    [House Hearing, 106 Congress]
    [From the U.S. Government Publishing Office]

                      VA HEALTHCARE IN THE NEXT MILLENNIUM

    =======================================================================

                                    HEARING

                                   before the

                       SUBCOMMITTEE ON NATIONAL SECURITY,
                      VETERANS AFFAIRS, AND INTERNATIONAL
                                   RELATIONS

                                     of the

                                  COMMITTEE ON
                               GOVERNMENT REFORM

                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED SIXTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 APRIL 10, 2000

                                   __________

                               Serial No. 106-190

                                   __________

           Printed for the use of the Committee on Government Reform

      Available via the World Wide Web: http://www.gpo.gov/congress/house
                          http://www.house.gov/reform

                       U.S. GOVERNMENT PRINTING OFFICE
    70-278                     WASHINGTON : 2001

    _______________________________________________________________________
     For sale by the Superintendent of Documents, U.S. Government Printing
                                     Office
    Internet: bookstore.gpo.gov  Phone: (202) 512-1800  Fax: (202) 512-2250
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                         COMMITTEE ON GOVERNMENT REFORM

                         DAN BURTON, Indiana, Chairman
    BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
    CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
    CHRISTOPHER SHAYS, Connecticut       ROBERT E. WISE, Jr., West Virginia
    ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
    JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
    STEPHEN HORN, California             PAUL E. KANJORSKI, Pennsylvania
    JOHN L. MICA, Florida                PATSY T. MINK, Hawaii
    THOMAS M. DAVIS, Virginia            CAROLYN B. MALONEY, New York
    DAVID M. McINTOSH, Indiana           ELEANOR HOLMES NORTON, Washington,
    MARK E. SOUDER, Indiana                  DC
    JOE SCARBOROUGH, Florida             CHAKA FATTAH, Pennsylvania
    STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
    MARSHALL ``MARK'' SANFORD, South     DENNIS J. KUCINICH, Ohio
        Carolina                         ROD R. BLAGOJEVICH, Illinois
    BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
    DAN MILLER, Florida                  JOHN F. TIERNEY, Massachusetts
    ASA HUTCHINSON, Arkansas             JIM TURNER, Texas
    LEE TERRY, Nebraska                  THOMAS H. ALLEN, Maine
    JUDY BIGGERT, Illinois               HAROLD E. FORD, Jr., Tennessee
    GREG WALDEN, Oregon                  JANICE D. SCHAKOWSKY, Illinois
    DOUG OSE, California                             ------
    PAUL RYAN, Wisconsin                 BERNARD SANDERS, Vermont
    HELEN CHENOWETH-HAGE, Idaho              (Independent)
    DAVID VITTER, Louisiana

                          Kevin Binger, Staff Director
                     Daniel R. Moll, Deputy Staff Director
               David A. Kass, Deputy Counsel and Parliamentarian
                        Lisa Smith Arafune, Chief Clerk
                     Phil Schiliro, Minority Staff Director
                                     ------

    Subcommittee on National Security, Veterans Affairs, and International
                                   Relations

                    CHRISTOPHER SHAYS, Connecticut, Chairman
    MARK E. SOUDER, Indiana              ROD R. BLAGOJEVICH, Illinois
    ILEANA ROS-LEHTINEN, Florida         TOM LANTOS, California
    JOHN M. McHUGH, New York             ROBERT E. WISE, Jr., West Virginia
    JOHN L. MICA, Florida                JOHN F. TIERNEY, Massachusetts
    DAVID M. McINTOSH, Indiana           THOMAS H. ALLEN, Maine
    MARSHALL ``MARK'' SANFORD, South     EDOLPHUS TOWNS, New York
        Carolina                         BERNARD SANDERS, Vermont
    LEE TERRY, Nebraska                      (Independent)
    JUDY BIGGERT, Illinois               JANICE D. SCHAKOWSKY, Illinois
    HELEN CHENOWETH-HAGE, Idaho

                                   Ex Officio

    DAN BURTON, Indiana                  HENRY A. WAXMAN, California
                Lawrence J. Halloran, Staff Director and Counsel
                  Kristine McElroy, Professional Staff Member
                               Jason Chung, Clerk
                        David Rapallo, Minority Counsel

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on April 10, 2000...................................     1
    Statement of:
        Martineau, Jean-Guy, director of Veterans Services, city of
          Salem; Donald T. Welsh, director of Veterans Services, city
          of Gloucester; Michael G. Ingham, director of Veterans
          Services, city of Haverhill; and Robert C. Hogan, director
          of Veterans Services, town of Burlington...................    45
        Murphy, Dr. Frances M., Acting Deputy Under Secretary for
          Health for Policy and Management, Department of Veterans'
          Affairs; Dr. Jeannette Chirico-Post, Director of Veterans'
          Integrated Service Network 1; and William Conte, director,
          Edith Nourse Rogers Memorial VA Medical Center.............    16
        Restani, Neil F., director of Veterans Services, town of
          Lynnfield..................................................    84
    Letters, statements, etc., submitted for the record by:
        Hogan, Robert C., director of Veterans Services, town of
          Burlington, prepared statement of..........................    64
        Ingham, Michael G., director of Veterans Services, city of
          Haverhill, prepared statement of...........................    58
        Martineau, Jean-Guy, director of Veterans Services, city of
          Salem, prepared statement of...............................    47
        Murphy, Dr. Frances M., Acting Deputy Under Secretary for
          Health for Policy and Management, Department of Veterans'
          Affairs, prepared statement of.............................    19
        Restani, Neil F., director of Veterans Services, town of
          Lynnfield, prepared statement of...........................    86
        Shays, Hon. Christopher, a Representative in Congress from
          the State of Connecticut, prepared statement of............     3
        Tierney, Hon. John, a Representative in Congress from the
          State of Massachusetts, prepared statement of..............     7
        Welsh, Donald T., director of Veterans Services, city of
          Gloucester, prepared statement of..........................    53

                      VA HEALTHCARE IN THE NEXT MILLENNIUM

                                  ----------

                             MONDAY, APRIL 10, 2000

                      House of Representatives,
           Subcommittee on National Security, Veterans
                  Affairs, and International Relations,
                                Committee on Government Reform,
                                                           Peabody, MA.
        The subcommittee met, pursuant to notice, at 10 a.m., at
    the Peabody Memorial Veterans High School, 485 Lowell Street,
    Peabody, MA, Hon. Christopher Shays (chairman of the
    subcommittee) presiding.
        Present: Representatives Shays and Tierney.
        Staff present: Lawrence J. Halloran, staff director and
    counsel; Kristine McElroy, professional staff member; Jason
    Chung, clerk; and David Rapallo, minority counsel.
        Mr. Shays. This hearing will come to order and welcome our
    witnesses and guests and ladies and gentlemen, I invite you to
    please rise as the Peabody Air Force Junior ROTC Color Guard
    posts the colors.
        Today, we came here to listen and to learn from those with
    a direct stake in the future of veterans' health care in New
    England.
        This is our third hearing on the impact of reorganization
    and funding shifts on the availability and the quality of care
    in Department of Veterans' Affairs [VA] facilities. Earlier
    testimony described long waits for access to specialists,
    lapses in health care standards and funding inequities within
    and between regional Veterans Integrated Service Networks
    (VSNS). VA officials said facility restructuring here in VISN-1
    and refinements in the Veterans Equitable Resource Allocation
    [VERA] system would, in time, bring improvements.
        But last July, Congress' auditing agency, the General
    Accounting Office [GAO], concluded VA could be wasting $1
    million or more every day critical health care restructuring
    decisions are delayed. Today, more than 8 months, or $263
    million later, GAO still reports the VA ``has been unsuccessful
    . . . in its efforts to design a capital asset realignment
    process.''
        So a significant portion of the $1.7 billion Congress added
    to the Veterans Health Administration budget this year may be
    spent operating and maintaining unneeded facilities, rather
    than enhancing access and improving the quality of needed
    health care for veterans.
        The effects of delaying the hard decisions in Washington
    are felt acutely here in New England. An older veterans'
    population, declining in numbers, but now in need of more
    extensive, more expensive, health interventions, cannot wait
    years, or drive hundreds of miles, for the basic care to which
    they are truly entitled. Today we need to talk candidly and
    objectively about how the VA can sustain and improve a health
    care system in New England that will meet veterans' needs in
    the new millennium.
        I want to thank Congressman John Tierney for inviting the
    subcommittee to the Sixth Congressional District of
    Massachusetts. We value his participation in this committee as
    an equal partner with the chair. We value this opportunity as
    well to discuss these important issues with those most directly
    involved, and we look forward to the testimony of all of our
    witnesses.
        John, I would like to personally thank you for asking us to
    come here and this committee oversees all of the VA, all of
    DOD, all of FEMA, all of terrorist activities at home and
    abroad and when I asked John what hearing was most important he
    said we needed to talk about the VA and to meet in his district
    and that is why we are here. We will do a lot of good listening
    today.
        John.
        [The prepared statement of Hon. Christopher Shays follows:]

        [GRAPHIC] [TIFF OMITTED] T0278.001

        Mr. Tierney. Thank you, Mr. Chairman, and I want to thank
    everybody that has taken the time today to join us here at the
    hearing.
        I want to be the first to officially welcome Congressman
    Chris Shays to join us in this particular district and I can
    say that we have a Congressman here as chairman of this
    committee who is truly a person that we can work with and who
    understands these issues and works very hard on them.
        I want to also welcome our witnesses from the Veterans'
    Administration, Dr. Murphy, Dr. Post and Mr. Conte with whom we
    worked with many, many times, as well as the veterans' agents
    from the surrounding areas who will also be testifying in the
    second panel. I am glad that you could all be with us and join
    us today.
        Let me also welcome all the veterans in attendance and the
    veterans service organizations who have provided written
    testimony for the record. It is imperative that we hear your
    concerns and your viewpoints today. I look forward to listening
    to your comments after the first two panels have concluded and
    you will see that we have microphones in the aisles and that we
    will have an opportunity for folks to make comments and ask
    some questions.
        Mr. Chairman, I have a written a statement from
    Representative Anthony Vera, the State Representative from
    Gloucester that I would like to ask be presented in the record.
    And I also have a written statement from Mayor Nicholas J.
    Costello, the mayor of Amesbury which I would like to ask be
    put in the record, as well as a written statement from
    Congressman Thomas Allen of Maine, which I believe is already
    in there and ask that you enter that in the record.
        Mr. Shays. Without objection, so ordered.
        Mr. Tierney. I would like to acknowledge and welcome Mayor
    William Scanlon from the city of Beverly who is also with us in
    the audience today who has been a great friend of veterans and
    a number of other veterans' agents who will not be testifying,
    but with whom my office works on a regular basis and provide
    great service to the veterans in this District.
        In Washington, veterans' health care is often analyzed as
    an issue of national scope, focusing on the processing,
    reengineering, streamlining initiatives and appropriations
    debates. Discussing the issue in this way sometimes removes and
    detaches policymakers from the concerns of individual veterans,
    veterans who live with the system on a daily basis, veterans
    who rely on the system for their most essential health care
    needs.
        That is why I am particularly gratified today to have a
    hearing analyzing the local point of view. In many ways, health
    care is rooted in local systems and infrastructure, so it
    behooves us to extract ourselves from the daily Washington
    processes to come here today and to analyze the issues from a
    different perspective, yours.
        For veterans in the Sixth Congressional District of
    Massachusetts, the facility that provides the primary and
    specialized medical care is the Edith Nourse Rogers Memorial VA
    Medical Center in Bedford. This institution has been providing
    care to veterans since 1929. It has always been a VA facility
    and last year it handled more than 186,000 visits.
        Today we have with us Mr. William Conte, the director of
    the facility who will provide additional background on the
    facility's capacity and his efforts to deal with shrinking
    budgets.
        A recent development, and one in particular that I am very
    excited about is the establishment of community-based out
    patient clinics. We now have two, one in Lynn and one in
    Haverhill. They greatly increase veterans' access to health
    care. These clinics are important to the effort to reach out to
    veterans and to serve them in the communities in which they
    live. We have helped to move forward the application of a third
    CBOC in Gloucester.
        Last year, the Lynn and Haverhill CBOCs handled more than
    5,600 visits and I know the representatives on the panel will
    be able to respond to questions about those clinics.
        Although these are positive developments, there are also a
    number of challenges, both for veterans and the system that
    serves them. Transportation, to and from VA facilities is a
    primary concern. Again, the clinics are extremely valuable in
    extending VA's outreach to other areas, but for veterans who
    need specialty care or report for multiple visits,
    transportation hurdles may be too great to overcome.
        I understand that if veterans go to one or two clinics,
    they can catch a shuttle to the Bedford facility if they need
    x-rays or other services not provided at the clinics. If they
    need more specialized services, however, such as an upper GI
    endoscopy, they may have to take another shuttle still into
    Boston.
        For veterans, the current transportation process can be
    insurmountable, especially if it involves anesthesia or other
    procedures that complicate traveling alone. I hope we can
    discuss transportation concerns today, both at the regional and
    the local levels.
        Long term care is also an issue that is gaining
    significance. VA has highlighted outpatient solutions and in-
    home care, which have their own advantages. If VA can assist
    veterans without uprooting them from their homes, this solution
    benefits everyone involved. My concern, however, relates to
    veterans with degenerative and other conditions that eventually
    may require hospitalization and inpatient treatment.
        VA is now in the process of downsizing its inpatient
    capacity as it redirects assets toward outpatient care. So how
    will short-term shift affect the extended term outlook? How
    will VA be able to deal with the increasing demand of long-term
    care when the baby boom generation moves into this stage? And
    how do these concerns relate to VA's ability to comply with the
    Millennium Health Care and Benefits Act?
        These are just a few of the issues I hope our witnesses
    will address today, and although I know there are many more of
    interest to the veterans in attendance, I look forward to
    hearing their testimony also.
        Before concluding, let me just extend my thanks to several
    people from Veterans Memorial High School here in Peabody who
    have helped to make this hearing possible: Principal Joe
    Patuleia, Elaine Kirby, Richard Carey, Major Grover, of course,
    and the students of the culinary arts and the Air Force Junior
    ROTC.
        In addition, I would like to thank the Peabody Police
    Department and Temple Beth Shalom for allowing us to use their
    parking lot.
        I would also like to recognize Michael King, who is the
    director of the North Shore Veterans Counseling Services, for
    his dedicated service to our country and for keeping our North
    Shore veterans informed about the timely issues in his
    veterans' column in the Salem Evening News.
        Finally, I would like to thank Chairman Shays again for
    calling this hearing. As I mentioned, I think this type of
    local focus adds immeasurably to our ability to address these
    issues. It is a special privilege to have the opportunity for
    the subcommittee to address issues specific to my own district.
        I appreciate your willingness, Mr. Chairman, to hold this
    hearing today in Peabody. I especially commend you for all the
    work that you do in addition to veterans' issues with the very
    serious matter of terrorism and preparedness in this country
    for any event that may occur and I look forward to today's
    hearing.
        Thank you.
        [The prepared statement of Hon. John Tierney and the
    information referred to follow:]

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        Mr. Shays. I thank the gentleman and we will just get some
    housekeeping taken care of.
        Pursuant to House rules and committee rules I note for the
    record that the subcommittee requests that all witnesses
    appearing in this hearing in a nongovernment capacity provide a
    resume and a disclosure of Federal grants and contracts
    received and further ask that all testimony be submitted for
    the record and remarks by our colleagues be submitted for the
    record as well.
        Without objection, so ordered.
        I would also like to say that before calling our panel that
    this committee has had an excellent working relationship with
    the Department of Veterans' Affairs and we realize this is a
    partnership, so this is not a committee that is just standing
    in judgment of the VA. We also look at how Congress and the
    administration play a role in providing better health care for
    our veterans.
        At this time, I am not sure if my mic is on all the time.
    Mine is not on at the time. I am not bringing the mic closer. I
    need the people in the back to get it better.
        At this time, we will call Dr. Frances M. Murphy, Acting
    Director, Under Secretary for Policy and Management, Veterans'
    Health Administration, Department of Veterans' Affairs,
    accompanied by Dr. Jeannette Chirico-Post, Director of
    Veterans' Integrated Service Network I; and Mr. William Conte,
    Director, Edith Nourse Rogers Memorial VA Medical Center. I
    invite them all.
        Remaine standing and I will swear you in.
        [Witnesses sworn.]
        Mr. Shays. Note for the record that the witnesses have
    responded in the affirmative.
        Dr. Murphy, you have the testimony, but we are going to
    invite both of our guests as well to respond to questions. That
    is why you are all three under oath. I will note this committee
    swears every one under oath. The only one who has ever gotten
    away without being sworn in was Senator Byrd. All other
    Senators and Representatives have been willing to cooperate.
        Thank you, Dr. Murphy.

