Veterans Affairs Committee knew problems in 2003

If you read back on transcripts from the Veterans Affairs Committee, you can see there were problems already known way back. This one from 2003 was a clear indication of what the veterans were heading into. The problem was no one did enough about any of it. Now they are trying to play catch up but they need to try a lot harder or we'll be reading about the problems they knew about five years from now and scratching our heads as to why so little was done to face them and correct the problems.

DEPARTMENT OF VETERANS AFFAIRS
HEALTH CARE SYSTEM
WEDNESDAY, JANUARY 29, 2003
HOUSE OF REPRESENTATIVES,
COMMITTEE ON VETERANS’ AFFAIRS,
Washington, DC
The committee met, pursuant to call, at 2:12 p.m., in room 334,
Cannon House Office Building, Hon. Christopher H. Smith (chairman
of the committee) presiding.
Present: Representatives Smith, Simmons, Brown of South Carolina,
Boozman, Bradley, Beauprez, Ginny Brown-Waite of Florida,
Renzi, Evans and Filner.

OPENING STATEMENT OF CHAIRMAN SMITH
The CHAIRMAN. The committee will come to order. Good afternoon.
Last night President Bush reported that the State of the Union
was strong. Today we will examine the state of veterans’ health
care to see if it is equally strong.
Only days ago the Department of Veterans Affairs announced
that for the first time it would use its authority to curtail new enrollments
for veterans’ health care. VA reported that at least, and
I emphasize at least, 200,000 veterans are waiting 6 months or
longer for their first appointment with a VA doctor, and that estimate
doesn’t count those still waiting to enroll in the system. Many
of those waiting are 100 percent disabled and paralyzed veterans.
In fact, when Secretary Principi sent one of his deputies, Gordon
Mansfield, a decorated Vietnam veteran paralyzed in combat, to try
and enroll in VA health care, he was turned away in state after
state due to overcrowding.
Earlier this month Chairman Buyer and committee staff visited
one medical center in Florida and discovered that over 2,700 veterans
are waiting to be scheduled to see a VA audiologist, over 4,000
veterans are waiting to see an eye specialist, and almost 700 are
waiting to see a cardiologist. More than half of these veterans were
high-priority veterans in categories 1 through 7. All reports indicate
that a similar situation exists at a majority of VA medical centers
throughout the country. Care delayed, I would respectfully
submit, is care denied.
At the same time there remain at least 275,000 homeless veterans
who—and that is a VA estimate, the VSO has put the number
even higher—who desperately need a helping hand, yet VA is unable
to fully fund programs that Congress approved less than 2
years ago. The VA has closed over 1,500 long-term care beds at a
time when World War II and Korean War veterans are most in
need of assistance. Despite an increase in the number of veterans
who have service-connected mental illnesses such as post-traumatic
stress disorder, VA is providing less care overall than it did in previous
fiscal years. And most troubling of all, according to the VA’s
own published documents in the Federal Register of January 17,
the VA will be short, $1.9 billion in their health care budget for
this fiscal year, and that assumes that the VA will receive the full
$23.9 billion for health care approved last year by both the House
and the Senate Appropriations Committees.
Let me emphasize what I just said. The VA projects that it needs
other $1.9 billion this year to meet the health care needs of veterans
already enrolled. To put this in perspective, $1.9 billion is the
annual cost of providing care to roughly 422,000 veterans from all
priority groups, veterans who are already in the system.
How does the VA plan to make up the difference this year? The
only proposal to date is the freeze on enrollment of new priority 8
veterans, a move that the VA projects could save at most $130 million
this year.
Some have suggested that Congress is to blame for the shortfall
in funding for the veterans’ health care, but the record over the
past 5 years is clear that each Administration request has been a
budget floor, while Congress has added funds above the request
each and every one of those years. For fiscal year 2003, the Administration
requested a 6 percent increase. The House passed and the
Congress is expected to approve an 11 percent increase. That is $1
billion above the VA budget request. Over the past 5 years Congress
has consistently provided greater funding than was requested
by the Administration, on average over $300 million each year. In
addition, last year Congress passed a supplemental appropriation
that included $417 million for VA health care. Regrettably, the Administration refused to accept $275 million of that supplemental targeted for veterans’ medical care.
Others have suggested that the VA’s problems are driven by enrollment
of veterans who were not injured during their service, socalled
lower-priority veterans in category 8. However, it is clear
that even if VA had never offered priority 8 veterans the opportunity
to receive care from the VA, it would still be swamped with
service-connected and low-income veterans who are in the high-priority
categories.
According to the VA, the number of high-priority veterans enrolled
in VA health care is projected to rise by 384,000, or 7.5 percent
this year, and by 281,000 next year. A total of 5.8 million
high-priority veterans will be enrolled for VA health care next fiscal
year, and this trend will not diminish for several more years.
The word ‘‘crisis’’ is often overused in this town, but clearly VA
health care is in crisis, the funding of VA health care, and it is at
a crossroads. Last year I, along with my good friend Lane Evans,
offered several bills seeking long-term solutions to VA health care
funding problems. H.R. 4939 would have allowed the VA to be reimbursed
by Medicare for providing care to Medicare-eligible veterans.
H.R. 5250 would have made VA health care funding a formula-
driven budget item, based upon demand and medical inflation
rather than a discretionary budget item. H.R. 5392 would have al3
lowed the VA to recover costs of medical care from third parties in
the same manner as if VA were a preferred provider organization.
And finally, H.R. 5530 would have enhanced the right of the VA
to recover payments from third parties for providing non-serviceconnected
care.
We are again preparing to introduce legislation on a bipartisan
basis to provide long-term solutions to VA’s funding problems, but
before we can arrive at solutions, we first need to agree on the nature
and scope of the problems. For some, the Secretary’s decision
to cut off enrollment of 164,000 category 8 veterans was a solution.
To me and many others it is a problem.
So I return to the central question of today’s hearing: How well
is VA fulfilling its statutory mandate to provide the full range of
health care services that veterans have earned? Are service-connected
disabled and paralyzed veterans receiving timely and comprehensive
care, including access to the latest advances in medicine
and technology? Is VA meeting its obligations to indigent veterans,
those who have fallen on hard times, including those suffering from
drug addiction and mental health problems? How about our elderly
veterans? Many who fought on the beaches of Normandy or in the
forests of the Ardennes, and the across the frozen Chosin Reservoir,
are they receiving the long-term care Congress mandated
for them in the Millennium Health Care and Benefits Act of 2000?
(Which again, was passed by a previous Congress and remains to
be adequately acted upon by the administration).
Many of you have heard of the American Legion’s project called
‘‘I Am Not a Number.’’ It is helping to put a human face on veterans’
health care issues rather than just focusing on numbers such
as budget allocations and enrollment projections. It reminds me of
a saying often used by Mark Twain, and it is quite appropriate for
today’s hearing. Twain said there were three kinds of lies: Lies,
damn lies, and statistics. I think that Mr. Twain and the American
Legion have it right: Veterans are not numbers, their health is not
a statistic, and our Nation’s debt to them must be more than just
words. We can do better, and I do believe we will.
[The prepared statement of Chairman Smith appears on p. 45.]
The CHAIRMAN. I would like to yield to Mr. Evans for any opening
comments he might have.

