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87–063PDF 2004

DEPARTMENT OF VETERANS AFFAIRS HEALTH

CARE SYSTEM

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHT CONGRESS

FIRST SESSION

JANUARY 29, 2003

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 108–1

(
COMMITTEE ON VETERANS’ AFFAIRS

CHRISTOPHER H. SMITH, New Jersey, Chairman

MICHAEL BILIRAKIS, Florida

TERRY EVERETT, Alabama

STEPHEN E. BUYER, Indiana

JACK QUINN, New York

CLIFF STEARNS, Florida

JERRY MORAN, Kansas

RICHARD H. BAKER, Louisiana

ROB SIMMONS, Connecticut

HENRY E. BROWN, JR., South Carolina

JEFF MILLER, Florida

JOHN BOOZMAN, Arkansas

JEB BRADLEY, New Hampshire

BOB BEAUPREZ, Colorado

GINNY BROWN-WAITE, Florida

RICK RENZI, Arizona

TIM MURPHY, Pennsylvania

LANE EVANS, Illinois

BOB FILNER, California

LUIS V. GUTIERREZ, Illinois

CORRINE BROWN, Florida

VIC SNYDER, Arkansas

CIRO D. RODRIGUEZ, Texas

MICHAEL H. MICHAUD, Maine

DARLENE HOOLEY, Oregon

SILVESTRE REYES, Texas

TED STRICKLAND, Ohio

SHELLEY BERKLEY, Nevada

TOM UDALL, New Mexico

SUSAN A. DAVIS, California

TIM RYAN, Ohio

PATRICK E. RYAN, Chief Counsel and Staff Director

(II)
(III)

C O N T E N T S

January 29, 2003

Page

Department of Veterans Affairs Health Care System .......................................... 1

OPENING STATEMENTS

Chairman Smith ...................................................................................................... 1

Prepared statement of Chairman Smith ........................................................ 45

Hon. Lane Evans, ranking democratic member, Committee on Veterans’

Affairs .................................................................................................................... 3

Prepared statement of Congressman Evans .................................................. 46

Hon. Rob Simmons .................................................................................................. 9

Hon. Bob Filner ....................................................................................................... 12

Prepared statement of Hon. Bob Filner .......................................................... 47

Hon. Ginny Brown-Waite ........................................................................................ 20

Hon. Henry E. Brown .............................................................................................. 14

Hon. John Boozman ................................................................................................. 15

Hon. Bob Beauprez .................................................................................................. 17

Hon. Jeff Miller, prepared statement of ................................................................ 51

Hon. Cliff Stearns, prepared statement of ............................................................. 54

WITNESSES

Cullinan, Dennis, Director, National Legislative Service, Veterans of Foreign

Wars ...................................................................................................................... 26

Prepared statement of Mr. Cullinan ............................................................... 65

Fuller, Richard, Deputy Executive Director, Paralyzed Veterans of America,

on Behalf of John C. Bollinger, Deputy Executive Director ............................. 36

Prepared statement of Paralyzed Veterans of America, with attachments . 84

Gaytan, Peter S., Principal Deputy Director, Veterans’ Affairs and Rehabilitation Commission, The American Legion ............................................................ 27

Prepared statement of Mr. Gaytan ................................................................. 69

Jones, Richard, National Legislative Director, AMVETS .................................... 38

Prepared statement of Mr. Jones .................................................................... 103

Roswell, Hon. Robert H., M.D., Under Secretary for Health, Department

of Veterans Affairs ............................................................................................... 4

Prepared statement of Dr. Roswell ................................................................. 56

Schwartz, Dr. Linda Spoonster, Chair, Health Care Committee, Vietnam Veterans of America .................................................................................................. 39

Prepared statement of Dr. Schwartz .............................................................. 107

Violante, Joseph A., National Legislative Director, Disabled American

Veterans ................................................................................................................ 29

Prepared statement of Mr. Violante ............................................................... 77

MATERIAL SUBMITTED FOR THE RECORD

Copy of 1993 brochure entitled, ‘‘Can you ignore 27 million Americans?—

27 million American Veterans didn’t ignore you!—How To Reinvent Health

Care:’’ prepared by A Partnership for Veterans’ Health Care Reform ............ 91

Written committee questions and their responses:

Congressman Evans to Department of Veterans Affairs .............................. 112

Congressman Evans to The American Legion ............................................... 118

Congressman Evans to Disabled American Veterans ................................... 120

(1)

DEPARTMENT OF VETERANS AFFAIRS

HEALTH CARE SYSTEM

WEDNESDAY, JANUARY 29, 2003

HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC

The committee met, pursuant to call, at 2:12 p.m., in room 334,

Cannon House Office Building, Hon. Christopher H. Smith (chairman of the committee) presiding.

Present: Representatives Smith, Simmons, Brown of South Carolina, Boozman, Bradley, Beauprez, Ginny Brown-Waite of Florida,

Renzi, Evans and Filner.

OPENING STATEMENT OF CHAIRMAN SMITH

The CHAIRMAN. The committee will come to order. Good afternoon.

Last night President Bush reported that the State of the Union

was strong. Today we will examine the state of veterans’ health

care to see if it is equally strong.

Only days ago the Department of Veterans Affairs announced

that for the first time it would use its authority to curtail new enrollments for veterans’ health care. VA reported that at least, and

I emphasize at least, 200,000 veterans are waiting 6 months or

longer for their first appointment with a VA doctor, and that estimate doesn’t count those still waiting to enroll in the system. Many

of those waiting are 100 percent disabled and paralyzed veterans.

In fact, when Secretary Principi sent one of his deputies, Gordon

Mansfield, a decorated Vietnam veteran paralyzed in combat, to try

and enroll in VA health care, he was turned away in state after

state due to overcrowding.

Earlier this month Chairman Buyer and committee staff visited

one medical center in Florida and discovered that over 2,700 veterans are waiting to be scheduled to see a VA audiologist, over 4,000

veterans are waiting to see an eye specialist, and almost 700 are

waiting to see a cardiologist. More than half of these veterans were

high-priority veterans in categories 1 through 7. All reports indicate that a similar situation exists at a majority of VA medical centers throughout the country. Care delayed, I would respectfully

submit, is care denied.

At the same time there remain at least 275,000 homeless veterans who—and that is a VA estimate, the VSO has put the number

even higher—who desperately need a helping hand, yet VA is unable to fully fund programs that Congress approved less than 2

years ago. The VA has closed over 1,500 long-term care beds at a
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time when World War II and Korean War veterans are most in

need of assistance. Despite an increase in the number of veterans

who have service-connected mental illnesses such as post-traumatic

stress disorder, VA is providing less care overall than it did in previous fiscal years. And most troubling of all, according to the VA’s

own published documents in the Federal Register of January 17,

the VA will be short, $1.9 billion in their health care budget for

this fiscal year, and that assumes that the VA will receive the full

$23.9 billion for health care approved last year by both the House

and the Senate Appropriations Committees.

Let me emphasize what I just said. The VA projects that it needs other $1.9 billion this year to meet the health care needs of veterans already enrolled. To put this in perspective, $1.9 billion is the

annual cost of providing care to roughly 422,000 veterans from all

priority groups, veterans who are already in the system.

How does the VA plan to make up the difference this year? The

only proposal to date is the freeze on enrollment of new priority 8

veterans, a move that the VA projects could save at most $130 million this year.

Some have suggested that Congress is to blame for the shortfall

in funding for the veterans’ health care, but the record over the

past 5 years is clear that each Administration request has been a

budget floor, while Congress has added funds above the request

each and every one of those years. For fiscal year 2003, the Administration requested a 6 percent increase. The House passed and the

Congress is expected to approve an 11 percent increase. That is $1

billion above the VA budget request. Over the past 5 years Congress has consistently provided greater funding than was requested

by the Administration, on average over $300 million each year. In

addition, last year Congress passed a supplemental appropriation

that included $417 million for VA health care. Regrettably, the Administration refused to accept $275 million of that supplemental

targeted for veterans’ medical care.

Others have suggested that the VA’s problems are driven by enrollment of veterans who were not injured during their service, socalled lower-priority veterans in category 8. However, it is clear

that even if VA had never offered priority 8 veterans the opportunity to receive care from the VA, it would still be swamped with

service-connected and low-income veterans who are in the high-priority categories.

According to the VA, the number of high-priority veterans enrolled in VA health care is projected to rise by 384,000, or 7.5 percent this year, and by 281,000 next year. A total of 5.8 million

high-priority veterans will be enrolled for VA health care next fiscal year, and this trend will not diminish for several more years.

The word ‘‘crisis’’ is often overused in this town, but clearly VA

health care is in crisis, the funding of VA health care, and it is at

a crossroads. Last year I, along with my good friend Lane Evans,

offered several bills seeking long-term solutions to VA health care

funding problems. H.R. 4939 would have allowed the VA to be reimbursed by Medicare for providing care to Medicare-eligible veterans. H.R. 5250 would have made VA health care funding a formula-driven budget item, based upon demand and medical inflation

rather than a discretionary budget item. H.R. 5392 would have al-
3

lowed the VA to recover costs of medical care from third parties in

the same manner as if VA were a preferred provider organization.

And finally, H.R. 5530 would have enhanced the right of the VA

to recover payments from third parties for providing non-serviceconnected care.

We are again preparing to introduce legislation on a bipartisan

basis to provide long-term solutions to VA’s funding problems, but

before we can arrive at solutions, we first need to agree on the nature and scope of the problems. For some, the Secretary’s decision

to cut off enrollment of 164,000 category 8 veterans was a solution.

To me and many others it is a problem.

So I return to the central question of today’s hearing: How well

is VA fulfilling its statutory mandate to provide the full range of

health care services that veterans have earned? Are service-connected disabled and paralyzed veterans receiving timely and comprehensive care, including access to the latest advances in medicine

and technology? Is VA meeting its obligations to indigent veterans,

those who have fallen on hard times, including those suffering from

drug addiction and mental health problems? How about our elderly

veterans? Many who fought on the beaches of Normandy or in the

forests of the Ardennes, and the across the frozen Chosin Reservoir, are they receiving the long-term care Congress mandated

for them in the Millennium Health Care and Benefits Act of 2000?

(Which again, was passed by a previous Congress and remains to

be adequately acted upon by the administration).

Many of you have heard of the American Legion’s project called ‘‘I Am Not a Number.’’ It is helping to put a human face on veterans’ health care issues rather than just focusing on numbers such

as budget allocations and enrollment projections. It reminds me of

a saying often used by Mark Twain, and it is quite appropriate for

today’s hearing. Twain said there were three kinds of lies: Lies,

damn lies, and statistics. I think that Mr. Twain and the American

Legion have it right: Veterans are not numbers, their health is not

a statistic, and our Nation’s debt to them must be more than just

words. We can do better, and I do believe we will.

[The prepared statement of Chairman Smith appears on p. 45.]

The CHAIRMAN. I would like to yield to Mr. Evans for any opening comments he might have.

OPENING STATEMENT OF HON. LANE EVANS, RANKING

DEMOCRATIC MEMBER, COMMITTEE ON VETERANS’ AFFAIRS

Mr. EVANS. Thank you, Mr. Chairman and members of this committee. I welcome the new members of the committee who are joining us for the first time today.

I am also deeply disappointed to learn that Secretary Principi

had recently decided to bar those highest-income veterans who had

not already enrolled for care from applying for VA services. I was

particularly disappointed, Mr. Chairman, given our bipartisan recommendation to the Budget Committee to increase the President’s

request for VA funding levels fiscal year 2003 by $2.2 billion. Unfortunately the appropriation that is before us is below that level

and will only aggravate the VA’s health care problems.

But, Mr. Chairman, there is a solution. You and I introduced

H.R. 5250, the Veterans Health Care Funding Guarantee Act of
4

2002, which would have established a mandatory funding stream

for the VA health care.

I want to reaffirm my commitment and ask for yours in working

together to address any obstacles that have been set in our path

in getting this legislation reintroduced in the near future. I look

forward to working with you, Mr. Chairman.

I yield back.

The CHAIRMAN. Thank you for your comments.

[The prepared statement of Congressman Evans appears on p.

46.]

The CHAIRMAN. I would like to introduce our very distinguished

Under Secretary for Health, Dr. Robert Roswell, who was confirmed by the Senate on March 22, 2002. Dr. Roswell has directed

the VA’s health care network for Florida and Puerto Rico since

1995. Dr. Roswell previously held positions as Chief of Staff at the

VA medical centers in Birmingham Alabama, Oklahoma City; and

held leadership positions in other VA facilities and VA central office in Washington.

He is a 1975 graduate of the University of Oklahoma School of

Medicine, where he completed his residency in internal medicine,

and a fellowship in endocrinology and metabolism.

Dr. Roswell served on Active Duty in the U.S. Army from 1978

to 1980 and is currently a colonel in the Army Reserve Medical

Corps.

Thank you for being here. We look forward to your testimony.

STATEMENT OF HON. ROBERT H. ROSWELL, M.D., UNDER

SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS

AFFAIRS

Dr. ROSWELL. Mr. Chairman, members of the committee, I am

pleased to be here today to discuss the challenges facing VA in

meeting the current demand for VA health care services. With your

permission, I will provide a brief summary of my formal statement

and ask that the formal statement be included in the record.

Today’s VA health care system is one of the most effective and

successful health care systems in the Nation. VA’s performance

now surpasses many government targets for health care quality as

well as measured private sector performance. For 16 of 18 indicators critical to the care of veterans and directly comparable externally, VA is now the benchmark for the entire Nation. VA is also

leading the way in assuring safe health environments and health

care delivery, and we are continuing our efforts to achieve additional cost efficiencies.

Today VA has nearly 1,300 sites of care and is providing care to

nearly 48 percent more veterans than in 1997. At the same time

we have reduced the cost of care per veteran by 26 percent through

more efficient and effective care delivery.

VA continues to place a strong emphasis on comprehensive speciality care, but we now also emphasize coordination of care

through primary care providers. With this transformation, and by

employing new models of care coordination and delivery, veterans

have gained access to an integrated health care system focusing on

addressing their health care needs before hospitalization becomes

necessary.
5

Mr. Chairman, while the changes in the VA health care system

have been profound, and the benefits have been recognized both inside and outside the Department, we also face significant challenges. VA is currently experiencing an unprecedented demand for

health care services. We had nearly 800,000 new enrollees in fiscal

year 2002 alone, and currently we have almost 6.6 million veterans

enrolled. We currently project that we will provide care to 4.6 million veterans this year. This represents a 70 percent increase since

1996. Continued workload growth of this magnitude is clearly

unsustainable within VA’s current level of available resources.

As discussed in my formal statement, VA has taken steps to assure priority access to service-connected veterans, veterans who are

poor and those with special needs.

And recently we announced our decision to suspend enrollment

of new Priority 8 veterans. We did not reach this decision easily.

However, it was a decision that had to be made in order to maintain the quality of health care we provide to currently enrolled veterans and those higher-priority veterans who have yet to enroll,

and to assure that our system will be ready and able to meet any

and all needs of veterans of a future conflict, should one occur.

