```
Veterans' Health Care: Veterans' Perceptions of VA Services and VA's Role
in Health Care Reform (Letter Report, 12/23/94, GAO/HEHS-95-14).

Focus group participants with whom GAO spoke expressed diverse views
about the care provided by Department of Veterans Affairs' (VA)
facilities and the role VA should play in a reformed health care system.
The perspectives of the 127 veterans who participated are not
statistically representative of the nation's 27 million veterans.
Still, many of the views expressed are consistent with the findings in
other studies.  For example, some of the concerns expressed in the focus
groups about VA health care--such as excessive waiting times and poor
customer service--have been highlighted in earlier GAO reports.
Apprehension about changes was a recurrent theme running through the
focus groups. Veterans expressed concern that changes could diminish or
eliminate veterans' health benefits, that allowing nonveterans to use VA
facilities could detract from care for veterans, that VA would lose its
individuality and its focus on the special health care needs of
veterans, and that veterans who are dependent on VA could be hurt
emotionally.  Some focus group participants thought that VA remained the
appropriate vehicle to provide health care for veterans.  Others,
however, said that VA can no longer adequately tend to these veterans
and that other options should  be explored.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-14
     TITLE:  Veterans' Health Care: Veterans' Perceptions of VA Services 
             and VA's Role in Health Care Reform
      DATE:  12/23/94
   SUBJECT:  Veterans benefits
             Veterans hospitals
             Hospital care services
             Patient care services
             Handicapped persons
             Surveys
             Health services administration
             Health resources utilization
             Health care planning
             Proposed legislation
IDENTIFIER:  Health Security Act
             Clinton Health Care Plan
             National Health Care Reform Initiative
             National Performance Review
             VA 1987 Survey of Veterans
             
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Cover
================================================================ COVER

Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs, House of Representatives

December 1994

VETERANS' HEALTH CARE - VETERANS'
PERCEPTIONS OF VA SERVICES AND
VA'S ROLE IN HEALTH CARE REFORM

GAO/HEHS-95-14

Perceptions of VA Health Care

Abbreviations
=============================================================== ABBREV

  GEHA - Government Employees Hospital Association
  HMO - health maintenance organization
  PVA - Paralyzed Veterans of America
  SOV - Survey of Veterans
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER

B-257442

December 23, 1994

The Honorable Lane Evans
Chairman, Subcommittee on
 Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives

Dear Mr.  Chairman: 

During the past 5 years, studies by GAO, the Department of Veterans
Affairs' (VA) Commission on the Future Structure of Veterans Health
Care, and the Paralyzed Veterans of America (PVA), among others,
identified the need for fundamental changes in the VA health care
system to enable it to play a more effective role in meeting the
changing health care needs of America's veterans.\1 But the type and
extent of changes needed in the VA system are closely related to
potential changes in other health care programs such as the changes
debated during the 103rd Congress. 

To help determine appropriate changes in the VA health care system,
you asked us to obtain information on veterans' (1) perceptions of
the VA health care system and (2) opinions about VA's future role in
meeting their health care needs.  To do this, we held 14 focus group
discussions with veterans in different parts of the country.\2 We met
with veterans who currently use VA health care--or have used it
within the last 3 years--and veterans who do not use VA health care. 
A total of 127 veterans participated in our focus groups. 

Focus groups provide qualitative information that must be interpreted
carefully.  Although focus groups provide a range of views on a
topic, the results cannot be quantified and are not necessarily
representative of the population as a whole.  Subject to that
limitation, they are an effective tool for collecting information on
complex issues of consumer choice.  Appendix I contains a more
detailed description of our scope and methodology. 

We presented the preliminary results of those focus groups in April
20, 1994, testimony before the Subcommittee.\3 As subsequently agreed
with your staff, this report provides further insights from those
groups and related studies. 

--------------------
\1 See Report of the Commission on the Future Structure of Veterans
Health Care, Department of Veterans Affairs (Nov.  1991); Strategy
2000, The VA Responsibility in Tomorrow's National Health Care
System, Paralyzed Veterans of America (Apr.  1992); Creating a
Government That Works Better and Costs Less, Report of the National
Performance Review (Sept.  1993); and Tracking the Course of National
Health Care Reform, Paralyzed Veterans of America (Mar.  1994).  A
list of related GAO products is included at the end of this report. 

\2 A focus group is a small group discussion led by a trained
moderator held at a neutral site.  While the moderator poses broad
discussion questions, the participants discuss the topics among
themselves. 

\3 Veterans' Health Care:  Veterans' Perceptions of VA Services and
Its Role in Health Care Reform (GAO/T-HEHS-94-150, Apr.  20, 1994). 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Focus group participants expressed views about the care provided by
VA facilities and the role VA should play in a reformed health system
that were as diverse as the veteran population itself.  The
perspectives of the 127 veterans who participated are not
statistically representative of the nation's 27 million veterans. 
Still, many of the views expressed are consistent with findings in
other studies.  For example, some of the concerns expressed in the
focus groups about VA health care--such as excessive waiting times
and poor customer service--have been highlighted in our prior
reports. 

Apprehension about change was a recurrent theme running through the
focus groups.  Veterans expressed concerns that changes could
diminish or eliminate veterans' health benefits, that allowing
nonveterans to use VA facilities could detract from care for
veterans, that VA would lose its individuality and its focus on the
special health care needs of veterans, and that veterans who are
dependent on VA would be hurt emotionally.  Some focus group
participants thought that VA remained the appropriate vehicle to
provide health care for veterans' service-connected needs.  Others,
however, believed that VA can no longer adequately tend to these
veterans and that other options to address veterans' health care
needs should be developed. 

   BACKGROUND
------------------------------------------------------------ Letter :2

When the VA health care system was established in 1930, public and
private health insurance were virtually nonexistent.  VA developed
its system as a direct delivery system, with the government owning
and operating its own health care facilities.  It became the nation's
largest direct delivery system, with 171 hospitals, 240 outpatient
clinics, 126 nursing homes, and 32 domiciliaries.\4

With the subsequent growth of public and private health insurance
programs, most veterans now have one or more alternatives to VA
health care.  In 1990, 9 out of 10 veterans had other health care
coverage in addition to access to services provided by VA.  For
example, about 26 percent of veterans were eligible for Medicare.  We
reported in 1992 that the availability of alternative public or
private health insurance is an important factor in predicting
veterans' use of VA health care services.\5

Still, VA continues to play an important role in meeting the health
care needs of veterans.  About 2.2 million veterans made more than 20
million outpatient visits to VA health care facilities and had more
than 970,000 hospital stays in 1991.  Of these veterans, about 1
million had disabilities incurred in or aggravated by military
service (service-connected), and 1.2 million had no disabling
conditions relating to military service (nonservice-connected). 

In its November 1991 report to the Secretary of Veterans Affairs, the
Commission on the Future Structure of Veterans Health Care
recommended substantial changes in the organization and mix of
services delivered by VA to meet the changing health care needs of an
aging veteran population.\6 Among the changes recommended were reform
of VA eligibility and entitlement provisions to enable veterans to
obtain the full continuum of VA health care services, redistribution
of VA health care resources to better meet veterans' needs, and use
of innovative approaches to improve access to VA health care. 
Although the need for fundamental restructuring of the VA health care
system was identified by the commission and others, the push to
restructure VA was soon overtaken by national health reform
proposals. 

Legislation considered during the 103rd Congress would have had
significant effects on VA's role as a health care provider.  Health
reform proposals would have made fundamental changes in how Americans
obtain and pay for health care.  Proposals ranged from reforming the
health insurance industry to make it easier for Americans to obtain
insurance to creating a universal coverage system based on employer
or individual mandates or a single-payer system.  Enactment of such
proposals would have further reduced the number of veterans lacking
basic health coverage, thus affecting VA's role as an acute care
provider. 

