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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 BEFORETHE SUBCOMMITTEE ON HOSPITALS AND HEALTH CAKE OFTHE COMMITTEE ON VETERANS' AFFAIRS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION OCTOBER 14 AND NOVEMBER 18, 1993 Printed for the use ofthe Committee on Veterans' Affairs Serial No. 103-29 U.S. GOVERNMENT PRINTING OFFICE WASHINGTON : 1994 ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice,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 BEFORETHE SUBCOMMITTEE ON HOSPITALS AND HEALTH CARE OFTHE COMMITTEE ON VETERANS' AFFAIRS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION OCTOBER 14 AND NOVEMBER 18, 1993 Printed for the use ofthe Committee on Veterans' Affairs Serial No. 103-29 "'*'"'SSgSP»B, m2 ©94 '^^^-feSL U.S. GOVERNMENT PRINTING OFFICE "'"-^fir^t X WASHINGTON : 1994 ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice,Washington,DC 20402 ISBN 0-16-045880-3 COMMITTEE ONVETERANS'AFFAIRS G.V. (SONNY)MONTGOMERY,Mississippi,Chairman DONEDWARDS,California BOBSTUMP,Arizona DOUGLASAPPLEGATE, Ohio CHRISTOPHERH. SMITH, NewJersey LANEEVANS, Illinois DANBURTON, Indiana TIMOTHYJ. PENNY,Minnesota MICHAELBILIRAKIS, Florida J. ROYROWLAND,Georgia THOMASJ. RIDGE,Pennsylvania JIMSLATTERY, Kansas FLOYDSPENCE, SouthCarolina JOSEPH P. KENNEDY, II,Massachusetts TIMHUTCHINSON,Arkansas GEORGE E. SANGMEISTER, lUinois TERRYEVERETT,Alabama JILLL. LONG, Indiana STEVE BUYER, Indiana CHETEDWARDS,Texas JACKQUINN,NewYork MAXINEWATERS, California SPENCERBACHUS,Alabama BOB CLEMENT,Tennessee JOHN LINDER,Georgia BOBFILNER, California CLIFFSTEARNS, Florida FRANKTEJEDA,Texas PETERT. KING,NewYork LUISV. GUTIERREZ, Illinois SCOTTYBAESLER, Kentucky SANFORDBISHOP, Georgia JAMESE. CLYBURN, SouthCarolina MIKE KREIDLER,Washington CORRINE BROWN,Florida MackG. Fleming,StaffDirectorandChiefCounsel SUBCOMMITTEE ON HOSPITALS AND HEALTH CARE J. ROYROWLAND,Georgia, Chairman DOUGLASAPPLEGATE, Ohio CHRISTOPHERH. SMITH, NewJersey JJIOLSLEPL.HLPO.NKG,ENINndEiDanYaII, Massachusetts BDOABNSBTUURMTPO,N,ArIinzdoinaana CHETEDWARDS,Texas MICHAELBILIRAKIS, Florida BOBCLEMENT,Tennessee TIMHUTCHINSON,Arizona BOBFILNER, California TERRYEVERETT,Alabama FRANKTEJEDA,Texas STEVE BUYER, Indiana LUISV. GUTIERREZ, Illinois JOHNLINDER,Georgia SCOTTYBAESLER,Kentucky SANFORD BISHOP, Georgia MIKE KREIDLER,Washington CORRINE BROWN, Florida (II) CONTENTS Page October 14, 1993 OPENING STATEMENTS ChairmanRowland 1 Hon. G.V. (Sonny) Montgomery, chairman, full Committee on Veterans' Af- fairs 4 Hon.BobStump 4 PreparedstatementofHon.BobClement 87 Hon.ChristopherH.Smith 3 Hon. MichaelBilirakis 5 Hon.DouplasP.Applegate 13 Hon.MikeKreidler 18 Hon.FrankTejeda 24 Hon.ThomasJ. Ridge 26 Hon.LuisV. Gutierrez 30 WITNESSES Brown, Hon. Jesse, Secretary of Veterans Affairs, Department ofVeterans 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. MarkCatlett,AssistantSecretaryforFinanceandInformation ResourcesManagement;andMs. MaryLouKeener,GeneralCounsel 7 PreparedstatementofSecretaryBrown 89 Feder, Judith, Ph.D., Principal DeputyAssistant Secretary for Planning and Evaluation,DepartmentofHealthandHumanServices 9 November 18, 1993 OPENING STATEMENTS ChairmanRowland 41 Hon. ChristopherH.Smith 42 PreparedstatementofHon.MichaelBilirakis 97 Hon.BobStump 43 WITNESSES Brinck,MichaelF.,NationalLegislativeDirector,AMVETS 66 PreparedstatementofMr.Brinck 140 Buxton,Frank,DeputyDirector,NationalVeteransAffairsandRehabilitation Commission,TheAmericanLegion 60 PreparedstatementofMr.Buxton 112 CuUinan, Dennis, Deputy Director, National Legislative Service, Veterans ofForeignWars 62 PreparedstatementofMr.Cullinan,withattachment 126 Davis,BetteL.,President,NursesOrganizationofVeteransAffairs 75 PreparedstatementofMs.Davis 165 (III) IV Page Dunn, Marvin, M.D., Dean, School ofMedicine, University ofSouth Florida, representingtheAssociationofAmericanMedicalColleges 44 PreparedstatementofDr.Dunn 98 Egan,Paul,ExecutiveDirector,VietnamVeteransofAmerica 80 PreparedstatementofMr.Egan 180 Garthwaite, Thomas L., M.D., President, National Association ofVA Chiefs ofStaff,andChiefofStaff,ZablockiVAMedicalCenter,Milwaukee,WI 45 PreparedstatementofDr.Garthwaite 108 Gorman, David W., Assistant National Legislative Director for Medical Af- fairs,DisabledAmericanVeterans 64 PreparedstatementofMr.Gorman 134 Lee, Alma, President, VA Council, American Federation ofGovernment Em- ployees 77 PreparedstatementofMs. Lee 