TWO
Hitting Bottom

No other health-care provider in the United States has had such a scandal-filled and controversial past as the VA, and so it is no wonder that many Americans have long pointed to its example as proof that government-provided health care is a very bad idea. Yet a closer look at the checkered history of the VA reveals subtler lessons, both about how government-run institutions can and do fail and about how ordinary men and women can reinvent them—even over the objection of their bosses.

The story begins with one of the biggest political scandals in American history. One afternoon in 1923, a visitor to the White House was mistakenly sent to “The Red Room” on the second floor. Approaching the door, the visitor encountered the commander in chief with his hands around a man’s neck shouting, “You yellow rat! You double-crossing bastard. If you ever …”

The object of Warren G. Harding’s wrath, so goes the story, was Colonel Charles R. Forbes. Forbes was a dashing and charismatic man, fond of playing poker and living the high life. Both Harding and, especially, his wife, it was said, found him to be great company when they first met him while on vacation in Hawaii. “Colonel Forbes was the type of man around whom women always have buzzed,” explained one Harding loyalist in his memoirs.

But Forbes was also the type of man who, despite being a deserter in World War I, somehow became a colonel, winning the Congressional Medal and enjoying a strong leadership role in the American Legion. And he was also the type of man who could win enough confidence from the president of the United States to be appointed to the politically sensitive and morally crucial role of heading up the newly formed Veterans Bureau, where he was tasked with organizing the health care of millions of wounded veterans of the Great War.

He was a poor choice, for he also turned out to be one of the greatest crooks ever to hold high office in the United States. By the time all the investigations were over, and Forbes had been sent off to serve hard time at Leavenworth, the total tally for his graft and flagrant waste of taxpayer dollars stood at $200 million, or about $2.1 billion in today’s money. Forbes took lavish kickbacks on the various veterans hospitals he built around the country. For example, he used taxpayer dollars to pay more than five times the market value for the land on which the VA hospital in Livermore, California, still stands. For his troubles, he and a fellow partner in crime each pocketed $12,500 in kickbacks. When he wasn’t touring the nation picking out other lucrative sites on which to build hospitals, he was entertaining extravagantly and living a life of luxury in Washington, ostensibly on his government salary of $10,000 a year.

To maintain his lifestyle, Forbes plied the Veterans Bureau with trainloads of unneeded provisions, such as a 100-year supply of floor wax, which he then sold off by the trainload for pennies on the dollar in exchange for kickbacks. Boxcars filled with bed sheets, drugs, alcohol, and other hospital supplies—many desperately needed by overcrowded veterans hospitals—would arrive at the railroad siding outside the Veterans Bureau’s warehouse in Perryville, Maryland, only to be reloaded out the back door almost immediately for resale as “government surplus.”

Not only was Forbes’s graft extraordinary, but he let down millions of Great War veterans, many of them poisoned by mustard gas and otherwise grievously wounded, thereby making a “lost generation” feel even more abandoned. Reflecting on his experience with Forbes and his cronies, Harding would later famously say, “I have no trouble with my enemies. I can take care of them. It is my friends. My friends that are giving me trouble.”

Routineers and Mediocrities

Yet it wasn’t just scandal—but attempts to avoid scandal—that marred the veterans health system for much of its history. One of the reasons the VA would later emerge as such a rule-bound and ossified bureaucracy was that, after the example of Charles Forbes, subsequent administrators were terrified by the prospect of unauthorized spending and insider graft. The first of these was Brig. Gen. Frank T. Hines. One chronicler of the VA describes him as a “bald-pated, slightly built shipbuilding businessman who spent the next twenty-two years trying to keep the Veterans Bureau (and beginning in 1930, the Veterans Administration) from the pit of financial corruption.”

In 1945, muckraking journalist Albert Deutsch testified before Congress about the type of bureaucracy Hines had created:

He placed excessive stress on paper work. Bureaucratic procedures were developed, which tied up the organization in needless red tape. Avoidance of scandal became the main guide of official action. Anything new was discouraged: “It might get us in trouble.” Routineers and mediocrities rose to high office by simple process of not disturbing the status quo. Good men were frozen out or quit.… The agency increasingly was controlled by old men with old ideas.

