[Congressional Record (Bound Edition), Volume 145 (1999), Part 13]
[Senate]
[Pages 18454-18456]
[From the U.S. Government Publishing Office, www.gpo.gov]



                       VA HEALTH CARE SHORTFALLS

  Mr. SPECTER. I address the Chair on a subject that is critical to the 
veterans of the armed forces of our nation, and to the Committee on 
Veterans' Affairs, which I am privileged to chair: the budget for the 
health care system of the Department of Veterans Affairs.
  Mr. President, I come to the floor of the United States Senate today 
to draw attention to a sure crisis in VA health care. Congress and the 
Administration must ask ourselves: what is the crisis, and what may be 
the acceptable remedy? It seems that the Department of Veterans Affairs 
must choose among difficult options of providing care for fewer 
veterans--that is, ``disenroll'' veterans already expecting care from a 
VA provider or plan; increase waiting times; cut VA staff; lower 
quality of care; close and consolidate numerous facilities, or Congress 
must increase VA's budget. For my money, Mr. President, the choice is 
clear and simple: we must act to increase VA's appropriation, and we 
must do so now.
  Yesterday after years of denial, the Director of the Office of 
Management and Budget, Mr. Jacob Lew made an amazing discovery--that 
there are problems in the VA health care system due to funding 
shortfalls. I ask unanimous consent that the text of OMB Director Jacob 
Lew's letter of July 26, 1999 be printed in the Record.
  There being no objection, the letter was ordered to be printed in the 
Record, as follows:

         Executive Office of the President, Office of Management 
           and Budget,
                                    Washington, DC, July 26, 1999.
     Hon. Arlen Specter,
     Chairman, Committee on Veterans' Affairs, U.S. Senate, 
         Washington, DC.
       Dear Mr. Chairman: Later this week we plan to send a fully 
     offset budget amendment to add $1 billion to support the 
     Department of Veterans Affairs (VA) medical care system. 
     Since the publication of our budget, we have become 
     increasingly concerned about reports of increased waiting 
     times and other operational problems in the system.
       Much has changed since January. As the VA has moved from a 
     largely inpatient system to an outpatient one, we have found 
     that the analysis and execution of these profound shifts are 
     more complex than initially believed. For example, in FY 1999 
     alone, we expect to open 70 new community-based outpatient 
     clinics from resources previously used for inpatient 
     services. The movement of these resources has proven more 
     difficult this year than in the first years of the 
     transformation of VA. As VA has improved access to care 
     through community clinics and continuity through universal 
     primary care provider teams, additional veterans have sought 
     care in VA. While the net cost of these new users is not 
     fully understood yet, they have stressed parts of the system 
     where management and operational flexibility is minimal. For 
     example, waiting times in primary care have increased in 
     several geographic areas.
       The nationwide enrollment of veterans for medical care 
     services was required for the first time in 1999. It was 
     decided in this first year to open enrollment to all 
     veterans, including higher-income non-service disabled 
     veterans who were traditionally treated on a space-available 
     basis only. As of April 30, we have provided treatment to 
     almost 2.7 million veterans, 0.4 million of whom are new 
     users of the system.
       The resources needed for this mixture of complex dynamics 
     are greater than expected when the President's FY 2000 budget 
     was prepared. We will be requesting $800 million in 
     additional funds to ensure quality and reduce waiting times 
     that have grown significantly over the last few months. To 
     ensure proper funding for spinal cord injury and 
     homelessness, the Department will forward to the Congress a 
     detailed description of how it will allocate a portion of 
     these additional funds to these two areas.
       Waiting times are also aggravated by an infrastructure not 
     conducive to rapid change. VA is saddled with an 
     infrastructure that no longer meets geographical and 
     treatment needs. Recently, GAO reported that VA is spending 
     $1 million per day on unneeded, outmoded facilities. We will 
     be requesting $100 million for construction activities that 
     will begin to ease the immediate problem and to plan for the 
     long-range solution. We hope to work with the Congress over 
     the next few months to address this critical issue on a broad 
     and sweeping basis.

