Reflections by Dr Tom Edes, C-TAC Senior Medical Advisor
In this time of federal service reorganization, we are called to remember what history has taught us: innovation rooted in both compassion and evidence can transform care for people with serious illness. Few institutions embody this lesson better than the U.S. Department of Veterans Affairs (VA). For decades, the VA has stood as both a care provider and an innovator, serving Veterans of all ages living with chronic diseases and disabilities.
In 1975, the VA planted a seed of innovation by establishing its first Geriatric Research, Education, and Clinical Centers. Their success grew into 20 innovation engines that continue to imagine, test and spread new models of care. By the late 1990s, as the country faced mounting concerns over the rising needs of an expanding older population, caregiver shortages, and costs, the VA sounded an alarm. Its 1998 report, VA Long-Term Care at the Crossroads, warned of storm clouds ahead and urged a shift away from institutions toward home and community care. Congress listened. The 1999 Millennium Act mandated a full spectrum of services, including hospice and palliative care in every setting.
From that moment, a story of transformation unfolded. Take the VA’s Home Based Primary Care (HBPC) program: interdisciplinary teams including nurses, doctors, social workers, dietitians, rehabilitation therapists and psychologists entering the homes of Veterans with multiple serious conditions not just to treat, but to walk through their daily lives and help them safely remain at home. Research showed this comprehensive longitudinal HBPC not only improved access but reduced hospital days by a third and cut costs for VA and Medicare alike. Its success sparked national replication, inspiring Medicare’s Independence at Home demonstration.
Innovation continued with the Medical Foster Home program, a quietly profound alternative to nursing homes. Imagine a Veteran, facing a move to an institution, instead welcomed into a caregiver’s personal home, surrounded by warmth and 24-hour support. Backed by HBPC, the program has delivered both comfort and fiscal stewardship, saving taxpayers $1 million every 10 days while giving Veterans dignity and belonging.
Perhaps the most striking transformation has been in end-of-life care. In 2000, only 5% of Veterans and 20% of Medicare beneficiaries experienced hospice, and families rarely spoke of “a good death.” But VA changed that story. By building palliative care teams in every hospital, forging community partnerships, tracking family satisfaction, and collaborating with university affiliates, VA helped make hospice mainstream. Within a decade, 40% of both Veterans and Medicare decedents received hospice—able to die at peace, in comfort, and in places they preferred.
The numbers tell the larger story: between 2000 and 2010, the population of Veterans over age 85 nearly tripled. Yet nursing home use rose only modestly, while home and community services grew nearly fivefold. A Congressional Budget Office analysis found that VA’s costs per beneficiary grew just 2% over seven years, compared to 29% for Medicare. VA proved it could expand services, improve quality, and bend the cost curve all at once.
But beyond the data are the faces. In every healthcare system, 10% of patients account for half of the costs. Nearly all of us, our parents, our children, and ourselves, will one day be part of that 10%. I know this not only from data, but through my family’s story. In recent years, my father, brother, and sister received high-quality, compassionate end-of-life care: in a VA palliative unit, in a community hospital, and at home with hospice. Each had what once seemed rare, “a good death”. They were comfortable, at peace, surrounded by those they loved, in the places they wished to be.
VA is a beacon, a powerful center of innovation. Time and again, it has piloted new models of advanced illness care that ripple far beyond its own walls—models that shape Medicare, influence hospitals and health systems, and set new standards for what is possible. But for this testing ground to continue delivering breakthroughs, the VA must be properly funded. Sustaining and expanding this innovation is not just what our Veterans deserve—it is what we all deserve.
I am forever grateful to all who have contributed and will continue to contribute to improving care for people with serious illness and disabilities. The VA’s story is not just about the past; it is about what is possible for the future of American health care if we choose to invest in it.
