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Role of Department of Veterans Affairs in national health care reform : hearings before the Subcommittee on Hospitals and Health Care of the Committee on Veterans' Affairs, House of Representatives, One Hundred Third Congress, first session, October 14 and November 18, 1993 online

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\\s ROLE OF DEPARTMENT OF VETERANS AFFAIRS
^ IN NATIONAL HEALTH CARE REFORM



Y 4, V 64/3; 103-29

Role of Oepartnent of Ueterans Affa...

HEARINGS

BEFORE THE

SUBCOMMITTEE ON
HOSPITALS AND HEALTH CAKE

OF THE

COMMITTEE ON VETERANS' AFFAIRS
HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRD CONGRESS

FIRST SESSION



OCTOBER 14 AND NOVEMBER 18, 1993



Printed for the use of the Committee on Veterans' Affairs

Serial No. 103-29







U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1994



For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
ISBN 0-16-045880-3



^ ROLE OF DEPARTMENT OF VETERANS AFFAIRS
IN NATIONAL HEALTH CARE REFORM



4. V 64/3: 103-29

le of Departnent of Veterans Affa...

HEARINGS

BEFORE THE

SUBCOMMITTEE ON
HOSPITALS AND HEALTH CARE

OF THE

COMMITTEE ON VETERANS' AFFAIRS
HOUSE OF REPRESENTATIVES

ONE HUNDRED THIRD CONGRESS

FIRST SESSION



OCTOBER 14 AND NOVEMBER 18, 1993



Printed for the use of the Committee on Veterans' Affairs

Serial No. 103-29




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U.S. GOVERNMENT PRINTING OFFICE "'"-^fir^t

X WASHINGTON : 1994

For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
ISBN 0-16-045880-3



COMMITTEE ON VETERANS' AFFAIRS
G.V. (SONNY) MONTGOMERY, Mississippi, Chairman



DON EDWARDS, California

DOUGLAS APPLEGATE, Ohio

LANE EVANS, Illinois

TIMOTHY J. PENNY, Minnesota

J. ROY ROWLAND, Georgia

JIM SLATTERY, Kansas

JOSEPH P. KENNEDY, II, Massachusetts

GEORGE E. SANGMEISTER, lUinois

JILL L. LONG, Indiana

CHET EDWARDS, Texas

MAXINE WATERS, California

BOB CLEMENT, Tennessee

BOB FILNER, California

FRANK TEJEDA, Texas

LUIS V. GUTIERREZ, Illinois

SCOTTY BAESLER, Kentucky

SANFORD BISHOP, Georgia

JAMES E. CLYBURN, South Carolina

MIKE KREIDLER, Washington

CORRINE BROWN, Florida



BOB STUMP, Arizona

CHRISTOPHER H. SMITH, New Jersey

DAN BURTON, Indiana

MICHAEL BILIRAKIS, Florida

THOMAS J. RIDGE, Pennsylvania

FLOYD SPENCE, South Carolina

TIM HUTCHINSON, Arkansas

TERRY EVERETT, Alabama

STEVE BUYER, Indiana

JACK QUINN, New York

SPENCER BACHUS, Alabama

JOHN LINDER, Georgia

CLIFF STEARNS, Florida

PETER T. KING, New York



Mack G. Fleming, Staff Director and Chief Counsel



SUBCOMMITTEE ON HOSPITALS AND HEALTH CARE



J. ROY ROWLAND,
DOUGLAS APPLEGATE, Ohio
JOSEPH P. KENNEDY II, Massachusetts
JILL L. LONG, Indiana
CHET EDWARDS, Texas
BOB CLEMENT, Tennessee
BOB FILNER, California
FRANK TEJEDA, Texas
LUIS V. GUTIERREZ, Illinois
SCOTTY BAESLER, Kentucky
SANFORD BISHOP, Georgia
MIKE KREIDLER, Washington
CORRINE BROWN, Florida