[[Page 18455]]

       The additional resources we are requesting are also 
     necessary to meet the critical challenge of providing long-
     term care. The overwhelming response to the introduction in 
     Congress of the so called ``Millennium Bill'' combined with 
     the President's commitment to long-term care for all 
     Americans has convinced us that we must increase available 
     funds immediately to meet these needs of our veterans. As our 
     veterans population ages, the need for long-term care is 
     increasing. We are committed to providing a range of home- 
     and community-based care for those high-priority veterans who 
     do not have access to such services. While we have concerns 
     with the mandatory approach of the Millennium Bill, we do 
     agree with the intent of the Bill. Consequently, we will be 
     including in our request $100 million for long-term non-
     institutional community-based care, targeted to VA's top 
     priority category of veterans with disabilities of 50% or 
     greater.
       At the same time that we add resources to the system, we 
     need to ensure that we are on target to provide care of the 
     highest quality, and that we are not overburdening the 
     system. We will therefore be discontinuing the enrollment of 
     category 7 veterans until such time as we feel confident that 
     we can accommodate these veterans in the system without 
     adverse consequences for service-disabled and lower-income 
     veterans. All veterans currently enrolled in the system will 
     continue to receive care. We believe that this action is 
     necessary to ensure that quality is maintained, that wait 
     times are reduced, and that we adhere to congressional 
     guidance. The House Committee on Veterans Affairs issued 
     report language along with the VA enrollment law stating that 
     ``VA may not enroll or otherwise attempt to treat so many 
     patients as to result either in diminishing the quality of 
     care to an unacceptable level or unreasonably delaying the 
     timeliness of VA's care delivery.''
       We are convinced that through these aggressive steps VA 
     will be able to provide better care, and more timely care to 
     the veterans that are in most need. We look forward to 
     working with you, the other members of your respective 
     committees, and the Congress as a whole to make these 
     proposals a reality.
           Sincerely,
                                                     Jacob J. Lew,
                                                         Director.

