PERCEPTIONS vary about the value of the Department of Veterans Affairs (VA) health care system. The VA has recently been described both as "a national asset"1 and "a second-rate health care system for poor elderly men."2 But strong opinions should not be the sole determinants of the future of the VA. Size alone demands that this future be given careful consideration. Although the VA's health care budget of $15 billion represents less than 2% of all US health expenditures, it is one of the largest single providers of health care and includes 171 hospitals, 350 outpatient clinics, and 126 nursing homes.3 In addition, the VA plays a major role in medical education and research. For editorial comment see page 667. Whether others could more effectively play these roles is an important question (Washington Post. March 6, 1993: A4; Wall Street Journal. December 6, 1993:A14). This article reviews