The Veterans Health Administration VHA

Federal hospitals for veterans date to the National Home for Disabled Volunteer Soldiers, created by Congress in 1865 for Union veterans of the Civil War. After World War I the Veterans Bureau built dozens more, and in 1946, with sixteen million World War II veterans home, General Omar Bradley reorganized the system and affiliated its hospitals with medical schools, a partnership that still trains most American doctors at some point in their careers. The health side of the VA became the Veterans Health Administration when the department was elevated to cabinet rank in 1989.

VHA runs about 170 medical centers and more than 1,100 outpatient clinics, along with nursing homes, residential treatment programs, and Vet Centers for readjustment counseling. About 9 million veterans are enrolled, and the system handles more than 100 million outpatient visits a year. Eligibility depends on service-connected disability, income, and other factors, and enrolled veterans are placed in priority groups. The system is a world leader in prosthetics, spinal cord injury care, post-traumatic stress treatment, and geriatric care, fields shaped by the needs of its patients.

With about 400,000 employees, VHA is the largest employer within the VA and among the largest health care employers anywhere. It pioneered the electronic health record in the 1990s with a system called VistA, which helped make VA hospitals, by several studies, as good as or better than private ones on many quality measures. Its effort to replace VistA with a commercial system, begun in 2018, has been plagued by patient safety problems and delays, and costs have run into the tens of billions. Its research program has produced the nicotine patch, the shingles vaccine, and the first liver transplant.

The central debate is how much of veterans' care should happen inside VA facilities and how much should be bought from private providers. The MISSION Act of 2018 made community care a permanent option when VA waits or distances exceed set limits, and community care now accounts for roughly a third of the health budget. Supporters say it gives veterans choice and shorter waits. Critics, including many VA clinicians, say it fragments care, costs more, and slowly hollows out a system that does specialized veterans care better than the private market.