Two health reform proposals included significant changes in the VA
health care system or veterans' health benefits.  First, the
administration's proposed Health Security Act (H.R.  3600/S.  1757),
including the Mitchell and Gephardt proposals, would have (1)
transformed the VA system into a series of managed care plans to
compete with private sector plans and (2) restructured VA eligibility
and entitlements.  The Dole/Packwood (S.  2374) proposal would have
given VA facilities increased flexibility to compete as health care
providers under state health reform legislation; it would not have
reformed VA eligibility. 

Although health reform legislation was not enacted during the 103rd
Congress, VA's Health Care Reform Office continues to develop plans
for converting VA into a managed care system in anticipation of
future health reforms at either the state or national level. 

--------------------
\4 Domiciliaries provide shelter, food, and necessary medical care on
an ambulatory self-care basis to veterans who are disabled by age or
disease but not in need of skilled nursing care or hospitalization. 

\5 VA Health Care:  Alternative Health Insurance Reduces Demand for
VA Care (GAO/HRD-92-79, June 30, 1992). 

\6 The 15-member commission was appointed by the Secretary of
Veterans Affairs to evaluate the VA health care system. 

   VETERANS TENDED TO USE VA
   HEALTH CARE TO SUPPLEMENT OTHER
   COVERAGE
------------------------------------------------------------ Letter :3

Veterans participating in our focus groups, other than those without
health insurance, seemed to use VA for certain services, such as
treatment of service-connected disabilities, rather than relying on
VA for all of their care.  For example, one veteran said, "I use the
VA as a safety net.  If I am working and .  .  .  covered with
insurance, I will not use VA .  .  .." Similarly, a service-connected
veteran said that ".  .  .  I use the VA for .  .  .  strictly things
that were service-connected."

Our prior studies showed that veterans who use VA health care
services tend to have lower incomes and less private insurance
coverage than veterans using other providers.  This has two important
implications for national health care reform. 

First, to the extent national reform expands the number of veterans
having health insurance and/or provide subsidies for low-income
veterans to help them pay for private sector health care, demand for
VA health care services could decrease.  Universal health insurance
could reduce demand for VA inpatient care by as much as 47 percent
and outpatient care by about 41 percent, we reported in June 1992.\7
While more modest insurance industry reforms would similarly reduce
demand for VA health care, the effect would depend on the number of
veterans gaining insurance coverage and the extent of subsidies for
the low-income, if any. 

Second, health reform that would require veterans to choose either VA
or another health plan to provide all of their comprehensive health
care benefits could significantly affect future demand for VA health
care.  Currently, veterans with multiple coverage, such as those with
both VA and Medicare, can pick and choose where they get health care
services.  For example, they may use Medicare for routine physician
care but use VA for a costly episode of inpatient care or to obtain
services, such as outpatient prescription drugs, not covered under
Medicare.\8 Many factors could affect veterans' choices between VA
and their alternative coverage(s) including established provider
relationships, convenience, covered services, and cost-sharing
arrangements. 

This choice could be particularly difficult for veterans with
service-connected disabilities.  Many of the veterans with
service-connected disabilities participating in our focus groups said
that they use VA only for treatment of their service-connected
disabilities.  While their use of VA may be limited, many veterans
participating in our focus groups expressed strong views about the
government's obligation to provide care for veterans with
service-connected disabilities.  For example, one veteran said "It's
the VA's responsibility to take care of those injuries you received
in the war, not your insurance company's." Health reforms that force
veterans to choose between VA and other health plans could limit the
ability of veterans with service-connected disabilities to seek
treatment from VA for their service-connected conditions if they
choose another health plan. 

Appendix II contains excerpts from the focus groups showing the range
of comments relating to why veterans use VA health care. 

--------------------
\7 GAO/HRD-92-79. 

\8 Veterans' Health Care:  Use of VA Services by Medicare-Eligible
Veterans (GAO/HEHS-95-13, Oct.  24, 1994). 

   VETERANS' PERCEPTIONS OF VA
   HEALTH CARE VARIED BY LOCATION
------------------------------------------------------------ Letter :4

Focus group participants' perceptions of VA health care varied by
location, but concerns focused primarily on poor customer service. 
Among the frequent complaints were comments about excessive waiting
times, poor staff attitudes, and inadequate parking.  For example,
one veteran said that

"[o]ut at VA you go to one place and sit there for 20 minutes reading
the newspaper.  You move down to another spot for 20 minutes reading
the newspaper.  Pretty soon you almost miss lunch, and you feel like
leaving .  .  .  I don't understand why it has to be that way."

Another veteran commented, "There's no parking, period."

The concerns about waiting times at VA facilities are consistent with
findings in our October 1993 report on VA's ambulatory care system. 
We found that waiting times varied widely, but veterans often
experienced lengthy service delays when they sought ambulatory care
at VA facilities.  Veterans with nonurgent conditions frequently
waited 1 to 3 hours before a physician examined them in the
emergency/screening clinics we surveyed.  In addition, veterans
frequently waited 8 to 9 weeks to obtain appointments in specialty
clinics.\9

Staff attitudes were a frequent source of both complaints and praise. 
For example, one veteran described VA as "uncaring and case
hardened," while another said that VA has "lost the attitude of
service." There were also comments, however, about the caring
attitudes of VA staff at some facilities.  For example, one veteran
described VA as "dedicated and helpful" while another said, "I'm
happy and I'm satisfied."

Prior findings by PVA and the National Performance Review highlighted
poor customer service as a barrier to VA competitiveness in a
reformed health care marketplace.\10 Not surprisingly, veterans in
cities having veterans' facilities with good reputations for customer
service also expressed more interest in enrolling in VA health plans. 
The reputation of individual facilities will likely be a significant
factor in determining whether veterans stay with VA under health care
reform. 

Just as veterans expressed both satisfaction and dissatisfaction with
VA's customer service, there was a wide range of views relating to
the quality of care provided by VA facilities.  Veterans in the focus
groups perceived that the quality of care offered by VA can be
erratic, and some veterans questioned the care offered in other
locations.  Others, however, credited VA with saving their lives or
identifying health problems not identified by private sector
providers. 

Veterans' views of VA quality of care may be shaped by personal
experience, anecdotal information from others, or from published
reports and studies.  For example, studies by GAO and VA's Inspector
General have highlighted continuing problems in correcting quality
assurance problems at VA medical centers.  In addition, several
highly publicized incidents involving alleged poor quality of care at
individual VA medical centers may contribute to veterans'
apprehension about quality of care. 

Whether groundless or not, veterans' misgivings about the quality of
care rendered by VA facilities would affect VA's ability to compete
in a reformed system.  Appendix III contains excerpts from the focus
group discussions showing the range of comments relating to veterans'
satisfaction with VA health care. 

--------------------
\9 VA Health Care:  Restructuring Ambulatory Care System Would
Improve Services to Veterans (GAO/HRD-94-4, Oct.  15, 1993). 

\10 Tracking the Course of National Health Care Reform, Paralyzed
Veterans of America (Mar.  1994) and Department of Veterans Affairs,
Accompanying Report of the National Performance Review, Office of the
Vice President (Sept.  1993). 

   VARIOUS BARRIERS LIMITED
   VETERANS' USE OF VA HEALTH CARE
------------------------------------------------------------ Letter :5

Focus group participants cited a variety of barriers that limit use
of VA health care.  Participants often cited being ineligible for VA
health care or being uncertain about their eligibility as impediments
to use of VA.  Distance to VA facilities, inconvenience associated
with using VA, and past negative experiences with VA were other
contributing factors mentioned in the focus group discussions. 

According to VA's 1987 Survey of Veterans (SOV), most veterans,
including about 30 percent of those with service-connected
disabilities and 56 percent of those without public or private health
insurance, had never used VA health care services.\11

Although the availability of other health care options through public
or private health insurance coverage is an important factor in
predicting VA use, many other factors may contribute to the limited
use of VA health care services by veterans. 

