[Senate Hearing 108-679]
[From the U.S. Government Publishing Office]
S. Hrg. 108-679
TESTIMONY OF RONALD F. CONLEY, NATIONAL COMMANDER, THE AMERICAN LEGION
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
JULY 15, 2003
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
ARLEN SPECTER, Pennsylvania, Chairman
BEN NIGHTHORSE CAMPBELL, Colorado BOB GRAHAM, Florida
LARRY E. CRAIG, Idaho JOHN D. ROCKEFELLER IV, West
KAY BAILEY HUTCHISON, Texas Virginia
JIM BUNNING, Kentucky JAMES M. JEFFORDS, (I) Vermont
JOHN ENSIGN, Nevada DANIEL K. AKAKA, Hawaii
LINDSEY O. GRAHAM, South Carolina PATTY MURRAY, Washington
LISA MURKOWSKI, Alaska ZELL MILLER, Georgia
E. BENJAMIN NELSON, Nebraska
William F. Tuerk, Staff Director and Chief Counsel
Bryant Hall, Minority Staff Director and Chief Counsel
C O N T E N T S
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July 15, 2003
SENATORS
Page
Specter, Hon. Arlen, U.S. Senator from Pennsylvania.............. 1
Prepared statement........................................... 2
Bunning, Hon. Jim, U.S. Senator from Kentucky.................... 3
WITNESSES
Conley, Ronald F., National Commander, The American Legion;
accompanied by Robert W. Spanogle, National Adjutant, The
American Legion; Steve A. Robertson, Director, National
Legislative Commission, The American Legion; and Peter S.
Gaytan, Principal Deputy Director, Veterans Affairs, and
Rehabilitation Commission, The American Legion................. 3
Prepared statement........................................... 9
Executive Report: A System Worth Saving...................... 17
Articles by:.....................................................
Kelly, Jack, National Security Writer, Post-Gazette, July 15,
2003....................................................... 64
Rosenblatt, Susannah, Times Staff Writer, LA Times, July 15,
2003....................................................... 64
APPENDIX
Graham, Hon. Bob, U.S. Senator from Florida...................... 71
TESTIMONY OF RONALD F. CONLEY,
NATIONAL COMMANDER, THE AMERICAN
LEGION
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TUESDAY, JULY 15, 2003
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 2:40 p.m., in
room SR-418, Russell Senate Office Building, Hon. Arlen Specter
(chairman of the committee) presiding.
Present: Senators Specter and Bunning.
OPENING STATEMENT OF HON. ARLEN SPECTER,
U.S. SENATOR FROM THE STATE OF PENNSYLVANIA
Chairman Specter. Good afternoon, ladies and gentlemen. We
will convene the hearing of the Veterans' Affairs Committee of
the United States Senate.
As this hearing assembles we are honored with the presence
of Mr. Ronald F. Conley, National Commander of the American
Legion. The American Legion is the foremost organization of
veterans. The first veteran I knew, my father Harry Specter,
was a member of the American Legion. I am not 100 percent sure
that he paid his dues. He was a member of the American Legion
during the Depression, and I think he planned to pay his dues
with the $500 bonus which the Federal Government promised World
War I veterans. When they reneged on the promise, I don't know
that he had the money to pay the dues to the American Legion.
But one of my earliest recollections--and I am not 100
percent sure that I recall the event or whether I recall it
having been told to me--was a veterans' march on Washington to
get that bonus. Today, when there is a demonstration in
Washington, they roll out the red carpet. For the veterans who
came that day, they rolled out the cavalry with drawn sabers.
The major in charge of the cavalry was George C. Patton, and in
command was the chief of staff, Douglas MacArthur. There is a
famous picture taken on The Mall of MacArthur standing next to
his aide-de-camp, Dwight Eisenhower. Veterans were killed on
that day, one of the blackest days in American history.
But I remember as a youngster growing up in Wichita,
Kansas, my father's best friend, Max Greenberg, was in the
cavalry and lost his hearing. He would come over for breakfast
every Sunday morning. My brother's name was Morton. Max would
always say, in Yiddish, ``Was macht du, Martin?'' He knew him
for 20 years, but he didn't know his name was Morton instead of
Martin. But he was a proud American Legionnaire, and it is a
great, great organization.
Ron Conley is now closing his term as the American Legion's
National Commander, and he is going to report on his very
active travel through the United States. It is very impressive
that Mr. Conley has visited 60 of the VA's 171 medical centers
since he was elected National Commander, and he has some
interesting and important observations and recommendations to
offer to the committee.
I want to thank you very much, Ron, for your fact-finding
work. My full statement will be made a part of the record, and
I am going to be relatively brief. It is too late now to be
brief, but I am going to be relatively brief.
[The prepared statement of Chairman Specter follows:]
Prepared Statement of Hon. Arlen Specter, U.S. Senator from
Pennsylvania
Good afternoon, ladies and gentlemen.
The purpose of the Committee's hearing this afternoon is to
receive the testimony of Mr. Ronald F. Conley, the National
Commander of The American Legion. I am proud to be able to say
that Mr. Conley is a constituent; Ron hails from the Pittsburgh
area where he is also a member of Steamfitters Local 449, where
he has served on the examining board, on the finance and
election committees, and as a union steward.
Mr. Conley joins us today, as he closes his 1-year term as
The American Legion's National Commander, to report on a year
of very active travel throughout the United States. Mr. Conley
has personally visited 60 of VA's 171 medical centers since he
was elected National Commander in August 2002--and he has some
interesting and important observations and recommendations to
offer to the Committee. We will be very attentive to those
observations and recommendations for we know they come from Mr.
Conley's conversations with veterans throughout the Nation.
Ron, I want to thank you for your fact-finding work--and I
want to thank you also for initiating the Legion's ``I Am Not a
Number'' campaign. The Legion is oh-so correct: veterans are
real men and women--men and women who answered the call to
service. They are not numbers or ``cases'' or ``claim
folders.'' VA--and the Congress--needs to be reminded of this
from time-to-time.
Before I turn the Floor over to Mr. Conley, let me share
with all who are assembled today just a quick rundown of Ron
Conley's life of service. As I have previously stated, Ron
Conley is currently the National Commander of The American
Legion. Prior to assuming that very high position, Ron served
in numerous other American Legion posts including:
I. Alternate National Executive Committeeman (1988-1992);
II. National Executive Committeeman (1992-present);
III. Department of Pennsylvania Vice Commander (1983-1984);
and
IV. Department of Pennsylvania Commander (1987-1988).
Ron also served as President of the Pennsylvania American
Legion Convention Corporation, which hosted the 1993 National
Convention in Pittsburgh. Perhaps most importantly, Ron is the
Founder and President of the American Legion for Homeless
Veterans Corporation, an entity which operates eight
residential and treatment facilities for homeless veterans in
the Commonwealth of Pennsylvania.
Ron served as an air policeman in the United States Air
Force from 1963 to 1966. He is an active leader of his union--
Steamfitters Local 449 in Pittsburgh, PA--and has been married
for 39 years to the former Barbara Lou Dilgen. Mr. and Mrs.
Conley have been blessed with five children and nine
grandchildren.
Ron, the floor is yours.
Chairman Specter. We customarily have a time clock, but we
are not going to put it on for you, Commander Conley. We are
going to let you speak at will, as the expression goes, but not
until we have heard from my distinguished colleague, Senator
Bunning of Kentucky.
Senator Bunning.
OPENING STATEMENT OF HON. JIM BUNNING, U.S. SENATOR FROM THE
STATE OF KENTUCKY
Senator Bunning. Thank you, Mr. Chairman.
Mr. Conley, I am glad you are here today to give us a
report on your work and findings as National Commander of the
American Legion. You have put in much hard work over the last
year, and I applaud your service to our veterans and their
families.
I am very impressed with your efforts to visit as many of
the VA medical centers across this country. You have visited
all three in Kentucky and made very candid assessments of each,
and I appreciate that very much.
The VA medical centers in Kentucky face problems similar to
others across the Nation. Demand for VA health care is higher
than the Department's ability to provide that care. Long waits
to see a doctor are unacceptable but very common. I think we
have seen some progress in recent months, but the Department
still has a long way to go.
One of the most prevalent issues and problems that you have
found were staffing issues. Some facilities do not have enough
personnel, and we need to be sure we are hiring the best people
for the job. I think everyone on this committee is dedicated to
ensuring our veterans receive the best care possible in a
timely manner. I know I am. Your report and recommendations
will help us to do just that, and I thank you for being here.
Thank you, Mr. Chairman.
Chairman Specter. Thank you very much, Senator Bunning.
Commander Ronald F. Conley, we await your discourse. The floor
is yours.
STATEMENT OF RONALD F. CONLEY, NATIONAL COMMANDER, THE AMERICAN
LEGION; ACCOMPANIED BY ROBERT W. SPANOGLE, NATIONAL ADJUTANT,
THE AMERICAN LEGION; STEVE A. ROBERTSON, DIRECTOR, NATIONAL
LEGISLATIVE COMMISSION, THE AMERICAN LEGION; AND PETER S.
