ROLE OF THE DEPARTMENT OF VETERANS
AFFAIRS IN THE NATIONAL HEALTH CARE
DELIVERY SYSTEM
HEARING
BEFORE THE
SUBCOMMITTEE ON
HOSPITALS AND HEALTH CARE
COMMITTEE ON VETERANS’ AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRD CONGRESS
FIRST SESSION
APRIL 28, 1993
Printed for the use of the Committee on Veterans’ Affairs
Serial No. 103-9
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U.S. GOVERNMENT PRINTING OFFICE
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46-4COMMITTEE ON VETERANS’ AFFAIRS
GY. (SONNY) MONTGOMERY, Mississippi, Chairman
DON EDWARDS, California, Vice Chairman
DOUGLAS APPLEGATE, Ohio
LANE EVANS, Illinois
TIMOTHY J. PENNY, Minnesota
J. ROY ROWLAND, Georgia
JIM SLATTERY, Kansas
JOSEPH P. KENNEDY II, Massachusetts
GEORGE E. SANGMEISTER, Illinois
JILL L. LONG, Indiana
CHET EDWARDS, Texas
MAXINE WATERS, California
BOB CLEMENT, Tennessee
BOB FILNER, California
FRANK TEJEDA, Texas
LUIS V. GUTIERREZ, Iinois
SCOTTY BAESLER, Kentucky
SANFORD BISHOP, Georgia
JAMES E. CLYBURN, South Carolina
‘MIKE KREIDLER, Washington
CORRINE BROWN, Florida
BOB STUMP, Arizona
CHRISTOPHER H. SMITH, New Jersey
DAN BURTON, Indiana
MICHAEL BILIRAKIS, Florida
THOMAS J. RIDGE, Pennsylvania
FLOYD SPENCE, South Carolina
‘TIM HUTCHINSON, Arkansas
TERRY EVERETT, Alabama
STEVE BUYER, Indiana
JACK QUINN, New York
SPENCER BACHUS, Alabama
JOHN LINDER, Georgia
CLIFF STEARNS, Florida
PETER T. KING, New York
‘Mack FLEMING, Staff Director and Chief Counsel
SUBCOMMITTEE ON HOSPITALS AND HEALTH CARE
J. ROY ROWLAND, Georgia, Chairman
DOUGLAS APPLEGATE, Ohio, Vice
‘Chairman
JOSEPH P. KENNEDY, II, Massachusetts
JILL L. LONG, Indiana
CHET EDWARDS, Texas
BOB CLEMENT, Tennessee
BOB FILNER, California
FRANK TEJEDA, Texas
LUIS V. GUTIERREZ, Illinois
SCOTTY BAESLER, Kentucky
SANFORD BISHOP, Georgia
MIKE KREIDLER, Washington
CORRINE BROWN, Florida
CHRISTOPHER H. SMITH, New Jersey
BOB STUMP, Arizona
DAN BURTON, Indiana
MICHAEL BILIRAKIS, Flor
TIM HUTCHINSON, Arkant
TERRY EVERETT, Alabama
STEVE BUYER, Indiana
JOHN LINDER, Georgia
(a)CONTENTS
April 28, 1993
Role of the Department of Veterans Affairs in the National Health Care
Delivery System .
OPENING STATEMENTS
Chairman Rowland . 1
Christopher H. Smith 4
Hon. Joseph P. Kennedy II .. 68
Hon. Corrine Brown ... 67
WITNESSES
Abrass, M.D., Itamar B., Chair, VA Geriatrics and Advisory
Committee ‘and Professor of Medicine and Head, Division of Gerontology
and Geriatric Medicine, University of Washington “4
14(
Prepared statement of Dr. Abrass
Brinck, Michael, Director of Veterans Service/Legisiation, AMVETS, accom-
panied by Noel Woosley, National Service Director
Prepared statement of Mr. Brinck
Brown, Jr, M.D., D. Earl, ABT Associates and former Associate Deputy
Chief Medical Director, Department of Veterans Affairs 43
Prepared statement of Dr, Brown 148
Burrow, M.D., Gerard N., Associati
Dean, Yale University School of Medicine .. 43
Prepared statement of Dr. Burrow 134
Cullinan, Dennis, Assistant Director,
of Foreign Wars 6
Prepared state 82
Egan, Paul, Executive Director, Vietnam a1
Prepared statement of Mr. Egan 109
Gorman, David, Assistant National
Disabled American Veterans 1
Prepared statement of Mr. Gormai 90
Hanson, John, Director, National Veter:
migsion, The American Legion 2
Prepared statement of Mr. Hanson. 69
Malphura, Fred, Director, VA Medical Center, Albany, 5B
Mansfield, Gordon, Executive Director, Paralyzed Veterans of 4
Ranpierared statement of Mr. Mansfield .. 73
Randall, Malcom Director, VA Medical Center, 87
Rockefeller IV, Hon. John D., Chairman, Committee on Veterans’
United States Senate u
Shine, M.D., Kenneth I, President, National Institute of Medicine 46
Prepared statement of Dr. Shine 142
Williams, Charles, Executive Director, American Bx-Prisoners of War 33
Prepared statement of Mr. Williams 128
Zamberlan, Al, Director, Central Region, Veterans Health Adminisération,
Department of Veterans Affairs .. 59
(qm)Statements:
Blinded Veterans Association
Air Force Sergeants Association
Written committee questions and the
Congressman Smith to Gordon
‘Medicine
Chairman Rowland to Gerard H. Burrow, M1
of Medicine ....
