been vice president for public affairs at the MHA and is now senior vice president for communications at the AHA.
But by offering an alternative, Wade says, the MHA gained some quiet backers in the government and the veterans community who could not side with them publicly because of the power of the veterans groups.
Narrower view. Others-VA officials in particular-define privatization more narrowly. They point to their expansion of community-based outpatient clinics, which number more than 400, about half of which are privately owned physician practices operating under contracts with the VA. Those outpatient clinics aim to expand access to healthcare provided or funded by the VA.
"The principle must be that people (receive) primary care," Garthwaite says. "But we don't have to own the building or employ the clinicians."
VA officials also point to several cases in which VA medical centers have shut down their inpatient services and contracted with private-sector hospitals to treat veterans with acute-care needs.
"Our goal has to be (responding to) what are the veterans' needs and how do we best serve them," Garthwaite says. "It's less and less about buildings and more and more about coordination of care. We see this increased partnering. We will continue to look at buy/build decisions: Where does it make sense to buy, and where does it make sense to build?"
The VA decided it made sense to buy in Grand Island, Neb. Last year, the VA shut down all of its six intensive-care beds and 14 medical beds and contracted for that care with nearby Saint Francis Medical Center, a 139-bed hospital owned by Catholic Health Initiatives, Denver.
Before the decision to contract with Saint Francis, the VA facility had an average of seven patients in its beds.
In fiscal 1998, Saint Francis saw 1,093 VA patients for inpatient care, observation or emergency care. The conditions treated most often were congestive heart failure, pneumonia and chest pains.
The VA facility kept its outpatient and residential substance-abuse services and a 76-bed nursing-home unit.
Karen Reese, Saint Francis' vice president of patient-care services, says the patient-satisfaction surveys from veterans for the hospital and the VA have been positive.
But veterans haven't always felt that way.
"It was quite controversial when VA made its decision," Reese says. "The veterans saw it as losing their facility."
Bad feelings. The Nebraska veterans weren't the only ones who have been apprehensive. National veterans groups don't like many of the changes they see. Without a doubt, they oppose anything that smacks of a voucher system. They point to a landmark 1996 law that redefines eligibility categories as evidence that Congress backs them up.
"The heart of the system is the system," says Richard Fuller, national legislative director for Paralyzed Veterans of America. "Eligibility reform has underscored the fact that there is a cohort of eligible veterans who are guaranteed healthcare through a system. VA is a provider, not a payer."
Such groups are backed by the VA, which says its research has shown that private-sector hospitals would incur more costs to treat veterans because they tend to be sicker than nonveterans. Therefore, any voucher the VA could offer to pay for private health insurance coverage would not cover the cost of treatment.
"(Researchers have) been able to conclude that the VA provides a reasonable price for (caring for) high-risk patients," Garthwaite says.
But even the idea of contracting with private hospitals, clinics and nursing homes gets a tepid response from veterans. They fear that the private sector is not well-equipped to meet the specialized needs of the chronically ill and disabled patients who often are treated by the VA.
Eligibility for VA care is based primarily on disabilities related to veterans' time in the military or on income.
The veterans groups say private providers cannot compete with the VA in treating disorders that are more common among veterans than civilians. Those include spinal-cord injuries, loss of limbs and mental illness.
"It's relatively easy to go out and buy routine medical and routine surgical care," Garthwaite says. But he adds that giving veterans a voucher to purchase excellent private treatment for spinal-cord injuries would prompt the veterans to respond, "We know what's out there, and we're going to fight hard" for specialized care in the VA.
Furthermore, the veterans groups say, privatizing VA healthcare through a voucher or contracting hinders the department from overseeing the treatment for which the federal government is paying.
"You're never quite sure if the contractor knows how to care for the spinal-cord-injured patient," Fuller says.
And the VA often serves as a safety net for sick, poor and homeless veterans who have no other source of healthcare. More than half of veterans enrolled in the VA's primary-care plans in May 1998 qualify for coverage because they are poor, and 21% of the VA's patients have no health insurance.
"We don't have the luxury of walking away from a market," Garthwaite says.
Commitment symbol. Veterans, too, see the VA healthcare system as a symbol of the nation's commitment to their service, and they are reluctant to give that up.
"The system is very much theirs," says Jacqueline Garrick, deputy director of healthcare for the American Legion. "It does ensure that veterans get the attention that they need."
But in private hospitals, "my big concern is that they would be considered as charity patients and treated as charity patients. That isn't so," says Robert Conroy, M.D., president of the National Association of VA Physicians and Dentists and a radiologist at the Long Beach, Calif., VA hospital.
Such resistance from the veterans community, which wears the whitest of white hats among Washington lobbyists, impedes any movement toward a more privatized VA healthcare system, particularly when the subject of vouchers arises.
"There are members who, behind closed doors, might see different futures for VA healthcare . . . , but for purposes of a public position, are going to reflect the position of the mainstream (veterans groups)," says one House aide, who asked not to be identified.
Adds a Senate aide, who also asked for anonymity: "There's nothing to be gained by trying to swim upstream."