Veterans' Affairs: Observations on Selected Features of the Proposed
Veterans' Millennium Health Care Act (Statement/Record, 05/19/99,
GAO/T-HEHS-99-125).

Pursuant to a congressional request, GAO discussed the proposed
Veterans' Millennium Health Care Act, which would modify policies and
practices of the health care system operated by the Department of
Veterans Affairs (VA).

GAO noted that: (1) the draft bill's facility service realignment,
long-term care, and cost-sharing provisions should help facilitate VA's
continuing transformation of its health care system and address concerns
that GAO has previously reported to Congress; (2) these proposals, in
combination with VA's enrollment process, provide a rational framework
for helping VA address the increasing health care needs of an aging
population of higher-priority veterans while operating within available
resources; (3) however, even with this enabling legislation, achieving
these multiple goals will be a challenge to VA because of their
complexity and far-reaching implications; (4) more specifically, the
combination of proposed changes should help VA provide care for veterans
in more appropriate settings, as well as help VA achieve its stated
goals of reducing per-patient costs, increasing the number of its
patients, and reducing reliance on appropriations; (5) facility
realignment and cost-sharing provisions are consistent with options GAO
has suggested to help VA reduce budget pressures and generate the
resources needed to serve more veterans and provide enhanced benefits;
and (6) long-term care provisions appear designed to reduce variability
in veterans' access to such care systemwide, which addresses, in
general, GAO's concern about the potential adverse effect of VA's
transformation on the equity of veterans' access to care.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-99-125
     TITLE:  Veterans' Affairs: Observations on Selected Features of
	     the Proposed Veterans' Millennium Health Care Act
      DATE:  05/19/99
   SUBJECT:  Proposed legislation
	     Veterans hospitals
	     Health resources utilization
	     Long-term care
	     Health services administration
	     Health care cost control
	     Veterans benefits
	     Health care planning
	     Reengineering (management)
	     Cost effectiveness analysis
IDENTIFIER:  VA Veterans Integrated Service Network
	     VA Medical Care Collections Fund

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Cover
================================================================ COVER

Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives

Not to Be Released
Before 10:00 a.m.
Wednesday, May 19, 1999

VETERANS' AFFAIRS - OBSERVATIONS
ON SELECTED FEATURES OF THE
PROPOSED VETERANS' MILLENNIUM
HEALTH CARE ACT

Statement for the Record by Stephen P.  Backhus, Director
Veterans' Affairs and Military Health Care Issues
Health, Education, and Human Services Division

GAO/T-HEHS-99-125

GAO/HEHS-99-125T

(406170)

Abbreviations
=============================================================== ABBREV

  VA - Department of Veterans Affairs
  VISN - Veterans Integrated Service Network

VETERANS' AFFAIRS:  OBSERVATIONS
ON SELECTED FEATURES OF THE
PROPOSED VETERANS' MILLENNIUM
HEALTH CARE ACT
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

We are pleased to contribute this statement for the record for the
Subcommittee's deliberations on the draft bill entitled the Veterans'
Millennium Health Care Act, which would modify policies and practices
of the health care system operated by the Department of Veterans
Affairs (VA). 

In October 1995, VA began to transform its health care delivery
structure from operating hospitals to providing health care through
integrated networks of VA and non-VA providers to serve veterans more
efficiently and effectively.  In 1996, the Veterans' Health Care
Eligibility Reform Act was passed, requiring VA to enroll veterans
for health care coverage by congressionally mandated priority groups
only to the extent that services could be provided within VA's
resources.  In January 1997, in response to this and other factors,
VA proposed a 5-year spending plan to reduce per-patient costs by 30
percent, increase the number of VA patients by 20 percent, and reduce
reliance on appropriations by 10 percent. 

Through numerous reports and testimonies, we have discussed the
progress of VA's ongoing transformation, as well as concerns about
critical challenges that VA faces (see the attached list of related
GAO products).  As you requested, our statement today draws on our
previous work to focus on how the draft Veterans' Millennium Health
Care Act could affect VA's ongoing transformation, including our
previously reported concerns about its future progress.  As agreed
with your staff, we have limited our comments to certain provisions
of the bill that address

  -- the realignment of services at underused facilities,

  -- access to long-term care services,\1 and

  -- cost sharing for medical care. 