The Secretary has also announced that work is under way with

the Department of Health and Human Services to determine how

to give Medicare-eligible Priority 8 veterans who cannot enroll in

VA’s health care system access to a VA+Choice Medicare plan

which would include prescription drug benefits very similar to the

type of plan the President mentioned last evening. Our goal is to

have this option available by the end of the year.

During much of the past year, we have had over 300,000 patients

on waiting lists to receive medical care. Currently, about 200,000

veterans are on those lists. VA has made concerted efforts to reduce waiting times and eliminate excessive waits. With the additional funding requested for fiscal year 2003 and the enrollment decision, we expect to significantly reduce these waits this year.

We must also continue to find better ways to deliver care. We

need new ways to partner with patients to more effectively manage

health care continuously. This approach will involve a fundamental

change in how we view health care from a provider-centric to a patient-centric focus. Implementing this approach will have a substantial impact on primary care, but an even more profound impact

on long-term care. Institutional long-term care is very costly and

may impair the long-term spousal relationships and reduce quality

of life.

The technology and skills exist to meet a substantial portion of

long-term care needs in noninstitutional settings. Nursing home

care should always be the option of last resort.

To oversee many of the initiatives needed to implement a new

patient-centered model for care in long-term care, I have created

the new Office of Care Coordination. This office will have in its

charge such issues as the use of technology and care coordination

and the development and implementation of policy and initiatives

for chronic disease management and long-term care.

But while there is much that VA can do on its own, we also need

the committee’s assistance. For more than 30 years VA has developed a continuum of institutional and noninstitutional services to
6

meet the extended care needs of veterans, including VA-provided

contracted and State home services. I believe that the capacity requirement included in the Millennium Act should be updated to reflect VA’s current direction in the provision of all types of long-term

care.

We also need your help to assure VA’s ability to remain competitive in pay and work force innovations. We expect to experience

increasing difficulties in the year ahead in maintaining our nursing

work force, and we currently expect to face severe challenges in recruiting physicians, especially in scarce specialties. VA’s current

pay authorities are stretched to the maximum and the Department

can no longer offer competitive salaries for many medical

specialties.

We are developing a comprehensive work force improvement proposal that would improve our ability to recruit and retain physicians, nurses and other health care occupations. The administration expects to submit this proposal by late spring of this year.

Mr. Chairman, the current state of VA health care is excellent.

We have—but we have much to do to maintain and build upon that

excellence. My vision of the future of VA health care is positive, but

we must deliberately address the challenges I have outlined today

or risk a very different future.

This concludes my statement. I will be happy to answer any

questions you or other members of the committee have. Thank you.

[The prepared statement of Dr. Roswell appears on p. 56.]

The CHAIRMAN. Thank you very much Dr. Roswell.

Let me just begin by congratulating you on a very, very difficult

job that you have undertaken. I think you do it with great passion,

but unfortunately, you get handicapped by the resources that you

have at your disposal and fault for that certainly can be spread in

a number of areas. OMB always comes to mind. Congress comes to

mind. I mean, it seems to me that our endeavor needs to be to

marry up the need with sufficient resources so that rationing, however unwittingly, doesn’t happen.

In the Secretary’s interim final rule, if I read the numbers correctly, is how we derive that shortfall of $1.9 billion. I hope that

you work with us, notwithstanding OMB’s direction, to try to get

that additional money.

I know the appropriations bill is moving, and it won’t even come

close to meeting that. But supplementals are something that happen frequently, or at least maybe once a year, and it seems to me

that once again, the veterans are voting with their feet. They are

choosing VA health care because of the services provided, in some

cases because of the pharmaceutical benefit which is significant for

the category 7s and 8s. But the sense is that there is a good health

care delivery network. They want to be a part of it. The CBOCs

have made it possible as access points for many veterans who may

not have even thought of it before to now become consumers of veterans’ health care.

As you and Secretary Principi have so ably pointed out, especially for our senior population, it is a good deal for the government

when they use VA health care—25, 30 percent less per capita per

patient than if they used a Medicare provider in a more traditional

sense or setting. It seems to me that when Uncle Sam, this spigot,
7

Medicare or some other spigot, or General Treasury funds, is paying, we can’t a case that we get a better utilization of our tax dollar

going into VA health care. I continue to be baffled. Why we can’t

make that case sufficiently to get these resources?

And so, generally you know where I’m coming from, because we

have had this discussion, but I hope maybe you can just speak to

it a little more and maybe talk about the $1.9 billion—is that the

shortfall for this coming year? Are we reading these papers

correctly?

What is the estimation going forward? I know the budget has not

been submitted yet. We will have our budget hearing, but give us

a sense of what kind of resources, year after year, we are going to

need to meet the need.

Dr. ROSWELL. Well, thank you, Mr. Chairman.

Using an actuary’s full-demand projection model, the 1.9 billion

shortfall you spoke about is roughly correct. But it is important to

understand, as much as I support and appreciate your advocacy for

veterans and your leadership in this committee and your tireless

efforts to generate the resources that are needed to provide care,

at this point in time it is more than simply resources. We have

reached a point with our VA health care system where the fundamental nature of the system has shifted because of recent demand for care and years of chronic underfunding.

Today we must rebuild the system. We have to hire new physicians, new specialists and new nurses, and we have to go back and

reexamine our tertiary care capability. We have had tremendous

demand for care, for pharmaceutical benefits and for outpatient

care. But over half of the new enrollees in the system have sought

just prescription drug benefits.

That shifted precious, limited resources away from our tertiary

care mission. It has created primary care clinics and prescription

drug delivery systems that are not at the fundamental nature of

our core system.

If, God forbid, we have a war with Iraq, and if we have, God forbid, new veterans returning with combat-related disabilities and

injuries, we must have in place the tertiary care system that will

meet those full and comprehensive needs. I’m sorry to say, Mr.

Chairman, that today we don’t have those specialists and we have

underfunded and neglected the tertiary medical equipment needs

that will create such a system to meet that need.

We need a standdown. We need time to recruit specialists to

bring on new capacity and to rebuild and replenish our tertiary

equipment capability.

The CHAIRMAN. I think you make our case, though, Dr. Roswell,

that funds are policy. I mean, notwithstanding the enrollment moratorium that Secretary Principi—and he has fully had the discretion to do so; I think he did so in very good faith, even though I

disagree. But I think he has the veteran at heart and especially,

you know, the service-connected and the indigent veteran. But it

seems to me that chronic underfunding in the past should not become perpetual. We need to break that cycle and break it decisively. And why not in the 108th Congress? Why not now? If not

us, who?
8

My question is: with this budget that we will soon get, knowing

that we have a $1.9 billion demand-model shortfall for this year,

won’t that only get exacerbated as we move forward?

Please work with us because we are only one part. I mean, half

of our budget is mandatory, thank God, and that is why when we

do a GI bill, it does get fully funded because it is mandatory. And

the benefits work that our new Chairman Brown will be working

on, so much of that is, if we do it, it happens. But, unfortunately,

the health care remains discretionary, and that has led to these

chronic shortfalls, as you describe them.

But let’s not let the past, I would respectfully request, color our

future. We need sufficient resources and we will fight and the Administration can put the marker down.

Last night I was very proud of the President on the AIDS crisis.

I am on the International Relations Committee; I am Vice Chairman of it. We have been working to get an AIDS bill passed that

will put more money, especially in Africa where you have an explosion, 25 to 30 million people carrying the HIV virus within their

bodies. And that will only get worse; you need to put a tourniquet

on that. And the President announced a $10 billion increase for

that, $15 billion in total.

It seems to me that we have a chronic shortfall, and it goes

through previous Administrations, no doubt about it. Congress

ponied up more money, but not enough. We can break that cycle

now and do it in a bipartisan way. The Presidential Task Force—

and you might want to speak to that, and then I will yield to my

colleague for any questions he might have—will be making its

recommendations.

I know they are looking at the mandatory scheme and other

schemes as possible solutions. I would hope that maximum input

would be made that what they produce won’t be like so many GAO

reports that get put on the shelf and nobody ever acts on it. We

need a real change now, and I think the time has come.

Dr. ROSWELL. Thank you. Certainly we have worked and continue to work closely with the Presidential task force. We don’t

know what their final recommendations will be. But let me tell you

that the concept of a VA+Choice benefit that the Secretary recently

announced actually had its genesis, its beginning, in discussions

with the chairperson of the Presidential task force, Gail Wilensky,

the former HCFA Administrator.

So we have been maintaining very close communication with the

Presidential task force. We are working to implement concurrently

many of the areas of interest and many of what we believe will be

their recommendations. Clearly, I think their interim report

showed that to maximize VA-DOD sharing we have to improve access to the VA health care system which is, in large measure, resource-related. But at this point, because we have saturated our capacity, we also need time to hire those physicians and nurses. And

in the health care field, the time to recruit and bring on additional

health care professionals can sometimes be lengthy.

The CHAIRMAN. I see my time is up, so I yield to Mr. Evans.

Mr. EVANS. Thank you, Mr. Chairman. I have a disturbing question to ask.
9

If we are already in debt to a great degree and are not providing

enough funding for the next fiscal year, how are we going to have

enough if this war gets very heated and starts costing us casualties. Particularly since a lot of the same people who are serving as

backfill are often the supply troops behind our lines?

Do you have any comment about that situation?

Dr. ROSWELL. Well, Congressman Evans, I share your concerns.

As many as 8 percent of VA personnel could be deployed with a full

deployment, and that would create a critical shortage of very vital

health care professionals at a time when we most need them. I

don’t have any solutions, but I can tell you that we are eager and

ready to begin an active recruitment program. If we receive the

2003 appropriation in the near future, we will activate that full effort to bring on a substantial number of additional nurses, as many

as 1,300 additional nurses this fiscal year, as many as 500 additional physicians.

We have worked with OPM to develop policies to rehire annuitants to come back and work on a part-time basis in the event of

a need to activate the DOD contingency mission. I have instructed

all of our network directors to begin to identify ways to accelerate

recruitment, bringing on additional personnel, bringing back retired or former employees in the event that we have that need.

But, yes, Mr. Evans, it is a very serious concern and one I share,

but one which will only get worse lacking an adequate appropriation this fiscal year.

Mr. EVANS. Dr. Roswell, you have also referenced outsourcing as

a possible source of significant savings for VA this year. What sort

of services are you investigating for potential outsourcing?

Dr. ROSWELL. Competitive outsourcing is a component of the

President’s management agenda, but I am pleased to tell you that

the only areas where we are looking at competitive sourcing as a

possible vehicle to outsourcing would be in nonclinical areas. Currently, we are looking at laundry services; soon we will be looking

at grounds maintenance and facility maintenance and management

issues. We will also be looking at such things as food service,

though not professional dietitian care for our patients.

Our agenda to address competitive sourcing and possible

outsourcing is strictly apportioned away from the health care delivery within the VA health care system.

Mr. EVANS. All right.

Thank you, Mr. Chairman.

The CHAIRMAN. Chairman Simmons.

Mr. SIMMONS. Thank you, Mr. Chairman. Thank you, Doctor.

Mandatory benefits. What’s the position of the VA on the issue

of mandatory benefits which has been discussed by this committee,

shifting that into health care?

Dr. ROSWELL. You are referring to H.R. 5250 from the 107th

session?

Mr. SIMMONS. Yes, or similar legislation.

Dr. ROSWELL. I can’t say that the Department has an official position on the bill. Obviously, the bill died with the termination of

the last session.

Certainly, the concept is one that is interesting to me. It would

require us to look at the specifics of the bill. One of the things that
10

we have determined is that in a typical year, our expenses increase

6 to 7 percent by new enrollment in Priorities 1 through 7. In addition to that, increased utilization, because the veteran population

ages, and health care expenditures and health care utilization increase. With every increasing year of age, particularly in an elderly

population, we have another 2 to 3 percent incremental cost every

year. So a 7 percent increase associated with enrollment in our

highest priority groups, coupled with another 2 to 3 percent of increased utilization costs, coupled with a conservatively estimated

health care inflation rate of 4.5 or 5 percent, yields a 13 or 14 percent per year increase in the money available to take care of just

our core population of veterans.

The mandatory funding bill would have to index the incremental

rate to reflect those needs, and certainly, working with the committee staff, we have addressed that. I think that the concept of mandatory funding is one that philosophically I embrace, but obviously

the Department would have to look at the specifics before there

could be any direct, express support for that. It is interesting that

we tend to treat VA health care as an entitlement, but we certainly

don’t fund it that way.

Mr. SIMMONS. And that is the whole point. Veterans tend to treat

it as an entitlement as well—in other words, as part of the promise. In some cases, it is hard to find where the promise was actually made, but that is the understanding. And so, like any entitlement, you are going to have a fixed cost which may escalate based

on access to the system. But certainly we deal with that with other

entitlement programs in other parts of the government including

health care programs.

Secondly, efficient use of resources. I am sure every Member of

this Committee has experienced a situation where there may be

military health care facilities in their district and there may also

be Veterans Administration health care facilities in their district,

and perhaps even other venues. It just seems to me that in numerous instances, these entities don’t know about each other’s activities. They don’t coordinate their acquisition of very expensive

equipment, and so on and so forth. What effort can we make within

the next couple of years to assess where these resources are located

and work to combine some of these resources with a common purpose of providing better health care? Not only for veterans, but

maybe for the active component.

Dr. ROSWELL. Well, I am pleased to tell you that there is a great

deal that has already been accomplished to move us towards that

goal. Working with the Department of Defense, we have this past

year created the Joint Executive Council as well as a Health Executive Council, that is specifically addressing those opportunities.

We have implemented a contractual arrangement that sets a fixed

discounted rate for any sharing between DOD facilities and VA facilities, a national rate schedule that eliminates the need for local

negotiation that we hope will greatly facilitate that.

VA is undergoing a comprehensive process to examine its capital

assets, its inventory of hospitals and clinic. Three representatives

from the Department of Defense actually serve on the CARES oversight steering committee, so that they have full participation and

DOD utilization in that process as a mandatory step in the devel-
11

opment of the market plans that the VISNs are now working on.

So a lot is going on.

Also, I might add that the VA+Choice program that the Secretary announced is an initial effort to really begin to, first time,

leverage Federal health care benefits across the Medicare program

and into the VA program. I totally agree with the agenda you have

laid down, and I am pleased to tell you that we are working aggressively on a variety of fronts to achieve those goals.

Mr. SIMMONS. Final question, I have always been confused about

the fact that veterans applying to the VA for prescription drugs

often are told they have to go through a complete rediagnosis of

their condition. As somebody who travels a fair amount and, for a

while, was on asthma medicine, if I presented a prescription just

about anywhere in the country at a drug store, I could get what

I needed. I don’t know why this same concept can’t apply to veterans going to VA.

What can we do to simplify that process and give them access to

prescription drugs without going through a lengthy, time-consuming and expensive rediagnosis?

Dr. ROSWELL. Currently, the law restricts VA from providing

drugs to any beneficiary unless the prescription is written by a VA

provider except in certain very unique circumstances. So it would

take a fundamental change in legislation.

