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95-698 PDF 2004

S. HRG. 108–679

TESTIMONY OF RONALD F. CONLEY, NATIONAL

COMMANDER, THE AMERICAN LEGION

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

JULY 15, 2003

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

(II)

COMMITTEE ON VETERANS’ AFFAIRS

ARLEN SPECTER, Pennsylvania, Chairman

BEN NIGHTHORSE CAMPBELL, Colorado

LARRY E. CRAIG, Idaho

KAY BAILEY HUTCHISON, Texas

JIM BUNNING, Kentucky

JOHN ENSIGN, Nevada

LINDSEY O. GRAHAM, South Carolina

LISA MURKOWSKI, Alaska

BOB GRAHAM, Florida

JOHN D. ROCKEFELLER IV, West Virginia

JAMES M. JEFFORDS, (I) Vermont

DANIEL K. AKAKA, Hawaii

PATTY MURRAY, Washington

ZELL MILLER, Georgia

E. BENJAMIN NELSON, Nebraska

WILLIAM F. TUERK, Staff Director and Chief Counsel

BRYANT HALL, Minority Staff Director and Chief Counsel

(III)

CONTENTS

JULY 15, 2003

SENATORS

Page

Specter, Hon. Arlen, U.S. Senator from Pennsylvania ......................................... 1

Prepared statement .......................................................................................... 2

Bunning, Hon. Jim, U.S. Senator from Kentucky ................................................. 3

WITNESSES

Conley, Ronald F., National Commander, The American Legion; accompanied

by Robert W. Spanogle, National Adjutant, The American Legion; Steve

A. Robertson, Director, National Legislative Commission, The American

Legion; and Peter S. Gaytan, Principal Deputy Director, Veterans Affairs,

and Rehabilitation Commission, The American Legion .................................... 3

Prepared statement .......................................................................................... 9

Executive Report: A System Worth Saving .................................................... 17

Articles by: ...............................................................................................................

Kelly, Jack, National Security Writer, Post-Gazette, July 15, 2003 ............ 64

Rosenblatt, Susannah, Times Staff Writer, LA Times, July 15, 2003 ......... 64

APPENDIX

Graham, Hon. Bob, U.S. Senator from Florida ..................................................... 71

(1)

TESTIMONY OF RONALD F. CONLEY,

NATIONAL COMMANDER, THE AMERICAN

LEGION

TUESDAY, JULY 15, 2003

U.S. SENATE,

COMMITTEE ON VETERANS’ AFFAIRS,

Washington, DC.

The committee met, pursuant to notice, at 2:40 p.m., in room

SR–418, Russell Senate Office Building, Hon. Arlen Specter (chairman of the committee) presiding.

Present: Senators Specter and Bunning.

OPENING STATEMENT OF HON. ARLEN SPECTER,

U.S. SENATOR FROM THE STATE OF PENNSYLVANIA

Chairman SPECTER. Good afternoon, ladies and gentlemen. We

will convene the hearing of the Veterans’ Affairs Committee of the

United States Senate.

As this hearing assembles we are honored with the presence of

Mr. Ronald F. Conley, National Commander of the American Legion. The American Legion is the foremost organization of veterans. The first veteran I knew, my father Harry Specter, was a

member of the American Legion. I am not 100 percent sure that

he paid his dues. He was a member of the American Legion during

the Depression, and I think he planned to pay his dues with the

$500 bonus which the Federal Government promised World War I

veterans. When they reneged on the promise, I don’t know that he

had the money to pay the dues to the American Legion.

But one of my earliest recollections—and I am not 100 percent

sure that I recall the event or whether I recall it having been told

to me—was a veterans’ march on Washington to get that bonus.

Today, when there is a demonstration in Washington, they roll out

the red carpet. For the veterans who came that day, they rolled out

the cavalry with drawn sabers. The major in charge of the cavalry

was George C. Patton, and in command was the chief of staff,

Douglas MacArthur. There is a famous picture taken on The Mall

of MacArthur standing next to his aide-de-camp, Dwight Eisenhower. Veterans were killed on that day, one of the blackest days

in American history.

But I remember as a youngster growing up in Wichita, Kansas,

my father’s best friend, Max Greenberg, was in the cavalry and lost

his hearing. He would come over for breakfast every Sunday morning. My brother’s name was Morton. Max would always say, in Yiddish, ‘‘Was macht du, Martin?’’ He knew him for 20 years, but he

2

didn’t know his name was Morton instead of Martin. But he was

a proud American Legionnaire, and it is a great, great organization.

Ron Conley is now closing his term as the American Legion’s National Commander, and he is going to report on his very active

travel through the United States. It is very impressive that Mr.

Conley has visited 60 of the VA’s 171 medical centers since he was

elected National Commander, and he has some interesting and important observations and recommendations to offer to the committee.

I want to thank you very much, Ron, for your fact-finding work.

My full statement will be made a part of the record, and I am going

to be relatively brief. It is too late now to be brief, but I am going

to be relatively brief.

[The prepared statement of Chairman Specter follows:]

PREPARED STATEMENT OF HON. ARLEN SPECTER, U.S. SENATOR FROM PENNSYLVANIA

Good afternoon, ladies and gentlemen.

The purpose of the Committee’s hearing this afternoon is to receive the testimony

of Mr. Ronald F. Conley, the National Commander of The American Legion. I am

proud to be able to say that Mr. Conley is a constituent; Ron hails from the Pittsburgh area where he is also a member of Steamfitters Local 449, where he has

served on the examining board, on the finance and election committees, and as a

union steward.

Mr. Conley joins us today, as he closes his 1-year term as The American Legion’s

National Commander, to report on a year of very active travel throughout the

United States. Mr. Conley has personally visited 60 of VA’s 171 medical centers

since he was elected National Commander in August 2002—and he has some interesting and important observations and recommendations to offer to the Committee.

We will be very attentive to those observations and recommendations for we know

they come from Mr. Conley’s conversations with veterans throughout the Nation.

Ron, I want to thank you for your fact-finding work—and I want to thank you

also for initiating the Legion’s ‘‘I Am Not a Number’’ campaign. The Legion is ohso correct: veterans are real men and women—men and women who answered the

call to service. They are not numbers or ‘‘cases’’ or ‘‘claim folders.’’ VA—and the Congress—needs to be reminded of this from time-to-time.

Before I turn the Floor over to Mr. Conley, let me share with all who are assembled today just a quick rundown of Ron Conley’s life of service. As I have previously

stated, Ron Conley is currently the National Commander of The American Legion.

Prior to assuming that very high position, Ron served in numerous other American

Legion posts including:

I. Alternate National Executive Committeeman (1988–1992);

II. National Executive Committeeman (1992–present);

III. Department of Pennsylvania Vice Commander (1983–1984); and

IV. Department of Pennsylvania Commander (1987–1988).

Ron also served as President of the Pennsylvania American Legion Convention

Corporation, which hosted the 1993 National Convention in Pittsburgh. Perhaps

most importantly, Ron is the Founder and President of the American Legion for

Homeless Veterans Corporation, an entity which operates eight residential and

treatment facilities for homeless veterans in the Commonwealth of Pennsylvania.

Ron served as an air policeman in the United States Air Force from 1963 to 1966.

He is an active leader of his union—Steamfitters Local 449 in Pittsburgh, PA—and

has been married for 39 years to the former Barbara Lou Dilgen. Mr. and Mrs.

Conley have been blessed with five children and nine grandchildren.

Ron, the floor is yours.

Chairman SPECTER. We customarily have a time clock, but we

are not going to put it on for you, Commander Conley. We are

going to let you speak at will, as the expression goes, but not until

we have heard from my distinguished colleague, Senator Bunning

of Kentucky.

Senator Bunning.

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OPENING STATEMENT OF HON. JIM BUNNING, U.S. SENATOR

FROM THE STATE OF KENTUCKY

Senator BUNNING. Thank you, Mr. Chairman.

Mr. Conley, I am glad you are here today to give us a report on

your work and findings as National Commander of the American

Legion. You have put in much hard work over the last year, and

I applaud your service to our veterans and their families.

I am very impressed with your efforts to visit as many of the VA

medical centers across this country. You have visited all three in

Kentucky and made very candid assessments of each, and I appreciate that very much.

The VA medical centers in Kentucky face problems similar to

others across the Nation. Demand for VA health care is higher

than the Department’s ability to provide that care. Long waits to

see a doctor are unacceptable but very common. I think we have

seen some progress in recent months, but the Department still has

a long way to go.

One of the most prevalent issues and problems that you have

found were staffing issues. Some facilities do not have enough personnel, and we need to be sure we are hiring the best people for

the job. I think everyone on this committee is dedicated to ensuring

our veterans receive the best care possible in a timely manner. I

know I am. Your report and recommendations will help us to do

just that, and I thank you for being here.

Thank you, Mr. Chairman.

CHAIRMAN SPECTER. Thank you very much, Senator Bunning.

Commander Ronald F. Conley, we await your discourse. The floor

is yours.

