Table Of Content\\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
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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
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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 sub-
committee 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 re-
form.
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 articu-
lated. I thinkitwould be helpful, accordingly, to restate those prin-
ciples 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 im-
portant 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 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 itselfto 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 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 sys-
tem, 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' commu-
nity. 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 con-
cerns 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 ques-
tions 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 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 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 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 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 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 ofthis sub-
committee 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 com-
mittee, 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
