Hostname: page-component-586b7cd67f-2brh9 Total loading time: 0 Render date: 2024-12-01T02:09:15.079Z Has data issue: false hasContentIssue false
  • English
  • Français

Innovation without Reputation: How Bureaucrats Saved the Veterans’ Health Care System

Published online by Cambridge University Press:  18 June 2015

Colin D. Moore
Get access Rights & Permissions [Opens in a new window]

Abstract

The Veterans Health Administration (VA) is among the most unusual and misunderstood institutions in the American welfare state. Unlike most American social services, veterans’ medical care continues to be administered directly by the state, contrary to the “antibureaucratic strategy” of “hidden” or “submerged” state-building that has dominated US social policy for decades. Drawing on extensive archival research, I attempt to make sense of the VA’s unique policy trajectory by exploring two puzzling episodes of institutional change in the delivery of veterans’ health care. Although many bureaucratic models predict large new undertakings initiated by agencies only when they benefit from the advantages of being well-regarded and relatively autonomous, both instances of institutional change occurred at the nadir of the VA’s reputation as a competent, innovative, and politically-powerful agency. To explain these unexpected transformations, I investigate the role of bureaucrats in shaping the development of the American welfare state and develop the concept of collaborative state-building to demonstrate how public-private partnerships may contribute to the expansion of social welfare programs in liberal states. Although public-private partnerships are usually seen as an erosion of state power or a way to hide the state’s role in the provision of social services, the case of the VA suggests that such partnerships may be used to support and expand such programs. I also focus on the VA’s many scandals and show how agency officials used these policy failures to expand the VA.

Type
Articles
Information
Perspectives on Politics , Volume 13 , Issue 2 , June 2015 , pp. 327 - 344
Copyright
Copyright © American Political Science Association 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Amenta, Edwin. 1998. Bold Relief: Institutional Politics and the Origins of Modern American Social Policy. Princeton, NJ: Princeton University Press.Google Scholar
American Medical Association. 1953. Medical and Hospital Care of Veterans with Non-Service-Connected Disabilities: A Review of American Medical Association Policy. Chicago, IL: American Medical Association.Google Scholar
American Medical Association. 1954a. “Council on Medical Service Resolution.” Journal of the American Medical Association 154(9): 755–762.Google Scholar
American Medical Association. 1954b. “Comment on Admiral Boone’s Article.” Journal of the American Medical Association 154(9): 762–764.Google Scholar
Asch, Steven M., Asch, Steven M., McGlynn, Elizabeth A., Hogan, Mary M., Hayward, Rodney A.; Shekelle, Paul; Rubenstein, Lisa, Keesey, Joan, Adams, John, and Kerr, Eve A.. 2004. “Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample.” Annals of Internal Medicine 141(12): 938–45.CrossRefGoogle Scholar
Bagalman, Erin. 2014. “The Number of Veterans That Use VA Health Care Services: A Fact Sheet.” Congressional Research Service June 3.Google Scholar
Baine, David. 1995. Testimony before the House Committee on Veterans’ Affairs: “The Future of the Veterans Health Administration.” 104th Cong.Google Scholar
Barbour, Galen L. 1996. Redefining a Public Health System: How the Veterans Health Administration Improved Quality Measurement. San Francisco, CA: Jossey-Bass Publishers.Google Scholar
