The Washington PostDemocracy Dies in Darkness

The veterans who fought for — and won — government health care

Marking a century of veterans' health care

For veterans, the federal government has played a central role in health-care policy for nearly a century. (Andrew Harrer/Bloomberg News)

Ninety-nine years ago today, an army captain from Cincinnati named Robert Marx lay unconscious in a mud-floored military hospital in France. A shower of German shells had left him with a skull fracture and gaping wounds on his legs, arms, shoulders and neck.

When Marx awoke on Nov. 12, 1918, and asked when he could return to his unit, a doctor matter-of-factly informed him: “No hurry, boy. The war is over.” The armistice, the physician explained, had been signed the day before.

Marx spent the next six months recovering in hospitals where fellow patients made a powerful impression on him. To “the legless, the armless, the lungless, the sightless,” he later reflected, “… the war was barely begun, for their suffering and sacrifice were just commencing.”

On Veterans Day, a century after the United States entered World War I, it is worth remembering a profound legacy of that conflict: It propelled activists like Robert Marx to fight for the creation of a federally sponsored health system that, to this day, shapes postwar life for millions of former service members. Marx and his fellow advocates had high hopes that government controlled, professionally administered care could alleviate the complex wounds of war. As generations since have benefited from, maligned and reshaped the system, that lofty goal has remained both alluring and elusive.

Marx was hardly the first to recognize that wars can have painful and lasting consequences for military personnel. Indeed, long before World War I, the U.S. government repaid veterans for their sacrifices with pensions and land grants. After the Civil War, former service members also had access to a network of state- and federally funded soldiers’ homes, which offered food, shelter and, in some cases, medical care.

But World War I took place after significant medical and scientific advancements in the late 19th century — including the advent of the germ theory of disease and the invention of the X-ray machine. By the time Marx sustained his wounds, many had come to accept that receiving care in modern hospitals, rather than antiquated soldiers’ homes, had profound advantages.

After the war, Marx, the only child of a Jewish shoe salesman, became a pillar in his community as a lawyer and judge, and fellow veterans soon tapped him to head a new advocacy organization that came to be called the Disabled American Veterans (DAV). Alongside representatives of the Veterans of Foreign Wars and the newly founded American Legion, Marx railed against the “tangle of red tape” former service members faced when seeking publicly sponsored care.

In 1921, he and other veterans’ advocates teamed with public health experts and bureaucrats to argue for the creation of a new agency — the Veterans’ Bureau — to oversee a variety of expanded benefits, including medical services. Testifying in Congress, Marx strategically noted that consolidating veterans’ benefits under one agency would alleviate the need for bureaucratic coordination and ultimately save the government money.

Over the next three years, the Veterans’ Bureau took over military and Public Health Service facilities, and built some of its own. Slowly, a nationwide network of veterans’ hospitals took root.

By 1924, Marx and his fellow advocates were again in Congress, arguing that all veterans of the Great War — not just those who could prove they had service-connected disabilities — deserved treatment. Federally sponsored care was a right that soldiers and sailors had earned, activists contended, because they had valiantly served — in some cases, only after being drafted against their will.

Some legislators were skeptical. Rep. Robert Luce (R-Mass.) worried that the proposal represented not only “an immeasurable expense over 50 to 75 years, but also… a long step toward that centralization of activities which some people call socialism.”

It didn’t help the cause that many veterans were seeking care for conditions — tuberculosis and mental illnesses, for example — that some legislators argued were hardly traceable to battle.

But despite the skepticism, growing the veterans’ health system was an idea that appealed to diverse groups. Aside from making arguments about legal and moral obligations, progressive-minded advocates for public health and for veterans maintained that access to federally sponsored health care could provide stability for vulnerable former service members, as well as bolstering economic self-reliance.

Meanwhile, their fiscally and socially conservative counterparts argued that offering veterans government entitlements like free medical care could stave off political radicalization — a top priority in the wake of the Bolshevik Revolution.

State and federal representatives, too, favored growth. Not only did their veteran constituents vocally support new hospitals, but the facilities also brought federal dollars and employment opportunities to local communities.

By 1932, the Veterans’ Bureau had grown into the Veterans Administration, and the agency was funding care for more than 44,000 patients in approximately 70 hospitals throughout the country.

In 1955, the year Marx died and left a portion of his fortune to the DAV, the veterans’ health system he helped to shape was serving not only thousands of elderly World War I veterans but also former service members of World War II and the Korean War.

In the years to come, during and after the United States’ many mass conflicts, the system continued to expand in response to changing demands wrought by modern warfare and the activism of veterans. Publicity surrounding the neglect and struggles of Vietnam veterans in the 1970s helped create an awareness of the unique challenges of re-adaptation to civilian life. As a result, the VA established and expanded community-based mental health counseling and programs aimed at combating substance abuse, homelessness and the long-term consequences of exposure to chemical weapons, such as Agent Orange.

Responding to the needs of a new cadre of veterans of the Persian Gulf War, VA leadership in the 1990s replaced the agency’s hospital-centered model with “integrated service networks,” which relied on a variety of in- and outpatient facilities in particular regions.

Today, as demands for health-care access swell, veterans’ advocacy groups have focused their efforts on opposing calls for increased “choice,” or more privately based care. VA, according to a recent issue brief from the DAV, “must remain the guarantor, coordinator and primary provider of care for most veterans.”

Marx and the WWI generation worked to ensure the existence of such a “guarantor.” The government, they believed, should oversee and be held accountable for tidying up the massive personal and physical consequences of wars via a federally administered medical system.

It was, and remains, both a perfect ideal and an utterly impossible task. Privatization will not necessarily make it easier to provide quality care. Indeed, reports about the implementation of the Choice program, which provides resources for veterans to access private care, are decidedly mixed, if not discouraging. That means that those hoping to apply a small-government approach to veterans’ care may soon find that, if their strategies are more widely adopted by a Trump administration friendly to their agenda, the private sector will bear the blame for failing to fulfill the hefty and nebulous responsibility of alleviating the wounds of war.