After World War II, Omar Bradley, the storied “soldier’s general,” took over the Veterans Administration for two years and did much to bring its health services into the modern age. At the time, the nation’s newspapers were full of headlines such as “Veterans Hospitals Called Backwaters of Medicine” and “Third-Rate Medicine for First-Rate Men.” In an attempt to turn the situation around and prepare for the huge wave of returning World War II veterans, Bradley had a memorandum sent to the deans of the nation’s medical schools, offering them an attractive deal. They could partner with local veterans hospitals and use their facilities to help train medical internists and residents, while also having their faculties control hiring and firing decisions.

This was a fateful decision that changed the course of the VA, and of American health care as a whole. Today, an estimated 65 percent of all doctors practicing in the United States have received all or part of their training in VA facilities. The deep collaboration with the nation’s medical schools also helped the VA to raise the caliber of its doctors and led to veterans hospitals enjoying much better reputations, at least among the World War II generation of veterans.

One prime example is former senator Bob Dole, who remains grateful for the prolonged treatment he received in veterans hospitals after being strafed by Nazi machine gun fire during the final weeks of World War II. He married his nurse and spoke movingly throughout his life about the men and women who helped him for over two years to recover from his paralysis. The VA, which also did a capable job of administering the generous educational and housing benefits extended to World War II vets under the GI Bill, enjoyed a golden moment of high public esteem.

But the moment was fleeting. By the mid-1950s, Congress was already rapidly cutting the VA’s budget, causing massive layoffs. Many Korean War vets discovered they could not get into VA hospitals unless they could prove they had service-related disabilities. At the same time, a census taken in 1954 found that 65 percent of patients had been in VA hospitals for more than ninety days and that 8 percent had been in the hospital for over twenty years! Many VA hospitals remained little better than warehouses for the homeless, the infirm, and the aged.

It was also true, however, that, thanks to its affiliation with medical schools, the VA continued to distinguish itself by developing many innovative medical techniques. During the 1950s, Rosalyn Yalow did her work in nuclear medicine at a VA hospital in the Bronx that would later earn her the Nobel Prize. In the early 1960s, endocrine oncologist Andrew V. Schally was doing the experiments in his lab at the New Orleans VA hospital that would make him a Nobel laureate as well. In the early 1970s, the VA became the first health-care provider in the United States to install nuclear-powered heart pacemakers.

But there were also recurring instances of veterans being subjected to medical experiments and treated as guinea pigs. As early as 1950, fourteen VA hospitals, all affiliated with medical schools, were performing radiation experiments on patients under the VA’s radioisotope program. Yet, while these experiments may have advanced the cause of science, there is no record that the VA even contemplated a program for acquiring informed consent until 1958.

Ironically, in the course of testing the effects of LSD in the early 1960s, the VA hospital in Palo Alto, California, gave it to a man named Vic Lovell, who enjoyed “the trip” so much that he “turned on” his friend and neighbor Ken Kesey to the psychedelic experience. Kesey got himself a job at the VA to secure his supply, eventually stealing LSD from the hospital when the trials were over. While tripping with schizophrenics in the hospital’s psychiatric ward, Kesey received the inspiration, he would later say, for his masterpiece, One Flew Over the Cuckoo’s Nest. He and his band of Merry Pranksters went on to make “acid” seem cool to a whole generation of Americans.

Broken Promises

At around the same time, veterans started returning from Vietnam to an ungrateful nation. Maybe it was the lucky ones who were treated to mind-altering drugs. Not only did many returning Vietnam vets find veterans hospitals woefully underfunded and run down, many found them staffed by people they regarded as hostile. Some were house officers and doctors their own age who opposed the war and had avoided the draft by going to medical school. Others were older vets who viewed Vietnam veterans as losers and who dismissed their complaints about post-traumatic stress and exposure to chemical agents like Agent Orange as unmanly. It wasn’t until 1978 that the VA even set up a registry of veterans exposed to the 19 million gallons of Agent Orange and other dioxin-laden defoliants dropped on Vietnam. It wasn’t until 1991 that the VA stopped demanding that Vietnam veterans exposed to Agent Orange offer proof.

Many Vietnam veterans were also insulted by the conditions they found in veterans hospitals. In an autobiography that later became the movie Born on the Fourth of July, Ron Kovic, a two-tour marine who was severely injured in Vietnam, told the story of his experience in a veterans hospital in the Bronx. After describing how the hospital lacked the equipment he needed as an amputee to learn how to walk again, he quoted a young doctor’s matter-of-fact explanation that it was all because of the war. “The government is not giving us money for the things we need.”

