“What’s past is prologue” may have originated as a Shakespearean bon mot, but it’s the U.S. Department of Veterans Affairs that lives it, the U.S. Military that frequently quotes it, and the U.S. Archives Building that bears it proudly etched on its façade—a handy metaphor for how history helps clarify the most obscure policy fights that occur again and again down the road on Capitol Hill.
The American public, along with many veterans, do not believe that the Federal government pays enough attention, or spends enough taxpayer money, on veterans. That assumption fuels the conclusion many politicians voice that helping veterans must equate with increasing public spending on veterans. Every Member of Congress could quip, as Senator Patrick Leahy (D-VT) did during the 2018 budget skirmishes, “You don’t go to a veterans assembly and say, ‘We’re not going to help the veterans.’” While the conflation of the two might make for superb PR, what the historical records show is that it’s hardly accurate. The Federal government has consistently set aside a hefty portion of its budget for veterans. In fact, more than 100 years of expanding Federal benefits for veterans have resulted in the VA’s current status as the second largest Federal agency overall. The most significant portion of that growth, however, has occurred in less than 30 years, with most of the period involving the Global War on Terror.
More intriguingly, that same historical record also reveals veterans’ policy to be among the most contentiously political, most resistant to independent analysis, policy field—that is, when outside scrutiny is even allowed.
Between 1980-2006—years spanning the height of the Cold War, the Balkans campaign, and the First and Second Iraq Wars, and the first years of the war in Afghanistan—the VA budget grew by 40 percent. It also saw the VA become a cabinet-level agency. Since 2006, and despite decreasing numbers of veterans nationwide, the VA’s budget has had stratospheric growth. Between 2006 and 2017 alone, VA’s budget had a 94 percent increase in real terms. (This compares with the Department of Defense’s actual 4 percent drop; Education’s 6 percent drop, and Labor’s 20 percent drop). For Fiscal Year 2020, President Trump proposed a 9.6 percent increase from FY 2019, for a total VA budget of $220.2 billion dollars.
On February 10, the Trump Administration submitted its Fiscal Year 2021 budget to Congress. With the new budget, VA receives a 13 percent increase in its top-line budget, making good on VA Secretary Robert Wilkie’s promise to the American Legion this past August, that 20 years of budget trends would hold true and that the VA wouldn’t see its funding decrease. The top-line budget request now stands at $243.3 billion, including a discretionary spending boost totaling $109 billion, making VA second only to the Department of Defense in discretionary spending. For a little context, the sum of the 2021 VA budget is now larger than each proposed budget of the separate branches of the Armed Forces (U.S. Army, $178 billion; U.S. Navy plus U.S. Marines, $207.1 billion; U.S. Air Force, $153.6 billion, and the new U.S. Space Force, $15.4 billion dollars).
Like President Trump’s 2020 budget, despite the 2021 top-line increase, the VA budget includes some modest cost-savings plans for a handful of programs within its three major administrations (Health, Benefits, and Cemeteries). These are to help offset the billion-dollar costs of implementing the 2018 Mission Act’s veteran community health care program and the 2019 Blue Water Navy Act. As in years past, these potential cuts will certainly invite controversy and condemnation: If there’s one reliable reaction to the flow of Federal monies for veterans, it’s characterizing any challenge to that flow, no matter how small, as playing (partisan) politics with veterans’ lives. Before we’re even able to delve into that dynamic, however, we have to grasp two truths: First, the VA does not serve all veterans. Second, the VA budget is hardly the only public money spent on veterans.
Contrary to public assumptions, the benefits and services that the VA’s budget enables it to provide are not meant for each individual who has worn the nation’s uniform. By law and by statute, not all active duty veterans (to say nothing of those who have served exclusively in the Reserves or National Guard) actually qualify to receive even VA health care benefits. Currently, there are an estimated 18 million living veterans in the United States. The Veterans Health Administration (VHA) cares for about nine million veterans, while the Veterans Benefits Administration (VBA) pays disability benefits to about 4.7 million, education benefits to about 900,000, and home loan guarantees to about 600,000 veterans (according to 2018 numbers). Other Federal departments, such as the Department of Labor, the Department of Housing and Urban Development, and the Small Business Administration, also have veterans’ programs specified for particular groups and classifications of veterans. They pay for these benefits out of their departmental budgets, so VA’s $243 billion doesn’t actually equal the full amount designated for veterans in the Federal budget.
This issue of who qualifies, when, and for what Federal veterans services and benefits helps explain why, despite its growing size, the VA budget isn’t the only public money spent on veterans. Each of the 50 states also have their own separate state departments of veterans affairs, called DVAs, each with their own budget and programs for the veterans residing in their state. In 2019, the Institute for Veterans and Military Families (IVMF) at Syracuse University calculated that in addition to the $220 billion that the Federal government budgeted the states collectively spent about $3.3 billion on veterans. And as several reports from the Center for a New American Security (CNAS) have detailed, thousands of private organizations also provide funding and services to veterans every year.