GAYTAN, PRINCIPAL DEPUTY DIRECTOR, VETERANS AFFAIRS AND
REHABILITATION COMMISSION, THE AMERICAN LEGION
Mr. Conley. Senator Specter, Senator Bunning, we want to
thank you for the opportunity to appear here this afternoon to
give you our assessment, but before I get into my oral
statement, I would like to introduce publicly to you the
National President of the American Legion Auxiliary, Elsie
Bailey, from New Jersey.
[Applause.]
Mr. Conley. We also have with us Past National Commander
from the State of Maryland, Clarence Bacon.
[Applause.]
Mr. Conley. We have John Brieden and Tom Cadmus that are
candidates for National Commander of the American Legion, and
we have Paul Moran, Ed Dentz, and Terry Lewis that are chairmen
of VA in our Legislative Council. We also have Mr. Johnson, our
National Vice Commander, here and, of course, Senator----
[Applause.]
Mr. Conley [continuing]. You know Dr. Sebastianelli from
Pennsylvania, who is a Past National Vice Commander.
Again, I want to thank you for the opportunity to be here
and give you our assessment of the VA hospitals, a system worth
saving. As National Commander of the Nation's largest veterans'
service organization, I pledged to visit at least one VA health
care facility in each State. With the information I gathered
through face-to-face meetings with faculty staff, firsthand
reports from the very veterans who comprise the 200,000-plus
backlog of patients waiting for appointments at VA, and surveys
submitted by the facility directors, the American Legion has
developed a comprehensive report dealing with the obstacles
faced by the VA to ensuring the timely delivery of quality
health care to America's veterans.
This report was guided by both duty and privilege. It has
been my honor to meet firsthand so many talented people who
fulfill our Government's health care obligations to veterans. I
investigated more than 60 VA facilities throughout America, the
Philippines, and Puerto Rico in the past 10 months, and the
information I gathered along the way reinforces the American
Legion's belief that the VA is indeed a system worth saving. In
touring these facilities, I made a conscientious effort to
break from the beaten path. I compared comments from
administrators and public affairs staff with the more
experienced opinions of hard-working doctors, nurses, and
technicians on the front lines. I also spoke with thousands of
veterans and their families who entrust their lives to this
system.
Among VA employees, I witnessed strong dedication,
professionalism, safety awareness, and resourcefulness. Among
veteran patients, I heard profound gratitude voiced for the
quality of care they had received. But from nearly everyone, I
also found frustration over the lack of timely access to VA
health care, under use of some facilities, overcrowding in
others, and an inconsistent budget and budget expectations.
America's excellent VA health care system is being consumed
by physical neglect. It is my duty as the leader of the
veterans to share my findings with those who have the power to
change it and to inform the public of the conditions that exist
and the reasons we believe they exist. It has been an eye-
opening journey.
My first stop was Dallas, Texas, last September 20th. There
I found the first in a long line of facilities where capital
improvements have been shelved for the sake of hitting the
bottom line. The Alzheimer's unit there is in an I-shaped
building and operates in the 1940s. In order to monitor the
Alzheimer's patients, they put an LPN nurse in a school chair
at the end of the hall, and that is the care and treatment they
get in that facility. It has been on the books to try to build
a new facility. The first cost was $19 million. It has now been
readjusted to $33 million, but it has been placed on hold
because of the CARES process.
In Bay Pines, Florida, I encountered a VA medical center
where the list of veterans' waiting time is 6 months or longer
for primary care appointments. But it has been reduced to
14,000 waiting.
In Prescott, Arizona, no one knew how many registered
nurses worked in the hospital or how many new veterans were
enrolling each year. I later learned that that particular
facility, where patient numbers have been more than doubled
since 1997, is on the chopping block because of CARES.
In Salisbury, North Carolina, the director said that 75 new
doctors and $17 million are coming soon to solve that medical
center's problems, a five-figure backlog. Why an increase at
this particular facility and where was the money coming from?
The director said he did not know, but he was sure it was
coming.
In Cheyenne, Wyoming, a hospital doctor explained that his
patient load had risen from 6,000 to 13,000 in the same period
that his staff numbers had been cut from 385 to 340.
A director in Louisville, Kentucky, said the VA hospital
under his supervision simply needs to be torn down and rebuilt.
One emergency room doctor there can expect to treat 50 or more
veterans a day.
A director in Manchester, New Hampshire, simply told me
that veterans would be better served in a non-VA facility.
Throughout America, it is obvious VA health care operations
are being forced to do more with less. Demand has soared and
the funding has failed to keep pace. Staff shortages are
everywhere.
In Cheyenne, the hospital director, a doctor himself,
treats patients alongside the physicians under his supervision.
That facility, where demand was more than double while staffing
has decreased by over 10 percent, must routinely shuffle
patients from floor to floor to put veterans near caregivers.
There, they are forced to perform the kind of triage one might
expect on a battlefield but not in a VA hospital.
At Edward Hines, Jr., VA Hospital in Illinois, there are
seven vacancies for spinal cord specialists. Despite finder's
fees and signing bonuses, they still experience hiring
difficulties.
In many locations, VA facilities are forced by urgent
demand to fill in with agency-contracted nurses, part-time
doctors, and short-term foreign physicians under J-1 visas.
Doctors hired under J-1 visas are required to practice for a
minimum of 3 years at a VA facility. Once that obligation is
met, many physicians leave the VA health care system and begin
practicing in the private sector, which does not solve VA's
long-term staffing shortages. What is worse is these same
doctors could possibly be contracted by the VA to provide care
at a much higher cost. We think this entire program needs
revision.
Staffing shortages result in closed beds, wards, emergency
rooms, nursing homes, and intensive care units. The shortages
force patients for whom the facilities were built to be turned
away. Shortages force the VA Secretary to reverse the clear
intent of the Veterans Health Care Eligibility Reform Act of
1996 by once again restricting enrollment only to the poorest
and the sickest among those who served.
To its credit, America's budget-strapped veterans' health
care system does not ration quality. Unfortunately, because the
funding pie cannot be cut into enough pieces for all, VA must
ration access. This is why tens of thousands of veterans are
waiting in line to see doctors. What good is high-quality care
if you cannot get an appointment to receive it?
As outlined in the President's budget, Priority 7 and 8
veterans will pay a $200 annual enrollment fee. This proposal
is meant to drive out 1.2 million veterans from the VA health
care system. That is unacceptable.
Capital improvement measures to cope with recent demand
growth remains stalled under the CARES recommendations.
Suspending all capital improvements until the completion of
CARES is proving detrimental in many locations. In
Indianapolis, the director reported his facilities must expand
immediately to handle the current patient load and to
accommodate all the projected growth. Meanwhile, VA facility
directors in other parts of the country are using up their
capital improvement reserves to handle day-to-day operations.
The final CARES recommendations must enhance services for CARES
and not simply realigning capital assets to downsize the
system.
Another area of concern is the VA requirement that each
hospital hire a minimum of two full-time armed police officers
per shift, as well as installing new electronic surveillance
equipment. This mandate was not funded, however. Hospital
directors have been forced to borrow from their medical budget
to meet the new security requirements. Funneling funds from the
medical budget means fewer doctors, nurses, technicians, and
pharmacists.
Since its creation, the VA health care system has worked
side by side with the Nation's medical schools. The value of
VA's affiliations with medical colleges and nursing schools is
beyond dispute. Ninety percent of the doctors at the VA
Connecticut Health Care System in West Haven, Connecticut, are
affiliated with Yale University. The University of Pennsylvania
Medical School runs the Philadelphia VAMC Emergency Room every
night.
The University of South Carolina School of Medicine, a
national leader in colorectal cancer research, shares the same
campus at the VA Medical Center in Columbia, South Carolina. On
any given day, 50 or more university physicians and interns
work in that VA facility.
One VA medical center reported having affiliations with 68
different institutions of health care education. But when VA
facilities are downsized out of the proximity to their medical
school partners, their relationships are gone forever.
This is happening right now in Chicago, where Lakeside VA
Medical Center is merging with a sister facility on the other
side of town, effectively dissolving VA's long and successful
relationship with Northwestern University Medical School.
Neither the veteran stakeholders nor the university
administration had a voice in that decision.
When I visited Lakeside Division of the VA Chicago Health
Care System on May 17th, I was told their patient population is
mostly poor, indigent, and unemployed veterans. The hospital
property has been valued as high as $100 million by the VA. In
an effort to keep a VA hospital in the downtown Chicago region,
Northwestern University developed an alternative plan that
would allow VA to assume ownership of Prentiss Women's Hospital
located across the street from the current Lakeside Hospital.
VA rejected that proposal and seems determined to sell the
property.