       STATEMENTS OF DR. FRANCES M. MURPHY, ACTING DEPUTY UNDER
     SECRETARY FOR HEALTH FOR POLICY AND MANAGEMENT, DEPARTMENT OF
      VETERANS' AFFAIRS; DR. JEANNETTE CHIRICO-POST, DIRECTOR OF
      VETERANS' INTEGRATED SERVICE NETWORK 1; AND WILLIAM CONTE,
        DIRECTOR, EDITH NOURSE ROGERS MEMORIAL VA MEDICAL CENTER

        Dr. Murphy. Good morning. Mr. Chairman, Mr. Tierney, Mayor
    Scanlon, and honored guests. I appreciate the opportunity to
    appear before you today to discuss VA Health Care in the New
    Millennium. With me today are Dr. Post and Mr. Conte from the
    Edith Nourse Rogers Memorial VA Medical Center in Bedford, MA.
        I would like to take the opportunity to compliment the Air
    Force ROTC and say it makes me proud to see our young people do
    so well.
        The past decade has been characterized by dramatic change
    in the delivery of health care services in the United States.
    In the past 5 years, the VA health care system has also had a
    tremendous transformation. VA has transformed itself from a
    disease-oriented, hospital-based health care system to an
    integrated system providing a continuum of accessible,
    coordinated, patient-centered, prevention-oriented care.
        We have seen demonstrable improvements in our capacity to
    achieve consistent, reliable, accessible, satisfying and high-
    quality care. We also continue to face challenges of reducing
    medical errors in health care and meeting the needs of an aging
    population, of incorporating the explosive growth of scientific
    knowledge into daily practice and of incorporating expensive
    new medical and information technologies, and of realigning our
    infrastructure to more effectively support current health care
    needs.
        Structurally, ``New VA'' is composed of 22 Veterans
    Integrated Service Networks [VISNs]. Each VISN forms a regional
    health care system that provides a continuum of health care to
    veterans who reside in a geographic area.
        More than at any other time in our history, VA more closely
    mirrors--and in many cases exceeds--the best in private sector
    health care. Indeed, the structural transformation underpins a
    quality transformation. Significant organizational changes
    include: closing more than 52 percent of all hospital beds
    since July 1994; reducing inpatient admissions by 34 percent
    between 1994 and 1999; providing health to over 700,000 more
    veterans in 1999 than in 1994.
        That is a 31 percent increase in the number of veterans
    cared for by the VA. Within the networks we consolidated
    managements and operation of 48 hospitals or clinics into 23
    locally integrated health care systems since September 1995.
    Also we approved and brought 388 new community-based outpatient
    clinics into operation since 1995. We will establish more than
    60 this year and that means that VA will have more than 1,200
    sites of care across this Nation in bringing health care
    services into more veterans' communities.
        Over that same period of time, we increased the rate of
    selected surgeries and procedures which are safely provided in
    the ambulatory setting to 92 percent of surgeries that are
    performed.
        Especially notable in clinical achievements are reduced
    avoidable hospitalizations and lowered mortality, resulting in
    cost-savings through reductions in avoidable health care
    expenditures.
        For example, the rates of pneumonia and influenza
    vaccinations provided to VA patients far exceed U.S. Public
    Health Service Healthy People 2000 goals and available
    benchmarks. Also, life-saving beta-blocker medications after
    heart attacks are provided at VA hospitals at rates that exceed
    all available benchmarks in the private sector. These two
    actions alone have saved, Mr. Chairman, an estimated 5,000
    lives since instituted. That is an incredible accomplishment in
    quality health care for veterans.
        Similar improvements have been seen in other areas of
    preventative health services such as screening for cervical and
    breast cancer and in the treatment of prevalent diseases such
    as diabetes and mental illnesses. Simultaneously, patient
    satisfaction has increased. In fact, VHA scored 79 on the
    externally conducted American Customer Satisfaction Index. This
    is significantly above the score obtained by the private sector
    health institutions who scored only 70 on that scale. Loyalty
    and Customer Service scores are even higher at 90 and 87,
    respectively.
        Mr. Chairman, the VA New England Health Care System has
    shared in the accomplishments of the VA health system and in
    some instances has led the way. Network 1 also faces the same
    challenges that confront many other areas of the country.
        I would like to take the opportunity briefly to discuss the
    accomplishments and challenges that are facing the New England
    Healthcare System (Network 1). Network 1 is an integrated and
    comprehensive health care system that delivers care to all six
    New England States, Maine, New Hampshire, Vermont,
    Massachusetts, Rhode Island and Connecticut.
        Twenty-five community-based outpatient clinics are
    strategically located throughout New England and provide
    increased access to health care services for veterans. Network
    1 has significant and long standing affiliations with some of
    the most prominent medical schools in the country. These
    include Boston University, Brown, Dartmouth, Harvard, Tufts,
    Yale, Universities of Connecticut, Massachusetts and Vermont
    Medical Schools and the University of New England. Funded
    research programs are another strong suit in Network 1 with the
    third highest research funding in VHA.
        Over the past 5 years, from 1995 to 1999, VHA faced a very
    challenging budget situation. Our budget in real dollars
    decreased by 23 percent over that time period. However, I am
    pleased to tell you that with the $1.7 billion increase that
    appropriated for VHA in 2000 and a $1.3 billion increase that
    has been proposed in the Presidential budget for fiscal year
    2001, we believe that we will be able to increase the access
    and decrease waiting times for veterans, further increasing the
    quality of care delivered by the Veterans Health
    Administration.
        Network 1 has seen several changes in leadership during the
    past year. Mr. Fred Malphurs was appointed as the Interim
    Network Director, following the retirement of the former
    Network Director. Mr. Malphurs has been instrumental in setting
    a course that promotes teamwork, ``open book management,'' and
    greater participation in network committees and strategic
    planning.
        Recently, Dr. Jeannette Post was appointed as the Network
    Director after serving as the Acting Clinical Manager for 6
    months. I am pleased to tell you that she brings to this
    position excellent management and clinical credentials and a
    passion for delivering quality health care services to the
    veterans of New England. We will provide effective leadership
    and expand the initiatives to provide quality, accessible
    health care services in an integrated delivery network.
        I would like to turn the microphone over to Dr. Post at
    this point to let her tell you about the initiatives that will
    take place in Network 1 over the next several months.
        Dr. Post.
        [The prepared statement of Dr. Murphy follows:]

