Benjamin Young (2012), Senior Research Project – History of American Medicine, Prof. Martin Pernick
In the midst of the deepest economic recession since the Great Depression, a time when the foundations of capitalism were questioned, Barack Obama, newly elected and unwilling to forego the prerogative of his first 100 days, surveyed the state of the American health care system. He found a patchwork of programs distributed between state and local governments. Private interests had come to dominate the health care insurance system, costs regularly exceeded national inflation, and access to care was uneven. Priorities were shaped by profits, not maximum health care provision. Democrats struggled to devise methods to reform the behemoth, knowing that previous administrations had failed in the same attempt. The bruising political process yielded the Patient Protection and Affordable Health Care Act of 2008, hybrid legislation that passed by a small margin and pleased few on the left or right.[1]
To many progressive analysts, the Obama Administration should not have strained to synthesize a new program. In the last seventy years, the Department of Veterans Affairs (VA) through its largest component, the Veterans Health Administration (VHA), has created a system of health care provision dedicated to wounded, poor and mentally ill veterans. Concurrently, the VA’s affiliation with major medical schools has propelled important research and provided for the training of thousands of physicians and other healthcare professionals.[2] The VA has also taken the lead in the adoption of electronic medical records and the articulation of ethical medical practice.
Not all policy makers share this positive perspective. As budgets have grown, the VA has encountered fierce critics among small government enthusiasts. Michael F. Cannon of the libertarian Cato Institute argues that the VA is a duplicative system and that veterans, using government backed vouchers, would be better served in the private sector. “Suppose that instead of providing benefits, the federal government increased military pay enough to enable new personnel to purchase private insurance to cover service-related injuries and illnesses.”[3]
This paper does not endeavor to serve as a micro-economic comparator of competing health models. It is rather, a brief history of the VA, both nationally and in Ann Arbor, and an exposition of the organization’s evolving mission. The VA has worked to serve the needs of its core constituency, model progressive positions on patient care and access, teach young clinicians, and sponsor clinical research most relevant to veterans. These guiding principles differ markedly from the forces driving private health care and must be identified in order to counter destructive libertarian political forces and to propose the modern VA as a model of national reform.
. ‘…let us strive onto finish the work we are in; to bind up the nation’s wounds; to care for him who shall have borne the battle, and for his widow and his orphan; to do all which may achieve and cherish a just and lasting peace, among ourselves and with all nations.”[4]
–President Abraham Lincoln, Second Inaugural Address, March 4, 1865
A Developing System
The United States has always expressed an interest in caring for its veterans. The first Federal hospital opened in Pittsburgh in 1778, but it was the magnitude of causalities from the American Civil War that forced the system to expand. The tradition of the era was for individual states to contribute to their militia’s care and by 1933, 43 states managed 55 state homes. The Michigan Soldiers’ Home in Grand Rapids exemplified this trend; State of Michigan Public Act 152 provided for the “establishment of a home for disabled soldiers, sailors and mariners” within the state of Michigan.[5] The facility was dedicated in 1866 by former Major and Michigan Supreme Court Justice Allen B. Morse as a testament to Michigan’s “disabled and enfeebled veterans who lost their health and energies in defense of our homes. May it stand forever.”[6] Applicant #4107 was Uriah Gress from the 6th Michigan Infantry. Gress, suffering from “a broken hip and piles”, agreed to abide by the home’s rules which included completing daily chores and turning over seven dollars of his twelve dollar Federal pension. He stayed in the home for 14 years but chose not to be buried in the adjacent Soldier’s Home Cemetery.[7]
Federal Care is Extended to Veterans