Eliminating VA health care services from Chicago will prove
detrimental to the local veteran population who will not be
able to travel across the city to the Hines facility.
Currently, Northwestern provides more than 300 doctors at no
cost each year to Lakeside VA Medical Center. Once Lakeside is
closed, the value of affiliation with Northwestern in terms of
expenses saved and veterans treated will be difficult to
recover.
Nearly all the strategies suggested to resolve VA's access
crisis have focused on reducing access, outsourcing services,
or finding ways around paying the actual costs of providing
care. Downsizing is not the answer.
Last January, the decision to cutoff new enrollment of
Priority 8 veterans was made in the interest of stemming demand
the VA health care system could not handle with existing
appropriations. However, by cutting off that particular group,
the system lost the population of patients most likely to have
health insurance policies and the ability to share in the cost
of their care. I found this decision especially ironic after
having heard frustration from every corner of the country about
VA's expectation for third-party reimbursements. Last year, in
Puerto Rico, third-party reimbursements target was $8 million.
The facility beat it by $200,000. This year, the target was
doubled to $16 million, a figure their director says is at
least $5 million too high.
I was also told a collection agency receives 25 percent of
third-party reimbursements collected in Puerto Rico. In
Minneapolis, the third-party reimbursement jumped from $15.5
million to $23 million. In Ann Arbor, Michigan, the target was
$7.5 million for third-party reimbursements. They did not make
it. They only collected $6.5 million. But their new target this
year is $11 million. That to me means a cut of services for the
veterans in that area.
Many directors I spoke with agreed that it is doubtful
major increases in third-party reimbursements targets can be
reached this year because the population of veterans driving
that revenue stream has been removed from the equation.
Scarcity of budget dollars creates competition among VA
facilities and inconsistent veteran care as a result. How else
can you explain shortage-based backlogs of 10,000 or more, such
as in Bay Pines, Florida, when only 750 miles away from that
facility in Jackson, Mississippi, they have next-day care?
A mandatory appropriations model for VA health care would
help ensure VA is funded at a level needed to reach the demand
for care. Funds must be allocated on a cost-per-veteran basis,
indexed annually for inflation. In addition to mandatory
funding for VA health care, the American Legion supports
allowing all veterans with the ability to use their insurance,
including Medicare and HMOs, to choose VA facilities for their
health care regardless of economic status or level of service-
connected disability. They would be required to reveal any
insurance coverage they have and make reasonable co-payments
for treatment of conditions unrelated to their military
service. For those veterans who don't have health insurance, VA
can offer a premium-based health care benefit package.
Mr. Chairman, my entire year as Commander has been spent
collecting examples of many ways in which the discretionary
appropriations model fails to fulfill the care giving purposes
of the VA. Mandatory funding models supported by the American
Legion, coupled with revenue-generating programs such as
Medicare reimbursement and premium-based health care plans,
will help to boost VA funding to a level that will allow VA to
meet the increased demand for care. History has proven that 30-
percent increases in demand cannot be served by 7-percent
increases of funds.
The Department of Veterans Affairs is America's biggest
managed care system. It is a national treasure, a good reason
for any young man or woman to serve in the United States Armed
Forces. This health care system was created to treat the unique
health care needs of America's veterans.
Call it a debt. Call it an obligation. Call it a promise.
The VA health care system serves tens of thousands of men and
women who were willing to give their lives for the freedom of
all others who make America their home.
Mr. Chairman, I did not come here today to simply point out
the deficiencies in the VA health care. I have come prepared to
offer recommendations.
The American Legion recommends an open exchange of
information leading to the final recommendations of the CARES
process. Any CARES recommendations should be considered in the
context of a fully utilized VA health care system that takes
into consideration the tenets of the GI Bill of Health, VA/DoD
sharing, the Veterans Millennium Health Care and Benefits Act,
and the mission of the Department of Homeland Security. VA must
also provide a list of capital assets to the Department of
Homeland Security for consideration and strategic planning at
the local, State, and national levels.
The American Legion supports the mutually beneficial
affiliations between VA and the medical schools of this Nation.
The American Legion also recommends appropriate representation
of VA medical school affiliates as stakeholders on any national
task force, commission, or committee established to deliberate
on veterans' health care.
The American Legion recommends Medicare reimbursement for
the VA on a fee-for-service basis for the treatment of
nonservice-connected medical conditions of enrolled.
The American Legion recommends that Congress designate VA
health care as mandatory funding and provide discretionary
funding required to fully operate other programs within the
Veterans Administration. Additionally, Congress should provide
supplemental appropriations for budgetary shortfalls in the
VHA's mandatory and discretionary appropriations.
The American Legion recommends the expansion of VA's third-
party reimbursement to include Medicare reimbursement as well
as optional premium-based health care plans for those veterans
choosing to seek treatment for nonservice-connected.
Mr. Chairman, from the founding of this great country to
the present, America has recognized its obligation to the men
and women of the Armed Forces--past, present, and future. As a
grateful Nation providing timely access to quality health care,
transitional assistance from military service to civilian life,
timely adjudication of disability claims, and a final resting
place continue to be a moral, ethical, and legal obligation.
Recently, new terms like ``core veterans'' and
``traditional users'' have been used to serve as justification
for America's failure to meet the health care needs of its
veterans. Yet neither term appears in Title 38 United States
Code. Such terms appear only in the minds of bureaucrats.
Mandatory funding for VA health care will provide a more
accurate mechanism for funding VA medical care at a level that
will ensure VA has the ability to serve all eligible veterans
and to meet its self-imposed access standards: 30 days for
primary care appointment, 30 days for specialty care
appointment, and an average waiting time of 20 minutes.
Rationing health care by denying access to Priority 8
veterans is not the answer. Charging an annual enrollment fee
for certain priority groups is not the answer. Raising co-
payments for outpatient services is not the answer. Raising co-
payments for prescriptions is not the answer. The answer is
designating VA medical care as mandatory funding within the
Federal budget.
Mr. Chairman, veterans have served, are serving, and will
continue to serve this Nation in an uncharacteristic manner--
putting duty, honor, and country before self.
If America can find the money to bail out failed savings
and loans institutions, commit troops to peacekeeping missions,
rebuild foreign governments, provide health care for Third
World countries, provide health care to those incarcerated in
our prisons, and forgive loans to foreign countries, then
surely America can find money to provide the needed care for
America's veterans. This is what veterans want, and I believe
it is what America believes is right.
Mr. Chairman and Members of the Committee, that concludes
my testimony, and I ask that a full copy of the final report be
included in the record. Please excuse me for my voice, but I
have not gotten adjusted from coming back from Europe and then
going to Texas and Oklahoma and then here. I have developed a
nice cold. So please excuse my raspy voice.
[The prepared statement of Mr. Conley follows:]
Prepared Statement of Ronald F. Conley, National Commander,
the American Legion
Chairman Specter and Members of the Committee, thank you for
allowing me to testify today. Last September during a hearing before a
joint session of the Committees on Veterans' Affairs, I made a promise
to report back to you and your colleagues the results of my extensive
visits to VA medical facilities across the United States. This final
report spotlights my personal observations during visits to 60 VA
medical facilities.
These visits were thorough, in depth, and probing. I preceded these
visits by providing a list of specific questions to each facility to
answer and return to The American Legion. Initially, I asked each VA
medical facility director a few questions while meeting with them.
However, over the course of my visits, the number of questions I asked
increased as I became aware of the areas that needed extra attention.
ENROLLMENT
In 1996, Congress enacted legislation authorizing all eligible
veterans to enroll in the VA health care system, within existing
appropriations. This legislation changed years of complicated rules and
regulations governing eligibility to health care. The complexity of
this paradigm created confusion among providers, as well as patients.
Frequently, rules were bent, stretched, or ignored to meet the health
care needs of patients. There were no defined health benefits packages,
no reliable data projecting future patient population, and no major
effort to capture third-party reimbursements or co-payments for the
treatment of nonservice-connected medical conditions. Access to the
system was severely limited to only three groups of veterans: service-
connected disabled veterans, other disabled veterans, and economically
indigent veterans. VA's patient population in 1996 was about 10 percent
of the total veterans' population. Once VA opened enrollment, it
attracted new patients for several reasons:
Quality of health care provided,
Patient safety record,
Accessibility,
Pharmaceutical program,
Specialized Services, especially long-term Care,
Affordability, and
VA's affiliation with medical schools.
Following the eligibility reform of 1996, many Medicare-eligible
veterans enrolled in the VA health care system, not only for access to
quality medical care, but also to benefit from VA's low co-payment
prescription program. Initially, VA's co-payment for nonservice-
connected medications was $2 per 30-day supply. Even when Congress
allowed VA to increase this co-payment from $2 to $7, veterans
continued to enroll. Now VA has an enrolled patient population of
nearly 7 million veterans, over half of them are also Centers of
Medicare and Medicaid Services (CMS) beneficiaries as well.