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        Dr. Post. Thank you for the opportunity to discuss the
    accomplishments and challenges that are facing the VA New
    England health care system. Network 1 is an integrated and
    comprehensive health care delivery system that delivers care in
    the six New England States. Twenty-five community-based
    outpatient clinics are strategically located throughout New
    England and provide increased access to health care services
    for veterans.
        Network has a significant and longstanding affiliation with
    nine of the most prominent medical schools in this country. We
    are the third highest research funding in VHA. Network 1 is
    committed to provide quality health care services to the
    veterans throughout New England. The goal is to provide the
    right care at the right time and at the right level required to
    safely and compassionately meet the unique needs of each
    veteran.
        A major Network 1 initiative has been the development of
    this integrated health care system based in primary care. This
    primary care model has resulted in improved continuity,
    improved satisfaction and an increase in the number of patients
    served.
        The Network opened a new CBOC in southern Maine on March 17
    and we expect to open 12 new CBOCs this year. Feedback from
    patients is one of the most significant measures of quality. We
    are currently No. 1 in the country in overall quality of care
    as rated by ambulatory care patients.
        Network 1 was the first network to obtain the joint
    commission of accreditation, network accreditation with
    commendation. It was recognized for meritorious achievement as
    a finalist for the kinds of quality achievement recognition
    grant last year.
        Network 1 has embarked on a new mission to communicate more
    often and in more detail with veterans, employees, affiliates,
    congressional offices, local unions and other stakeholders. A
    number of communication tools have been developed that are
    responsive to the needs of patients, employees and stakeholders
    and enhance the understanding of network initiatives.
        All nine VA Medical Centers are utilizing the computerized
    patient medical record. We have implemented a state-of-the-art
    information technology called Webtop which will allow a
    clinician anywhere in New England to access the electronic
    medical record for any enrolled patient. Both of these systems
    will foster communication and consultation among physicians
    throughout New England.
        One of the greatest challenges facing Network 1 is the need
    to come together as one network instead of its current,
    parochial orientation of nine individual medical centers.
    Network needs to move from a hospital-centered system to a
    Network patient centered system which provides health care
    services along the entire health care continuum. The Network
    must re-engineer its business processes and implement clinical
    practice guidelines to ensure there is a single, consistent
    standard of quality health care regardless of geographic
    location of care and delivery.
        Another strategic goal of Network 1 is to integrate health
    services by fully implementing Care Line management. Care Lines
    are intended to enhance the provision of uniform, high quality
    services throughout the network by reducing variations in care
    and standardizing availability and coordination of services.
    This allows for improved management of patients along a
    seamless continuum of care.
        Another major initiative is the consolidation of the local
    Boston facilities, Jamaica Plain, West Roxbury and Brockton.
    The consolidation will reduce duplicate clinical services and
    business processes. The Bureau of Resource Allocation System
    was developed to match resources with patient needs across the
    country. Although the network received reductions in resource
    allocations in the first 2 years, in fiscal year 2000 Network 1
    received a 5\1/2\ percent increase or $43 million more than the
    prior year. It is projected that our next year's funding will
    be a 2.9 percent increase equated to $24 million.
        Network 1 has a cost per unique patient that is
    approximately $400 greater than the national need and has
    staffing ratios that are some of the highest in the country. We
    have made strides to reduce overall cost per patient, however,
    we need to gain additional efficiencies through reorganization
    of health care delivery systems. These efforts will improve the
    network's ability to deliver high quality care and serve more
    patients at a reduced cost in the future.
        Thank you for the opportunity to discuss the achievements
    of Network 1.
        Mr. Conte. For those who do not know the scope of the
    Bedford Hospital, it is basically a long term care facility
    psychiatric care with rehab focus, a large Alzheimer's
    component and a primary care clinic around the eastern
    Massachusetts area and a large research component.
        Since this hearing today is being held in Peabody, MA, I
    will provide you with information of a few of the many
    successful local initiatives. VHA Network 1 appreciates the
    support and encouragement of the New England Congressional
    Delegation in the opening of new community based outpatient
    clinics.
        Congressional support was instrumental in the success of
    the clinics in Lynn and Haverhill, and to the proposed clinic
    for Gloucester. The clinic in Haverhill is located with the
    Hale Hospital, a facility owned and operated by the city of
    Haverhill, creating a mutually beneficial partnership with the
    community. The clinic in Lynn is located in a private sector
    medical building. Both the Lynn and Haverhill clinics provide
    primary care services and have expanded recently to include
    mental health counseling.
        The Edith Nourse Rogers Memorial Veterans Administration
    Hospital in Bedford operates an Alzheimer's care program that
    is nationally known for its comprehensive quality care. It is
    comprised of an Outpatient Program, an Adult Day Care Center
    and an Inpatient Program.
        The Alzheimer's care program is fully integrated with the
    Geriatric Research Education and Clinical Center known as a
    GRECC in the VA facility. The Bedford GRECC program is a unique
    program in that it is fully integrated with clinical care, a
    full partner with its academic affiliate, Boston University,
    and designated by VHA Headquarters as a National Center to
    facilitate cooperative efforts between the VA, private sector
    health care organizations and pharmaceutical companies.
        To enhance the continuum of health care services provided
    to veterans, the Bedford VA Medical Center has embarked on two
    innovative projects utilizing the Enhanced Use leasing
    authority. The first proposal is to establish a cooperative
    venture with a private sector organization for construction and
    operation of an Assisted Living Center at the Bedford VA
    Medical Center with an emphasis on Alzheimer's.
        In return for the ability to utilize VA property, the
    private sector organization will provide bed space for VA
    patients at no charge. This proposal is expected to be approved
    and construction started in 2001. The second proposal would
    establish a cooperative venture with the New England Shelter
    for Homeless Veterans, a nonprofit organization for
    construction and operation of 40 units of Single Residency
    Housing at Bedford. In return for the ability to utilize VA
    property, the New England Shelter will lease the building and
    this will help us offset some of our operational costs. This is
    a change in the testimony. This proposal is expected to be
    approved and construction started in the near future.
        Another example of a VA-private sector partnership is in
    the area of health care services to homeless veterans. A
    private sector homeless services provider, Ms. Leslie
    Lightfoot, has received a VA Grant to obtain, equip and operate
    a health care van in the greater Worcester, MA area. This
    program will provide the van at scheduled, designated locations
    to perform basic health screenings and followup.
        The Bedford VA Medical Center will provide expertise in the
    planning phases of this project and will provide equipment,
    supplies and personnel to support this important homeless
    outreach effort which is expected to be operational by this
    fall.
        Thank you.
        Mr. Shays. At this, Mr. Tierney, I invite you ask any
    questions you would like.
        Mr. Tierney. Thank you very much, Mr. Chairman, I thank the
    members of the panel for their testimony.
        I want to ask Mr. Conte a question first, but I think I
    would be remiss if I did not share with the folks that are
    here, as well as with the chairman, just the wonderful work
    that the folks at the VA Hospital in Bedford have done and the
    cooperation that they have given my office and the veterans'
    councils and agents throughout the district.
        We have had a number of health fairs that probably could
    not have happened without Mr. Conte and his staffs volunteering
    considerable amounts of their time on several days in this past
    couple of years in Haverhill, in Lynn and out in Gloucester
    where people gave their time to run the tests, to sign people
    up to make sure that we had appreciation for the number of
    veterans who would, in fact, utilize those services.
        And so I want to thank you publicly and your staff through
    you for the cooperation that you have had. And it went beyond
    that. Once the CBOCs were actually cited first on the North
    Shore and then in Haverhill. The staff worked with local
    veterans' councils and gave them a voice in where they would be
    located and how they would be established and how they would be
    staffed and that continues to go on, so we are very, very
    appreciative of that.
        Last, let me just say we gave you a major headache at one
    point in time when we put out a veterans' newsletter that
    indicated that there was a prescription drug benefit to which
    veterans were entitled and I think the next day you had over
    500 phone calls rushing into the clinics and your office was
    good natured and gracious about building those and making sure
    that the veterans, in fact, got the benefit of those services
    so on behalf of veterans I would thank you for making sure that
    they were well served with the right disposition and attitude
    when that increase of calls came in.
        As you know, Mr. Conte, I am very much a proponent of the
    community-based outpatient clinics. Can you tell us roughly
    what resources these clinics that are in this district have had
    and how many physicians and nurses they have and what type of
    care they are generally provided?
        Mr. Conte. Yes. I will start with Lynn. Lynn was originally
    staffed with the positions of a physician and a nurse
    practitioner and administrative support and that would be
    roughly in the area of about $350,000 worth of personal
    services and then in the Lynn area we contracted with a medical
    building there and I believe the lease was in probably the
    $30,000 range, so we are looking at about $400,000 roughly that
    goes into that clinic when it started a year and a half ago.
        We have increased services. At this point we have mental
    health practitioners going up there now, so I would say we are
    well up over $500,000, according to that clinic. That does not
    count all the new patients or the new prescription drugs and
    all the services we provide back at the Bedford facility.
    Haverhill was brought up the same way.
        Both of these clinics were brought up as a startup
    initiative, let it grow and let us meet the demand. Haverhill
    is very similar in terms of its original start. It was a nurse
    practitioner, physician and administrative support, again in
    the $300,000 to $500,000 range at this point in time.
        Mental health services are expanding in both those areas as
    we speak.
        Mr. Tierney. Does the entire budget for those facilities
    come from the Bedford facility?
        Mr. Conte. In the past, yes, that has been true and the
    issue was that if we did get an outpatient clinic we would
    generate those dollars within the facility and the VA facility
    at Bedford, we have been very dynamic in rearranging,
    reprogramming dollars.
        We have done a lot of sharing with other facilities. We
    have done a lot of consolidations for things like
    administrative services. For example, a good example, we used
    to have a large kitchen staff, now we do cook/chill which is
    basically cooked in West Roxbury, the food is prepared there,
    it is brought to the veterans facility and that saves us a lot
    of dollars and that provided the dollars to expand to those
    clinics.
        The Haverhill staff are part of the Bedford facility and so
    are the Lynn staff, so is the Winchendon staff. There is
    another group out in Winchendon that people do not realize has
    been there for many years. Also the VCC in the Lowell area,
    Veterans' Community Care Center.
        Mr. Tierney. And despite, has the Bedford facility been
    able to maintain its patient case load, the waiting time has
    been about the same and not increased?
        Mr. Conte. Two questions. The waiting time, 5 years ago, we
    have a member of the GPRA, Government Performance Review Act.
    We are a pilot site. We establish times that were in the range
    of 7 days and less than 30 minutes to be seen in a primary care
    clinic. Over those 5 year periods, I do not think we have
    exceeded those times four or five times. We have a strong QA
    program that monitors that, so we have been working with that
    for many years, so yes, we have been able to maintain our times
    by shifting staff in the ambulatory care.
        The other issue is that the dollars that we have taken from
    programs have enhanced that ability to expand those clinics. We
    have expanded some clinics and have been able to maintain those
    times, yes.
        Mr. Tierney. One of the issues I expect me hear about
    something today, but I heard about it quite frequently in our
    offices is transportation. I understand there is shuttle
    service to the Bedford facility, but I would like for you to
    take a moment, if you would to describe how often the shuttle
    runs and what is entailed in participating in that
    transportation.
        Mr. Conte. Difficult question. They change quite a bit.
    There is shuttle that runs from the Worcester clinic, excuse
    me, from the Lynn clinic to Bedford and back, I believe four
    times a day, a morning run and the afternoon run. There is also
    a shuttle that runs to the Haverhill clinic back to Bedford and
    then there is part of a consolidated transportation network
    that is working out of Boston that the VISN initiative startup
    was a VISN initiative about a year and a half ago when they
    were working the transportation network.
        We, ourselves, at the Bedford facility decided to run this
    shuttle to try to get people back to the Bedford facility when
    they need that kind of care and I think it has been reasonably
    successful. As the clinic expands, there may be need for more
    transportation. Obviously, you identified that earlier.
        Mr. Tierney. How is the staff of these programs being paid?
    Are they being paid by the clinics themselves or?
        Mr. Conte. Out of our operating dollars at the veterans
    facility, certainly.
        Mr. Tierney. Are there any other plans for that network
    transportation concern in the future?
        Mr. Conte. At the VISN letter there is a Boston
    consolidated transportation network and actually there was a
    contract let out about a year and a half ago and there was an
    evaluation period. We are going through that right now, for the
    private sector vendor who was coordinating that transportation
    network in the Boston area. Lynn and Haverhill are not included
    the initial startup of that, so we ran the vans ourselves, but
    we have to look at that, yes.
        Mr. Tierney. With the indulgence of the chair I would like
    to continue. I am beyond my time for a couple of seconds.
        Can you describe how someone who wanted to go to the clinic
    in Haverhill would actually get to say Jamaica Plain or Bedford
    or West Roxbury if they needed to get there, how that works?
        Mr. Conte. I believe there is a van that is going down to
    Jamaica Plain, but it is not as regular, I believe, as the one
    we have running back from Bedford, but you could take two
    routes, obviously, public transportation being another option,
    but you could take a van from the Lynn clinic to Bedford and
    then from Bedford into Jamaica Plain which makes it a little
    difficult sometimes and I believe we are starting an initiative
    to run a van from those clinics because they have gotten to the
    point where you have enough demand. In the past there has not
    been that demand.
        Mr. Tierney. Is the demand for the service of the clinics
    actually helping our budget here locally, the way the current
    funding situation is going?
        Mr. Conte. I would think so. Our numbers alone have gone
    from about 9,700 veterans to over 11,000 and we have been
    trying to put a finger on that, if they were coming to Bedford
    and now to Lynn or if they were new at Lynn and I would
    strongly support the idea that more people are coming to the
    Lynn and Haverhill clinics because of access and therefore we
    are earning more dollars under this VERA model, yes.
        Mr. Tierney. Now a lot of veterans have asked questions
    about the plans to implement the new millennium bill, maybe you
    could help us first by telling us a little bit about the
    requirements of the bill or Dr. Murphy or Dr. Post or whoever,
    just give a brief outline about the millennium bill and then
    maybe I think somebody was a little perplexed about the lack of
    funding, a vital functioning of that particular bill and all
    that it calls for and I would like for you to tell us what your
    approach is going to be in dealing with that.
        Dr. Murphy. I will start and then I will turn it over to
    Dr. Post. The millennium bill is a rather complex piece of
    legislation. The millennium bill provides for a continuum of
    long-term care. In fact, it provides long-term care to veterans
    who are greater than 70 percent service connected and allows VA
    to provide that care on a more consistent basis.
        It also gives us the ability to provide noninstitutional
    long-term care by allowing us to set up pilots for assisted
    living and to do more home-based, long-term health care. It
    also changes some of the provisions for the State homes.
        As you can imagine, the implementation of this legislation
    requires many policy decisions and publication of regulations.
    We are well into that process and expect to be able to move
    forward relatively quickly. In fact, Dr. Post spent last week
    down in Leesburg, VA leading one of the seven subcommittees
    working on the implementation plan for that bill. It is a
    complex piece of legislation, but it does give veterans more
    access to the long-term care that they are going to need in the
    future.
        Were there specific aspects of the bill?
        Mr. Tierney. I was interested in the funding of it which I
    think is problematically probably more on our level than yours,
    but I am curious to know what your approach is going to be.
        Dr. Murphy. We did put specific funding into the 2001
    budget that will allow us to fully fund the long term care
    piece of that legislation.
        In addition, the legislation set out VA authority to charge
    copayments for some long-term care and so part of what will pay
    for that is some of the co-payments that we will collect from
    veterans who use the long-term care.
        Mr. Tierney. Does that also include--I was concerned that
    as that bill was coming through Congress with the prescription
    drug aspect of that. I was very concerned at the beginning, but
    there is now an allowance for an increase in the co-pay on
    that. Do you anticipate that that is going to a severe
    increase, moderate increase, no increase?
        Dr. Murphy. We do not believe that there will be a very
    large increase in the pharmacy co-payments. The problem was
    that the level of co-payment the VA was charging was not even
    paying for the administrative costs of sending out the bills
    for the copayments. I think the copayments are likely to be
    under $10 and probably closer to $5 per monthly medication
    refill.
        Mr. Tierney. Thank you.
        Dr. Post. I just wanted to add to the comments that Dr.
    Murphy just gave you about the implementation of the millennium
    bill. If you believe that all health care should be local I
    think VA has moved in the right direction by establishing an
    increasing number of access points or CBOCs and in our network