There’s no question that there is a strong flow of government money for veterans. Is it enough money? Is it too much? Is it finally just right? The Goldilocks answer is unnervingly obscure. The VA doesn’t measure outcomes, and only sometimes outputs, rendering it difficult for anyone to know what the VA is doing well—or not well. The instinctive resistance to even superficial independent critiques that the legacy veterans’ organizations often voice, that the VA and even many veterans echo, further insulates the VA from serious accountability. A century-worth of this dynamic means that policy analysts and scholars pay little attention to veterans’ policy; that politicians use veterans-related legislation for purposes well beyond improving actual veterans’ lives; and that the public assumes Federal funding is shamefully neglectful of veterans.
But if there is a lack of serious, policy-backed challenges to the VA appropriations process and its many programs, and if funding is consistently increasing, what are all the VA budget controversies about?
The most recent slew of scandals—touched off by the Phoenix VA secret waitlist scandal and several veteran deaths in 2014—have focused the more intense VA budget fights on the administration of veterans’ health care. The issues have revolved around the question of how much money Congress should allocate to paying for (private) community care for veterans rather than—or in conjunction with—increasing funding for the VA’s internal, aging hospital system. This is a debate that has resonated nationwide. However, a little more time spent in the historical weeds shows that that’s not really because of a serious public demand for what’s best for veterans’ health (genuine as those demands may be). Rather, it’s resonated as a microcosm of the larger debate about the merits of private versus government-run health care, and about the size of government’s role in providing for the needs of each individual citizen.
Neither the 2018 VA Mission Act nor the original 2014 Veterans Choice Act, backlit by the Obamacare debates, actually initiated the present VA budget ruckus. The 1993 “Hillarycare” plan dredged up similar concerns, though from a slightly different angle: The Clinton plan for universalizing health insurance would have extended private insurance to half of veterans utilizing the VHA, meaning that the VHA would have faced the possibility of competing for and potentially “losing” these patients. This plan was actually leveraged as a way to save VHA, rather than see it shuttered in favor of a voucher system. At the time, VA was a poor caterer to either chronic or preventative health needs and had few primary care facilities, many of which were located too far away for many veterans to use. The VHA’s poor performance metrics, juxtaposed with its high cost, were well recognized and publicized, and made for a fair target for the newly elected Republican-controlled Congress in 1994, anxious to limit public expenditures.
But by the 1990s, VHA was also the nation’s largest trainer of health care professionals, providing at least some measure of financial support and clinical training to one-third of all medical residents in the United States. There were still substantial numbers of veterans in Congress, as well as many opportunities for constituent patronage across multiple sectors of society tied to the VA, such as the medical school partnership. Thus no one had stomach enough to gut the VHA. The threat did, however, prompt the Veterans Service Organizations to support the (truly groundbreaking) Clinton White House-backed VA reforms articulated by Kenneth Kizer in his 1995 plan, Vision for Change. The initial success of the Kizer reforms still resonates, prompting many even today to call VHA “the best care anywhere.”
Prior to the VA health care debates of the 1990s were the debates of the 1980s. These were partly responsible for President Reagan’s elevation of the VA to Cabinet status in 1988, as a counterbalancing measure emphasizing the public’s high valuation of veterans. And prior to those 1980s debates were some severely rancorous machinations of the post-Vietnam 1970s.
In 1973, Congress mandated the VA to contract with the National Academy of Sciences (NAS) to do an extensive study of the VA health care system. When NAS delivered its 300-plus page report to Congress in 1977, recommending the gradual integration of VA medical facilities with the private sector, VA’s feathers were intensely ruffled, despite its acknowledgment of the vast majority of the report’s 37 points. A handful of Congressmen, several of whom were themselves veterans, retaliated not just by publicly attacking the NAS study, but also by initiating an audit of its books by the General Accounting Office. The furor prompted more than one New England Journal of Medicine editorial about the futility of attacking patriotism-wrapped “sacred cows,” on the one hand, and about the report being full of policy “pabulum” and the NAS being a political meddler, on the other. That “the whole subject is so loaded with political emotion and vested interest that rational public discourse is hardly possible,” was a notable consensus—one that surely resonated beyond the pages of a single medical journal.
“In this political arena, it seems our arms are too short to box with God,” sighed Dr. Saul Farber, the lead NAS study author, in a postmortem editorial. What the NAS study and analytical attempts before and since have run into is politics, pure but not simple. It’s hard to find data on the VA, and harder still to find public policy analysts knowledgeable about it. Mere commentary has seemed the safer route, traditionally, and so from the safety of historical overviews, the occasional scholar will narrate the kerfuffles involving veterans’ and VA policy, to echo other authors’ opining that any rigorous analysis “trigger[s] a powerful, protective, conditioned reflex.”