Georgia, Chairman

CHRISTOPHER H. SMITH, New Jersey

BOB STUMP, Arizona

DAN BURTON, Indiana

MICHAEL BILIRAKIS, Florida

TIM HUTCHINSON, Arizona

TERRY EVERETT, Alabama

STEVE BUYER, Indiana

JOHN LINDER, Georgia



(II)



CONTENTS

Page

October 14, 1993

OPENING STATEMENTS

Chairman Rowland 1

Hon. G.V. (Sonny) Montgomery, chairman, full Committee on Veterans' Af-
fairs 4

Hon. Bob Stump 4

Prepared statement of Hon. Bob Clement 87

Hon. Christopher H. Smith 3

Hon. Michael Bilirakis 5

Hon. Douplas P. Applegate 13

Hon. Mike Kreidler 18

Hon. Frank Tejeda 24

Hon. Thomas J. Ridge 26

Hon. Luis V. Gutierrez 30

WITNESSES

Brown, Hon. Jesse, Secretary of Veterans Affairs, Department of Veterans
Affairs, accompanied by John T. Farrar, M.D., Acting Under Secretary
for Health; Victor P. Raymond, Ph.D., Assistant Secretary for Policy and
Planning; D. Mark Catlett, Assistant Secretary for Finance and Information

Resources Management; and Ms. Mary Lou Keener, General Counsel 7

Prepared statement of Secretary Brown 89

Feder, Judith, Ph.D., Principal Deputy Assistant Secretary for Planning and
Evaluation, Department of Health and Human Services 9



November 18, 1993

OPENING STATEMENTS

Chairman Rowland 41

Hon. Christopher H. Smith 42

Prepared statement of Hon. Michael Bilirakis 97

Hon. Bob Stump 43

WITNESSES

Brinck, Michael F., National Legislative Director, AMVETS 66

Prepared statement of Mr. Brinck 140

Buxton, Frank, Deputy Director, National Veterans Affairs and Rehabilitation

Commission, The American Legion 60

Prepared statement of Mr. Buxton 112

CuUinan, Dennis, Deputy Director, National Legislative Service, Veterans

of Foreign Wars 62

Prepared statement of Mr. Cullinan, with attachment 126

Davis, Bette L., President, Nurses Organization of Veterans Affairs 75

Prepared statement of Ms. Davis 165

(III)



IV

Page

Dunn, Marvin, M.D., Dean, School of Medicine, University of South Florida,

representing the Association of American Medical Colleges 44

Prepared statement of Dr. Dunn 98

Egan, Paul, Executive Director, Vietnam Veterans of America 80

Prepared statement of Mr. Egan 180

Garthwaite, Thomas L., M.D., President, National Association of VA Chiefs

of Staff, and Chief of Staff, Zablocki VA Medical Center, Milwaukee, WI 45

Prepared statement of Dr. Garthwaite 108

Gorman, David W., Assistant National Legislative Director for Medical Af-
fairs, Disabled American Veterans 64

Prepared statement of Mr. Gorman 134

Lee, Alma, President, VA Council, American Federation of Government Em-
ployees 77

Prepared statement of Ms. Lee 172

Mansfield, Gordon, Executive Director, Paralyzed Veterans of America 67

Prepared statement of Mr. Mansfield, with attachment 146

Prigmore, Charles, Ph.D., Senior Vice Commander and Legislative Chairman,
American Ex-prisoners of War, Inc., accompanied by William E. Bearisto,

National Commander 79

Prepared statement of Mr. Prigmore 177

Spagnolo, Samuel V., M.D., President, National Association of VA Physicians

and Dentists 74

Prepared statement of Dr. Spagnolo 162

MATERIAL SUBMITTED FOR THE RECORD

Document:

"Academic Initiatives to Address Physician Supply in Rural Areas of
the United States — A Compendium" submitted by Association of Amer-
ican Medical Colleges 220

Statements:

Blinded Veterans Association 188

Green, Howard H., M.D., Chief of Staff, Department of Veterans Affairs

Medical and Regional Office Center, White River Junction, VT 193

Written committee questions and their responses:

Congressman Bilirakis to Department of Veterans Affairs 196

Congressman Smith of New Jersey to Department of Veterans Affairs 198

Congressman Smith of New Jersey to Department of Health and Human

Services 204

Con^essman Hutchinson to Department of Veterans Affairs 206

Chairman Rowland to National Association of VA Chiefs of Staff 208

Congressman Smith of New Jersey to National Association of VA Chiefs

of Staff 210

Chairman Rowland to National Association of VA Physicians and Den-
tists 213

Congressman Smith of New Jersey to National Association of VA Physi-
cians and Dentists 215

Chairman Rowland to Association of American Medical Colleges 216

Congressman Smith of New Jersey to Association of American Medical

Colleges 218

Congressman Tejeda to Department of Veterans Affairs 279



ROLE OF DEPARTMENT OF VETERANS AF-
FAIRS IN NATIONAL HEALTH CARE
REFORM



THURSDAY, OCTOBER 14, 1993

House of Representatives,
Subcommittee on Hospitals and

Health Care,
Committee on Veterans' Affairs,

Washington, DC.
The subcommittee met, pursuant to call, at 2 p.m., in room 334,
Cannon House Office Building, Hon. Roy Rowland (Chairman of
the subcommittee), presiding. Present: Representatives Rowland,
Kennedy, Long, Edwards of Texas, Clement, Filner, Tejeda,
Gutierrez, Kreidler, Brown, Smith, Stump, Bilirakis, Hutchinson,
and Buyer. Also present: Representatives Evans, Ridge, Quinn, and
Montgomery (ex officio).

OPENING STATEMENT OF CHAIRMAN ROWLAND

Mr. Rowland. The subcommittee will come to order.

We are going to have a vote, I am sure, in the next 20 minutes
or so, but I think it would serve us well if we get started now and
save as much time as we can.

I want to thank our witnesses for juggling their busy schedules
to be with us, and particularly to welcome Secretary Brown and
Deputy Assistant Secretary Feder, who are both making their first
appearances before this subcommittee.

Today's hearing will further the discussion on the VA's role in
national health care reform. As many of you will recall, the sub-
committee held a far-reaching hearing on this subject in April. We
heard from many health care experts, veterans' groups, and the VA
health care administrators. Through their testimony, we identified
an agenda for shaping a VA role on the national health care re-
form.

In essence, we articulated a set of principles intended to govern
the development of that VA role. These same principles can now
serve as a touchstone to assess the Administration's proposal.
Chairman Montgomery and I discussed several of these issues with
Mrs. Clinton, and I made certain that the principles were brought
to her attention following our April hearing.

Based on the most recent briefings we received, the President's
plan is to go a great distance towards meeting the goals we articu-
lated. I think it would be helpful, accordingly, to restate those prin-
ciples briefly. Key among these is the importance of maintaining

(1)



the independence and viability of the VA health care system as a
provider offering a full range of services. To that end, a second im-
portant principle is for all veterans to have access to the VA as an
enrollment option and to be offered a continuum of care.

Under the proposed health care plan, the VA will maintain its
independence and will be open to ^1 veterans. If a veteran elects
to receive care through a VA health care plan, the veteran would
have access to a broader and more comprehensive rginge of services
than under current law.

A third principle calls for VA to be able to compete as an enroll-
ment option for all veterans. We are told VA health care will be
among the options open to veterans choosing health plans through
new health alliances. As a competing health plan, VA must, there-
fore, position itself to be an attractive, health care option for veter-
ans.

A fourth concern is that any plan maintain the commitment of
providing cost-free care to those with the highest priority. The Ad-
ministration has apparently adopted that policy and would provide
that any service-connected and low-income category A veterans
who elect VA care would be relieved of cost-sharing obligations im-
posed on most other citizens.