Lincoln’s sentiments anticipated greater federal involvement, and in the decades following the Civil War, Washington assumed the administration of several state-run homes. The National Asylum for Disabled Volunteer Soldiers opened in Maine in 1866, the first of 13 branches to address the needs of aging veterans. This fusion of lightly funded state and federal programs survived through World War I.[8] In 1921, brief correspondence about opening a veterans’ hospital in Ann Arbor transpired between an official at the US Veterans Bureau and the Brigadier General of the Michigan Reserves, but neither man followed through and the concept languished through the next decade.[9] The creation the Veterans Administration in 1930 was intended to streamline decision making and consolidate the various governmental agencies involved in the care of the nation’s five-million veterans. Between the war years, the need for expansion became evident and the many voices alerted central planners that Michigan had an inadequate number of beds. The VA acknowledged the shortage and Grand Rapids and Saginaw were awarded 200-bed hospitals. The Veterans Hospital in Dearborn, built in 1939, added 300 beds to the system. Ann Arbor was slated for a new 500-bed tubercular hospital.[10]
World War II
The triumph of World War II was tempered by the responsibility of attending to the needs of the returning soldiers. President Roosevelt responded by creating the GI Bill of Rights which established an elaborate system of federal educational support.[11] The war had created 17 million new veterans and the crush on the existing care structure was severe. The Saturday Evening Post foretold the crisis; VA hospitals were “short of doctors, nurses, beds, efficiency and the medical spirit that gives patients’ faith in their doctors.” Veterans’ hospitals were called the “Backwater of Medicine” and “Third Rate Medicine for First Rate Men.”[12] In1946, Harry S Truman appointed General Omar Bradley to lead the Veterans Administration and to repair the “vast dehumanized bureaucracy …prescribing medieval medicine.”[13] Congress was required to exempt the five-star general from the restriction forbidding active duty officers to lead civil agencies.[14] Bradley leveraged his prestige to transform the “national scandal to a model establishment.”[15] Among his first appointments was General Paul Hawley, a WWII surgeon, to Chief Medical Director. Hawley tapped Dr. Paul Magnusson from Northwestern University, an accomplished orthopedic surgeon with a reputation for combating inefficient bureaucracies. Together they enlarged the VA’s treatment capacity, rebuilt the organization on a regional basis and transformed the agency’s relationship to physician training and education.[16]
Federal veterans’ hospitals had loose affiliations with various medical schools since the 1880s, but few resources supported these relationships.[17] The Civil Service Commission demanded that all VA personnel pass a civil service examination, a requirement that discouraged part time participation of medical school faculty. Magnusson clashed with the Commission and prevailed by creating a separate medical personnel management system. With this political victory, Magnusson implored colleagues at Northwestern University and the University of Minnesota to place attending staff at the local VA hospitals. The Northwestern physicians moved quickly to analyze the existing system. Their report concluded that the VA management structure was insular and over-hospitalization of sub-acute patients blocked access to veterans with more dire need.[18] [19]
The VA Affiliates with Medical Schools
The Northwestern report represented a synergy between the VA and academic medicine, and it spurred the development of Policy Memorandum No. 2 (1946). This policy recognized the “necessity of understanding and cooperation” between the VA and leading medical schools. The Department “is embarking on a program that is without precedent in the history of Federal hospitalization.” The responsibilities of both parties were briefly outlined; the Department would maintain their mandate for veterans care and the cooperating medical schools would accept responsibility for graduate education and training.”[20] The memo details little about additional funding to the medical schools; ostensibly the agreement offered the universities an expanded number of beds to train their house staff. The opportunity for the Department to improve veterans care by increasing the supply of attending physicians was profound. Prior to Memorandum 2, the one-thousand bed VA hospital in Palo Alto had only five doctors. “The outside of the hospital was beautiful… but what went on inside was beyond description.”[21] Over the next generation, the hospital’s affiliation with Stanford Medical School transformed the facility into a world class hospital.[22]