But more importantly, the provision of prescription drug benefits

through the VA allows us to oversee the quality of care being provided, our comprehensive system of clinical oversight. And the sophisticated, computerized patient records system allows us to monitor patients for drug/drug interactions which can seriously affect

health.

We also make sure that we provide the necessary clinical and

therapeutic monitoring that is required with many of the new

medications. And that affords a much higher quality of care and

patient safety to veterans in the VA health care system. For that

reason, we oppose filling prescriptions written by non-VA providers

who may not be familiar with VA formulary or VA’s clinical monitoring and oversight processes.

I also would have to question, given finite resources, if that is the

best utilization of the VA dollar when we truly need to rebuild this

tertiary capacity, this comprehensive capacity in our systems.

Over the last several years, through no strategic direction, by no

intent or policy, VA has shifted from a comprehensive tertiary

health care system meeting a full spectrum of veterans’ needs to

a system that has focused and shifted towards primary care and

prescription drug benefits. And while that is laudable if we have

the resources to do it, we can’t let the system shift and be stripped

of the resources that would be necessary to meet the needs of both

current, high-priority, disabled veterans and possible future combat-disabled veterans.

Mr. SIMMONS. Thank you, Mr. Chairman. My time has expired.

The CHAIRMAN. Thank you very much. Mr. Filner.
12

OPENING STATEMENT OF HON. BOB FILNER

Mr. FILNER. Thank you, Mr. Chairman. As I listen to the testimony and the questions, I am struck by almost an unreal world I

think we are living in at this moment.

Dr. Roswell, you said, God forbid, if we go to war. The chairman

spoke of the President’s very great proposal of AIDS funding. The

President declared war last night, and we are going to go to war,

it looks to me. And all these other discussions have no meaning because there is not going to be money for AIDS if we are at war,

and there is not going to be the money that we are all talking

about. So in some respects, it is an unreal world we are talking

about.

More practically, Dr. Roswell, I think you said with the increase

we will get in fiscal year 2003, we will be okay.

I don’t see any increase coming. You know there is no increase

coming. The omnibus bill was cut across the board. There may be

even more cuts in VA, for all we know; in fact you may be on a

CR for the rest of the year. Now, under any of those scenarios,

which seem more real than anyone has been suggesting here, you

are in trouble. And I would like to know what you are requesting

us to do about it.

It looks like there are going to be to have layoffs and other such

incredibly difficult measures. You are going to have to cut off more

veterans, and that is the real world we live in.

Everybody’s talking about this increase that is coming. It isn’t

coming. If we are at war, there aren’t going to be any of these other

things that are even going to be discussed. So I would like you to

respond to that if you want to.

In addition, I see several of the freshmen here still. I want to

point out the order of our panels has an impact on our hearings,

and several of the subcommittees in this committee at certain

times have said, why don’t we hear from the public first, from the

VSOs, and then from the administration, because then they raise

really good questions and important questions, and we could have

him answer those. This way, he goes first and then all the members leave and the VSOs are left by themselves without us really

getting their expertise; and the kind of questions that ought to be

asked of Dr. Roswell or Secretary Principi are simply not asked. So

I would hope, Mr. Chairman, that at least we vary the rotation of

these panels at times and have the public members and the VSOs

first. These people work day in and day out for the veterans, and

then they come here and testify and there is no one here listening

to them. I just want everybody to keep that in mind as we proceed

with the year’s hearings.

The CHAIRMAN. Will the gentleman yield on that point?

Mr. FILNER. Yes.

The CHAIRMAN. Because we have done that in the hearings. I

think it is a good idea. But even when they go second and third,

we do listen and we listen carefully. But thank you.

Mr. FILNER. We try to listen. But many of the top VA administrators—I don’t know if you are leaving, Bob, but they depart so

they don’t hear. They are in and out. And they don’t hear all the

testimony, although I am sure they get reports of it.
13

So under the real, more realistic scenario, you have cut off Priority 8. We have 300,000 waiting for their first appointment. We

have a quarter million homeless on the street. We may not even

have a budget for fiscal year 2003. So you are on a CR basis. What

is going to happen? And are you going to insist on a supplemental

for 2003?

Dr. ROSWELL. The situation is dire without a budget this year.

Certainly, the omnibus bill you alluded to, resulting in the 2.9 percent cut in the House-Senate mark would significantly impact our

ability to operate during the current fiscal year. We anticipate that

we would need to see almost a quarter of a million fewer patients.

We would have almost 2 million fewer outpatients visits and our

efforts to reduce the waiting list would virtually be totally ineffective. It would require us to really refocus on addressing emergent

and urgent care needs, and it is not a situation that truly provides

the comprehensive, quality health care that our veterans need and

deserve.

Mr. FILNER. I think you are right, and I think we have to face

that reality here on this committee.

Another reality, and I know you have worked on this for a time,

we are about to send 150,000 troops into an area where, the last

time we sent them, 200,000 came back with something we are calling Persian Gulf War illness. We have neither a cure nor an explanation of what occurred.

As you know, my opinion has been that DOD especially, but also

VA, have stonewalled—trying to get an answer to this, because

maybe people would be embarrassed by the answers—for example,

the vaccines that were given to the young men and women who

were in the Gulf.

We are about to do this again. Do we have any better answer

than we had? We are sending folks back in; we don’t even know

what happened to them last time.

Dr. ROSWELL. It is a fair question.

Mr. FILNER. Is that a fair summary that I gave?

Dr. ROSWELL. It is an appropriate question. It is a legitimate

question. It is one that we have given a great deal of consideration

to.

We have worked very carefully with the Department of Defense.

VA has asked and been assured that full deployment health survey

information will be obtained on all personnel being deployed and

that that information would be provided to the VA. During the 10-

year interval between Gulf War I and the current conflict that we

are looking at as a possibility, tremendous strides have been made

in our ability to identify hazards associated with the use of chemical-biological agents. There would be enhanced monitoring. There

would be enhanced surveillance. DOD has taken steps, I am told,

to implement a way to track the location of personnel assigned to

the theater of operations which will allow us to better coordinate

potential risk exposures.

Mr. FILNER. You are learning this job of obfuscation very well.

If you look at the transcript that comes out, I asked, do we have

any explanation for what happened?

Dr. ROSWELL. We don’t have an answer for the Gulf War

illnesses.
14

Mr. FILNER. We could be sending the guys right back into what

happened before. Now, I have asked again for the historical

record—I would appreciate if I could have 1 more minute, Mr.

Chairman.

The CHAIRMAN. Just one, and then we will go to Mr. Brown.

Mr. FILNER. We had asked—many years ago—DOD if they had

the a record of the inoculations that were given to each of the servicemen and -women. They claimed—I cannot accept the truth of

this—that they didn’t have such records, which is beyond the pale

of credibility.

Now, one of your colleagues, at a hearing, mentioned these

records; and I said, Oh, can I get them, because they told me they

didn’t have them. And she said, Sure. I never heard from her

again, by the way.

We are claiming we have no record of the past situation in terms

of injections, vaccines given, and yet we are going right out again.

We don’t have any answers for these folks. People have suggested answers, and VA and DOD have refused to look at them.

That is what gets my dander up, that there have been legitimate

scientists and researchers who have said, We think we know why,

and nobody will give them the opportunity to prove it. And we are

going to have another 125,000 come back.

Dr. ROSWELL. I agree with your frustrations, and I share those

frustrations. There has been over $200 million committed to research into Gulf War-related illnesses. In fact, we have recently announced as much as $20 million to be made available by fiscal year

2004 to focus on the sequelae of Gulf War illnesses. We have just

created a commitment to fund a Neuroimaging Center of Excellence to look at neurodegenerative diseases that may be associated

with environmental exposures, including Gulf War types of exposures. We have a new research advisory committee that we take

very seriously concerning their recommendations about continuing

to explore the causes of Gulf War illnesses.

So there is an unprecedented level of cooperation with DOD. We

have renewed our commitment to research. We have redoubled our

efforts to focus on those illnesses.

But, yes, this is a major concern, which is exactly why I feel so

strongly about making sure that what finite resources are available

to the Department are redirected to the services we know we will

need if we have men and women injured or disabled by a future

combat experience.

The CHAIRMAN. Thank you. Chairman Brown.

Mr. BROWN. Yes, thank you.

Dr. Roswell, thank you for coming today and thank you for all

you do for the veterans of this Nation. My question would be, how

is the pilot project working now, where we allow veterans to use,

you know, outside medical facilities to meet their needs?

Dr. ROSWELL. We have a couple of efforts in that regard Chairman Brown. We have an emergency hospital benefit that is available to all veterans who may need emergency care and haven’t

been able to get it through the VA. On the other hand, routine care

in non-VA hospitals is usually restricted to veterans with serviceconnected disabilities.
15

We do have one pilot program operating in Florida that was authorized by this committee several years ago that basically allows

veterans treated at this particular clinic location in Brevard County, Florida, to receive hospitalization in the community. Because

we don’t have access to Medicare as a primary payer, like

TRICARE For Life beneficiaries do, that pilot program has proven

very costly for veterans who have third-party insurance. It is very

manageable for the small number of veterans who have no health

care benefits or insurance, we are able to cover that, but for the

veterans who are Medicare-eligible, because we can’t coordinate

Federal health care benefits, we have to ask those veterans to selfrefer; otherwise, the cost would be prohibitive.

I think we have learned a lot from that pilot program. A full report has been submitted to this committee during a past session,

and it is certainly something that we continue to monitor.

Mr. BROWN. I know my particular reason—I think we talked

about it personally, but we had—one part of our district was some

100 miles or so from primary care. They have to make appointments and commute that long distance. And if there was available,

you know, the health care delivery right there in that location, it

would certainly be of some benefit to those veterans that have to

travel.

And also I think the variety of care that could be offered, rather

than just the, you know, specialized care, I guess, that is being offered at the veterans hospital itself.

So do you think there is any chance that we could maybe coordinate those benefits with Medicare and private pay and—to meet

some special needs for the veterans?

Dr. ROSWELL. I think we could. I think there are two possible encouragements, and with regard to the Myrtle Beach area that you

refer to, certainly the CARES process will allow us to examine

that. We are undergoing that process and we expect to have final

recommendations approved by the Secretary by November of this

calendar year. So that is one effort that will address the specific

needs in your home State.

With regard to the coordination of benefits, I am optimistic

TRICARE For Life, a benefit approved by this Nation for military

retirees, essentially is a benefit that allows Medicare to be the first

payer and DOD to be the second payer. If it is good enough for

military retirees, why isn’t it good enough for veterans? If we could

let Medicare be a primary payer and VA be a secondary payer

where we had to use non-VA facilities to meet a dire need for care,

then why would we waste appropriated VA health care dollars to

pay the full cost of care if Medicare could be the primary payer?

The legislation has precedent. Certainly I would like to work

with the committee to seek that benefit.

The CHAIRMAN. Mr. Chairman, are you finished?

Mr. BROWN. Yes, sir. Thank you.

The CHAIRMAN. Thank you very much.

The Chair recognizes Mr. Boozman.

Mr. BOOZMAN. Dr. Roswell, I do want to thank you and your

staff. You have got a very difficult job and we have always found

you very, very helpful in the problems that we have come across.

I think one of the committee’s concerns is that we would like to
16

know a little bit about your plans as far as the relationship between the Office of Research Compliance and Assurance and the

Office of Research and Development.

Mr. ROSWELL. We created the Office of Research Compliance and

Assurance in 1999 because of concerns with the conduct of human

research. Human research in safeguarding our subjects is one of

our highest priorities. But since the creation of the Office of Research and Compliance in 1999 we have continued to have significant, potentially serious problems with the conduct of human research. The Office of Research Compliance and Assurance, or

ORCA, which is easier for me to say, was set up as an independent

entity within the Veterans’ Health Administration to look at compliance and facilitate compliance through education and policy

formulation.

What we have found since 1999 is that ORCA has been very effective at determining compliance. But because it is a separate entity the ability to formulate needed policy changes that will facilitate compliance and then provide the necessary education not only

to investigators but to research administrators and support staff

has not taken place because of ineffectual communication between

the ORCA office and the Office of Research and Development.

Therefore, we have recently taken an effort to integrate to a certain, but very limited, extent the ORCA office and the Office of Research and Development. ORCA will still have a separate budget,

a separate funding stream. They won’t have any programmatic responsibilities over research funding or administration. They will

keep their evaluation responsibilities, but they will report dually to

the Chief Research and Development Officer and to my office.

Then in addition, to make sure that we have sufficient external

oversight, we have contracted with a National Committee for Quality Assurance, or NCQA, to do independent audits and certification

of our research programs at every location in the Nation. We also

have independent external accreditation that is exercised by the

Office of Human Research Protection in the Health and Human

Services Department as well as our own Inspector General and in

many cases the Food and Drug Administration as well.

With these four types of external oversight, we believe that the

ORCA efforts will be more effective in facilitating the needed policy

changes and education of staff that will allow us to finally reach

full compliance by having it better integrated with the Office of Research and Development.

Mr. BOOZMAN. Okay. Again, in looking through this it does appear that the committee has been very interested in keeping that

unbiased objective and along those lines. It appears that you might

have a conflict though if basically people are working with each

other, maybe for each other and then trying to regulate the entity

that they are potentially working for. Is that not——

Mr. ROSWELL. I understand your concern. But let me assure you

that there is no one in the Department of Veterans’ Affairs, VHA,

and certainly not in the Office of Research and Development, who

wants anything more than to absolutely totally protect the rights

of patients who are involved in the conduct of research. This is not

the fox watching the hen house. The fox watching the hen house

wants to eat the chickens. In this case the Office of Research and
17

Development is doing everything it can to protect the research investigators, and that is the intent of both programs, to make sure

that the integrity of our research programs is absolutely beyond reproach. But the inspection could be separate, and I understand

that. But when inspection after inspection continues to identify

problems and we don’t make progress in facilitating changes, then

it is time to figure out how to integrate those efforts so they are

more effective.

Mr. BOOZMAN. I understand. I haven’t been here a long, long

time and yet sadly I have sat through hearings where, you know,

somebody in your position several years ago probably was making

the same statements and yet things were being done that never

should have been done, okay? Now, are you going to at some point

then report to Congress your changes as to how you are proposing

to do this or are doing it now?

Mr. ROSWELL. Yes, sir. In fact, tomorrow we have a meeting with

the Oversight Subcommittee staff to address some of the proposed

changes and we will be certainly making all of our progress towards that end. We will be communicating on a regular basis, most

likely through the Subcommittee on Oversight.

Mr. BOOZMAN. Okay. Thank you.

The CHAIRMAN. Mr. Bradley.

Mr. BRADLEY. No, thank you at this time.

The CHAIRMAN. Mr. Beauprez.

Mr. BEAUPREZ. Thank you, Mr. Chairman. Dr. Roswell, forgive

me as a freshman if my questions are overly naive or perhaps repetitious, but I have two questions I would like to raise. I am from

Colorado. Are you familiar with the Fitzsimmons Army Base and

the redevelopment of that site?

Mr. ROSWELL. Yes, sir, I am.

