A physician and former head of California's Health Services Department, Kizer immediately began preparing for changes. Within a year, he began the largest reorganization of VA hospitals since Congress created the VA medical system in 1946. VHA shifted its focus from costly inpatient hospital care to outpatient services offered in more than 100 new VA clinics and by the private sector. The VISN system gives network directors unprecedented freedom to allocate resources. In exchange for that discretion, directors sign tough performance agreements linked to VHA's strategic goals.
Most observers remain at least cautiously supportive as restructuring proceeds.
The strength of support for reorganizing VHA is due in large part to the dire need for change. Until recently, VHA had not kept up with the changing demographics of American veterans. During the same period, the proportion of veterans under 45 will fall from nearly a third to just 16 percent. Veterans also are moving in significant numbers from the once veteran-heavy Northeast and Midwest to the South and West. Veterans now need outpatient or nursing home care more often than hospital stays.