STATEMENT OF RONALD F. CONLEY, NATIONAL COMMANDER,

THE AMERICAN LEGION; ACCOMPANIED BY ROBERT W.

SPANOGLE, NATIONAL ADJUTANT, THE AMERICAN LEGION;

STEVE A. ROBERTSON, DIRECTOR, NATIONAL LEGISLATIVE

COMMISSION, THE AMERICAN LEGION; AND PETER S.

GAYTAN, PRINCIPAL DEPUTY DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION, THE AMERICAN

LEGION

Mr. CONLEY. Senator Specter, Senator Bunning, we want to

thank you for the opportunity to appear here this afternoon to give

you our assessment, but before I get into my oral statement, I

would like to introduce publicly to you the National President of

the American Legion Auxiliary, Elsie Bailey, from New Jersey.

[Applause.]

Mr. CONLEY. We also have with us Past National Commander

from the State of Maryland, Clarence Bacon.

[Applause.]

Mr. CONLEY. We have John Brieden and Tom Cadmus that are

candidates for National Commander of the American Legion, and

we have Paul Moran, Ed Dentz, and Terry Lewis that are chairmen

of VA in our Legislative Council. We also have Mr. Johnson, our

National Vice Commander, here and, of course, Senator——

[Applause.]

Mr. CONLEY [continuing]. You know Dr. Sebastianelli from Pennsylvania, who is a Past National Vice Commander.

4

Again, I want to thank you for the opportunity to be here and

give you our assessment of the VA hospitals, a system worth saving. As National Commander of the Nation’s largest veterans’ service organization, I pledged to visit at least one VA health care facility in each State. With the information I gathered through face-toface meetings with faculty staff, firsthand reports from the very

veterans who comprise the 200,000-plus backlog of patients waiting

for appointments at VA, and surveys submitted by the facility directors, the American Legion has developed a comprehensive report

dealing with the obstacles faced by the VA to ensuring the timely

delivery of quality health care to America’s veterans.

This report was guided by both duty and privilege. It has been

my honor to meet firsthand so many talented people who fulfill our

Government’s health care obligations to veterans. I investigated

more than 60 VA facilities throughout America, the Philippines,

and Puerto Rico in the past 10 months, and the information I gathered along the way reinforces the American Legion’s belief that the

VA is indeed a system worth saving. In touring these facilities, I

made a conscientious effort to break from the beaten path. I compared comments from administrators and public affairs staff with

the more experienced opinions of hard-working doctors, nurses, and

technicians on the front lines. I also spoke with thousands of veterans and their families who entrust their lives to this system.

Among VA employees, I witnessed strong dedication, professionalism, safety awareness, and resourcefulness. Among veteran

patients, I heard profound gratitude voiced for the quality of care

they had received. But from nearly everyone, I also found frustration over the lack of timely access to VA health care, under use of

some facilities, overcrowding in others, and an inconsistent budget

and budget expectations.

America’s excellent VA health care system is being consumed by

physical neglect. It is my duty as the leader of the veterans to

share my findings with those who have the power to change it and

to inform the public of the conditions that exist and the reasons we

believe they exist. It has been an eye-opening journey.

My first stop was Dallas, Texas, last September 20th. There I

found the first in a long line of facilities where capital improvements have been shelved for the sake of hitting the bottom line.

The Alzheimer’s unit there is in an I-shaped building and operates

in the 1940s. In order to monitor the Alzheimer’s patients, they put

an LPN nurse in a school chair at the end of the hall, and that is

the care and treatment they get in that facility. It has been on the

books to try to build a new facility. The first cost was $19 million.

It has now been readjusted to $33 million, but it has been placed

on hold because of the CARES process.

In Bay Pines, Florida, I encountered a VA medical center where

the list of veterans’ waiting time is 6 months or longer for primary

care appointments. But it has been reduced to 14,000 waiting.

In Prescott, Arizona, no one knew how many registered nurses

worked in the hospital or how many new veterans were enrolling

each year. I later learned that that particular facility, where patient numbers have been more than doubled since 1997, is on the

chopping block because of CARES.

5

In Salisbury, North Carolina, the director said that 75 new doc- tors and $17 million are coming soon to solve that medical center’s

problems, a five-figure backlog. Why an increase at this particular

facility and where was the money coming from? The director said

he did not know, but he was sure it was coming.

In Cheyenne, Wyoming, a hospital doctor explained that his patient load had risen from 6,000 to 13,000 in the same period that

his staff numbers had been cut from 385 to 340.

A director in Louisville, Kentucky, said the VA hospital under

his supervision simply needs to be torn down and rebuilt. One

emergency room doctor there can expect to treat 50 or more veterans a day.

A director in Manchester, New Hampshire, simply told me that

veterans would be better served in a non-VA facility.

Throughout America, it is obvious VA health care operations are

being forced to do more with less. Demand has soared and the

funding has failed to keep pace. Staff shortages are everywhere.

In Cheyenne, the hospital director, a doctor himself, treats patients alongside the physicians under his supervision. That facility,

where demand was more than double while staffing has decreased

by over 10 percent, must routinely shuffle patients from floor to

floor to put veterans near caregivers. There, they are forced to perform the kind of triage one might expect on a battlefield but not

in a VA hospital.

At Edward Hines, Jr., VA Hospital in Illinois, there are seven vacancies for spinal cord specialists. Despite finder’s fees and signing

bonuses, they still experience hiring difficulties.

In many locations, VA facilities are forced by urgent demand to

fill in with agency-contracted nurses, part-time doctors, and shortterm foreign physicians under J–1 visas. Doctors hired under J–1

visas are required to practice for a minimum of 3 years at a VA

facility. Once that obligation is met, many physicians leave the VA

health care system and begin practicing in the private sector,

which does not solve VA’s long-term staffing shortages. What is

worse is these same doctors could possibly be contracted by the VA

to provide care at a much higher cost. We think this entire program needs revision.

Staffing shortages result in closed beds, wards, emergency rooms,

nursing homes, and intensive care units. The shortages force patients for whom the facilities were built to be turned away. Shortages force the VA Secretary to reverse the clear intent of the Veterans Health Care Eligibility Reform Act of 1996 by once again restricting enrollment only to the poorest and the sickest among

those who served.

To its credit, America’s budget-strapped veterans’ health care

system does not ration quality. Unfortunately, because the funding

pie cannot be cut into enough pieces for all, VA must ration access.

This is why tens of thousands of veterans are waiting in line to see

doctors. What good is high-quality care if you cannot get an appointment to receive it?

As outlined in the President’s budget, Priority 7 and 8 veterans

will pay a $200 annual enrollment fee. This proposal is meant to

drive out 1.2 million veterans from the VA health care system.

That is unacceptable.

6

Capital improvement measures to cope with recent demand

growth remains stalled under the CARES recommendations. Suspending all capital improvements until the completion of CARES is

proving detrimental in many locations. In Indianapolis, the director

reported his facilities must expand immediately to handle the current patient load and to accommodate all the projected growth.

Meanwhile, VA facility directors in other parts of the country are

using up their capital improvement reserves to handle day-to-day

operations. The final CARES recommendations must enhance services for CARES and not simply realigning capital assets to

downsize the system.

Another area of concern is the VA requirement that each hospital

hire a minimum of two full-time armed police officers per shift, as

well as installing new electronic surveillance equipment. This mandate was not funded, however. Hospital directors have been forced

to borrow from their medical budget to meet the new security requirements. Funneling funds from the medical budget means fewer

doctors, nurses, technicians, and pharmacists.

Since its creation, the VA health care system has worked side by

side with the Nation’s medical schools. The value of VA’s affiliations with medical colleges and nursing schools is beyond dispute.

Ninety percent of the doctors at the VA Connecticut Health Care

System in West Haven, Connecticut, are affiliated with Yale University. The University of Pennsylvania Medical School runs the

Philadelphia VAMC Emergency Room every night.

The University of South Carolina School of Medicine, a national

leader in colorectal cancer research, shares the same campus at the

VA Medical Center in Columbia, South Carolina. On any given day,

50 or more university physicians and interns work in that VA facility.

One VA medical center reported having affiliations with 68 different institutions of health care education. But when VA facilities

are downsized out of the proximity to their medical school partners,

their relationships are gone forever.

This is happening right now in Chicago, where Lakeside VA

Medical Center is merging with a sister facility on the other side

of town, effectively dissolving VA’s long and successful relationship

with Northwestern University Medical School. Neither the veteran

stakeholders nor the university administration had a voice in that

decision.

When I visited Lakeside Division of the VA Chicago Health Care

System on May 17th, I was told their patient population is mostly

poor, indigent, and unemployed veterans. The hospital property has

been valued as high as $100 million by the VA. In an effort to keep

a VA hospital in the downtown Chicago region, Northwestern University developed an alternative plan that would allow VA to assume ownership of Prentiss Women’s Hospital located across the

street from the current Lakeside Hospital. VA rejected that proposal and seems determined to sell the property.