    alone with the additional 10 to 12 that will happen in this
    year, that will be a plus.
        The millennium bill affords us the opportunity to make all
    long term care local and that includes not only the
    institutional care, but the noninstitutional care and we in New
    England have already started to move to enhance that access,
    our relationships with the State Veteran Homes, the further
    development of the geriatric and long-term care on that. We
    have additional development of 24 hour day, 7 day a week
    contact with us from the emergency room.
        Mr. Tierney. Can you tell me how that will work? Are you
    going to reduce bed space now and bring it more out to the
    community and more outpatient based. What about the long term
    care inpatient demand? When that increases in the future, will
    we have what we need to address that?
        Dr. Post. I think that is part of the process for us. Part
    of the process is to decide where is the right level for the
    patient to be maintained for the longest period of time for the
    patient to maintain his functional independence.
        Mr. Conte talked about our Alzheimer's unit at the Bedford
    VA which maintains the patient from an ambulatory care through
    a day care and then up through institutional care. I think that
    over time the issue for us is to have the right size and I do
    not know if I can predict the numbers that are there for right
    now.
        Mr. Tierney. Are you in the process of doing any sort of
    survey or determining what the likely demand for in-patient
    care is going to be for baby boomers?
        Dr. Post. I think that is part of our geriatric/long term
    care line to make an assessment of where we should be and then
    to address, as Dr. Murphy has said, through the millennium
    bill, the additional placement of those patients that are 70
    percent or greater.
        Mr. Tierney. Thank you. Mr. Chairman, why do not I let you
    have a few questions.
        Mr. Shays. Thank you. I am going to ask these questions as
    if I were in Washington and not be concerned that I am asking
    them in Massachusetts, but the purpose is to understand the
    challenges and to give you an opportunity to respond to it.
        In Connecticut, we felt we did our duty by consolidating
    Newington and West Haven and making it one system which is
    referred to as the Connecticut Health Care System. You have a
    facility in Vermont. You have a facility in New Hampshire. You
    have a facility--I am talking major facilities, not community-
    based health care clinics, a major facility in Rhode Island as
    well. And you have four facilities in Massachusetts, I believe,
    and now you have consolidated two and I just want to sense, is
    there going to be eventually one Massachusetts Health Care
    System coordinating the major hospitals?
        Dr. Post. The process to look at the delivery of health
    care in Massachusetts was thoroughly reviewed. That review
    process began some 2 to 3 years ago as we came to be an
    integrated delivery system. And actually, Mr. Conte and I were
    on one of the first groups to look at what we should do in the
    network for those two locations, 5 miles apart, Jamaica Plain
    and West Roxbury. West Roxbury had already been joined with the
    Brockton VA I think some 10 years prior to----
        Mr. Shays. How many major facilities are we talking about
    in community based health care clinics?
        Dr. Post. Bedford, JP, Jamaica Plain, West Roxbury and
    Brockton.
        Mr. Shays. Five facilities. I am sorry, four.
        Dr. Post. Four facilities.
        Mr. Shays. Right, consolidated into how many?
        Dr. Post. No, Bedford is still unique. The Jamaica Plain,
    West Roxbury and Brockton have been in the process of
    consolidating and integrating into a single health care system.
        Mr. Shays. And it will have one so then you will have two
    budgets.
        Dr. Post. Right.
        Mr. Shays. And the savings from that, it seems to me can
    then be poured into--it does not go back down to Washington, it
    stays up in District 1?
        Dr. Post. Correct, in VISN 1.
        Mr. Shays. When will that consolidation be concluded?
        Dr. Post. It is projected to be finished within the next 3
    to 4 years.
        Mr. Shays. So right now we have five community based health
    care clinics in Connecticut. Is there any plan to open any
    others, do you know?
        Did I ask the wrong question? [Laughter.]
        Dr. Post. And I did not even answer yet.
        Mr. Shays. Is that your final answer? I would just be
    interested in knowing how the transcriber records that event.
    [Laughter.]
        I saw some veterans actually dive for--as they are trained.
        Yes?
        Dr. Post. If I may answer the question, as we as a network
    look at where care is delivered and I said it before and I will
    repeat my phrase of health care is local, so there are
    additional CBOCs planned for Massachusetts as well as
    Connecticut.
        Mr. Shays. Will any of these go through--you have 5 in
    Connecticut, 6 in Maine, given the size of the State, 2 in
    Vermont, 10 in Massachusetts, 2 in New Hampshire and none in
    Rhode Island, community based health care clinics. Do I have
    old information?
        Dr. Post. No, that is correct.
        Mr. Shays. Now do you have plans to increase the number in
    Connecticut, in Massachusetts? Are there any specific ones that
    you can mention?
        Dr. Post. I would be happy to mention some of them. We
    actually have just submitted, I think it is four or five that
    have gone into headquarters for the technical review that is
    required and I will check on the site of the Connecticut one. I
    just cannot remember. I think it is Danbury.
        Mr. Shays. I think you are right.
        Dr. Post. OK, and in Massachusetts, it is the Gloucester
    clinic, it is Quincy, two sites, Turners Falls in the western
    part of the State of Massachusetts and additional ones in
    Massachusetts to be considered. And in Rhode Island, there is
    one in Newport, Martha's Vineyard in Massachusetts as well is
    being considered.
        Mr. Shays. Massachusetts now has three community based
    health care clinics?
        Dr. Post. That is correct.
        Mr. Tierney. This is a powerful man.
        [Applause.]
        Mr. Tierney. These clinics have enabled you, it seems to
    me, to provide a better service for those particular needs at a
    reduced cost, is that correct?
        Dr. Post. That is correct and as I mentioned in my opening
    testimony that as an integrated delivery system, as we move
    toward an ambulatory care or primary care service line, we will
    develop as a network a standard of care across the network that
    is to the best practice so that the care that is rendered in
    Lynn and Haverhill is the same that is rendered in Newington
    and West Haven clinics in Connecticut. We can, as an integrated
    delivery system, then grow in terms of meeting the needs of our
    patients.
        As Mr. Conte said, the majority of care that is delivered
    in our CBOCs is primary care. Good primary care can meet 80 to
    85 percent of the needs of our veteran population. Following
    that, the specialty services, the mental health services. As we
    know the population that we are managing, then we need to
    provide the additional support for both the mental health and
    the specialty clinics.
        Mr. Tierney. Now the way the system works, as you service
    more veterans, you get more resources provided, correct?
        Dr. Post. Correct.
        Mr. Tierney. So it is based on the number of veterans
    served.
        Dr. Murphy. Correct.
        Mr. Tierney. And it strikes me that by expanding community-
    based health care clinics you are reaching more veterans as
    they get older who need this service who do not have to go into
    a larger facility with the bureaucracy sometimes associated
    with the larger facility. It is more personal and so on. I
    think the next hearing that I want to know is why does one
    Member of Congress get three in a State with only 10 Members,
    but that is for another hearing.
        Mr. Shays. Let me just ask you another question. One of the
    tragedies of our failure to properly--is there someone who is
    kicking the mic that we do not know about? It is a shocking
    sound.
        Let us give it a try. Our failure to properly protect our
    blood supply resulted in the HIV virus working--that pathogen
    working into our blood supply, but one of the silent killers
    was hepatitis C and in the course of our hearings we learned
    about hepatitis C a number of years ago.
        My sense is that the VA has done a better job than almost
    any other health care network in terms of dealing with
    hepatitis C and I would just like to know if, Dr. Murphy, you
    could give us a sense of what is happening there?
        Dr. Murphy. I would be happy to. Thank you for the
    compliment on our hepatitis C program. I think VA has been very
    proactive on this issue. And one of the reasons for that is
    that VA or veterans have a higher rate of hepatitis C than the
    general population. The population in the United States has a
    rate of about 1.8 percent of hepatitis C and veterans at least
    by our estimates from a 1-day screening program have a rate of
    about 6.6 percent, so it is significantly elevated in the
    veteran population.
        In our drug treatment programs it can be up to 40 percent
    of the IV drug abusers being treated, so it is a very important
    problem for veteran.
        Hepatitis C can cause chronic liver disease, including
    cirrhosis and liver failure and sometimes result 20 or 30 years
    down the line in liver cancers. So it is important to identify
    the infection by screening veterans and the risk factors
    include exposure to infected blood products from transfusions
    or from IV drug abuse and also other blood exposures.
        If you go into a VA medical center the physicians and
    health care providers will ask you about risk factors for
    hepatitis C and offer you a blood test that can rule out
    hepatitis C. Prior to 1992 there was not a blood test that
    could be done and so individuals who received blood
    transfusions prior to that date may have received infected
    blood products.
        We have screened several hundred thousand veterans, in our
    health care system and have found about 60,000 individuals who
    are infected with hepatitis C. We have provided our health care
    providers with guidelines for treatment. There are drugs
    available, very good drugs that can help treat hepatitis C and
    prevent the complications and so I would encourage any of you
    who might be worried about being exposed to this infection to
    go into your local VA medical center and get screened.
        We are also providing a lot of education to our providers.
    We will have done three national training programs, face to
    face conferences with our health care providers as of the end
    of this year. We have done national teleconferences. We have
    participated with NIH in training programs and with the
    American Liver Foundation. So VA has been a leader in this
    area.
        Mr. Shays. Thank you. Would you tell me what veterans have
    been most exposed to hepatitis C, what era veteran?
        Dr. Murphy. It appears that there was an epidemic that
    occurred in the 1960's and early 1970's and the highest rate of
    hepatitis C appears to occur in Vietnam Era veterans. However,
    any veteran who is exposed to infected blood products would be
    at risk for hepatitis C.
        Mr. Shays. Let me go to Mr. Tierney in just 1 second. I
    want to ask these two questions for the record and I would like
    to know how are the allocations distributed to the facilities
    in VISN 1? How do you decide what, how they are allocated?
        Dr. Post. The process that has been used in the past is the
    historical information of workload that was done in the prior
    year and then an adjustment made to that for various incentives
    that may on in the facility. That has been the allocation up
    through this fiscal year.
        Mr. Shays. And is it likely to change in the next few
    years?
        Dr. Post. It is our intent as we move toward better
    definition of an integrated delivery system to have the
    resources delivered, some of it will continue to go to the
    facilities, but the majority of it will be through our care
    wants.
        Mr. Shays. Last question. What is the timeframe which VISN
    1 hopes to achieve the goals of increasing the number of
    veterans' users by 5 percent and to decrease the cost by 5
    percent?
        Dr. Post. This year. We hope to make that achievement this
    year.
        Mr. Shays. Thank you.
        Mr. Tierney.
        Mr. Tierney. Thank you. I know how good we are getting
    because we are not letting the interruptions bother us now. We
    just go straight through.
        Let me just say I understand some veterans need to obtain
    replacement copies of their discharge forms from the National
    Veteran Center in order to obtain various services and although
    turn around time has significantly improved, I understand,
    there is still quite a backlog. Could you tell us whether or
    not there are efforts under way to address this particular
    issue?
        Dr. Murphy. I cannot answer the question specifically about
    providing the DD214 form, but I will find that information and
    get back to you.
        Mr. Tierney. Thank you. Also, the average processing time,
    I guess, the original compensation claim is about 204.8 days.
    And I am just curious, are there ways that we can reduce this
    for veterans. Sometimes these two problems interact and create
    a significant difficult and I just see that issue coming up
    over and over again.
        Dr. Murphy. All three of us are with the Veterans Health
    Administration and the claims processing is administered by the
    Veterans Benefits Administration which is administratively
    separated from VHA. However, I know that Joe Thompson, the
    Under Secretary for Benefits has been taking VBA through a
    reengineering process.
        The waiting times have actually gone up slightly in the
    past year as they have been training more rating specialists
    and they knew that their performance would get worse before it
    got better because as you are training it takes more time and
    more resources to process a claim, but they expect that with
    the increased number of rating specialists that are being
    trained that in a very short period of time processing time for
    claims should come down. So we are wishing them great luck and
    we hope that their performance does improve in the very near
    future.
        Mr. Tierney. Let me just ask you one last question, you
    mentioned that the network has a cost per unique patient, as
    you phrased it. It is approximately $400 greater than the
    national average. Would you define for me that unique patient?
        Dr. Post. You would like to know the actual cost?
        Mr. Tierney. When you said that you have one type of
    patient that was approximately $400 greater than the national
    mean you mentioned that it was pertaining to a unique patient.
    What constitutes a unique patient?
        Dr. Post. Actually, that term is referring to a unique
    Social Security number, so it is per individual and the way we
    calculate the cost per patient by network is to take the total
    resource allocation, the number of dollars for Network 1 and
    divide it by the number of veterans that are being served. So
    that is the unique veteran.
        The allocation is actually done as a basic and a complex
    patient and the complex patients get almost 10 times the number
    of dollars that the basic care patients do, so we do make some
    adjustment for the complexity of the medical care required.
        Mr. Tierney. Thank you for clarifying that. Let me end, Mr.
    Chairman, with just a couple of questions about proposed
    communications.
        During your statement you described the new communications
    council and you mentioned several electronic means of
    communication. Do we have an estimate of the number of all the
    veterans that actually use computers? Do we have any statistics
    on that?
        Dr. Post. I do not have the number of veterans who have
    access to computers. I can tell you that in many of our
    facilities we are trying to provide them that opportunity.
        Mr. Tierney. And you have some idea, you must have an idea
    of how many veterans actually receive your printed newsletter?
        Dr. Post. I am sure that we have that number. I just do not
    have it off the top of my head. I apologize.
        Mr. Tierney. Since this is going to be the cornerstone of
    the new VHA where else can veterans obtain information related
    to the new services, charges of existing services, is there
    anything else that veterans here and others ought to know
    about, ways that they can access information?
        Dr. Post. Other than the printed material, there is access
    on the Web to the VISN 1 Website which has lots of information
    on it about the CBOCs, the services that we provide and what is
    available to them.
        Mr. Tierney. Thank you very much. I would like to thank all
    three of you for your testimony here this morning and for
    joining us.
        Mr. Shays. I would just conclude by making this comment. I
    think the most significant complaints we have from our veterans
    tend to be with the major facilities, the waits, the
    bureaucracy and so on. I think and I may find it is different,
    so I am sharing it with all of you to get your comments when
    you take to the mic, but I think the biggest area of compliment
    comes with the community based health care clinics, so it will
    be interesting to see from our veterans if that holds up. Is
    that something, is that consistent with what you are hearing?
        Dr. Murphy. That is actually very consistent with what we
    hear from veterans at the national level and at the local
    level. In fact, that is why we chose access and waiting times
    as a major initiative that we will take on in 2000 and 2001.
        Veterans want to be able to get in to see their physician
    in a short period of time. We have made a commitment that every
    veteran who calls for a first time primary care appointment
    will be seen within 30 days and they will be seen for a
    specialty appointment within 30 days. We know that in many
    facilities we are not meeting those goals at this point.
        Sometimes for services like orthopedic consults or
    ophthalmology consults or hearing testing, the waits are
    considerably longer. And in order to help us understand how we
    can reduce the waiting time for appointments, we have actually
    worked with the--we have an IHI initiative and it is amazing
    what we have learned through that.
        We have looked at how we have organized clinics. We have
    found about even changing the number of nurses or doctors
    assigned to that clinic. In one case we were able to reduce the
    waiting time from 159 days down to 7 days, just by changing the
    way the clinic was organized. That is astounding.
        So that kind of reengineering and improvement process can
    provide better service to veterans and it really did not take
    any increased dollars. It just took a focus on making a change.
        Mr. Shays. We are preparing to go on to our next panel, but
    if any of you would like to just make a closing comment, I
    would be happy to have you do that.
        Mr. Conte. I would just like to thank John and the rest of
    the people that work with John for the support and we have
    brought on these clinics. I really do not think we could have
    done it without the support of congressional people and working
    with the community and I think that is a real example how the
    VA should do this in the future.
        Mr. Shays. Thank you. Dr. Murphy.
        Dr. Murphy. I also want to thank the chairman and all the
    members of the subcommittee. You have been extremely supportive
    of the re-engineering process and the transformation of VHA.
    You have been clear with the Department that what they want to
    see is better health care to more veterans in a timely way and
    we thank you for your efforts on behalf of veterans.
        Mr. Shays. Thank all three of you.
        At this time we would call our next panel.
        All four of our next panelists are directors of Veterans
    Services. We have Mr. Robert Hogan, town of Burlington; Mr.
    Michael Ingham, city of Haverhill; Mr. Donald Welsh, city of
    Gloucester, and Mr. Jean-Guy Martineau, city of Salem.
        Will all four of you gentlemen raise your right hand,
    please?
        [Witnesses sworn.]
        Mr. Shays. Thank you. Note for the record, all four of our
    witnesses have responded in the affirmative. And I am going to
    have you testify in the reverse order I gave you, so Mr.
    Martineau, I will have you go first, then Mr. Welsh, then Mr.
    Ingham and Mr. Hogan, in that order.