Memorandum 2 called for the formation of a Dean’s Committee’s at each affiliated site. The governance structure, still in operation, was to be chaired by the head of the medical school, co-chaired by the VA chief of staff and comprised of officials from both institutions. The Dean’s Committee served to merge the interests of the medical schools and the VA and set the standards for hiring medical staff.[23] With this partnership the VA underwrote undergraduate and graduate education and created joint resident training programs. The first formal affiliation occurred in 1946 between Northwestern University, the University of Illinois and the Edward T. Hines Hospital outside Chicago. The affiliation coincided with plans to increase the number of VA hospitals nationwide. Heretofore, the Department’s belief was that wounded veterans should recuperate in relaxed and bucolic settings. Memorandum 2 recognized that remote outposts were difficult to staff and to the chagrin of congressmen from rural areas; new hospitals were planned for urban areas with concentrations of well-trained physicians.[24]
Memorandum 2 and the University of Michigan
The impact of Memorandum 2 resonated in Ann Arbor and factions emerged to influence Washington policies. S.E. Jones asserts that the University of Michigan Vice President Marvin Niehus did not welcome the proposed tubercular hospital, owing to the perils of maintaining an infectious disease hospital in proximity to campus. The University’s objective was to attract a general medical and surgical hospital although available records do not clarify whether the Medical School realized the full value of an affiliated program. A battle ensued between Detroit and Ann Arbor and over the next two years, the proposed location of the new hospital shifted three times between the two areas. Finally, the Federal Board of Hospitalization assigned the tuberculosis hospital to the Dearborn VA and awarded Ann Arbor the general hospital. “Since the University of Michigan Medical School is located in Ann Arbor, it appears logical in accord with present thinking that (the hospital) be built in that city near the medical school.”[25]
In 1947 the Federal Board acquired 16 acres of land outside the northeast city limits of Ann Arbor situated between Glacier Way, Geddes Road and Oakway. After extended debate, the Ann Arbor City Council agreed to extend sewer and water lines outside previously defined city boundaries. In the autumn of 1949, the J.D. Hedin Construction Company broke ground on the $7.1 million project. The construction took four years to complete and was riddled by opposition from local neighborhoods, lawsuits, and labor and material shortages. Construction on the land was surprisingly challenging, and the placement of the building’s deep foundation required significant engineering ingenuity. The Korean War created labor shortages and this prompted the Hedin Company to offer salaries in excess of the war-time imposed wage freeze. Hedin was successfully sued by the government for this practice; litigation that further slowed the construction schedule.[26] [27]*
The Ann Arbor Veterans Administration Hospital opened in 1953 – thirty months behind schedule. It was dedicated by Vice Admiral Joel T. Boone who hailed the hospital’s affiliation with the University of Michigan Medical School.[28] The Ann Arbor News published photographs of the opening ceremonies; the Ypsilanti High School Band performed as did the color guard from the American Legion Post in Dexter.[29] The original information guide welcomed visitors to the multi-building hospital which featured 488 beds, a full operating room, diagnostic laboratories, comprehensive X-ray equipment and research space. The hospital was built with a patient solarium and equipped with a state of art radio station and a pneumatic tube system to expedite inter-department communication. The first Dean’s Committee was chaired by A.C. Furstenberg, Dean of the Medical School. Other notable members of the original committee included the chairmen of surgery, internal medicine and psychiatry – Frederick A. Coller, Cyrus C. Sturgis and Raymond W. Waggoner, respectively. Dr. Morley Beckett, the hospital’s long time manager, represented the Veterans Administration.[30]
Expanding Access to Care