In January 2003, the VA Secretary suspended enrollment of Priority
Group 8 veterans--regardless of their service-connected disabilities,
their third-party insurance coverage, or their ability to pay for care.
Those with service-connected disabilities are authorized to seek
treatment of their service-connected medical condition, but are not
authorized to enroll for treatment of their nonservice-connected
medical conditions.
From the very beginning of my term as National Commander, I was
aware of lengthy waiting lists for primary care; however, I did not
grasp the magnitude of the problem until I began to visit VA medical
centers. Initially, I thought these waiting lists were just regional
problems, but soon realized it was system wide. I discovered the
deplorable conditions resulting from VA's inability to meet its own
established acceptable access standards. VA's access standard for a
primary care appointment is 30 days--extremely modest compared to
nearly every other health care delivery system, public or private.
Personally, I would find that standard unacceptable for my private
health care system. In actuality, some veterans have waited longer than
the standards--even as long as 2 years or more. Clearly, a patient
could die while waiting for care--and, sadly, some have. Unfortunately,
only a few isolated exceptions are meeting VA's own acceptable access
standards for primary care.
As staggering statistics of thousands of veterans waiting 6 months
or longer for their initial VA appointments became public knowledge, I
was reminded of a statement made by former National Commander F.W.
Galbraith during an American Legion meeting in 1920:
``The trouble is that the men in these hospitals are `cases.'
They are represented by so many pieces of paper in some bureau
in Washington. We want to humanize the whole thing, and say,
`Here is Jim Smith's case, my friend. What do you propose to do
about him?' That is the thing that we want to do, and we can do
it. It is our primary motive for living.''
To evaluate the severity of this situation, The American Legion
developed a program to put a ``human face'' on the growing problem--
thus the ``I Am Not a Number'' campaign began. Veterans across America
were asked to share their personal experiences in the VA health care
system. These are my comrades, not just statistics. Thousands of
veterans responded to The American Legion's survey between November
2002 and February 2003. Stories of frustration stretch from coast-to-
coast.
The survey form was established and distributed to help develop a
global picture through self-reporting. The survey sought veterans'
self-assessment of their health care delivery system. Some reports were
favorable, while others were extremely critical. On the whole, those
veterans actually receiving care were pleased with the quality of that
care and the professionalism of their VA health care providers.
Predictably, those waiting 6 to 18 months were far more critical of the
lengthy delays and perceived indifference toward their situation.
Complaints of multiple rescheduled appointments were common. The
results of this survey reveal problems throughout the VA health care
system. The bottom line: too many veterans are being denied timely
access to quality health care. The ``waiting game'' is being played at
nearly every VA medical facility across the country. And America's
veterans are suffering.
The American Legion prepared a short video, which I have provided
to your staff, in which veterans tell their own personal stories. I
hope you and your colleagues will review this video. It highlights the
obstacles encountered by the men and women--veterans of the Armed
Forces--attempting to access the VA health care system. These
individuals aren't the only ones with stories to tell. There are tens
of thousands of veterans just like them, nationwide.
Mr. Chairman and Members of the Committee, if you or a member of
your family were ill and in need of health care, would you find it
acceptable to wait 6 months to a year for a primary care appointment?
How would you feel if you were eligible to enroll as a result of your
honorable military service, but were prohibited from enrolling because
you earned more than $29,000 a year or lived in the wrong geographic
area?
DEMAND VS. FUNDING
Recently the President's Task Force to Improve Health Care Delivery
to Our Nation's Veterans (PTF) issued its final report. Among the many
areas discussed in that report, one issue stands out--the current
mismatch between demand for timely access to care and Federal funding
throughout the VA health care system. Not only does this crisis
prohibit meaningful collaboration between VA and the Department of
Defense (DoD), but it also causes uncertainty about VA's ability to
fulfill its four primary missions.
The PTF recommended full funding of VA to care for all enrolled
Priority Group 1-7 veterans. However, the best recommendation the PTF
could reach to address Priority Group 8 veterans was for the President
and Congress to study and resolve the mismatch problem. This was the
only recommendation on which the PTF Commissioners failed to reach
consensus. This is truly unfortunate since Priority Group 8 comprises
the majority of veterans; therefore, future access to VA health care
remains uncertain for them--at least for now.
Three PTF Commissioners offered a dissenting opinion regarding the
funding of Priority Group 8 veterans, which is supported by The
American Legion. The recommendations outlined in this dissenting
opinion place a financial obligation on each enrolled Priority Group 8
veteran. Mr. Chairman, I would encourage you and your colleagues to
consider these recommendations.
MEDICAL CARE COLLECTION FUND (MCCF)
Although adamantly opposed by The American Legion, all third-party
reimbursements and co-payments collected by VA's MCCF are scored as an
offset against VA's annual discretionary appropriations. Since this
money is for the treatment of nonservice-connected medical conditions,
The American Legion continues to advocate scoring MCCF as a supplement
to VA's annual medical care appropriations.
During my visits, I discovered that MCCF is handled differently
from medical facility to medical facility. Some MCCF activities are
contracted to private collection firms, while others are done
internally. This year, VA's MCCF collections were the highest ever, yet
its actual collection rate is extremely low compared to the industry
standard. Since VA is prohibited from collecting from CMS for the
treatment of nonservice-connected medical conditions of CMS
beneficiaries, VA bills CMS in order to collect from private medical
supplemental policies.
With a patient population comprised of more than 3.5 million CMS
beneficiaries, VA medical facilities cannot realize their full
potential in MCCF collections. Nearly every VA medical facility I have
visited is expected to increase MCCF collections in fiscal year 2003.
Yet, the President's budget request for fiscal year 2004 seeks to drive
away as many as 1.2 million Priority Group 7 and 8 veterans by
authorizing increased co-payments and an annual enrollment fee.
Both Indian Health Services (IHS) and DoD's TRICARE effectively
used third-party reimbursements, co-payments, and premiums to
supplement their discretionary appropriations and resolve the demand
versus funding crisis. IHS turned to third-party reimbursements from
CMS and the private sector to help improve quality of care and timely
access problems. DoD developed TRICARE to solve the problems and meet
the cost generated by CHAMPUS in delivering timely access to quality
health care for military retirees and eligible dependents. Enrollment
in TRICARE, requires co-payments and premiums based on the degree of
health care coverage desired. TRICARE for Life requires Medicare-
eligible beneficiaries to purchase Part B coverage and DoD serves as
the supplemental insurer. All three approaches appear to be meeting the
health care needs of affected patient populations.
One of the interesting observations is the effective use of
``certified'' coders by IHS in its third-party reimbursement efforts.
Although not authorized to hire ``certified'' coders by the Office of
Personnel Management (OPM), IHS sent selected coders to attend training
to become ``certified.'' Fortunately, these ``certified'' coders choose
to continue with IHS even though they are underpaid based on their
enhanced abilities and skills. The difference in the collection rate
between coders and ``certified'' coders is significant and cost-
efficient. Certified coders within VA would help to increase third
party reimbursement rates.
SPECIALIZED SERVICES
Most notable among the health care services provided by VA are its
specialized services, especially spinal cord injury, geriatrics,
prosthetics, blind rehabilitation, and long-term care. As the veterans'
population ages, greater demand for these services are anticipated,
particularly, long-term care. The Millennium Health Care and Benefits
Act of 1999 mandated VA to provide long-term care for all veterans
rated 70 percent or more service-connected. Currently, VA is not
meeting the mandated inpatient bed levels also prescribed by this
legislation. I did not visit a single VA long-term care program without
a waiting list.
I am greatly concerned that mental health and long-term care
inpatient beds are not included in the current CARES ``market plans''
developed by each VA medical facility. Ignoring these services does not
diminish demand by veterans with Alzheimer's or dementia. Mr. Chairman
and Members of the Committee, these veterans answered the nation's call
to national service--it is time for the Nation to answer their calls
for assistance.
STAFFING SHORTAGES
The VA health care system is blessed with many dedicated
employees--both health care providers as well as the support staff. The
former Secretary Jesse Brown may have officially coined the phrase
Putting Veterans First, but most VA employees institutionalized the
concept decades earlier. Unfortunately, VA has failed tremendously in
the recruitment of health care professionals and other support
positions. Nearly every VA medical facility expressed staffing
shortages stemming from one of three sources--normal staffing
shortages, inadequate salaries, and the Federalization of Guard and
Reserve personnel in support of the War on Terrorism and Operation
Iraqi Freedom.
Additionally, medical research must be funded at levels adequate to
continue VA's long tradition of ground breaking medical advances. The
research opportunities available through VA continue to be a strong
incentive to attract health care professionals.
A serious review of performance standards, compensation, and actual
work performed by ``part-time'' physicians is desperately needed.
During my visits, I learned of a serious problem with some ``part-
time'' physicians receiving compensation, but performing no services.