Eliminating VA health care services from Chicago will prove detrimental to the local veteran population who will not be able to

travel across the city to the Hines facility. Currently, Northwestern

provides more than 300 doctors at no cost each year to Lakeside

VA Medical Center. Once Lakeside is closed, the value of affiliation

7

with Northwestern in terms of expenses saved and veterans treated will be difficult to recover.

Nearly all the strategies suggested to resolve VA’s access crisis

have focused on reducing access, outsourcing services, or finding

ways around paying the actual costs of providing care. Downsizing

is not the answer.

Last January, the decision to cutoff new enrollment of Priority 8

veterans was made in the interest of stemming demand the VA

health care system could not handle with existing appropriations.

However, by cutting off that particular group, the system lost the

population of patients most likely to have health insurance policies

and the ability to share in the cost of their care. I found this decision especially ironic after having heard frustration from every corner of the country about VA’s expectation for third-party reimbursements. Last year, in Puerto Rico, third-party reimbursements

target was $8 million. The facility beat it by $200,000. This year,

the target was doubled to $16 million, a figure their director says

is at least $5 million too high.

I was also told a collection agency receives 25 percent of thirdparty reimbursements collected in Puerto Rico. In Minneapolis, the

third-party reimbursement jumped from $15.5 million to $23 million. In Ann Arbor, Michigan, the target was $7.5 million for thirdparty reimbursements. They did not make it. They only collected

$6.5 million. But their new target this year is $11 million. That to

me means a cut of services for the veterans in that area.

Many directors I spoke with agreed that it is doubtful major increases in third-party reimbursements targets can be reached this

year because the population of veterans driving that revenue

stream has been removed from the equation.

Scarcity of budget dollars creates competition among VA facilities

and inconsistent veteran care as a result. How else can you explain

shortage-based backlogs of 10,000 or more, such as in Bay Pines,

Florida, when only 750 miles away from that facility in Jackson,

Mississippi, they have next-day care?

A mandatory appropriations model for VA health care would help

ensure VA is funded at a level needed to reach the demand for

care. Funds must be allocated on a cost-per-veteran basis, indexed

annually for inflation. In addition to mandatory funding for VA

health care, the American Legion supports allowing all veterans

with the ability to use their insurance, including Medicare and

HMOs, to choose VA facilities for their health care regardless of

economic status or level of service-connected disability. They would

be required to reveal any insurance coverage they have and make

reasonable co-payments for treatment of conditions unrelated to

their military service. For those veterans who don’t have health insurance, VA can offer a premium-based health care benefit package.

Mr. Chairman, my entire year as Commander has been spent collecting examples of many ways in which the discretionary appropriations model fails to fulfill the care giving purposes of the VA.

Mandatory funding models supported by the American Legion, coupled with revenue-generating programs such as Medicare reimbursement and premium-based health care plans, will help to boost

VA funding to a level that will allow VA to meet the increased deVerDate 03-FEB-2003 12:17 Dec 08, 2004 Jkt 095698 PO 00000 Frm 00011 Fmt 6633 Sfmt 6601 D:\VA\95698.TXT SSC2 PsN: SSC2
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mand for care. History has proven that 30-percent increases in demand cannot be served by 7-percent increases of funds.

The Department of Veterans Affairs is America’s biggest managed care system. It is a national treasure, a good reason for any

young man or woman to serve in the United States Armed Forces.

This health care system was created to treat the unique health

care needs of America’s veterans.

Call it a debt. Call it an obligation. Call it a promise. The VA

health care system serves tens of thousands of men and women

who were willing to give their lives for the freedom of all others

who make America their home.

Mr. Chairman, I did not come here today to simply point out the

deficiencies in the VA health care. I have come prepared to offer

recommendations.

The American Legion recommends an open exchange of information leading to the final recommendations of the CARES process.

Any CARES recommendations should be considered in the context

of a fully utilized VA health care system that takes into consideration the tenets of the GI Bill of Health, VA/DoD sharing, the Veterans Millennium Health Care and Benefits Act, and the mission

of the Department of Homeland Security. VA must also provide a

list of capital assets to the Department of Homeland Security for

consideration and strategic planning at the local, State, and national levels.

The American Legion supports the mutually beneficial affiliations between VA and the medical schools of this Nation. The

American Legion also recommends appropriate representation of

VA medical school affiliates as stakeholders on any national task

force, commission, or committee established to deliberate on veterans’ health care.

The American Legion recommends Medicare reimbursement for

the VA on a fee-for-service basis for the treatment of nonserviceconnected medical conditions of enrolled.

The American Legion recommends that Congress designate VA

health care as mandatory funding and provide discretionary funding required to fully operate other programs within the Veterans

Administration. Additionally, Congress should provide supplemental appropriations for budgetary shortfalls in the VHA’s mandatory and discretionary appropriations.

The American Legion recommends the expansion of VA’s thirdparty reimbursement to include Medicare reimbursement as well

as optional premium-based health care plans for those veterans

choosing to seek treatment for nonservice-connected.

Mr. Chairman, from the founding of this great country to the

present, America has recognized its obligation to the men and

women of the Armed Forces—past, present, and future. As a grateful Nation providing timely access to quality health care, transitional assistance from military service to civilian life, timely adjudication of disability claims, and a final resting place continue to

be a moral, ethical, and legal obligation.

Recently, new terms like ‘‘core veterans’’ and ‘‘traditional users’’

have been used to serve as justification for America’s failure to

meet the health care needs of its veterans. Yet neither term apVerDate 03-FEB-2003 12:17 Dec 08, 2004 Jkt 095698 PO 00000 Frm 00012 Fmt 6633 Sfmt 6601 D:\VA\95698.TXT SSC2 PsN: SSC2
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pears in Title 38 United States Code. Such terms appear only in

the minds of bureaucrats.

Mandatory funding for VA health care will provide a more accurate mechanism for funding VA medical care at a level that will ensure VA has the ability to serve all eligible veterans and to meet

its self-imposed access standards: 30 days for primary care appointment, 30 days for specialty care appointment, and an average waiting time of 20 minutes.

Rationing health care by denying access to Priority 8 veterans is

not the answer. Charging an annual enrollment fee for certain priority groups is not the answer. Raising co-payments for outpatient

services is not the answer. Raising co-payments for prescriptions is

not the answer. The answer is designating VA medical care as

mandatory funding within the Federal budget.

Mr. Chairman, veterans have served, are serving, and will continue to serve this Nation in an uncharacteristic manner—putting

duty, honor, and country before self.

If America can find the money to bail out failed savings and

loans institutions, commit troops to peacekeeping missions, rebuild

foreign governments, provide health care for Third World countries,

provide health care to those incarcerated in our prisons, and forgive loans to foreign countries, then surely America can find money

to provide the needed care for America’s veterans. This is what veterans want, and I believe it is what America believes is right.

Mr. Chairman and Members of the Committee, that concludes

my testimony, and I ask that a full copy of the final report be included in the record. Please excuse me for my voice, but I have not

gotten adjusted from coming back from Europe and then going to

Texas and Oklahoma and then here. I have developed a nice cold.

So please excuse my raspy voice.

[The prepared statement of Mr. Conley follows:]

PREPARED STATEMENT OF RONALD F. CONLEY, NATIONAL COMMANDER,

THE AMERICAN LEGION

Chairman Specter and Members of the Committee, thank you for allowing me to

testify today. Last September during a hearing before a joint session of the Committees on Veterans’ Affairs, I made a promise to report back to you and your colleagues the results of my extensive visits to VA medical facilities across the United

States. This final report spotlights my personal observations during visits to 60 VA

medical facilities.

These visits were thorough, in depth, and probing. I preceded these visits by providing a list of specific questions to each facility to answer and return to The American Legion. Initially, I asked each VA medical facility director a few questions

while meeting with them. However, over the course of my visits, the number of

questions I asked increased as I became aware of the areas that needed extra attention.

ENROLLMENT

In 1996, Congress enacted legislation authorizing all eligible veterans to enroll in

the VA health care system, within existing appropriations. This legislation changed

years of complicated rules and regulations governing eligibility to health care. The

complexity of this paradigm created confusion among providers, as well as patients.

Frequently, rules were bent, stretched, or ignored to meet the health care needs of

patients. There were no defined health benefits packages, no reliable data projecting

future patient population, and no major effort to capture third-party reimbursements or co-payments for the treatment of nonservice-connected medical conditions.

Access to the system was severely limited to only three groups of veterans: serviceconnected disabled veterans, other disabled veterans, and economically indigent veterans. VA’s patient population in 1996 was about 10 percent of the total veterans’

10

population. Once VA opened enrollment, it attracted new patients for several reasons:

• Quality of health care provided,

• Patient safety record,

• Accessibility,

• Pharmaceutical program,

• Specialized Services, especially long-term Care,

• Affordability, and

• VA’s affiliation with medical schools.

Following the eligibility reform of 1996, many Medicare-eligible veterans enrolled

in the VA health care system, not only for access to quality medical care, but also

to benefit from VA’s low co-payment prescription program. Initially, VA’s co-payment for nonservice-connected medications was $2 per 30-day supply. Even when

Congress allowed VA to increase this co-payment from $2 to $7, veterans continued

to enroll. Now VA has an enrolled patient population of nearly 7 million veterans,

over half of them are also Centers of Medicare and Medicaid Services (CMS) beneficiaries as well.