The U of M-VA affiliation exemplified similar partnerships that were replicated throughout the country. The affiliations in Minneapolis, Boston, New York and San Francisco resulted in improved doctor-patient ratios. Six months after Memorandum No. 2 was issued, four-thousand new doctors were involved in veteran care. Within the decade, 63 of the nation’s 77 existing medical schools became affiliated with the Veterans Department. [31] [32] Initially the infusion of physicians allowed hospitals to offer increasingly sophisticated inpatient hospital services. By the 1990s, American medicine began to move away from inpatient admissions for low acuity conditions and started to emphasize outpatient care.[33] The Ann Arbor VA followed this trend and slashed the number of inpatient beds to 104. Resources were transferred to geriatric care and primary care outpatient clinics. In the mid-Nineties, Congress opened the door to low-income veterans and those without service-connected conditions.[34] Recently, the VA mandated that its hospitals provide outreach to homeless veterans, many of whom have chronic mental illness.[35] Taken together, these policies dramatically expanded the pool of eligible patients. In 2011, the Ann Arbor VA, covering a fifteen-county region in Michigan and northern Ohio, had 455,000 outpatient visits.[36] [37]
Manpower and Teaching
With their medical school affiliations,VA hospitals were recognized as desirable teaching arenas [38] Between 1960 and 1986 the number of trainees in the system increased from 16,000 to 105,000. Twenty percent of the trainees received some form of VA training stipend. Plans for expansion continued as the country entered Korea and Vietnam. Congress foresaw a national shortage of physicians in the 1960s and provided federal funds to enlarge the class size of existing medical schools. This did not satiate the demand and in 1972, the VA subsidized five new medical schools in underserved areas.[39]
During this period, the Ann Arbor Veterans Health System (now VAAAHS) became integral to the educational mission of the University of Michigan. The medical school benefited most directly; each decade saw an increase in the VA’s contribution to graduate medical training. Monies from Washington also flowed freely to the schools of Nursing, Dentistry, Pharmacy and Social Work, enabling each school to broaden their reach. VA training revenue came to fund many faculty positions and support the University’s mission to increase diversity among faculty and students.[40] The University demanded that capable physicians train its medical residents and only VA staff with University appointment were allowed to participate formally in medical education. [41] The strong alliance with the medical school has a downside as well, according to former Ann Arbor VA clinical psychologist Lawrence Perlman. “The prestige of the medical school attracts fine doctors, but the VA is often exploited and used as a place to train the most inexperienced residents.”[42] Overall, the relationship outlined in Memorandum No. 2 has benefitted non-veterans as well. A recent analysis reports that a large number of health care professionals practicing in the private sector spent a portion of their training in the VA and have transferred their knowledge to the general population.[43]
Libertarians might argue that this training mission could exist within the private sector, but this argument is not persuasive. In a profit-oriented system, the expense of training resident physicians would inevitably yield to cost-cutting. The emphasis would shift from collaboration and teaching to the provision of reimbursed medical services. Training of health care professionals requires full time faculty and modern facilities, elements already in place in the nation’s university-affiliated VA hospitals.
Key VA Clinical Programs:
The VA-medical school collaboration has focused on specific clinical conditions commonly facing servicemen. VAAAHS and its sister institutions have played leading roles in many areas of clinical investigation. Research priorities have changed over the years, reflecting the VA’s central mission to meet the dynamic needs of the veteran population. It is unlikely that the private sector could respond as fluidly. Among the key priorities have been programs for the blind and vision-impaired, physically injured and mentally ill.
Blind and Vision-Impaired
Traditionally, the VA’s highest priority has been the care of veterans injured in combat. A disproportionate number of returning World War II soldiers suffered service-connected blindness, and a concerned President Roosevelt responded to their needs. “No blinded serviceman from WWII would be returned to their homes without adequate training to meet the problems of necessity imposed on them by their blindness.” [44] General Bradley mandated that dedicated treatment programs be led, whenever possible, by veterans experiencing the same affliction. In a strategy that has been maintained to the present, the VA has designated certain hospitals as centers of clinical excellence. The Hines VA Medical Center west of Chicago established the first Blind Rehabilitation Center (BRC) in 1948.[45]