A fifth concern is that we be assured that the plan would provide
adequate funding for VA health care. We are told that the plan will
meet this goal through a combination of funding streams, including
revenues from employer contributions and Congressional appro-
priations, and in the case of higher-income veterans, fund medicare
reimbursements and insurance premiums.

A plan for VA health care must build on VA's strengths, and
thus must maintain VA's role in education and research. We are
assured that this principle is fundamental to the plan's architec-
ture.

Finally, the plan must recognize and provide the means for VA
to reform itself— through new construction funding and an expan-
sion of community clinics, establishment of a cost accounting sys-
tem, improved information systems, and structural changes. Tlie
planners reportedly have recognized these needs as well.

The Administration has signaled its willingness to be flexible re-
garding specific outlines of health reform. As the debate unfolds in
the ensuing months, however, it will be critical that the Adminis-
tration not waiver in its commitment to veterans' health care and
to the fundamental principles reflected in its plan.

Equally important will be the support of the veterans' commu-
nity. To their credit, veterans' organizations have closely monitored
the evolution of the President's plan, and their views have helped
shape its outline.

As I understand it, their meetings with the First Lady and over-
view of the plan have prompted near-unanimous endorsements.
Such support will be critical to final passage of the President's
plan.

This morning, we look forward to learning more about the plan
as well as laying the foundation for reviewing legislation which will
be submitted in the weeks to come.

As the President has indicated, the health care proposal is not
being presented as if it is written in stone. Rather, the Administra-



tion expects the Congress to fine-tune its proposal, where nec-
essary. We will certainly review the bill closely to help ensure that
the final product has broad support both within the Congress and,
more importantly, within the veterans' community.

I commend the Administration and Secretary Brown for their ef-
forts to stand by America's veterans as we tackle health care con-
cerns affecting all of our citizenry.

At this time, I am going to recognize Chris Smith, the ranking
minority member, and let me say that each individual will have 5
minutes if they desire to make opening statements, but I hope you
won't take the 5 minutes.

OPENING STATEMENT OF HON. CHRISTOPHER H. SMITH

Mr. Smith. Thank you very much, Mr. Chairman. I would like
to join you in welcoming Secretary Brown and Judy Feder, who I
understand is at the Ways and Means Committee right now, to our
subcommittee this afternoon.

Despite the helpful briefings provided to the committee and the
subcommittee from Assistant Secretary for Policy and Planning,
Vic Raymond, the health care reform bill has generated many ques-
tions in our minds. Frankly, how can any plan of this scope, which
took over 9 months to complete, not generate a whole host of tough
and difficult questions?

I know you are prepared, Mr. Secretary, to give us some firm an-
swers to at least some of the these questions, and I know many
more specific questions will arise as we get the actual legislative
document which I understand should be tendered sometime next
week.

Mr. Chairman, this subcommittee has previously conducted hear-
ings on the impact of national health care reform and the impact
it will have on the VA. In April, we released our nine-point agenda
which outlined the key components any health care reform plan
must embrace. Overall, I am pleased to see that the Nation's com-
mitment to our veterans will not be overlooked by the President's
plan.

However, there remain a number of serious concerns which must
be addressed concerning the implementation of the President's plan
or any other plan that might be enacted by the Congress.

In particular, I am troubled by the Canadian experience and how
we may be condemned to repeat that failure. As my colleagues re-
call, after implementing a national health care plan, the separate
veterans health care system in Canada simply withered away. We
cannot allow that to happen in the United States fi"om the enact-
ment of any health care plan.

Mr. Chairman, I am also deeply concerned that the President
may insist on providing abortion on demand throughout the De-
partment of Veterans Affairs, turning those 171 hospitals and 350
outpatient clinics into abortion mills.

The VA's health care network has been and must continue to be
dedicated to the preservation of human life. I believe, as do many
members of this committee, that the overwhelming number of
Americans, the taxpayers, do not want their money being used to
subsidize the demise of unborn children, and that exactly is what
abortion is all about, it is the taking of a baby's life.