This is absolutely unacceptable and does not reflect favorably on the
medical facility director or those responsible for monitoring
employees' attendance and performance of duties. At a time of lengthy
waiting periods for primary care and specialized care appointments, the
unauthorized absence of ``part-time'' health care providers is
inexcusable. It would seem timesheets and work schedules should
document work performance before paychecks are released. There must be
a better tracking system to monitor and evaluate the job performance of
``part-time'' physicians.
ORGANIZATIONAL STRUCTURE
While visiting VA medical facilities, I noticed a change in
management styles and philosophies from one VISN to the next. It seemed
as though there were 21 distinct VA systems instead of one. The effort
to decentralize the management and leadership of VA appears to have
created inconsistencies in focus and conflicting policies and
directives. Unilateral actions by individual VISN directors do not
improve the system as a whole and seem to lack coordination of efforts.
Clearly, subjective budgetary decisions have taken their toll on some
VA medical systems to efficiently meet the needs of the local patient
population. The most obvious example is the loss of inpatient beds for
specialized services such as mental health and long-term care. Some
MCCF collection practices are clearly more successful than others.
Management efficiencies also cover the spectrum, but do not reflect a
unified VA system. Performance standards seem to vary from VISN to
VISN.
MEDICAL SCHOOL AFFILIATIONS
Currently, there are 126 accredited medical schools in the United
States. VA Medical Centers (VAMC) have formal affiliations with 107 of
these medical schools and some 1,200 other educational institutions.
The value of medical school affiliations to the national health care
system has been well demonstrated. VA provides critical clinical
settings for physician trainees. The high level of care provided by VA
medical facilities is the result, in part, of numerous external
accrediting agencies and the supervision of residents who consider the
educational role as a critical component of their VA duties.
Medical research is yet another large component of medical school
affiliations. Staff physicians affiliated with medical schools
customarily hold academic positions, including tenured positions,
provide direct patient care, teach students, advise residents, and
conduct research--all of which contribute to excellence in a teaching
hospital environment.
CAPITAL ASSETS REALIGNMENT FOR ENHANCED SERVICES (CARES)
CARES remains a major topic of concern in every VA community I
visited. The fear of the unknown spawned the question, ``Do you think
they will close this facility?'' This uncertainty causes anxiety among
health care providers, medical researchers, patients, and support
staff. The individual marketing plans are being carefully crafted to
meet the anticipated health care needs of the local veterans'
community, but are being altered by external guidelines from the VA
Central Office in Washington, D.C. Recently, the VA Central Office
returned local marketing plans of some 20 medical facilities for
additional review. This seems inconsistent with the intent of having
locally generated marketing plans developed to meet the health care
needs of their patient population.
As National Commander, I created The Veterans Affairs Facility
Advisory Committee on CARES (VAFACC) to The American Legion's Veterans
Affairs and Rehabilitation Commission. The committee's charge was to
review the VISN Market Plans, Planning Initiatives, and VA Facility
Assessment Reports relating to the CARES process, keeping in mind
VISN's were tasked to cut 10 percent of their vacant space by 2004 and
30 percent by 2005.
The VAFACC developed an independent assessment of the facility
recommendations resulting from the CARES process. The committee was
composed of experts in the fields of construction, engineering,
veterans' benefits, medical school affiliations, health care policy,
health care delivery, and health care administration.
Committee members reviewed each Market Plan and Planning
Initiative submitted to the National CARES Planning Office (NCPO) for
each of the 20 VISN's going through Phase II of CARES.
After a thorough review of the proposed Market Plans, the VAFACC
raised the following concerns:
Funding.--Clearly, billions of dollars in discretionary
appropriations will be needed to accomplish the new construction and
renovations approved in the final CARES plan. CARES is an ongoing
process and incremental changes are anticipated. With the proposed
consolidations and transferring of services, it is imperative that no
veteran experience any delays in timely access to the delivery of
quality health care, and patient safety must not diminish. No VA
medical facilities should be closed, sold, transferred or downsized
until the proposed movement of services is complete and veterans are
being treated in the new locations. Funding levels should be adequate
to ensure services are available during periods of transition.
Veterans' Population.--There is some concern that the
projected veterans' population is underestimated. Certainly with regard
to long-term care, mental health, domiciliary, and other specialized
care populations, the CARES process has yet to incorporate projections.
Long-Term Care.--VA spent close to $3.3 billion on long-
term care in fiscal year (FY) 2002. With the enactment of the
Millennium Health Care Act, demand will most likely increase due to the
aging of the veteran population over the next decade. VA estimates that
the number of veterans most in need of long-term care, those veterans
85 and older, will more than double to about 1.3 million in 2012. Yet,
even with these numbers, veterans' long-term care needs and projected
growing demand was omitted from the CARES process.
Mental Health.--Due to several factors concerning the
initial projections, NCPO and several other experts are reviewing the
mental-health inpatient and outpatient projections. Because of the
questionable demand decline in several markets, networks were
instructed to plan for increases in mental-health services only. VA
must include accurate mental health projections in order to ensure
effective recommendations from the CARES process.
Domiciliary.--The inappropriate distribution of
domiciliary beds based on demand projections gave rise to several
policy and programmatic concerns and questions. Because the original
projections were based upon a national average utilization rate, the
model redistributed beds from existing domiciliaries to areas where
there are none. For those reasons, further study is needed and
projections must be revised before the next planning cycle.
Unutilized Space.--Among the criteria the VISN's were
tasked to evaluate was unutilized space. The VISN performance measure
was a reduction of 10 percent by 2004 and 30 percent by 2005. According
to VA's Office of Facilities Management (OFM), VA facility assets
include 5,300 buildings; 150 million square feet of owned and leased
space; 23,000 acres of land--the total replacement value of all
elements is estimated at $38.3 billion. OFM assessed and graded 3,150
buildings for a total of 135 million square feet with correction costs
estimated at $4.5 billion. These assessments were used at the local
level as a tool to help manage medical centers and VISN's vacant or
underutilized space.
More development is needed by the VISN's to effectively utilize
unused space in lieu of selling or demolishing these buildings. Once
the buildings are gone, there will be no way of getting them back.
Before any unutilized space is sold, transferred, destroyed, or
otherwise disposed of, the CARES process must consider alternative uses
of that space to include: services for homeless veterans, long-term
care, and the expansion of existing services to alleviate the extreme
backlog of patients waiting to receive care at many VA medical
facilities. Such considerations were lacking in most of the VISN Market
Plans.
Contracting Care.--Throughout the VA health care system,
contracting out of care is very prevalent, especially the Community
Based Outpatient Clinics (CBOC's). While contracting out of care is
necessary in some circumstances, the wholesale use of this health care
delivery tool should be exercised with caution. In certain areas, it
will be difficult at best based on availability of approved medical
staffing and the contract fee schedules.
Contracting out of care was extensive in the VISN proposals. Some
VISN's made the blanket statement that care would be contracted out to
meet excess demand in 2012 and 2022. That is not much of a plan. What
if the resources are not available? Additionally, VA's history with
contracting is not enviable. VISN 10 proposed contracting with local
providers/hospitals for inpatient beds to bring their access standards
from the current 32 percent to 83 percent in 2012. That is an enormous
gap to cover through contracted care. VISN 6 proposed 19 new CBOC's.
VA-wide, there are more than 130 new CBOC's planned to enhance access
to care.
Enhanced Use Lease Agreements.--With Enhanced Use Lease
Agreements (EU) VA can maximize return from property that is not being
fully utilized. EU leases also allow VA to reduce or eliminate facility
development and maintenance costs. Through the use of EU leases, VA can
receive cash or ``in-kind'' consideration (such as facilities, services
goods, or equipment).
Several of the VISN's proposed enhanced use lease agreements with
the public and private sectors. Uses include homeless shelters or
housing, cultural arts centers, cemeteries, inpatient beds, mental
health services and many other veterans' service enhancing ideas.
VA should continue to seek opportunities in the area of enhanced
use leasing. It can certainly have a positive impact on service
delivery to veterans and the local community.
There have been 27 projects awarded so far. The VA Secretary has 23
on the priority list with over 50 more currently in development.
Clearly, VA is continuing to urge the VISN's to consider using this
valuable tool even more. However, the committee recognizes that the
approval process involved in obtaining an enhanced use lease is lengthy
and complex.
VA/DoD Sharing.--There are many opportunities for sharing
between VA and the Department of Defense (DoD). The VISN Market Plans
contain many proposals addressing the possibility of service sharing to
increase access to health care for veterans. Both VA and DoD benefit
from these agreements and every effort should be made by the VISN's to
pursue this avenue in order to save money through cost avoidance, in
particular pharmaceuticals, supplies and maintenance services.
Extra effort on the part of these agencies to cooperate is
essential to the success of sharing agreements. Some parts of the
country are reluctant to ``share'' services or programs between
agencies. It is imperative that we overcome that obstacle and look to
the future of providing quality health care and reasonable access to
this nation's veterans.