The barriers cited in the focus group discussions are consistent with
findings in our prior studies.  For example, we previously reported
the following: 

Complex eligibility and entitlement provisions limit the ability of
veterans, particularly those with no service-connected disabilities,
to access VA outpatient care services.  Veterans with
nonservice-connected disabilities can generally obtain outpatient
services only if they are needed to obviate the need for inpatient
care, are provided in preparation for inpatient care, or are provided
as a follow-up to inpatient care.\12

Veterans' access to outpatient care at VA medical centers varies
widely because of differing interpretations of eligibility criteria
and varying decisions on whether and how to ration care.\13

VA facilities are geographically inaccessible to many veterans.  Both
public and private insurance programs generally give veterans options
for obtaining care closer to their homes.  For example, over 6,000
hospitals participate in the Medicare program, compared to 171 VA
hospitals. 

In addition, many veterans were unaware of their eligibility for
veterans health benefits.  VA's SOV found that only 41 percent of
veterans were aware of VA hospital benefits for low-income veterans
and less than half were aware of VA outpatient care benefits. 

Under health reform, VA would need to attract many of the veterans
who currently do not use its facilities if it is to be a viable
competing provider.  Without an aggressive strategy to address the
barriers discussed above, VA would not be able to market competitive
health care plans. 

Appendix IV contains excerpts from the focus group discussions
showing the range of barriers to VA use identified by focus group
participants. 

--------------------
\11 The Bureau of the Census conducted the SOV based on its Current
Population Survey, a monthly nationwide survey designed to obtain
information on the employment status and other characteristics of the
population.  A total of 11,439 veterans were sampled.  Among other
things, the survey contains information on the number of veterans,
their employment status, and their health insurance coverage.  A VA
contractor completed an independent study in 1989, validating the
survey methodology. 

\12 VA Health Care:  Comparison of VA Benefits With Other Public and
Private Programs (GAO/HRD-93-94, July 29, 1993). 

\13 VA Health Care:  Variabilities in Outpatient Care Eligibility and
Rationing Decisions (GAO/HRD-93-106, July 16, 1993). 

   VETERANS' VIEWS OF VA'S ROLE IN
   HEALTH REFORMS VARIED WIDELY
------------------------------------------------------------ Letter :6

Veterans participating in our focus groups disagreed about the
appropriate role for VA in a reformed health system.  Topics such as
whether VA should remain a separate system, offer general health care
or specialized services to veterans, and serve veterans' families
elicited strong opposing views. 

Veterans frequently expressed concerns that changes could reduce VA's
emphasis on veterans' health care.  Some veterans worried that
selecting non-VA providers could have a detrimental effect on their
disability ratings and on the timely diagnosis of service-related
conditions.  Such veterans generally expressed a desire to maintain
separate VA health care facilities under health reform, seeing it as
a tangible symbol of the nation's commitment to its veterans.  For
example, one veteran commented that

"I feel like you [have to] keep the veterans' benefits separate.  If
they don't, we're going to lose them."

Other veterans, however, did not see the need for a separate VA
system as long as veterans were given a workable alternative.  These
veterans suggested options such as VA becoming a payer rather than
provider of services.  The primary concern of this group was that
veterans be given something of value equal to what they have now. 
For example, one veteran commented that

"I see nothing wrong with being incorporated into one big deal, as
long as I got the same value as I get now."

Focus group participants had similarly divergent views on whether VA
should provide health care services to veterans' dependents, and if
so, whether those services should be provided in VA facilities.  For
example, one veteran said

"I have no problem with the VA taking care of families, but I don't
want to see it at the expense of veterans."

Another, however, said that

"[t]he VA was created to take care of the individuals who bore the
brunt of the battle, not for my wife and not for my kids."

Concerns were also expressed about taking family members to VA
hospitals.  For example, one veteran noted, "I can't see my wife
going to the VA hospital". 

Appendix V contains excerpts from the focus group discussions showing
the range of views concerning the appropriate role for VA in a
reformed health care system. 

   VETERANS' FUTURE USE OF VA
   WOULD DEPEND ON MANY FACTORS
------------------------------------------------------------ Letter :7

Veterans in the focus groups discussed various factors they would
evaluate when assessing VA as a possible health care provider.  The
types of services offered by VA compared with those of other
providers as well as the associated out-of-pocket costs were topics
that were prominently featured in these discussions.  Veterans also
mentioned that the changes implemented by VA to compete in health
reform would influence their choice.  On the other end of the
spectrum, certain veterans in the focus groups mentioned that they
would not consider VA as a health provider regardless of services
offered or changes implemented. 

Appendix VI contains excerpts from the focus group discussions
showing the range of comments concerning factors veterans would
consider in deciding whether to choose VA as a health care provider. 

   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

We did not request comments from the Department of Veterans Affairs
on this report.  We did, however, meet with officials from the
Department to discuss our preliminary findings as presented in our
earlier testimony. 

---------------------------------------------------------- Letter :8.1

As agreed with your office, we are providing copies of this report to
the Chairman and Ranking Minority Member, Senate Committee on
Veterans' Affairs; the Chairmen and Ranking Minority Members of the
House Committee on Veterans' Affairs and the Senate and House
Committees on Appropriations; the Secretary of Veterans Affairs; and
other interested parties.  Copies will be made available to others
upon request. 

Please call me at (202) 512-7101 if you or your staff have any
questions about this report.  Other contributors to this report are
listed in appendix VII. 

Sincerely yours,

David P.  Baine
Director, Federal Health Care
 Delivery Issues

SCOPE AND METHODOLOGY
=========================================================== Appendix I

The qualitative information presented in this report was obtained
from focus group discussions held in Baltimore, Maryland;
Martinsburg, West Virginia; San Francisco, California; Denver,
Colorado; and Charlotte, North Carolina.  A total of 127 veterans
participated in 14 focus group discussions.  The groups ranged in
size from 5 to 14 participants. 

In the focus groups, veterans discussed their attitudes and
perceptions about veterans' health care, health care coverage in
general, and the VA health care system.  Focus groups are small
groups of people who get together to talk about a given topic.  A
specially trained moderator conducts the meetings, posing broad
discussion questions, but essentially allowing focus group
participants to discuss the topics among themselves.  Focus groups
provide a range of views on a topic, but the results cannot be
quantified and are not necessarily statistically representative of
the population as a whole.  Subject to that limitation, focus groups
are an effective tool for collecting information on complex issues of
consumer choice. 

Among the issues discussed in our focus groups were veterans' views
on

the reasons and extent to which they use VA health care services;

their overall satisfaction with the care VA provides;

barriers that prevent veterans from getting care at VA;

the issues of whether VA should be a full service provider, whether
VA should set up managed care plans to compete with private sector
plans, and whether these VA plans have the potential to be
competitive;

the need to maintain a separate VA health care system;

the question of whether the VA health care system should be expanded
to cover dependents;

the factors the veterans would consider in deciding whether to select
a VA health plan; and

the ways in which VA could be changed to make it a more competitive
provider. 

We selected the topics after reviewing current literature on the
future of VA, the need for eligibility reform, and possible ways to
restructure VA.  We reviewed documents such as Report of the
Commission on the Future Structure of Veterans Health Care, written
for VA in 1991; Strategy 2000:  The VA Responsibility in Tomorrow's
National Health Care System, written by the Paralyzed Veterans of
America in 1992; and the relevant sections of the National
Performance Review, Creating a Government That Works Better and Costs
Less.  We also used information from VA's 1987 Survey of Veterans on
veterans' health insurance and use of medical benefits to shape our
moderators' guide.  Finally, past and ongoing work at GAO shaped our
topic selection as well. 