Mr. Chairman, I agree that we must take action to halt the esca-
lating costs of health care and to guarantee that health insurance
is available to all Americans. I also agree that the VA has an im-
portant role to play in America's health care delivery network.
There are simply several key issues that need to be resolved as we
move forward.

Mr. Chairman, I look forward to the testimony of Secretary
Brown. He is most welcome by the minority members of this sub-
committee as well as the majority, and I yield back to you the bal-
ance of my time.

Mr. Rowland. The Chairman of the full committee, Mr. Mont-
gomery.

Mr. Montgomery. Mr. Chairman, I would like to welcome the
Secretary, and I will submit my remarks for the record because of
time. Thank you.

Mr. Rowland. Without objection.

[The prepared statement of Chairman Montgomery follows:]

Prepared statement of Hon. G.V. (Sonny) Montgomery, Chairman, Committee
ON Veterans' Affairs, House of Representatives

Mr. Chairman, I just wanted to mention that the President and the First Lady
sought the views of veterans' advocates in the Congress and the national veterans'
service organizations during the development of the health care reform plan. It was
evident from these meetings that they nave a genuine concern for the well-being of
veterans. Senator Jay Rockefeller and I met twice with Mrs. Clinton and she was
very receptive to our ideas. We were very impressed with her knowledge of the VA.
She talked about how her father had preferred VA care.

VA had a lot of input into this plan. We were pleased to see the President appoint
Jesse Brown to the health care task force headed by Mrs. Clinton. We also were
pleased that 33 VA employees were among the health care professionals and experts
making up the staff of the task force.

As I understand it, the President's plan maintains the VA as an exclusive option
for all veterans. It will expand access to veterans who currently are denied VA serv-
ices due to inadequate resources. Veterans with service-connected disabilities or low
incomes who choose VA as a provider will pay nothing for their care, no copayments
nor deductibles. Higher income veterans whose conditions are not related to military
service will be required to pay a share of the cost of their treatment just like other
citizens.

If the President's proposal pertaining to veterans is adopted, veterans should have
no real concern about their nealth care services. And I should point out that the
veterans' organizations and military associations have endorsed it.

Mr. Rowland. I recognize the ranking member of the full com-
mittee, Mr. Stump.

Mr. Stump. Thank you, Mr. Chairman.

I will do the same. I will just welcome the Secretary here, and
I do have a statement for the record, please.

[The prepared statement of Congressman Stump follows:]

Prepared statement of Hon. Bob Stump, Ranking Minority Member,
Committee on Veterans' Affairs, House of Representatives

Thank you Mr. Chairman. I appreciate the opportunity to review for the first time
in this Subcommittee, the potential impact of the President's National Health Re-
form Plan as it relates to veterans.

It is my belief that this Subcommittee's role in designing the future structure of
veterans' health care deliverv is the most monumental issue facing us this Congress.
It is my intention to proceed very cautiously and with great deliberation before rec-
ommending any legislation which would change the veterans' health care system.

Most importantly, the veterans of this Nation need to be heard and they must
have details of any proposals which come before this Subcommittee. It is my hope



that we will be able to uncover many details of the President's plan today. Until
now, we have had broad overviews of what that plan entails. This hearing will pro-
vide us the opportunity to explore the President's proposal further and make impor-
tant determinations as to what it may mean for veterans.

I look forward to the testimony of the Secretary of Veterans Affairs, Jesse Brown
and also to the insights of the White House Health Care Task Force as provided
by Ms. Judy Feder. I thank them both for being here.

Mr. Rowland. Are there any members who desire to make open-
ing statements.
Mr. BILIRAKIS. Mr. Chairman.
Mr. Rowland. The gentleman from Florida.

OPENING STATEMENT OF HON. MICHAEL BILIRAKIS

Mr. BILIRAKIS. Mr. Chairman, I commend you for holding this
important hearing. I also welcome Secretary Brown and his staff
to the subcommittee and look forward to their testimony.