Like many innovative VA programs, at first the BRC was controversial. Some within the blind community believed that residential treatment would promote self-pity and paternalism; they held that veterans should receive rehabilitation while living at home. This issue intensified during the Korean conflict when 500 servicemen – nearly 5% of all casualties – were blinded. The focus of treatment during this era was mobility reorientation and psychosocial adjustment. Critics maintained that veterans’ recovery be managed by established civilian organizations.[46] The VA relentlessly pursued novel medical and surgical intervention, and in the 1960s this resolve paid dividends. Combined VA and University research contributed to active technologies including micro-surgery for eye trauma and ophthalmologic disease. The VA also advanced digital assistance technology for low vision. [47] Since the Vietnam War, the Hines residential program has expanded to nine other facilities throughout the country.[48] This reflected the Department’s organization into Veterans Integrated Service Networks (VISN), a system premised on regional control and the equitable distribution of specialized services throughout the country. VAAAHS, located in VISN 11, has been designated the Health Services Research and Development Center of Excellence.[49] The Center researches ways to improve healthcare delivery in patients with chronic physical and mental illness.[50]
Rehabilitation Medicine
The physical medicine challenges of veterans have evolved as advances in trauma care allowed more soldiers to survive their injuries. In the Vietnam era, 60% of soldiers wounded on the battlefront survived; in Iraq and Afghanistan survival rates improved to 95%.[51] Those who survived were often severely wounded. Spinal cord injuries became an unfortunate result of modern warfare and the VA addressed this need, again led by the collaboration of the Hines Veterans Hospital and University of Illinois. Since the Civil War when the ubiquitous Minié ball splintered limbs, Army surgeons perfected amputation techniques.[52] Post-operative rehabilitation of these veterans was of inconsistent quality until 1950 when the Vocational Rehabilitation Act developed systemized programs for injured veterans. During the reorganization of the VA in 1953, prosthetic research became a top priority and Public Act 729 ensured that veterans obtain high quality prosthetic devices. The VA actively funded research in physical medicine and continues to publish the Journal of Rehabilitation Research and Development.[53] Recent VA contributions have included the Computer Leg, myoelectric hands and arms, and the use of composite materials for functional limbs. [54] Since the opening of the hospital, VAAAHS has had a dedicated unit for physical medicine. The first patient admitted in 1953 was Elvio Rosati, a double amputee from Detroit who was among the honored invitees to the hospital’s 50th anniversary in 2003.[55] [56]
Mental Health
The Greek historian Herodotus described the psychiatric casualties of war in the 6th century BC. His depiction of an Athenian soldier who, physically uninjured at the Battle of Marathon, became blind after witnessing the death of a fellow soldier, might be the earliest report of post-traumatic stress disorder.[57] One-tenth of mobilized American soldiers were psychiatrically hospitalized between 1942 and 1945; after prolonged combat, over 90% manifested psychiatric symptoms.[58] Bradley issued specific instructions to expand the supply of counselors to meet the many needs of returning veterans.[59]
Psychological trauma has long been identified by military medicine, albeit with different nomenclature. In World War I, military physicians diagnosed “shell shock.” During World War II the afflicted were described as having “battle fatigue;” in Korea, the phenomenon was described as “traumatic war neurosis.” The term, Post-traumatic Stress Disorder (PTSD) was coined in the 1970s and codified in subsequent editions of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM). [60] In more recent years, the condition has expanded to include survivors of childhood abuse, but VA physicians have remained focused on the consequences of war trauma. Given the high prevalence of the condition, most VA mental health clinics including VAAAHS have designated PTSD programs. Many of the academic leaders in PTSD research have VA affiliation and much of the academic literature emanates from VA funding.