To identify potential participants for 12 of the 14 groups, we used
information from VA's compensation and pension files.  From this
information, we identified low-income veterans, those with service-
connected disabilities that rendered them 50-percent or more
disabled, those with service-connected disabilities that rendered
them less than 50-percent disabled,\14 women veterans,
Medicare-eligible veterans, and veterans who did not live within a
40-mile radius of a VA medical facility.  For the remaining two
groups, we used Office of Personnel Management and Department of the
Interior data to identify federal employees who claimed a veteran's
preference when hired.  In our view, these veterans, who currently
have multiple insurance options, are representative of high-income
veterans that VA seeks to attract. 

Using the criteria mentioned above, we selected names and addresses
from the compensation and pension data and found telephone numbers
for those listed.  Generally, we recruited 12 to 15 individuals to
participate in the discussions in anticipation that 8 to 10 would
actually be able to participate.  To minimize selection bias, we
telephoned many of the veterans during the late afternoon, early
evening, and on weekends so that a broad spectrum of veterans would
be invited to participate.  We mailed confirmation letters and
directions to veterans who agreed to participate.  The day before the
scheduled meeting, we called veterans to remind them of the meeting
to help ensure their attendance.  At the end of the focus group
sessions, participants were paid a nominal stipend of $25 to defray
travel and related expenses. 

When inviting veterans to participate, we asked them whether they
currently used VA health services or had used them within the last 3
years.  We considered those veterans who had not used VA within the
last 3 years to be nonusers of VA services.  The general
characteristics of the veterans in each of the focus groups are
listed in table I.1. 

                         Table I.1
          
            Profile of Focus Group Participants

Location        Users                 Nonusers
--------------  --------------------  --------------------
Baltimore, MD   Veterans with         Veterans with
                service-connected     service-connected
                disabilities equal    disabilities equal
                to or greater than    to or greater than
                50%                   50%

Martinsburg,    Low-income veterans   Low-income veterans
WV\a

San Francisco,  Female veterans       Female veterans
CA

                Medicare-eligible     Medicare-eligible
                veterans              veterans

Denver, CO      Veterans with         Veterans with
                service-connected     service-connected
                disabilities rated    disabilities rated
                less than 50%         less than 50%

                High-income veterans  High-income veterans
                (Department of the    (Department of the
                Interior employees)   Interior employees)

Charlotte, NC   Veterans who do not   Veterans who do not
                live within a 40-     live within a 40-
                mile radius of a VA   mile radius of a VA
                facility              facility
----------------------------------------------------------
\a To recruit participants for the Martinsburg, WV, focus groups, we
started with a list of veterans in the area who received VA pensions. 
However, not all veterans participating in these groups received VA
pensions, nor were they necessarily veterans with low incomes. 

The focus group discussions were held in neutral locations intended
to encourage open discussion.  Twelve of our focus groups were held
at market research facilities designed to record and observe group
discussions unobtrusively.  In Martinsburg, where facilities were not
available, two meetings were conducted in a hotel conference room. 
GAO employees who are trained moderators guided the discussions. 
Using an outline of relevant topics, the moderators posed broad
questions and encouraged participating veterans to converse among
themselves.  The group discussions were audiotaped and later
professionally transcribed.  Each group discussion generally lasted 2
to 2-1/2 hours. 

We analyzed focus group information using an interactive text
retrieval and database program that facilitates searches of
transcript information by topic and keywords to categorize
participants' responses. 

We did this work between November 1993 and September 1994 in
accordance with generally accepted government auditing standards. 

--------------------
\14 A service-connected disability is one that results from an injury
or disease or other physical or mental impairment incurred or
aggravated during military service.  VA determines if veterans have
service-connected disabilities and, for those with such disabilities,
assigns ratings of from 0 to 100 percent based on the severity of the
disability.  These ratings form the basis for determining both the
amount of compensation paid to the veterans and the types of health
care services to which they are eligible and entitled. 

FACTORS INFLUENCING VETERANS' USE
OF VA MIGHT CHANGE UNDER HEALTH
CARE REFORM
========================================================== Appendix II

Veterans in our focus groups relied in varying degrees on VA to
provide their health care.  In general, veterans, other than those
without health insurance, said they use VA selectively, for treatment
of service-connected disabilities, rather than relying on VA for all
of their care.  Many of these veterans viewed VA's care as an
entitlement.  Veterans without other health insurance said they use
VA as a safety net, in part because they have few other options. 
These veterans did not necessarily see themselves as entitled to care
from VA.  Finally, a group of veterans said they use VA as their
provider of choice for all their care. 

Amid this diversity, veterans expressed some common reasons for using
VA.  A core of veterans believed that VA understands and has the
resources to best treat their special health needs.  Others believed
they are entitled to VA care.  The administrative practices and
preexisting condition clauses of alternative health insurance are
another factor influencing the use of VA, because some private
insurers promote use of VA for care of veterans' service-connected
conditions.  Finally, the low cost associated with VA was mentioned
as a reason to use VA. 

   EXTENT OF VA USE VARIED, BUT VA
   GENERALLY SUPPLEMENTED OTHER
   COVERAGE
-------------------------------------------------------- Appendix II:1

As shown by the following quotations, veterans in the focus groups
relied on VA to provide different aspects of their care.  Some
veterans used VA primarily for treatment of their service-connected
disabilities.  Other veterans said they use VA as a safety net when
they have no other insurance coverage.  On the other hand, some
veterans said they use VA for all their care. 

"The only thing I use the VA for is strictly on the things that were
service-connected.  I don't use them for anything else.  I have my
own private doctor outside of the VA for all other medical purposes."

"Basically, I have no insurance.  The VA is about all I have to fall
back on."

"I have always thought of the VA as providing medical care at the
last resort [when] .  .  .  a veteran couldn't afford private care,
and [he or she] would go into the Veterans Administration.  Or
perhaps they could afford private care, but did not want to pauperize
themselves."

"I have had all my care done through the VA.  The only reason I carry
CompreCare [a local preferred provider organization] is for my wife
so she can have health insurance.  I've never made a claim against
it.  Before that I was with GEHA.  [Government Employees' Hospital
Association].  Before that I was with Blue Cross/Blue Shield.  I've
never made a claim.  She uses them.  All my primary care has been
through the VA."

Generally speaking, veterans with service-connected conditions seemed
to use VA because they feel that they are entitled to health care
from the government.  Still, not all veterans or even all veterans
with service-connected disabilities saw themselves as entitled to
care from VA. 

Selected quotations from veterans follow: 

"It's the VA's responsibility to take care of those injuries that you
received in the war, not your insurance company's.  I can fall back
on that [other insurance].  I'm lucky, but I shouldn't have to. 
Because they didn't injure me, the company didn't injure me, the U.S. 
service did."

"Every veteran in the United States feels that because we did our
share, we did what we did, we should receive the treatment.  We
should not have to go somewhere else and have our insurance company
pay for it, or us end up paying for it .  .  ..  [VA has] to be
responsible to take care of us, because nobody else is going to do
it."

"[VA is] a safety net for me [and] that's just what it's supposed to
be.  I don't think that if I'm working, I should abuse it by going
there and getting in line when there are others who don't have the
money [and] really need it.  If I am insured, I don't believe that I
should abuse what's given to me."

"If I'm sick and I've got the flu and I can't shake it, I don't feel
that the VA should have to provide that for me.  I could go to the VA
hospital for treatment for my service-connected disability if I
chose, but since I have another place to go, I choose not to."

"Anybody that has had any problems in the service, they need to be
taken care of.  I think it should only be service-connected
disabilities.  [If] you got out and had absolutely nothing wrong with
you, 20 years after you get out how .  .  .  can that guy have a
service-connected disability?  That is not going to work.  It has to
be while you are in the service that these things happen."

"I don't think the basic veteran is looking for anything above and
beyond.  I think that he is looking for the same care as anybody
else."

