[Congressional Record Volume 145, Number 107 (Tuesday, July 27, 1999)]
[Senate]
[Pages S9343-S9345]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          VETERANS HEALTH CARE

  Mr. ROCKEFELLER. Mr. President, I had not expected to talk this 
afternoon. But I am here. The Senator from West Virginia is here. I am 
the ranking Democrat on the Veterans' Committee. I am overwhelmed with 
the sense of urgency, and almost despair, about the condition of health 
care for veterans in our country.
  Because of caps, the veterans health care budget, which is really the 
most important part of the veterans operation--benefits are important 
but what they really care about is, is health care going to be there if 
they need it?--has been flat-lined for the next 5 years. By flat-lined, 
I mean there is no increase. Even though there are more expenses, there 
is more requirement for their services, there is no more money.
  The Veterans' Administration is the largest health care system in the 
country. The only difference from any other health care system is that 
it is entirely a Government health care system. Therefore, the 
Government determines what it can spend and what it cannot spend. 
Unlike the private health care systems, it cannot spend a dime over 
what it is appropriated. So the Balanced Budget Act of 1997, which 
capped all discretionary programs--which said they could not increase--
obviously, therefore, included the veterans health care budget.
  I cannot tell you the damage that is being done to our veterans 
across this country. We talk about veterans, and we talk about them in 
very florid terms because they deserve that. Those who use the veterans 
hospitals, who have been in combat, who have sacrificed for their 
country--America kind of entered into a compact and said that these 
people will be treated with a special respect, special honor, and 
special care, and that they will get the health care they need under 
all conditions and at any time.
  The Republican tax cut, along with any other that might be suggested, 
including the one that is being talked about at $500 billion, would 
make a mockery of that commitment to the American veteran. I want 
people to understand that very clearly.
  I will talk specifically about some particular types of needs, such 
as spinal cord injuries, injuries resulting in blindness or 
amputations, posttraumatic stress disorder. Beginning in October of 
last year, I asked my committee staff to undertake an oversight project 
to determine if the Veterans' Administration is, in fact, maintaining 
their ability to care for veterans with these kinds of special needs.

  PTSD, posttraumatic stress disorder, we always associated with the 
Vietnam war. We have discovered it is not just that war; it is the gulf 
war, it is the Korean war, it is the Second World War, and it even goes 
back to the First World War. It is an enormous problem and a special 
need.
  This oversight project, which I asked my staff to do, reviewed 57 
specialized programs housed in 22 places around the country.
  I say at the outset that the VA specialized services are staffed with 
incredibly dedicated workers, people who could be working for higher 
pay in private situations, private hospitals. They are trying to do 
more, and they are trying to do it with increasingly less. They are 
often frustrated in their desire to provide the high-quality services 
that they went to the Veterans' Administration to provide in the first 
place. I salute them.
  I will mention three of the findings in this oversight effort, and 
then that is all I will do.
  First, the Veterans' Administration is not maintaining capacity in a 
number of specialized programs and is barely maintaining capacity in a 
number of others. Despite resource money shortfalls, field personnel 
have been able--but just barely--to maintain the level of services in 
Veterans' Administration prosthetics, blind rehabilitation, and spinal 
cord injury programs.
  Staffing and funding reductions have been replete. The VA's mental 
health programs are no longer strong. For example, my staff found that 
veterans are waiting an average of 5 and a half months to enter 
posttraumatic stress disorder programs. This is completely unacceptable 
for a veteran.
  Secondly, the VA is not providing the same level of services in all 
of its facilities. There is wide variation. Staff found this variation 
from site to site in capacity in how services are provided. The 
availability of services to veterans seems to depend on where they 
reside, not what they have done but where they reside. In my view, all 
veterans are entitled to the same quality of service regardless of 
whether they live in West Chester County or in Berkeley, WV. It should 
make no difference. They all have suffered the rigors of combat. They 
have all earned it. We promised it to them. We are not delivering it to 
them.

  Third, and finally, competing pressures on Veterans' Administration 
managers make it virtually impossible for them to maintain their 
specialized medical program. Hospital administrators particularly are 
being buffeted by competing demands because from central headquarters 
comes the lack of money, from the veterans comes the demand for 
services, which used to be there and which now aren't, and they are, 
therefore, caught in the middle. In many cases, they are suffering 
across-the-board cuts and have been for a number of years.
  I can tell Senators that under neither Democratic nor Republican 
administrations has the veterans' health care program been adequately 
funded and funded up to the cost-of-living increase and the so-called 
inflationary aspect, which reflects what actually true health care 
represents. We are robbing Peter to pay Paul in many of our veterans' 
hospitals and to maintain other services on which a higher priority is 
placed.
  Mental health services, I come back to it. Why is it in this country 
that we will not put down mental health as a disease? Why is it we do 
not consider it as a medical condition? Why is it that we put it off in 
the category of human behavior as opposed to something that has a cause 
in something, such as posttraumatic stress disorder. For veterans, to 
blindside mental health, to push mental health to the side is beyond 
comprehension and beyond humanity.
  In summary, it is imperative that we all understand what the budget 
crunch has meant to each VA health service. I say all of this because, 
again, of the $792 billion tax cut. If that takes place, everything I 
have talked about not only continues to be true but grows somewhere 
between 15 and 30 percent worse, not if we are to increase programs, 
but taking already that we are funding below where programs ought to 
be, where we have shortchanged veterans' health care services for 
years, and now we are going to cut billions and billions of more 
dollars out of that over these next years. That is absolutely 
intolerable.
  I ask unanimous consent to print a copy of the summary of the 
committee minority staff report in the Record at this point.
  There being no objection, the summary was ordered to be printed in 
the Record, as follows:

  Minority Staff Review of VA Programs for Veterans With Special Needs


                               background

       From its inception, the Department of Veterans Affairs (VA) 
     health care system has

[[Page S9344]]

     been challenged to meet the special needs of its veteran-
     patients with combat wounds, such as spinal cord injuries, 
     blindness, and post-traumatic stress disorder. Over the 
     years, VA has developed widely recognized expertise in 
     providing specialized services to meet these needs.
       In recent years, VA's specialized programs have come under 
     stress due to budget cuts, reorganizational changes, and the 
     introduction of a new resource allocation system. In 
     addition, passage of Public Law 104-262, the Veterans' Health 
     Care Eligibility Reform Act of 1996, brought significant 
     changes in the way VA provides health care services.
       In passing eligibility reform, Congress recognized the need 
     to include protections for the specialized service programs. 
     As a result, Public Law 104-262 carried specific provisions 
     that the Secretary of VA must maintain the ``capacity'' to 
     provide for the specialized treatment needs of disabled 
     veterans in existence at the time the bill was passed 
     (October 1996), including ``reasonable access'' to such 
     services.
       VA has been required to report annually to Congress on the 
     status of its efforts to maintain capacity, with its most 
     recent report published in May 1998. In that report, VA 
     stated that ``by and large, the capacity of the special 
     programs . . . has been maintained nationally.'' However, 
     others have been more critical, including the General 
     Accounting Office, which found that ``much more information 
     and analyses are needed to support VA's conclusion,'' and the 
     VA Federal Advisory Committee on Prosthetics and Special 
     Disability Programs, who called VA's ``flawed'' and 
     consequently refused to endorse VA's report.


                         minority staff project

       Beginning in October 1998, at the direction of Ranking 
     Member John D. Rockefeller IV, Senate Committee on Veterans' 
     Affairs minority staff undertook an oversight project to 
     determine how well VA is complying with Public Law 104-262's 
     mandate to maintain capacity in the VA's specialized 
     programs. After first meeting with VA Headquarters officials 
     in charge. of the various specialized projects, as well as 
     representatives of the veterans service organizations, we 
     designed a questionnaire and interview protocol for each 
     of the five service programs we selected to study.
       Our starting place was defining ``capacity,'' since the law 
     did not do so. After extensive consultation with experts in 
     the field, we chose to focus on the following six factors: 
     (1) number of unique veterans treated; (2) funding; (3) the 
     number of beds (if applicable); (4) the number of staff; (5) 
     access to care, in terms of waiting times and geographical 
     accesssibility; and (6) patient satisfaction. Capacity was 
     rated by comparing data from FY 1997 to FY 1998 to determine 
     whether the program has or has not maintained the same level 
     of effort in each of these areas.
       In order to maximize efficiency, we primarily visited sites 
     that included more than one specialized program; most were 
     within reasonable geographical distance of Washington, DC. 
     The sites selected are not a random or representative sample. 
     Nevertheless, we believe the information gathered is 
     significant because we believe capacity should be maintained 
     uniformly throughout the system. There should be no gap in 
     services, regardless of where in the country a veteran goes 
     for treatment.
       We reviewed 22 facilities, with a total of 57 specialized 
     services programs: Prosthetics and Sensory aid Services (16 
     sites); Blind Rehabilitation (3 sites); Spinal Cord Injury (8 
     sites); PTSD (14 sites); and Substance Use disorders (16 
     sites).


                      Data collection and Validity

       Data collection and validity is a known area of VA 
     weakness, confirmed by our own observations in this study. 
     Despite the fact that we provided program managers ample time 
     to fulfill our data requests, many lacked the basic, everyday 
     data that should have been easily accessible to them. In many 
     cases, the data provided to us by VA were revised upon our 
     discovery of inherent discrepancies or our questioning of the 
     methodology used. Nevertheless, because it would have been 
     beyond the scope of our resources to conduct a full-scale 
     audit, we relied on the unvalidated data provided to us by VA 
     as the basis for this report.