OPENING STATEMENT OF HON. LANE EVANS, RANKING
DEMOCRATIC MEMBER, COMMITTEE ON VETERANS’ AFFAIRS
Mr. EVANS. Thank you, Mr. Chairman and members of this committee.
I welcome the new members of the committee who are joining
us for the first time today.
I am also deeply disappointed to learn that Secretary Principi
had recently decided to bar those highest-income veterans who had
not already enrolled for care from applying for VA services. I was
particularly disappointed, Mr. Chairman, given our bipartisan recommendation
to the Budget Committee to increase the President’s
request for VA funding levels fiscal year 2003 by $2.2 billion. Unfortunately
the appropriation that is before us is below that level
and will only aggravate the VA’s health care problems.
But, Mr. Chairman, there is a solution. You and I introduced
H.R. 5250, the Veterans Health Care Funding Guarantee Act of
2002, which would have established a mandatory funding stream
for the VA health care.
I want to reaffirm my commitment and ask for yours in working
together to address any obstacles that have been set in our path
in getting this legislation reintroduced in the near future. I look
forward to working with you, Mr. Chairman.
I yield back.
The CHAIRMAN. Thank you for your comments.
[The prepared statement of Congressman Evans appears on p.
46.]
The CHAIRMAN. I would like to introduce our very distinguished
Under Secretary for Health, Dr. Robert Roswell, who was confirmed
by the Senate on March 22, 2002. Dr. Roswell has directed
the VA’s health care network for Florida and Puerto Rico since
1995. Dr. Roswell previously held positions as Chief of Staff at the
VA medical centers in Birmingham Alabama, Oklahoma City; and
held leadership positions in other VA facilities and VA central office
in Washington.
He is a 1975 graduate of the University of Oklahoma School of
Medicine, where he completed his residency in internal medicine,
and a fellowship in endocrinology and metabolism.
Dr. Roswell served on Active Duty in the U.S. Army from 1978
to 1980 and is currently a colonel in the Army Reserve Medical
Corps.
Thank you for being here. We look forward to your testimony.