   VETERANS' REASONS TO USE VA
   VARIED
-------------------------------------------------------- Appendix II:2

Veterans discussed reasons why they currently use VA for their health
care.  Among other factors, veterans mentioned that VA understood and
could treat their special needs.  One veteran, in particular,
mentioned that VA had treated him in the past and had maintained his
medical records for 20 years.  Certain veterans thought that VA had
greater resources than other providers to treat their problems.  The
administrative practices and the coverage exclusions for preexisting
conditions in private insurance policies can force veterans with
service-connected conditions to use VA for their service-connected
illnesses.  Cost was a significant reason for some veterans to use VA
for their health care.  Specifically, veterans used VA to minimize
their out-of-pocket costs or to receive services that were not
covered by their other insurance plans. 

Selected quotations from veterans follow: 

"Why use the VA?  Because they're experienced in the kind of
difficulties veterans have.  And even if it's a new doctor there, he
gets experience very quickly."

"My main reason for going to VA exclusively is that they have a
medical record now.  We're talking about 20 years of medical
records."

"The VA, even though they've got a budget .  .  .  they have deep
pockets .  .  ..  If you walk in there with a problem, they're going
to keep working on you.  They have a budget, but it's still the
government.  It's not like for-profit hospitals or for-profit medical
plan or whatever .  .  ..  And they take care of a lot of different
problems, you know, like mental problems and things like that,
regular insurances, you are limited to so many hours, so much
counseling."

"The reason I don't mix my VA and Blue Shield is because I've had . 
.  .  a couple of real knock downs with Blue Cross.  For one thing, I
know with the VA, they're going to cover me for what I am disabled
for.  Blue Cross .  .  .  all of a sudden I have a clerk making a
diagnosis and telling me they're not going to pay my bill.  And I'm
stuck with it."

"If you have a service-connected injury and you've got one of the
health care plans .  .  .  they require you, if it's
service-connected, to get it [care] from the VA."

"[VA care] is free.  And it cost me hundreds, maybe thousands of
dollars for the operations I've had.  I don't complain.  I'm happy."

"If something happens to me where it's going to cost me mucho money,
I've got someplace I know I can go to .  .  ..  I've got someplace to
go without somebody saying when I walk in there, `How are you going
to pay for this?'"

"I recently had the flu and the VA took care of me, but the reason
why I went to the VA is because I couldn't afford to go to the
doctor.  The insurance would have paid for it, but there was a
difference of $65 that I didn't have .  .  .  so the VA was there."

"In my case, they [VA] supply me with equipment, which would be very
expensive if I had to buy it myself .  .  ..  I am not sure what
other insurances may or may not cover in this case.  But it doesn't
cost me anything at VA."

   VETERANS' INCENTIVES TO USE VA
   MIGHT CHANGE UNDER HEALTH CARE
   REFORM
-------------------------------------------------------- Appendix II:3

Veterans' current use of VA might change in a reformed system in
which they might have to choose between their health care plans. 
Under certain of the reform proposals considered in the 103rd
Congress, veterans who currently use VA only for treatment of their
service-connected disabilities would no longer be able to obtain such
treatment from VA if they enrolled in non-VA health plans, if their
plans did not contract with VA to provide health care services, or if
their plans did not reimburse VA for their care.  Under universal
coverage, veterans who currently use VA as a safety net would have
other health care options at their disposal.  Under health care
reform, low-income veterans who currently use VA to minimize their
out-of-pocket expenses might qualify for subsidized health care when
using other health plans.  Also, many reform proposals would
eliminate preexisting condition clauses that motivate certain
veterans to use VA.  Of course, those veterans who consider VA as
their provider of choice would be able to select VA for their health
care. 

VETERANS' SATISFACTION WITH VA
HEALTH CARE VARIED BY LOCATION
========================================================= Appendix III

As shown by the following quotations from veterans participating in
the focus groups, the level of veterans' satisfaction with VA health
care varied by location.  The principal concerns voiced in the focus
groups addressed VA's poor customer service and employees' attitudes. 
These veterans might have direct experience with different facilities
or might be relying on anecdotal information regarding the
reputations of different VA facilities.  Some veterans in the focus
groups perceived that the care offered by VA can be erratic, and
others questioned care offered by facilities in other locations. 
Whether groundless or not, veterans' misgivings about the quality of
care rendered would affect VA's ability to compete in a reformed
system. 

"Each facility seems like it's a little bit different.  Now, I've
been to the one in Baltimore.  I didn't care for the attitudes in
Baltimore.  I didn't care for the way they treated people.  But when
you walk into the one down here at Martinsburg, it's a little bit
different.  It's--they don't walk up to the door and greet you and
pat you on the back and say `come on in friend,' but it's not as much
hassle to get into the system."

"Winston-Salem was great .  .  .  Salisbury stank.  I wouldn't go
back.  I felt [I was] getting jockeyed [around].  But in
Winston-Salem, everybody was just real up front and more than willing
to help you."

"My knowledge is that VA hospitals connected with major medical
centers are much better than VA hospitals that aren't."

"If you [were] out of town or some place and got in one of [those]
wrong ones, you might be disappointed that you picked VA .  .  .. 
[I]f you picked VA, then you would have to take VA wherever you
[were], right?  If you [were] traveling some place .  .  .  and got
in .  .  .  VA in New York, maybe that might not be as good as one
that's local."

VA's customer service, in particular, came under sharp criticism by
several veterans in different areas of the country.  Specifically,
some veterans thought that scheduling delays, waiting times, and
employee attitudes need to be improved to humanize care at VA.  In
one veteran's view, negative employee attitudes accentuated the
problem of waiting times. 

Selected quotations from veterans illustrate this view: 

"They try to make it as difficult for you as possible.  They have
lost the attitude of service.  You are just a number."

"VA is the last place I'll go.  And it is not so much the medical
care as it is customer service.  I don't think they provide good
customer service because half the time I walk out before I get to the
doctor."

"I think it would be nice if you could make an appointment and have
it kept so that it could be something that would be conducive to your
schedule."

"I hate to be unfair to all the people that work in the VA system,
that they're all callous.  And it is individual.  But being an
employed person that has a boss who wants me to be at work and I'm
trying to schedule an appointment through the VA who says that, `I
don't care what you come in here for, you're going to be here all
day.  We can't tell you what time your appointment is going to be. 
You come in early and you stay late.'"

Without question, some veterans thought that the care at VA had
declined in recent years, to the point where certain veterans thought
that VA offered them less care than they expected or felt they were
entitled to.  Funding shortfalls were seen as the fundamental cause
of the decline of VA's care. 

Selected quotations from veterans follow: 

"Like I said, I have had probably 14 operations or 15 operations at
the VA hospital, and at that time the care was exemplary .  .  .. 
What has happened in the meantime is they have quit giving much care
at all.  In the last few years, if you have a serious injury, you
have to go through .  .  .  paperwork.  Was it service-connected?  If
it was not service-connected, there are all sorts of different
qualifications that come into it that didn't used to be a main
consideration."

"[A]t one time, I won't say all VA hospitals but a great many of them
used to put out some pretty quality service.  Due to the fact of
budgets .  .  .  congressmen and the presidents who take this away
and this away, they just slowly but surely are stripping it to the
bones to where they can't provide adequate care."

While, generally speaking, VA's quality of care was not the primary
concern voiced by the veterans participating in the discussions, some
veterans were not complimentary about the care offered by VA.  In
particular, continuity of care was a concern for some veterans who
felt they saw different physicians each time they went in for
treatment at VA.  The competence of existing VA physicians coupled
with the perception that VA would not be able to compete with private
sector salaries alarmed several veterans. 

Selected quotations from veterans follow: 

"My experience with the VA tells me that a lot of them are
incompetent to do their job, and overworked."

"People with a military-connected mental problem or a back problem
that was created in the military, they should take care of it.  You
should be able to get excellent care, not this `iffy' care."

"When I first got out of the service, I spent a great deal of time in
the VA hospital .  .  ..  [T]he doctor that I had when I first got
there wasn't the [same] doctor that I had when I left there. 
[C]onsequently, I [had] a lack of confidence in the doctor."