In January 2003, the VA Secretary suspended enrollment of Priority Group 8 veterans—regardless of their service-connected disabilities, their third-party insurance

coverage, or their ability to pay for care. Those with service-connected disabilities

are authorized to seek treatment of their service-connected medical condition, but

are not authorized to enroll for treatment of their nonservice-connected medical conditions.

From the very beginning of my term as National Commander, I was aware of

lengthy waiting lists for primary care; however, I did not grasp the magnitude of

the problem until I began to visit VA medical centers. Initially, I thought these

waiting lists were just regional problems, but soon realized it was system wide. I

discovered the deplorable conditions resulting from VA’s inability to meet its own

established acceptable access standards. VA’s access standard for a primary care appointment is 30 days—extremely modest compared to nearly every other health care

delivery system, public or private. Personally, I would find that standard unacceptable for my private health care system. In actuality, some veterans have waited

longer than the standards—even as long as 2 years or more. Clearly, a patient could

die while waiting for care—and, sadly, some have. Unfortunately, only a few isolated exceptions are meeting VA’s own acceptable access standards for primary care.

As staggering statistics of thousands of veterans waiting 6 months or longer for

their initial VA appointments became public knowledge, I was reminded of a statement made by former National Commander F.W. Galbraith during an American Legion meeting in 1920:

‘‘The trouble is that the men in these hospitals are ‘cases.’ They are represented by so many pieces of paper in some bureau in Washington. We want

to humanize the whole thing, and say, ‘Here is Jim Smith’s case, my friend.

What do you propose to do about him?’ That is the thing that we want to do,

and we can do it. It is our primary motive for living.’’

To evaluate the severity of this situation, The American Legion developed a program to put a ‘‘human face’’ on the growing problem—thus the ‘‘I Am Not a Number’’ campaign began. Veterans across America were asked to share their personal

experiences in the VA health care system. These are my comrades, not just statistics. Thousands of veterans responded to The American Legion’s survey between November 2002 and February 2003. Stories of frustration stretch from coast-to-coast.

The survey form was established and distributed to help develop a global picture

through self-reporting. The survey sought veterans’ self-assessment of their health

care delivery system. Some reports were favorable, while others were extremely critical. On the whole, those veterans actually receiving care were pleased with the

quality of that care and the professionalism of their VA health care providers. Predictably, those waiting 6 to 18 months were far more critical of the lengthy delays

and perceived indifference toward their situation. Complaints of multiple rescheduled appointments were common. The results of this survey reveal problems

throughout the VA health care system. The bottom line: too many veterans are

being denied timely access to quality health care. The ‘‘waiting game’’ is being

played at nearly every VA medical facility across the country. And America’s veterans are suffering.

The American Legion prepared a short video, which I have provided to your staff,

in which veterans tell their own personal stories. I hope you and your colleagues

will review this video. It highlights the obstacles encountered by the men and

women—veterans of the Armed Forces—attempting to access the VA health care

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system. These individuals aren’t the only ones with stories to tell. There are tens

of thousands of veterans just like them, nationwide.

Mr. Chairman and Members of the Committee, if you or a member of your family

were ill and in need of health care, would you find it acceptable to wait 6 months

to a year for a primary care appointment? How would you feel if you were eligible

to enroll as a result of your honorable military service, but were prohibited from

enrolling because you earned more than $29,000 a year or lived in the wrong geographic area?

DEMAND VS. FUNDING

Recently the President’s Task Force to Improve Health Care Delivery to Our Nation’s Veterans (PTF) issued its final report. Among the many areas discussed in

that report, one issue stands out—the current mismatch between demand for timely

access to care and Federal funding throughout the VA health care system. Not only

does this crisis prohibit meaningful collaboration between VA and the Department

of Defense (DoD), but it also causes uncertainty about VA’s ability to fulfill its four

primary missions.

The PTF recommended full funding of VA to care for all enrolled Priority Group

1–7 veterans. However, the best recommendation the PTF could reach to address

Priority Group 8 veterans was for the President and Congress to study and resolve

the mismatch problem. This was the only recommendation on which the PTF Commissioners failed to reach consensus. This is truly unfortunate since Priority Group

8 comprises the majority of veterans; therefore, future access to VA health care remains uncertain for them—at least for now.

Three PTF Commissioners offered a dissenting opinion regarding the funding of

Priority Group 8 veterans, which is supported by The American Legion. The recommendations outlined in this dissenting opinion place a financial obligation on

each enrolled Priority Group 8 veteran. Mr. Chairman, I would encourage you and

your colleagues to consider these recommendations.

MEDICAL CARE COLLECTION FUND (MCCF)

Although adamantly opposed by The American Legion, all third-party reimbursements and co-payments collected by VA’s MCCF are scored as an offset against VA’s

annual discretionary appropriations. Since this money is for the treatment of nonservice-connected medical conditions, The American Legion continues to advocate

scoring MCCF as a supplement to VA’s annual medical care appropriations.

During my visits, I discovered that MCCF is handled differently from medical facility to medical facility. Some MCCF activities are contracted to private collection

firms, while others are done internally. This year, VA’s MCCF collections were the

highest ever, yet its actual collection rate is extremely low compared to the industry

standard. Since VA is prohibited from collecting from CMS for the treatment of nonservice-connected medical conditions of CMS beneficiaries, VA bills CMS in order to

collect from private medical supplemental policies.

With a patient population comprised of more than 3.5 million CMS beneficiaries,

VA medical facilities cannot realize their full potential in MCCF collections. Nearly

every VA medical facility I have visited is expected to increase MCCF collections

in fiscal year 2003. Yet, the President’s budget request for fiscal year 2004 seeks

to drive away as many as 1.2 million Priority Group 7 and 8 veterans by authorizing

increased co-payments and an annual enrollment fee.

Both Indian Health Services (IHS) and DoD’s TRICARE effectively used thirdparty reimbursements, co-payments, and premiums to supplement their discretionary appropriations and resolve the demand versus funding crisis. IHS turned to

third-party reimbursements from CMS and the private sector to help improve quality of care and timely access problems. DoD developed TRICARE to solve the problems and meet the cost generated by CHAMPUS in delivering timely access to quality health care for military retirees and eligible dependents. Enrollment in

TRICARE, requires co-payments and premiums based on the degree of health care

coverage desired. TRICARE for Life requires Medicare-eligible beneficiaries to purchase Part B coverage and DoD serves as the supplemental insurer. All three approaches appear to be meeting the health care needs of affected patient populations.

One of the interesting observations is the effective use of ‘‘certified’’ coders by IHS

in its third-party reimbursement efforts. Although not authorized to hire ‘‘certified’’

coders by the Office of Personnel Management (OPM), IHS sent selected coders to

attend training to become ‘‘certified.’’ Fortunately, these ‘‘certified’’ coders choose to

continue with IHS even though they are underpaid based on their enhanced abilities

and skills. The difference in the collection rate between coders and ‘‘certified’’ coders

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is significant and cost-efficient. Certified coders within VA would help to increase

third party reimbursement rates.

SPECIALIZED SERVICES

Most notable among the health care services provided by VA are its specialized

services, especially spinal cord injury, geriatrics, prosthetics, blind rehabilitation,

and long-term care. As the veterans’ population ages, greater demand for these services are anticipated, particularly, long-term care. The Millennium Health Care and

Benefits Act of 1999 mandated VA to provide long-term care for all veterans rated

70 percent or more service-connected. Currently, VA is not meeting the mandated

inpatient bed levels also prescribed by this legislation. I did not visit a single VA

long-term care program without a waiting list.

I am greatly concerned that mental health and long-term care inpatient beds are

not included in the current CARES ‘‘market plans’’ developed by each VA medical

facility. Ignoring these services does not diminish demand by veterans with Alzheimer’s or dementia. Mr. Chairman and Members of the Committee, these veterans

answered the nation’s call to national service—it is time for the Nation to answer

their calls for assistance.

STAFFING SHORTAGES

The VA health care system is blessed with many dedicated employees—both

health care providers as well as the support staff. The former Secretary Jesse

Brown may have officially coined the phrase Putting Veterans First, but most VA

employees institutionalized the concept decades earlier. Unfortunately, VA has

failed tremendously in the recruitment of health care professionals and other support positions. Nearly every VA medical facility expressed staffing shortages stemming from one of three sources—normal staffing shortages, inadequate salaries, and

the Federalization of Guard and Reserve personnel in support of the War on Terrorism and Operation Iraqi Freedom.

Additionally, medical research must be funded at levels adequate to continue VA’s

long tradition of ground breaking medical advances. The research opportunities

available through VA continue to be a strong incentive to attract health care professionals.