172 Mansfield,Gordon,ExecutiveDirector,ParalyzedVeteransofAmerica 67 PreparedstatementofMr.Mansfield,withattachment 146 Prigmore, Charles, Ph.D., SeniorViceCommanderandLegislativeChairman, American Ex-prisoners ofWar, Inc., accompanied by William E. Bearisto, NationalCommander 79 PreparedstatementofMr.Prigmore 177 Spagnolo, SamuelV., M.D., President, NationalAssociationofVAPhysicians andDentists 74 PreparedstatementofDr.Spagnolo 162 MATERIAL SUBMITTED FORTHE RECORD Document: "AtchaedeUmniicteIdniSttiaatteisve—sAtoCoAmdpdernesdsiuPmh"yssiucbimainttSeudpbpylyAsisnocRiautriaolnAofreAamsero-f icanMedicalColleges 220 Statements: BlindedVeteransAssociation 188 Green, Howard H., M.D., ChiefofStaff, Department ofVeterans Affairs MedicalandRegionalOfficeCenter,WhiteRiverJunction,VT 193 Writtencommitteequestionsandtheirresponses: CongressmanBilirakistoDepartmentofVeteransAffairs 196 CongressmanSmithofNewJerseytoDepartmentofVeteransAffairs 198 Congressman SmithofNewJerseytoDepartmentofHealth and Human Services 204 Con^essmanHutchinsontoDepartmentofVeteransAffairs 206 ChairmanRowlandtoNationalAssociationofVAChiefsofStaff 208 Congressman Smith ofNew Jersey to NationalAssociation ofVA Chiefs ofStaff 210 Chairman Rowland to National Association ofVA Physicians and Den- tists 213 Congressman Smith ofNewJersey to National Association ofVA Physi- ciansandDentists 215 ChairmanRowlandtoAssociationofAmericanMedicalColleges 216 Congressman Smith ofNew Jersey to Association ofAmerican Medical Colleges 218 CongressmanTejedatoDepartmentofVeteransAffairs 279 ROLE OF DEPARTMENT OF VETERANS AF- FAIRS IN NATIONAL HEALTH CARE REFORM THURSDAY, OCTOBER 14, 1993 House of Representatives, Subcommittee on Hospitalsand Health Care, Committee onVeterans'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). OPENINGSTATEMENTOFCHAIRMANROWLAND Mr. Rowland. The subcommitteewill 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 ifwe get started now and save as muchtime 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 subcommittee held a far-reaching hearing on this subject in April. We heard from manyhealth 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 reform. In essence, we articulated a set ofprinciples 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 ofthese issues with Mrs. Clinton, and I made certain that the principles were brought to her attention followingourAprilhearing. Based on the most recent briefings we received, the President's plan is to go a great distance towards meeting the goals we articulated. I thinkitwould be helpful, accordingly, to restate those principles briefly. Key among these is the importance of maintaining (1) the independence and viability ofthe VA health care system as a provider offering a full range ofservices. To that end, a second important principle is for all veterans to have access to the VA as an enrollment option andtobe offered a continuum ofcare. 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 ofservices than under currentlaw. A third principle calls for VA to be able to compete as an enrollment 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 itselfto be an attractive, health care option for veterans. 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 ofcost-sharing obligations im- posed on most other citizens. Afifth concern is that we be assured that the plan would provide adequate fundingforVAhealth care. We are told thatthe planwill meet this goal through a combination offunding streams, including revenues from employer contributions and Congressional appro- priations, and in the case ofhigher-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 system, improved information systems, and structural changes. Tlie planners reportedlyhave recognized these needs as well. The Administration has signaled its willingness to be flexible re- garding specific outlines ofhealth 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 inits plan. Equally important will be the support of the veterans' community. To their credit, veterans' organizations have closely monitored the evolution ofthe 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 layingthe foundation for reviewinglegislationwhichwill be submitted in the weeks to come. As the President has indicated, the health care proposal is not being presented as ifit 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 theveterans' community. I commend the Administration and Secretary Brown for their ef- forts to stand by America's veterans as we tackle health care concerns affecting all ofourcitizenry. 