Bauman, Robert E. 1994. “70 Years of Federal Government Health Care: A Timely Look at the U.S. Department of Veterans Affairs.” CATO Policy Analysis2207.Google Scholar
Boone, Joel T. 1954. “The Medical and Hospital Program of the Veterans Administration: An Examination of Certain Popular Misconceptions.” Journal of the American Medical Association 154(9): 755–61.Google Scholar
Carpenter, Daniel P. 2001. The Forging of Bureaucratic Autonomy: Reputations, Networks, and Policy Innovation in Executive Agencies, 1862–1928. Princeton, NJ: Princeton University Press.Google Scholar
Carpenter, Daniel P. 2010. Reputation and Power: Organizational Image and Pharmaceutical Regulation at the FDA. Princeton, NJ: Princeton University Press.Google Scholar
Carpenter, Daniel P., and Moore, Colin D.. 2007. “Robust Action and the Strategic Use of Ambiguity in a Bureaucratic Cohort: FDA Officers and the Evolution of New Drug Regulations, 1950–70.” In Formative Acts: American Politics in the Making, ed. Skowronek, Stephen and Glassman, Matthew. Philadelphia: University of Pennsylvania Press.Google Scholar
Carswell, John. 1992. “Health Reform and the VA Medical Care System.” Journal of American Health Policy 2(6): 17–21.Google Scholar
Carter, Susan B., Sigmund Gartner, Scott, Haines, Michael R., Olmstead, Alan L., Sutch, Richard, Wright, Gavin, ed. 2006. Historical Statistics of the United States. New York: Cambridge University Press.Google Scholar
Congressional Budget Office. 2005. “The Potential Costs of Meeting Demand for Veterans’ Care.” March.Google Scholar
Congressional Budget Office. 2009. “Quality Initiatives Undertaken by the Veterans Health Administration.” August.Google Scholar
Congressional Budget Office. 2010. “Potential Costs of Veterans’ Health Care.” October.Google Scholar
Department of Veterans Affairs. 1991. Report of the Commission on the Future Structure of Veterans Health Care. Washington, DC: Department of Veterans Affairs.Google Scholar
Derthick, Martha. 1979. Policymaking for Social Security. Washington, DC: Brookings Institution.Google Scholar
Derthick, Martha. 1990. Agency under Stress: The Social Security Administration in American Government. Washington, DC: Brookings Institution.Google Scholar
Esping-Andersen, Gosta. 1990. The Three Worlds of Welfare Capitalism. Princeton, NJ: Princeton University Press.Google Scholar
Esping-Andersen, Gosta. 1999. Social Foundations of Postindustrial Economies. New York: Oxford University Press.CrossRefGoogle Scholar
Evans, C. Lawrence. 1995. “Committees and Health Jurisdictions in Congress.” In Intensive Care: How Congress Shapes Health Policy, ed. Mann, Thomas E. and Ornstein, Norman J.. Washington, DC: American Enterprise Institute and Brookings Institution Press.Google Scholar
Gambone, Michael D. 2005. The Greatest Generation Comes Home: The Veteran in American Society. College Station: Texas A&M University Press.Google Scholar
General Accounting Office. 1993. VA Healthcare: Variabilities in Outpatient Care Eligibility and Rationing Decisions. Washington, DC: General Accounting Office.Google Scholar
General Accounting Office. 1994. Veterans' Health Care: Implications of Other Countries' Reforms for the United States. Washington, DC: General Accounting Office. Google Scholar
General Accounting Office. 2000. Veterans' Health Care: VA Needs Better Data on Extent and Causes of Waiting Times. Washington, DC: General Accounting Office Google Scholar
Gilens, Martin. 1999. Why Americans Hate Welfare: Race, Media, and the Politics of Antipoverty Policy. Chicago, IL: University of Chicago Press.CrossRefGoogle Scholar
Gotham, Kevin Fox. 2012. “Disaster, Inc.: Privatization and Post-Katrina Rebuilding in New Orleans.” Perspectives on Politics 10(3): 633–46.CrossRefGoogle Scholar
