Editor's note: In Montana and the nation, the cost and availability of health care has become a burning issue. Nearly one-fifth of the state's citizens are without health insurance and health care costs continue to climb faster than inflation.

In 2006, the Lee Newspapers State Bureau began examining factors behind these costs, as well as looking at alternatives to our current health care system.

The series' fifth installment begins today, with a look at the track record of a socialized medicine system in America: the Veterans Administration Health Care System.

FORT HARRISON - Vietnam veteran William Smith, sitting outside Montana's only veterans hospital as he recovers from an appendectomy, has nothing but praise for the care he's had here.

"Some people complain about the care; they've got it in their head that it's not a good deal," he said from a bench at the hospital entrance, IV tubes still in his arm. "But it's good care. People have to understand how many people they take care of. It might be a little slower, but the volume is just tremendous. I think it's amazing what they do."

Smith, 59, of Helena is talking about a little-known success story of American medicine: The federal Veterans Administration Health Care System, which provides a full spectrum of care to 5.2 million military veterans, including some 30,000 in Montana last year.

It's also a pure example of "socialized medicine." Its hospitals and clinics are owned by the government; its doctors, nurses and other staff are government employees; it's largely supported by taxpayer dollars; the care is made available to eligible veterans at little or no charge.

By most accounts, it's socialized medicine that works. Veterans groups, patients and VA staffers speak highly of the system, saying it provides top-notch care that emphasizes patient needs and prevention -- without the pressures of making a profit.

"In the private sector, it's definitely dollar-driven," said Durand Lindbo, a physical therapist and supervisor for rehabilitation services at Fort Harrison. "Don't get me wrong -- everything is dollar-driven, to some extent.

"But there is never a push to discharge a patient here because of (payment) issues."

The VA also boasts a sophisticated, computerized medical-records systems, whereby complete data on any patient are accessible at any of its 1,400 hospitals and clinics nationwide. And it's increasingly able to recruit medical professionals to its staff, because of its solid reputation, officials say.

"To go to a VA hospital when I started out, I wouldn't have done it. I'd have gone downtown," said Alex Brown, a dentist who used to be in private practice but has been with the VA for 29 years. He's the clinical coordinator of the computerized records system at Fort Harrison. "Today, there is no difference. The only difference is that the VA has become a respectable medical community."

As Brown alludes, it wasn't always that way. Nearly two decades ago, VA hospitals and health care had a reputation as neglected and outdated, as portrayed in movies like "Born on the Fourth of July" and "Article 99."

But things began to change in the 1990s under Kenneth Kizer, the VA Health Care chief appointed by President Bill Clinton.

Kizer, a physician specializing in emergency medicine and public health, began transforming the VA from a hospital-based system to one that focused more on "outpatient care," treating patients at local clinics and emphasizing preventive care.

Also under Clinton and a Republican-controlled Congress, the eligibility rules changed in the 1990s so that once a veteran became covered by the system, he or she stayed covered, enabling complete "managed" treatment.

"Those two things truly changed the whole focus of the VA system," said Joe Underkofler, director of VA Health Care in Montana and a 36-year employee of the VA. "Kizer was the one who said, 'We're not going to sit in our hospitals and treat patients. We're going to go out and build clinics where the patients live.' "

In Montana, the change meant closing a veterans hospital at Miles City and downsizing the Fort Harrison hospital from 150 to 45 beds. But it also meant opening new out-patient clinics across the state, from Glendive to Kalispell, as well as keeping Fort Harrison as a surgery and specialty-care center.

The system now has 11 clinics, including one in Lewistown that opened last week. It's also planning to open another clinic in Havre this year and is looking at opening perhaps two more, possibly in the Bitterroot Valley and northeast Montana.

Veterans with at least two years of active duty in the Armed Forces or the National Guard generally are eligible for lifetime health coverage by the VA, if they want to apply for it. Those who enlisted or served in the military before September 1980 have shorter service requirements to become eligible, and Iraq and Afghanistan war veterans get five years of automatic coverage when they come home.

Since January 2003, however, some veterans with higher incomes may not be eligible. A veteran's income and disability rating also will determine whether they get free care from the VA or have to make co-payments for some services.

About 50,000 veterans are eligible in Montana; 30,600 used the system in 2007 -- a 30 percent increase since 2003.

Enrolled veterans can see a primary-care physician at local clinics, or can come to the urgent-care center at Fort Harrison.