A serious review of performance standards, compensation, and actual work performed by ‘‘part-time’’ physicians is desperately needed. During my visits, I learned

of a serious problem with some ‘‘part-time’’ physicians receiving compensation, but

performing no services. This is absolutely unacceptable and does not reflect favorably on the medical facility director or those responsible for monitoring employees’

attendance and performance of duties. At a time of lengthy waiting periods for primary care and specialized care appointments, the unauthorized absence of ‘‘parttime’’ health care providers is inexcusable. It would seem timesheets and work

schedules should document work performance before paychecks are released. There

must be a better tracking system to monitor and evaluate the job performance of

‘‘part-time’’ physicians.

ORGANIZATIONAL STRUCTURE

While visiting VA medical facilities, I noticed a change in management styles and

philosophies from one VISN to the next. It seemed as though there were 21 distinct

VA systems instead of one. The effort to decentralize the management and leadership of VA appears to have created inconsistencies in focus and conflicting policies

and directives. Unilateral actions by individual VISN directors do not improve the

system as a whole and seem to lack coordination of efforts. Clearly, subjective budgetary decisions have taken their toll on some VA medical systems to efficiently meet

the needs of the local patient population. The most obvious example is the loss of

inpatient beds for specialized services such as mental health and long-term care.

Some MCCF collection practices are clearly more successful than others. Management efficiencies also cover the spectrum, but do not reflect a unified VA system.

Performance standards seem to vary from VISN to VISN.

MEDICAL SCHOOL AFFILIATIONS

Currently, there are 126 accredited medical schools in the United States. VA Medical Centers (VAMC) have formal affiliations with 107 of these medical schools and

some 1,200 other educational institutions. The value of medical school affiliations

to the national health care system has been well demonstrated. VA provides critical

clinical settings for physician trainees. The high level of care provided by VA medical facilities is the result, in part, of numerous external accrediting agencies and

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the supervision of residents who consider the educational role as a critical component of their VA duties.

Medical research is yet another large component of medical school affiliations.

Staff physicians affiliated with medical schools customarily hold academic positions,

including tenured positions, provide direct patient care, teach students, advise residents, and conduct research—all of which contribute to excellence in a teaching hospital environment.

CAPITAL ASSETS REALIGNMENT FOR ENHANCED SERVICES (CARES)

CARES remains a major topic of concern in every VA community I visited. The

fear of the unknown spawned the question, ‘‘Do you think they will close this facility?’’ This uncertainty causes anxiety among health care providers, medical researchers, patients, and support staff. The individual marketing plans are being

carefully crafted to meet the anticipated health care needs of the local veterans’

community, but are being altered by external guidelines from the VA Central Office

in Washington, D.C. Recently, the VA Central Office returned local marketing plans

of some 20 medical facilities for additional review. This seems inconsistent with the

intent of having locally generated marketing plans developed to meet the health

care needs of their patient population.

As National Commander, I created The Veterans Affairs Facility Advisory Committee on CARES (VAFACC) to The American Legion’s Veterans Affairs and Rehabilitation Commission. The committee’s charge was to review the VISN Market

Plans, Planning Initiatives, and VA Facility Assessment Reports relating to the

CARES process, keeping in mind VISN’s were tasked to cut 10 percent of their vacant space by 2004 and 30 percent by 2005.

The VAFACC developed an independent assessment of the facility recommendations resulting from the CARES process. The committee was composed of experts

in the fields of construction, engineering, veterans’ benefits, medical school affiliations, health care policy, health care delivery, and health care administration.

Committee members reviewed each Market Plan and Planning Initiative submitted to the National CARES Planning Office (NCPO) for each of the 20 VISN’s

going through Phase II of CARES.

After a thorough review of the proposed Market Plans, the VAFACC raised the

following concerns: • Funding.—Clearly, billions of dollars in discretionary appropriations will be

needed to accomplish the new construction and renovations approved in the final

CARES plan. CARES is an ongoing process and incremental changes are anticipated. With the proposed consolidations and transferring of services, it is imperative

that no veteran experience any delays in timely access to the delivery of quality

health care, and patient safety must not diminish. No VA medical facilities should

be closed, sold, transferred or downsized until the proposed movement of services

is complete and veterans are being treated in the new locations. Funding levels

should be adequate to ensure services are available during periods of transition. • Veterans’ Population.—There is some concern that the projected veterans’ population is underestimated. Certainly with regard to long-term care, mental health,

domiciliary, and other specialized care populations, the CARES process has yet to

incorporate projections. • Long-Term Care.—VA spent close to $3.3 billion on long-term care in fiscal year

(FY) 2002. With the enactment of the Millennium Health Care Act, demand will

most likely increase due to the aging of the veteran population over the next decade.

VA estimates that the number of veterans most in need of long-term care, those veterans 85 and older, will more than double to about 1.3 million in 2012. Yet, even

with these numbers, veterans’ long-term care needs and projected growing demand

was omitted from the CARES process. • Mental Health.—Due to several factors concerning the initial projections, NCPO

and several other experts are reviewing the mental-health inpatient and outpatient

projections. Because of the questionable demand decline in several markets, networks were instructed to plan for increases in mental-health services only. VA must

include accurate mental health projections in order to ensure effective recommendations from the CARES process. • Domiciliary.—The inappropriate distribution of domiciliary beds based on demand projections gave rise to several policy and programmatic concerns and questions. Because the original projections were based upon a national average utilization rate, the model redistributed beds from existing domiciliaries to areas where

there are none. For those reasons, further study is needed and projections must be

revised before the next planning cycle.

• Unutilized Space.—Among the criteria the VISN’s were tasked to evaluate was

unutilized space. The VISN performance measure was a reduction of 10 percent by

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2004 and 30 percent by 2005. According to VA’s Office of Facilities Management

(OFM), VA facility assets include 5,300 buildings; 150 million square feet of owned

and leased space; 23,000 acres of land—the total replacement value of all elements

is estimated at $38.3 billion. OFM assessed and graded 3,150 buildings for a total

of 135 million square feet with correction costs estimated at $4.5 billion. These assessments were used at the local level as a tool to help manage medical centers and

VISN’s vacant or underutilized space.

More development is needed by the VISN’s to effectively utilize unused space in

lieu of selling or demolishing these buildings. Once the buildings are gone, there will

be no way of getting them back. Before any unutilized space is sold, transferred,

destroyed, or otherwise disposed of, the CARES process must consider alternative

uses of that space to include: services for homeless veterans, long-term care, and

the expansion of existing services to alleviate the extreme backlog of patients waiting to receive care at many VA medical facilities. Such considerations were lacking

in most of the VISN Market Plans.

• Contracting Care.—Throughout the VA health care system, contracting out of

care is very prevalent, especially the Community Based Outpatient Clinics

(CBOC’s). While contracting out of care is necessary in some circumstances, the

wholesale use of this health care delivery tool should be exercised with caution. In

certain areas, it will be difficult at best based on availability of approved medical

staffing and the contract fee schedules.

Contracting out of care was extensive in the VISN proposals. Some VISN’s made

the blanket statement that care would be contracted out to meet excess demand in

2012 and 2022. That is not much of a plan. What if the resources are not available?

Additionally, VA’s history with contracting is not enviable. VISN 10 proposed contracting with local providers/hospitals for inpatient beds to bring their access standards from the current 32 percent to 83 percent in 2012. That is an enormous gap

to cover through contracted care. VISN 6 proposed 19 new CBOC’s. VA-wide, there

are more than 130 new CBOC’s planned to enhance access to care.

• Enhanced Use Lease Agreements.—With Enhanced Use Lease Agreements (EU)

VA can maximize return from property that is not being fully utilized. EU leases

also allow VA to reduce or eliminate facility development and maintenance costs.

Through the use of EU leases, VA can receive cash or ‘‘in-kind’’ consideration (such

as facilities, services goods, or equipment).

Several of the VISN’s proposed enhanced use lease agreements with the public

and private sectors. Uses include homeless shelters or housing, cultural arts centers,

cemeteries, inpatient beds, mental health services and many other veterans’ service

enhancing ideas.

VA should continue to seek opportunities in the area of enhanced use leasing. It

can certainly have a positive impact on service delivery to veterans and the local

community.

There have been 27 projects awarded so far. The VA Secretary has 23 on the priority list with over 50 more currently in development. Clearly, VA is continuing to

urge the VISN’s to consider using this valuable tool even more. However, the committee recognizes that the approval process involved in obtaining an enhanced use

lease is lengthy and complex.

• VA/DoD Sharing.—There are many opportunities for sharing between VA and

the Department of Defense (DoD). The VISN Market Plans contain many proposals

addressing the possibility of service sharing to increase access to health care for veterans. Both VA and DoD benefit from these agreements and every effort should be

made by the VISN’s to pursue this avenue in order to save money through cost

avoidance, in particular pharmaceuticals, supplies and maintenance services.

Extra effort on the part of these agencies to cooperate is essential to the success

of sharing agreements. Some parts of the country are reluctant to ‘‘share’’ services

or programs between agencies. It is imperative that we overcome that obstacle and

look to the future of providing quality health care and reasonable access to this nation’s veterans.

The American Legion will remain an active partner with VA during this critical

process of realigning the agency’s capital assets to better serve America’s veterans.