Gordon, Colin. 2009. Dead on Arrival: The Politics of Health Care in Twentieth-Century America. Princeton, NJ: Princeton University Press.CrossRefGoogle Scholar
Government Accountability Office. 2012. “Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement.” Washington, DC: Government Accountability Office.Google Scholar
Granovetter, Mark. 1973. “The Strength of Weak Ties.” American Journal of Sociology 78: 1360–80.CrossRefGoogle Scholar
Hacker, Jacob S. 2002. The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States. New York: Cambridge University Press.CrossRefGoogle Scholar
Hacker, Jacob S. 2004. “Privatizing Risk without Privatizing the Welfare State: The Hidden Politics of Social Policy Retrenchment in the United States.” American Political Science Review 98(2): 243–60.CrossRefGoogle Scholar
Hacker, Jacob S. 2008. The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream. New York: Oxford University Press.Google Scholar
Horgan, Constance, Taylor, Amy, and Wilensky, Gail. 1983. “Aging Veterans: Will They Overwhelm the VA Medical Care System?” Health Affairs 2(3): 77–86.CrossRefGoogle Scholar
Howard, Christopher. 2001. The Hidden Welfare State: Tax Expenditures and Social Policy in the United States. Princeton, NJ: Princeton University Press.Google Scholar
Howard, Christopher. 2007. The Welfare State Nobody Knows: Debunking Myths about U.S. Social Policy. Princeton, NJ: Princeton University Press.Google Scholar
Huber, Evelyne, and Stephens, John D.. 2001. Development and the Crisis of the Welfare State. Chicago, IL: University of Chicago Press.CrossRefGoogle Scholar
Inglehart, John K. 1996. “Reform of the Veterans Health Care System.” New England Journal of Medicine 335: 1407–1412.CrossRefGoogle Scholar
Jha, Ashish K., Perlin, J. B., Kizer, K. W., and Dudley, R. A.. 2003. “Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care.” New England Journal of Medicine 348(22): 2218–27.CrossRefGoogle Scholar
Kelly, Patrick J. 1997. Creating a National Home: Building the Veterans’ Welfare State, 1860–1900. Cambridge: Harvard University Press.CrossRefGoogle Scholar
Kerr, Eve A., Gerzoff, Robert B., Krein, Sarah L., Selby, Joseph V., Piette, John D., David Curb, J., Herman, William H., Marrero, David G., Venkat Narayan, K. M., Safford, Monika M., Thompson, Theodore, and Mangione, Carol M.. 2004. “Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study.” Annals of Internal Medicine 141(4): 272–81.CrossRefGoogle Scholar
Klein, Robert. 1981. Wounded Men, Broken Promises. New York: MacMillan.Google Scholar
Kubie, Lawrence S. 1945. “How Should the Medical Care of Veterans be Organized?” Military Affairs 9(2): 119.CrossRefGoogle Scholar
Leape, Lucian L., and Berwick, Donald M.. 2005. “Five Years After To Err is Human.” Journal of the American Medical Association 293(19): 2384–390.Google Scholar
Lewis, David E. 2002. “The Politics of Agency Termination: Confronting the Myth of Agency Immortality.” Journal of Politics 64(1): 89–107.CrossRefGoogle Scholar
Lindsay, C. 1975. Veterans Administration Hospitals. Washington, DC: American Enterprise Institute Press.Google Scholar
Lipsky, Michael, et al. Street-Level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russell Sage Foundation.Google Scholar
Lipsky, Michael et al. 1976. “The Future of the Veterans’ Health Care System.” Journal of Health Politics, Policy, and Law 1(3): 285–94.CrossRefGoogle Scholar
Lipsky, Michael. 1980.Google Scholar
Longman, Phillip. 2007. Best Care Anywhere: Why VA Health Care Is Better Than Yours. Sausalito, CA: PoliPointPress.Google Scholar
Mahoney, James, and Thelen, Kathleen. 2009. Explaining Institutional Change: Ambiguity, Agency, and Power. New York: Cambridge University Press.Google Scholar