"I go to VA for my service-connected problems .  .  ..  I haven't
really had a problem with care.  It's just .  .  .  that you never
see the same doctor twice.  If you could see the same doctor when you
go into a VA hospital, and they'd follow your case along, it wouldn't
be any big thing, but you never see the same one."

"There doesn't seem to be any continuity in that because you are also
getting a different doctor almost every time you go in there [VA]."

"Universally, the military doctors are young, relatively new out of
school, and you see one and he calls in two others to get some advice
and help from them.  When I went out to the civilian doctors, I [got]
a lot better treatment in .  .  .  a lot less time.  I vote for
civilian doctors compared to military doctors or VA doctors."

"I don't see how the VA can possibly hire competent people .  .  .. 
How can they compete salary-wise with their counterparts in the
private industry?"

Still, in contrast, other veterans offered a generally positive
assessment of VA's care.  In fact, some veterans felt that VA's
quality of care was better than that offered by private sector
providers.  In certain instances, veterans viewed the care

Following are quotations from veterans on these topics: 

"I have found the quality of medical care to be excellent, but the
bureaucracy is a little wearing and the waits are a little
exasperating, but once you get in to see the doctor, they have no
incentive to get you in and out as quickly as possible because they
are not paid on a per capita basis.  So you get really excellent
care.  They are considerate and thorough.  I was pleased."

"The hospital in Reno, for example, my uncle was in there with a
stroke, he couldn't talk.  I walked in the place, I didn't expect to
find much.  The place [could not have been] more spotless.  They
didn't know I was coming.  He was clean .  .  ..  Certainly, I can
say, [from] what I've seen visiting people in the VA hospital[s], the
conditions are very good."

"I've been to Kaiser and UC [University of California] and the VA. 
The biggest difference, of course, [is that] the doctors are better
at the VA.  At UC .  .  .  a private doctor, my own doctor .  .  . 
examines me.  And then [I am turned] over to their teaching people
anyway .  .  .  he [the doctor] is making half-a-million a year; he's
not spending a lot of time with me.  And Kaiser, of course, is an HMO
situation where they're limited by time and .  .  .  have absolutely
no feeling for you.  It's probably the worst situation that I've ever
been in.  As far as the VA is concerned, you do get some bad apples
occasionally, but there you can just stop and get another one."

In summary, although many users of VA services see the need to
decrease scheduling delays and improve customer service and employee
attitudes, these veterans may be well satisfied with other aspects of
VA's health care.  Still, the level of veterans' satisfaction with VA
care does vary significantly by location.  Taken to the extreme, VA
may not be able to offer a seamless provider network across the
country without some cost to VA if certain facilities cannot attract
sufficient veterans to remain viable.  Under health reform, VA's
challenge would be to retain its perceived strengths while moving to
form managed care plans.  This transition might be formidable, in
part because not all of VA's current users endorse the care provided
by managed care plans. 

VETERANS' CONFUSION OVER
ELIGIBILITY AND OTHER BARRIERS
PRECLUDED CURRENT USE OF VA HEALTH
CARE
========================================================== Appendix IV

As discussed in the focus groups, various barriers impeded veterans'
access to VA health care.  Ineligibility for VA care or confusion
over their eligibility for VA care were often cited as contributing
factors.  For example, several veterans who participated in the focus
groups were reluctant to use VA because they did not know whether
they were eligible.  In other instances, veterans who thought that
they might be eligible only clarified their status when they needed
VA services.  More than one focus group participant concluded that
veterans should be more aggressively informed about their benefits. 

Other factors hamper veterans' use of VA as well.  Distance and the
inconvenience associated with using VA were mentioned as
disincentives to using VA.  Past negative experiences with VA were
also discussed as reasons not to use VA.  Some veterans participating
in the focus groups stopped using VA because VA does not currently
offer care for veterans' dependents.  Other veterans said they have a
non-VA primary care physician. 

Selected quotations from veterans follow: 

"I was in the military but I don't know whether I would be covered. 
I don't have any disabilities or anything from the military.  I don't
know whether I'd be eligible for anything through the VA or not. 
I've never really checked on it, to tell you the truth .  .  ..  Some
people say that I am but I don't know how that is."

"Until there is a need present, you know, why go looking for it?  . 
.  .  [I]n my case when I retired I had a very good outbriefing .  . 
.  program .  .  .  and like a good little soldier I ran around and
did all those things .  .  ..  Some of my friends never bothered to
go down and get their physical and see if they had any disabilities
when they very obviously did .  .  ..  If something comes up .  .  . 
they're going to say, `oh yes, that was an old war wound' and that's
when they find out what they are entitled to or what they are not
entitled to."

"When I retired about 5 years ago, someone said to me, `What are you
going to do about your insurance?' So I said, `I don't know.' So they
said `Well, you are a veteran, aren't you?' And I said, `Yes.' So I
called the [VA] and they put me in the computer and I'm more than 50
percent disabled, service-connected, and I was also a prisoner of war
.  .  ..  I am .  .  .  completely, 100 percent covered [for health
care services]."

"The first problem is that when you are coming out of the service . 
.  .  when you are going through the discharge processing they don't
tell you what the VA will do for you."

"My son .  .  .  just got out of the Navy not too long ago .  .  . 
looked at the packet of papers and went phfftt and he tossed them. 
He wasn't going to go until I insisted that he go up to the VA and
get examined .  .  ..  [H]e really didn't know what he was entitled
to because the VA really doesn't advertise a whole lot of what you're
entitled to .  .  .  [H]ow many times do you see something laying
around saying .  .  .  you're entitled to this from the VA?  Where do
you see it laying around .  .  .  unless you go to a VA facility or
one of these little vet centers around here some place?"

"The VA is generally a little bit too far away .  .  .  if you get a
heart attack or a stroke, they're too far away for emergency
treatment.  So, you don't want to mess with them if you've got
insurance."

"I have certain entitlements over at the VA and I choose not to use
them because it is much easier to take care of it in my case with
Blue Cross."

"There are a lot of people right now--myself for example, if I didn't
have some other place to go, I'd have to be on my deathbed before I'd
go to VA.  That's just how bad I feel about the place.  Now how many
other people out there that need treatment that won't go look for
that treatment because they have had a bad experience inside the
system?"

"I would not have myself admitted to this hospital here in town. 
Like you said, you feel like you are going to get sick when you walk
in the door.  You need help when you go in the door there."

"I used the VA until I got married; then when I got married it was
fine for me, but my wife needs insurance, too, and at that time it
was cheaper for both of us to be on a policy than just one of us to
be on the policy."

"I have totally written the VA off because basically I have my own
primary care physician through CompreCare.  Anything I need, I mean,
it is $10 for an office visit.  He will look at me and do whatever
the VA does.  At least I'm guaranteed seeing a doctor."

"I'd just as soon go see my family doctor, someone who deals with me
all the time, than go to the VA."

VA will need to attract a portion of the veterans who currently do
not use its services to be a viable competitor in a reformed health
system.  Certain of the barriers reducing veterans' access to VA can
be addressed fairly readily.  For instance, VA can take steps to
inform veterans of their eligibility for services.  Other solutions,
such as establishing satellite clinics to reduce the distance
veterans travel, may require legislative and budgetary actions. 
Still, overcoming other obstacles, such as past negative experiences,
may be more difficult.  Without an aggressive strategy to allay these
concerns, VA may not be able to maintain a competitive role in health
reform. 

VETERANS WERE UNSURE ABOUT VA'S
ROLE IN A REFORMED HEALTH SYSTEM
=========================================================== Appendix V

Veterans participating in our focus groups expressed widely ranging
views on whether VA should (1) remain a separate system or become a
payer of veterans' care, (2) offer general health care services or
specialized care to veterans, and (3) serve veterans' dependents. 