Congressman Sinith to Gerard #.‘Burrow, Mf.
‘Yale University School
sian Smith to D, Barl Brown, Jr, M. ABT “Associate
Chairman Rowland to Al Zamberlan, Centrs
Administration, Department of Veterans Affairs
Congressman Smith to Al Zamberlan, Central Re;
istration, Department of Veterans Affairs
Rowland to Malcolm Randall, VA Med
FL
Congressman Smith to Malcolm Randall, VA Medical Center, Gainesville,
Chairman Rowland to Fred Maiphure, VA Medical Center, Albany, NY
Congressman Smith to Fred Mal rau, VA Medical Centet, albany, NY
essman Smith Paul Egan, Vietnam Veterans of America
Chairman Rowland to American Ex-Prisoners of War .
Chairman Rowland to John A. Talbott, M.D.
154ROLE OF THE DEPARTMENT OF VETERANS
AFFAIRS IN THE NATIONAL HEALTH CARE
DELIVERY SYSTEM
WEDNESDAY, APRIL 28, 1993
HOUSE OF REPRESENTATIVES,
SUBCOMMITTEE ON HOSPITALS AND HEALTH CARE,
COMMITTEE ON VETERANS’ AFFAIRS,
Washington, DC.
The subcommittee met, pursuant to call, at 9:37 a.m., in room
334, Cannon House Office Building, Hon. J. Roy Rowland (chair-
man of the subcommittee), presiding.
Present: Representatives Rowland, Kennedy, Long, Edwards of
Texas, Filner, Tejeda, Gutierrez, Baesler, Bishop, Kreidler, Brown,
Smith, Bilirakis, Hutchinson, Everett, Buyer, and Linder.
OPENING STATEMENT OF CHAIRMAN ROWLAND
Mr, ROWLAND. ing now to the subject of our hearing, all of
us, I’m sure, await with great interest submission of the Presi-
dent’s proposal for comprehensive health reform.
Certainly our hearings have underscored that proposal that envi-
sions far-reaching change and, with it, both challenges and oppor-
tunities for the VA health care system.
At one time there was a concern that the development of this re-
form proposal might simply ignore the VA health care system. That
concern has been allayed.
The First Lady herself has made it clear to Chairmen Rocke-
feller, Montgomery, and myself that the President’s proposal will
address VA health care and will assure the independence of the VA
health care system. She has given the same assurances to the vet-
erans’ service organizations.
I feel that all of us who pressed to have VA play a role in shap-
ing this reform are very pleased that Secretary Brown has been
serving on the White House task force, and that more than 30 VA
staffers are participating in the supporting work groups.
Notwithstanding the extent of VA’s participation, I know that the
President will not want to send up this legislation without knowing
that there’s support for it in the veterans’ arena.
So this hearing provides us an important vehicle to identify the
principles against which the President can gauge whatever specific
proposal for VA emerges from his task force. Similarly, the hearing
can provide our committee a basis against which to gauge the
President’s proposal.
reo)2
I look forward to gaining several important perspectives this
morning: most importantly, from the representatives of those who
rely on the VA system; from academicians and who have
worked in, or in affiliation with, the VA; and, lastly, from among
highly experienced, successful managers of VA facilities.
As we Preeeed on this important course, I’m delighted that the
Senate’s leading health care expert and leading veterans’ advocate,
Senator Jay Rockefeller, the chairman of the Senate Veterans’ Af-
fairs Committee, I hope will join us as a witness today. And if he
comes in during the testimony of other witnesses, we would ask
your indulgence that he be allowed to testify at that time.
So I want to welcome all of you here this morning to this hear-
ing, and we'll call our first panel now to the witness table: Mr.
John Hanson, who is director of national veterans affairs—one mo-
ment before I do that.
Well, I'll go ahead and call the witnesses up to the table: Mr.