  Mr. SPECTER. OMB postures--implausibly--that much has changed since 
January 1999, but veterans organizations in their Independent Budget 
have been warning Congress and the Administration for the past three 
years running that VA health care is in dire straits. On April 30 of 
this year, 50 of my colleagues joined Senator Rockefeller and me in 
signing a letter to the Chairman and Ranking Member of the 
Appropriations Committee, requesting that VA health care be 
supplemented with $1.7 billion for Fiscal Year 2000. My discussions 
with VA officials lead me to believe that, while such a supplement will 
not eliminate VA's problems, these funds will go a long way to easing 
its crisis and will back-fill gaps that we have permitted to occur 
based solely on resource shortages. In his July 26 letter, Director Lew 
refers to the need for $100 million in new health-related construction; 
as Chairman of the authorizing committee for VA major construction, I 
cannot reply, not having seen a proposal for sites or specific 
justifications. He also admits that so-called ``category 7'' veterans 
cannot continue to be enrolled in VA care for fear that quality of care 
for higher priority poor and service-disabled veterans will suffer. 
While I concur with Director Lew's premise that we do no harm to those 
already enrolled in VA health care, I must reserve judgment until I see 
the basis for this conclusion about the middle class veteran. The 
Administration is proposing $1 billion is emergency funding, but I 
believe, as I have since last year, that this level still would be 
insufficient overall.
  Mr. President, as to more recent developments even than OMB's late-
coming realization of need, I appreciate the work of the House 
Appropriations Sub-Committee last evening to add $1 billion in 
additional spending to the VA health care appropriation for the new 
year. Like my counterparts in the House, I want to help the system help 
veterans, as we all do. I want to do so with great care, as we all do. 
However, as I said earlier about the Administration's $1 billion, I say 
that the House's $1 billion is only enough to push the problem down the 
road a little further. We need to solve the problem, not push it down 
the road. We can do that with a substantial increase of $1.7 billion in 
the Medical Care appropriation for Fiscal Year 2000--a supplement that 
would take VA health care funding to the unprecedented level of $19 
billion--and let us join together to see what kind of sustained funding 
level VA truly needs to carry out its important and vital mission for 
America's veterans. I proposed then, and remind the Senate now, that 
$1.7 billion is needed to keep VA's head above water.
  America's veterans put a human face on freedom. Veterans agreed to 
put their lives on the line, or certainly they were prepared to do so, 
to defend the very freedoms all of us enjoy. Most of them sought 
nothing in return. They served honorably, then returned to civilian 
life. However, some of these veterans whom we turned to for assistance 
in our time of need have now turned to the nation in their time of 
need. I am referring specifically to those who were disabled during 
their service to the nation and those who for one reason or another 
have been left behind in this competitive economy and cannot sustain 
themselves. For these people in particular we established the 
Department of Veterans Affairs and its many programs for veterans and 
their families.
  We have given VA a mission, one most astutely described by President 
Abraham Lincoln during his second inaugural address when the President 
said, the Nation's mission was ``. . . to care for him who shall have 
borne the battle and for his widow and his orphan.'' Lincoln's eloquent 
words describe VA's success for most of its existence. It is a system 
whose sole purpose is to recognize that veterans make a special 
contribution to society, and therefore deserve special status and 
attention by a grateful nation. It saddens me to report to the Senate 
that this Administration is failing our veterans. But I do not intend 
to sit idly by and allow veterans' needs to go unnoticed and unmet.
  In Fiscal Year 1999, Congress appropriated $17.3 billion to fund the 
health care activities of the Department of Veterans Affairs. I know 
that many of my colleagues have heard while traveling throughout your 
respective states that this amount was barely enough to allow VA to 
provide decent care for veterans. Earlier this year, the President sent 
Congress a budget that requested precisely the same amount for next 
year. Mr. President, that request is completely unacceptable to me, and 
I know it is for all my colleagues here.
  The VA, under the leadership of the most recent Under Secretary for 
Health, Dr. Kenneth Kizer, made remarkable changes in the way health 
care is provided to eligible and enrolled veterans. The VA launched a 
veritable revolution in its delivery system by changing the basic 
structure of care delivery from one that treated patients in a so-
called ``sickness model,'' a mostly reactive stance that was premised 
on a veteran seeking care for a specific ailment, to one of a 
functioning health care system that offers a basic benefits package of 
services to enrolled veterans, including preventive medical treatment, 
primary care, alternatives to institutionalization, pharmaceuticals and 
limited long term care programs, all premised on maintining a veteran's 
health. Further, according to testimony given before the Committee on 
Veterans' Affairs, VA has opened hundreds of local community-based 
outpatient clinics, reduced the number of days patients must spend in 
hospitals and, according to testimony by the Secretary of Veterans 
Affairs, still treats any veteran who arrives at VA's doorstep. 
Unfortunately, both the Secretary and the President of the United 
States have failed to recognize that this system, like any health care 
system, needs sufficient funding to function properly. It is impossible 
to increase the quality of care provided, increase the number of places 
at which care can be obtained and increase the number of people who can 
receive care without providing any additional resources. This is 
impossible on its face, Mr. President--impossible.
  The budget the President sent to Congress would not even permit the 
VA to maintain the current services it provides to veterans today. In 
fact, in order to maintain today's level of service, the budget admits 
that VA must ``streamline'' itself to the tune of $1.14

[[Page 18456]]

