Can government run a health care system?

The medically debatable outcome was that Secretary of Veterans Affairs Jesse Brown ruled on Sept. 27, 1993, after years of VA studies costing millions of dollars, that certain types of respiratory cancers suffered by veterans--cancers equally attributable to smog or excessive tobacco use--are to be presumed by law to be based on exposure to Agent Orange. That makes any Vietnam War veteran with those respiratory conditions eligible for a disability pension and free health care. The five-year cost: $350,000,000 and climbing. Pres. Clinton praised Brown's decision, saying it was "a continuation of the costs of war."

A similarly costly VA scenario is developing with the "Gulf War Syndrome," a mysterious malady said to be afflicting thousands of veterans of the Persian Gulf War. Under pressure from the news media, veterans' groups, and their friends in Congress, the VA has designated a special medical task force to investigate eligibility of the new disease.

There is a far more telling indictment of the massive VA health system. With an estimated 26,700,000 veterans, most of whom are eligible from some degree of VA medical care, fewer than 10% seek VA assistance. The other 90% apparently prefer to go elsewhere when ill. Even many of the VA-eligible poor veterans choose private-sector Medicaid-paid health care providers. Those who can afford their own private physicians invariably avoid the hassle of the VA medical system.

During the first year of the Clinton Administration, the internal circles of the VA, especially top administrative and medical personnel, experienced a deep-seated, widespread anxiety. That malaise was prompted only partially by the change in the White House, although many second-level VA officials, theoretically nonpartisan, had come to power under the regimes of Presidents Reagan and Bush.

Nerves became even more frayed when the Clintons made clear that they were serious about national health care reform. VA bureaucrats wondered where the VA would fit into that brave new world and worried that it might disappear altogether, eaten up by a greater, even more bureaucratic national health system.

They need not have worried. Together with their allies in the organized veterans' groups, the VA staff provided the talent of no fewer than 33 of its members for Hillary Clinton's secret health task force, which hammered out the statutory structure for the proposed new system. By the time the Clinton plan actually was reduced to 1,342 pages of proposed legislation in November, 1993, the VA had ensured itself a significant role in health care "reform." The VA's massive structure was not to be dismantled, as insiders had feared.

The Clinton proposal projected an expanded VA system treating not only more veterans, but their spouses and dependents as well. Although required to offer a benefits package to all veterans through newly created local health care alliances, the VA would continue to provide free health care to those with service-connected disabilities and to indigent veterans. In addition, Secretary Brown would be given wide powers to draw up rules governing expanded VA benefits for veterans and their families. If the Clinton plan ever should become law, the VA also will be permitted to receive payments for its services from Medicare, Medicaid, and private insurers.