Mr. BEAUPREZ. A rather glorious project I assume you would

agree. And I assume from your response that you are also familiar

with the ongoing efforts to relocate the existing Veterans’ Administration Hospital from Denver out to the Fitzsimmons base.

Mr. ROSWELL. Yes, sir.

Mr. BEAUPREZ. I think that holds, from my admittedly biased

perspective, holds a tremendous opportunity for improved health

care for our many veterans in that area, in that region, certainly

an opportunity for them to access quality health care by the many

other providers at that site and partner with non-VA providers, as

you have indicated apparently a growing willingness to do. Our

veterans are very excited about that, and what put me over the

edge in supporting it is the relatively short-term recovery of the

initial cost by improved operational overhead and expense. So I am

pleased to see that you are aware of it and hope that somehow we

can collectively move that project forward and see it to fruition.

Mr. ROSWELL. Well, I am delighted with your support for the

project and I am pleased to tell you that we are very interested in

the project. We have actually taken it a level beyond the VA because the Air Force and the Department of Defense have also expressed interest in relocating to the University Hospital Colorado

site at the former Fitzsimmons Army Center. We have recently created a task force that includes both DOD and VA representation

to explore feasibility and options to begin a relocation to that cam-
18

pus, and within the next 2 weeks I will personally be meeting with

the chief executive officer of the facility to discuss some of the specifics of that relocation effort.

Mr. BEAUPREZ. Good. I appreciate that. Let me explore one other

avenue with you. I was taken last night in the President’s comments by his concern for drug addicts and their needs and certainly

for some of the most needy in our society. The question comes up

about homelessness, and especially the 250,000 to 300,000 veterans

that sadly are homeless every night. What is the VA doing? Are we

being proactive enough or are we simply reactive or is it a problem

that just won’t go away and we are simply not addressing it actively enough at all?

Mr. ROSWELL. We have aggressive efforts to address the problem

but it is not a simple answer. Solving homelessness is not simply

a matter of providing housing. Homeless veterans are homeless because of an underlying problem, and to be able to break the cycle

of homelessness it is absolutely essential that we take the time and

effort to understand what the underlying problem is—often it is

substance abuse—and make sure that the veteran gets the needed

therapy and treatment to assure that that cycle is broken in addition to providing transitional housing and a resocialization, retraining, reeducation, reintegration model into society.

We have had a very effective homeless grant and per diem program that provides grants for nonprofit agencies to create transitional beds. But sadly sometimes they haven’t had the rehabilitation services effectively integrated. We continue to expand that program, and I am pleased to say that this year we are adding $10

million in benefits for dental care for homeless vets to help with

much needed dental care. We are adding an additional $5 million

to a program to integrate homeless care through the Department

of Health and Human Services and HUD along with VA to address

that. We are adding $2.5 million to address the fire and safety

issue, life safety issue in the existing homeless beds that we have.

But I have asked our Homeless Advisory Committee, not once but

on two separate occasions, to help me address how we break the

cycle of homelessness to make sure that the rehabilitation services,

the substance abuse treatment, the treatment for serious mental

illness is available throughout the transitional housing process because that is where we continue to have recidivism and the homeless veteran winds up back on the streets.

Mr. BEAUPREZ. I would hope that in my time on this committee

that I could see progress made in breaking that cycle. I have very

close personal experience with that tragedy, and it impacts not only

certainly the veteran but the veteran’s family, and it is a tragic

cycle.

Doctor, thank you very much. Mr. Chairman.

The CHAIRMAN. Mr. Beauprez, would you yield on that, on the

question of homeless veterans?

Mr. BEAUPREZ. Yes.

The CHAIRMAN. Perhaps you could elaborate further, Dr. Roswell,

because, as you know, the homeless assistance legislation that we

enacted and the President signed, authorized over a 5-year period

approximately a billion dollars. It was a bipartisan effort and it

had the dental benefit in it. Maybe you might want to elaborate on
19

that $10 million. Is that a proposal in the budget that will come

to us in a week or so or is that something you are doing with existing funds?

Mr. ROSWELL. No. We have authorized dental care, which we anticipate will probably—when fully annualized will probably—our

best estimates are 12- to $14 million a year, but we anticipate because that has now been fully implemented that the dental health

care benefit for homeless veterans will probably reach about $10

million this fiscal year. So that, coupled with the 2.5 million for fire

and life safety issues, coupled with the 5 million we have recently

made available to the HUD-HHS joint project, really is beginning

to seriously address the kind of commitment that is needed.

The CHAIRMAN. That is encouraging. Last month I met with the

Secretary and I asked him if he would help us secure $36 million

for additional homeless programs, and I wonder what might be the

status of that. And secondly, it is my understanding of the 270

grant applicants only 52 or approximately 50, maybe 52 is the right

number, so one in five, and I am sure more than one in five were

deemed credible and ought to be funded if the money were available. What is the status on that? And I thank my friend for yielding his time.

Mr. ROSWELL. Well, in fact, many of the grant applications are

not ready to be funded because of the nature of the nonprofit organizations, which are often well-intentioned and very dedicated and

compassionate community leaders; they don’t have the experience

in grant development and we really need to provide help. Many of

the grants simply don’t meet the standards that would allow us to

provide the money and assure the safety and ongoing welfare of the

veterans who might be housed there. To that end we have made

available another $750,000 this fiscal year to specifically offer technical assistance to those individuals who seek to apply for a homeless grant program. So we are really addressing this in a comprehensive way to build over a multi-year period a much more comprehensive homeless program.

The CHAIRMAN. Again, if the gentleman would continue to yield. If you could get back to us on the $36 million, because we had that

itemized as to how we would have hoped that money would be

spent. And you might recall, and I am glad the 750,000 is being

used, that is how we had it in the bill because there is a technical

assistance that is required or helpful for these NGOs to get the job

done. But on the issue of the domiciliaries, which is another homeless issue that we found—and as a matter of fact it was the VA

itself that gave us the input from the existing doms that they were

working so well. But we need more of them. And I have been to

doms. I have seen how well they work, how they train up our formerly homeless veterans as they matriculated back into society by

teaching life skills and really getting those good habits deeply impressed into them. We had authorized 10 more. What is your

thought on that?

Mr. ROSWELL. We are looking at that through the CARES process. Let me point out if I may, Mr. Chairman, the distinction between the VA dom and the transitional beds provided through the

homeless grant. That is exactly what I am talking about. When we

have a homeless program situated in a domiciliary collocated with
20

a VA medical center we have that access to substance abuse treatment, to counseling, and we are able to provide the intensive services that really provide the needed therapy for many of the underlying problems that have triggered homelessness. And that is an

excellent model. The problem is that sometimes our doms aren’t located where homelessness is a problem. I recently visited one of

our medical centers that had a large domiciliary. And yet it was

in a very wealthy neighborhood, and as I was talking to one the

clinicians, I said, you know, you would have to drive up and down

the street for the better part of a month to find one homeless veteran in this neighborhood. So we have to sometimes look at the

mismatch between where the doms are, where the need for transitional housing is because homeless veterans have certain biases.

They tend to be regional. And we have to look at the geographical

location of where the doms could be and should be to address

homelessness. But we are doing that, I am pleased to tell you,

through our CARES process.

The CHAIRMAN. Just for the record, it has been my experience

that proximity to where one was homeless is not a determinative

factor for many, even a place like Vets Haven, which Mr. Ryan and

I visited. We found not to our surprise that most of the veterans

who were there who are homeless and now getting the needed care

were from North Jersey and this is in South Jersey. So it is a matter of putting them into a bus. They are living in the facility.

Mr. ROSWELL. Relocation sometimes can be effective, I would

agree.

The CHAIRMAN. Okay. Ms. Brown-Waite. And thank you, Mr.

Beauprez.

OPENING STATEMENT OF HON. GINNY BROWN-WAITE

Ms. BROWN-WAITE. Thank you very much. Dr. Roswell, I come

from an area where we have waiting lists of up to 18 months for

the initial appointment. And I think one of the saddest constituent

cases I had was a woman whose husband was at the 16-month period of waiting, had another 2 months, and she realized he was so

sick he couldn’t wait that extra 2 months. He had cancer. Had he

had an appointment sooner, he would be here today, but he is not.

While you talked about reducing the waiting period, I am afraid it

is not geographically spaced and that it is not geographically relevant to where people are moving to. They are obviously moving

to the Sun Belt. They are moving to Arizona. They certainly followed me to Florida, and I have a large number of veterans in my

area. I would like to know, A, what you are doing about having geographic representation of whittling down those waiting lists.

And number two, on the specialty care, if you are looking for specialists, I hear complaints that at the VA clinics that there are no

dermatologists in the Sunshine state, that the wait for an audiologist is well—once you get in then you have to wait another 2 years

to see an audiologist. And if you are looking to recruit specialists,

let me share with you that I am hearing from doctors, because of

the high cost of medical liability insurance, that they are very anxious to join the VA system because they would get sovereign immunity. So this may be the time to encourage the specialists to come
21

to the VA and have a retention program. I would like to know what

you are doing there also.

Mr. ROSWELL. Thank you for both of those questions, and certainly your district is an area that I am familiar with from my previous experience. Let me begin with the misallocation of funds, if

you will. We recognize that waiting lists are distributed inequitably

or variably around the country. That is exactly why we use a resource allocation model to distribute Medicare dollars to those regions of the country that have greater workload. We have asked

each of the VISN directors to develop a certification plan based on

the expected 2003 budget. The director of VISN–8, the area you are

from, has done a remarkable job within finite resources of addressing the waiting lists throughout Florida, but he clearly needs the

additional resources that will be brought with the 2003 appropriation at the full House and Senate mark to allow him to build the

capacity that will eliminate those waiting lists this year. The

VERA model, that is the Veterans Equitable Resource Allocation

model, that distributes those funds with the full House-Senate appropriation mark would distribute a minimum of 5 percent additional dollars and a maximum of 12 percent additional dollars to

various portions of the country. VISN–8, your region, would receive

the full 12 percent increase in allocation, which is about at much

as can be effectively used on an incremental basis in a single year,

and that would really allow Network 8 to address the waiting list

in a way that we believe would come very close if not completely

eliminating those lists by the end of this fiscal year.

With regard to the specialists, I still haven’t been able to find

dermatologists in Florida who would come to work for VA salaries.

In some specialities you are absolutely right. Certainly VA offers

a remarkable practice setting for many physicians in an increasingly litigious society. We recognize that. But we also recognize

with some of the scarcer specialities, such as a dermatologist, in

Florida VA’s pay schedules, pay latitude is still insufficient to attract them. That is exactly why we need the committee’s support

with the physician and nurse pay legislation package that will be

forwarded later this year.

Ms. BROWN-WAITE. Just for a follow-up question, what assurances do we have that we won’t be hearing the same thing next

year, that I won’t be going home at the end of this year and hearing the same, and I mean this, the same stories that rip your heart

out because we need to act and we need to act now. The woman

that I told you about, she not only lost her husband, but she then

had extensive bills because she ended up taking him to a non-VA

facility. I don’t want that to ever happen again. And she called me

and she said, I am just letting you know, this at the time I was

a Senator. She said, senator, I am just letting you know so that you

realize, please don’t let this happen to anyone else. I will never forget that call that she made to me. I don’t want this year to be over

and not have that take place. So what do we need to do? And that

may be a very naive question for a freshman but I need your help

in answering that, please.

Mr. ROSWELL. It is a very appropriate question and it is one that

I feel just as strongly as you do. First, let me assure you that our

policies are that any veteran on any waiting list who has an urgent
22

need for care will receive that care and no veteran to my knowledge has been turned away who had an urgent need for care. The

waiting list is intended to be used solely for those people who are

seeking elective primary care and access specialty care. The audiologist you spoke of, in fact, that wait is often predicated by veterans

who are seeking hearing aids because they have had hearing loss

associated with increasing age, like happens to all of us. But you

are absolutely right, we have got to make sure that that doesn’t

happen again. That is why we need to take a suspension in enrollment of priority 8 veterans and use the additional dollars in the

2003 appropriation with the special pay authority that is very

much needed to be able to recruit additional primary care physicians and specialty physicians, build the nursing and support staff

that will absolutely guarantee we don’t have waiting lists a year

from now.

Ms. BROWNE-WAITE. Thank you.

The CHAIRMAN. Thank you very much. Appreciate it, and I just

had a couple of additional questions before we go to our second

panel, if you could, Doctor. The four major organizations from the

Independent Budget, the AMVETS, PVA, DAV and VFW, signed a

letter dated today, January 29, to Speaker Hastert strongly asking

him for the $23.9 million that was approved initially by the Veterans’ Subcommittee of the Appropriations Committee. And as they

point out, H.J. Res. 2, the Senate bill, has been subjected to a $700

million across-the-board cut, which would be devastating. Again if

my math is right, if we use the demand model even the 23.9 is $1.9

million less than what really is needed. So they are asking modestly for this 23.9 and it is unclear whether or not that will even

be forthcoming.

Is the Administration running the full court press to try to ensure that this amount of money minimally is available for fiscal

year 2003, 23.9?

Mr. ROSWELL. Certainly we are deeply committed to that funding

level. As I have tried to express today, the almost 700 million cut

that would be imposed by the Senate bill would have serious impacts, and Congressman Brown-Waite, it would not allow us to address the waiting list and there would be waiting lists a year from

now if, in fact, we receive no more than what the Senate bill provided in this fiscal year.

The CHAIRMAN. Again, the more high level it is in terms of what

catastrophe awaits if this is not corrected.

Earlier you had indicated to Chairman Simmons that philosophically you thought the mandatory funding bill had merit. I wonder

if you could either orally and/or for the record, provide us—I mean

you have to manage an incredibly large number of health care assets in the country. It has got to be a daunting challenge with an

ever increasing demand that is being put on that health care delivery system. The mandatory gives you a capitation model. It gives

you an ability to have some predictability rather, I mean, and I assume total goodwill on the part of the appropriators and others.

They are always between a rock and a hard place of not having

enough money. If you don’t know how much you have from one

given year to the next, how do you plan? I wonder if you could provide us—and I would hope and I say this sincerely that it not go
23

through every clearance—I need to know from you as a manager,

as a leader, as an Under Secretary of Health, why this would be

needed philosophically. If you can’t get into the actual numbers

without a thousand and one clearances, that is fine. But we need

to know. I mean all that matters is how do we, in the most transparent way possible, as lawmakers, who take our oath of office very

seriously, get this money to where it should be gotten to, to meet

our obligations and our duty to our veterans? I know you share

that.

If you could provide an answer to this question, I would be deeply appreciative. I think when the President’s Task Force is making

its recommendations we need a grand debate on a sustainable

funding formula that is not subjected to the crowding out and the

competition within the VA appropriations that ordinarily goes on.

You know, Jim Walsh is very dedicated to veterans’ health care

expenditures. He is between a rock and hard place as he looks at

his allocation that says how do I do it. He wants to, but how does

he do it? I don’t envy him and the difficult choices he has to make

(which he makes with the best of intentions). We need to think outside the box perhaps. But we need that input from you, because

you are a very able leader and your wisdom would be deeply appreciated by this committee. So if you could do that perhaps orally

now or if you wanted to provide that for the record so it is as detailed as possible, we would appreciate it.