billion in FY 2000. But we already know that VA cannot maintain the 
status quo. There are so many challenges facing the system and the 
veterans it treats that we as a Congress, and the President as Chief 
Executive, must address. For example, the package of benefits available 
to our veterans today does not include basic emergency care services. 
Today, if a veteran must visit a private hospital emergency room for 
treatment, in most cases payment is out-of-pocket, or through a third 
party insurance claim, Medicare or Medicaid, that may cover this care. 
The only exception to this policy is for service connected conditions 
in limited emergency situations, for which VA will reimburse expenses. 
A bill recently reported out of my Committee would correct this 
injustice and mandate that any veteran enrolled in VA care be provided 
basic, covered emergency services if they are needed. The Congressional 
Budget Office estimates that this provision will cost $80 million in 
the first year and approximately $400 million over five years.
  Emergency care is just the tip of the VA's health care ``iceberg.'' 
For example, another very important issue is one that dramatically 
affects Vietnam veterans. According to a recent VA survey, nearly 18% 
of veterans in VA care could be afflicted with the disease hepatitis C. 
Hepatitis C is a serious disease that has been associated with 
battlefield injuries, blood transfusions and intravenous drug use. 
Hepatitis C causes liver damage and, as one can imagine, ultimately 
hepatitis C can be fatal. Fortunately, there are a number of new drug 
therapies available that will help control or arrest the progress of 
hepatitis C. However, treatment is expensive. VA estimates that they 
need approximately $135 million in FY 2000 to screen, test and car for 
veterans suffering from hepatitis C, and much more in the future. This 
special funding for hepatitis C would be in addition to the amount 
needed to maintain the status quo in VA health care that the President 
has otherwise proposed.
  Frankly, Mr. President and colleagues, the most difficult challenge 
facing the Department into the foreseeable future is its ability to 
care for our aging veteran population. Many World War II and Korean War 
veterans are nearing the end of life. But hundreds of thousands of them 
need long term care services, and the numbers grow dramatically while 
the overall veteran population declines. VA maintains over 120 nursing 
homes now, and has thousands of contracts with private nursing 
facilities and other long term care providers. If the VA is going to do 
more than simply maintain these programs--which I argue may be 
exceedingly difficult to do, given other challenges--rather than expand 
them to fit the changing demographic face of VA's patient population, 
additional resources will be needed. There is no question about this 
fact, Mr. President, and no real choice but to do it, in my view.
  Until yesterday, in response to all of these challenges, the 
Administration proposed to make one major move to address the crisis 
situation: cut health care off. As incredible as it may seem, VA is 
proposing employee ``buyout'' authority for the Veterans Health 
Administration. Based on my analysis of this request and its 
implications, I concluded that buyout legislation was really a sell 
out, offering a golden handshake to those whom really needed to stay. 
It is the wrong move, and I am most pleased to say so.
  VA proposes to buy out--that means reduce--its current workforce by 
about 15,000 staff over a five-year period, by use of a voluntary 
separation incentive payment of up to $25,000 to each such employee who 
leaves by retiring. I think most of you would agree that health care is 
an enterprise that needs, above all else, trained staff. So, as I 
mentioned earlier, VA says it strives to increase quality, access and 
the number of patients enrolled, but would do so without additional 
financial resources and with a greatly reduced work force. I cannot 
foresee how these kinds of results are at all possible. How could it be 
so? A retirement bonus is a fine gesture, but how does it help 
veterans?
  The VA buyout proposal was accompanied by a weak ``strategic plan.'' 
VA cannot say with any degree of confidence how it could continue to 
provide care to all of the veterans the Secretary has admitted to the 
system with his ``open door'' policies, if the staff were so severely 
reduced. In fact, it appeared to me that what VA intended to do in its 
``real'' strategic plan--a plan that is yet to be revealed to us--was 
simply to increase waiting time which already is at unacceptably high 
levels in many places across the country. As but one small example, Mr. 
President, let me review for you the most recent facts on VA waiting 
times from VA medical centers in the Commonwealth of Pennsylvania. 
These statistics deal only with primary care appointments, not 
specialty care: 34 days of waiting in Altoona; 31-60 days in Lebanon; 
up to 54 days in Pittsburgh; up to 64 days at the Sayre clinic; and up 
to 94 days of waiting in Wilkes-Barre. Looking at a medical specialty 
that is crucial for aging veterans, let me report to my colleagues 
waiting times for VA urology clinics in Pennsylvania: 85 days in 
Altoona; 90 days in Philadelphia; up to 95 days in Pittsburgh.
  I know that the distinguished Ranking Member of my Committee, Senator 
Rockefeller, has been very concerned about waiting times at VA 
hospitals in West Virginia; Senator Campbell is alarmed about the 
situation at the Medical Center in Fort Lyon, Colorado and has said so; 
and Senator Murray has relayed her concerns about the status of VA 
facilities in the state of Washington. But these problems are 
everywhere, Mr. President. These kinds of delays in care are not 
acceptable for our veterans. In fact, I would argue that a waiting time 
of 60 days for an outpatient primary care appointment or an enrolled 
veteran constitutes nothing; such a patient is not really receiving 
care from VA.
  I ask my colleagues: is this a situation that you are comfortable in 
defending? I am not, and I am not willing to remain silent while 
veterans receive nothing from a grateful nation. VA needs these funds, 
and this need is clear. Let the United States Senate not shrink from 
its duty. Let us do the right thing for America's veterans by providing 
an emergency supplement of $1.7 billion in funding in Fiscal Year 2000 
to help VA help our veterans.

                          ____________________