Magunson, Paul B. 1960. Ring the Night Bell. Boston: Little, Brown, and Co.Google Scholar
Marrow, Helen B. 2009. “Immigrant Bureaucratic Incorporation: The Dual Roles of Professional Missions and Government Policies.” American Sociological Review 74(5): 756–76.CrossRefGoogle Scholar
Matishak, Martin. 2014. “Obama Signs VA Reform Bill into Law.” The Hill, August 7.Google Scholar
McAllister, Bill. 1993. “Expanded VA Care System Proposed.” Washington Post March 6.Google Scholar
Mettler, Suzanne. 2011. The Submerged State: How Invisible Government Policies Undermine American Democracy. Chicago, IL: University of Chicago Press.Google Scholar
Miller, Michael A. 1996. Testimony before the House Committee on Veterans’ Affairs: “The Future of the Veterans Health Administration.” 104th Cong.Google Scholar
Miller, Louis Mattox, and Monahan, James. 1947. “Veterans' Medicine: Second to None.” Reader’s Digest. 51(September): 53–57.Google Scholar
Mirvis, David M., Ingram, Leslie A., Kilpatrick, Anne Osborne. 1994. “Medical School Affiliations with Department of Veterans Affairs Medical Centers: Attitudes of Medical Center Leadership.” American Journal of Medical Sciences 308(3): 162–6.CrossRefGoogle Scholar
Moore, Colin D. 2011. “State Building through Partnership: Delegation, Public-Private Partnerships, and the Political Development of American Imperialism, 1898–1916.” Studies in American Political Development 25(1): 27–55.CrossRefGoogle Scholar
Morgan, Kimberly J., and Campbell, Andrea Louise. 2011. The Delegated Welfare State: Medicare, Markets, and the Governance of Social Policy. New York: Oxford University Press.CrossRefGoogle Scholar
Nabors, Ronald. 2014. “Issues Impacting Timely Care at VA Medical Facilities.” June 27. The White House. http://www.whitehouse.gov/sites/default/files/docs/va_review.pdf , accessed March 1, 2015.Google Scholar
Page, William Frank. 1982. “Why Veterans Choose Veterans Administration Hospitalization.” Medical Care 20(3): 308–20.CrossRefGoogle Scholar
Panangala, Sidath Viranga. 2013. “Veterans Medical Care: FY2013 Appropriations.” Congressional Research Service June 13.Google Scholar
Panangala, Sidath Viranga, and Jansen, Don J.. 2011. “TRICARE and VA Health Care: Impact of the Patient Protection and Affordable Care Act (PPACA).” Congressional Research Service, January 21.Google Scholar
Paralyzed Veterans of America. 1995. “The Federal Budget, FYs 1990-2000.” Washington, DC: Paralyzed Veterans of American Health Policy Department.Google Scholar
Patashnik, Eric M., and Zelizer, Julian E.. 2013. “The Struggle to Remake Politics: Liberal Reform and the Limits of Policy Feedback in the Contemporary American State. Perspectives on Politics 11(4): 1071–87.Google Scholar
Pierson, Paul. 1994. Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment. New York: Cambridge University Press.CrossRefGoogle Scholar
Pierson, Paul. 1996. “The New Politics of the Welfare State.” World Politics 48(2): 143–79.CrossRefGoogle Scholar
Pisani, Donald J. 2002. Water and American Government: The Reclamation Bureau, National Water Policy, and the West, 1902–1935. Berkeley: University of California Press.CrossRefGoogle Scholar
Prucha, Francis Paul. 1984. The Great Father: The United States Government and the American Indians. Lincoln: University of Nebraska Press.Google Scholar
Roberts, Patrick S. 2013. Disasters and the American State: How Politicians, Bureaucrats, and the Public Prepare for the Unexpected. New York: Cambridge University Press.CrossRefGoogle Scholar
Rosenheck, Robert. 2000. “Primary Care Satellite Clinics and Improved Access to General and Mental Health Services.” Health Services Research 35(4): 777–90.Google Scholar