   VETERANS WERE APPREHENSIVE THAT
   CHANGES TO VA WOULD DIMINISH
   BENEFITS
--------------------------------------------------------- Appendix V:1

Apprehension that change would diminish the commitment to veterans'
health needs was a recurrent theme in the focus groups.  Some
veterans were concerned that the incidence of time-delayed,
service-related conditions, such as illnesses related to exposure to
Agent Orange, would not be monitored without a separate VA.  In their
view, payments for service-related conditions could be adversely
affected as well. 

Some veterans in the focus groups thought that VA should not be
involved in health reform.  Others saw the proposed changes as an
effort to fortify a declining VA at some cost to veterans.  These
veterans thought that VA should concentrate on treating veterans,
particularly in light of the limited resources constraining VA care
today.  Generally, these veterans expressed a desire to maintain
separate VA health care facilities under health reform, regardless of
whether they would select VA as a provider of care, seeing it as a
tangible symbol of the nation's commitment to its veterans. 

Quotations from veterans on these topics follow: 

"If we take the VA away, what else is next?  They are trying to lump
us all in with everybody now that have never went to war, never got
hurt .  .  ..  I feel like you [have to] keep the veterans' benefits
separate.  If they don't, we're going to lose them."

"It's my opinion that as things do get changed around like that,
where outside facilities are open to the veterans, then the VA
hospitals are going to be open to people from the outside, too.  And
surely little by little we'll just be phased right out of the VA .  . 
..  I for one would just like to keep the VA for the veterans."

"VA should stay the same as it is now and they should not allow
civilians to be in it because for one thing it's going to put too
much of a burden on the facilities now, which means that the veteran
would get less care."

"VA .  .  .  shouldn't become part of any national plan, it should
remain separate and along with the national plan the veterans should
be treated just like everybody else, but the VA is always there for
the veteran."

"We don't know what effect those chemicals are going to have on those
guys [Persian Gulf veterans] 20 years from now."

"If you're going to throw us [the veterans] into a plan like this,
what's going to happen to the disability ratings .  .  .  they should
only go up as your injuries that you received in a war get worse .  . 
.  .  You don't know, just like anyone here, what's going to happen
20 years down the road from what happened when you were in a war."

"I think emotionally it would hurt one group--a group of veterans
that have been dependent [on VA].  That's their security, and I think
it would be devastating to those people that have been using VA all
along."

"I don't think they [veterans] are psychologically or emotionally
attached to the VA.  They are attached to the care provided at a
certain cost to them, which is probably zero.  As long as you keep
providing good care at that cost, I don't see that there would be any
trauma at all."

"This sounds to me like some VA agency has been told we're going to
decide whether the VA is going to exist or not.  And somebody is
trying to justify their existence."

"It comes back down to the basics where we served our country, we
deserve to be separated from the whole country .  .  ..  I don't know
what kind of health plan they'll come up with.  Yes, it's great that
they are, but I still feel veterans should have their own health
coverage, their own facilities, because they did serve their country
and they are unique .  .  .  in treatment and everything else.  Even
though I might not be part of it."

   VETERANS BELIEVED THEY DESERVE
   HEALTH CARE BUT EXAMINED VA AS
   A PROVIDER OF CARE
--------------------------------------------------------- Appendix V:2

As shown in the following quotations, some veterans suggested that VA
should no longer provide care directly to veterans, but merely pay
for their care.  While some believed that VA could be vulnerable to
budget cuts if it no longer provides services directly to veterans,
there was a perception that commitment to the veteran is at risk if
the VA remains separate from health care reform. 

"If the VA would close all the hospitals and get rid of all their
staff, they could afford to send us to a civilian hospital where we
would get some good care and a cheerful atmosphere."

"I think it is important to still draw the distinction between the
responsibility to take care of conditions caused by activities that
you participate in for the government versus having the Veterans
Administration provide those services."

"The government should take care of them, but that doesn't
necessarily mean that it has to build a hospital to take care of
them.  They should pay for the cure or the treatment, but not
necessarily build the building to do it in."

"I think it is also a tendency, in my point of view, to make veterans
look like they are something abnormal.  They are not mixed in with
the general population.  They want to set them aside in a specific
facility.  They [veterans] will do much better .  .  .  [if they are
put] in with the general population.  The government can pay for the
care, but let them be treated like any other person in the country."

"There is a commitment to the people in this room who went into the
military .  .  .  the VA was going to be there to take care of those,
and the country owes that to the people that served .  .  .. 
[C]ontracting [VA services] out puts that at risk."

"As you get further away from a war or whatever, they tend to forget. 
That is why you don't get support from the politicians.  If you are
in a segregated system where the rest of the public doesn't benefit,
they soon forget that they need to keep that up .  .  ..  It [VA]
needs to be part of the mainstream.  We need to be part of everybody
else, which we are in every day life, so why in this particular
aspect should we segregate ourselves?"

   FUTURE LEVEL AND EXTENT OF VA'S
   SERVICES WAS DEBATED
--------------------------------------------------------- Appendix V:3

Certain veterans in the focus groups had a hard time viewing VA as a
general health care provider because veterans see VA as primarily for
treatment of their service-connected illnesses.  Veterans believed
that VA should care for those veterans who are dependent on VA and
who will need care from VA in the future.  Certain veterans believed
that VA should improve the care rendered for service-connected
problems before expanding the scope of its responsibilities. 

Some veterans believed that a separate VA should offer specialized
care to veterans but that veterans' general health care needs could
be met by other providers.  Other veterans saw VA's role primarily as
a keeper of medical records to establish service-connected
conditions. 

Selected quotations from the focus groups follow: 

"My orientation [is] that the VA is available for me on
service-connected situations."

"We're all kind of talking about it, but it doesn't seem to be a
place you'd go for general medicine."

"We've been discussing the VA's role in health care reform.  The VA
is going to make some changes, they're going to do something. 
Whatever they finally decide to do, if they look at it from the most
needy vet in the system, the guy who needs the services the VA
provides more than anybody else, .  .  .  .  [h]e should be taken
care of.  And as long as they do that, then everybody else will fall
in line behind that.  Whatever they do, the vets need to be taken
care of."

"What VA is supposed to do was administer veterans affairs programs
for the U.S.  government .  .  ..  [T]hey need to get their act
together doing what they're supposed to do before we start talking
about them taking on additional responsibilities."

"The average stuff could be pretty well contracted out and subsidized
through other insurance companies with government assistance.  I
think the VA should lead on the specific diseases .  .  .  that are
not covered by your normal, every day health plan."

"That is why you have to have the Veterans Administration to maintain
the records on these people so they know what happened to the
veterans while they were on active duty and then provide the medical
care through other services, not through the veteran hospital."

   VA'S ABILITY TO CARE FOR
   VETERANS' DEPENDENTS WAS
   QUESTIONED
--------------------------------------------------------- Appendix V:4

The topic of VA offering dependent care elicited a range of
responses.  Some of the participating veterans were strongly opposed
to VA offering dependent care.  In contrast, other veterans thought
that VA would have to offer dependent care to attract veterans with
families to VA.  Some of those veterans, however, thought that VA
would be unable to meet the needs of the family or that dependents
would be uncomfortable seeking care at VA.  One proposal that
elicited a favorable response from these veterans was the option that
VA provide care for the veterans and offer contract care for
veterans' dependents. 

Selected quotations on this topic include the following: 

"I adamantly stand against the use of Veterans Administration
hospitals and facilities by the general public .  .  .  [i]ncluding
vet families.  The VA was created to take care of the individuals who
bore the brunt of the battle, not for my wife and not for my kids."

"I don't think a veteran would particularly want to split his family
up .  .  ..  The veteran .  .  .  is going to go with his family."

"Almost everybody here is a family man .  .  ..  So you have got to
take
into .  .  .  [account] your spouse, your offspring.  And the thing
is that if you are saying, well, you're going to have to make one
decision, are you saying we make that one decision just for our
personal needs?  Or are we making them for our family's needs? 
Because for family's needs, if it's our family needs, `Bye-bye VA,'
because I've got to take care of my family."