When they need to see a specialist or have surgery, they travel to Fort Harrison, which has more than 50 physicians and 300 other medical staffers, including nurses, physical therapists, dietitians, pharmacists and chiropractors.

Some vets can get mileage reimbursement for traveling to Fort Harrison or, if it's available, ride on a van driven by volunteers organized by the Disabled American Veterans, or DAV.

For complex or highly specialized surgery, Montana veterans may have to travel to the VA facility in Salt Lake City or Denver.

Underkofler said access to care in rural areas like Montana is "always a challenge," and is a weakness of the system. Veterans covered by the system must get most of their care from a VA facility; if a needed surgery can be done at a private hospital in Montana, the veteran usually can't go there and have it covered.

The system does contract with the private sector for some services in Montana, such as mental health, radiology and some surgeries. Still, veterans often have to travel long distances to get anything other than primary care.

Yet this drawback hasn't stopped military veterans from signing up for care with the VA -- or from being mostly satisfied with the system.

Allan Thompson, an 80-year-old World War II veteran from Billings, rode in one of the DAV vans to Fort Harrison this month to see a podiatrist about problems he'd been having with a toe.

Thompson said he signed up for VA coverage five years ago because it was a good financial deal. He doesn't have service-related injuries or illnesses and is not disabled, so he has co-payments of $50 to see a specialist and $8 for a month's worth of a prescription drug.

Thompson gets treatment for his Type II diabetes and a heart bypass surgery he had several years ago, before he was covered by the VA.

"I'm very pleased with the way they treat me," Thompson said in a recent interview in the Fort Harrison hospital patient lobby. "They have very good doctors. And people are super-friendly and accommodating."

President Bush and a Republican-controlled Congress (until 2007) also have generously funded this socialized system for veterans. Since Bush became president, funding for the VA health care system has gone from $21 billion in 2001 to $34 billion last year, a 60 percent increase.

Montana's VA health system also is one of the highest rated of any VA region in the country, according to a series of performance standards that look at things like diabetic care, cancer screening, smoking cessation and other items. In 2006, it was the highest-rated in the nation.

The standards generally focus on steps the VA can take to ensure its patients stay healthy and avoid costly surgeries and hospital stays. It's this "patient-driven" focus that physicians and other staffers at the VA say makes it an attractive place for them to work -- and a good health care system for its patients.

Mike Evans, one of three general surgeons at the Fort Harrison hospital, joined the VA 10 years ago, after spending 20 years in private practice in Minnesota.

He earns a salary less than he could earn in the private sector, but said he prefers a system where he gets to practice medicine and not worry about whether he's doing enough surgeries to pay the bills.

"And the patients are happier," Evans adds. "One of the big reasons is they don't have to worry about money. But I think they realize that when they come in, that we're not making big money, and we're not driving BMWs, and they see that we're trying to do the best we can for them."

Evans said he sometimes was told by former private-sector colleagues that he wasn't doing enough surgeries to produce income for the practice. The VA system has no such pressure, and instead emphasizes preventive care and lower-cost options, he said.

Lindbo, who left the hospital in Glendive to join the VA's physical therapy staff in 2003, said an example of the VA's preventive care is a new program to help overweight veterans lose some pounds to avoid or mitigate future health programs.

It even includes a fitness program where vets come to the hospital and the Missoula clinic to work out three times a week. In two months of participation, vets in the program averaged a 13-pound weight loss, Lindbo said.

"It's something that I think the Fort excels in," he said. "Providing this is not something you would find out in the private sector. Insurance wouldn't cover that. It's a preventative intervention that I don't know that you'll find anywhere else."

When asked whether this socialized, managed-care system could work on a larger scale and serve more Americans besides veterans, VA officials and medical staffers often say, "Why not?"

But they quickly acknowledge that, as a practical matter, any such change is a huge political question and couldn't occur without wholesale shifts in the for-profit culture of medicine and health insurance in America.

Some 20 years ago, a VA health executive proposed expanding the system in southern Alabama to cover everyone who needed care. Veterans objected, Underkofler said, because they felt the system was a benefit they had earned and that should be focused on veteran care.

Veterans are certainly protective of their health care system, although Smith, the Vietnam vet from Helena, said he doesn't see why the same care that's extended to him shouldn't be available to every citizen in America.

In addition to his appendectomy, Smith has had treatment for tongue cancer and cirrhosis. Because he's disabled, he doesn't pay anything for the care.

"We should be doing this for everybody," Smith said. "People say to me, 'You should get something for your service, you deserve it.' I say, you deserve it, too."