In summary, the draft bill's facility service realignment, long-term
care, and cost-sharing provisions should help facilitate VA's
continuing transformation of its health care system and address
concerns that we have previously reported to the Congress.  These
proposals, in combination with VA's enrollment process, provide a
rational framework for helping VA address the increasing health care
needs of an aging population of higher-priority veterans while
operating within available resources.  However, even with this
enabling legislation, achieving these multiple goals will be a
challenge to VA because of their complexity and far-reaching
implications. 

More specifically, the combination of proposed changes should help VA
provide care for veterans in more appropriate settings, as well as
help VA achieve its stated goals of reducing per-patient costs,
increasing the number of its patients, and reducing reliance on
appropriations.  Facility realignment and cost-sharing provisions are
consistent with options we have suggested to help VA reduce budget
pressures and generate the resources needed to serve more veterans
and provide enhanced benefits.  In addition, long-term care
provisions appear designed to reduce variability in veterans' access
to such care systemwide, which addresses, in general, our concern
about the potential adverse effect of VA's transformation on the
equity of veterans' access to care. 

--------------------
\1 We are using the term long-term care to refer to the services
described in parts of the draft legislation under the term extended
care because "long-term care" is more frequently used in current
discussions of these services in VA, other federal agencies, and the
private sector. 

   BACKGROUND
---------------------------------------------------------- Chapter 0:1

Over the last 6 decades, VA's system has grown into our nation's
largest direct provider of health care, serving veterans at over 600
locations nationwide.  During that time, VA's system focused
primarily on hospital care, using high technology and medical
specialization.  The system did not keep pace, however, with such
industry and societal changes as the restructuring of health care to
emphasize managed care and the evolving medical needs of an aging
veteran population. 

VA's transformation from a hospital-based operator to a health care
provider emphasizing outpatient care began in fiscal year 1996, when
22 regional offices, known as Veterans Integrated Service Networks
(VISN), were established to make basic budgetary, planning, and
operating decisions for veterans living within defined geographical
areas.\2 VA's goal is to develop local or regional networks of health
care providers that offer a continuum of care grounded in ambulatory,
rather than hospital, settings.  VA is encouraging this
transformation by allocating resources on the basis of user
populations rather than hospitals. 

The Veterans' Health Care Eligibility Reform Act, enacted in 1996,
furnishes tools that VA believes are key to a successful
transformation, including

  -- new eligibility rules that allow VA to treat veterans in the
     most appropriate setting,

  -- a uniform benefits package for all eligible veterans that allows
     VA to provide a continuum of services,

  -- expanded authority to purchase services from private providers
     when doing so benefits veterans, and

  -- an enhanced ability to generate revenue by selling excess
     services to nonveterans. 

At that same time, the Congressional Budget Office and we concluded
that these reforms could generate additional demand for services
because more veterans would use outpatient services.\3 The
Congressional Budget Office also estimated that rising utilization
could produce dramatic cost increases, potentially in the billions of
dollars. 

To address such concerns, the Eligibility Reform Act required VA to
implement an enrollment system to manage access in relation to
available resources.  The act established seven priority categories,
with the highest priority given to veterans with service-connected
conditions and the lowest priority given to higher-income veterans
without such conditions.  Each year, VA is to enroll veterans in
those priority categories for which it has sufficient resources to
provide care that is timely and acceptable in quality.  The act also
requires VA to maintain treatment capacity for veterans with special
disabilities, including spinal cord injury, blindness, amputation,
and mental illness. 

At VA's request, the Congress also authorized VA to retain all
medical care cost recoveries, beginning July 1, 1997, to increase its
nonappropriated revenues.\4 Such recoveries include collections from
veterans' private health insurance as well as copayments to VA.  VA
is to deposit these collections in a Medical Care Collections Fund
and use them to supplement appropriations to meet veterans' health
care needs.  VA may spend these funds in the year collected or in any
subsequent year. 

VA's health care system currently touches the lives of 15 percent, or
about 4 million, of our nation's 25 million veterans.  The rest rely
on private insurance, other public programs, or their own resources
to finance their health care needs. 

--------------------
\2 VA Health Care:  Status of Efforts to Improve Efficiency and
Access (GAO/HEHS-98-48, Feb.  6, 1998). 