Mr. Chairman, many issues are making national headlines these
days, and probably no single issue will impact as many individuals
as national health care reform. Obviously, national health care re-
form has serious implications for the VA health care system — seri-
ous implications. Therefore, any proposal that impacts on the sta-
tus, role, or autonomy of the VA health care system must be closely
examined.

Last year, the veterans in my district were concerned, and I
would dare say probably veterans all over America, that their
health care needs were being overlooked in the debate over a new
national health care system. At that time, I urged the VA to be-
come an active player in the debate, and I was encouraged to learn
that Secretary Brown was a member of Mrs. Clinton's health care
reform task force and that VA staff participated in the various
working groups that were formed.

At first glance, it appears that the President's health care pro-
posal will maintain the VA's independence. However, I do have nu-
merous questions regarding whether or not the VA can effectively
play the role envisioned for it in the Administration's proposal, and
I also have serious doubts as to whether or not the VA will be able
to compete with other health care providers.

For years, a tremendous backlog — I believe you mentioned this,
Mr. Chairman — in construction projects and medical equipment ac-
quisitions have hampered the VA's ability to treat the Nation's vet-
erans. Unless these and some other concerns are addressed at the
start — and I underline the word "start" — of the reform process, I
am afraid that the VA will be the last runner to cross the finish
line in the race to attract health care consumers. In other words,
it would not be competitive.

I have long believed that the VA health care system is a national
asset and, I think virtually every member of this committee is com-
mitted to ensure that it continues to be one. The men and women
who have served in our armed forces have met their obligations to
our coimtry, and as we move toward reforming the Nation's health
care system we need to show our veterans they have not been for-
gotten or abandoned.

I had a quote in here from Theodore Roosevelt, but I will pass
that up in the interest of time. In closing I want to repeat some-
thing that I try to repeat in most of our hearings, and that is to



6

encourage the members of the veterans' service organizations that
are in the audience to remain diligent. The health care debate is
far from over. We have got to be open-minded. We have got to
reach out and be a part of the solution, but at the same time we
have got to be diligent. It is imperative that you continue to be ac-
tive players in the ongoing deliberations over national health care.

Thank you, Mr. Chairman.

[The prepared statement of Congressman Bilirakis follows:]

Prepared statement of Hon. Michael Bilirakis

Thank you Mr. Chairman.

First, let me take this opportunity to commend you for holding this important
hearing. I would also like to take a moment to welcome Secretary Brown to the sub-
committee. I look forward to hearing his testimony.

Many issues are making national headlines these days, and probably no single
issue will impact as many individuals as national health care reform. Obviously, na-
tional health care reform has serious implications for the VA health care system.
Therefore, any proposal that impacts on the status, role, or autonomy of the VA
health care system must be closely examined.

Last year, the veterans in my district were concerned that their health care needs
were being overlooked in the debate over a new national health care system. At that
time, I urged the VA to become an active player in the debate. Therefore, I was en-
couraged to learn that Secretary Brown was a member of Mrs. Clinton's health care
reform task force and that VA staff participated in the various working groups that
were formed.

At first glance, it appears that the President's health care proposal will maintain
the VA's independence. However, I do have numerous questions regarding whether
or not the VA can effectively play the role envisioned for it in the Administration's
proposal. Moreover, I also have serious doubts as. to whether or not the VA will be
able to compete with other health care providers.

For years, a tremendous backlog in construction projects and medical equipment
acquisitions have hampered the VA's ability to treat the Nation's veterans. Unless
these and some other concerns are addressed at the start of the reform process, I



Online LibraryUnited States. Congress. House. Committee on VeterRole of Department of Veterans Affairs in national health care reform : hearings before the Subcommittee on Hospitals and Health Care of the Committee on Veterans' Affairs, House of Representatives, One Hundred Third Congress, first session, October 14 and November 18, 1993 → online text (page 1 of 31)