"I'd go back to the VA, but I don't think they're equipped to handle
the problems that my family has.  I don't think they're equipped to
handle the problems that my daughters have and that my wife has.  I
don't think they have the technology."

"Can you imagine taking your kid into the waiting room?"

"I couldn't understand why family members would want to go to a VA
hospital .  .  ..  The VA is still geared to the veteran and is more
.  .  .  a military type hospital.  I don't think a lot of what you'd
call civilians would really feel that comfortable going there."

"If they really want families to come in, they are going to have to
change the attitude of the wives that are already around because my
wife wouldn't go down there."

VETERANS' SELECTION OF VA WOULD
DEPEND ON SHAPE OF HEALTH CARE
REFORM AND EXTENT OF VA'S CHANGES
========================================================== Appendix VI

Veterans in the focus groups discussed various factors they would
consider when evaluating VA as a possible health care provider.  The
types of services offered by VA compared with those of other
providers as well as the associated out-of-pocket costs were
prominently featured in those discussions.  Others thought veterans
would be inclined to select VA if their disability compensation would
be affected. 

Some veterans mentioned that the changes VA implements to compete in
health reform would be important considerations.  Focus group
participants suggested that VA would have to improve customer
service, invest in modern equipment and new technologies, and improve
the level of amenities to compete with the private sector.  Other
veterans suggested that VA would have to establish clinics or
satellite offices to reduce the distance and travel time for them to
get care at VA.  Certain veterans suggested that VA would have to
improve its image, initiate marketing efforts, and implement other
changes to its business practices to become competitive. 

On the other end of the spectrum, certain veterans in the focus
groups said that they would not consider VA as a health provider
regardless of the services offered or the changes implemented.  In
part, their reluctance stems from a sense of uncertainty about
whether VA will make sufficient improvements to become a competitive
health provider. 

Selected quotations from the focus groups follow: 

"If they [VA] offer the same care but they offered more than what the
general population got, then the veteran would say yes."

"If they said the only way you get your VA disability is by coming to
the VA hospital, man, they would be so swamped they wouldn't be able
to keep up with it."

"If I choose to go on the outside versus the VA, what happens to my
compensation?  Does that get cut off?"

"I would be willing to bet that there are vets out there that would
be willing to do a copayment type situation like CompreCare [a local
preferred provider organization] does if the VA could expand its
services and give it to them .  .  .  and if you would get halfway
decent care."

"They have to treat you like a human being when you go down there [to
VA]."

"If the customer service was there in the VA, I would prefer to be
there .  .  ..  Management from the administrative side, not the
medical side, needs to get improved."

"Even if I knew I could get as good a care in a VA hospital as I
could at Lutheran Medical Center [a local hospital], I wouldn't go to
the VA because the interior of it is terrible.  There is no
atmosphere to make you want to get better.  It makes you want to
die."

"I think it's a lot better now .  .  ..  But I think it's outdated."

"I personally would have to say that they're [VA's technology]
prehistoric .  .  ..  Hammer and chisel."

"If I was close to a VA hospital, I wouldn't go near anybody else. 
I'd stay with the VA."

"For the VA to get into contention as a runner in this business of
providing health care to the people out there, it's going to have to
improve its image."

"They just have to change the way they do business in terms of
looking at what is succeeding in other HMOs and other places and
taking some of the stuff that private industry is doing to economize
in the way they are delivering medical care to people and take some
of those practices and transport it to the VA."

"I would try to make sure that my local administration had some kind
of autonomy to service their [veterans] populations."

"To put it in perspective, [VA has] a bad reputation and a bad rap to
deal with right off the bat .  .  ..  Nobody would pick them right
now, all things being equal.  Is the government going to put all that
money in to build up all these facilities to compete with the others
and then have nobody choose it?  That is my question."

"We know the amount of federal funds that are spent on these VA and
military hospitals today; how is it that the government can say that
they can make these VA hospitals competitive with private industry . 
.  .  when they haven't done it already?"

"They [veterans] would have to be guaranteed that the VA is going to
upgrade its services.  As long as the VA is funded by the government,
we just don't have enough trust in the government to expect that to
happen."

"I would not go to the VA if it became like an ordinary place .  .  . 
a one-size-fits-all institution .  .  .  trying to provide services
to everybody and cater to everybody's needs .  .  ..  I just don't
think I would go there."

"They couldn't [attract veterans].  If the veterans were fully
informed about what an HMO is, then the VA would just be another
competitor.  Some might choose, because of the name, .  .  . 
convenience, .  .  .  location, but otherwise, they would simply be
on the horizon with two or three others in a given community."

"[O]ne thing I would wonder about is how much assurance is there that
the VA hospital system would continue to be in operation, readily
available to veterans everywhere .  .  ..  I've watched Public Health
Service hospitals get closed down; I've watched military hospitals
get closed down, .  .  .  every time that happens, if you've been a
part of that system and have needed the care, you're left floundering
for a while .  .  ..  I would be a little reluctant to go to another
system where I wasn't really sure that maybe because fewer and fewer
veterans were going into the system five years from now they might . 
.  .  close that down and you'd end up starting all over again from
scratch trying to find somebody to take care of you."

GAO CONTACTS
AND STAFF
ACKNOWLEDGMENTS
========================================================= Appendix VII

GAO CONTACTS

Jim Linz, Assistant Director, (202) 512-7116
Sibyl Tilson, Senior Evaluator, (202) 512-7161

ACKNOWLEDGMENTS

In addition to those named above, the following individuals made
important contributions to this report:  Linda Diggs set up focus
group meetings, analyzed transcripts, and wrote sections of the
report; Michael O'Dell and Edward Murphy moderated focus group
meetings and assisted with analysis of transcripts; and Clarita Mrena
moderated focus group meetings. 

RELATED GAO PRODUCTS
============================================================ Chapter 0

Veterans' Health Care:  Use of VA Services by Medicare-Eligible
Veterans (GAO/HEHS-95-13, Oct.  24, 1994). 

Veterans' Health Care:  Implications of Other Countries' Reforms for
the United States (GAO/HEHS-94-210BR, Sept.  27, 1994). 

Health Security Act:  Analysis of Veterans' Health Care Provisions
(GAO/HEHS-94-205FS, July 15, 1994). 

Veterans' Health Care:  Efforts to Make VA Competitive May Create
Significant Risks (GAO/T-HEHS-94-197, June 29, 1994). 

VA Health Care:  VA and the Health Security Act (GAO/HEHS-94-159R,
May 9, 1994). 

VA Health Care Reform:  Financial Implications of the Proposed Health
Security Act (GAO/T-HEHS-94-148, May 5, 1994). 

VA Health Care:  Most Care Provided Through Non-VA Programs
(GAO/HEHS-94-104BR, Apr.  25, 1994). 

Veterans' Health Care:  Veterans' Perceptions of VA Services and Its
Role in Health Care Reform (GAO/T-HEHS-94-150, Apr.  20, 1994). 

VA Health Care:  A Profile of Veterans Using VA Medical Centers in
1991 (GAO/HEHS-94-113FS, Mar.  29, 1994). 

VA Health Care:  Comparison of VA Benefits With Other Public and
Private Programs (GAO/HRD-93-94, July 29, 1993). 

Veterans Affairs:  Accessibility of Outpatient Care at VA Medical
Centers (GAO/T-HRD-93-29, July 21, 1993). 

VA Health Care:  Variabilities in Outpatient Care Eligibility and
Rationing Decisions (GAO/HRD-93-106, July 16, 1993). 

VA Health Care:  Veterans' Efforts to Obtain Outpatient Care From
Alternative Sources (GAO/HRD-93-123, June 30, 1993). 

Veterans' Health Care:  Potential Effects of Health Care Reforms on
VA's Major Construction Program (GAO/T-HRD-93-19, May 6, 1993). 

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