Writing specifically about its health care system in her book Burdens of War, Jessica Adler offers some insight into why this is the case. She details how policymakers, veterans, caregivers, and advocacy organizations have continuously reimagined the U.S. veterans’ health system to reflect contemporaneous “ideals and apprehensions” about war, government, health care, and employment, ever since its formal inception after World War I. That is a heavy burden for the VA to shoulder, combining weighty notions of social justice with practical needs. At the same time, the VA is a proud creature of the legislative process. And because VA-delivered health care has a physical footprint, legislators and VA administrators, not to mention veterans’ advocates, have not hesitated to leverage the size, number, and location of VHA facilities as a means of projecting political and social power.
In 1965, for example, VA Administrator W. J. Driver knew that the shifting needs of the aging population of World War I veterans were not the same as those of the World War II veterans (nor of the remaining 3,000 Spanish-American War veterans) and that several medical facilities built in the 1920s couldn’t safely house patients and geographically no longer made sense. There were 168 VA hospitals then, treating 730,000 patients, 158 of which had research projects or partnerships involving more than 5,587 “investigators.” But in total, the inventory of VA-owned properties was 17,400. After extensive study, Driver proposed closing 11 hospital or domiciliary facilities as part of a total recommendation of 32 VA installation closures.
The outrage over these proposals was immediate. More than 75 Members of the House demanded to testify at a February 1965 hearing hosted by the Subcommittee on Hospitals of the Committee on Veterans’ Affairs, producing a published written record totaling more than 1,400 pages for “Part I” alone. Their overwhelming demand: The old hospitals must stay.
“[L]awmakers, veterans’ groups, and other interested citizens [are] angrily charging the VA with trying to do war heroes dirt and creating pockets of poverty at the same time,” wrote one individual in the New York Daily News in response. The author was conflicted though: “Anyone who knows anything about the operation of VA hospitals will agree that the legitimate heroes . . . are usually outnumbered by patients with ailments not even remotely service-connected.” The then-VFW commander in chief, John Jenkins, publicly wondered if veterans were to be the first victims in President Lyndon Baines Johnson’s newly declared War on Poverty. The pushback against VA Administrator Driver’s plan to close 32 properties was sufficiently powerful that he had to modify it, scaling it back.
In total, between 1950-1965, so intense was the opposing pressure that it appears VA successfully closed only 19 hospitals, even while it was offsetting those closures by building new ones. Most of the closed facilities had not been well suited to modern medicine, originally having been converted from schools or hotels, or had been designed for a specific type of medical care, such as treating tuberculosis. Partly because of VA’s research into tuberculosis, it successfully reduced the number of veteran tubercular patients from 17,000 in 1954 to 7,000 in 1964, reducing its need for those kinds of hospitals. Of the 11 VA hospitals Driver had proposed closing in 1965, five had been tuberculosis hospitals. But regardless of whether it was needed to treat veterans any longer or not, each of those physical buildings had created its own constituency, both in the local community and in the larger congressional district. Everyone understood that they were economic tools that could be leveraged politically. More than a decade later, President Carter found himself bowing to political pressure and reversing a decision not to award a VA hospital to Camden, New Jersey. He had originally argued that there were sufficient VA facilities in nearby Philadelphia. But Camden’s Mayor won out in 1978, in the process arguing that the hospital project would be “the cornerstone of a rebuilding program intended to restore the city’s economic viability,” the New York Times reported.
Is it the VA’s responsibility to be the economic cornerstone of any municipality? Given the intertwined opportunities and incentives that VA facilities and veterans benefits present for veterans and non-veterans alike, it’s not surprising that veterans’ policy and the VA budget should attract as many protectors as it does. Whether this dynamic is healthy, or actually beneficial to the veterans that public money is supposed to serve, is another question entirely.
It’s a question that the policy community and the American public should be asking, however, and one that Congress and the VA will be forced to reckon with alarmingly soon. Our national arguments about the role of government in financing and providing health care are hardly exhausted. Additionally, baked into the 2018 VA Mission Act is a mandated Asset and Infrastructure Review (AIR), tasked with compiling a list of facilities to “modernize or realign,” meaning to close down, consolidate, or be reconfigured. This is made necessary in part by the dramatically shrinking demographics of the veteran population, as World War II and Vietnam era veterans pass away, as much as by the sheer age and crumbling quality of many VA properties. It’s also vital because of the VA’s need to align its funding with the needs of actual veterans.
But the not-so-distant past is already prologue: Already, several U.S. Senators have called on the VA to “do what’s right for veterans,” and to abolish the AIR review.