Dr. ROSWELL. Certainly I would like to get back with you on

that, but, Mr. Chairman, we appreciate your leadership and your

advocacy for full funding. As in the past, I pledge to you that we

will do everything we can to work with you in seeking sufficient resources to assure the quality of care for veterans and will certainly

be pleased to work with the committee staff.

I think one of the difficulties we face is the unpredictability of

health care. We don’t know where veterans will seek care because

it is related to economic conditions, it is related to situations that

may be regional in nature; and even though we used the very best

actuaries we can obtain to help us predict a full demand model, we

don’t always hit that with the exact precision we like. And then

you impose other factors, not only the economic conditions but, for

example, the mobilization of health care personnel through a military deployment. There are so many unpredictable factors that impact upon this that our ability to accurately project funding needs

and get that through the OMB and appropriation process with sufficient lead time to accurately address needs is difficult at best.

I think that some of the merits of a model that you have spoken

of would do a tremendous—would make tremendous strides to help

address that. We will be delighted to work with you.

The CHAIRMAN. I appreciate that.

Mr. FILNER. May I have additional questions?

The CHAIRMAN. As soon as I am done.

And if I could, last May, in response to questions that I posed

to the Secretary, he pointed out that if additional funds are added

to VA’s medical care appropriation I can assure you that the funds

needed to restore the VA’s nursing home capacity to the ’98 levels

will be used for that.
24

And, again, this is another issue, the 1,500 beds that have evaporated over the last 5 years or so, perhaps could you get back to us,

if you would, with your recommendations or plan maybe within a

month or so? Because, obviously, we are losing core capacity at a

time when we have an aging World War II and Korean veterans’ population in need of those beds.

Dr. ROSWELL. I would be pleased to get back with you, but if we

have time now I would like to share with you that since 1998 our

total long-term capacity has actually increased by almost 10,000

beds, or 10,000 average daily census. Most of that or virtually all

of that expansion has been in the noninstitutional care. But using

now interactive technology we believe that we can continue to

make significant strides to address that full demand for long-term

care in the World War II and Korean-era population.

We will clearly always need institutional beds, but today, despite

the fact that we aren’t meeting the ADC requirements associated

with the mil bill, we have staffed, but empty, VA nursing home

beds in certain locations around the country because the demand

for an institutional level of care is not there at the VA location. So

we would like to work with the committee to explore a variety of

ways to expand both institutional and noninstitutional care for

long-term care needs of the veteran population.

The CHAIRMAN. I appreciate that.

Let me ask you another question with regards to the emergency

preparedness centers. As you know, that legislation was signed by

the President. It establishes those centers of excellence and also

would establish an office which takes a minimal amount of funds

to get up and running. You do have plans for that, I hope?

Dr. ROSWELL. Yes, sir, Mr. Chairman. I am glad you brought

that up.

The provisions of Public Law 107–287 that addressed centers for

emergency preparedness is something that we have paid a great

deal of attention to. In our Office of Environmental and Occupational Health we have already put together a concerted plan to

begin to identify an oversight committee, a steering committee that

will be meeting in the very near future to develop criteria for which

we would issue a request for proposals, asking people to submit

proposals.

We anticipate with the needed funding, which as you know is a

statutory requirement to move forward on that, we would then

issue that RFP and begin a review process, identifying no later

than June or July of this year the location of the center selected

and would expect to provide funding and initiative activation of the

centers by the end of the fiscal year.

The CHAIRMAN. Thank you for that. Thank you for moving ahead

so aggressively on that. Mr. Filner.

Mr. FILNER. Just briefly, Doctor, what is the status of the congressional mandate for the VA to provide chiropractic care for our

veterans?

Dr. ROSWELL. We have—— Mr. FILNER. Ms. Brown-Waite, you said, am I going to have to

wait until the next year? We mandated—I don’t know how many

years ago—chiropractic care, and it has been I don’t know how

many years since we passed legislation. This stuff takes forever. I
25

hope you are not disappointed at the end of this year, but you have

to sometimes keep on them.

Again, we passed legislation—I think two pieces of legislation to

mandate this, and it just hasn’t happened.

Dr. ROSWELL. Well, the Chiropractic Advisory Committee has

been appointed. We are eagerly anticipating their recommendations.

Mr. FILNER. That is another way to slow down the process, but

go ahead.

I mean, we see things differently. All you have to do is hire chiropractors, but you didn’t do it, so now you have to set up a chiropractor advisory committee. I mean, this is not rocket science here;

and yet we can’t seem to do it.

Dr. ROSWELL. We have policy that allows hiring of chiropractic

and the use of chiropractic on a consultative basis in our medical

centers.

Mr. FILNER. As I understood it, we mandated the availability of

that for all our veterans; and it is still not available for the vast

majority of veterans. Is it mainly because your doctors don’t like

chiropractors, or somebody in your upper administration? I just

can’t understand why you can’t say, just do it.

Dr. ROSWELL. We have issued that guidance. I think it is more— my sense is it is more an issue of local implementation whether a

directive is looked at and chiropractic care is available but it is not

readily utilized. That is why we needed advisory committee to sort

through what the barriers are to full utilization of chiropractic care

where it has clinical applications and would benefit the veteran

population. But I certainly will look into that and be happy to report back to you with more detailed information.

Mr. FILNER. Yes, I know you will.

Again, when we put people on the committee who are committed

not to have chiropractic care, it is unlikely that we are going to get

a lot of rapid progress out of that committee as we have tried to

tell the Secretary. There were lots of experts in this field available

to serve. You chose not to pick them but to pick people who had

doubts about chiropractic. So now, Congresswoman Brown-Waite, it

will be I don’t know how many years before we see that one.

The CHAIRMAN. Would the gentleman yield?

Our legislation, as you know, Doctor, mandated one program per

visit. We did not have a time certain for when it actually had to

be established, and perhaps that was an oversight. But we expect

good faith that this is something that Congress in a bipartisan way

hopes would happen.

Without any further questions from our panelists and Members,

Doctor, thank you so much for your coming and I look forward to

working with you and going forward. I appreciate all of your good

work on behalf of our veterans.

I would like to ask our second panel if they would come to the

witness table: Dennis Cullinan, who is the Director of the National

Legislative Service for the Veterans of Foreign Wars, the VFW. Mr.

Peter Gaytan, who is the Principal Deputy Director of the American Legion; and he works with the Veterans’ Affairs and Rehab

Commission. And Mr. Joseph Violante, who is the National Legislative Director for the Disabled American Veterans.
26

STATEMENTS OF DENNIS CULLINAN, DIRECTOR, NATIONAL

LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS;

PETER S. GAYTAN, PRINCIPAL DEPUTY DIRECTOR, VETERANS’ AFFAIRS AND REHABILITATION COMMISSION, THE

AMERICAN LEGION; AND JOSEPH A. VIOLANTE, NATIONAL

LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS

The CHAIRMAN. Dennis, if you could begin.

STATEMENT OF DENNIS CULLINAN

Mr. CULLINAN. Thank you, Mr. Chairman.

Members of the committee, on behalf of the 2.7 million members

of the Veterans of Foreign Wars of the United States and our Ladies Auxiliary, I thank you for conducting and including us in a

hearing of vital importance to America’s veterans today.

Mr. FILNER. Could you just yield for a second?

I want the record to show, in follow-up to my statement, that you

should have been on an hour and a half ago, that there are four

members of the committee here, there are only one-third of the

press here. Dr. Roswell is a trooper. But, again, the kind of environment in which the VSOs get the maximum attention is just

practically not here. If we had had a vote in between, nobody would

be here. I know the chairman agrees with me, at least in part, that

we can rotate this around—— The CHAIRMAN. And I have done it before. Mr. Cullinan.

Mr. CULLINAN. The Department of Veterans’ Affairs medical system is now in crisis. Amid the climate of rising health insurance

premiums and costly prescription drugs, open enrollment under the

Health Care Eligibility Reform Act and a shift from primarily inpatient care to outpatient care has flooded the health administration’s

facilities with millions of new users. The growth produced by these

reforms quickly outpaced existing facilities and clinics capacity to

provide access to quality, timely health care for veterans.

Mr. Chairman, last night President Bush, in addressing the state

of health care for our seniors in this Nation, stated, Medicare is the

binding commitment of a caring society. It is the conviction of the

men and women of the Veterans of Foreign Wars that VA health

system represents the spirit and substance of this Nation’s sacred

obligation to care for her defenders in this time of need, and it is

clear to us that this most hallowed trust is not being met.

Successive years of improper budgeting and inadequate appropriations, coupled with the impact of soaring demand, have forced

VHA to ration care, turning a once national treasure into a national tragedy. The most obvious manifestation of health care rationing has been the lengthening of appointment waiting times.

Mr. Chairman, I would ask, how long do any of us have to wait

for us to see our doctors? I know that in my case 24 hours is more

than enough time. But what about those veterans who rely on the

VA health care system? According to a recent VHA survey, there

is currently a backlog of over 200,000 veterans waiting 6 months

or more for nonemergency clinic visits. It takes over 12 years in

parts of the country to even access the system. Of course, it is impossible to truly know how many veterans are being denied care

because VA’s data bases are so severely deficient. We do know that
27

Americans veterans must wait way too long for medical care departmentwide. The situation is deplorable.

Most recently, the Secretary of Veterans’ Affairs was compelled

to suspend enrollment of Category 8 veterans in order to focus inadequate resources on, quote, those with service-connected disabilities, the indigent and those with special health care needs. It is

our belief that no veteran should ever be left behind. The enrollment announcement would not have been necessary had past budgets been truly adequate, not just historic. As one VFW member

stated, we need a White House budget that adequately reflects the

demand for veterans’ health care, congressional budgets that mirror the administration’s adequate budget request, and final appropriations that meet or exceed these amounts, and we need these

funding levels now.

In the end, Mr. Chairman, I believe the blame lies with all of us.

Somehow we should have done more toward ensuring that VA has

all the resources necessary to fully and compassionately provide

veterans with the care and services they need and have earned.

And it is toward this end that the VFW has joined forces with the

American Legion and Disabled American Veterans, along with numerous other veterans and military organizations, to secure passage of legislation that would guarantee mandatory funding for all

enrolled users of the VA health care system.

We thank you, Mr. Chairman, and the ranking member for introducing legislation that would have accomplished this goal last Congress; and we are hopeful that such legislation will be reintroduced

this Congress, where it will once again enjoy our full support.

The health care needs of millions of veterans depend upon the

Nation’s courage to adopt and stick to policies that will produce the

optimal results over the long run. Unequivocally, the Veterans of

Foreign Wars is committed to the proposition that no veteran

should be denied VA medical treatment due to budgetary shortfalls

or, worse yet, a lack of commitment or caring.

Mr. Chairman, once again, on behalf of our entire membership,

I thank you. That concludes my oral remarks.

The CHAIRMAN. Thank you very much for your testimony and for

the good work you do.

[The prepared statement of Mr. Cullinan appears on p. 65.]

The CHAIRMAN. Mr. Gaytan.

STATEMENT OF PETER S. GAYTAN

Mr. GAYTAN. Thank you, Mr. Chairman. I appreciate the opportunity to present the American Legion’s views on the VA health

care system’s capacity to meet the growing demand for health care.

Mr. Chairman, with more than 200,000 veterans currently waiting in line to receive health care through the Department of Veterans’ Affairs, the importance of this committee to offer real solutions

to this problem is overwhelming. Although VA has made progress

in reducing the incredible backlog of veterans awaiting care, much

more must be done.

As you mentioned earlier, and we appreciate your recognition of

our efforts, the American Legion has initiated a national campaign

to collect stories from actual veterans who are being forced to wait

as long as a year to receive health care through the VA. Dubbed
28

the ‘‘I am not a number campaign,’’ as you mentioned earlier, this

national program provides surveys to all 15,000 American Legion

posts to collect firsthand accounts of these veterans who make up

this incredible backlog of patients seeking care from the VA.

The information we are receiving in the returns of the surveys

reflect what Congresswoman Brown-Waite mentioned earlier, that

she may have a constituent who has waited 18 months to receive

care. We are hearing this over and over again in these surveys that

we are receiving back. We are hearing that they are waiting up to

18 months, which is unconscionable; that they are receiving phone

calls from the VA about rescheduling two, three, maybe four times

before they receive their first appointment; and in some cases some

veterans who have to travel to meet their—to their VA medical

centers when they arrive they are learning that their appointments

were rescheduled or even canceled and they are not learning that

until they arrive at the VA facility. Of the survey responses that

we received, this is a growing trend that we are receiving back.

And even of more interest than the information that we are receiving, National Commander Conley—if you remember during the

joint session last year in September when Commander Conley took

over, he committed to you and to your colleagues to visit VA medical facilities nationwide during his term as National Commander.

Over the last 4 months, Commander Conley has visited over 25 facilities in 17 different States. In his visits to VA medical centers

he is hearing directly from the VA facility directors that their waiting times are excessive, that many facilities are struggling to meet

the demand for health care due to staff shortages, and budgets are

being realigned to acquire much-needed nursing and medical staff.

The American Legion is extremely concerned that veterans are

suffering because funding for VA health care is inadequate for VA

to meet current demand for care. The American Legion hopes that

this committee will consider several different possibilities that will

serve to improve VA’s ability to provide quality health care in a

timely manner. Designating VA health care as a mandatory spending item will guarantee yearly appropriations for the earned health

care entitlement of enrolled veterans, especially those severely disabled service connected veterans.

The American Legion fully supported H.R. 5250, the Veterans

Health Care Funding Guarantee Act, introduced in the 107th Congress; and we look forward to working with this committee to develop legislation that will change funding for VA health care from

discretionary to mandatory.

Medicare reimbursement for VA will also serve to improve VA’s

capacity to meet current demand. The American Legion urges Congress to authorize VA to bill, collect and retain third-party reimbursements from CMS for treatment of Medicare allowable, nonservice-connected medical conditions of Medicare-eligible veterans.

Since Medicare is a federally mandated prepaid health insurance

program, the American Legion believes Medicare-eligible veterans

should be allowed to choose their health care provider. If VA is an

enrolled Medicare-eligible veteran’s health care provider of choice,

then VA should be reimbursed for that care.

The American Legion also recommends that VA explore the possibility of offering premium-based health care plans to eligible vet-
29

erans. Offering premium-based health care plans would create a

new revenue stream for VA and allow veterans the opportunity to

access the full continuum of care offered by VA.

The American Legion realizes the struggles being faced by the

Secretary, and we applaud his efforts to reduce the backlog of veterans waiting for health care. We do not, however, agree that rationing care is the answer. Squeezing the system to meet the budget is not the solution. Providing a budget adequate enough to allow

VA to meet the demand is.

Mr. Chairman, again thank you for this opportunity; and that

concludes my testimony.

The CHAIRMAN. Thank you very much, Mr. Gaytan, for your testimony and your fine work.

[The prepared statement of Mr. Gaytan appears on p. 69.]

The CHAIRMAN. Mr. Violante.

