The president’s 2013§ budget included more than $53.3 billion for the Veterans Health Administration (VHA)1 ; this outlay constituted nearly 40 percent of the Department of Veterans Affairs (VA) budget. The VHA houses what is considered to be the largest integrated health care system in the United States, serving 8.8 million veterans^λ in 2012.²  The VA health care facilities include 152 hospitals and 827 community-based outpatient clinics.³  An estimated 130 of the VA hospitals provide acute medical and surgical services, and these hospitals accounted for approximately 703,500 inpatient admissions in 2012.²  The VA assigned an inpatient surgical complexity level of “complex” (versus “intermediate” or “standard”) to more than half of its medical centers that perform surgery, indicating that they have special facilities, equipment and staff for difficult operations such as cardiac surgery and craniotomies.⁴