Not all psychiatric casualties are service connected. Compared to the general population, veterans have higher rates of psychotic disorders, depression and substance use disorders.[61] According to Nicholas Kristof, for every one soldier killed on the battlefield in 2012, about 25 veterans die by suicide.[62] The outpatient substance abuse treatment program at the VAAAHS is full; the VA also provides residential treatments in Battle Creek and North Chicago. This commitment contrasts with University Hospital, which has largely withdrawn from substance abuse treatment due to poor third party reimbursement. Recently, the resources the VA has devoted to mental health has exceeded available manpower, particularly in remote areas or in hospitals unaffiliated with medical schools. For example, a new 24- bed mental health facility in Helena, Montana has generous funding and a waiting list of patients but is unable to open because it cannot recruit attending psychiatrists.[63]
Electronic Medical Records
The VA has been at the forefront of information technology. In the 1970s, the US Public Health Service began developing an electronic medical record (EMR). The concept was heralded by VA leadership and several years later, Veterans Health Information Systems and Technology Architecture (VistA) was gradually introduced. VistA was highly innovative; it demanded typed progress notes, eliminating communication errors that resulted from illegible handwriting. Laboratory values were placed in a discrete part of the medical chart making it easier to track trends. Radiology images could be viewed from any location. VistA spelled the end of easily lost or misplaced paper charts. An unstable patient seen in the Toledo clinic could be admitted to the fully informed Ann Arbor VA that evening without the attending staff having to wait days for the physical chart to appear. Medications and patient identification were bar-coded, a step that significantly reduced dispensing errors. VistA revolutionized clinical and epidemiological research by centralizing all data.[64]
Thirty years later, it is clear that the impact of VistA on medical care has been extensive. Electronic medical records are standard practice and soon the paper chart will be extinct. The program’s technological success prompted the adoption of EMRs as a centerpiece of the Affordable HealthCare Act. Medicare and Medicaid incentivize medical practices, both private and public, to adopt electronic records. The magnitude of VistA along with the structural obstacles blocking its adoption and the lengthy development process make it unlikely that the private sector could have borne the initial costs.[65]
Conclusion
The future of the VA parallels the larger debate in this country about the size and scope of the federal government. At present, the discussion is at low tide; the VA’s funding is sacred after war when the plight of wounded veterans is raw. This protected status became evident early in the Republican primary season, when Mitt Romney criticized the VA during an early campaign stop. Romney was met with a barrage of hostility from various political factions and no further critical comments by him is found by search engines.[66] The election season did not stop his ally, Rep. Paul Ryan from holding hearings on deep cuts to VA funding.[67] Traditionally, opposition to the VA intensifies in peacetime and the issue will be reignited in a conservative administration.
To be sure, the idea of granting vouchers to veterans for care in private facilities has allure. As an example, Chelsea Hospital, a non-teaching facility in Washtenaw Country, offers greater creature comforts than the cross-town VA Hospital. A case could be made that consolidating the two hospitals would create efficiencies and a larger civilian hospital could accommodate the needs of veterans. This reform would be short sighted. The VA has a laudable record of responding to clinical need and expanding access to health care. It has advanced medical research tailored to conditions afflicting the veteran population. It has sponsored technological innovation and maintained a steadfast commitment to high ethical principles. These events have occurred because the VA has been driven by popular mandate and not by profit motivations. Privatizing the VA would disrupt a robust site of training and impede veterans’ access to health care.
Endnotes and Works Cited
[1] Starr, Paul. “Introduction.” Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. New Haven: Yale UP, 2011. 17-21. Print.
[2] Gronvall, John A. “The VA’s Affiliation with Academic Medicine: An Emergency Postwar Strategy
Becomes a Permanent Partnership.” Academic Medicine 64.2 (1989): 61-66. Print.
[3] Cannon, Michael F. “Curing Walter Reed Syndrome; A Proposal Even Anti-War Doves Should Embrace.” The Cato Institute. 19 Mar. 2007. Web. 15 Apr. 2012. <http://www.cato.org/publications/commentary/curing-walter-reed-syndrome-proposal-even-antiwar-doves-should-embrace>.
[4] The Origin of the VA Motto. US Department of Veterans Affairs, Washington D.C. Web. 15 Apr. 2012. <http://www.va.gov/opa/publications/celebrate/vamotto.pdf>.
[5] “Civil War Resources – Soldier’s and Sailor’s Homes Records.” Bentley Historical Library, University of Michigan. Web. 15 Apr. 2012. <http://bentley.umich.edu/research/genealogy/cw/soldiershome.php>.
[6] Zimmeth, Mary. “A Testimonial to the Worth and Services of Her Sons.” Seeking Michigan. Web. 15 Apr. 2012. <http://seekingmichigan.org/look/2011/11/29/michigan-soldiers-home>.
[7] Zimmeth
[8] Bentley Historical Library, Civil War Resources
[9] Jones, S.E. In The Beginning: A History of the VA Hospital, Ann Arbor, Michigan. Ann Arbor: Bentley Historical Library, 1973. Print.