        STATEMENTS OF JEAN-GUY MARTINEAU, DIRECTOR OF VETERANS
    SERVICES, CITY OF SALEM; DONALD T. WELSH, DIRECTOR OF VETERANS
     SERVICES, CITY OF GLOUCESTER; MICHAEL G. INGHAM, DIRECTOR OF
      VETERANS SERVICES, CITY OF HAVERHILL; AND ROBERT C. HOGAN,
           DIRECTOR OF VETERANS SERVICES, TOWN OF BURLINGTON

        Mr. Martineau. Thank you, Mr. Chairman.
        With well over 1,000 visits to the VA I feel qualified to
    tell you what has taken place in the VA health care system here
    in the Northeast. Within the past 9 years I have had a first
    hand look at the Department of Veterans' Affairs health care
    system.
        Daily, the Salem Veterans Services Department provides
    transportation to local VA medical centers. This includes the
    VA in Boston, Bedford, West Roxbury, Causeway Street clinic as
    well as the clinics in Lynn. My visits to these health care
    centers has brought me into contract with a great number of VA
    administrators and VA health care providers. I have also worked
    with VA social workers and patient representatives at the
    Chelsea Soldiers Home and the New England Shelter for Homeless
    Veterans in Boston.
        The impact of health care restructuring and reallocation of
    funding priorities has had the ``down sizing'' effect on the
    quality of care for veterans. Once a veteran has completed the
    eligibility process and enrolled in the health care system, he
    or she will not be seen by a primary care doctor for a month or
    more. Once they are assigned a primary care doctor, the veteran
    finds that the doctor is not experienced or is a medical
    student. I have found this to be particularly true in the
    mental health clinic in Bedford. Also, with so many foreign
    doctors, especially in the J.P. hospital, many veterans cannot
    easily communicate with their doctors. Real communication and
    patient confidence in their doctors is lacking.
        Also medical tests, which are required for proper doctor
    diagnosis in many cases cannot be given on a timely basis.
    Recently, one veteran I transported to the VA in February could
    not get an MRI until this coming May, a 3-month waiting period.
    I do not think that is good medical care. Beyond the inadequate
    medical care mentioned, personnel and administrative problems
    exists, morale among workers is at a long term low.
        Down sizing has resulted in many good experienced personnel
    retiring or having to do two or three additional jobs. This is
    especially noticeable in the social services and patient
    support groups. Another major problem caused by ``down sizing''
    is the complete ``inaccessibility'' of existing medical units.
        Long term, in patient nursing home care is for all intents
    and purposes unavailable. I have one veteran who filed for
    nursing home care 4 years ago. He is 100 service connected and
    we are still waiting for him to be admitted. Unfortunately,
    this case is a good example of the lack of any nursing home
    care for our veterans.
        I have some recommendations. As an experienced and
    concerned veterans advocate, I would be wrong not to take
    advance of this opportunity to offer some recommendations to
    improve the VA health care system.
        Reallocate funding to allow for Bedford VA to provide
    timely and appropriate nursing home care for all veterans who
    are 50 percent service connected.
        Target increased funding to the directors of Bedford and
    Boston to make sure that the existing administrative staffs
    have the funds to provide proper qualified and more experienced
    doctors and medical care providers.
        Provide more bed availability for the in-patient study and
    inpatient care in the GRECC unit which deals with dementia and
    Alzheimer health care.
        Increase the funding for existing outpatient clinics as
    well as providing for more neighborhood VA clinics.
        Gentlemen, you have only given me 5 minutes to provide
    testimony on 9 years of travel and first hand knowledge of the
    VA health care system. Five days of testimony would not be
    enough. So let me summarize by saying that I would never
    subjugate myself, a Vietnam veteran, or any member of my family
    to the VA health care system.
        I have always, in the past, in all my work's challenges,
    where I have spoken or testified had one model and that is
    ``better to light one candle than to curse the darkness,'' so
    if I see one hope it is in the newly opened and ever increasing
    VA clinics in Lynn and in Haverhill.
        In ending, I would be remiss if I did not thank Mr. Conte,
    the director of Bedford and his staff. Although Mr. Conte and I
    have in many cases agreed and in many cases disagreed, he has
    always and his staff have always made themselves available to
    me.
        I want to thank Congressman Tierney. I have worked my 9
    years with previous Congressmen Marvoulas, previous Congressman
    Torkelson and now with Congressman Tierney and he is one of the
    bright stars that represent us in Washington insofar as being a
    champion of veterans' issues and veterans' concerns and I want
    to thank Congressman Tierney for that.
        And one guy I want to thank that is in the audience and
    there are many people that I could single out, but you know,
    with the downsizing of the VA, to get immediately health and
    direct care, to make a difference, you can it right away if you
    go to New England Shelter for Homeless Veterans.
        Thank you, Tommy Lyons and your staff and also the Chelsea
    Soldiers' Home. I don't see anybody here from the Chelsea
    Soldiers' Home, but God bless them too. And I want thank all of
    you and the chairman and the congressional staff that is here
    for allowing the veterans to have this opportunity to listen to
    you, for you to come to us and I want to thank all of the
    veterans that come here that show enough concern to listen what
    you have to say. God bless the veteran.
        [The prepared statement of Mr. Martineau follows:]

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        [GRAPHIC] [TIFF OMITTED] T0278.027

        Mr. Shays. God bless the veteran and thank you.
        [Applause.]
        Mr. Shays. Mr. Welsh, if you would just get that mic and
    just lower it down a bit.
        Mr. Welsh. Mr. Chairman, Congressman Tierney, fellow
    veterans, ladies and gentlemen, good morning.
        My name is Don Welsh, as has been mentioned. I am the
    director of Veterans' Services for the beautiful city of
    Gloucester, MA and I do appreciate the opportunity to address
    this committee about the State of VA health care in my area of
    Massachusetts which I will refer to as Cape Ann. Having spent
    24 years in the Marine Corps I can tell you I thoroughly enjoy
    taking care of veterans and the more we can do for the veteran,
    the better.
        Let me start by saying the status of VA health care for the
    veterans I represent is generally speaking not good and it is
    getting worse. But I have a reason for saying that. It is
    because of the difficulty for veterans of Cape Ann to get to VA
    health care facilities. There are none in Cape Ann. Thus, these
    veterans have to travel many miles to the nearest facility
    after waiting a lengthy period for an appointment and often
    have to go back for a second or third time to complete
    treatment.
        What we need is a community based outpatient clinic [CBOC],
    in my area. You have heard a lot about that already this
    morning. I am well aware of the CBOCs that in recent years were
    opened in Haverhill and Lynn and the great relief they provided
    for the veterans in and near those cities. And as you have
    already heard, thanks to Congressman Tierney and his staff,
    application for a CBOC in my area has been made. How great it
    would be to open a VA clinic in Gloucester to service our aging
    veteran population which finds it more and more difficult to
    get around.
        Let me point out that in my city of Gloucester there is a
    higher percentage of veterans per capita than anywhere else in
    Massachusetts. It has been calculated that the average number
    of veterans in relation to the overall population of each city
    in Massachusetts is about 11 percent. In Gloucester, the
    veteran population is about 21 percent.
        And as I have mentioned it is an aging population. World
    War II veterans are in their late 70's or 80's and the Korean
    War Era vets are not far behind. It is very difficult for them
    to travel long distances for VA treatment. Many of them just go
    without much needed services, rather than make repeated trips
    to a VA facility.
        As Tom Brokow so eloquently wrote in his book, ``The
    Greatest Generation,'' which was about World War II veterans,
    ``They persevered through war . . . and then went to create
    interesting and useful lives in the America we have today . . .
    They answered the call to save the world from the two most
    powerful and ruthless military machines ever assembled . . .
    but they did not protest. They won the war; they saved the
    world.''
        Now, these veterans and veterans of other conflicts need
    our help. They need better health care services and the VA can
    and should be the instrument for those services. Let us not let
    our veterans down.
        As everyone knows, HMOs are cutting back on providing
    prescription drugs and this is becoming a real burden for many
    of our veterans, particularly those who are on fixed incomes.
    This is an area where the VA can pick up the torch and provide
    relief. But in order to do so we need more facilities, staff
    and dollar resources.
        Another area that should be addressed is the need to
    provide dental care for our veterans. Today, that service is
    almost nonexistent. I get inquiries every week from veterans
    about availability of dental care, but very few veterans are
    eligible under current rules for such VA health care. With
    skyrocketing dental costs and again with an aging veteran
    population, a more liberal dental policy should be adopted by
    the VA.
        I will close with a request for another area to be
    addressed by this committee. It concerns communication by or
    about VA health care services. What I am experiencing these
    days with veterans who are being discharged from active duty is
    that many are not informed about the VA services available to
    them. It should be a mandatory policy that every member of the
    Armed Forces be given a Veterans' Affairs briefing prior to
    release from active duty. If that is a policy, it is not
    working in many cases. As a result, veterans are missing out on
    benefits, particularly in the health services area.
        Thank you very much.
        [The prepared statement of Mr. Welsh follows:]

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        Mr. Tierney. Your last suggestion is something that we will
    just separate right now and we will write a letter to the
    Secretary of Defense and those who have direct responsibility.
    It is an excellent idea. If it is happening, I am not sure if
    it is a requirement. I agree, I am not sure it is happening.
    And we will make sure that that is something we deal with right
    away when we get back. It is an excellent suggestion.
        Mr. Welsh. Thank you, Mr. Chairman.
        Mr. Shays. Mr. Ingham.
        Mr. Tierney. I have already tasked one of my task. I will
    have her announce her name later, so if it does not happen, you
    will know who to call.
        Mr. Ingham. Congressman Shays, Congressman Tierney, fellow
    veterans, the ROTC students here--I just left 2 weeks at the
    Air Force Academy, the Air Force Reserves and hopefully, you
    students will attend that college and serve.
        As the Veterans Services director for the city of
    Haverhill, MA, one of the most common requests from veterans of
    my office is assistance with medical care and prescriptions.
        With this in mind, I was very fortunate to meet William
    Conte, the director of the Bedford VA and formulate plans for
    health care services for veterans outside of the Bedford
    Hospital. These were dramatic steps for the VA to go outside
    the traditional system of providing care and bring health care
    services directly to the veterans in their community.
        The first step was to develop a survey to define the health
    needs of the veterans and what issues that might be preventing
    them from using the VA health care service. Along with local
    organizations, the Veterans Council of Haverhill, we held a
    health day with medical teams from the Bedford VA Hospital.
    Over 700 veterans and their families attended.
        The results of the survey indicated that a lack of
    knowledge of the VA system and services that were available was
    the primary reason for not using the VA. The second problem
    identified was transportation as many of the veterans were
    elderly, driving to distant VA facilities was too difficult.
    The survey also showed priorities of care that the veterans
    would utilize. The most overwhelming need was assistance with
    prescriptions. An interesting point of the survey was the
    income level; many veterans earn under $25,000 annually. Many
    veterans identified needs that related directly to age such as
    ophthalmology, cardiology, urology and rheumatology.
        With the health needs established, transportation issues to
    address and education priorities outlined, we brought our
    findings to Dr. Fitzgerald, the director of the New England
    Health Care System for submission to the VA for congressional
    consideration.
        Thanks to the support of Congressman Tierney, local and
    State officials, veterans organizations, the Veterans Outreach
    Center and Veterans Services of Haverhill, we were able to
    approve as a site for a veterans community based outpatient
    clinic.
        With staffing from the Bedford VA Hospital and site work
    completed, the Haverhill Clinic opened in November 1998 at the
    city-owned Hale Hospital. The staff members, half of whom work
    part-time out of the Bedford VA, the clinic is now serving over
    1,200 veterans. With new patients enrolling daily, staff and
    services continue to increase with the demand.
        Substance abuse and psychological care is now available
    twice a week and plans are to expand the service with added
    space when available. Issues such as agent orange and the Gulf
    War Syndrome, as well as assistance with VA compensation claims
    can be addressed at the clinic. The Haverhill Clinic staff
    often assists agents with placement for substance abuse, Post
    Traumatic Stress Disorder treatment, often while the veteran is
    in the Veterans Services Office and in need of immediate help.
        The clinic is only primary outpatient care, but importantly
    the Haverhill Clinic is tied into a network of extensive health
    care between the Bedford VA and the Boston VA hospitals. The
    clinic provides accessibility to a coordinated and a continuity
    of care with courtesy, family involvement and patient
    education. In a new era of health care, the VA must reach
    veterans and educate them on their benefits, and we in the
    service of veterans are responsible to do the best we can to
    see that they receive the benefits available.
        The Haverhill Community Based Outpatient Clinic has
    dramatically impacted the veterans of Haverhill as well as
    other communities in the Merrimack Valley and lower New
    Hampshire. The overwhelming response of the veterans using the
    clinic is that they are totally satisfied with the treatment
    they received, both personally as well as physically.
        Dr. Balse and his staff have done an outstanding job
    providing health services to veterans that should be used as an
    example for future clinics throughout the country. I have had
    veterans tell me how much their lives have changed with the
    care they are now receiving at the Haverhill Veterans
    Outpatient Clinic.
        Some feel their lives were saved as a direct result of
    visiting the clinic. I know of one veteran that thought he was
    in good health, and upon a visit to the clinic found he had a
    life threatening heart condition that resulted in cardiac
    surgery that was performed by the VA doctors at Jamaica Plains,
    Boston.
        The pharmacy program is probably the most used service at
    the clinic. Medications are requested by the primary doctor and
    filled by mail from the Bedford pharmacy. Veterans are saving
    substantially on medications enabling them to lead healthier
    lives as well as a better standard of living.
        Bedford, Lynn and Haverhill, due to the marriage of health
    care services provided over 190,000 visits to veterans in 1999,
    in these hospitals alone. That equals to approximately three
    visits per veteran in the system. This is a dramatic result for
    1 year in business and we have only reached approximately 15
    percent of the 36,000 veterans in the Merrimack Valley.
        As I mentioned earlier, transportation is a primary reason
    veterans are not taking advantage of the VA health care system.
    Many veterans with illnesses depend on family members to take
    them for medical treatment. This is a stress on the entire
    family, not just the veteran.
        With the clinic centrally located in the Merrimack Valley,
    many veterans are able to take advantage of care they often
    went without. Haverhill is very fortunate to have a van and a
    driver under the Department of Veterans' Services to take
    veterans to the VA hospitals. The Northeast Veterans Outreach
    Center is also under the Department of Veterans' Services,
    provides transportation to the clinic with a van donated by the
    Massachusetts Department of Disabled American Veterans.
        Haverhill also provides transportation through the
    Department of Human Services. This is free transportation for
    Haverhill's elderly, handicapped and veteran residents.
    Transportation is available from the Haverhill Clinic to the
    Bedford VA with a daily shuttle. Haverhill also has the MVRTA
    bus system.
        The problem for veterans outside of Haverhill is getting to
    the clinic as well as transportation to VA hospitals in Boston.
    Expanded public transportation, discounts for existing
    transportation, or grants to towns and cities to provide
    limited transportation for veterans will make it possible for
    them to take advantage of the health services available.
        It is in our best interest to see that veterans are made
    aware of the advantages of the New England health care system.
    Prevention and treatment will ensure healthier and more
    productive lives and save on taxpayers in the future. Many
    veterans have service related injuries both physically, as well
    as psychologically, the Haverhill Clinic fulfills and
    obligation to them for their service to our Nation with the
    best health care we can provide.
        We are here today to request of you to express to
    Washington that it is imperative to maintain the quality of our
    VA health care system and to see that adequate funds are there
    in the new millennium for a generation that preserved the
    freedom of this country that all of us in the 21st century will
    hopefully enjoy.
        I wish to close by thanking you for listening to our
    comments today and commend you for your efforts to best serve
    all veterans of the U.S. Armed Forces.
        Thank you.
        [The prepared statement of Mr. Ingham follows:]

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        Mr. Shays. Thank you, Mr. Ingham.
        Mr. Hogan.
        Mr. Hogan. Chairman Shays, Congressman Tierney, Mr. Conte,
    ladies and gentlemen and fellow veterans, thank you for
    allowing me the opportunity to discuss the impact of VA health
    care service restructuring and resource allocation in the
    delivery and quality of health care.
        I have three areas that I intend to address here today, one
    being long term care for our veterans, another is continued
    access to VA health care services for all veterans, and finally
    and briefly, some comments on hepatitis C care and funding.
        We need to make sure that the VA health care system is
    sound enough and funded well enough, not for the healthy among
    us, but for those among us that hope for quality health care
    during their journey through this life and at the end of our
    life. We need to live up to the promises and expectations of
    our elderly veterans who need the coverage that the VA health
    care system promised them, over the five, six or seven decades.
        That coverage may take several forms, such as VA nursing
    home care, community based nursing home care, and nursing care
    for the veterans in their own home. But we cannot be told that
    there is no room at the inn or that specific alternative care
    that is promised has not yet be established or funded.
        The funding for the new Millennium Health Care and Benefits
    Act should be applauded for its beginnings, but it must
    continue to grow and expand with the very increasing needs of
    our veterans as they age and need proper medical care.
        In the March edition of VFW Magazine, Republic Congressman
    Bob Stump stated that this health care package is a blueprint
    for the next century. Well, that sounds good, but without the
    required funding, the blueprint will sit and collect dust and
    the lack of funding can in no way diminish the VA's obligation
    to maintain and deliver proper and appropriate health care to
    our veterans. And it is the responsibility of every Member of
    Congress to help the VA meet this obligation. In that same
    edition, Democratic Congressman Lane Evans reaffirmed Congress'
    proud support for our Nation's veterans.
        Now comes the difficult task of trying to wed that concept
    to reality. The passage of the Veterans Millennium Health Care
    and Benefits Act in November of this past year has good
    direction, but there needs to be significant plans on how to
    get to the goals stated, and money is one key component in that
    plan.
        The bill directs that the VA operate and maintain a
    national program of extended care services including geriatric
    evaluations, nursing home care, both in-house and contract,
    adult day care, domiciliary care and respite care. With a
    national nursing home crisis we are seeing nursing homes
    closing due to cutbacks in Federal funding. In Massachusetts
    alone, 93 of the State's 580 nursing homes are already in
    bankruptcy with 13 homes closing over the past 2 years.
        The VA should not depend on there being enough good quality
    nursing homes available and with there being almost 5,000
    complaints against nursing homes sin this State alone last
    year, the good quality part of that equation is also in doubt.
    The VA should not be dumping its veterans out to lesser quality
    care.
        The Millennium Health Care Act requires the VA to develop
    and begin to implement a plan for carrying out the
    recommendations of the Federal Advisory Committee on the Future
    of Long Term Care, and that the VA increase both home care and
    community based care options.
        The elderly veterans who need this care now are the
    builders of this great society. They sacrificed in war and they
    sacrificed in peace and now just because they have aged does
    not mean the VA and this country can forget them. They are an
    important part of this great society and they have earned the
    right to expect to be treated with dignity and be accorded the
    care any decent society can afford, not years from now.
        Throughout the 20th century, brave young men and women,
    young boys and girls actually, who gave up their youth and the
    comfort of their home and the safety of their families
    volunteered and were drafted to serve their country and on many
    occasions either died or were injured because of that service
    to their country. And what is not in the testimony, Mr.
    Chairman, if I could just remember the 19 Marines who passed
    away this weekend and note that service to this country can be
    hazardous both here and around the world, both in peace and in
    war.
        Throughout America's history, American veterans have served
    and served well. They saw democracy challenged, here and around
    the world and they defended it. They saw civilization
    threatened here and around the world and they rescued it. They
    saw human rights endangered and they sought to restore them.
        Their heroism was prompted by faith in the fundamentals
    that have guided this Nation from its beginnings. The idea was
    that liberty must be protected, whatever the cost. And the VA
    health care system owes that same dedication to those men and
    women, whatever the cost.
        And the VA must consider itself a supplier of a service and
    that customer satisfaction is their top priority. The VA must
    develop a communication plan so that anyone and everyone at the
    VA who answers the telephone or sits at a desk must know what
    the game plan is and where the resources are for the veterans
    and their families and the VA must be user friendly. The VA
    must be veteran friendly.
        And Congress to guarantee permanent funding for all
    veterans. We cannot continue to inflict emotional distress upon
    the veterans who quality for VA health care, that they will not
    have this taken away from them based simply on cost
    considerations.
        There is a health care prescription medicine crisis in the
    broader health care structure that affects the VA health care
    system. Many veterans who have private health insurance have no
    prescription coverage for the drugs they need. Even in our most
    extensive public insurance program, Medicare, three out of five
    seniors in this country do not have dependable drug coverage.
        According to a recent report from the House Government
    Reform Committee of which both Congressman Tierney and
    Congressman Shays are members, drug companies charge older
    Americans discriminatory prices. Seniors in many parts of this
    country, including New England, are being forced to pay on
    average, more than twice as much for prescription drugs than
    other customers.
        Health care is one of the most important issues in this
    country today. And it is so because of the explosion of health
    care crises around the country. President and future health
    care crises will send veterans to the VA in droves to secure
    the proper health care. The VA will need to be ready to handle
    that need and the VA must continue to provide care to the
    veterans that has been promised to them, that VA health care
    must provide quality care to the right patient at the right
    time and at the right level of care.
        If we do not take dramatic steps now to address these
    issues, it will only be harder for us down the road to be more
    diligent to ensure good quality care for our aging veterans.
        And finally and quickly I would like to comment about
    hepatitis C care and funding. Hepatitis C is a fairly new, yet
    very disturbing medical risk and the veterans are on the high
    side of the curve when it does come to those infected, as you
    heard us talk earlier. It is also very costly and it will be a
    major impact on the VA budget line item. Treatment can be
    expected to run a minimum of $10,000 per year for each veteran
    infected with the disease and future prevention and treatment
    to try and prevent additional damage to one's liver are also
    considerable. It is on the radar screen for one very good
    reason. It is important.
        Thank you for allowing me this opportunity to address these
    issues.
        [The prepared statement of Mr. Hogan follows:]