STATEMENT OF JOSEPH A. VIOLANTE

Mr. VIOLANTE. Thank you, Mr. Chairman and members of the

committee. I appreciate this opportunity to discuss the Department

of Veterans’ Affairs health care system today.

The timely access to VA health care is a matter of paramount

importance to the 1.2 million members of the Disabled American

Veterans. The effectiveness of a VA health care system is dependent upon sufficient funding and resources for the timely delivery of

medical benefits.

Ten years ago, the DAV, along with nine other organizations,

formed a partnership for veterans’ health care reform. At that time

we petitioned Congress to reinvent the VA health care system because it was not serving veterans properly, it was not cost effective,

and we got part of what we had asked for, a reform of the system.

However, at that time we also said that if you do reform this system, guaranteed funding was a requirement. Ten years later, we

are still asking for the same thing.

I was very encouraged by what I have heard here today, particularly from Dr. Roswell. Although he did not come out and formally

endorse guaranteed funding that was introduced last year, much of

what he said certainly should give this committee and the veterans’

community some hope that you are on the right track. I believe the

formula that was set out in that bill would address many of Dr.

Roswell’s concerns with regards to the increases that he believes

are needed annually. Also, it would address the uncertainty that

VA faces year in and year out with regards to what is going to

come out of OMB in regards to their funding level. Your legislation

would guarantee VA would have assurances by midsummer as to

what their budget is going to be on October 1 and what they will

receive.

Mr. Chairman, I would like to thank you and the ranking member, Mr. Evans, for taking that bold step to introduce that legislation last year. I would like to thank all the members of this committee who signed on to that legislation, and I would hope that this

year we can see that bill reintroduced and all the members of this

committee as well as bipartisan support from the rest of the Congress to be behind that legislation because I believe without it we

are not going to be able to solve the problems of VA and veterans.
30

There is decisive action that is needed now. Now is the time to

tackle this problem. I believe in your opening remarks you commented that it is up to this Congress, the 108th, to take those

steps; and I am very encouraged by that.

The alternative to this situation is to see exactly what the Secretary has done and that is to cut off enrollment and possibly even

disenroll veterans in the future. That is an unacceptable solution.

I don’t blame the Secretary for what has happened. I believe his

hands are tied. But, again, I would encourage this committee to

move forward with the guaranteed funding bill.

In closing, just let me say again thank you for your strong advocacy on behalf of veterans. We appreciate the bipartisan spirit that

has been rekindled in this committee over the last couple of years.

That concludes my testimony, and I would be happy to answer

any questions.

The CHAIRMAN. Thank you very much for your testimony.

[The prepared statement of Mr. Violante appears on p. 77.]

The CHAIRMAN. As you know, based on your previous testimonies

and that of the DAV, with the full support of the other VSOs, that

was the genesis of the bill in the first place. I looked at it as primarily a management reform. If you are going down a hospital system, if you want that hospital system or health care delivery system to be world class, you need sufficient funds. When it is discretionary and however well-meaning and good-willed—and we always

assume that on the part of both sides of the aisle and presidents,

including Clinton, who underfunded for whatever reason, you assume goodwill. But they are faced with budget priorities and shifting amounts that are available, and it seems to me this is first

priority.

That is why the mandatory scheme, while it has some kind of

shock effect on some people, mandatory, as in—you know, we are

talking about an entitlement that is already there for service-connected and indigent veterans especially. It is there. Why not fund

it in a way that is rational, with predictability, so that Dr. Roswell

and any other undersecretary of health can manage a system so

that there is no loss of quality of care. Because that has to be an

issue here as well. When you don’t know what is coming, how do

you plan so that the best utilization of those dollars can be

realized?

I do have one question. You know, the estimates from the Office

of Management and Budget and from CBO were wildly different.

The gulf was very, very extreme. If my memory is right, the number of enrollees anticipated over the next decade from OMB was

about 15 million; for CBO was in the order of magnitude of about

10 million. Big difference. It seems to me that some people are

looking at it from a worst-case scenario, if you want to call it that.

I am loathe to do that.

In terms of utilization I think it is good if people are utilizing it.

That is why it is there. If they are not using VA, people are going

to get sick and be in need of care, they are going to utilize something. So health care dollars will be expended, and if they are elderly it will be most likely Medicare. If they are poor, most likely

Medicaid. So Uncle Sam will be paying one way or the other in

most instances.
31

What is your sense in terms of enrollees? I ask you to factor into

that if we do indeed this Congress, the 108th, pass a prescription

drug benefit. Whether it be the $350 billion anticipated by the Republicans or the 800 to a trillion anticipated by the Democrats, I

think this year something will pass. So the magnet for the 8s and

7s disappears to some extent in terms of enrollees wanting to use

the system.

We do get back down to core mission. What about this wild gulf

and what is your sense, are they getting it right? Mr. Cullinan.

Mr. CULLINAN. Thank you, Mr. Chairman.

The $15 million figure struck us as being phenomenally high. For

one thing, a significant portion of the veteran population already

has insurance. You know they would, of course, use Medicare. $15

million, that is something like three-fifths of the entire veteran

population. There are a lot of veterans that won’t use VA because

at this point in time they can’t bring their dependents in. So $15

million on the face of it is absolutely absurd. $10 million struck us

as being somewhat high. $15 million is out the question.

As you just pointed out, there are other changes in reforms in

the air that affect the entire population that also mitigate against

that particular figure. It is inconceivable to us that that many veterans would turn to VA.

Mr. GAYTAN. Although those numbers may be considered high, it

is a reality that we need to consider and realize that the number

is increasing.

A conversation I had with a veteran over the weekend, he served

34 years in the Navy, retired as a three-star. We were discussing

health care. In his retirement position he doesn’t consider VA as

an option. I was discussing with him some of the problems we are

dealing with right now with VA health care, and his statement as

a veteran who served 34 years in the military was that he understands that veterans are dying at a rate that we don’t need to consider their health care needs.

I had to explain that, although the veteran population of the

United States may be decreasing, the number of enrollees is increasing. That section of veterans that was discussed earlier, the

Vietnam veterans, they are the next generation that will be seeking health care at the VA. That number is going to increase, and

we need to be ready for that. No matter what the projections are

from any agency, we need to be ready for those individuals who

knock on the VA’s door and say we need to be taken care of.

Mr. VIOLANTE. I don’t think there is any real way to make a projection. However, I believe the ones that have been made are extremely high. As you know, we haven’t made any changes to the

VA’s mission or how they provide that service. The only thing that

is changing is the funding source and, hopefully, and I have to believe it would, improve the timeliness standards. That may cause

more veterans to seek care from the VA, but I don’t think we will

see anywhere near the projections that have been made.

The CHAIRMAN. Appreciate that. Chairman Simmons.

Mr. SIMMONS. Thank you, Mr. Chairman.

To the two members of the panel who are Vietnam veterans, welcome home.
32

Now let’s get some health care. In the memo that was issued by

the Chairman at the beginning of today’s meeting and hearing, he

said at the bottom that the Subcommittee on Health plans to continue reviewing the status of the VA health care system with a series of hearings early in Congress focusing on access, pharmaceutical policy, human resource needs, and so on and so forth. I

look forward to working with the Ranking Member to explore some

of these issues in further detail, more detail than we can perhaps

get into today because of timing issues.

There are a couple of things that intrigue me about your testimony. First of all, Mr. Gaytan talks in some detail about Medicare

reimbursement and the issue that, for many of our veterans who

are Medicare eligible, they go to the VA for service. We know about

the waiting lines, we know about the difficulties in getting through

the bureaucracy, but then at the end of the day VA itself picks up

the tab. There is no Medicare reimbursement.

I have had discussions with my colleague, the Dean of the delegation in Connecticut, Nancy Johnson, who also happens to be the

Chair of the Health Subcommittee of Ways and Means; and she

has done some research on this and related issues.

I guess my question to you gentlemen is as follows, and all three

can answer if you wish: In the past when I discussed with veterans

such issues as the provision of health care and if the VA system

may be cooperating with other elements of the health care community, whether it be military or civilian, and the issue of reimbursement under Medicare, Medicaid and other provisions, there was a

tendency for them to say, ‘‘well, we want to keep it all in VA.’’ We

don’t want to reach out. We don’t want to be involved with other

systems.

What kind of feedback are you getting from that? Is that an accurate statement? Or, in fact, do veterans today look forward to

looking for other methods to fund VA for reimbursement and work

with VA and other health care providers to get the job done?

Mr. GAYTAN. Well, sir, I can say that the American Legion does

have an organizational resolution that supports Medicare reimbursement through the VA; and all of our resolutions are voted on

by our members. So, yes, the feedback we are receiving from veterans who are seeking health care through the VA is that they want

VA to allow them to bring their Medicare benefits to the VA.

Mr. SIMMONS. Thank you. The other organizations?

Mr. CULLINAN. Mr. Simmons, the VFW has a resolution calling

for Medicare reimbursement. Clearly, our membership supports

bringing their Medicare dollars with them, particularly among military retirees. They rather insist on being able to bring their Medicare dollars with them into the VA system. We want to facilitate

that end as well.

Mr. VIOLANTE. The DAV’s position, under the present scheme of

things, would support Medicare reimbursement to supplement the

VA’s appropriations. Under a guaranteed funding stream, I am not

sure if it is necessary to have to shift monies from one pot to another, but if Congress was to determine that the lower priority veterans in coming to the system would benefit the system by bringing

their Medicare dollars—we certainly would support that, although
33

we don’t believe with guaranteed funding it would be absolutely

necessary.

Mr. GAYTAN. I want to add, with any Medicare program, be it the

VA + Choice that is being developed by VA or full Medicare reimbursements being the key to any successful joint venture between

Medicare and VA, would be to make sure that the reimbursement

rates are adequate to cover the cost of care to the VA.

Mr. SIMMONS. I certainly agree with that last statement. You

know, there was a time when one government entity, if you will,

did not seek reimbursement from another government entity because it all seemed to be government.

I remember years ago when I was a staff person in the Congress

we had franking privileges, and you know there were all sorts of

activities that were not funded. Let’s say, in the case of franking,

your mailing privilege put you into the U.S. Postal Service and

they essentially gave you free mail.

In recent years, and I think appropriately so, different organizations need to account for their costs. That is why one government

entity will actually charge another government entity, so there is

an accounting system and we can keep control of costs. I certainly

support that. I would be interested to work on that issue in this

session of the Congress.

The CHAIRMAN. Mr. Filner.

Mr. FILNER. Thank you, Mr. Chairman.

Mr. Simmons, that issue has been around for a long time, the

decade that I have been here. And I know it was introduced because San Diego—some San Diego veterans wrote a Medicare subvention bill in 1990, 1988, and these guys are too polite to say what

is happening. You need to go visit your chairman of your Ways and

Means Committee—he has blocked it up until now. So there has

been a lot of support, but Mr. Thomas hasn’t liked it.

Mr. SIMMONS. Is he from California?

Mr. FILNER. Yes.

Mr. SIMMONS. So you must get along very well with him.

Mr. FILNER. Yes, sir.

Mr. SIMMONS. I have got the Subcommittee Chairmanship from

Connecticut, so maybe you can cut a deal.

Mr. FILNER. Don’t use my name when you talk to him.

Which brings me—actually, it was a good segue in terms of your

politeness—look, we are in a crisis. You guys fight every day for

your constituents who are the veterans who served our Nation. And

you do a great job. I have always felt, I think I have told you over

the last few years, you have power in terms of your membership

that you have not unleashed. That is, they live in every district,

they are voters in every district, and you have got to name names

and take some prisoners here and let your constituents know what

is going on in this House.

Generally, I think you use kid gloves. I don’t know if you are

afraid you are going to lose something, but, look, we can’t lose

much more at this point. Look, when people vote for an authorization and say how much they are for veterans and vote against an

appropriations that would in fact implement it, tell your members

that. And have them go visit, go sit in, if necessary, at the office

of those Members. Come to Washington and camp out for a while
34

during the appropriations process until we do what the veterans

need. I think you have power that you’ve got to unleash in terms

of your grass-roots support. That is the only thing that

Congresspeople understand, is that if their own constituents know

what is happening and tell them that based on that knowledge

they are either angry or they like it or whatever, for good or for

bad.

I think too often you end up pulling your punches at the very end

of the process. When the compromise is made, you think you have

to support it because you hope you will be working with us in the

future. I think you have to take us on a little bit more directly. Because we are in a crisis, and we are going to sacrifice veterans

more if there is no noise from them.

You lobby every day, and you are doing a great job, but if there

is no noise from our districts, they are going to cut, and they are

going to cut, and they are going to cut. I don’t see any other, frankly, tactic or strategy for you to take. You got millions of members.

Let’s use them.

You can respond or not as you want.

Mr. VIOLANTE. I will go ahead and respond to that, Mr. Filner.

I appreciate your comments, and when the situations do arise

and there are certainly lines that can be seen, we have in the past

tried to mobilize our members. One of the prime examples was

back 5 or 6 years ago with the tobacco issue and the transportation

by—we put those who voted for us and those who voted against us

in our magazines. Unfortunately, what that translates into is if you

look at the surveys that are out there, people may not like what

Congress is doing in general but they seem to like what their Members are doing particularly; and I think that affects the veteran

population also. So it is very difficult.

Mr. FILNER. But you have to tell them. When Members come

home on Memorial Day and Veterans Day and say how wonderful

everybody is but they just voted to cut everything out of here, we

have to name those names. And when you give awards to folks in

previous Congresses who help to block funding but because they

are chair of the committee, not the present chair, because they are

chair of the committee you want to be nice to them. You give them

an award when they are the ones that stopped the funding. We

have to, I think, be a little bit more direct.

Frankly, again, there is nothing more to lose. They are going to

cut and lay off people and do all kinds of things that are going to

hurt your members if we don’t speak up from the grass roots.

I didn’t mean to interrupt you all.

Mr. VIOLANTE. That is quite all right. I think I was finished.

We have mobilized our members on the issue of guaranteed funding. I think that that snowball is coming down the hill, and more

and more of our members are bringing it up. They are going to be

in here in less than 4 weeks for a midwinter conference. I am hoping we will have some legislation introduced before then. Because

I know they are going to be meeting with their Members and discussing that issue.

Mr. GAYTAN. I also appreciate your comments. The American Legion understands the importance of a grass-roots effort. We have

a legislative council that has been in effect for years. We have
35

legionaires in every State and every district that we can reach out

to, that our legislative director here in DC. Reaches out to and

communicates with them and lets them know what is going on here

on the Hill and what their Members of Congress and Senators are

doing. It has been very effective.

As Joe mentioned, we have made progress on the duty to assist

issue in the past and the tobacco issue. We realize that our strongest weapon, if you will, on achieving anything on the Hill is our

communication with the grass roots and their ability to get out and

let it be known how they feel about the decisions that are being

made by their Members of Congress.

So the American Legion as well is continuing to relay the information on what we are doing up here, what you are doing up here.

And, again, we are having our Washington conference where thousands of legionaires will be here on the Hill in the beginning of

March. Our secret weapon this year will be the Commander’s report on the I am Not a Number campaign, the information we are

receiving firsthand from veterans.

