On Watch With Jesse Brown

Aug. 1, 1996

Veterans are the most deserving members of our society,” said Jesse Brown, the Secretary of Veter­ans Affairs. He smiled as he said it, but he was not trying to be funny. He was signaling that, for him, the point wasn’t open to debate.

“Look, veterans are the only Ameri­cans who have actually paid for the benefits they received,” he went on. “They did not get these benefits be­cause they were lucky enough to be born here.”

Secretary Brown, in the midst of his fourth year as leader of the De­partment of Veterans Affairs, is a true believer when it comes to pay­ing off the nation’s debt to men and women who have served in the United States armed forces. His passion stems from a simple conviction: You deserve to be first in line for the benefits when you pay for them with your blood.

He has firsthand experience. In 1965, as a young Marine in Vietnam, Secretary Brown suffered serious wounds in combat. His injury left his right arm partially paralyzed. Since that time, he has devoted his professional life to work as an advo­cate for veterans. He spent more than twenty-five years as one of the top leaders of the Disabled American Veterans. He served as executive director from 1989 to 1993.

Now Secretary Brown runs the federal government’s second-largest agency (only the Department of De­fense is bigger), with a responsibility for serving the needs of the nation’s roughly twenty-six million veterans. The VA provides veterans six major services—compensation and pensions, education and train­ing, home-loan assistance, insurance, medical care, and medical research.

It is an immense job, one that Sec­retary Brown said will only grow in the coming years.

Double Hit

In a recent interview, the Secre­tary said two factors are converging to put the squeeze on the depart­ment. On the one hand, he said, the decreasing size of the veteran popu­lation and escalating budget pres­sures will surely lead many in Wash­ington to try to cut the Department of Veterans Affairs or even dismantle it. On the other hand, the aging of the overall veterans community will bring new and expanded tasks.

The need for the VA is greater than ever, he asserted. He explained that, in the decade 1993 to 2002, the size of the veteran community will decrease by twelve percent, while overall demand for VA services will increase by approximately fifteen percent. For the latter estimate, he referred to projections showing that the agency will be called on to pro­vide services for more chronically ill veterans from the huge World War II cohort.

Secretary Brown argued that, in the current circumstances, any at­tempt to shrink the VA or to reduce veterans benefits would be nothing less than “a cruel trick” on those who left the military with the expec­tation that the government would, to quote the agency’s creed, “care for him who shall have borne the battle and for his widow and his orphan.”

Even so, Secretary Brown said he knows that the VA, in order to sur­vive and prosper, must make pro­found changes in the way it does business, especially in its health-care system.

The VA health-care operation is vast. Secretary Brown oversees the nation’s largest medical system, a network of 171 hospitals, 126 nurs­ing homes, and more than 350 out­patient clinics that provide care to an estimated 2.7 million veterans per year. This is the largest single function the VA performs, and health­care operations comprise about ninety percent of the agency’s staff and roughly half of its budget, or about $18 billion a year.

Critics charge, with ample justifi­cation, that the VA system is fre­quently unresponsive and rigid, gov­erned by rules that seem outmoded and overly bureaucratic. Secretary Brown said he wants to change this. His major goal is to make the VA’s health-care system more flexible so that it can respond to veterans more efficiently.

Needed: New Rules

In order to do this, he said, today’s eligibility rules must be altered to permit a more comprehensive ap­proach to treatment.

Currently, the VA can treat an eli­gible veteran for a service-connected condition and for life-threatening ailments not related to military ser­vice. The irony of this situation can be illustrated with a simple example. If, during the fitting of a new pros­thetic limb, the VA physician dis­covers that the veteran has diabetes or hypertension, the agency cannot by law give the patient ongoing care in most cases. “But,” Secretary Brown said, “if [the veteran] walks out of the hospital and has a stroke or ends up with a massive infection as a re­sult of the diabetes, we can bring him back into the hospital and give him everything he needs.”

This, claimed Secretary Brown, is ridiculous.

“It’s wasteful and antiquated, and it’s not good medicine,” he said. “We need a system that looks at [patients] from the ‘entire-person’ perspective,” meaning that, if veterans are sick, the VA should be allowed “to do everything to make them well, whether it’s inpatient care, outpa­tient care, or whatever.”

In other words, Secretary Brown wants the agency’s doctors to be able to treat the veteran with hyperten­sion or diabetes on an outpatient basis and thus avoid having to hospitalize that person when the condition be­comes life-threatening.

To accomplish this, however, the VA must shift emphasis from in­patient treatment to caring for veter­ans on an outpatient basis. “With the advancements made in modern medi­cine, eighty percent of the problems people have today can be resolved on an outpatient basis,” said Secre­tary Brown.

In addition, the agency must con­vince Congress to loosen eligibility rules that prevent it from treating less serious conditions.

The Secretary also wants to open up the VA health-care system to more people. “When I got out of the ser­vice thirty years or so ago, a veteran with an honorable discharge who was sick could get treatment from a VA hospital,” said Secretary Brown. He then noted that the situation is very different today. Only about ten mil­lion veterans—about thirty-eight percent of the total—are eligible for some sort of free VA care under existing law.

Secretary Brown knows that his agency will not go back to the days when it covered the health care of every veteran, but he does think it is practical to have a larger pool of potential patients in the future. The VA is experimenting with treating military retirees and their dependents who are eligible for the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

Down at the Heels

These steps all begin with the as­sumption that more people will want to use the VA health-care system, which, at present, is not a safe as­sumption.