STATEMENT OF HON. ROBERT H. ROSWELL, M.D., UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS
AFFAIRS

Dr. ROSWELL. Mr. Chairman, members of the committee, I am
pleased to be here today to discuss the challenges facing VA in
meeting the current demand for VA health care services. With your
permission, I will provide a brief summary of my formal statement
and ask that the formal statement be included in the record.
Today’s VA health care system is one of the most effective and
successful health care systems in the Nation. VA’s performance
now surpasses many government targets for health care quality as
well as measured private sector performance. For 16 of 18 indicators
critical to the care of veterans and directly comparable externally,
VA is now the benchmark for the entire Nation. VA is also
leading the way in assuring safe health environments and health
care delivery, and we are continuing our efforts to achieve additional
cost efficiencies.
Today VA has nearly 1,300 sites of care and is providing care to
nearly 48 percent more veterans than in 1997. At the same time
we have reduced the cost of care per veteran by 26 percent through
more efficient and effective care delivery.
VA continues to place a strong emphasis on comprehensive speciality
care, but we now also emphasize coordination of care
through primary care providers. With this transformation, and by
employing new models of care coordination and delivery, veterans
have gained access to an integrated health care system focusing on
addressing their health care needs before hospitalization becomes
necessary.
Mr. Chairman, while the changes in the VA health care system
have been profound, and the benefits have been recognized both inside
and outside the Department, we also face significant challenges.
VA is currently experiencing an unprecedented demand for
health care services. We had nearly 800,000 new enrollees in fiscal
year 2002 alone, and currently we have almost 6.6 million veterans
enrolled. We currently project that we will provide care to 4.6 million
veterans this year. This represents a 70 percent increase since
1996. Continued workload growth of this magnitude is clearly
unsustainable within VA’s current level of available resources.
As discussed in my formal statement, VA has taken steps to assure
priority access to service-connected veterans, veterans who are
poor and those with special needs.
And recently we announced our decision to suspend enrollment
of new Priority 8 veterans. We did not reach this decision easily.
However, it was a decision that had to be made in order to maintain
the quality of health care we provide to currently enrolled veterans
and those higher-priority veterans who have yet to enroll,
and to assure that our system will be ready and able to meet any
and all needs of veterans of a future conflict, should one occur.
The Secretary has also announced that work is under way with
the Department of Health and Human Services to determine how
to give Medicare-eligible Priority 8 veterans who cannot enroll in
VA’s health care system access to a VA+Choice Medicare plan
which would include prescription drug benefits very similar to the
type of plan the President mentioned last evening. Our goal is to
have this option available by the end of the year.
During much of the past year, we have had over 300,000 patients
on waiting lists to receive medical care. Currently, about 200,000
veterans are on those lists. VA has made concerted efforts to reduce
waiting times and eliminate excessive waits. With the additional
funding requested for fiscal year 2003 and the enrollment decision,
we expect to significantly reduce these waits this year.
We must also continue to find better ways to deliver care. We
need new ways to partner with patients to more effectively manage
health care continuously. This approach will involve a fundamental
change in how we view health care from a provider-centric to a patient-
centric focus. Implementing this approach will have a substantial
impact on primary care, but an even more profound impact
on long-term care. Institutional long-term care is very costly and
may impair the long-term spousal relationships and reduce quality
of life.
The technology and skills exist to meet a substantial portion of
long-term care needs in noninstitutional settings. Nursing home
care should always be the option of last resort.
To oversee many of the initiatives needed to implement a new
patient-centered model for care in long-term care, I have created
the new Office of Care Coordination. This office will have in its
charge such issues as the use of technology and care coordination
and the development and implementation of policy and initiatives
for chronic disease management and long-term care.
But while there is much that VA can do on its own, we also need
the committee’s assistance. For more than 30 years VA has developed
a continuum of institutional and noninstitutional services to
meet the extended care needs of veterans, including VA-provided
contracted and State home services. I believe that the capacity requirement
included in the Millennium Act should be updated to reflect
VA’s current direction in the provision of all types of long-term
care.
We also need your help to assure VA’s ability to remain competitive
in pay and work force innovations. We expect to experience
increasing difficulties in the year ahead in maintaining our nursing
work force, and we currently expect to face severe challenges in recruiting
physicians, especially in scarce specialties. VA’s current
pay authorities are stretched to the maximum and the Department
can no longer offer competitive salaries for many medical
specialties.
We are developing a comprehensive work force improvement proposal
that would improve our ability to recruit and retain physicians,
nurses and other health care occupations. The administration
expects to submit this proposal by late spring of this year.
Mr. Chairman, the current state of VA health care is excellent.
We have—but we have much to do to maintain and build upon that
excellence. My vision of the future of VA health care is positive, but
we must deliberately address the challenges I have outlined today
or risk a very different future.
This concludes my statement. I will be happy to answer any
questions you or other members of the committee have. Thank you.
[The prepared statement of Dr. Roswell appears on p. 56.]