\3 VA Health Care:  Issues Affecting Eligibility Reform Efforts
(GAO/HEHS-96-160, Sept.  11, 1996). 

\4 In 1986, the Congress had authorized VA to recover third-party
payments for medical care, but VA was required to turn over these
collections to the Department of the Treasury. 

   REALIGNING FACILITIES' SERVICES
   COULD BENEFIT VETERANS
---------------------------------------------------------- Chapter 0:2

VA's large, aged infrastructure could be the biggest obstacle
confronting the agency's ongoing transformation efforts.  VA spends a
major portion of its health care budget--about 1 out of every 4
health care dollars--to operate, maintain, and improve its
facilities. 

At the Subcommittee's March 10 hearing, we suggested that VA could
reduce significantly the amount of funds used to operate and maintain
unneeded or inefficient health care delivery locations and reinvest
the savings to enhance care provided to veterans.\5 By systematically
analyzing health markets to identify unneeded delivery locations, VA
could redirect the operation and maintenance budgets of these
locations to establish and enhance community-based clinics and other
service options for veterans.  Without such realignment of delivery
locations, resources might be increasingly shifted to operating and
maintaining unneeded, aged assets at the expense of veterans' health
care needs. 

At the March 10 hearing, VA agreed to assess 106 markets in which it
operates 181 major delivery locations.  VA owns 4,700 buildings and
18,000 acres of land at these locations.  VA's assessments will
include a determination of veterans' health care needs, a survey of
existing assets, and an evaluation of alternatives for meeting
veterans' needs in the most cost-effective manner. 

The draft Veterans' Millennium Health Care Act contains three key
features designed to benefit veterans through such facility services
realignment.  The act requires

  -- VA to develop enhanced-service plans to address veterans' health
     care needs,

  -- VA's stakeholders to participate in plan development, and

  -- VA to use efficiency savings locally. 

Developing enhanced-service plans would provide an appropriate
structure for VA to use when addressing its infrastructure challenge. 
The proposed legislation requires that VA develop enhanced-service
plans to provide needed health care to veterans in markets where VA
delivery locations are ineffective or inefficient in providing
services and alternative health care providers are available.  By
requiring enhanced-service planning, this proposal would address
concerns that we raised during a July 1997 hearing before this
Subcommittee that VA was implementing changes at facilities without
adequate planning.\6 This proposal is also consistent with guidelines
that VA issued in April 1998 to help VA regional offices improve
their planning for service delivery changes. 

Requiring stakeholders' involvement in plan development is also an
essential element, as we noted during the July 1997 hearing.  While
facility service realignments could provide significant benefits for
veterans, they could also have important consequences for a wide
variety of stakeholders, such as VA employees and residents of local
communities.  For this reason, plans must be developed with
comprehensive stakeholder involvement to maximize benefits and
minimize adverse impacts.  The draft bill proposes a process that VA
has already used to develop a plan to integrate medical services in
Central Alabama.\7

Requiring VA to use efficiency savings that are generated by facility
service realignments locally should provide incentives for developing
effective enhanced-use plans.  This approach is consistent, for
example, with a suggestion we made concerning the potential savings
that VA could realize if it realigned the services of four hospitals
in Chicago.  In essence, we suggested that savings could be used to
enhance the services for veterans in the Chicago area through
establishing additional community-based clinics or other services.\8

--------------------
\5 VA Health Care:  Capital Asset Planning and Budgeting Need
Improvement (GAO/T-HEHS-99-83, Mar.  10, 1999). 

\6 VA Health Care:  Lessons Learned From Medical Facility
Integrations (GAO/T-HEHS-97-184, July 24, 1997). 

\7 VA Health Care:  VA's Plan for the Integration of Medical Services
in Central Alabama (GAO/HEHS-98-245R, Sept.  23, 1998). 

\8 VA Health Care:  Closing a Chicago Hospital Would Save Millions
and Enhance Access to Services (GAO/HEHS-98-64, Apr.  16, 1998). 

   ENHANCING LONG-TERM CARE
   SERVICES COULD BENEFIT
   HIGHER-PRIORITY VETERANS
---------------------------------------------------------- Chapter 0:3

VA faces major challenges in serving a rapidly aging veteran
population.  Veterans 65 and older constitute about 34 percent of the
veteran population, or about 8.8 million veterans, and will make up
42 percent of the veteran population by 2010.  This aging of the
veteran population will result in a growing need for long-term care. 