When it comes to evaluations of its basic medical programs, the VA has numerous critics. Many say that the entire system and physical fa­cilities are so run down and misman­aged that the VA offers woefully inadequate care compared to most private-sector hospitals. Some crit­ics even maintain that it should be broken up and replaced with a vouch­er system, which would permit eli­gible veterans to receive care at pri­vate hospitals.

Secretary Brown scoffed at this last suggestion. He asserted that the private sector will only be inter­ested in those VA patients who can pay from private funds when their voucher financing has been ex­hausted.

For instance, he said, private-sector hospitals will not want the many psychiatric and chronically disabled patients currently being cared for by the VA. “These are long-term patients who are very expen­sive and . . . are a lifetime commit­ment because there is no cure.”

In addition, Secretary Brown ar­gued, it makes no sense to judge the operations of Veterans Affairs by comparing it to the private sector, because his department “has more oversight than any other entity in this country,” be it from Congress, the press, or the veterans service organizations. The Secretary con­tends that he welcomes the scrutiny, but he pointed out that such action leaves many of the VA’s warts ex­posed.

He suggested that the VA acquired a negative reputation unfairly and that “we have to bring our record to the American people.”

Secretary Brown said he is con­cerned about the image of the vet­eran in American society.

The Secretary said that, because far fewer young people serve in the armed forces today than during the draft era of the 1940s to the 1960s, he is concerned that most people won’t feel any connection to the nation’s veterans.

“The farther and farther we get away from national emergencies and wars,” he said, “the more people tend to forget the contributions made by our citizen-soldiers.”

As a result, he warned, the nation’s politicians and the public may not care if Washington acts to curtail or eliminate programs that have helped millions of veterans through the years. This year, the Clinton Admin­istration proposed a $39.3 billion VA budget for Fiscal 1997. The top line represents an increase of about $1 billion over the Fiscal 1996 spend­ing plan.

Status of Vets

Today, the status of veterans in the US is, in the words of the Secre­tary, “good.” For instance, accord­ing to the VA, the median veteran income in 1994 was $24,708, com­pared with $21,941 for nonveterans over the age of nineteen. Veterans are also less likely to be unemployed and more likely to have some col­lege education than their nonveteran counterparts.

Secretary Brown attributed these positive aspects to suchvernment programs as the GI Bill, which has helped to educate and train more than 20.7 million veterans since Congress founded it in 1944. He cred­its the bill with helping to create the great US domestic economic expan­sion that followed World War II.

“If you look at the history of this nation,” said the Secretary, “you’ll see that when you invest in the people, you get the greatest return.”

According to the Bureau of Labor Statistics, an agency of the Depart­ment of Labor, about ten percent of Vietnam-era veterans had a service-connected disability and about half of these veterans had participated in a special education or training pro­gram. Disabled veterans were more likely than nondisabled veterans to have participated. By far, the most popular benefit was the GI Bill, which was used by nearly everyone who had used any of the programs.

However, Secretary Brown warned that programs like the GI Bill and its successors are constantly under at­tack in Congress, where they are targets of budget-cutters.

“We sit back and we put billions into the defense budget to prepare our men and women to go to war,” he said, but “when they come back home, we want to nickel and dime them to death looking for ways to cut here and cut there.”

Secretary Brown explained that he is particularly troubled by past efforts to impose a “means test” to determine whether “so-called afflu­ent veterans” qualify for participa­tion in the VA’s disability, pension, and other benefits.

One idea recently put forth by some members of Congress would have scaled back payments to veterans who annually earned $40,000 or more. According to Secretary Brown, if such a proposal were enacted, a veteran who lost his arms and legs but had managed to overcome ad­versity and become prosperous would be penalized for his success.

“It’s absurd,” he said, adding that it was the veteran’s carrying out of his duty to his country that led to such injuries and that the nation must honor its responsibility to that vet­eran under all circumstances.

Secretary Brown has had a hand in adding a few responsibilities to the federal government’s list. In the most recent major example, the VA ex­tended new benefits to Vietnam vet­erans afflicted with prostate cancer and a type of neurological disorder that may be the result of exposure to the chemical defoliant Agent Orange.

Under the new guidelines, Viet­nam veterans suffering from such ailments will now be entitled to dis­ability payments, though they will not be compelled to prove a link between their service in Vietnam and their maladies. He also stated that the VA will propose new legislation to aid children of Vietnam veterans who suffer from the congenital de­fect spina bifida, said to be related to exposure of a parent to Agent Or­ange.

Agent Orange was a herbicide—containing dioxin—used in Vietnam to defoliate trees and remove cover. The VA said 2.6 million veterans potentially were exposed.

Benefit of the Doubt

The link between Agent Orange and some medical disorders has never been clear. Secretary Brown indi­cated that the VA decisions gave the veterans the benefit of the doubt. “The evidence, pro and con, is quite evenly balanced regarding these con­ditions,” he said, “but the President and I firmly believe that the VA needs to be on the side of veterans and their children.”

As of April, the VA had received 75,084 claims from Vietnam veter­ans or their survivors seeking dis­ability compensation and death ben­efits related to Agent Orange.

Secretary Brown said that, in such cases, the government has an obliga­tion to do the right thing without regard to cost.

“First of all, I think that it is im­portant for everyone to understand that, from our perspective, from a philosophical perspective, we looked at the dollar amount last,” said Secre­tary Brown. “We believe very strong­ly [that] when people are placed at risk as a result of serving in the armed forces and something hap­pens to them, there is an inherent obligation assumed by our society as a whole.”

David Masci, a reporter in Washington, D. C., covers veterans affairs for Congressional Quarterly. His most recent article for Air Force Magazine, “Fixing the Mess in Veterans Benefits,” appeared in the April 1996 issue.