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        [GRAPHIC] [TIFF OMITTED] T0278.034

        [GRAPHIC] [TIFF OMITTED] T0278.035

        Mr. Shays. Thank you very much. I should have asked. I make
    an assumption and maybe incorrectly that all of you have served
    in the military and I would love for you to each just share
    where you served and what branch.
        Mr. Hogan. All of us have served. I served in the U.S. Army
    and I served in Vietnam in the late 1960's.
        Mr. Shays. Thank you for your service. Mr. Ingham.
        Mr. Ingham. Yes, I served in the U.S. Air Force. I was
    there during the Vietnam Era. I served in Germany and in the
    United States. I was activated for Desert Storm. Again, I
    served here in the States at Westover Air Force Base and I am
    currently in the Air Force Reserves as a Senior Master
    Sergeant. I have approximately 26 years and still going.
        Mr. Shays. Sergeant, thank you for your service. Mr. Welsh.
        Mr. Welsh. Twenty-four years in the Marine Corps, starting
    with Tet Offensive in Vietnam, finishing up with Desert Storm.
        Mr. Shays. Thank you. Mr. Martineau.
        Mr. Martineau. I served from 1968 to 1972, U.S. Navy with 2
    years in Vietnam.
        Mr. Shays. Thank you, sir. Thank you all for your service.
        [Applause.]
        Mr. Shays. I am going to recognize Mr. Tierney, but I am
    going to ask you a question now that I would like you to just
    think about, if he is not asking you a direct question. And I
    would like you, I want to make the assumption that the clinics
    tend to be more user friendly and that they are a relatively
    new innovation of the VA that you are pleased with, but I would
    like to know if that is true.
        I would like to know the best and the worse VA clinic and I
    would also like to know the best and the worse of the major
    facilities, what you think, so for instance, Mr. Martineau, I
    am going to force you to think of something really good about
    the major facility and we will get to it later. I will get the
    answers to my questions when Mr. Tierney is finished. Thank
    you.
        Mr. Tierney.
        Mr. Tierney. Thank you. As Irish as I look, part of me is
    French so I know for sure that it is Martineau on that and I
    hope, I see that you have so much to say and so little time to
    say it, it is always easy to speak for about an hour when you
    are passionate on an issue, but not quite as easy to speak for
    5 minutes. So the next time you turn to C-SPAN you will see
    Chairman Shays and I struggling to get our thoughts in in 1
    minute and you will know of the difficulty that is there.
        Let me just say, Mr. Chairman, as I waive the deduction,
    you see four of our veterans' agents who I am proud to have in
    our District and work with and they are just an example of the
    great veterans' agent that we have in this District and that
    make our job that much easier and they represent the veterans
    so well. So I want to thank you publicly for the work that each
    of you do and for those that are in the audience that also work
    with us.
        Jean-Guy, I know you are busy thinking of Chris' question,
    the chairman's question, but I do want to ask you, I know for a
    fact the amount of time that you spend on transportation, you
    personally, take any number of veterans where they have to go
    and Mr. Ingham, I am going to ask you the same question because
    I know you do a lot of the same and I suspect that the others
    do also.
        What can we do to improve the transportation situation
    between the veterans' homes and the clinics and the clinics and
    the hospitals in Jamaica Plain, in West Roxbury and in Bedford?
        Mr. Martineau. That is a very complicated question.
    Basically, it is almost impossible to really improve the
    immediate needs of transportation because the majority of the
    veterans that we transport to hospital, the reason why we do it
    is because they cannot take public transportation because they
    cannot even go to the clinics because they are either in
    wheelchairs or they have walking problems and they have to use
    walkers.
        So we have to literally get them from their doorstep to the
    door of a parking lot over at the VA Clinic in Lynn and we do
    transportation, of course, as we told you at the Chelsea
    Soldiers' Home as well as the VA Clinic in Boston and the one
    in Bedford.
        And again, many of these elderly veterans are World War II
    veterans and now Korean War veterans do have mobility problems.
    So to improve the transportation I think what you would have to
    do is guarantee funding for transportation that is more
    personal and more accessible to those veterans who cannot walk
    on their own. They cannot even get up from a wheelchair on
    their own without assistance.
        So it is nice to have a car. It is even nicer to have a DAV
    van and I compliment the DAV. I can go on complimenting other
    organizations. However, unless you have someone who can
    physically assist the veteran out of his wheelchair or help him
    with his walker, he or she with his walker, it will not really
    make an immediate difference, but again, any support in funding
    that you can give on the short term and the long term directly
    to the cities and towns, veteran funding directly targeted at
    the clinics to provide transportation would be a definite
    assistance.
        Mr. Tierney. Thank you.
        Just by way of note I am going to talk to the chairman
    about this at some point in time and the committee members,
    probably trying to establish some sort of a pilot program, but
    I do not know just where we are going with it yet.
        Mr. Ingham, maybe you can give us some suggestions too
    about what we might think of in terms of trying to get together
    an idea of how we go about this and also tell me if you would
    about Mass. Ride and whether or not positively impacts or gives
    you any assistance in this area?
        Mr. Ingham. One of the important issues is not so much as
    getting the vehicles. There are many organizations out there
    who are willing to donate vehicles. It is finding drivers.
    Volunteer drivers are very difficult to get. I deal with a lot
    of volunteer drivers for elderly transportation as well as for
    veterans and it is more a funding issue.
        If you make it through either grants or through the
    government, really any kind of forms of funding where you make
    this affirmative position for driving is probably the largest
    improvement that you could do for help getting veterans into
    the hospitals.
        As far as the outreach center, they looked for quite a
    while to get a volunteer driver. They had a van donated from
    the DAV, but again, the most difficult part was finding a
    volunteer driver. So I think if there is any way that you could
    push for funding, through grants or whatever forms you can to
    get a permanent driver that would basically be the best
    solution.
        Mr. Tierney. Thank you. Mr. Hogan and Mr. Welsh, I would
    like to talk to you a little bit about the communication
    aspect.
        Mr. Hogan, you indicated that not every veteran is aware of
    his rights, what might be available to him or her within the
    health care, VA health care system. Can you tell us what you
    believe is the most used source of information by veterans, at
    least from your information?
        Mr. Hogan. I have most access in my community to the local
    newspaper, the local cable and I work very well with Mr. Conte
    and Mr. Bill Davis from the Bedford VA and for the chairman's
    information, my proximity to the Bedford VA is rather close, so
    I have a different perspective than the other gentleman.
        I think if the VA and its representatives were to continue
    to do that, to work with the agents and the service
    organizations within the communities to have them disseminate
    the information, when I came on board as a veterans' agent, I
    was surprised at how little so many of the veterans knew about
    what was available to them through the VA. So I think the VA by
    itself putting out a newsletter on a Website is one thing, but
    I think they have to network just as well with the agents and
    the service offices within the communities.
        Mr. Tierney. What sort of information you get as veterans
    agents when you are dealing with the Veterans' Administration?
        Mr. Welsh. You mean----
        Mr. Tierney. The Veterans' Administration, how do they
    communicate with you and how often do you meet with
    representatives, how often do you get either e-mails----
        Mr. Welsh. The Website is a good source. There is also a
    book, we call our bible so to speak. It is ``What Every Veteran
    Should Know.'' I use the 800 number a lot. There is no problem
    with communication between an office like mine or the other
    veterans' offices across Massachusetts. Massachusetts is unique
    with this veterans' benefits, the agents that we are.
        I think there is only one or two other States that have the
    same system, so the veterans in our communities can come to our
    office and ask any question whether it is a State-related
    question or Federal VA and we have all sorts of way to get this
    information, as I mentioned, not only by the literature that is
    put out, the Website, but also the regional number and I have
    had no problem in getting good feedback from the VA system and
    in particular, the health care system.
        I want to make a little pitch here in case I am not asked
    about the Bedford system. I think they are super. They provide
    a great service and I know the veterans from Gloucester, at
    least the majority of them and have never had one complaint
    about the VA system in Bedford.
        Mr. Tierney. While I have you at the mic, I know that you
    believe strongly in traditional clinics, community based
    outreach clinics. Could you take just a moment to put on the
    record what that would mean to the average Gloucester veteran
    resident?
        Mr. Welsh. A lot. As I mentioned there are so many veterans
    in Gloucester and particularly from the World War II area, many
    on oxygen. There is no transportation system to the other
    facilities, something that I know your office and I will be
    working on. And particularly for those World War II veterans,
    just to be able to go down the street to a clinic if we had one
    in Gloucester, I would be happy to go pick them up at their
    door and take them because it is just so difficult for them to
    get out. We have facilities in Gloucester and I know again for
    the older veterans it would just be a tremendous thing.
        And even the younger veterans, many of them do not have the
    ability to drive. They have problems that keep from even taking
    public transportation, but particularly for the older veteran
    it would be a tremendous thing.
        Mr. Tierney. Thank you very much for that. Let me just ask
    one last question, Mr. Ingham. I am gratified that so many
    veterans find the community clinics helpful as you indicated,
    but in the course of your testimony described as key to the
    earlier detection and prevention as well as life saving
    capabilities, things that have talked about, do you have a
    specific example in mind when you mentioned those issues?
        Mr. Ingham. I have a specific case. An individual came into
    my office. He was having a hard time in trying to get health
    insurance and he came and asked me how could I help him out and
    that was right when we started the clinic, he was probably one
    of the first ones to get in. He was the individual I was
    talking about that had the heart condition. So he went in, got
    into the system, saw Dr. Balse, was found to have a heart
    condition, went through the VA system, was treated and still
    comes in to see me regularly.
        We did have another individual, Walter Hamal, who is our
    last World War I veteran. He was also one of the first into the
    clinic, as our first customer, basically. Unfortunately, he
    just passed away, but he did take quite advantage of the system
    and was very happy for it.
        I want to bring up one point brought up earlier by
    Congressman Tierney, two, possibly three. I think it is because
    of his commitment and a stronger point was education. We
    throughout the veterans organizations in Haverhill, we all as
    veterans' councils, came together very closely as a unit to get
    the clinic into Haverhill and because I think of that we are
    able to get more education out there and there was more
    information brought into the community. So that is a big reason
    that we do have the clinic.
        Mr. Tierney. Well, you lobbied it last night, the staff
    tried to get me lost in Boston, trying to explain how difficult
    it is to get into Boston from here, so it never ends. They work
    on everyone.
        One last question. This is just a curiosity question, Mr.
    Welsh. I want to know if it is ever been determined why we have
    the higher concentration of veterans in Gloucester?
        Mr. Welsh. Fishermen. Many of them are natives.
        Mr. Tierney. Last, let me just reiterate as some of our
    witnesses have said before, we have an excellent homeless
    shelter here and Tom Lyons is in the audience and does a great
    deal of work with that. We have spent a lot of attention in
    Congress trying to deal with special veterans' issues, that is
    one of them, obviously and I just want to add my commendations
    to Tom and people who work with him for the great work they do.
        Mr. Shays. I hope he will address the committee so we will
    have him on record as well.
        Mr. Tierney. Thank you, Mr. Chairman. Thank you, witnesses.
        Mr. Shays. I am wanting to know the best and worse of both
    the clinics and the primary VA facilities. And Mr. Hogan, I
    will start with you.
        Mr. Hogan. The best part of it, I think, is the care, once
    you get into the door.
        Mr. Shays. Which facility?
        Mr. Hogan. I am with the Edith Nourse Rogers, again, I am
    the director which is next door to Bedford.
        Mr. Shays. So you do not really utilize the clinics?
        Mr. Hogan. No. But the care in the facility, I think, is
    wonderful once you get through the door. The worse part
    sometimes is beds, there is not enough time and with the aging
    population, an awful lot more people with education are trying
    to use the facility, so I think sometimes the weight could be
    the worse part, but I think the care, once we get through the
    door is the best Bedford has to offer.
        Mr. Shays. Mr. Ingham.
        Mr. Ingham. I think the best of the care dealing with the
    CBOC. A comment was made that their staff should be commended,
    Dr. Balze, the nurses, nurse practitioners, everybody there is
    just excellent and willing to work with the veterans. It has
    been a unique experience to start just developing the clinic
    and where we went with that and getting the organizations
    together with a letter of writing and calling of Congress and
    everything.
        But the work of the facility, like the Bedford VA is so
    advanced to look ahead into the future as Mr. Conte did, we
    started out with really nothing and got health care into
    Haverhill. It is just an amazing event.
        Mr. Shays. What about the larger facilities?
        Mr. Ingham. I think the problem with the larger facilities
    is transportation, getting into them. A lot of the older
    veterans, especially, are intimidated trying to take the
    services to get in there. And I think our future too with the
    geriatric type situations. We were just told as agents at our
    last meeting that there is a high rate of Alzheimer's with
    veterans and they do not really know why. It seems that in the
    general population that veterans----
        Mr. Shays. What would be the best that you would see in the
    larger facilities?
        Mr. Ingham. Probably just the overall care. They can handle
    anything from cardiac, heart conditions, all type of care. It
    is there, it is available and it is a shame that many are not
    taking use of it.
        Mr. Shays. Mr. Welsh.
        Mr. Welsh. As I have already mentioned I believe the
    Bedford Medical Center is the best in the area. I am not very
    familiar with Haverhill because people do not go from
    Gloucester to Haverhill, but those that have gone to the Lynn
    outpatient clinic seem to be satisfied. The worse is the clinic
    on Causeway Street in Boston, that is my----
        Mr. Shays. So your point rather than saying what is the
    best or the worse of the clinics, you are actually saying which
    clinic you think needs the most improvement?
        Mr. Welsh. Yes sir.
        Mr. Shays. Let me just quickly, why do you think that needs
    the most improvement? Just in terms of the interaction or
    parking or what, the facility itself?
        Mr. Welsh. When we talk about the outpatient clinic?
        Mr. Shays. Yes.
        Mr. Welsh. In Lynn, there is no problem with parking. You
    cannot get to Lynn from Gloucester. It is one of those tough
    things, but there is adequate parking. I think the people are
    very courteous and that is why I do not have many complaints
    about the Lynn outpatient clinic. Causeway is a big problem
    because there is no parking and there seems to be a different
    attitude at the Causeway----
        Mr. Shays. Do they have more queuing up there? Is it more
    like the traditional motor vehicle department?
        Mr. Welsh. I think there is more of a downsizing of
    Causeway. Someone else could answer it better than me, but it
    seems as though it is going away.
        Mr. Shays. OK, Mr. Martineau.
        Mr. Martineau. Mr. Chairman, I am not here to throw hand
    grenades, maybe a few rocks and pebbles, but not hand grenades.
        Mr. Shays. He says that because he is a veteran not only of
    the service, but a veteran of the city council and they know
    how to do this. [Laughter.]
        Mr. Martineau. I am a good Republican, Mr. Chairman.
    [Laughter.]
        Mr. Shays. I want to give you special time. I have not met
    a Republican in Massachusetts, so this is--[laughter.]
        Mr. Martineau. I knew we had something in common, Mr.
    Chairman. You know, I just want to preface my remarks by saying
    that I find my responsibility with the veteran initially is to
    give him the best first visit he can get at a VA health care
    facility.
        This is why I personally take that veteran to the hospital,
    clinic myself, so I know what I am talking about. I do this
    almost on a daily basis. So I had some initial problems with
    the Lynn clinic as the Congressman knows, and his staff. He is
    got a fantastic staff. And they have ironed those problems out.
        The good part about the Lynn clinic is many of our veterans
    will go there on their own. It is a short ride today and it
    lessens their transportation time. The bad part about the Lynn
    Clinic is many of the veterans will travel to the Lynn Clinic
    and then will find that they will have to leave the Lynn
    Clinic, take a shuttle and go to Bedford of JP for testing.
        Mr. Shays. So these are services they are not really going
    to get?
        Mr. Martineau. And I will be at Bedford or I will be at
    Jamaica Plain and once I get there and transport my veterans
    there, some of the veterans will recognize me who are on a
    shuttle from Lynn, will ask me to take them home from Bedford
    and take them back to Lynn because it is really on our way back
    to Salem.
        So as far as the Lynn Clinic goes, my hats off to the
    decisionmakers to go that route. I think the neighborhood
    clinics as Lynn and elsewhere are very important because
    generally speaking it does save time in the veterans' traveling
    day.
        Mr. Shays. How about the primary major facilities? What is
    the best and the worse?
        Mr. Martineau. I can speak for a long time on Bedford and
    Jamaica Plain and the Causeway Street clinic, but let me just
    generalize, because--I do not understand communication between
    Bedford and Boston. There is none. I have had one veteran as
    recently as a couple of months ago who had been treated in the
    JP Clinic in Boston, the Jamaica Plain for years and it took
    him 4 hours administratively eligible for medical care in
    Bedford, 4 hours. So here is a guy that had VA health care in
    Boston and going to Bedford he had to be re-enrolled all over
    again.
        Mr. Shays. Fair enough, so communication----
        Mr. Martineau. Computer linkup, Mr. Chairman.
        Mr. Shays. And common sense.
        Mr. Martineau. Yes, there is no--I do not know what the
    computer linkup is, but as far as I can see, there is not any.
        The other problem that I have experienced is going in with
    the veterans, the doctors are not experienced for the most
    part. You have too many foreign doctors and you have too many
    doctors that are really not experienced. They are students who
    are practicing medicine on our veterans and I do not think that
    is right.
        Mr. Shays. OK.
        Mr. Martineau. Insofar as the administrative staffs, I
    think that now too many of our administrators, health care
    providers, social workers and patient representatives are doing
    two and three jobs and I do not think--it is because of the
    downsizing effect and I think that is a drawback.
        Let me just say some good comments that I would like to
    make about Bedford and Jamaica Plain. Accessibility to the
    administrators and the social workers in these hospitals is
    excellent. I have never been refused on a moment's basis. They
    have always taken time from their day. I do not know if it is
    because I will go to their bosses.
        Mr. Shays. But it is a very important positive and it is
    nice that you are expressing that. So access is there and that
    is great to hear.
        Mr. Martineau. Also Bedford provides terrific adult day
    care and especially their branch office over at the Chelsea
    Soldiers Home. I think that could be expanded, but I
    congratulate Bedford for their adult day care and the services
    that they provide with their staff at the Chelsea Soldiers
    Home, that is really great. But you know what is really
    fantastic about both Bedford and Jamaica Plain and that is
    their detox.
        A lot of homeless veterans can get detox in Bedford and
    Jamaica Plain and when you take them they immediately get the
    care that they need.
        They have teams of people that surround themselves with
    these veterans and take care of their emotional needs, their
    physical needs, their rehabilitation needs, getting them back
    on their feet, both personally, professionally, medically and
    also followup. So as far as detox goes in Bedford and Jamaica
    Plain. They are the best. So that is about it.
        Mr. Shays. Thank you very much. I have some questions that
    I would just love to get on the record. I am going to look for
    shorter answers because I do want to hear from the veterans
    that are going to speak. By the way, I would invite you all to
    stay up there if you like while the veterans are making
    comments and if it is not abused invite you to make short
    comment periodically about what you have heard, if you would
    like.
        I would like to first ask have you noticed an increase in
    veterans taking part in the VA health care system? If the
    answer is yes, why do you think this is the case? If no, what
    can be done to encourage veterans. I not looking for long
    answers, but are you seeing the increase and then respond why
    you think your answer is what it is.
        We will go with you, Mr. Martineau, first since you have
    the mic.
        Mr. Martineau. As it has been stated by my fellow veterans'
    advocates up here, we have definitely seen an increase in
    people going to the VA because of the downsizing of the HMOs
    and the downsizing of their private health services.
        Mr. Shays. OK, the reason I am having trouble with a French
    name is because I am married to a French woman named Deraine so
    there is no excuse.
        Yes?
        Mr. Welsh. Definitely an increase in veterans signing up
    because we have had some great health fairs, thanks to
    Congressman Tierney's office. Also, our veterans' services
    organizations in Gloucester, AMVETS, VFW, American Legion, they
    have gotten the word out, so communication, publicity, we have
    newspaper articles from time to time, veterans say I can sign
    up and they do.
        Mr. Shays. I know Mr. Martineau was responding, nodding the
    head as you made that point too, so Mr. Ingham?
        Mr. Ingham. Yes, definitely, the CBOC in Haverhill is
    seeing an increase close to approximately 50 a month. I said
    1,200 over the year. I think most of it is due to education and
    the biggest is on word of mouth. Veterans talk to veterans.
    That is one of the biggest ways of getting it around.
        Mr. Shays. Mr. Hogan.
        Mr. Hogan. I agree also. I think there is an increase of
    use going on right now. A lot of it has to do with the
    publicity that we are able to get out through veterans'
    newsletters, newspaper articles. Once the veterans realize that
    they are eligible now and I think one of the big issues right
    now is that there is a pharmacy use and the hospitals because
    of the explosion of co-payments and insurance problems with
    medications and pharmaceuticals, they are going to the VA and
    they are signing up.
        Mr. Shays. Let me do this, let me--if you do not mind
    staying up there you are welcome if you have to leave for a
    second and want to come back. We will invite from our audience
    anyone who wants to make some comments and this is how it is
    going to work.
        I am going to ask, Karen, I am going to ask you to get
    their name and address on a file card after they have spoken so
    we can get the transcriber the exact spelling of your name. We
    are going to want to know if you served, where you served, what
    branch you served in and where you served. We can use the
    portable mic if that works.
        Jason, you have the mic. Let us do that.
        Mr. Tierney. Mr. Chairman, just 1 second. I think it should
    be noted for those that might not already know it, several of
    the veterans service organizations have representatives here,
    but they have also been invited by the chairman to submit for
    the record. We would like to have that and it will all be
    entered on the record.
        Mr. Shays. It will all be entered into the record. So sir,
    I see you are standing up and we will invite you on that side.
        Let me ask you, are there mics on both--we do not need the
    portable mic--do the mics work that are there? Can you turn the
    floor mics on to see if they are--would you see if that one
    works? Just speak into it a second. Yes, both of them work, so
    we will use that, Jason, so we do not need you to hold the mic
    there, but Karen, when they are done, get the full name and
    address so we will be able to have it on the record.
        OK, and if you would state your name, if you served, the
    branch of service and where you served.
        Sgt. Bryan. My name is Staff Sergeant Edward J. Bryan. I am
    still active in the Massachusetts National Guard. I joined the
    service in 1974, U.S. Army.
        Mr. Shays. Let me say this. I am going to do 2 minutes a
    statement. Is that all right?
        Sgt. Bryan. Yes. I only have a few basic questions, they
    are kind of loaded ones, but I am not throwing hand grenades.
        Mr. Shays. You have got a lot of pages, that is why I am
    concerned.
        Sgt. Bryan. I already submitted them for the record.
        Mr. Shays. OK, sir, again your name.
        Sgt. Bryan. Edward J. Bryan.
        Mr. Shays. Mr. Bryan, thank you.
        Sgt. Bryan. I served with the 1173rd Transportation
    Terminal Unit in Boston. Went to Saudi Arabia. I am now retired
    from the fire department because of my Gulf war service and I
    am disabled from the National Guard from my Gulf war service.
        I have a couple of questions. I know you are here, there is
    a $1 million plus a day that you are worried about from the
    GAO, you stated that in your statement. I know it is a problem
    with the U.S. Government and going to combat like World War II
    veterans, Vietnam veterans, Korea, Gulf war and other
    conflicts, I think the budget should be either level funded or
    increased. I got an increase of $25 billion in the statement
    that I submitted. The reason why is because we just had a
    conference in Washington on April 5th and the next hall over
    was asking for $600 billion for infectious diseases. That is a
    concern.
        The first question I wanted to ask today was on the program
    up here in Bedford. Are the biopsies sent to the Armed Forces
    Institute of Pathology? Now how are we going to get to the
    bottom of Alzheimer's Disease if nobody is recording it? I
