Taking Care of Heroes: A Cultural Study of Health Policy Formation

Abstract

This dissertation examines the formation of health policy as a cultural process in a large federal bureaucracy in the United States, namely the Department of Veterans Affairs (VA). The everyday experience of bureaucrats working in the VA is used to answer the question: why does the VA fail to meet veterans’ needs in the face of a sacred trust, available political will, and robust resources? To answer the question, this project employs ethnographic methods that draw on participant observation at the headquarters office of the VA in Washington DC, archival research, and interviews with current and former VA employees during the Obama administration. I argue that care of veterans during post-war periods are critical moments of intervention that not only improved the population health of veterans but also impacted the ways in which America conceives and responds to health challenges. I also argue that when the VA operates at its best, it is often the leading edge of health reform, setting new standards for care and effectively establishing alternative models of care. Finally, my findings show that institutional factors play an important role in the process of health policy formation in ways that contribute to new understanding about causal conceptions of health. I conclude with a framework that draws on the lessons the VA affords, for health reform and advancing just health for all.