VA currently spends about $2 billion of its $18.4 billion health care
budget to provide long-term care services.  Of this, nearly $1.7
billion is used for care in 131 VA-operated nursing homes, contract
nursing homes, and state veterans' nursing homes.  The remaining $353
million is used for noninstitutional care, including residential care
and home- and community-based long-term care services, such as adult
day health care, respite care, homemaker assistance, home health
care, and other services. 

About 4 million veterans are currently enrolled in VA's health care
system.  While VA's uniform health care benefits package includes
inpatient hospital care, outpatient care, and other related services,
the package does not include long-term care, such as nursing home,
domiciliary, and adult day health care.  However, enrolled veterans
are eligible to receive such services to the extent that resources
are available.  VA currently provides long-term care services to
about 63,000 veterans a day, on average. 

The Federal Advisory Committee on the Future of VA Long-Term Care
recently reported that VA currently meets about 20 percent of the
need for long-term care nationally among veterans with
service-connected conditions and those with low incomes.\9 As a
result, most veterans use other systems for long-term care services,
such as Medicaid and Medicare.\10 The Federal Advisory Committee also
found that access to VA long-term care among veterans with
service-connected conditions and those with low incomes varied
greatly among VA's 22 regions.  We have voiced similar concerns in
prior work about the lack of equitable access to a range of VA care,
including primary outpatient care and more expensive services, such
as nursing home care.\11

The draft Veterans' Millennium Health Care Act contains three key
features designed to enhance veterans' access to long-term care: 

  -- requiring the development of a national program of long-term
     care services,

  -- increasing the percentage of VA's budget spent on
     noninstitutional long-term care services, and

  -- mandating coverage for long-term care services for certain
     higher-priority veterans. 

Requiring VA to establish a program that provides a comparable
continuum of long-term care services nationally is a reasonable way
to ensure that veterans have equitable access to care.  It is
consistent with the Federal Advisory Committee's recommendation that
VA create financial incentives and performance measures to ensure
adequate access to long-term care services, while preserving the
flexibility of VA's 22 regional offices to develop and structure
long-term care services.  This proposal should also help address our
concerns about historical inequities in long-term care and other
services, inadequate monitoring of incentives in VA's resource
allocation system that could lead to unintended outcomes, and the
lack of VA oversight of the equity of the 22 regional offices'
allocations of resources to health care delivery locations. 

Requiring VA to spend a greater percentage of its budget on
noninstitutional long-term care services is a reasonable strategy to
address the growing need for long-term care as the veteran population
continues to age, and it is consistent with the Federal Advisory
Committee's recommendation to increase investment in these services
to better meet the long-term care needs of veterans.  This approach
is also consistent with other long-term care programs' evolution to
expand noninstitutional services to offer a continuum of less
expensive services and more efficiently serve veterans when care
outside the nursing home is clinically appropriate.  An expansion of
these services would enable VA to serve more veterans in the home and
in the community, as most people prefer, rather than in institutions. 

Mandating long-term care services for certain higher-priority
veterans is also consistent with eligibility reform legislation and
addresses concerns we have previously raised about targeting VA
health care benefits to those with the highest priority for services. 
The proposed legislation would mandate long-term care services for
veterans with 50 percent or more service-connected disabilities and
for others whose need for long-term care is a result of a
service-connected disability, essentially authorizing VA to offer an
enhanced benefit package for these veterans. 

VA's statutory enrollment process provides a mechanism for enhancing
benefit coverage for higher-priority veterans and managing the costs
of these enhancements within the limits of VA resources.  This
process requires VA to determine the cost of meeting the needs of
higher-priority veterans and to target remaining resources to provide
a basic benefits package to as many lower-priority veterans as
possible.  Although the enrollment process provides the mechanism to
adjust VA health care delivery according to congressional priorities,
the process is only in its first year of operation.  Enrolling
veterans, projecting the costs of meeting their health care needs,
and managing according to the services required and resources
available is a complicated challenge that has far-reaching
implications for veterans' access to care and the quality of that
care. 

