From humble roots at a single naval hospital in Philadelphia in 1812, the U.S. veterans healthcare system has expanded into the biggest healthcare system in the country, with 172 hospitals and more than 700 clinics, nursing homes and other facilities.
VA hospitals admitted 671,000 patients in federal fiscal 1997, and veterans visited ambulatory clinics nearly 32 million times. In May 1998, 3.3 million veterans were enrolled in VA primary-care plans. Of those, nearly 1.9 million qualified for care because of their income.
The sprawling system is shaped as much by pork-barrel politics as it is by veterans' needs. Many of the VA facilities are concentrated in Northeastern urban centers partly because of affiliations with large academic medical centers. But as they've aged, many veterans have moved from those centers to the Sun Belt.
Cities including Boston, Chicago, Cleveland and New York have multiple VA medical centers and dwindling veteran populations.
Other medical centers are, surprisingly, in rural communities in the South and West, because chairmen of powerful congressional committees and subcommittees wanted those facilities built in their home states or districts.
This maldistribution of facilities and the distance many veterans have to travel to get to them have reduced access for many.
The VA has sought to equalize access, however, by putting all 22 of its integrated networks on capitated budgets. That move caused financial losses for seven networks, all in the Northeast and Great Lakes states; the rest have made money.
It wasn't always so. In the early 19th century, the federal government's safety net for combat-wounded soldiers consisted of homes for disabled veterans. The first, the Naval Home in Philadelphia, opened in 1812. It was followed by the Soldier's Home and St. Elizabeth's Hospital, built in Washington in the mid-19th century.
After the Civil War, local branches of the National Home for Disabled Volunteer Soldiers, established largely as a residence for disabled soldiers, also began providing medical care to disabled and indigent veterans.
During World War I, there were more than 200,000 wounded U.S. soldiers. The armed forces hospitals didn't have enough beds to treat all disabled patients through recovery. After the war, the federal government transferred responsibility of disabled veterans to the Public Health Service.
But even with new hospitals, the federal government could not meet the needs of the returning disabled veterans and had to contract with local hospitals for care. The National Homes for Disabled Volunteer Soldiers also increased the intensity of care it provided, so that by the late 1920s, it was equivalent to hospital care.
With more than 670,000 wounded in World War II, the federal government vastly expanded the healthcare mission of its Veterans Administration. From 1942 to 1950, the VA grew to 151 facilities from 97 hospitals. Many of those were converted hotels, tuberculosis sanitariums and military hospitals.