[10] Jones
[11] Gronvall
[12] Ducharme, Erin E. “Thanksgiving Day Post-The History of Veterans Healthcare.” Clinical Correlations. NYU Langone, 27 Nov. 2008. Web. 15 Apr. 2012. <http://www.clinicalcorrelations.org/?p=969>.
[13] Ducharme
[14] Appointment of Gen. Omar N. Bradley as Administrator of the Veterans’ Affairs, 79th Congress House of Representatives, 1st Session, Report No. 840
[15] Downs, Frederick. “Prosthetics in the VA: Past, Present, and Future.” Feb. 2008. 57-59. Web. 15 Apr. 2012. <http://www.usni.org/magazines/proceedings/2008-02/prosthetics-va-past-present-and-future>.
[16] Worthen, David M. “The Affiliation Partnership between U.S. Medical Schools and the Veterans Administration.” The Alabama Journal of Medical Sciences 24.1 (1987): 83-89. Print.
[17] Gronvall
[18] Worthen
[19] Gronvall
[20] Policy Memorandum No. 2: Policy in Association of Veterans’ Hospitals With Medical Schools (1946). Print.
[21] Worthen
[22] Rabinowitz, Jonathan. “Huge VA Project to Boost Med School Admission.” Office of Communications and Public Affairs Stanford University, 24 Oct. 2011. Web. 30 Mar. 2012. <http://med.stanford.edu/ism/2011/october/veterans-1024.html>.
[23] Young, Eric (6 April 2012). Personal conversation with Chief of Staff, VA Ann Arbor Healthcare System
[24] Gronvall
[25] Jones, 10
[26] Jones
[27] “J.D. Hedin Construction Compnay, Inc., For Its Own Use and for the Use of Fischbach & Moore, Its Subconstrator v. United States.” Professor Schooner’s Government Contracts Homepage. Web. 15 Apr. 2012. <http://docs.law.gwu.edu/facweb/sschooner/hedin.html>.
* The conflict between the Hedin and the government was not fully resolved until 1965 in a detailed Federal Court decision that is often cited as the standard for resolving liability over delays for government projects.
[28] Jones, 16
[29] Photo from archives of The Detroit Times, Friday October 16 1953
[30] Veterans Administration Hospital. Information Guide: Welcome to Ann Arbor Veterans Administration Hospital. By Morley Beckett. Vol. Archives, Ann Arbor Veterans Administration Health Systems. Ann Arbor, 1953. Print.
[31] Gronvall
[32] Worthen
[33] Demsky, Ian. “Hurdles Ahead for Health Care Reform Primary Care Model, U-M Study Shows.” University of Michigan Health System, 11 Nov. 2010. Web. 17 Apr. 2012. <http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1826>.
[34] Philpott, Tom. “VA Care End Eyed for 1.3 Million Vets.” 7 Apr. 2011. Web. 17 Apr. 2012. <http://www.military.com/features/0,15240,229352,00.html>.
[35] “Contract Notice: Department of Veterans Affairs (Michigan) Issues Solicitation for “Homeless Program” Ann Arbor (Toledo)”. US Federal News Service. ProQuest. 11 Mar. 2011. Web. 17 Apr. 2012.
[36] Bomey, Nathan. “Ann Arbor’s VA Hospital Seeking 26,000 Square Feet for Research Center.” AnnArbor.com. 9 Dec. 2011. Web. 17 Apr. 2012. <http://www.annarbor.com/business-review/ann-arbors-veterans-affairs-hospital-seeking-26000-square-feet-for-research-center/>.
[37] Iglehart, John. “Reform of the Veterans Affairs Health Care System.” The New England Journal of Medicine 335.18 (1996): 1407-11. Print.
[38] W.E. Longo. “The Role of the Veterans Affairs Medical Center in Patient Care, Surgical Education, Research and Faculty Development.” American Journal of Surgery. Web. 17 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/16226937>.