--------------------
\9 In Mar.  1997, VA convened this Committee of long-term care
experts to evaluate VA long-term care and develop a strategy for
meeting veterans' future needs.  The Committee recommended 24
measures to enhance VA's long-term care in its report, VA Long-Term
Care at the Crossroads (Washington, D.C.:  Department of Veterans
Affairs, June 1998). 

\10 For a discussion of other long-term programs, see Long-Term Care: 
Baby Boom Generation Presents Financing Challenges
(GAO/T-HEHS-98-107, Mar.  9, 1998). 

\11 VA Community Clinics:  Networks' Efforts to Improve Veterans'
Access to Primary Care Vary (GAO/HEHS-98-116, June 15, 1998), VA
Health Care:  Resource Allocation Has Improved, but Better Oversight
Is Needed (GAO/HEHS-97-178, Sept.  17, 1997), and VA Health Care: 
More Veterans Are Being Served, but Better Oversight Is Needed
(GAO/HEHS-98-226, Aug.  28, 1998). 

   ENHANCING MEDICAL COST SHARING
   COULD BENEFIT VETERANS
---------------------------------------------------------- Chapter 0:4

In 1986, the Congress authorized VA to require higher-income
veterans\12 without service-connected conditions to help offset the
costs of their medical care through copayments for both inpatient
care (acute and long-term) and outpatient care.  In 1990, the
Congress added a copayment requirement for outpatient medications
used to treat non-service-
connected medical conditions.  VA estimates that it billed about $143
million in copayments in fiscal year 1998. 

The draft bill contains provisions that would address VA cost sharing
in four areas: 

  -- prescription drugs,

  -- outpatient services,

  -- long-term care, and

  -- certain high-cost supplies. 

The draft bill would, for example, authorize the Secretary of VA to
increase the prescription drug copayment on the basis of regulations
prescribed by the Secretary.  Currently, VA is required by law to
charge a copayment of $2 for each 30-day or less supply of medication
for the treatment of a non-service-connected disability or condition. 
The proposal to permit VA to increase the copayment for prescription
drugs appears to be reasonable, given VA's rapidly escalating drug
costs.  Since the $2 copayment was legislatively mandated, VA's total
prescription drug costs have more than doubled.  VA billed for about
$64 million in copayments in fiscal year 1998.  Increasing the
copayment amount for prescriptions is consistent with options we have
previously reported to the Congress for helping VA cope with
budgetary pressures.  In 1996, for example, we suggested that the
Congress could offset VA spending for medications by increasing
copayment amounts.\13 Moreover, the draft proposal would provide VA
flexibility to adjust rates in a timely manner as conditions change. 

The draft bill also proposes to give the Secretary the authority to
establish copayment amounts for outpatient services by regulation for
veterans with non-service-connected conditions who are above the
low-income threshold.  VA billed for about $57 million in outpatient
copayments in fiscal year 1998.  Currently, the law requires that VA
charge a copayment to these veterans of 20 percent of the estimated
VA-wide average cost of an outpatient visit.  This copayment is
currently about $46. 

Giving the Secretary authority to change outpatient copayments
appears reasonable, given the transformation of VA outpatient
services in recent years.  VA now provides many more expensive
services in the outpatient setting, like other health care providers,
than it did when the current law was enacted.  Procedures at VA such
as colonoscopy, arthroscopy, and cystoscopy are now frequently
performed in an outpatient setting.  As a result, the VA outpatient
copayment amount has grown and is disproportionately high for
low-cost outpatient care, such as immunizations.  Authorizing VA to
set a schedule of outpatient copayments could help remove financial
deterrents that might discourage the use of preventive care.  It
could also enable VA to establish a copayment schedule more similar
to that used by other health care programs.\14

The draft bill also proposes that VA increase cost sharing by
charging certain veterans a copayment for long-term care services of
more than 21 days in any year.  Veterans with 50 percent or more
service-connected disability and those who are receiving long-term
care services for a service-connected disability would be excluded
from making copayments under this proposal.  VA would be required to
develop a methodology for determining copayment amounts on the basis
of the income and assets of the veteran and spouse, protecting the
spouse from financial hardship, and allowing the veteran to maintain
a monthly allowance.  Currently, VA bills nursing home care at a rate
equal to the Medicare inpatient deductible for the first 90 days of
care during any 365-day period.  In addition, VA bills $5 a day for
nursing home care.  In total, VA currently bills for about $4 million
from these sources. 