    found that out at Walter Reed Institute last summer. I am doing
    research on Alzheimer's itself because there is an interaction
    between Gulf war veterans, Vietnam veterans and ADD people.
        Question No. 2, Persian Gulf war appointments are not being
    done in Massachusetts. They are not being followed, according
    to Public Law 103-446. I got a letter from Colorado with a
    gentleman having problems. We are seeing this all across the
    Nation. This is a national problem.
        I am a member of Merrimack Committee here, VISN 1 and we
    are trying to address that problem with a basic test versus a
    full screen test. We are trying to get that through all the way
    to VISN 1 and all the way to the Network Director, Mr. Clark, I
    think it is.
        Mrs. Murphy stated on HIV and hepatitis C, but she did not
    mention leishomeniosis or other infectious diseases. Whatever
    the cost----
        Mr. Shays. Mr. Bryan, I am going to interrupt you a second.
    I am just going to have--we do not have so many people here
    that I maybe can adjust the time. We are going to try to get
    out of here by 1:15 at the latest and I would like to just ask
    how many people would like to speak and then I am going to--
    keep your hands up nice and tall. I am going to be real strict
    then.
        I am going to say 3 minutes at most and the questions are
    going to be rhetorical in the sense that we are going to have
    them in the record and then we are going to try to get some
    answers for them and we will make the answers part of the
    record as well. OK, is that something we can do.
        So yes, you have about a minute left and thank you.
        Sgt. Bryan. Because I found out that doctors are not doing
    the tests because the VA, thanks to the VA in Washington put
    out these big booklets that all of the doctors are supposed to
    review, but they are only reviewing the little booklet and they
    are doing the tests. They have to look at the whole spectrum.
    So that is a big national problem.
        A lot of the times you will look back at these suffering
    Gulf war veterans and Public Law 103-346 is not fully enforced
    and I think that is a key question, enforcement of it. I got
    that in the documentation and I want to--I know there are State
    issues here also, but there are major problems. You are going
    to be hearing from me and a few other Gulf war veterans
    throughout the Nation, your committee, within the next several
    months to another year because we need much more treatment
    trials and the two treatment trials that are out in the VA are
    not very promising.
        We need at least 10 more before September and I want to be
    trying to work with Dr. Pughsner. I am having troubles, but it
    is an IG complaint, but I want to see if I can step through
    your committee to get that accomplished.
        Thank you.
        Mr. Shays. I would be happy to have you work through our
    committee. I will invite you all, just take notes and at the
    end when they are done I will invite just brief comments from
    all of you on any comments you want to say that you have heard.
    Thank you, Mr. Bryan.
        Sgt. Bryan. Thank you, Congressman Shays for sticking your
    neck out. Thank you.
        Mr. Shays. Thank you, sir. Sir?
        Mr. Hart. Good afternoon, sir. Mr. Chairman, Congressman
    Tierney, my name is Terry Hart. I am the veterans' service
    agent, director of Veterans' Service from Ipswich.
        Mr. Shays. Excuse me, I am just going to interrupt you just
    a second. Karen, are you doing it? I want to make sure that the
    names are totally verified with the individual after you get
    them. OK, thanks. I am sorry, sir.
        Mr. Hart. No problem, sir. Seeing as the veterans' agents
    up here represent the Army, Air Force, Marine Corps and Navy, I
    wanted to let you know that I represent that fifth service,
    having spent 27 years in the U.S. Coast Guard.
        Mr. Shays. Yes sir. As did my brother.
        Mr. Hart. I am adjacent, my area, four towns, adjacent to
    Gloucester, the towns of Ipswich, Essex, Hamilton and Wedham
    and I have been using the clinic at Haverhill significantly in
    the last year that I have been a veterans' agent, sending
    people there right, left, up and down. Would also very strongly
    support the concept of a clinic at Gloucester.
        I have a lot of people who drive very little and being
    stuck in the middle there between major cities of Gloucester
    and Haverhill, major for our area anyway, we have some of our
    senior veterans who will go to Haverhill, will not go to
    Gloucester. Others who will go to Gloucester, will not go to
    Haverhill. So we like the idea of having a clinic in Gloucester
    as well.
        I would also like to make a couple of comments with respect
    to what has gone on this morning. Dr. Post indicated that there
    will be an increase probably in the cost of co-pays for
    pharmaceuticals through the VA clinic. I would like to go on
    record as stating that I hope (a) we can extend that then to a
    90-day prescription in terms of the co-pay cost because I think
    that is a logical extension.
        Right now, it is $2 per 30-day supply per prescription. If
    somebody can get a 90-day supply for whatever the co-pay goes
    up to, I think that would be a logical way of doing it since
    you said the cost is based on the administrative costs.
        By the same token, you should know that that is one of the
    key drawing cards for us to send people to your clinics is the
    idea that those costs to pharmaceuticals going down is a big
    factor in people wanting to use the VA clinics. I would also
    like to praise Mr. Conte. As a member of the Northeast
    Veterans' Service Officers Association we met at Bedford a
    month or so ago and the suggestion was made by me that they
    ought to have some of us on their board of advisors. Mr. Conte
    now has four of us, including myself on his board of advisors
    for Bedford VA and I think that improves the communication
    tremendously in our area.
        And communication is the key. What we find, of course, is
    many service organizations represented here, each of them have
    members. They have their own newsletters. We all go through the
    newspapers to try to get our word out to people. The Department
    of Veterans' Services provides word as well as they can, but
    until we get some sort of linkage in communication. We are
    still not reaching all the veterans and that is a key part of
    what we are doing, sir.
        Mr. Shays. Thank you very much.
        Mr. Callanan. Good morning. My name is Dan Callanan. I was
    born in 1924, joined the Marines on my 18th birthday. Three
    years later I was lucky enough to come back from the Pacific
    without a scratch on me. I was told that the Veterans'
    Administration was for people with disabilities. I did not know
    anything about anything to the contrary, but I visited many of
    my old mates at VA hospitals, people without arms and legs,
    people I had known, people I got to know.
        Recently, thanks to you people in Congress, you have passed
    a law which provides prescription drugs and I came out here
    today to thank you for that and to leave with you a bunch of
    eyedrops which cost me a small fortune in the past year and a
    half.
        I say a small fortune, but I had a detached retina. I do
    not know what caused it. It happened in August a year ago while
    I was mowing my lawn. I thought it was just another fleck of
    dust that comes out of this power plant in Salem which is soot
    all over the neighborhood, but maybe it was a bee that bit me,
    but before the day was over a retina surgeon at the Lynn Clinic
    told me it was detached retina. I went almost a whole year
    without being able to read a newspaper, spending a lot of money
    on eyedrops. Now I am getting them for $2 each. According to
    the letter that I received last week, it is on file here. Thank
    you for this opportunity.
        Mr. Shays. Thank you very much.
        Mr. Cascella. My name is Craig Cascella. I am a retired
    sergeant in the Marine Corps. I served as a Military Police
    Officer in Quantico, VA and I was also stationed in Washington,
    DC. I served as Presidential Security Guard. Mr. Chair and
    members of the committee----
        Mr. Shays. You know what, we have a problem. And that is we
    need to get you on tape. So I am going to let you start over
    again? We will insert the written statement in the record then.
    The reason I said that this is not just an exercise in
    futility. We actually transfer this transcript. Then the staff
    studies it. Then we make recommendations and so this is not
    idle chatter that you are participating in. This is a
    congressional hearing in which what you say we hope to have
    some impact in what happens in government.
        Let me just do this. I am going to have, I am going to see
    if we can solve the problem of you being on the mic and I am
    going to just interrupt. I am going to have someone else speak
    and let me, see, Karen, you put your head together and think
    how we can do that. If you do not mind, I am just going to have
    you wait a sec and have this gentleman speak.
        Are you going to be here later, sir? Will you be here for a
    while?
        Mr. Cascella. Yes.
        Mr. Shays. OK, let us see if we can solve the problem
    getting you on the transcript. Yes sir?
        Mr. Bowers. Thank you, Mr. Chairman and Congressman
    Tierney. I am Alan Bowers, third national junior vice commander
    of the Disabled American Veterans [DAV]. I was medically
    retired from the Air Force in 1974 after I injured my spine
    when I ejected from an aircraft in Vietnam. I am here to
    present the views of the nearly 45,000 members of the DAV and
    auxiliary who reside in Massachusetts.
        We have submitted to you, sir, a written text and we
    respectfully request that that text become part of the record.
        Mr. Shays. That will be part of the record.
        Mr. Bowers. Thank you, sir, and I will just make a couple
    of quick comments to highlight a couple of points.
        Since 1985, the buying power of VA medical care
    appropriations has fallen because of inflation. The total 2000
    VA medical care appropriation is worth only 82 percent of the
    1985 appropriation. That decreased buying power has adversely
    affected the Department's ability to provide safe, quality
    assured care.
        In 1996, VISN 1 had $856 million. In 2000, it has $867
    million. That equates to a 1.21 percent increase in allocations
    and MCCF receipts over 5 years. I note from a fax that I
    received from the National Office of the DAV Friday afternoon
    that on April 7th in the morning, the Senate passed the Johnson
    amendment which would add $500 million to President Clinton's
    proposed $1.4 billion increase. That is completely in line with
    what the DAV independent budget requests and we would hope that
    the House would go along with that effort and match that
    effort. It would go a long way to helping the VA have the
    dollars they need to give quality care.
        With respect to the hepatitis C, Dr. Murphy mentioned the
    1-day test sample where approximately 6.6 percent of the
    veterans tested came up positive for the virus. Under VERA,
    veterans who have the virus are considered basic care patients.
    As I understand it, that means that the VA or the VISN gets
    $3,249 a year for that patient. We suggest that a health care
    diagnosis should be reimbursed at the rate of a complex
    patient.
        One of the individuals testifying this morning mentioned
    high staff ratios in VISN 1. But in fact, the DAV has heard
    testimonials from frustrated and demoralized health care
    providers, including physicians and nurses, when they are
    working with sicker patients and they are working longer shifts
    or perhaps even double shifts, both the patient and the
    provider are at risk. So we ask you to take a very hard look at
    the staffing levels and make sure that they are adequately
    staffed so that there is quality care and there are no medical
    errors.
        Mr. Shays. I am going to extend your time a little bit
    here. How much longer do you need?
        Mr. Bowers. One final comment. I just want to say thank
    you. The Disabled American Veterans has one purpose, to build
    better lives for disabled veterans and their families. We rely
    on you and the VA to help us provide safe care, adequate care,
    accessible care. The DAV pledges to work with you and I am
    confident that together we can build better lives for the
    individuals who fought for America's freedoms.
        Thank you very much.
        Mr. Shays. Thank you for your service. It is wonderful to
    have you up front so I can see your smiling face in the light.
        Mr. Cascella. It is great to be down here.
        Mr. Shays. Is this mic on now?
        Mr. Cascella. Do you want me to start with my intro again
    or do you know who I am?
        Mr. Shays. Yes, I want you to start all over again. Thank
    you for your cooperation.
        Mr. Cascella. It is no problem, Mr. Chairman. My name is
    Craig Cascella. I am a retired military--from the Marine Corps.
    I was a sergeant from 1988 to 1992, stationed in Quantico, VA
    and also in our Nation's Capital, Washington, DC. I was a
    military police officer and also served as a Presidential
    security guard for Presidents Reagan and Bush, respectively.
        I am currently the secretary of the New England Chapter of
    the Paralyzed Veterans. On behalf of our members, I would like
    to thank you, Mr. Chairman, and members of the committee, for
    holding this hearing in our area and allowing us to provide
    this statement.
        I have submitted copies of my written statement and I hope
    that they have been distributed to you. If not, I would be more
    than happy to give you another one.
        First, I would like to comment on the fiscal year 2001 VA
    budget that was submitted by the administration. For the first
    time in many years, a reasonable increase has been proposed for
    veterans health care. The $1.5 billion total increase including
    the $1.355 billion for health care is a good and welcome
    beginning, although it is less than the $1.9 billion increase
    that is recommended by PVA.
        It is our understanding that the $1.9 billion increase is
    more in line with what the VA requested to pay for all existing
    and new programs. The PVA recommendation is based on careful
    analysis of present and future health care trends and includes
    the costs of the new initiatives such as emergency care,
    hepatitis C and long term care provisions called for in the
    Veterans Millennium Health Care and Benefits Act.
        The PVA has recommended a $20.66 billion appropriation for
    medical care. This amount represents a $1.8 billion increase
    over the amount provided in fiscal year 2000. The PVA has
    recommended a $386 million appropriation for medical and
    prosthetic research. This represents a $65 million increase
    over the administration's flat line request. The PVA recommends
    a $71 million appropriation for the medical administration and
    miscellaneous operating expenses account. This represents a $6
    million increase over the administration's request.
        In total, the PVA has recommended a total increase for
    Veterans' Health Administration of $1.9 billion, $555 million
    over the administration's requests which includes nearly a $1
    billion increase just to meet the routine escalating costs such
    as salary increases and inflation.
        Mr. Chairman and members of the committee, we ask that you
    support the recommendations of PVA. We also ask for your
    assistance to insure that the VA receives the funding that it
    needs to insure that veterans who rely upon the VA for their
    health care needs are accorded adequate and quality health
    care.
        Let us work together, building upon the accomplishments of
    last year to secure for a solid budget base for health care in
    the years ahead.
        We ask you to reaffirm our Nation's covenant to veterans
    and to remain faithful with generations of promises.
        Last, I would like to comment on a local issue.
        Mr. Shays. If you could just bring it to a conclusion.
        Mr. Cascella. Yes, Mr. Chairman. Analysis showed that
    millions of dollars could be saved if the West Roxbury at
    Boston VA Medical Centers were consolidated. In order to
    complete a successful consolidation, some construction and
    renovations were needed at approximately a cost of $30 million.
    At first it was thought the VA Central Office would provide all
    funds needed for construction and renovations. That thinking
    proved to be wrong.
        The VISN will have to provide the funding for the entire
    consolidation. We have learned that in order to fund the cost
    of construction and renovations, the VISN will have to use all
    of their minor construction funds and equipment purchasing
    funds for the next 3 years. We believe that this is the wrong
    way to fund the consolidation.
        Overall, quality of health care provided and quality of
    care in not purchasing replacement equipment or new equipment
    will be sacrificed. We believe that the VA Central Office must
    provide the necessary funds to complete the consolidation.
        Mr. Chairman and members of the committee, we ask that you
    look into this matter and encourage the VA Central Office to
    provide the necessary funding to complete the consolidation
    that will eventually save significant resources.
        Mr. Chairman, that concludes my statement. Again, I thank
    you for coming to our area and allowing us to present our
    comments to you all. Thank you.
        Mr. Shays. Thank you. And I appreciate you being flexible
    with us in coming up front like this so we could record your
    statement.
        Mr. Cascella. Thank you for being flexible.
        Mr. Shays. Thank you. Who would like to speak at this
    moment?
        Ms. Maguire. My name is Hilary Maguire representing the
    Veterans Northeast Outreach Center in Haverhill, MA. I also
    served on the 782nd Maintenance Battalion under the 82nd
    Airborne Division during Desert Storm.
        Just for a real quick note to clarify, our van was donated
    by the VFW of Massachusetts and also Congressman Tierney, just
    so you know in regards to your question about 214s. There is a
    number in Boston. It needs some revamping, but it is another
    option for those that live in Massachusetts trying to get their
    214s.
        My question today and I hope at some point there will be
    some clarification, I have had several women come into my
    outreach center who suffered from sexual trauma while on active
    duty. I have read the law. It is my understanding that they are
    eligible for sexual trauma counseling, but I do not know if it
    needs to be clarified or if they are eligible for health care
    benefits.
        Two women have come into my center and have been denied
    benefits due to their time while on active duty. It is my
    understanding that they need to serve a minimum of 2 years. I
    am hoping that maybe this could be addressed and the 2-year
    eligibility requirement dropped.
        Mr. Shays. If they have served less then 2 years, they are
    not entitled to benefits?
        Ms. Maguire. Yes, that is the answer that they have been
    given.
        Mr. Shays. I am seeing a shaking of the head of someone who
    is in a position to know, so let us say this. We will get the
    answer and hopefully respond to it to you before we leave
    today.
        Ms. Maguire. Thank you.
        Mr. Shays. Thank you. Will you make sure that happens,
    please?
        Mr. Daley. Good morning, Congressmen, Tom Daley, State
    Adjutant for the DAV. And I just want to say on that DD 214,
    Congressman, in Massachusetts, anybody who has received a bonus
    in Massachusetts going all the way back to the first World War,
    the Department of the Adjutant General's Office will have a
    copy of that discharge.
        Mr. Shays. Thank you.
        Mr. Daley. And also I would like to present this written
    testimony concerning the hepatitis C, Gulf war veterans
    compensation and DIC entitlement which I will----
        Mr. Shays. Excuse me, 1 second. Do we have a tape problem
    here? No problem. We will take care of it. We want it on the
    record. I have to tell you this is my most favorite part of the
    hearing.
        Mr. Daley. I will be submitting written testimony on long
    term care, hepatitis C, Gulf war and veterans issues and
    conversations with DIC, means testing, etc.
        I just want to say we have good working relationship with
    the veterans agents in Massachusetts. They are very supportive
    of us and we work together on case loads. Dan Stack, a
    supervisor here for the DAV National Service Office, so we do
    work together.
        Roughly 15 of the 20 percent of the veterans across this
    country belong to veterans organizations and the rest of the
    veterans do not even know what is going on in this country.
    That is the problem.
        In Massachusetts, to be a veteran in Massachusetts, you
    have to have 1 day wartime, 90 day service. We have a lot of
    veterans in--I know that is not a Federal issue, but it is
    important to us because we are trying to get legislation passed
    in Massachusetts to pick up all what we call old war veterans
    and we want to make sure that they are included in the benefits
    across the Commonwealth because that will enhance, that will
    bring in issues, that will bring more people and more
    penetration into the VA system. We are trying to work on that
    now.
        So again, concerning the veterans issues in the
    Commonwealth. On that 90-day, 1 day wartime, they are not
    entitled to benefits because they are not entitled to real
    estate exemptions. They are not entitled to Chapter 115
    benefits administered out of the Department of Veterans Affairs
    and they are not entitled to Civil Service preference.
        But my own opinion is if anybody who puts the uniform on in
    this country is entitled to benefits, so I would like to see
    that happen. We are working on it in Massachusetts, the DAV and
    all the veterans organizations to pick up all the old war
    veterans and I am sure that it will help the VA long term care
    down there, more veterans penetrating the system into the VA
    health care system.
        That is all I have to say, thank you very much.
        Mr. Shays. Thank you very much.
        Mr. Boutin. Mr. Chairman, Congressman Tierney, my name is
    Gerard Boutin. I am Commandant for the Marine Corps League for
    the Department of Massachusetts and I have two very quick
    questions. The first concerns the screening for the
    establishment of the Lynn Clinic which I think is a great
    thing.
        At that time they were looking for members to sign up so
    they could have a large member on their rolls. I just recently
    have been re-enrolled and one of the things that they state is
    what if I am sick when I am traveling. It says you may receive
    health care at any VA health care facility in the country,
    well, that is really not true.
        Recently, I was in Florida last February and I noticed a
    sign for a VA clinic so I went in and I presented my card and
    said if I needed medical assistance could I come into the
    clinic and their answer was no. You are not in the system. And
    they proceeding then to give me a whole bunch of paperwork that
    I would have to fill out and which I brought home.
        Shortly thereafter, I went over to St. Petersburg and had
    to take a blinded veteran to the VA hospital and I did the same
    thing. I asked if I had to take care of any medical problems
    and I presented my card again, I said could I come to this
    facility and the answer again was no. You are not in the
    system.
        So I really do not understand if we are in the VA and we
    are not in the system, as I understand in asking questions when
    I get back, we are here in the system in Wheaten and that is
    about it, but it does not take care of when we travel and I
    think a lot of the veterans, that is what they need. We will
    look for the benefit if we are traveling.
        Second, I am receiving bills from the VA because the VA
    cannot bill Medicare for services and maybe you know all about
    that and I would like to bring that up as a point. The VA, as I
    understand cannot bill Medicare for services. Therefore, any
    services that I get in the VA hospital in Bedford, I have to
    pay out of my own pocket.
        Mr. Shays. I was under the impression that services were
    available wherever you are and so I would like to nail that one
    down and maybe that can be dialogued before we leave directly
    with Dr. Murphy or our other two panelists who were there.
        Mr. Boutin. Incidentally, you asked, I was in the Marine
    Corps from 1946 to 1952. I served as a Staff Sergeant with the
    2nd Marine Division.
        Mr. Shays. Thank you for your service, sir. Yes sir?
        Mr. Becker. My name is Bernard Becker. I am a past State
    commander and past regional commander of Jewish War Veterans. I
    served in the Air Force from 1950 to 1954. VISN 1 as far as I
    am concerned stinks. We are closing up wards at hospitals. We
    are closing buildings at Brockton VA and then people who have
    the Alzheimer's cannot find a place to go. They are told by
    their families, take them to a private place and they will take
    care of them.
        As far as I am concerned they should keep these buildings
    open, keep the wards open and take care of the veterans in the
    facilities. Holyoke, Chelsea Soldiers Home, there are waiting
    lists. They cannot put any more in there, but when they are
    closing up these buildings, I cannot see why they cannot keep
    them open and put the veterans in those buildings and I also
    have from my national organization, they did send me a fax on
    veterans issues.
        Mr. Shays. Thank you.
        Mr. Calomo. Thank you for letting me speak today. I am a
    past Vietnam combat medic and I served in the Army in the
    199th. I am from Gloucester, MA and I support Colonel Welsh, a
    veterans' agent, because of the veterans, I am the past city
    council of Gloucester, and many----
        Mr. Shays. You are not a Republican?
        Mr. Calomo. No, I am a Democrat. [Laughter.]
        I am sorry, I am a Democrat. I have had many veterans also
    call me and tell me they cannot get transportation to Bedford
    or Boston and I myself go to Bedford and Boston. I go to
    Jamaica Plain and I have a lot of trouble driving into Boston,
    so I do not do that. I take the train and I spend the whole day
    trying to get to my appointment and get back to Gloucester.
        Also a lot of the veterans cannot get a ride from Boston to
    Bedford. They have tried. A lot of time the drivers are
    unavailable through the DAV. They do have vans, but a lot of
    times the drivers are unavailable. So it is hard to meet
    scheduled appointments.
        I also work for a home health service and I have had
    clients that ask me to take them and I have done that. So at
    this point I reemphasize a real need for us to have something
    in Gloucester, a medical facility.
        Thank you very much.
        Mr. Shays. Can you say your name into the mic?
        Mr. Calomo. Samuel Calomo. Thank you.
        Mr. Shays. Thank you, sir.
        Mr. Gonzalez. Good morning, Mr. Chairman and Congressman
    Tierney. My name is Salvatore Gonzalez and I am from Chapter
    3240, the name of it is General John S. Patton, Jr. from
    Beverly and I am here to request information from you, if I
    may.
        We have a member of our chapter who has been very sick and
    lives on the second floor and he needs assistance because he
    cannot negotiate the stairs. He has to sit down two to three
    times before he can out to the second floor.
        I went to make an initial contact in Jamaica Plain about
    what we could do to help him out as far as getting an electric
    chair. The doctor had to recommend then to the Rehab Medicine
    in the fourth floor so that they could approve the
    recommendation before he could be eligible to receive an
    electric chair. By the way, this veteran is 50 percent service
    connected for the Second World War.
        I made the initial contact in March and the closest I could
    get a doctor to see him at the VA, it is May 17th, so the guy
    is still trying to get off the second floor which is very hard
    for him.
        My question is this, what does a person like that have to
    do when he has to go out and get help? Where does he go from
    here?
        Mr. Shays. We are not going to take any questions right
    now, but we are going to have your question on the record and
    we have staff here that can respond to the question.
        Mr. Gonzalez. Thank you, sir.
        Mr. Shays. Thank you.