These people, they are not numbers that we kick around every

day. These are people in line waiting. These are individuals who

have worn the uniform that are entitled or do receive health care

through the VA. We are making an example of that. We are reminding those veterans that we are here to help them.

Mr. FILNER. I was getting all these e-mails about concurrent receipt which said, you have to vote for this, pass this. Concurrent

receipt was cut down in secret by a few people. We need to identify

who did that, for example. People wrote us and they have no idea

what happened in that situation. The House passed concurrent receipt, the Senate passed concurrent receipt, we didn’t get concurrent receipt. What happened in that conference committee? How

did it get to the floor like that?

I don’t know who did it, frankly, but we should find that out and

make sure the people who are writing about concurrent receipt

know. All of a sudden, it is gone. There are no fingerprints anywhere.

Mr. SIMMONS (presiding). Have the gentlemen finished their responses? Mr. Bradley? Mr. Beauprez?

If I could just briefly comment, I am a life member of the VFW

and also a life member of the American Legion. It has been my experience over the years that I have been involved with both organizations that they could do more to identify Members’ voting

records. The Legion actually has been pretty successful on the flag

amendment of listing who supports and who does not. But there is

nothing to prevent any of the veterans’ service organizations from

adding health care issues to the list of those issues where they

identify Member votes.

I think we have a third panel that we are going to be dealing

with today, and I would like to take this moment to thank the

panelists for their testimony. I look forward to seeing them again

before the subcommittee before too much longer, and we can perhaps explore some of these issues in greater detail. Thank you,

gentlemen.

Mr. Richard Fuller, who is the Deputy Executive Director of the

Paralyzed Veterans of America. He will be joined by Mr. Richard
36

Jones, who is the National Legislative Director of American Vets,

or AMVETS. And they will both be joined by the most distinguished and honored Dr. Linda Spoonster Schwartz who is the

Chair of the Health Care Committee, Vietnam Veterans of America, and also a resident of the great State of Connecticut.

Welcome to all three of you and thank you for being here.

Mr. FILNER. Let the record show that we still have Dr. Roswell

pinned down here.

STATEMENTS OF RICHARD FULLER, DEPUTY EXECUTIVE

DIRECTOR, PARALYZED VETERANS OF AMERICA, ON BEHALF OF JOHN C. BOLLINGER, DEPUTY EXECUTIVE DIRECTOR; RICHARD JONES, NATIONAL LEGISLATIVE DIRECTOR,

AMVETS; AND DR. LINDA SPOONSTER SCHWARTZ, CHAIR,

HEALTH CARE COMMITTEE, VIETNAM VETERANS OF

AMERICA

Mr. SIMMONS. How would you like to proceed?

STATEMENT OF RICHARD FULLER

Mr. FULLER. I am Richard Fuller, National Legislative Director

for Paralyzed Veterans of America. I am sitting in today for our

Deputy Executive Director, John Bollinger, who is under the

weather.

Paralyzed Veterans of America appreciates this opportunity to

present our views on VA’s efforts to meet current health care demand. PVA is the only national veterans’ service organization,

chartered by the United States Congress and recognized by the Department of Veterans’ Affairs, to represent and advocate on behalf

of our members and all Americans with spinal cord injury or dysfunction. All of PVA’s members, in each of the 50 States and Puerto

Rico, are veterans with spinal court injury or dysfunction. Because

of the unique nature of these disabilities and the highly specialized

care provided through VA’s network of spinal cord injury centers,

up to 80 percent of PVA’s members use VA for all or part of their

care. This is a higher utilization rate than any other veterans’ service organization can claim.

According to a recent study, VA spinal cord injury programs provide more acute rehabilitative and sustaining services with higher

quality and at lower cost than any other comparable system in the

world.

Mr. Chairman, I think that my colleagues have pretty well laid

out the groundwork of the discussion of what this hearing is all

about, the crisis that is facing VA health care and the serious and

constant underfunding that the system has experienced for many,

many years. But I would just like to raise a couple of points here

which haven’t been made, which are potentially Paralyzed Veterans of America specific, but I think also underscore the problems

that we are facing.

PVA was saddened by the decision to curtail enrollment for new

Category 8s. Still, that decision would have at first glance very little impact on most PVA members. Under current enrollment regulations, veterans who are classified as catastrophically disabled are

eligible to enroll as Category 4, which is currently a protected classification. On a second look, however, PVA members have not
37

found a safe haven in the VA enrollment system seeking services.

Those who gain entry into the system are just as much at risk of

losing access to services as those who are seeking care for the first

time. Budget strains are affecting every aspect of health care the

VA now provides.

This committee and the Congress over the years have certainly

recognized the threat to VA’s expensive impatient specialized services programs such as those provided in VA spinal cord injury centers. Rising costs, increasing demand and the shifting of resources

from inpatient to outpatient programs has seriously eroded the

ability to fund beds and staff in these centers.

Mr. Chairman, I was interested and encouraged to hear Dr.

Roswell’s comments on this very fact. Since 1995, when the VA

began the shift from inpatient to outpatient programs and opened

up hundreds and hundreds of outpatient centers across the country, because of the finite amount of resources that shift reduced the

ability of inpatient tertiary programs of which the specialized services of spinal cord injury are one.

We greatly appreciate the efforts of this committee in recognizing

that situation and requiring VA to maintain the capacity of this

core VA program by putting the capacity requirement in the statute. We have worked diligently with the Department to help shape

a directive that has gone out to the field setting specific capacity

levels for beds and staff, and we have monitored and report on capacity levels on a monthly basis.

Statutory capacity language notwithstanding, VA has never met

the capacity requirements defined in its own directive. According to

our most recent survey in December, the directive calls for a staff

bed requirement of 824 acute and sustaining beds in the system.

In December, 2002, VA only had 747 staffed acute and sustaining

beds. As for staffing, the December report showed a deficit of 117

registered nurses in spinal cord injury centers below the capacity

requirement.

The point we are trying to make here is that underfunding is not

a new threat to the system. It has been around for years and years.

The Independent Budget which you all will be receiving in about

2 weeks, the annual budget policy analysis published by AMVETS,

DAV, PVA and VFW, is now in its 17th year. The Administration

and the Congress have never met the Independent Budget recommendations that are determined on need-based formulas and

annual projections for the cost of health care services. The VA

funding shortfall has been and still is a major cause of concern for

all of these years.

In closing, I would just like to reiterate something that my colleague from the DAV, Joe Violante, mentioned; and this goes back

to Mr. Filner’s concern that the more things change the more

things stay the same. But back in 1993 when the Administration

and the Congress were debating the future of a national health

care system, the 10 major veterans organizations, including PVA,

joined together to form something called a Partnership for Veterans’ Health Care Reform. Our object was to make certain that if

national reforms were to take place the VA and veterans’ health

care would have to be part of that solution. Among a list of rec-
38

ommendations we made at that time was to guarantee VA health

care funding on an annual basis.

Citing chronic underfunding, the partnership—and this particular brochure has probably now become a collector’s item—said the

following, quote: ‘‘Funding must be guaranteed for the provision of

a comprehensive benefits package to all eligible veterans who

choose VA. Rationing must stop. Congress must make VA health

care accounts nondiscretionary, set at risk adjusted capitated rates

that reimburse VA adequately for care provided. Unlike today’s situation, currently eligible veterans must be guaranteed provision of

promised services,’’ unquote.

Mr. Chairman, those words were true 10 years ago; and they are

even more so today.

That concludes my testimony. I will be happy to answer any

questions you may have.

Mr. SIMMONS. Thank you very much.

[The prepared statement of Paralyzed Veterans of America, with

attachments, appears on p. 84.]

Mr. SIMMONS. I think we will go through each of the witnesses

and save questions for the period after.

STATEMENT OF RICHARD JONES

Mr. JONES. Mr. Chairman, members of the committee, on behalf

of AMVETS National Commander Bill Kilgore I am pleased to appear before you and the distinguished members of the committee

to examine the VA’s health care system’s capacity to meet current

demand for health care.

The VA health care system is a unique and irreplaceable national treasure. It is critical to the Nation and its veterans. Many

veterans consider health care to be one of the most important benefits they receive for their military service. Frankly, the VA health

care system’s capacity to meet demand is in critical condition.

AMVETS has reported this situation over the years. We have

served to bring the report about chronic underfunding shortfalls

that have resulted in denial, delay, and rationing of veterans’

health care.

We do not believe these circumstances represent what you and

your full committee have collectively fought for on behalf of veterans. Last year, your committee’s bipartisan leadership presented a

solid recommendation for funding the VA health care system. Unfortunately, as VA entered fiscal year 2002, over a quarter million

veterans seeking health care were waiting more than 6 months for

an appointment.

Today, as we discuss the condition of the VA health care system,

funding for the current fiscal year remains uncertain. Unless better

things happen, the picture remains troubled. Last week, the Senate

recommended a 2.9 percent across-the-board cut in veterans’ health

care. If allowed to go forward, it is estimated that a total of 400,000

veterans would be denied health care over the next 9 months.

To further underscore this critical challenge facing VA’s health

care, the administration dropped a bombshell on January 17 by announcing a policy to ban future access to the system for so-called

Category 8 veterans who had not previously enrolled in the system.
39

Prior to the ban on enrollment, VA had implemented a policy

aimed to ensure that severely disabled veterans receive prompt

care. AMVETS gave its full support to this policy, and AMVETS

continues, as always, to support the core mission of VA health care.

But we are deeply troubled by the decision to ban access.

Blocking access for a certain segment of veterans is not the answer. Instead of discouraging veterans from seeking health care,

AMVETS would like to see VA present a budget sufficient to cover

its true costs, instead of seeing, as we saw in VHA Directive 2003–

003, issued on January 17 in sentence 4(d), a directive for health

care workers to refer veterans in need of health care services who

are not enrolled in VA to community social work for assistance.

Chronic underfunding has stretched the system like a rubber

band, and it is ready to pop. A partial solution beyond adequate appropriations would be to allow VA to accept Medicare payments for

those veterans who are eligible and wish to be treated for VA facilities. Frankly, a large majority of those seeking treatment for nonservice-connected disabilities are Medicare eligible.

We hear a lot about veterans being older than the regular stream

of people seeking health care. That is the definition of veteran. It

is an individual who spent his youth in the military service.

Another suggestion supported by AMVETS is to provide mandatory funding. Clearly, discretionary funding has proven fickle and

inconsistent. AMVETS believes mandatory funding of VA health

care provides a comprehensive solution to the current funding problem. Once health care funding matches the actual average cost of

care for veterans enrolled in the system with annual indexing for

inflation, the VA can fulfill its mission.

Mr. Chairman, as we continue to move forward together we believe the sustained availability of quality health care is central to

VA’s mission. AMVETS calls on the administration and Congress

to provide the resources needed to care for American veterans. We

believe that adequate funding will remain central to VA’s ability to

sustain the timely delivery of quality health care to the men and

women who have sacrificed and served in the military.

This concludes my testimony. Thank you for extending the opportunity to appear before you today. Thank you for your support of

veterans.

Mr. SIMMONS. Thank you.

[The prepared statement of Mr. Jones appears on p. 103.]

Mr. SIMMONS. And now Dr. Schwartz.

STATEMENT OF DR. LINDA SPOONSTER SCHWARTZ

Ms. SCHWARTZ. Good afternoon, Mr. Chairman. Let me congratulate you from Pawcatuck, Connecticut, on your election as the

chairman of the Subcommittee on Health. I look forward to working with you.

As some of you may not know, I don’t live here in Washington.

In the Vietnam Veterans of America, our leadership comes from

the lay leadership. So I am, in essence, not only on the faculty of

the Yale School of Nursing, I am also the Chair of Health Care for

Vietnam Veterans of America.
40

I was looking at—Richard and everyone before me have made a

very good a case for your consideration, but I would like to share

with you some information.

During our last board meeting we did a trajectory on how many

veterans in America do not have health care insurance, because

this has been a topic today. Just so you know, our actuarial figures

indicate that there is about 4.1 million veterans in America who

don’t have health insurance; and as far as the mandatory funding

category goes, that is our number one legislative priority for this

year.

I was back there in 1993, walking the halls with Richard. At that

time, we looked for some overhaul of the VA health care system.

When we had the prescription of change, some of the changes occurred which did actually improve the service to veterans, but it

did—there was not the massive savings that were envisioned then,

that all of the changes have really come at the expense of America’s veterans.

Dr. Roswell has been very candid, and I thank him for that

today. As a nurse who cared for battle casualties during World War

II, I wish—during Vietnam, I actually did take care of casualties

just as they came out of Vietnam, both as a flight nurse and stationed at Tachikawa. So I can tell you the idea of battlefield casualties coming to VA hospitals is indeed frightening, and that is what

we are looking at right here.

The lack of a consistent, reliable budget has, in essence, obstructed VA’s capacity to respond to the changing needs of the

health care system, to efficiently grow, as Dr. Roswell pointed out,

to acquire competent personnel and maintain a viable service infrastructure. VVA enthusiastically joins with the other veterans’ service organizations in endorsing the need to upgrade the VA health

care system from the discretionary funding category to the more

binding commitment of the mandatory funding classification. We

believe that this action is necessary to abate what usually amounts

to the annual funding frenzy that VHA faces in its attempts to balance their mission to protect and safeguard veterans in their care

and keeping.

Truthfully, I guess I can bring you the perspective that most people in America believe that it is an obligation of this government

to care for veterans. When you say it is in the discretionary category, they are shocked. They can’t believe that that is what has

happened here. They believe that this is an obligation of our government to those men and women who step forward to defend freedom in this Nation.

I would just say at a time when we just sent a nephew off to war

and when our President is asking this new generation to bear the

brunt of war, we need we must keep faith with their dedication by

making the commitment to ensure that the funds to care for their

injuries and disabilities is not relegated to a discretionary duty of

this government and country that they have sworn to defend.

Budgets are a reflection of the values and priorities of the administrators who design and legislators who approve them. What does

discretionary funding for the care of men and women who defend

this country say about us, say about America, say about our

beliefs?
41

I would just like to quickly share with you this recent issue of

Consumer Reports. On it, it says, how safe is your hospital? What

you need to know that hospitals don’t reveal. And to capsulize it

just a little bit and to take it out of the money category and talk

about the people, let me just say any risk of receiving substandard

care must be taken seriously.

There are three crucial factors that were identified by the Journal of the American Medical Association and reported here, and Dr.

Roswell was a perfect lead-in to this: sufficient staff, especially

RNs; a good system of organized care; experience with your particular medical condition. That makes the most difference in both

patient satisfaction and recovery.

And hospitals with ample nursing staffs have 9.4 percent fewer

cases of cardiac arrest and shock than hospitals with lower staffing

levels. Let me just finally say, and I have said it before, in the discussion to provide for the health care of America’s veterans, this

really does boil down to a question of honor. For, in essence, this

committee and both Houses of Congress are the board of trustees

of the largest health care system in the world. It does not matter

what you, this body authorizes for insurance organ transplants or

any other health care legislation. Congress does not bear the responsibility to those issues as directly as specifically as absolutely

as the health care of the men and women who defend this nation.