Recent developments in the CARES process serve to reinforce some of my concerns.

The Under Secretary for Health has sent back the Market Plans to 15 VISNs/20

facilities with instructions to further develop other options and look at further consolidating inpatient services in many of the facilities. Additionally, the CARES Commission hearings have been postponed until August 2003, another 60 days. Delays

such as these give rise to many questions and concerns on the part of the stakeholders.

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RECOMMENDATIONS

Capital Asset Realignment For Enhanced Services (CARES).—The American Legion recommends an open and transparent process that continually and fully informs VSO’s of CARES initiatives, criteria, proposals and timeframes. Any CARES

recommendations should be considered in the context of a fully utilized VA health

care delivery system that takes into consideration the tenets of the GI Bill of

Health, VA/DoD sharing, the Veterans Millennium Health Care and Benefit Act and

the mission of the Department of Homeland Security. VA must also provide a list

of capital assets to the Department of Homeland Security for consideration in strategic planning at the local, state, and national level.

Medicare Reimbursement.—The American Legion recommends Medicare Reimbursement for VA on a fee-for-service basis for the treatment of nonservice-connected medical conditions of enrolled, Medicare-eligible veterans. Additionally, veterans should be authorized to participate in the Medicare + Choice option by choosing VA as their primary health care provider.

Medical School Affiliations.—The American Legion supports the mutually beneficial affiliations between VA and the medical schools of this nation. The American

Legion also recommends appropriate representation of VA Medical School affiliates

as stakeholders on any national task force, commission, or committee established to

deliberate on veterans’ health care.

Mandatory Funding for VA Medical Care.—The American Legion recommends

that Congress designate VA medical care as mandatory spending and provide discretionary funding required to fully operate other programs within VHA’s budgetary

restrictions. Additionally, Congress should provide supplemental appropriations for

budgetary shortfalls in VHA’s mandatory and discretionary appropriations to meet

the health care needs of America’s veterans.

Expanded Third-Party Reimbursement.—The American Legion recommends the

following to improve accessibility to VA health care and expand third party reimbursement:

• All enrolled veterans would be required to identify their public/private health

insurers.

• VA would be authorized as a Medicare provider and be permitted to bill, collect

and retain all or some defined portion of third-party reimbursements from CMS for

the treatment of non-service-connected medical conditions.

• VA should be authorized to offer a premium-based health insurance policy to

any enrolled veteran having no public/private health insurance.

• All enrolled veterans would be required to make co-payments for the treatment

of non-service connected medical conditions and prescriptions.

• All enrolled veterans with no public/private health insurance would agree to

make co-payments for treatment of non-service connected medical conditions.

SUMMARY

The history of the veterans’ health care system is a lengthy story of evolution. Although its mission is simply stated in President Lincoln’s Second Inaugural Address—to care for him who shall have borne the battle, his widow and his orphan—

financial obligation toward meeting that mission continues to lag. VA has never

faced a shortage of patients, but has always endured financial pressures. From the

beginning, VA was open to any veteran in need, until the 1980s when Congress enacted legislation that divided veterans into three groups—service-connected veterans, economically indigent veterans, and all other veterans. For the first time,

honorable military service wasn’t enough to qualify a veteran for access to a VA

medical facility.

From the founding of this great country to the present, America has recognized

its obligation to the men and women of the armed forces—past, present, and future.

As a grateful nation, providing timely access to quality health care, transitional assistance from military service to civilian life, timely adjudication of disability claims,

and a final resting place continue to be a moral, ethical, and legal obligation.

Recently, new terms like ‘‘core veterans’’ and ‘‘traditional users’’ have been used

to serve as justification for America’s failure to meet the health care needs of its

veterans. Yet, neither term appears in Title 38, United States Code. Such terms appear only in the minds of bureaucrats. Veterans’ status has always had a direct correlation to honorable military service. A veteran is a veteran. So why has Congress

and VA chosen to place veterans in separate priority groups? How could serviceconnected veterans in Priority Group 8 be denied enrollment in the VA health care

system, when nonservice-connected veterans in Priority Group 7 can enroll? Neither

Social Security nor Medicare places beneficiaries in priority groups, so why are veterans treated differently?

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Neither Social Security nor Medicare has limitations placed on beneficiaries like

Priority Group 8 veterans based solely on means testing or the HUD geographic

index. Why the inequity?

Granted financial contributions are normally made to both Social Security and

Medicare throughout a beneficiary’s working life, but few Americans (less than 10

percent) make a personal commitment toward national security as do veterans. If

Social Security and Medicare beneficiaries are ‘‘guaranteed’’ funding or ‘‘guaranteed’’

timely access to medical care, why are veterans treated differently?

It seems entitlement to Social Security benefits and Medicare coverage is unquestioned by Congress. Yet, a veteran’s entitlement to timely access to health care—

even for those willing to pay—is always being questioned, budget year after budget

year.

There seems to be a misconception among certain groups that designating VA

Medical Care as a mandatory funding item within the Federal Budget would provide free health care for all veterans. This is not true. Mandatory Funding for VA

Medical Care will provide a more accurate mechanism for funding VA Medical Care

at a level that will ensure VA has the ability to serve all eligible veterans and to

meet it’s self-imposed access standards—30 days for a primary care appointment,

30 days for a specialty care appointment and an average wait time of 20 minutes

to be seen by a VA physician.

Years of under-funding have created the current crisis in VA health care. Budgetary constraints have led to staffing shortages, elimination of services and unmet

demand for care. Rationing health care by denying access to Priority Group 8 veterans is not the answer. Charging an annual enrollment fee for certain Priority

Groups is not the answer. Raising co-payments for outpatient services is not the answer. Raising co-payments for prescriptions is not the answer. Designating VA Medical Care as a mandatory funding item within the Federal Budget is a solid step

toward improving accessibility of health care for all veterans and The American Legion fully supports this.

Mr. Chairman, veterans have served, are serving, and will continue to serve this

Nation in an uncharacteristic manner—putting duty, honor, and country before self.

Many national leaders have issued the challenge for Americans to serve this Nation

as a member of the Armed Forces, both on active-duty and in the Reserve components. Fortunately, every day men and women freely accept that challenge.

If America can find the money to bail out failed savings and loans institutions,

commit troops to peacekeeping missions, rebuild foreign governments, provide

health care for Third World countries, and forgive loans to foreign countries, then,

surely, America can find the money to provide the needed care for America’s veterans. This is what veterans want, and I believe it is what America believes is right.

Those same soldiers, sailors, airmen, and Marines securing the safety of foreign citizens may one day turn to VA for their health care needs. I am committed to ensuring that those brave men and women have a VA that can provide the care they

need.

Not far from here are the acres of white headstones at Arlington National Cemetery that serve as a constant reminder that the cost of freedom is a recurring debt

paid every day by men and women in uniform. Each headstone represents a debt

that can never be repaid. We honor those men and women by caring for their comrades. This is something that no one disputes, yet is it also something that we as

a Nation can do better—we will do better—we must do better.

Mr. Chairman and Members of the Committee, that concludes my testimony. I

ask that an electronic version of the final report be included in the record.

Chairman SPECTER. Commander Conley, your voice sounded fine,

and your testimony was profound, and we thank you for it. The

special report by Commander Conley, ‘‘A System Worth Saving,’’

will be included in the record as requested.

To repeat, we are very proud of you in Pennsylvania, our State,

Ron, for the prodigious service you have performed, but all of

America is proud of you. Veterans are indebted to you for your very

comprehensive report.

I note that your comments have been reported in a Pittsburgh

Post Gazette article by Jack Kelley in today’s paper and by

Suzanna Rosenblatt, Los Angeles Times staff writer. We will include both of those reports as well, summarizing the testimony.

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[From the Pittsburgh Post-Gazette, July 15, 2003]

AMERICAN LEGION ASSAILING VETERANS ADMINISTRATION HOSPITALS, CLINICS

(By Jack Kelly, National Security Writer)

Veterans Administration hospitals and clinics are under funded and understaffed,

and veterans feel betrayed, the American Legion plans to say at a news conference

in Washington, D.C., today.

Ronald Conley, national commander of the American Legion, will issue a report

on his visits to more than 50 VA hospitals and clinics and his conversations with

thousands of doctors, nurses, veterans and family members of veterans.

‘‘From nearly everyone, I found acute frustration about the lack of timely access

to VA health care, under-use of some facilities, overcrowding in others, and inconsistent budgets and budget expectations,’’ Conley’s prepared statement says. Conley

is a resident of Scott but none of the medical facilities mentioned in his statement

are located in southwestern Pennsylvania.

With 162 hospitals, 850 clinics, 137 nursing homes and 43 domiciliaries, the Department of Veterans Affairs runs America’s largest medical system. The number

of veterans being treated at VA facilities has more than doubled since 1998, from

2.9 million to 6.8 million. About 25 million veterans are eligible for VA care.

Veterans with service-connected disabilities and those with serious ailments go to

the head of the line. But veterans with disabilities unrelated to their military service often must wait up to 6 months for treatment.