The result of all these tensions, hard feelings, and strained budgets was something approaching complete institutional failure at many veterans hospitals. Part of the problem was that, thanks to improvements in combat medicine and air evacuation, many Vietnam veterans were men who would have died of their wounds in previous wars, and who were now coming home instead with severe injuries and disabilities. But that was hardly an excuse for the conditions many of them faced. Activists among the new generation of vets did everything they could to draw media and public attention to the failings of various veterans hospitals, even if it sometimes meant exaggerating how bad they were.

One of those activists was Oliver Meadows, a former commander of Disabled American Veterans and staff director of the House Veterans Affairs Committee. He would later proudly recall how he and others “literally staged specials with ABC, NBC, and CBS. We staged the network spectaculars. We had major articles in Reader’s Digest and Life magazine. They were all over the country. We had a specially tailored story written for St. Louis, for example, and the local papers would pick it up. Every VA hospital in the country was covered. We released material to those papers where the hospital was located.”

On May 22, 1970, Life published a photo essay about conditions in the Kingsbridge VA hospital in the Bronx that fixed the reputation of veterans hospitals in the post-Vietnam era. The story quoted a quadriplegic lance corporal: “Nobody should have to live in these conditions. We’re all hooked up to urine bags, and without enough attendants to empty them, they spill over the floor. It smells and cakes something awful.… It’s like you’ve been put in jail, or you’ve been punished for something.” Worst of all, the lance corporal continued, were the rats.

Meadows would later say the Life story “was totally contrived, we helped them all the way.” And indeed, according to Robert Klein, author of the 1981 book Wounded Men, Broken Promises, which is generally an exposé of veterans hospitals, some VA officials, and at least one veteran interviewed for the Life story, claimed that conditions in the various VA hospitals were actually staged by activists to make them look more awful and sensational than they really were. Yet there is also no doubt that many veterans hospitals in this era had sunk into squalor and become little better than medical slums.

During the Carter years, the VA was headed by Max Cleland, himself a Vietnam veteran and a triple amputee, who would later use his considerable political skills to become a U.S. senator from Georgia and a Democratic Party icon. Yet during his tenure at the VA, many vets came to believe that Cleland had been “fragged” by his own men in Vietnam and resented his attempts to portray himself as one of them. Furious at Cleland’s refusal to acknowledge the link between exposure to Agent Orange and their subsequent cancers and disabilities, a throng of Vietnam vets came close to physically attacking Cleland in his wheelchair during a Senate hearing, taunting, “Did you lose your balls in Vietnam, too?”

The Iron Triangle

Probably the only reason the veterans’ health system survived this era was the “iron triangle” of inside politics. Medical schools benefited from their access to, and in many cases, control over, veterans hospitals. The major veterans service organizations, whose leadership often wound up being appointed to high positions in the VA, wanted the system improved and expanded, not eliminated, as did the public employee unions that represented much of the VA workforce. Politicians benefited from the jobs and money the VA brought to their communities, to say nothing of “free” health care the VA provided to indigent and low-income vets who otherwise would have become a local responsibility.

Even those politicians who believed that “patriotism should be its own reward,” and who regarded the veterans hospitals as “socialized medicine” gone predictably amok, did not feel comfortable voting to close veterans hospitals and found it easy not to. To this day, the various conservative organizations that rank members of Congress count votes for veterans benefits, not as examples of supporting the welfare state, but as votes for national defense.

And so the checkered course of the VA continued. Fortunately, however, in the deepest recesses of the VA’s moribund bureaucracy, a quiet revolution, initially driven by a few lowly dissidents—some idealistic computer geeks, others idealistic doctors, pharmacists, and other medical personnel—had been set in motion. It was a revolution from below that, once embraced by charismatic new leadership, would lead to the VA’s becoming by the end of the century a world leader in safe, high-quality, and innovative health care. The revolution got ugly at times. At one point, a suspicious fire damaged one of the dissident’s computers. Others were forced to quit or were driven into effective exile. “There were some nasty, nasty games played,” recalls one participant. But in the end, not even the most entrenched plutocrats in the VA’s Washington office, nor their enablers in political office, could put down the insurrection of the Hardhats, as the dissidents came to call themselves.