The question of honor is not their honor, but how Congress and

this country honors them. Thank you, Mr. Chairman, that concludes my testimony.

Mr. SIMMONS. Thank you, Dr. Schwartz.

[The prepared statement of Dr. Schwartz appears on p. 107.]

Mr. SIMMONS. A quick question to Mr. Fuller. You made reference to a set of recommendations made in 1993 and I think you

had a copy of a booklet that was published at that time. I hope we

could have a copy for the record.

Mr. FULLER. These are very rare, but I will see what I can do.

(See p. 91.)

Mr. SIMMONS. I will put it in the custody of the Full Committee

so that all Members have access to it at one point or another, perhaps to make a point, but I would be interested to see it. Secondly,

your organization is probably one of the most substantial consumers of tertiary care. There may be some other categories of veterans

out there that are also consumers of that. But I think you would

probably be one of the greatest consumers. You heard the testimony of the Veterans Administration earlier today on that subject.

Do you have any comments that you would like to make about Dr.

Roswell’s concerns about tertiary care?

Mr. FULLER. Well, I think I would like to underscore that this

is what we have been saying and what the committee has been

saying for 6 or 7 years, that as the VA began to reinvent itself

going from an inpatient hospital-based program to an outpatientbased program, that was wonderful for a lot of veterans but the

shift in resources going to outpatient primary care, obviously with

a finite pot of money, had to come at the expense of the expensive

in-patient specialized services, like spinal cord injury care. Dr.

Roswell knows very well that we beat this drum constantly. But it

is the only way that we have been able to get the attention of the
42

Committee and the VA to actually set parameters now on what the

capacity is. Because the strain is on at every hospital that has an

SCI center, constantly trying to find ways to shift those resources

around when they only have so much. So that is why we run into

problems and why we have agreed on a directive that Dr. Roswell

sent out saying this is how many beds you need, how many staff

you need to actually meet the committees’ requirement.

Mr. SIMMONS. When we look at the issue of mandatory funding

for veterans health benefits under VA, is there any thought that

certain types of services should be funded in a mandatory fashion?

Should other types of services which are more complicated that

might involve tertiary care be left discretionary so that the Administrators have a full range of options for those categories of

veterans?

Mr. FULLER. Well, if we were to leave part of the VA mandatory

and the other part discretionary in a Congressional sense I would

fear having to go to the appropriators every year and having to say,

‘‘Hi there.’’

Mr. SIMMONS. Thank you. That is a good answer. For Dr.

Schwartz, I think the third or fourth page of your testimony, you

state that Vietnam Veterans of America supports the efforts of Secretary Principi to stabilize VHA by suspending enrollment of category 8 veterans until such time as there are resources adequate

to take care of service disabled veterans, combat veterans, and indigent veterans. It seems to me that position is somewhat different

from what we are hearing from some of the other VSOs. Would you

like to comment on that position?

Ms. SCHWARTZ. Let me just say that I think in the past, some

of the secretaries and some of the administrators before they were

secretaries, really didn’t move fast to try to make any changes. But

I have to say that I am impressed with some the things that Secretary Principi has done, especially with trying to reduce the backlogs with his taking a real pragmatic look at what I do have. And

I think, in essence, what he has said because I don’t think this decision came to him easily. He said he is tapped out. The system is

tapped out. Because of the way, I mean no one foresaw when Secretary Derwinsky very nicely said I would like to give veterans a

break and let’s give them a low co-pay of $2 on all their pharmaceuticals. He didn’t realize they would grow into the largest growing group of people.

A friend of mine showed me a senior citizens health letter that

goes all over the United States telling them to go to the VA because they have such low, if you are a veteran, here is one of your

benefits, go and get your medication. I don’t think they realized

they have to see VA doctors in order to rewrite the prescriptions.

That is a problem that we have heard too. And as someone who

is both a disabled veteran and also uses Tri-Care, I get my prescriptions that are written by the VA is actually filled at the Navy

Groton hospital. So there is that question, and also the question of

what could you possibly do to alleviate it.

And I think the run on VA health care is more of a symptom of

a larger social ill which is adequate funding for medication for people who now have—their lives depend on medications. I saw some-
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body yesterday taking 15 drugs. She says I have to or I can’t stay

alive. That is what we have evolved in.

So I know perhaps it is not, but we have had to be pragmatic,

and if people remember VVA has always had the position that him

who has borne the battle is our number one—and her, who has

borne the battle is our number one priority, and I think when Secretary Principi talks about core constituency, he is talking about

the poor and the patriots. And he is telling us that if you want us

to do all the rest of this, okay, I need a little bit more commitment

from this Congress on the funding. That is what is the problem

here. The first time I ever met Tony Principi, he said the problem

with Washington is they give you—you have 5 years of problems

on one, and you go on an annual budget and so you can’t really

solve your problems. And that was in 1992 when I was just a mere

girl.

Mr. SIMMONS. Thank you very much. Mr. Filner.

Mr. FILNER. Just briefly, just to make sure you know my connections. I have taken courses at the Yale School of Medicine.

Ms. SCHWARTZ. Uh -oh. Okay.

Mr. SIMMONS. What was the nature of those courses?

Mr. FILNER. I am a historian of science, and history of medicine

was taught through that school there. I don’t know if it still is.

Ms. SCHWARTZ. Yes, it is.

Mr. FILNER. Just briefly, I have said all I need to say today, I

think. But regarding your last comments on honor, in an ideal

world I think you can rely on the honor of us politicians here. We

are all honorable men and women, but the political system responds to pressure. Everybody wants to do everything. And everybody is honorable. But people have to make choices and they have

to vote. And they vote by the pressure that is exerted on them. So

I wouldn’t trust totally the honor. I would get your members after

us.

Ms. SCHWARTZ. Well, let me just say, you mentioned that before

and we do have in operation right now an identification of all of

the ZIP codes of our members and who are their congressional representatives. But I think sometimes, and I don’t live here in the

city and I try not to drink the water because I don’t want to become jaded. But the point is, the point is, I do think that sometimes people who serve in this Congress and people who serve in

the Senate forget that. And I have a very burning thought in my

mind. If we cannot affect the change for mandatory funding for VA

health care while we are sending men and women overseas to serve

this country, shame on us.

Mr. FILNER. I agree. Shame on us for not doing it. But also

shame on you if you don’t apply the pressure to get it done. That

is, you know, American politics.

Ms. SCHWARTZ. I said shame on us.

Mr. FILNER. I mean shame on us if we don’t do it.

Ms. SCHWARTZ Us, not you. Us.

Mr. FILNER. Okay. Shame on all of us.

Ms. SCHWARTZ. Yes. If we can’t get it now, when are we going

to get it.

Mr. FILNER. Well, we aren’t going to get it.

Mr. SIMMONS. Thank you, Mr. Filner. Mr. Bradley.
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Mr. BRADLEY. I have no—excuse me. I have no questions. But

this has been a very interesting debate and I certainly feel very

welcome to be on the committee and look forward to working with

all of you on these health care issues that are so important to our

Nation. Thank you.

Mr. SIMMONS. I thank you all very much. I thank our panelists

and I note for the record that Dr. Roswell has been sitting in the

second row listening carefully and taking notes. You know, I am a

freshman in the House, but spent a number of years as a Senate

staffer, and it’s often that public officials come in and make their

statements, answer the questions and disappear out the door with

a great flurry and entourage following along. It is very refreshing

to see somebody who is sufficiently interested in the issues on the

table today that he will stay for the full hearing and listen to all

of the testimony. So I note that for the record. I thank the Doctor.

I thank all of our participants here today and this hearing is now

concluded.

[The statement of Hon. Jeff Miller appears on p. 51.]

[The statement of Hon. Cliff Stearns appears on p. 54.]

[Whereupon, at 4:42 p.m., the subcommittee was adjourned.]
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A P P E N D I X

PREPARED STATEMENT OF CHAIRMAN SMITH

Last night, President Bush reported that the State of the Union was ‘strong’.

Today, we will examine the state of veterans’ health care to see if it is equally

strong.

Only days ago, the Department of Veterans Affairs announced that for the first

time it would use its authority to curtail new enrollments for veterans’ health care.

VA reported that at least—and I emphasize at least—200,000 veterans are waiting

six months or longer for their first appointment with a VA doctor, and that estimate

doesn’t count those still waiting to enroll in the system. Many of those waiting are

100 percent disabled and paralyzed veterans. In fact, when Secretary Principi sent

one of his deputies, a decorated Vietnam veteran paralyzed in combat, to try and

enroll in VA health care, he was turned away in state after state due to overcrowding.

Earlier this month, Chairman Buyer and Committee staff visited one medical center in Florida and discovered that over 2,700 veterans are waiting to be scheduled

to see a VA audiologist, over 4,000 veterans are waiting to see an eye specialist,

and almost 700 are waiting to see a cardiologist. More than half of these veterans

were high priority veterans in categories 1 to 7. All reports indicate that a similar

situation exists at a majority of VA medical centers throughout the country. Care

delayed is care denied.

At the same time, there remain at least 275,000 homeless veterans who desperately need a helping hand, yet VA is unable to fully fund programs that we approved less than two years ago. VA has closed over 1,500 long-term care beds at

a time when WWII and Korean War veterans are most in need of assistance. Despite an increase in the number of veterans who have service-connected mental illnesses, such as Post Traumatic Stress Disorder, VA is providing less care overall

than it did in previous fiscal years.

And most troubling, according to VA’s own published documents in the Federal

Register of January 17, VA will be short $1.9 billion in their health care budget for

this fiscal year—and that assumes VA will receive the full $23.9 billion for health

care approved last year by both the House and Senate Appropriations Committees.

Let me reemphasize what I just said—VA projects that it needs another $1.9 billion

this year to meet the health care needs of veterans already enrolled.

To put this in perspective, $1.9 billion is the annual cost of providing care to

422,000 veterans—from all priority groups—veterans who are already in the system.

How does VA plan to make up the difference this year? The only proposal to date

is the freeze on enrollment of new priority 8 veterans, a move that VA projects could

save at most $130 million this year.

Some have suggested that Congress should be blamed for the shortfall in funding

for veterans health care, but the record over the past five years is clear that each

Administration request has been a budget floor, while Congress has added funds

above that request every single year. For FY 2003, the Administration requested a

6 percent increase; the House passed, and Congress is expected to approve, an 11

percent increase—that’s 1 billion above VA’s budget request. Over the past five

years, Congress has consistently provided greater funding than was requested by

the Administration, on average over $300 million each year.

In addition, last year Congress passed a supplemental appropriation that included

$417 million for VA health care. Regrettably, the Administration refused to accept

$275 million of that supplemental targeted for veterans’ medical care.

Others have suggested that VA’s problems are driven by enrollment of veterans

who were not injured during their service, so-called ‘‘lower priority’’ veterans in category 8. However, it is clear that even if VA had never offered priority 8 veterans

the opportunity to receive care from VA, it would still be swamped with service-connected and low-income veterans who are in the ‘‘high priority’’ categories.

According to VA, the number of ‘‘high priority’’ veterans enrolled in VA health

care is projected to rise by 384,000, or 7.5 percent, this year and by 281,000 next

year. A total of 5.8 million ‘‘high priority’’ veterans will be enrolled for VA care next

fiscal year and this trend will not diminish for several more years.

The word crisis is often overused in this town, but clearly VA health care is in

crisis and at a crossroads.
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Last year, I, along with my good friend Lane Evans, offered several bills seeking

long-term solutions to VA’s health care funding problems. H.R. 4939 would have allowed VA to be reimbursed by Medicare for providing care to Medicare eligible veterans. H.R. 5250 would have made VA health care funding a formula driven budget

item—based upon demand and medical inflation—rather than a discretionary budget item. H.R. 5392 would have allowed VA to recover costs of medical care from

third parties in the same manner as if VA were a preferred provider organization.

And finally, H.R. 5530 would have enhanced the right of VA to recover payments

from third parties for providing non-service-connected care. We are again preparing

to introduce legislation—on a bipartisan basis—to provide long-term solutions to

VA’s funding problems.

But before we can arrive at solutions, we first need to agree on the nature and

scope of the problems. For some, the Secretary’s decision to cut off enrollment of

164,000 category 8 veterans was a solution; to me, and many others, it is a problem.

So I return to the central question of today’s hearing: how well is VA is fulfilling

its statutory mandate to provide the full range of health care services that veterans

have earned. Are service-disabled and paralyzed veterans receiving timely and comprehensive care, including access to the latest advances in medicine and technology?

Is VA meeting its obligations to indigent veterans, those who have fallen on hard

times, including those suffering from drug addiction and mental health problems?

How about our elderly veterans, many who fought on the beaches of Normandy, in

the forests of Ardennes, and across the frozen Chosin Reservoir; are they receiving

the long-term care Congress mandated for them in the Millennium Health Care and

Benefits Act of 2000?

Many of you may have heard of The American Legion’s project called ‘‘I am not

a number’’. It is helping to put a human face on veterans’ health care issues, rather

than just focusing on numbers, such as budget allocations and enrollment projections. It reminds me of a saying, often used by Mark Twain, and appropriate for

today’s hearing. Twain said that ‘‘there are three kinds of lies: lies, damn lies and

statistics.’’

I think that Mr. Twain and The American Legion have it right: veterans are not

numbers, their health is not a statistic, and our Nation’s debt to them must be more

than just words.

PREPARED STATEMENT OF CONGRESSMAN EVANS

Good afternoon. Mr. Chairman, and members of the Committee on Veterans Affairs. Welcome to the new members of the Committee who are joining us for the

first time today.

Mr. Chairman, you have chosen a timely matter to inaugurate this Committee in

this Congress. Many of us have seen recent press that discusses Secretary Principi’s

decision to only allow those ‘‘highest income’’ veterans who have already enrolled

for care in the Department of Veterans Affairs (VA) to apply for services. It is obviously a deeply disappointing decision to veterans, as well as to the Members of

Congress.

It is particularly disappointing given the bipartisan efforts of this Committee to

improve the funding for VA health care. Mr. Chairman, as you recall, we forwarded

views and estimates to the Budget Committee asking them to increase President

Bush’s request for VA health care funding for FY 2003 by $2.2 billion. We still

haven’t passed an appropriation, but reports indicate the conferees may pass a bill

that adds only $400 million to VA’s health care budget. This will seriously aggravate

VA’s existing problems with access, even with the new rationing mechanisms in

place, and threaten the high level of quality the struggling system has managed to

uphold through years of uneven funding.

Mr. Chairman, you and I stood ready to do something about this in the dwindling

days of the last Congress. Together, we introduced H.R. 5250, the Veterans Health

Care Funding Guarantee Act of 2002 which would have established a mandatory

funding stream for VA health care. You are to be commended for your leadership

in tackling this issue. Every veterans’ organization testifying today has applauded

our efforts to champion this legislation. It was the right thing to do, Mr. Chairman.

I want to reaffirm my commitment to working together to address any obstacles

that have been set in our path and getting this legislation re-introduced in the near

future.
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