                        Findings and Conclusions

       In general, we found that VA specialized programs are 
     staffed with incredibly dedicated workers, trying hard to do 
     more with less, but often frustrated in their desire to 
     provide high quality services. One of the most consistent 
     complaints we heard about were staffing shortages, which left 
     employees feeling they were working ``close to the edge.'' 
     When staffing is cut to the minimum, programs quickly become 
     vulnerable to disruptions and service delays, and staff 
     suffer from overwork, poor morale, burnout, and/or reduced 
     motivation and quality of performance as a result.
       In summary, we reached the following conclusions:
       I. VA is not maintaining capacity in a number of 
     specialized programs, and is barely maintaining capacity in 
     the others. We found that despite resource shortfalls, VA 
     field personnel have been able--just barely--to maintain the 
     level of services in the Prosthetics, Blind Rehabilitation, 
     and SCI specialized service programs, but have not maintained 
     capacity in the PTSD and Substance Use Disorder programs. 
     Because of staff and funding reductions, and the resulting 
     increases in workloads and excessive waiting times, the 
     latter two programs are failing to sustain service levels in 
     accordance with the mandates in law.
       II. VA is not providing the same level of services in all 
     facilities. In the specialized programs we visited, there was 
     wide variation from site to site in capacity and provision of 
     services. It appears that the relative availability of 
     services to veterans depends on where they reside. However, 
     we believe all veterans are entitled to the same level and 
     quality of service, regardless of where they live in the 
     country.
       III. A gross lack of data, as well as lack of validation of 
     the available data, prevents VA from making verifiable 
     assessments as to whether capacity in its specialized 
     services programs is being maintained. In almost every 
     program we visited, it was difficult to obtain the 
     information we requested, despite the fact that programs were 
     given ample time to complete the data sheets we provided. 
     Frequently, we were told data had been lost, was 
     irretrievable, or was not compiled in a useful format. There 
     were often inherent discrepancies in the data we were 
     initially presented that took a great deal of discussion to 
     resolve. Without solid, readily available data, VA cannot 
     itself ascertain whether it is meeting its own capacity 
     standards. In fact, this problem with data reconciliation is 
     one reason why VA is late in producing this year's capacity 
     report.
       IV. VA's shift from inpatient to expanded outpatient 
     treatment has improved access and saved money. At the same 
     time, certain programs, which require a mix of in- and 
     outpatient services, have been weakened. We are concerned 
     that patient outcomes may have suffered in the process. VA is 
     struggling to find the right mix of inpatient and outpatient 
     services. Expanded outpatient services often improve 
     geographical access for veterans and are a good way to 
     stretch limited resources. However, we believe VA may be 
     moving too quickly to close certain inpatient programs, such 
     as PTSD and Substance Use Disorders. This trend is 
     controversial among many clinicians, who are concerned about 
     the appropriateness and effectiveness of outpatient services 
     for many in this patient population. We believe much more 
     research is needed in this area.
       V. VA's specialized services suffer from a lack of 
     centralized oversight. As with all VA's health care services, 
     decentralization has resulted in a lack of effective 
     oversight. Headquarters issues directives, but for the most 
     part, there is little followup to monitor how well these 
     directives are being carried out. In addition, once money is 
     allocated to the VISNs, there is little or no monitoring of 
     how this money is being spent. As a result, we found that VA 
     is not in a position to say with any certitude whether or not 
     specialized services are being adequately maintained.
       The lack of centralized oversight is particularly critical 
     in the PTSD and Substance Use Disorder programs. VA 
     Headquarters program consultants, by and large, are not 
     consulted when inpatient programs in the facilities are 
     closed or altered in size or format. We believe their 
     expertise should be sought before any decisions are made to 
     change established programs.
       VI. Competing pressures on VISN directors make it virtually 
     impossible for them to maintain capacity in their specialized 
     service programs. VISN directors, particularly those most 
     affected by funding reductions resulting from VERA, are being 
     buffeted by competing demands for the declining resources 
     allocated to them. In many cases, they are suffering across-
     the-board cuts, or may be having to ``rob Peter to pay Paul'' 
     to maintain other programs on which they place a higher 
     priority. With the lack of centralized oversight, VA has 
     little ability to ensure that VISN directors are spending 
     their money for specialized services as directed.

  Mr. ROCKEFELLER. I thank the Chair.
  Mr. LOTT. Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. DORGAN. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DORGAN. Mr. President, might I inquire, are we presently in 
morning business?
  The PRESIDING OFFICER. The Senate is in morning business.
  Mr. LOTT. Mr. President, if I could be recognized, we hope to 
momentarily get an agreement with regard to proceeding with the 
Interior appropriations bill. We are waiting to hear from the 
Democratic leader before we enter this agreement. I think we have it 
worked out. I certainly hope so. If the Senator wishes to proceed as in 
morning business, I hope he will yield once we get the agreement all 
squared away.
  Mr. DORGAN. Mr. President, of course, I will yield, if the majority 
leader requests. I had wanted to make some comments about the trade 
deficit

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that was announced late last week and show a few charts. I ask 
unanimous consent to proceed for 10 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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