Backlogs are uneven. More than 10,000 veterans wait for treatment at the VA facility in Bay Pines, Fla., but the VA hospital in Jackson, Mississippi, just 750 miles

away, offers next-day service.

Conley is critical of a cost-saving measure instituted by Veterans Affairs Secretary

Anthony Principi. This year, veterans with nonservice-connected disabilities and incomes of $36,000 or more a year are not eligible for treatment at VA hospitals. The

policy will be reviewed at the end of the fiscal year.

Principi is breaking a promise America made to veterans, Conley said. ‘‘A veteran

is a veteran. Anyone who raised an M–16 in basic training, ran five miles in boots

and packs, rappelled from a helicopter into an ocean, or discovered firsthand what

it means to fix bayonets meets the criteria.

There should be a mandatory appropriation model for VA medical care, similar

to what exists for Medicare, Conley said. He acknowledged this would raise costs

of running the VA medical system far beyond the 7.7 percent increase President

Bush has proposed, But Conley said veterans deserve it.

‘‘The government always seems to produce billions for foreign aid, millions for

pork-barrel projects that range from restoring statues of mythological gods to subsidizing Elvis impersonators . . . and always enough to keep sending young men and

women off to fight our government’s battles in foreign lands,’’ Conley said.

[From the Los Angeles Times, July 15, 2003]

VA HEALTH SYSTEM FAILING, SURVEY SAYS

(By Susannah Rosenblatt, Times Staff Writer)

VETERANS HAVE TO WAIT UP TO HALF A YEAR FOR AN APPOINTMENT, THE AMERICAN

LEGION REPORTS. CLINICS CAN’T KEEP UP WITH DEMAND

WASHINGTON.—Veterans are waiting 6 months or more for medical care as a severely overburdened Veterans Affairs health system fails to keep pace with growing

demand, a report to be presented to Congress today concludes.

‘‘Washington, D.C., operates on a mentality of statistics,’’ said American Legion

national commander Ronald Conley, the author of the report.

‘‘We wanted to make everybody aware that these are not just numbers, but are

actual, real people and they’re sick and they need to see a doctor and they can’t

wait.’’

An estimated 110,000 veterans are waiting for initial appointments for nonservice-related medical problems at hundreds of VA centers around the country, the

VA acknowledges.

Conley is scheduled to testify today before the Senate Veterans’ Affairs Committee.

The VA expects to see 4.7 million veterans in its hospitals and clinics this year,

up more than 54 percent from 1996. The rising cost of private health insurance and

prescription drugs have led more veterans to rely on VA medical care. About 7 milVerDate 03-FEB-2003 12:17 Dec 08, 2004 Jkt 095698 PO 00000 Frm 00068 Fmt 6633 Sfmt 6621 D:\VA\95698.TXT SSC2 PsN: SSC2
65

lion of the nation’s 25 million veterans, or 28 percent, are receiving VA medical benefits.

‘‘A lot of people who may have been able to afford health insurance in the past

are finding it difficult to afford it,’’ said David Autry, a spokesman for Disabled

American Veterans. ‘‘They are turning to VA, where they feel their country should

take care of them.’’

Dr. Robert Roswell, VA undersecretary for health, said he also attributes the influx of patients to new VA community clinics and improvements in the quality of

care. The waiting list for appointments had been considerably longer, he added, with

315,000 veterans on it just last summer.

President Bush’s 2004 budget allots $27 billion for VA health care, an increase

of 7.7 percent from last year, Roswell said. ‘‘We’re quite pleased with the support

the President has shown,’’ he said, but the funds are still not enough to ‘‘keep pace

with truly phenomenal growth.’’

The chairwoman of a Presidential task force that examined the VA health system

in 2001 agreed with veterans’ groups that the system is unable to meet patients’

needs.

‘‘It was very clear that there were not enough resources currently available to

fund services for veterans in a way that would allow them to get health care without undue delay,’’ said Gail Wilensky, now a senior fellow at Project HOPE, a

health-care advocacy group.

The American Legion’s Conley visited 60 VA medical facilities over 10 months,

talking to hospital directors, doctors, nurses and patients to assess how well the system meets patient demand.

The 162 hospitals, 850 clinics and 137 nursing homes that constitute the nation’s

largest managed-care system are chronically under funded, his report concluded.

The VA Greater Los Angeles Health Care System, one of the largest in the country with 12 outpatient clinics and an operating budget of nearly $500 million, was

not included in the report and a spokesman there declined to comment.

Veterans’ groups are calling for a change in the way VA health care is funded,

so that it would receive a guaranteed stream of income much like Medicare already

does.

Currently, each year’s VA spending must be set by Congress, making it subject

to the constraints of the overall Federal budget. Such unpredictability makes it difficult for hospitals and other facilities to operate, Conley said.

‘‘No matter what the number is that may actually be needed, there is no guarantee that that amount of money will be provided in the end,’’ Autry said. ‘‘The VA

doesn’t have enough money to begin with, we can’t plan from month to month and

we don’t know when we’re going to get this money and how much it’s going to be.’’

In 1996, Congress relaxed eligibility requirements for VA health care, allowing

more veterans to enroll. A generous prescription benefit is one reason that many

have for enrolling. The VA offers a 30-day supply of each medication for a $7 copayment.

The President’s budget includes provisions to increase the co-payment to $15 for

higher-income veterans and eliminate it for those with lower incomes. The budget

also proposes a $250 enrollment fee for higher-income veterans.

An American Legion survey last year of about 4,000 veterans found the average

wait for an appointment is 7 months and that 58 percent had appointments rescheduled, many for several months later.

‘‘All I did was put in 20 years of separations, hardships, sacrifices,’’ wrote one survey responder, Robert Thomas, who served in Korea and Vietnam in the Navy.

‘‘The thanks I received is to be told that it will be another year before I see my

first VA doctor.’’

Chairman SPECTER. Commander Conley, I want to ask you just

a couple of questions relating to your statements about mandatory

funding. If VA were to have been so funded this year, it would have

a 1.4-percent increase this year. But instead of that, the VA requested an increase of 5.8 percent, and the Congress increased VA

medical care funding by some 11.3 percent. While the veterans appropriations, I agree with you, have not been adequate, we have

been able to do better even than the administration that is a great

friend of the veterans.

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What would your thinking be considering the larger amounts

made available through the discretionary approach as opposed to

the 1.4 percent, which would have been the mandatory increase?

Mr. CONLEY. Well, Senator, first of all, the budget included $2.1

billion in third-party reimbursements. Under the mandatory funding, the third-party reimbursements should not come into play. If

you take out the increase that the administration is asking for on

a fee basis for prescription and the enrollment fee that they are

proposing, if you take all those out of the budget, there really was

not an increase as far as VA health care. The mandatory funding

would actually give you the real dollars necessary for health care,

plus you can then add on the additional amounts of money.

What is happening now, the directors are greatly stressed in two

areas: One is to be able to collect third-party reimbursements. I

don’t know what formula was used on how to increase that amount

of money by each hospital. The second is a lot of hospitals, including VISN’s, have to dip into their capital investment money in

order to take care of the health care of those veterans. So now they

don’t have any money that they can go out and buy new equipment

and fix the roof and keep the facility from deteriorating because

they need to do it to hire doctors and nurses.

Chairman SPECTER. Let me shift gears, Commander, to the issue

of the veterans who are enrolled for VA care in order to get VA

pharmaceutical benefits.

Legislation has been introduced, Senate bill 1153, which provides

that you wouldn’t have to become an enrollee in the VA in order

to get Medicare doctor-written prescriptions filled by the VA without first having seen a VA physician. If the veteran wanted to enroll, fine, he could. But if veterans are enrolling solely to get the

prescription benefits, it wouldn’t be necessary for them to enroll.

That might ease the burden on the VA, but still leave the veteran

with what the veteran is really looking for, and that is, the VA prescription program.

Do you think Senate bill 1153 is a good idea?

Mr. CONLEY. Well, what I think on that, Senator, one, is the liability if the VA is just going to hand out prescriptions and become

a drug store without having the veteran seeing a doctor. I think

probably the easiest way to do this is if you have Medicare reimbursement, Medicare subvention, then you would have a one-stop

shop where the veteran would go to the VA, see the doctor, get his

prescription filled, and that would take care of it. But if you are

going to go from outside the system and just have the VA become

a drug store, I think it is something the American Legion has to

seriously take a look at.

Chairman SPECTER. Well, I agree with you, Commander, on the

idea of Medicare subvention. I think that is a good idea. We have

been trying to push that, and also third-party insurance payments

ought to go directly to the VA installation where the service is performed to give a boost to funding available.

But when the veterans would come with their prescriptions, they

would have already seen a doctor. I agree with you that you should

not dispense prescriptions without a medical authorization. But

that having been achieved, we would appreciate your further consideration.

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Note that I ended with 1 second left, Ron.

Mr. CONLEY. Yes.

Chairman SPECTER. Senator Bunning.

Senator BUNNING. Thank you, Mr. Chairman.