The CHAIRMAN. Thank you very much Dr. Roswell.
Let me just begin by congratulating you on a very, very difficult
job that you have undertaken. I think you do it with great passion,
but unfortunately, you get handicapped by the resources that you
have at your disposal and fault for that certainly can be spread in
a number of areas. OMB always comes to mind. Congress comes to
mind. I mean, it seems to me that our endeavor needs to be to
marry up the need with sufficient resources so that rationing, however
unwittingly, doesn’t happen.
In the Secretary’s interim final rule, if I read the numbers correctly,
is how we derive that shortfall of $1.9 billion. I hope that
you work with us, notwithstanding OMB’s direction, to try to get
that additional money.
I know the appropriations bill is moving, and it won’t even come
close to meeting that. But supplementals are something that happen
frequently, or at least maybe once a year, and it seems to me
that once again, the veterans are voting with their feet. They are
choosing VA health care because of the services provided, in some
cases because of the pharmaceutical benefit which is significant for
the category 7s and 8s. But the sense is that there is a good health
care delivery network. They want to be a part of it. The CBOCs
have made it possible as access points for many veterans who may
not have even thought of it before to now become consumers of veterans’
health care.
As you and Secretary Principi have so ably pointed out, especially
for our senior population, it is a good deal for the government
when they use VA health care—25, 30 percent less per capita per
patient than if they used a Medicare provider in a more traditional
sense or setting. It seems to me that when Uncle Sam, this spigot,
Medicare or some other spigot, or General Treasury funds, is paying,
we can’t a case that we get a better utilization of our tax dollar
going into VA health care. I continue to be baffled. Why we can’t
make that case sufficiently to get these resources?
And so, generally you know where I’m coming from, because we
have had this discussion, but I hope maybe you can just speak to
it a little more and maybe talk about the $1.9 billion—is that the
shortfall for this coming year? Are we reading these papers
correctly?
What is the estimation going forward? I know the budget has not
been submitted yet. We will have our budget hearing, but give us
a sense of what kind of resources, year after year, we are going to
need to meet the need.