The American Legion will remain an active partner with VA during
this critical process of realigning the agency's capital assets to
better serve America's veterans. Recent developments in the CARES
process serve to reinforce some of my concerns. The Under Secretary for
Health has sent back the Market Plans to 15 VISNs/20 facilities with
instructions to further develop other options and look at further
consolidating inpatient services in many of the facilities.
Additionally, the CARES Commission hearings have been postponed until
August 2003, another 60 days. Delays such as these give rise to many
questions and concerns on the part of the stakeholders.
RECOMMENDATIONS
Capital Asset Realignment For Enhanced Services (CARES).--The
American Legion recommends an open and transparent process that
continually and fully informs VSO's of CARES initiatives, criteria,
proposals and timeframes. Any CARES recommendations should be
considered in the context of a fully utilized VA health care delivery
system that takes into consideration the tenets of the GI Bill of
Health, VA/DoD sharing, the Veterans Millennium Health Care and Benefit
Act and the mission of the Department of Homeland Security. VA must
also provide a list of capital assets to the Department of Homeland
Security for consideration in strategic planning at the local, state,
and national level.
Medicare Reimbursement.--The American Legion recommends Medicare
Reimbursement for VA on a fee-for-service basis for the treatment of
nonservice-connected medical conditions of enrolled, Medicare-eligible
veterans. Additionally, veterans should be authorized to participate in
the Medicare + Choice option by choosing VA as their primary health
care provider.
Medical School Affiliations.--The American Legion supports the
mutually beneficial affiliations between VA and the medical schools of
this nation. The American Legion also recommends appropriate
representation of VA Medical School affiliates as stakeholders on any
national task force, commission, or committee established to deliberate
on veterans' health care.
Mandatory Funding for VA Medical Care.--The American Legion
recommends that Congress designate VA medical care as mandatory
spending and provide discretionary funding required to fully operate
other programs within VHA's budgetary restrictions. Additionally,
Congress should provide supplemental appropriations for budgetary
shortfalls in VHA's mandatory and discretionary appropriations to meet
the health care needs of America's veterans.
Expanded Third-Party Reimbursement.--The American Legion recommends
the following to improve accessibility to VA health care and expand
third party reimbursement:
All enrolled veterans would be required to identify their
public/private health insurers.
VA would be authorized as a Medicare provider and be
permitted to bill, collect and retain all or some defined portion of
third-party reimbursements from CMS for the treatment of non-service-
connected medical conditions.
VA should be authorized to offer a premium-based health
insurance policy to any enrolled veteran having no public/private
health insurance.
All enrolled veterans would be required to make co-
payments for the treatment of non-service connected medical conditions
and prescriptions.
All enrolled veterans with no public/private health
insurance would agree to make co-payments for treatment of non-service
connected medical conditions.
SUMMARY
The history of the veterans' health care system is a lengthy story
of evolution. Although its mission is simply stated in President
Lincoln's Second Inaugural Address--to care for him who shall have
borne the battle, his widow and his orphan--financial obligation toward
meeting that mission continues to lag. VA has never faced a shortage of
patients, but has always endured financial pressures. From the
beginning, VA was open to any veteran in need, until the 1980s when
Congress enacted legislation that divided veterans into three groups--
service-connected veterans, economically indigent veterans, and all
other veterans. For the first time, honorable military service wasn't
enough to qualify a veteran for access to a VA medical facility.
From the founding of this great country to the present, America has
recognized its obligation to the men and women of the armed forces--
past, present, and future. As a grateful nation, providing timely
access to quality health care, transitional assistance from military
service to civilian life, timely adjudication of disability claims, and
a final resting place continue to be a moral, ethical, and legal
obligation.
Recently, new terms like ``core veterans'' and ``traditional
users'' have been used to serve as justification for America's failure
to meet the health care needs of its veterans. Yet, neither term
appears in Title 38, United States Code. Such terms appear only in the
minds of bureaucrats. Veterans' status has always had a direct
correlation to honorable military service. A veteran is a veteran. So
why has Congress and VA chosen to place veterans in separate priority
groups? How could service-
connected veterans in Priority Group 8 be denied enrollment in the VA
health care system, when nonservice-connected veterans in Priority
Group 7 can enroll? Neither Social Security nor Medicare places
beneficiaries in priority groups, so why are veterans treated
differently?
Neither Social Security nor Medicare has limitations placed on
beneficiaries like Priority Group 8 veterans based solely on means
testing or the HUD geographic index. Why the inequity?
Granted financial contributions are normally made to both Social
Security and Medicare throughout a beneficiary's working life, but few
Americans (less than 10 percent) make a personal commitment toward
national security as do veterans. If Social Security and Medicare
beneficiaries are ``guaranteed'' funding or ``guaranteed'' timely
access to medical care, why are veterans treated differently?
It seems entitlement to Social Security benefits and Medicare
coverage is unquestioned by Congress. Yet, a veteran's entitlement to
timely access to health care--even for those willing to pay--is always
being questioned, budget year after budget year.
There seems to be a misconception among certain groups that
designating VA Medical Care as a mandatory funding item within the
Federal Budget would provide free health care for all veterans. This is
not true. Mandatory Funding for VA Medical Care will provide a more
accurate mechanism for funding VA Medical Care at a level that will
ensure VA has the ability to serve all eligible veterans and to meet
it's self-imposed access standards--30 days for a primary care
appointment, 30 days for a specialty care appointment and an average
wait time of 20 minutes to be seen by a VA physician.
Years of under-funding have created the current crisis in VA health
care. Budgetary constraints have led to staffing shortages, elimination
of services and unmet demand for care. Rationing health care by denying
access to Priority Group 8 veterans is not the answer. Charging an
annual enrollment fee for certain Priority Groups is not the answer.
Raising co-payments for outpatient services is not the answer. Raising
co-payments for prescriptions is not the answer. Designating VA Medical
Care as a mandatory funding item within the Federal Budget is a solid
step toward improving accessibility of health care for all veterans and
The American Legion fully supports this.
Mr. Chairman, veterans have served, are serving, and will continue
to serve this Nation in an uncharacteristic manner--putting duty,
honor, and country before self. Many national leaders have issued the
challenge for Americans to serve this Nation as a member of the Armed
Forces, both on active-duty and in the Reserve components. Fortunately,
every day men and women freely accept that challenge.
If America can find the money to bail out failed savings and loans
institutions, commit troops to peacekeeping missions, rebuild foreign
governments, provide health care for Third World countries, and forgive
loans to foreign countries, then, surely, America can find the money to
provide the needed care for America's veterans. This is what veterans
want, and I believe it is what America believes is right. Those same
soldiers, sailors, airmen, and Marines securing the safety of foreign
citizens may one day turn to VA for their health care needs. I am
committed to ensuring that those brave men and women have a VA that can
provide the care they need.
Not far from here are the acres of white headstones at Arlington
National Cemetery that serve as a constant reminder that the cost of
freedom is a recurring debt paid every day by men and women in uniform.
Each headstone represents a debt that can never be repaid. We honor
those men and women by caring for their comrades. This is something
that no one disputes, yet is it also something that we as a Nation can
do better--we will do better--we must do better.
Mr. Chairman and Members of the Committee, that concludes my
testimony. I ask that an electronic version of the final report be
included in the record.
Chairman Specter. Commander Conley, your voice sounded
fine, and your testimony was profound, and we thank you for it.
The special report by Commander Conley, ``A System Worth
Saving,'' will be included in the record as requested.
To repeat, we are very proud of you in Pennsylvania, our
State, Ron, for the prodigious service you have performed, but
all of America is proud of you. Veterans are indebted to you
for your very comprehensive report.
I note that your comments have been reported in a
Pittsburgh Post Gazette article by Jack Kelley in today's paper
and by Suzanna Rosenblatt, Los Angeles Times staff writer. We
will include both of those reports as well, summarizing the
testimony.
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[From the Pittsburgh Post-Gazette, July 15, 2003]
American Legion Assailing Veterans Administration Hospitals, Clinics
(By Jack Kelly, National Security Writer)
Veterans Administration hospitals and clinics are under funded and
understaffed, and veterans feel betrayed, the American Legion plans to
say at a news conference in Washington, D.C., today.
Ronald Conley, national commander of the American Legion, will
issue a report on his visits to more than 50 VA hospitals and clinics
and his conversations with thousands of doctors, nurses, veterans and
family members of veterans.
``From nearly everyone, I found acute frustration about the lack of
timely access to VA health care, under-use of some facilities,
overcrowding in others, and inconsistent budgets and budget
expectations,'' Conley's prepared statement says. Conley is a resident
of Scott but none of the medical facilities mentioned in his statement
are located in southwestern Pennsylvania.
With 162 hospitals, 850 clinics, 137 nursing homes and 43
domiciliaries, the Department of Veterans Affairs runs America's
largest medical system. The number of veterans being treated at VA
facilities has more than doubled since 1998, from 2.9 million to 6.8
million. About 25 million veterans are eligible for VA care.