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 ifthey desire to make opening statements, but I hope you won'ttake the 5 minutes. OPENINGSTATEMENTOFHON.CHRISTOPHERH. 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 questions in our minds. Frankly, how can any plan ofthis scope, which took over 9 months to complete, not generate a whole host oftough and difficultquestions? 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 subcommitteehas previously conducted hearings 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 commitment to our veterans will not be overlooked by the President's plan. However, there remain a number ofserious concerns which must be addressed concerningthe implementation ofthe President's plan or any other plan that might be enacted bythe Congress. In particular, I am troubled bythe Canadian experience and how we may be condemned to repeat that failure. As my colleagues recall, 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 ofanyhealth care plan. Mr. Chairman, I am also deeply concerned that the President may insist on providing abortion on demand throughout the De- partment ofVeterans 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 ofhuman 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, itis the taking ofa baby's life. Mr. Chairman, I agree thatwe must take action to halt the esca- lating costs ofhealth care and to guarantee that health insurance is available to all Americans. I also agree that the VA has an important 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 ofthis subcommittee as well as the majority, and I yield back to you the bal- ance ofmytime. 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. Thankyou. Mr. Rowland. Without objection. [The prepared statement ofChairman Montgomeryfollows:] PreparedstatementofHon.G.V.(Sonny)Montgomery,Chairman,Committee ONVeterans'Affairs,HouseofRepresentatives Mr. Chairman, Ijust wanted to mention that the President and the First Lady sought theviews ofveterans' advocates in the Congress and the nationalveterans' serviceorganizationsduringthedevelopmentofthehealthcarereformplan. Itwas evidentfrom these meetings thattheynaveagenuine concern forthewell-beingof vveetreyrarnesc.eptSievneattoorouJrayidReoacsk.eWfeellewreraendverIymiemtprtewsicseedwiwtihthMhresr.kCnloiwntloendgaendofsthheewVaA.s ShetalkedabouthowherfatherhadpreferredVAcare. VAhadalotofinputintothisplan.WewerepleasedtoseethePresidentappoint Jesse Brown to the health care task force headed by Mrs. Clinton. We also were pleasedthat33VAemployeeswereamongthehealthcareprofessionalsandexperts makingupthestaffofthetaskforce. forAsallIvuentdeerarnsst.anIdtwiit,lltheexpParnedsidaecncte'sssptolavnetmearianntsaiwnhsotchuerrVeAntlaysaarneedxecnliuesdivVeAopsteirovn- icesduetoinadequateresources. Veteranswithservice-connecteddisabilitiesorlow incomeswhochooseVAasaproviderwillpaynothingfortheircare, nocopayments nordeductibles. Higherincomeveteranswhoseconditionsarenotrelatedtomilitary servicewillbe required to payashare ofthecostoftheirtreatmentjustlikeother citizens. IfthePresident'sproposalpertainingtoveteransisadopted,veteransshouldhave no real concern about their nealth care services. And I should point out that the veterans'organizationsandmilitaryassociationshaveendorsedit. Mr. Rowland. I recognize the ranking member of the full committee, Mr. Stump. Mr. Stump. Thankyou, Mr. Chairman. I will do the same. I will just welcome the Secretary here, and I dohave a statementforthe record, please. [Theprepared statementofCongressman Stump follows:] PreparedstatementofHon.BobStump,RankingMinorityMember, CommitteeonVeterans'Affairs,HouseofRepresentatives ThankyouMr. Chairman. Iappreciatetheopportunitytoreviewforthefirsttime in this Subcommittee, the potential impact ofthe President's National Health Re- formPlanasitrelatestoveterans. It is my beliefthat this Subcommittee's role in designingthe future structure of veterans'healthcaredelivervisthemostmonumentalissuefacingusthisCongress. Itis myintentiontoproceedverycautiouslyandwith greatdeliberation before rec- ommending any legislation which would change the veterans' health care system. Most importantly, the veterans ofthis Nation need to be heard and they must have details ofany proposals which come before this Subcommittee. It is my hope