The proposal to revise the structure of long-term care copayments
appears reasonable because it would give VA flexibility to determine
the most appropriate copayment amount for these services by taking
into account a veteran's financial resources while protecting the
financial independence of a veteran's spouse living in the community. 
Because these funds would be directed to an earmarked fund for
long-term care services, these copayments might also provide
additional long-term care services to veterans.  In 1992, we
suggested a copayment approach using similar principles to offset
long-term costs.\15 These principles are already used in VA state
homes and in state Medicaid programs. 

The draft bill also proposes to establish copayments for certain
high-cost items, such as hearing aids, eyeglasses, certain electronic
equipment, and other items for non-service-connected conditions. 
Wheelchairs and artificial limbs would be excluded from these
copayments.  Currently, VA is not required to collect copayments for
these items. 

Requiring some veterans to pay a copayment for hearing aids,
eyeglasses, certain electronic equipment, and other costly items
seems reasonable.  Total VA expenditures for these prosthetic items
are expected to increase from $420 million in fiscal year 1998 to
about $524 million in fiscal year 2000.  During the course of our
ongoing review of VA's enrollment process, several VA network
directors commented that they are experiencing increased demand from
veterans whose primary care is provided elsewhere but who obtain from
VA services not covered by their private insurance or Medicare, such
as eyeglasses and hearing aids.  Giving VA the authority to establish
copayment amounts would provide flexibility to generate additional
revenues to enhance veterans' health care while still affording
veterans a substantial health care benefit, because the costs for
such items, according to VA officials, are not routinely covered by
other health care programs. 

--------------------
\12 Higher-income veterans are those whose incomes are above a
statutory threshold--for example, a veteran with no dependents with
an income of $22,351 or greater.  Income thresholds are higher for
veterans with dependents. 

\13 VA Health Care:  Opportunities to Significantly Reduce Outpatient
Pharmacy Costs (GAO/HEHS-97-15, Oct.  11, 1996). 

\14 In general, veterans are subject to less cost sharing than is
required under most public and private health benefit programs.  See
VA Health Care:  Comparison of VA Benefits With Other Public and
Private Programs (GAO/HRD-93-94, July 29, 1993). 

\15 VA Health Care:  Offsetting Long-Term Care Costs by Adopting
State Copayment Practices (GAO/HRD-92-96, Aug.  12, 1992). 

   CONCLUDING OBSERVATIONS
---------------------------------------------------------- Chapter 0:5

In conclusion, the Veterans' Millennium Health Care Act provides a
rational framework for addressing such important needs as

  -- enhancing services at underused facilities,

  -- enhancing long-term care services for an aging veteran
     population, and

  -- providing VA flexibility to generate additional revenues to
     offset budget pressures and serve more veterans. 

Most importantly, the draft bill strives to achieve these objectives
in a manner that is consistent with the overall goal of VA's
enrollment process, which is to manage veterans' access to health
care in relation to available resources. 

RELATED GAO PRODUCTS

Veterans' Affairs:  Progress and Challenges in Transforming Health
Care (GAO/T-HEHS-99-109, Apr.  15, 1999). 

Major Management Challenges and Program Risks:  Departments of
Defense, State, and Veterans Affairs (GAO/T-NSIAD/HEHS-99-84, Feb. 
25, 1999). 

Major Management Challenges and Program Risks:  Department of
Veterans Affairs (GAO/OCG-99-15, Jan.  1999). 

Veterans' Health Care:  Challenges Facing VA's Evolving Role in
Serving Veterans (GAO/T-HEHS-98-194, June 17, 1998). 

VA Health Care:  Assessment of VA's Fiscal Year 1998 Budget Proposal
(GAO/T-HEHS-97-121, May 1, 1997). 

Department of Veterans Affairs:  Programmatic and Management
Challenges Facing the Department (GAO/T-HEHS-97-97, Mar.  18, 1997). 

Veterans' Health Care:  Challenges for the Future (GAO/T-HEHS-96-172,
June 27, 1996). 

VA Health Care:  Challenges and Options for the Future
(GAO/T-HEHS-95-147, May 9, 1995). 

VA Health Care:  Retargeting Needed to Better Meet Veterans' Changing
Needs (GAO/HEHS-95-39, Apr.  21, 1995). 

*** End of document. ***