[39] Worthen, 85
[40] Longo
[41] Young, Eric (6 April 2012). Personal conversation with Chief of Staff, VA Ann Arbor Healthcare System.
[42] Perlman, Lawrence (16 April 2012). Phone conversation with former clinical psychologist, VA Ann Arbor Healthcare System.
[43] “The Report of the Blue Ribbon Panel on VA-Medical School Affiliations: Transforming an Historic Partnership for the 21st Century.” (2009). Veterans Health Administration Office of Academic Affiliations.
[44] “History of Blind Rehabilitation Service – Blind Rehabilitation Service.” U.S. Department of Veterans Affairs, 17 Dec. 2012. Web. 17 Apr. 2012. <http://www.va.gov/BLINDREHAB/BRS_History.asp>.
[45] History of Blind Rehabilitation Service, 4
[46] History of Blind Rehabilitation Service, 6
[47] Downs
[48] “Edward Hines, Jr. VA Hospital.” United States Department of Veterans Affairs. Web. 17 Apr. 2012. <http://www.hines.va.gov/services/blind/hbrhistory.asp>.
[49] “Veterans In Partnership (VISN11) Healthcare Network Home.” Web. 17 Apr. 2012. <http://www.visn11.va.gov/>.
[50] “VA Center for Clinical Management Research.” Web. 17 Apr. 2012. <http://www.annarbor.hsrd.research.va.gov/>.
[51] Downs, 58
[52] Keegan, John. “Walt Whitman and Wounds.” The American Civil War: A Military History. New York: Alfred A. Knopf, 2009. 314-15. Print.
[53] “Brief Chronology of our Contemporary Mission.” Journal of Rehabilitation Research and Development 46. 4 Nov. 2009. Web. <http://www.rehab.research.va.gov/jour/09/46/4/mcaleer.html>.
[54] “Brief Chronology of our Contemporary Mission.” Journal of Rehabilitation Research and Development 46. 4 Nov. 2009. Web. <http://www.rehab.research.va.gov/jour/09/46/4/mcaleer.html>.
[55] Young, E. (6 April 2012). Personal conversation with Chief of Staff, VA Ann Arbor Healthcare System.
[56] Jones, Bentley Historical Library (Ann Arbor)
[57] Herodotus. Herodotus: The Histories. Harmondsworth, Middlesex: Penguin, 1954. 400-402. Print.
[58] Audoin-Rouzeau, Stéphane, and Annette Becker. 14-18: Understanding the Great War. New York: Hill and Wang, 2003. Print.
[59] “Opportunities in the Veterans Administration for Professional Counslers.” The Vocational Guidance Journal 24.8 (1946): 491-97. Print.
[60] Andreasen, Nancy C. Brave New Brain: Conquering Mental Illness in the Era of the Genome. Oxford: Oxford UP, 2001. Print.
[61] Henkin, Cheryl S. “Mental Disorders and Mental Health Treatment Among U.S. Department of Veterans Affairs Outpatients: The Veterans Health Study.” The American Journal of Psychiatry 156.12 (1999). Print.
[62] Kristof, Nicholas D. “A Veteran’s Death, the Nation’s Shame.” The New York Times. 14 Apr. 2012.
[63] KFBB News Team. “VA Mental Health Facility Sitting Two-Thirds Empty.” 7 Mar. 2012. Web. <http://www.kfbb.com/news/local/VA-Mental-Health-Facility-Sitting-Two-Thirds-Empty-141838353.html>.
[64] Longman, Phillip. Best Care Anywhere: Why VA Health Care Is Better than Yours. Sausalito, CA: PoliPointPress, 2007. Print.
[65] Young, E. (6 April 2012).
[66] McAuliff, Michael. “Mitt Romney: Maybe Veterans’ Health Care Should Be Privatized.” The Huffington Post. 11 Nov. 2011. Web. 18 Apr. 2012. <http://www.huffingtonpost.com/2011/11/11/mitt-romney-veterans-health-care-privatization_n_1089061.html>.
[67] Philpott
Benjamin Samuel Young 