Veterans with service-connected disabilities and those with serious
ailments go to the head of the line. But veterans with disabilities
unrelated to their military service often must wait up to 6 months for
treatment.
Backlogs are uneven. More than 10,000 veterans wait for treatment
at the VA facility in Bay Pines, Fla., but the VA hospital in Jackson,
Mississippi, just 750 miles away, offers next-day service.
Conley is critical of a cost-saving measure instituted by Veterans
Affairs Secretary Anthony Principi. This year, veterans with
nonservice-connected disabilities and incomes of $36,000 or more a year
are not eligible for treatment at VA hospitals. The policy will be
reviewed at the end of the fiscal year.
Principi is breaking a promise America made to veterans, Conley
said. ``A veteran is a veteran. Anyone who raised an M-16 in basic
training, ran five miles in boots and packs, rappelled from a
helicopter into an ocean, or discovered firsthand what it means to fix
bayonets meets the criteria.
There should be a mandatory appropriation model for VA medical
care, similar to what exists for Medicare, Conley said. He acknowledged
this would raise costs of running the VA medical system far beyond the
7.7 percent increase President Bush has proposed, But Conley said
veterans deserve it.
``The government always seems to produce billions for foreign aid,
millions for pork-barrel projects that range from restoring statues of
mythological gods to subsidizing Elvis impersonators . . . and always
enough to keep sending young men and women off to fight our
government's battles in foreign lands,'' Conley said.
______
[From the Los Angeles Times, July 15, 2003]
VA Health System Failing, Survey Says
(By Susannah Rosenblatt, Times Staff Writer)
VETERANS HAVE TO WAIT UP TO HALF A YEAR FOR AN APPOINTMENT, THE
AMERICAN LEGION REPORTS. CLINICS CAN'T KEEP UP WITH DEMAND
Washington.--Veterans are waiting 6 months or more for medical care
as a severely overburdened Veterans Affairs health system fails to keep
pace with growing demand, a report to be presented to Congress today
concludes.
``Washington, D.C., operates on a mentality of statistics,'' said
American Legion national commander Ronald Conley, the author of the
report.
``We wanted to make everybody aware that these are not just
numbers, but are actual, real people and they're sick and they need to
see a doctor and they can't wait.''
An estimated 110,000 veterans are waiting for initial appointments
for nonservice-related medical problems at hundreds of VA centers
around the country, the VA acknowledges.
Conley is scheduled to testify today before the Senate Veterans'
Affairs Committee.
The VA expects to see 4.7 million veterans in its hospitals and
clinics this year, up more than 54 percent from 1996. The rising cost
of private health insurance and prescription drugs have led more
veterans to rely on VA medical care. About 7 million of the nation's 25
million veterans, or 28 percent, are receiving VA medical benefits.
``A lot of people who may have been able to afford health insurance
in the past are finding it difficult to afford it,'' said David Autry,
a spokesman for Disabled American Veterans. ``They are turning to VA,
where they feel their country should take care of them.''
Dr. Robert Roswell, VA undersecretary for health, said he also
attributes the influx of patients to new VA community clinics and
improvements in the quality of care. The waiting list for appointments
had been considerably longer, he added, with 315,000 veterans on it
just last summer.
President Bush's 2004 budget allots $27 billion for VA health care,
an increase of 7.7 percent from last year, Roswell said. ``We're quite
pleased with the support the President has shown,'' he said, but the
funds are still not enough to ``keep pace with truly phenomenal
growth.''
The chairwoman of a Presidential task force that examined the VA
health system in 2001 agreed with veterans' groups that the system is
unable to meet patients' needs.
``It was very clear that there were not enough resources currently
available to fund services for veterans in a way that would allow them
to get health care without undue delay,'' said Gail Wilensky, now a
senior fellow at Project HOPE, a health-care advocacy group.
The American Legion's Conley visited 60 VA medical facilities over
10 months, talking to hospital directors, doctors, nurses and patients
to assess how well the system meets patient demand.
The 162 hospitals, 850 clinics and 137 nursing homes that
constitute the nation's largest managed-care system are chronically
under funded, his report concluded.
The VA Greater Los Angeles Health Care System, one of the largest
in the country with 12 outpatient clinics and an operating budget of
nearly $500 million, was not included in the report and a spokesman
there declined to comment.
Veterans' groups are calling for a change in the way VA health care
is funded, so that it would receive a guaranteed stream of income much
like Medicare already does.
Currently, each year's VA spending must be set by Congress, making
it subject to the constraints of the overall Federal budget. Such
unpredictability makes it difficult for hospitals and other facilities
to operate, Conley said.
``No matter what the number is that may actually be needed, there
is no guarantee that that amount of money will be provided in the
end,'' Autry said. ``The VA doesn't have enough money to begin with, we
can't plan from month to month and we don't know when we're going to
get this money and how much it's going to be.''
In 1996, Congress relaxed eligibility requirements for VA health
care, allowing more veterans to enroll. A generous prescription benefit
is one reason that many have for enrolling. The VA offers a 30-day
supply of each medication for a $7 co-payment.
The President's budget includes provisions to increase the co-
payment to $15 for higher-income veterans and eliminate it for those
with lower incomes. The budget also proposes a $250 enrollment fee for
higher-income veterans.
An American Legion survey last year of about 4,000 veterans found
the average wait for an appointment is 7 months and that 58 percent had
appointments rescheduled, many for several months later.
``All I did was put in 20 years of separations, hardships,
sacrifices,'' wrote one survey responder, Robert Thomas, who served in
Korea and Vietnam in the Navy.
``The thanks I received is to be told that it will be another year
before I see my first VA doctor.''
Chairman Specter. Commander Conley, I want to ask you just
a couple of questions relating to your statements about
mandatory funding. If VA were to have been so funded this year,
it would have a 1.4-percent increase this year. But instead of
that, the VA requested an increase of 5.8 percent, and the
Congress increased VA medical care funding by some 11.3
percent. While the veterans appropriations, I agree with you,
have not been adequate, we have been able to do better even
than the administration that is a great friend of the veterans.
What would your thinking be considering the larger amounts
made available through the discretionary approach as opposed to
the 1.4 percent, which would have been the mandatory increase?
Mr. Conley. Well, Senator, first of all, the budget
included $2.1 billion in third-party reimbursements. Under the
mandatory funding, the third-party reimbursements should not
come into play. If you take out the increase that the
administration is asking for on a fee basis for prescription
and the enrollment fee that they are proposing, if you take all
those out of the budget, there really was not an increase as
far as VA health care. The mandatory funding would actually
give you the real dollars necessary for health care, plus you
can then add on the additional amounts of money.
What is happening now, the directors are greatly stressed
in two areas: One is to be able to collect third-party
reimbursements. I don't know what formula was used on how to
increase that amount of money by each hospital. The second is a
lot of hospitals, including VISN's, have to dip into their
capital investment money in order to take care of the health
care of those veterans. So now they don't have any money that
they can go out and buy new equipment and fix the roof and keep
the facility from deteriorating because they need to do it to
hire doctors and nurses.
Chairman Specter. Let me shift gears, Commander, to the
issue of the veterans who are enrolled for VA care in order to
get VA pharmaceutical benefits.
Legislation has been introduced, Senate bill 1153, which
provides that you wouldn't have to become an enrollee in the VA
in order to get Medicare doctor-written prescriptions filled by
the VA without first having seen a VA physician. If the veteran
wanted to enroll, fine, he could. But if veterans are enrolling
solely to get the prescription benefits, it wouldn't be
necessary for them to enroll. That might ease the burden on the
VA, but still leave the veteran with what the veteran is really
looking for, and that is, the VA prescription program.
Do you think Senate bill 1153 is a good idea?
Mr. Conley. Well, what I think on that, Senator, one, is
the liability if the VA is just going to hand out prescriptions
and become a drug store without having the veteran seeing a
doctor. I think probably the easiest way to do this is if you
have Medicare reimbursement, Medicare subvention, then you
would have a one-stop shop where the veteran would go to the
VA, see the doctor, get his prescription filled, and that would
take care of it. But if you are going to go from outside the
system and just have the VA become a drug store, I think it is
something the American Legion has to seriously take a look at.
Chairman Specter. Well, I agree with you, Commander, on the
idea of Medicare subvention. I think that is a good idea. We
have been trying to push that, and also third-party insurance
payments ought to go directly to the VA installation where the
service is performed to give a boost to funding available.
But when the veterans would come with their prescriptions,
they would have already seen a doctor. I agree with you that
you should not dispense prescriptions without a medical
authorization. But that having been achieved, we would
appreciate your further consideration.
Note that I ended with 1 second left, Ron.
Mr. Conley. Yes.
Chairman Specter. Senator Bunning.
Senator Bunning. Thank you, Mr. Chairman.