John Hanson, director of national veterans Affairs and rehabilita-
tion commission from the American Legion; Mr. Gordon Mansfield,
executive director of Paralyzed Veterans of America; Mr. Dennis
Cullinan, assistant director, national legislative service, Veterans
of Foreign Wars; and Mr. David Gorman, assistant national legisla-
tive director for medical Affairs of Disabled American Veterans.
Is there anyone here is that making an opening statement at this
hearing this morning, any members desire to be heard?
(No response.)
Mr. ROWLAND. If not, then we will proceed with the testimony
from the witnesses. We're going to limit, if you will, 5 minutes to
statements. So you can submit your statement for the record and
try to summarize, if you can, within that period of time.
‘Mr. Hanson, you’re recognized. Proceed as you so desire.
STATEMENTS OF JOHN HANSON, DIRECTOR, NATIONAL VET-
ERANS AFFAIRS AND REHABILITATION COMMISSION, THE
AMERICAN LEGION; GORDON MANSFIELD, EXECUTIVE DI-
RECTOR, PARALYZED VETERANS OF AMERICA; DENNIS
CULLINAN, ASSISTANT DIRECTOR, NATIONAL LEGISLATIVE
SERVICE, VETERANS OF FOREIGN WARS; DAVID GORMAN,
ASSISTANT NATIONAL LEGISLATIVE DIRECTOR FOR MEDI-
CAL AFFAIRS, DISABLED AMERICAN VETERANS
STATEMENT OF JOHN HANSON
Mr. Hanson, Thank you, Mr. Chairman, for the chance to come
here this morning to talk about the potential role of the Depart-
ment of Veterans Affairs in any future national health care
program.
The American Legion believes that there is a role for the VA
health care system in any plan that’s proposed by the President.
And while we have been assured by members of the task force look-
ing at health care reform that VA will continue to exist as an inde-
pendent health care delivery network, we're concerned about the
shape VA’s health care delivery system might be asked to take in
tne atnber of have been talking about global bud
number of experts have been talking about glol geting
and for health care in general and speculating that global budget-3
ing and spending caps would drive the costs of health care down.
‘Well, as you know, VA’s Veterans Health Administration has been
forced to use global budgeting and spending caps for a number of
years.
Those of us who monitor VA health care know that such dollar
constraints do force health care systems to be more efficient, but
to accomplish this efficiency, sometimes the price is paid.
All the corners must be cut. Sometimes other medical programs
are cannibalized. And the ultimate choice in our minds is the pros-
pect that this drive for efficiency and lower cost could lead to a ra-
tioning of health care.
As you know, Mr. Chairman, fewer veterans are being treated at
VA. The cost of care that’s delivered keeps escalating. Because the
VA has had so much rience in this environment, a universal
‘lobal budgeting approach might give VA a slight advantage in de-
ivering health care.
But we feel that it could lead to a rationing of health care for
all Americans, and that could further reduce the number of veter-
ans who receive medical care at VA facilities and elsewhere.
As far as managed competition goes, we feel that if the health
care playing field were level, VA could perform well and compete
for le seeking health care. We know that as the Nation’s larg-
est health care deliverer, VA has experience in providing healt
care to a range of people across the country.
Our lessons learned by VA could be invaluable to planners look-
ing at a national system for all Americans. But for VA to compete,
we've got to look at how it operates now and how its current pa-
tient load will be handled by the Federal Government.
As each of you knows, the majority of patients at VA receive care
because they've fallen into a mandatory service category. A large
number of others receive long-term nursing home care, the kind of
care that might or might not be addressed by the health care re-
form task force.
The American Legion is convinced that these categories of veter-
ans must continue to be served by VA, but that a number of our
veterans, other veterans, should also be served. I'm speaking, of
course, about veterans who use Medicare or other federal health
care programs to poy, for their health care.
The American Legion is happy to be working with the Disabled
American Veterans, the Veterans of Foreign Wars to develop what
we consider to be an appropriate role for VA in national health
care.
On the Legion’s part, our recommendations have been published
and circulated to all of you in the form of our gold book on VA
health care. Briefly we think that service-connected disabled or
medically indigent veterans should continue to receive care, but re-
ceive all of their care at VA hospitals.
Furthermore, we recommend that Medicare, Medicaid, and other
federally mandated health care funders should be permitted to pay
VA for the cost of health care for veterans who are not service-con-
nected disabled and who would be using the federal programs for
their medical and pharmaceutical needs anyway.
For veterans without a federal entitlement, we recommend that
non-service connected disabled veterans should be able to choose to4
go to VA if they want to. These veterans would then pay for their
care by using whatever resources they would use for their health
care, either their own private insurance or their own funds.