Mr. Conley, you said some good things in your testimony about

VA affiliation with medical schools. Do you think that the VA

should be actively increasing their dealings with medical schools?

Mr. CONLEY. Absolutely. One of the things that I was able to notice, first of all, with affiliation with schools, it brings research

money into the VA, and I was just in Oklahoma and they received

a total of $4 million—or $6 million in research money. Two million

of that comes out of the VA budget. The rest of it is from outside

grants that they invest into the research program.

You are also able to achieve probably the best physicians in the

world that work at the VA because of their associations with the

medical schools. Over 50 percent of doctors in our country have

been trained through the VA. So we see so many things that are

positive about it.

Some of the hospitals, such as Oklahoma, they end up paying

part of the physician’s pay because the VA cannot afford to pay the

salaries that some of these physicians require. So the schools themselves then pick up their salaries.

The thing that greatly disturbs me about Chicago is that Northwestern University has gone out of their way to try to keep a hospital there by offering a whole hospital to the VA for free. All they

have to do is maintain it. They give them 300 doctors at no cost

to the VA a year to help keep their population down, but the VA

turned that request down. That is something I am having a hard

time understanding.

Senator BUNNING. Well, what was the explanation of the Veterans Administration? Have you approach them on that?

Mr. CONLEY. Yes, sir, and we do not have an explanation. If you

go through—we have the full records of my visits to these hospitals, and——

Senator BUNNING. Well, could you make that specific connection

between Northwestern University and the VA hospital in Chicago,

the report on that? Is that part of your report?

Mr. CONLEY. Yes, sir.

Senator BUNNING. Okay. That is something that I will get into.

I have not read that portion.

Mr. CONLEY. Well, if it is not in there, it should be.

Senator BUNNING. It should be.

Mr. CONLEY. It should be in there.

Senator BUNNING. Okay. Let me ask you a further question. Do

you think that the VA should locate new facilities near medical

school campuses when possible? In other words, I know where the

VA hospital is in Louisville, for instance, and that is not near any

medical school in the Louisville area because one is in eastern Jefferson County and the other one is in southern Jefferson County.

If, in fact, we were to get the ability to locate a new VA hospital

or a facility in Louisville, it would behoove us to move it a lot closer

to the University of Louisville where the medical school and the

doctors are more available for training? Was it my understanding

of what you said that 50 percent—did you just make the statement

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a minute ago that 50 percent of the training of doctors in our medical schools have some relationship to the VA?

Mr. CONLEY. That is correct.

Senator BUNNING. That is also in the report, I assume.

Mr. CONLEY. That should be in there. But that is correct. The

number of doctors in our country, at least 50 percent——

Senator BUNNING. Either had something to do with the VA hospitals or were trained and spent time as an intern or whatever it

might be.

Mr. CONLEY. Yes. Steve just mentioned the senior member of the

Republican Senate is an example who was trying——

Senator BUNNING. Ted Stevens.

Mr. CONLEY. Senator Frist.

Senator BUNNING. Well, Ted is the Senior Member of the Senate,

isn’t he? Yes, Ted Stevens. You are talking about the Leader.

Mr. CONLEY. Majority Leader.

Senator BUNNING. Majority Leader, okay. He is not the oldest

guy in the Senate, though.

[Laughter.]

Senator BUNNING. I think the satisfaction of veterans who are actually receiving care speaks well for the changes made in the VA

in recent years, especially in the quality of the care, as you mentioned. But, unfortunately, the VA is often unable to recruit and retain many of our best doctors and nurses because of salaries and

other issues.

When visiting the medical centers, what did the doctors and

nurses and other personnel have to say to you about their working

conditions? What did they say could help improve those conditions

and their jobs? This is my last question.

Mr. CONLEY. I don’t want you to repeat that again, but how they

can improve——

Senator BUNNING. In other words, in talking to the doctors,

nurses, and other personnel, what was the main thrust how their

job conditions and the improvement in the health care facilities

that they are providing for the veterans in, how can we do better

and make their jobs easier and more functional?

Mr. CONLEY. By being able to hire more doctors and nurses. A

lot of them are placed under stress because of having to work overtime in order to fulfill that commitment.

When I visited Togus, Maine, Senator Snowe traveled with me,

and this was reported to her, not to me, as we walked through the

hospital. A patient came up to Senator Snowe and said that the

nurse was just getting ready to dispense medication to him again

for the second time. The reason was that she was totally exhausted

from working overtime that she forgot that she already dispensed

that medication.

So the care is good, and that is just one incident off the side. The

quality of care was excellent wherever I went. The problem is that

they are under a lot of stress because of so much overtime or there

is not enough nurses, doctors, or technicians to fulfill the need of

giving that care.

Senator BUNNING. Thank you, Mr. Chairman.

Chairman SPECTER. Thank you very much, Senator Bunning,

and thank you, Commander Conley, thank you, Mr. Robertson, Mr.

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Gaytan, and Mr. Spanogle. Thank you, ladies and gentlemen, who

have come here to hear the Commander’s testimony.

Mr. CONLEY. We want to thank you, too, Senator.

Chairman SPECTER. Thank you.

That concludes our hearing.

[Applause.]

[Whereupon, at 3:21 p.m., the committee was adjourned.]

(71)

A P P E N D I X

PREPARED STATEMENT OF HON. BOB GRAHAM, U.S. SENATOR FROM FLORIDA

Thank you, National Commander Conley and the American Legion for both your testimony and your report on the condition of VA

health care in America. You are to be congratulated for your ‘‘I am

Not a Number’’ Campaign. Waiting times for both primary and specialized care remain abysmal, but you’ve managed to put a very

real face on the problem.

For example, one veteran profiled in the American Legion report

from Arcadia in my home State of Florida, detailed his plight in

trying to obtain his first doctor’s appointment at the Fort Myers

VA Medical Center. He describes how despite applying in early

2000, he was not enrolled until December of 2001, and has been

waiting another whole year to be scheduled for his first appointment. He spent 20 years in the military, which included service in

both Korea and Vietnam. It is truly shameful that veterans are

being treated this way by the very system designated to take care

of them following their service to this country.

The Administration has chosen to blame Congress for the long

waiting times. Officials blame Congress for opening up VA’s

doors—in 1996—to all eligible veterans. This move is known as

‘‘eligibility reform1’’ and was done to correct the problem described

in Commander Conley’s testimony. Prior to eligibility refom1, the

Veterans Health Administration operated under a very complex

system. As Commander Conley’s testimony points out, ‘‘There were

no defined health benefits packages, no reliable data projecting future patient population . . . Access to the system was severely limited to only three groups of veterans: service-connected disabled

veterans, other disabled veterans, and economically indigent veterans.’’

For years, when we looked at the VA health care system, we focused on the declining veteran population and declining demand.

We are in a totally different predicament today. More veterans are

turning to the VA health care system, and that is a success story.

There can be little doubt that the proposed funding for medical

care in the President’s budget is below the amount needed to fully

fund the system. Veterans Service Organizations estimate that ‘‘the

President’s budget is, at a minimum, some $2 billion below what

is required to assure veterans the health care services they earned

in military service.’’

In addition, the Administration’s approach to deal with burgeoning numbers is to directly reduce demand by cutting off enrollment to higher-income veterans and to artificially reduce demand

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by impinging new deductible and cost sharing requirements on

those already enrolled. This is unacceptable.

In my view, the only real path—the path that reflects the true

sacrifice of our veterans—is to own up to the demand for health

care services and provide funding. I am pleased that the Conference Report on the Budget Resolution approximates the increase

for VA health care recommended by the consortium of veterans’

services organizations that author the Independent Budget for Fiscal Year 2002, and I will work to make these numbers real.

Commander Conley also discusses the CARES process in his testimony. CARES is designed to better prepare VA to serve veterans

in the future, and I totally support this kind of examination of VA

care. But, it is absolutely critical that this be done right because

there is too much at stake. So far, I have been disappointed in

CARES because of the lack of attention to the future health care

needs of veterans, including long-term care and alternatives to

nursing home care. As Commander Conley points out, despite the

incredible demand for long-term care, VA has chosen to ignore it

in its planning for the future.

I remain adamant that when considering the future of VA, a key

factor must be the aging veterans population. Right now, there are

10 million veterans over age 65. Even the number of veterans age

85 or older will double by 2012. Given these demographics, I am

as perplexed as Commander Conley as to why the demand for longterm care has been ignored.

Another serious concern is that VA appears to be manipulating

the CARES process. In early June, 20 facilities submitted their recommendations to VA as part of the process, but were subsequently

requested to re-evaluate their plans in order to find a way to move

from 24-hour operations to 8-hour-a-day clinics. Not only does this

action appear to target long-term care beds in particular—since

these 20 facilities currently house thousands of veterans in need of

long-term care—but it also appears to be a significant manipulation of the CARES process.

As ranking member of the Senate Committee on Veterans’ Affairs, I appreciate your insights into the challenges of VA’s health

care system. While the problems may seem significant, I am confident that we can work together to improve VA health care for all

veterans. Veterans are depending on us.

Thank you.

Æ