Mr. Conley, you said some good things in your testimony
about VA affiliation with medical schools. Do you think that
the VA should be actively increasing their dealings with
medical schools?
Mr. Conley. Absolutely. One of the things that I was able
to notice, first of all, with affiliation with schools, it
brings research money into the VA, and I was just in Oklahoma
and they received a total of $4 million--or $6 million in
research money. Two million of that comes out of the VA budget.
The rest of it is from outside grants that they invest into the
research program.
You are also able to achieve probably the best physicians
in the world that work at the VA because of their associations
with the medical schools. Over 50 percent of doctors in our
country have been trained through the VA. So we see so many
things that are positive about it.
Some of the hospitals, such as Oklahoma, they end up paying
part of the physician's pay because the VA cannot afford to pay
the salaries that some of these physicians require. So the
schools themselves then pick up their salaries.
The thing that greatly disturbs me about Chicago is that
Northwestern University has gone out of their way to try to
keep a hospital there by offering a whole hospital to the VA
for free. All they have to do is maintain it. They give them
300 doctors at no cost to the VA a year to help keep their
population down, but the VA turned that request down. That is
something I am having a hard time understanding.
Senator Bunning. Well, what was the explanation of the
Veterans Administration? Have you approach them on that?
Mr. Conley. Yes, sir, and we do not have an explanation. If
you go through--we have the full records of my visits to these
hospitals, and----
Senator Bunning. Well, could you make that specific
connection between Northwestern University and the VA hospital
in Chicago, the report on that? Is that part of your report?
Mr. Conley. Yes, sir.
Senator Bunning. Okay. That is something that I will get
into. I have not read that portion.
Mr. Conley. Well, if it is not in there, it should be.
Senator Bunning. It should be.
Mr. Conley. It should be in there.
Senator Bunning. Okay. Let me ask you a further question.
Do you think that the VA should locate new facilities near
medical school campuses when possible? In other words, I know
where the VA hospital is in Louisville, for instance, and that
is not near any medical school in the Louisville area because
one is in eastern Jefferson County and the other one is in
southern Jefferson County.
If, in fact, we were to get the ability to locate a new VA
hospital or a facility in Louisville, it would behoove us to
move it a lot closer to the University of Louisville where the
medical school and the doctors are more available for training?
Was it my understanding of what you said that 50 percent--did
you just make the statement a minute ago that 50 percent of the
training of doctors in our medical schools have some
relationship to the VA?
Mr. Conley. That is correct.
Senator Bunning. That is also in the report, I assume.
Mr. Conley. That should be in there. But that is correct.
The number of doctors in our country, at least 50 percent----
Senator Bunning. Either had something to do with the VA
hospitals or were trained and spent time as an intern or
whatever it might be.
Mr. Conley. Yes. Steve just mentioned the senior member of
the Republican Senate is an example who was trying----
Senator Bunning. Ted Stevens.
Mr. Conley. Senator Frist.
Senator Bunning. Well, Ted is the Senior Member of the
Senate, isn't he? Yes, Ted Stevens. You are talking about the
Leader.
Mr. Conley. Majority Leader.
Senator Bunning. Majority Leader, okay. He is not the
oldest guy in the Senate, though.
[Laughter.]
Senator Bunning. I think the satisfaction of veterans who
are actually receiving care speaks well for the changes made in
the VA in recent years, especially in the quality of the care,
as you mentioned. But, unfortunately, the VA is often unable to
recruit and retain many of our best doctors and nurses because
of salaries and other issues.
When visiting the medical centers, what did the doctors and
nurses and other personnel have to say to you about their
working conditions? What did they say could help improve those
conditions and their jobs? This is my last question.
Mr. Conley. I don't want you to repeat that again, but how
they can improve----
Senator Bunning. In other words, in talking to the doctors,
nurses, and other personnel, what was the main thrust how their
job conditions and the improvement in the health care
facilities that they are providing for the veterans in, how can
we do better and make their jobs easier and more functional?
Mr. Conley. By being able to hire more doctors and nurses.
A lot of them are placed under stress because of having to work
overtime in order to fulfill that commitment.
When I visited Togus, Maine, Senator Snowe traveled with
me, and this was reported to her, not to me, as we walked
through the hospital. A patient came up to Senator Snowe and
said that the nurse was just getting ready to dispense
medication to him again for the second time. The reason was
that she was totally exhausted from working overtime that she
forgot that she already dispensed that medication.
So the care is good, and that is just one incident off the
side. The quality of care was excellent wherever I went. The
problem is that they are under a lot of stress because of so
much overtime or there is not enough nurses, doctors, or
technicians to fulfill the need of giving that care.
Senator Bunning. Thank you, Mr. Chairman.
Chairman Specter. Thank you very much, Senator Bunning, and
thank you, Commander Conley, thank you, Mr. Robertson, Mr.
Gaytan, and Mr. Spanogle. Thank you, ladies and gentlemen, who
have come here to hear the Commander's testimony.
Mr. Conley. We want to thank you, too, Senator.
Chairman Specter. Thank you.
That concludes our hearing.
[Applause.]
[Whereupon, at 3:21 p.m., the committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Bob Graham, U.S. Senator From Florida
Thank you, National Commander Conley and the American
Legion for both your testimony and your report on the condition
of VA health care in America. You are to be congratulated for
your ``I am Not a Number'' Campaign. Waiting times for both
primary and specialized care remain abysmal, but you've managed
to put a very real face on the problem.
For example, one veteran profiled in the American Legion
report from Arcadia in my home State of Florida, detailed his
plight in trying to obtain his first doctor's appointment at
the Fort Myers VA Medical Center. He describes how despite
applying in early 2000, he was not enrolled until December of
2001, and has been waiting another whole year to be scheduled
for his first appointment. He spent 20 years in the military,
which included service in both Korea and Vietnam. It is truly
shameful that veterans are being treated this way by the very
system designated to take care of them following their service
to this country.
The Administration has chosen to blame Congress for the
long waiting times. Officials blame Congress for opening up
VA's doors--in 1996--to all eligible veterans. This move is
known as ``eligibility reform1'' and was done to correct the
problem described in Commander Conley's testimony. Prior to
eligibility refom1, the Veterans Health Administration operated
under a very complex system. As Commander Conley's testimony
points out, ``There were no defined health benefits packages,
no reliable data projecting future patient population . . .
Access to the system was severely limited to only three groups
of veterans: service-connected disabled veterans, other
disabled veterans, and economically indigent veterans.''
For years, when we looked at the VA health care system, we
focused on the declining veteran population and declining
demand. We are in a totally different predicament today. More
veterans are turning to the VA health care system, and that is
a success story.
There can be little doubt that the proposed funding for
medical care in the President's budget is below the amount
needed to fully fund the system. Veterans Service Organizations
estimate that ``the President's budget is, at a minimum, some
$2 billion below what is required to assure veterans the health
care services they earned in military service.''
In addition, the Administration's approach to deal with
burgeoning numbers is to directly reduce demand by cutting off
enrollment to higher-income veterans and to artificially reduce
demand by impinging new deductible and cost sharing
requirements on those already enrolled. This is unacceptable.
In my view, the only real path--the path that reflects the
true sacrifice of our veterans--is to own up to the demand for
health care services and provide funding. I am pleased that the
Conference Report on the Budget Resolution approximates the
increase for VA health care recommended by the consortium of
veterans' services organizations that author the Independent
Budget for Fiscal Year 2002, and I will work to make these
numbers real.
Commander Conley also discusses the CARES process in his
testimony. CARES is designed to better prepare VA to serve
veterans in the future, and I totally support this kind of
examination of VA care. But, it is absolutely critical that
this be done right because there is too much at stake. So far,
I have been disappointed in CARES because of the lack of
attention to the future health care needs of veterans,
including long-term care and alternatives to nursing home care.
As Commander Conley points out, despite the incredible demand
for long-term care, VA has chosen to ignore it in its planning
for the future.
I remain adamant that when considering the future of VA, a
key factor must be the aging veterans population. Right now,
there are 10 million veterans over age 65. Even the number of
veterans age 85 or older will double by 2012. Given these
demographics, I am as perplexed as Commander Conley as to why
the demand for long-term care has been ignored.
Another serious concern is that VA appears to be
manipulating the CARES process. In early June, 20 facilities
submitted their recommendations to VA as part of the process,
but were subsequently requested to re-evaluate their plans in
order to find a way to move from 24-hour operations to 8-hour-
a-day clinics. Not only does this action appear to target long-
term care beds in particular--since these 20 facilities
currently house thousands of veterans in need of long-term
care--but it also appears to be a significant manipulation of
the CARES process.
As ranking member of the Senate Committee on Veterans'
Affairs, I appreciate your insights into the challenges of VA's
health care system. While the problems may seem significant, I
am confident that we can work together to improve VA health
care for all veterans. Veterans are depending on us.
Thank you.