Further, Mr. Chairman, we think that given the chance, VA
would be able to compete with other health care providers. We
don’t deny that some mistakes have been made at some facilities
across the country, but we don’t know about the mistakes that pri-
vate hospitals have made. And we don’t want to overlook the tre-
mendous medical discoveries and procedures that the VA has pio-
neered that have benefitted all Americans.
Mr. Chairman, VA has shown an uncanny ability to keep costs
low while delivering a good health care product. We're certain that
VA's experience can lead a number of hospitals to use the lessons
learned and other ideas to cut their costs where possible.
What we feel most, though, is the notion it the VA should
somehow revert to a narrowly specialized service deliverer, there
would be very few veterans who could use those services.
The way TA in pioneering prosthetic research, blind rehabilita-
tion, and long-term nursing home care can’t be overstated, but nei-
ther can we Jump to the conclusion that those functions will be all
the VA has to offer in the future.
We want to use this opportunity to commend Secretary Brown
for insisting that VA be an active player in the health care task
force that is prapping up its work, we hope, in the next few weeks.
And we want to e First Lady for her commitment to a con-
tinued and strong role for VA in health care across this Nation.
_ That concludes our statement, Mr. Chairman. Thanks for your
e.
[The prepared statement of Mr. Hanson appears on p. 69.]
Mr. RowLanp. Thank you very much.
Mr. Mansfield.
STATEMENT OF GORDON MANSFIELD
Mr. MANSFIELD. Thank you, Mr. Chairman. The Paralyzed Veter-
ans of America would like to thank you for your continuing advo-
cacy for a viable VA health care system.
erhaps the best place to start is to outline my understanding
of what Mrs. Clinton said at the White House meeting, which was
that the VA would continue to be a national independent system,
that there would be a basic package of benefits provided, there
would be portability, the system would have to be economic, and
there would be some competition involved.
I think we ought to realize that the VA system currently and
probably in the future will continue to have a responsibility of
ing the DOD backup. It is a research asset that should be contin-
ued.
There's a health care education factor that has to be factored into
the overall plan; i.e., the VA has educated approximately 50 per-
cent of the medical care professionals in this country. And the VA
has the only national specialized medicine system, for example, in
spinal cord injury.
I would refer the committee to the full testimony, which outlines
Fvas Strategy 2000, directed by Dr. Custis and presented pre-
viously.5
I think we have to understand that as we move into this new
system, PVA believes that there are some elements that need to be
considered and are priorities. The first is entitlement reform, and
that includes a core entitlement group, which should include the
service-connected and other currently statutorily entitled veterans,
catastrophically disabled non-service connected veterans, and the
non-service connected veterans who are poor. The VA also should
be required to provide a full continuum of care, and there should
be a capitated funding mechanism.
The role of the VA in the new environment would include it
being in competition with AHPs. To do that, we believe there
should be a level playing field. This requires that there should be
adequate fiscal support, as a congressional obligation to provide the
veterans a capitation budget based on obligation to the system
users, that we should remember that the VA is not a for-profit pro-
vider nor the beneficiary of charitable or community support.
We should ensure that the infrastructure of the VA is taken care
of in that it must be perceived as a comparable provider to be com-
petitive. This requires contemporary equipment, facilities that are
up to date, adequate clinic space, good maintenance, and patient
amenities. The staffing needs to be adequate in both numbers and
skills to be competitive in timeliness and quality of service.
There should be a maintenance of affiliations which requires a
balance of programs which attract a range of patients in order to
support a range of residency programs and try to maintain top
quality health manpower.
In addition, we believe there should be operational streamlining,
which would reduce the waiting time, both in clinics and for ap-
pointments. We should attempt to minimize administrative re-
quirements and procedures. We need an ability to meet accounting
and reporting requirements that exist in the AHP environment.
In addition, there are parts of the system that are going to have
to be put in place that don’t currently exist. For example, in addi-
tion to being able to account for the cost for each veteran client,
we may need to look at a marketing capability.
Based on this, we believe that the incentives that are needed to
make the VA a player in the new national system demand that the
entitlement for the core group have unrestricted access to VA
health care so that the VA can provide medicine as other providers
do, that the full continuum of care be provided, and that access to
specialized services; i.e., for those veterans in the non-core group
or others, be provided.
Mr. Chairman, I think that the basic line here, as we all recog-
nize, we're moving into a new environment. We want to see the VA
continue to be a major player in this environment. And we want
to see the VA be able to carry out the commitment this country has
to its veterans.
Thank you.
[The prepared statement of Mr. Mansfield appears on p. 73.]
Mr. RowLanp. Thank you, Mr. Mansfield.
Mr. Cullinan.