     STATEMENT OF NEIL F. RESTANI, DIRECTOR OF VETERANS SERVICES,
                           TOWN OF LYNNFIELD

        Mr. Restani. Mr. Chairman, my name is Neil Restani. I am
    the director of Veterans Services for the town of Lynnfield. I
    have a statement that I would like to read. Also, I served from
    1942 to 1946.
        Regarding health care at the local level. Our office in
    Lynnfield is very satisfied with the treatment and care that
    our veterans receive at the Bedford health facility. They
    receive excellent care and the cases are handled in a
    professional manner.
        Also, the veterans walk-in clinic at Lynn also provides our
    veterans with much needed assistance. Just last week at our
    American Legion meeting, one of our members was very grateful
    to the treatment that he receives from the Jamaica Plain
    facility regarding his prostate condition.
        I have one concern. My office has this concern. I do
    receive many referrals from veterans who are not eligible for
    many services only because they do not qualify. They do not
    receive any disability. These are veterans of World War II and
    Korea and they are getting up there in years and now they feel
    that they would like some kind of assistance, but they are not
    qualified. I wonder if that matter could be looked into. Thank
    you.
        [The prepared statement of Mr. Restani follows:]
        [GRAPHIC] [TIFF OMITTED] T0278.036

        Mr. Shays. Thank you very much. I am going to try to get an
    assessment of how many more speakers we have, if you would
    raise your hand. Those are the eight speakers, so we are going
    to have to move along. If you can be closer to 2 minutes, it
    would be great, but we will live with 3.
        Yes sir.
        Mr. Ouellette. Mr. Chairman and panel, my name is Joseph
    Ouellette. I am a disabled combat veteran having served with
    the U.S. Army in Vietnam with 173rd Airborne Brigade.
        I am here to represent the Essex County Correctional
    Facility. I am the veterans outreach coordinator and I also do
    the HIV coordination with the hepatitis C virus. So there is a
    link between veterans and the hepatitis C/HIV and there is also
    a tremendous link because 90 percent of the incarcerated people
    are in there because of substance abuse.
        So what I have found for 10 percent being the veterans'
    population, I have approximately 120, 130 veterans. Most of
    them do not know that they have any veterans' benefits at all
    and the crimes committed are because they have a substance
    abuse issue. Most of my connections have been with the Bedford
    VA, the homeless shelter in Boston, and the veterans mansion in
    Haverhill which has been a tremendous asset to help out.
        My question or my concern is in the future let us not
    forget about the incarcerated veteran. OK? Thank you.
        Mr. Shays. Thank you, sir. I am struck, sir, by the fact
    that your comments are very well taken, I mean as are all the
    others, but sometimes that group does get overlooked.
        Mr. Smith. Good afternoon, Mr. Chairman.
        My name is Arthur Smith. I am the past department commander
    for the State of Massachusetts, the American Legion and I would
    ask your indulgence because I have a statement here projecting
    what the American Legion feels about this----
        Mr. Shays. Let me just say though if it is longer than 3
    minutes, it needs to be submitted and you need to summarize.
        Mr. Smith. This is from past national commander, John P.J.
    Komer and past national commander, Anthony T. Jordan. Mr.
    Chairman and members of the subcommittee, the American Legion
    continues to follow the changes in health care delivery in New
    England with great interest.
        The American Legion appreciates the opportunity to submit
    its observations and concerns regarding the impact and
    restructuring and the resource allocation of delivery of
    quality VA health services on the national, regional and local
    level. The American Legion will address the specific issues
    identified in the invitation to submit testimony, the VA budget
    for fiscal year 2001 and the VISN 1 budget for fiscal year 2001
    and access care for the veterans infected with hepatitis C.
        The American Legion has previously acknowledged the
    administration's request of $20.3 billion to veterans' health
    care as reasonable, although the American Legion believes that
    the President's budget requests falls short of the required
    spending level for several reasons. The American Legion
    recommends that the VA health care receive $20.5 billion
    appropriation for fiscal year 2001. First, the American Legion
    questions the VA projections of medical care collection fund,
    called MCCF and sharing other collections.
        The President's fiscal year 2001 budget request is based,
    in part, on the availability of a cost of $600 million from
    MCCF and another $115 billion from sharing in other
    collections. The revenue sources that compromise these funds
    include veterans co-pays, third party insurance and contracts
    with the Department of Defense and Tricare.
        Since the enactment of legislation allowing VHA to transfer
    revenues from MCCF fund, the administration projections have
    been off in each of the past 2 years. National projection fell
    nearly $100 billion short of projections to the fiscal year
    1999.
        In VISN 1 alone, the overestimate was $14 million, just
    under 2 percent of its total VERA budget. VHA has made
    adjustments to its formula in projecting collections. Despite
    these adjustments however, the American Legion is not fully
    convinced that the projected collections for fiscal years 2000
    and 2001 by VHA are accurate. This lack of confidence is not
    due to the lack of consideration of VHA's effort, rather it is
    attributed to the unknown ramifications for similar changes in
    policies and operations.
        Mr. Shays. Can I ask you if you could summarize the
    conclusion and we will submit the whole thing?
        Mr. Smith. OK, sir.
        Mr. Shays. Thank you sir, I appreciate your cooperation. We
    are just trying to make sure we get to votes this afternoon,
    there are votes on the floor of the House. That is our
    challenge.
        Mr. Smith. Finally, the American Legion is committed to the
    issues of the best care to veterans with hepatitis C virus,
    HCV. The American Legion has indicated strong support for VA
    programs geared toward increasing education among both veterans
    and providers that involve treatment of HCV, expanding VA
    treatment and research.
        The national field services of the American Legion
    continues to monitor access to HCV treatment as well as other
    aspects of the HCV issue and a special focus within its
    oversight program.
        Mr. Chairman, if I might be allowed to say on behalf of
    myself, when I entered the U.S. Air Force I raised my right
    hand. The government did not say if you were 10 percent, 20
    percent or 30 percent service connected with a disability that
    we would take care of you.
        The government said that if you needed health care, we will
    take of you and I know earlier this morning they were talking
    about lowering the requirements from 70 percent to 50 percent.
    I do not think that is fair enough to my fellow veterans that
    fought in World War II or my fellow veterans that fought in
    Korea. I think the limit should be down to 30 percent. Thank
    you, Mr. Chairman.
        Mr. Shays. Thank you, sir. Yes sir.
        [Applause.]
        Mr. Koontz. Ron Koontz. I am the director of Veterans'
    Service for Amesbury. I am also a combat veteran from Vietnam,
    1968, 25th Division and you can stop me after 1 minute.
        What I would like to discuss is with the first panel was
    the disability claim process. I believe it was Dr. Murphy
    talked about the turnaround time for the initial claims. The
    180 days does sound good, but it is once that decision has been
    made, once it goes into the appeal process, there is definitely
    a long term wait on this, anywhere from 18 months to 3 years to
    7 years and probably beyond.
        The other issue would be I have gone through Boston JFK
    Building and I have seen stacks of claims on the floor at least
    3 foot high and I hope this is not indicative of throughout the
    United States, but there does seem to be a backlog on the
    claims process. Thank you.
        Mr. Shays. Thank you very much, appreciate it.
        Ms. Troubetaris. My name is Maureen Troubetaris, I come
    here on behalf of my brother, John Day, served 1967 to 1971,
    United States Air Force Staff Sergeant, served in Vietnam, war
    veteran, served in Bangkok, Thailand as a crash fire fighter.
    My brother has been hospitalized for the past 14 months in the
    veterans hospital and cannot speak for himself. My family are
    his eyes and his ears and his mouthpiece. My greatest concern
    is the money available. You fund it for the veterans who have
    long term health care, health indeed necessities.
        Two weeks ago today I got a call at work out of the clear
    blue sky from the veterans in Jamaica Plain and was told my
    brother ran out of benefits and where do I want him. It is 100
    percent service connected, Vietnam War veteran and this was a
    shock to our family. Where would we place him?
        Once they placed him in a nursing home and they almost
    killed him there. I guess my answer today is quality health
    care for all veterans, quality of where you place your
    veterans. There is no followup after you place your veterans in
    places that you contract out to. Some of these places that you
    have contracted to have great violations. You need to have a
    followup. There needs to be continuity in health care with the
    doctors. With long term health care, you do not have continuity
    in medical health care. Every month there is a new team of
    doctors. The only continuity is in the nursing staff. You need
    to have that for a family to understand.
        I ask that the committee and I thank Congressman Tierney
    for all the help his office has given our family. It is a scary
    thing that my brother cannot speak for himself, but I do ask
    for help that you continue to finance all the veterans programs
    and look at the millennium bill as soon as possible. You cannot
    leave a generation of people, totally unprepared for long term
    health care at the mercy of this kind of treatment. Thank you.
        Mr. Shays. Thank you for being a supportive sister on
    behalf of your brother, ma'am.
        [Applause.]
        Mr. Tierney. I want to note that Maureen is not only a good
    voice for her brother and family and veterans, but is a
    counselor in the city of Beverly.
        Mr. Passeri. Mr. Chairman, Representative Tierney, Angelo
    Passeri. I am a VA/VS deputy representative for the Vicotira
    Rocky Post and Beverly, a membership of 600 plus. I want to
    thank the panel. They covered every question that was presented
    to me by my membership. You did a fantastic job. You covered
    everything I wanted to cover.
        I just want to augment one thing. When I heard one of the
    objectives that they had was to downsize the in-patient
    complement at the Bedford Hospital. I got a little nervous
    because most of my recourse are to help gain access to that
    facility for our Alzheimer's and no doubt it is probably the
    best institution we have in the Nation.
        I work very close with the first line staff and it is a
    showpiece and it hurts to see that we cannot gain admittance to
    that particular unit. And I just want to hope that you people
    will just keep in mind when we are talking about downsizing in-
    patient, that this facility and others like it are definitely
    needed. Please give this a lot of consideration. Thank you very
    much.
        Mr. Shays. Thank you very much.
        [Applause.]
        Mr. Shays. Yes sir.
        Mr. Boucher. Yes, my name is Gerard Boucher. I entered the
    Marine Corps December 15, 1966 when I was 19. Wounded October
    11, 1967. I am an advocate for the blind and all disabled,
    veterans in quotation. First of all, I want to come up here and
    thank you all for a day like this. The Congressman, the
    Chairperson, all the dignitaries, everybody that had anything
    to do with this assembly. I am just sorry that there are not
    enough veterans here to stick up for themselves.
        I came up here to mention two--one thing I got off my e-
    mail the Johnson amendment that just went through the Senate
    for the $500 million, I heard the gentleman mention that
    earlier, I would like to see the House support that, if I
    could, and also this young lady that was up here earlier, just
    before me mentioned about her brother not knowing where to put
    him.
        Now all this space after downsizing these medical
    facilities, Jamaica Plain, Brockton, Broadsbury, what are they
    going to do with all that empty space? Are they going to
    utilize it or sell it or whatever? Would that not be a nice
    place for a nursing home for veterans? That is my suggestion.
        There are a lot of things I would like to say, but I do not
    want the chairman to throw me out. This is what I really want
    to say, it is all in here, but I do not think you are going to
    give me the time.
        Mr. Shays. Let me just say, sir, I would never throw you
    out and it is an honor to have you testify before this
    committee and it is an honor to know you have served so well
    for your country.
        Mr. Boucher. And I want to thank you all again. Today like
    this here is what we need the most. You more you have of this,
    the better. And it is up to us to get the rest----
        Mr. Shays. I have a feeling that when Mr. Tierney asked
    this committee to come up here he was thinking of you.
        Mr. Tierney. This gentleman does a good job and he writes
    to my office at least once a month, always with pertinent
    information and insight and so we thank you very much for that.
        Mr. Boucher. Thank you, sir. Thank you all.
        Mr. Shays. Thank you. Sir.
        Mr. Lyons. Thank you, Mr. Chairman. My name is Tom Lyons. I
    am the executive director of the New England Shelter for
    Homeless Veterans. I want to thank you for being here today and
    also thank my good friend, Congressman Tierney, for allowing me
    to be here today.
        I am a former Marine. I served in 1967 to 1970 with a tour
    of duty in Vietnam in 1968.
        Mr. Chairman, I run probably one of the largest homeless
    shelters in New England, 320-bed facility for men and women. We
    are unique, Mr. Chairman, because we are drug and alcohol free
    and our programs are based on structure and discipline,
    structure and discipline that these men and women had when they
    were in the miliary, we use it as a way of building them back
    to self-sufficiency.
        We have emergency shelter, temporary housing and we also
    have permanent housing right inside our facility. We built a
    new medical clinic with the help of the VA. We are now not only
    providing basic medical care, but we are providing complete eye
    exams as well as dental care.
        We have a training program that over the last 3 years have
    put over 1,100 men and women back into the work force in
    Massachusetts at an average wage of $12. So as you can see, Mr.
    Chairman, we are a program that works and I am proud to say
    that we have been a player within the veterans community over
    the last number of years.
        But the concern I have today, Mr. Chairman, is that the VA
    is talking about doing away with detox programs and are leaning
    toward out-patient detox. As someone who sees 85 percent of our
    clients at our facility who are drug and alcohol dependent, to
    think of an outpatient kind of a detox program scares the hell
    out of me to be quite honest because we have men and women in
    our program 8 months to a year or to a year and a half who are
    drug and alcohol free.
        They were able to do it because of the structure and the
    discipline and the counseling services that we have in our
    facility.
        I ask you, Mr. Chairman, and I ask your committee to look
    at whatever the VA has in terms of surveys, whatever, to
    outpatient clinics and see if they actually work or is this
    just another way of creating another out source within the VA
    system. Thank you, Mr. Chairman.
        Mr. Shays. Thank you very much. I would just like to note
    for the record, it is 1:18, so I think we are almost done with
    our speakers. We have one gentleman here. We have three
    speakers all on this side and I do need to limit it to that so
    we have three speakers left.
        I am going to just before you speak, I just want to take
    note that Dr. Frances Murphy has been here the entire time. She
    could have left and she stayed and I appreciate that very much
    as well as Dr. Jeannette Post and I appreciate you staying here
    as a well, Doctor, as well as Mr. William Conte. It is
    important that you hear what the veterans say and I did not
    need to tell you that because you know that. You might be able
    to interact with one or two, but we need to make sure the
    record is straight, particularly on one issue dealing with
    counseling for women and also whether services are available
    throughout wherever you go.
        We have three speakers left. I am also going to allow our
    gentlemen, the panel up here to just make a closing comment if
    they would like if they are short. I think maybe what we will
    do, Dr. Murphy, I am going to have you respond to those two
    questions before we leave so that they are part of the record,
    afterwards.
        Yes sir.
        Mr. Hinds. Good afternoon, Mr. Chairman. My name is John
    Hinds and I would like to put a face behind some of what you
    have been talking about today. I am a disabled Vietnam veteran,
    a career employee in the Veterans Administration and a veteran
    who is suffering from hepatitis.
        I would like to thank Dr. Murphy, Dr. Post, Mr. Conte, Mr.
    Martineau and Mr. Hogan this morning because they were kind
    enough to show me something that I have never seen as a VA
    employee. I am taking annual today from my job in order to come
    here and to thank personally Congressman Tierney for the work
    he does not only on behalf of disabled veterans, but also
    particularly my district. I live in Georgetown.
        Since 1988 I have been an employee of the Veterans
    Administration and I have worked at the VA Regional Office and
    the Kennedy Building in Boston. I have worked at the VA Medical
    Center and Jamaica Plain and I have worked at the outpatient
    clinic in Boston and for the last 9 years I have worked on the
    staff at the Med Center in Boston.
        I have never had anything lower than an outstanding
    performance appraisal on an annual basis and yet I have been
    frustrated in every attempt, despite my education which
    includes a Bachelor of Arts degree and several completions of
    several courses on a master's degree level. I have been
    frustrated because I see what is being given to the veterans on
    the front line basis.
        Thank you, Mr. Martineau for your comments. They are very
    appropriate. I have been thrwarted in my attempts to improve
    myself as a VA employee. I have gone from a grade 5 to a grade
    6 in the 11 years that I have been with Veterans Administration
    and I have been labeled, despite being chosen as 1 of the 12 VA
    employees to give performance training and individual customer
    relations training to fellow employees as angry, troubled and
    frustrated in my attempts to improve myself and improve the
    care of service to veterans.
        So I am the face behind which you have been talking about
    today. I just wanted to thank you for this hearing and I wanted
    to thank you for your help, but I would like to say if you do
    one thing today, please make an attempt to recognize the front
    line employees who are there for the veterans every day and
    yes, they are frustrated because of the inability to improve
    ourselves and to improve the system. Thank you.
        Mr. Shays. Thank you very much, sir. Our second to last
    speaker.
        Mr. Themes. Good afternoon, gentlemen. I am Charles Themes,
    22 years military service. I am retired military. Three major
    battle scars. I spent 26 months in Korea. There is 1,500 lost
    in Korea. We do not know where they are. We do not know if they
    are prisoners of war. I know Korea better than most of the
    students know this high school. I spent 26 months in Vietnam. I
    was in combat section in Vietnam. I jumped out of helicopters,
    2nd, 3rd, 4th, 5th Corps, Laos and Cambodia borders.
        And so I think a lot of my friends were lost over there.
    What I am saying is that military retirees and some of the
    veterans who were combat veterans have a lot of disabilities. I
    cannot get my teeth cleaned at the Veterans Administration with
    22 years of military service, five honorable discharges and 6
    years reserve. I cannot get my teeth cleaned. When I go to
    Veterans Administration to have my teeth cleaned they say head
    on down the road, that has been gone, Jack. I said that is
    there it was. That is where my helicopter is, taking me to Laos
    and Cambodia.
        But I speak for a lot of men, not only retirees, but the
    veterans. But if they want to know about North Africa, I spent
    3\1/2\ years in North Africa, if they want to know about Cuba,
    I spent 11 months in Cuba. I spent 11 months in the South Pole.
    I spent a lot of places in a lot of other areas. Islands in the
    Indian Ocean and when they look for a demo technician, we need
    you to do the work, you go out and do your job. We came back.
        When I was relieved from the military service they said you
    are all set. I came to VA and they said there is a dental
    office down the street, get going. Thank you very much for your
    time and patience. Have a very nice day.
        Mr. Shays. Thank you, you too, sir, and our final speaker
    from the floor. I am sorry, we have two speakers left.
        Mr. Clark. Good morning, Mr. Chairman, and Congressman
    Tierney. Thank you for giving me the opportunity to speak. My
    name is Larry Clark. I am a disabled Vietnam veteran. I was in
    the U.S. Air Force from 1965 to 1969. For the last 20 years I
    have worked with the veterans an employment specialist in the
    disabled veteran outreach program.
        My statement to you is when we were talking about having
    enough drivers to bring the veterans to and from the hospitals
    it might be appropriate if possibly in the budget you could
    appropriate some funding for van drivers because we do have a
    good CBO program that is coming out of the shelter and that
    would be appropriate, if you could fund that in the budget.
        Mr. Shays. Thank you, sir. Ma'am? You are our final
    speaker.
        Ms. Zuberek. My name is Eleanor Zuberek. I am not a
    veteran. I am here speaking for my father who is not well
    enough to be here today. Congressman Tierney was kind enough to
    let me know about this in spite of the fact that I am
    frequently consorting with known Republicans.
        I wanted to address the problem of transportation and
    waiting times at the VA hospitals too. I get my dad in and out
    of there myself. I have elected to work part-time so I can be
    there for him. I do not know how many veterans have somebody
    who is willing or able to do that or who is married to a saint
    who is willing to put up with that.
        I want to tell you about 1 day last December, I just
    decided to summarize this into one experience we had. My dad
    called me in the morning and said he was not feeling well so I
    went flying over there and he is 82. He has service connected
    disabilities from World War II. He was having chest pains and
    his lips and his fingernails were turning blue.
        I said let us go to Beverly Hospital. He said no because
    there had been an incident 2 years ago when we had called the
    VA in the middle of the night and they said he is too sick, you
    cannot bring him here from Danvers, it is a 40-mile trip. Take
    him to Beverly, we give you permission. Well, the next day they
    did not know about that.
        And my father got stuck with the bill, so he insisted this
    time that we call Roxbury and I take him down there. We got
    there probably 8:30 and 9 a.m. and we sat in the emergency room
    with a lot of people who were very, very sick until 6 p.m. when
    he could be seen. He had very bad pneumonia and he had been
    released from the hospital the previous week.
        One of the men in the emergency room waiting with him had
    had bypass surgery 8 days before that. He waited longer than my
    father did, at least I think he did. They got there before we
    did. And I do not think this is unusual. We have been in there,
    I was waiting outside in the hall for my Dad to have chest x-
    rays and I met two men.
        One came down from Togas to have some simple tests done and
    another one came down from White River Junction. This is to
    West Roxbury. With the distance reversed, my father would not
    have made it up there. He is too fragile to travel that far.
    Never mind, you are providing transportation. And I just want
    to say anything you can do for these guys, when you called them
    to serve their country they did not say let us study it for 60
    days and we will see if it is affordable before we go.
        Mr. Shays. Thank you very much for speaking for your Dad.
        [Applause.]
        Mr. Shays. In one way it is regretful to have our last
    speaker have such a negative message, but it is an important
    message to hear so I appreciate you sharing your remarks.
        I would like to make sure I do not forget this, so I am
    going to do this now before I just ask for closing comments and
    thank David Rapallo who is the minority staff member who I
    appreciate his presence and always his participation as an
    equal in this committee, with Larry Halloran, the staff counsel
    and also Christine McElroy who I said I would identify as
    ultimately responding, Mr. Welsh, to your suggestion about a
    briefing on VA benefits by DOD before you are discharged.
        She is going to give a card to you today and then we will
    give you the correspondence that we are going to have back and
    forth. It is something that we can easily deal with right away.
    And Gary Batt from Mr. Tierney's staff and Cara Siegel and Tony
    Cooper, as well as from my staff, Karen Shirest and from the
    subcommittee staff as well, Jason Chung and Suzanne French,
    Apex Reporting and also to Richard Carey who is in, fact, and
    Patrick O'Shay the student who has made our sound system work
    quite well.
        Some of the problem was external and we appreciate how they
    have gotten the system to work so nicely. And it is a lot of
    hard work. We appreciate both of your participation. And also
    to Peabody Veteran Memorial High School. Mr. Tierney leaves
    nothing out. He saw the name veteran and he said this is the
    place it had to be.
        I would just encourage, I realize, Dr. Murphy that the
    answer to the sexual trauma answer may be a little more
    complex, but if you do not mind getting to the mike and just
    putting on the record, in general terms, to be followed by more
    extensive remark in writing.
        Dr. Murphy. Congress would pass legislation to make all
    veterans who sustained sexual trauma, whether men or women,
    eligible for counseling and treatment for that in the
    Department of Veterans' Affairs and we work closely with DOD
    and make sure we identify those individuals and get them into
    counseling.
        The general eligibility rules after eligibility reform are
    that any veteran who served honorably and has an honorable
    discharge for 90 days or more can enroll for VA health care.
    They would undergo a means test, but all priority levels one
    through seven, are eligible to enroll in the VA at this time.
        Mr. Shays. Any area of the country?
        Dr. Murphy. Any area of the country. This is nationwide.
        Mr. Shays. So sometimes the policy may not be followed, but
    that is the rules, so one suggestion is to contact your local
    Congressman or woman to make sure that that service is provided
    and also as well, we are happy to assist, Mr. Tierney, as well
    in any of the work that he has done with his veterans.
        Dr. Murphy. And I am sure the network staff or headquarters
    staff would be happy to help us.
        Mr. Shays. Right. To be aware of that problem and to be
    able to step in. Thank you very much. And gentlemen, I would
    just, very brief comments, I literally need to get a plane soon
    and Mr. Tierney, actually he needs to get on his way because
    you have a meeting on census before you get on the plane.
        Mr. Tierney. And in fact, if you gentlemen might excuse me
    because we are good enough friends that we can talk to each
    other at any time. I am due over in Lynn where the issue of
    census is very important to us and we are taking some efforts
    today to make sure that we get a count so that all of the
    services to all of our citizens will, in fact, reflect our
    population.
        So let me just thank all of our witnesses from the first
    panel very much for not only testifying but for staying and
    listening; to all of our members of the second panel, for all
    the good work that you do day in and day out as well as your
    testimony here today and to all of the veterans who both asked
    questions and made testimony and those that cared enough to
    show up or who were able to show up today and the
    representation that you made for all of those who were unable
    to attend. I look forward to working with all of you. I thank
    you, Mr. Chairman, and staff very much for having the meeting
    held here today.
        Thank you.
        [Applause.]
        Mr. Shays. And I would be very remiss because everybody in
    this room knows one individual on my staff who does a
    tremendous amount of work with veterans, is himself a retired
    veteran and that is Harry Hoffmander and I want to thank him.
        [Applause.]
        Mr. Shays. We have not yet adjourned yet. If there is any
    comment that the four of you would like to make, if there is
    not, that is fine.
        Mr. Welsh.
        Mr. Welsh. Thank you, Mr. Chairman. I am from Connecticut,
    like you and if you ask me the question about party
    affiliation, you would like the answer, but I have and always
    will vote for Congressman Tierney.
        Mr. Shays. You know what, in this committee we are
    Americans first and Republicans and Democrats second, just as
    you are when you risked your life for your country.
        I thank all of you. This hearing is adjourned. I will be
    running out very quickly. I hope I do not appear to be rude,
    but I need to get to that plane. Thank you very much.
        [Whereupon, the hearing was adjourned.]
        [Additional information submitted for the hearing record
    follows:]

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