Safire, William. 1995a. “Most Sacred Cow.” New York Times, January 1,: A25.Google Scholar
Safire, William. 1995b. “Sacred Cow, II.” New York Times, January 19, A23.Google Scholar
Schickler, Eric. 2001. Disjointed Pluralism: Institutional Innovation and the Development of the U.S. Congress. Princeton, NJ: Princeton University Press.Google Scholar
Schlesinger, Mark, and Wetle, Terrie. 1986. “Care of the Elder Veteran: New Directions for Change.” Health Affairs 5(2): 59–71.CrossRefGoogle Scholar
Selim, Alfredo J., Kazis, Lewis E., Rogers, William, Qian, Shirley, Rothendler, James A., Lee, Austin, Ren, Xinhua S., Haffer, Samuel C., Mardon, Russ, Miller, Donald, Spiro, Avron III, Selim, Bernardo J., Fincke, Benjamin G.. 2006. “Risk-Adjusted Mortality as an Indicator of Outcomes: Comparison of the Medicare Advantage Program with the Veterans’ Health Administration.” Medical Care 44(4): 359–65.CrossRefGoogle Scholar
Schleifer, Theodore, and Oppel, Richard A. Jr. 2014. “Deal Allots $17 Billion for Overhaul of V.A. Health Care System.” New York Time,s July 29, A11.Google Scholar
Sheingate, Adam D. 2003. “Political Entrepreneurship, Institutional Change, and American Political Development.” Studies in American Political Development 17(2): 185–203.CrossRefGoogle Scholar
Skocpol, Theda. 1992. Protecting Soldiers and Mothers. Cambridge: Harvard University Press.Google Scholar
Skocpol, Theda. 1996. Boomerang: Health Care Reform and the Turn against Government. New York: W.W. Norton.Google Scholar
Skocpol, Theda. 1997. “The G.I. Bill and U.S. Social Policy.” Social Philosophy and Policy 14(2): 95–115.CrossRefGoogle Scholar
Skocpol, Theda, and Finegold, Kenneth. 1982. “State Capacity and Economic Intervention in the Early New Deal.” Political Science Quarterly 97(2): 255–78.CrossRefGoogle Scholar
Starr, Paul, Nader, Ralph, Henry, James F., and Bonner, Raymond P.. 1974. The Discarded Army: Veterans after Vietnam—The Nader Report on Vietnam Veterans and the Veterans Administration. New York: Charterhouse.Google Scholar
Stavisky, Sam. 1953. “We’re Selling Out Our Disabled Veterans!” Collier’s 14: 24–28.Google Scholar
Stevens, Rosemary. 1991. “Can the Government Govern? Lessons from the Formation of the Veterans Administration.” Journal of Health Politics, Policy and Law 16(2): 281–305.CrossRefGoogle Scholar
Stevenson, Charles. 1949. “How Bureaucracy Swindles the Taxpayer.” Readers Digest March, 61–66.Google Scholar
Thelen, Kathleen. 2003. “How Institutions Evolve: Insights from Comparative-Historical Analysis.” In Comparative Historical Analysis in the Social Sciences, ed. Mahoney, James and Rueschemeyer, Dietrich. New York: Cambridge University Press.Google Scholar
U. S. Congress. House Committee on Veterans’ Affairs. 1996. Hearings: “Future of the Veterans Health Administration.” 104th Cong.Google Scholar
Veterans' Administration. 1946. “VA Policy Memorandum Number Two.” January 30. http://www.va.gov/oaa/Archive/PolicyMemo2.pdf , accessed March 3, 2014.Google Scholar
Veterans' Administration. 1980. 1977 National Survey of Veterans. Washington, DC: U.S. Government Printing Office.Google Scholar
Wagner, Dennis. 2014. “Deaths at Phoenix VA Hospital May Be Tied to Delayed Care.” Arizona Republic, April 10.Google Scholar
Weir, Margaret, Shola Orloff, Ann, and Skocpol, Theda. 1988. The Politics of Social Policy in the United States. Princeton, NJ: Princeton University Press.Google Scholar
Young, Gary J. 2001. “Transforming the Veterans Health Administration: The Revitalization of the VHA.” In Transforming Organizations, ed. Abramson, Mark A. and Lawrence, Paul R.. Lanham, MD: Rowman & Littlefield.Google Scholar