Dr. ROSWELL. Well, thank you, Mr. Chairman.
Using an actuary’s full-demand projection model, the 1.9 billion
shortfall you spoke about is roughly correct. But it is important to
understand, as much as I support and appreciate your advocacy for
veterans and your leadership in this committee and your tireless
efforts to generate the resources that are needed to provide care,
at this point in time it is more than simply resources. We have
reached a point with our VA health care system where the fundamental
nature of the system has shifted because of recent demand
for care and years of chronic underfunding.
Today we must rebuild the system. We have to hire new physicians,
new specialists and new nurses, and we have to go back and
reexamine our tertiary care capability. We have had tremendous
demand for care, for pharmaceutical benefits and for outpatient
care. But over half of the new enrollees in the system have sought
just prescription drug benefits.
That shifted precious, limited resources away from our tertiary
care mission. It has created primary care clinics and prescription
drug delivery systems that are not at the fundamental nature of
our core system.
If, God forbid, we have a war with Iraq, and if we have, God forbid,
new veterans returning with combat-related disabilities and
injuries, we must have in place the tertiary care system that will
meet those full and comprehensive needs. I’m sorry to say, Mr.
Chairman, that today we don’t have those specialists and we have
underfunded and neglected the tertiary medical equipment needs
that will create such a system to meet that need.
We need a standdown. We need time to recruit specialists to
bring on new capacity and to rebuild and replenish our tertiary
equipment capability.

The CHAIRMAN. I think you make our case, though, Dr. Roswell,
that funds are policy. I mean, notwithstanding the enrollment moratorium
that Secretary Principi—and he has fully had the discretion
to do so; I think he did so in very good faith, even though I
disagree. But I think he has the veteran at heart and especially,
you know, the service-connected and the indigent veteran. But it
seems to me that chronic underfunding in the past should not become
perpetual. We need to break that cycle and break it decisively.
And why not in the 108th Congress? Why not now? If not
us, who?
My question is: with this budget that we will soon get, knowing
that we have a $1.9 billion demand-model shortfall for this year,
won’t that only get exacerbated as we move forward?
Please work with us because we are only one part. I mean, half
of our budget is mandatory, thank God, and that is why when we
do a GI bill, it does get fully funded because it is mandatory. And
the benefits work that our new Chairman Brown will be working
on, so much of that is, if we do it, it happens. But, unfortunately,
the health care remains discretionary, and that has led to these
chronic shortfalls, as you describe them.
But let’s not let the past, I would respectfully request, color our
future. We need sufficient resources and we will fight and the Administration
can put the marker down.
Last night I was very proud of the President on the AIDS crisis.
I am on the International Relations Committee; I am Vice Chairman
of it. We have been working to get an AIDS bill passed that
will put more money, especially in Africa where you have an explosion,
25 to 30 million people carrying the HIV virus within their
bodies. And that will only get worse; you need to put a tourniquet
on that. And the President announced a $10 billion increase for
that, $15 billion in total.

It seems to me that we have a chronic shortfall, and it goes
through previous Administrations, no doubt about it. Congress
ponied up more money, but not enough. We can break that cycle
now and do it in a bipartisan way. The Presidential Task Force—
and you might want to speak to that, and then I will yield to my
colleague for any questions he might have—will be making its
recommendations.

I know they are looking at the mandatory scheme and other
schemes as possible solutions. I would hope that maximum input
would be made that what they produce won’t be like so many GAO
reports that get put on the shelf and nobody ever acts on it. We
need a real change now, and I think the time has come.

Dr. ROSWELL. Thank you. Certainly we have worked and continue
to work closely with the Presidential task force. We don’t
know what their final recommendations will be. But let me tell you
that the concept of a VA+Choice benefit that the Secretary recently
announced actually had its genesis, its beginning, in discussions
with the chairperson of the Presidential task force, Gail Wilensky,
the former HCFA Administrator.
So we have been maintaining very close communication with the
Presidential task force. We are working to implement concurrently
many of the areas of interest and many of what we believe will be
their recommendations. Clearly, I think their interim report
showed that to maximize VA-DOD sharing we have to improve access
to the VA health care system which is, in large measure, resource-
related. But at this point, because we have saturated our capacity,
we also need time to hire those physicians and nurses. And
in the health care field, the time to recruit and bring on additional
health care professionals can sometimes be lengthy.

The CHAIRMAN. I see my time is up, so I yield to Mr. Evans.

Mr. EVANS. Thank you, Mr. Chairman. I have a disturbing question
to ask.
If we are already in debt to a great degree and are not providing
enough funding for the next fiscal year, how are we going to have
enough if this war gets very heated and starts costing us casualties.
Particularly since a lot of the same people who are serving as
backfill are often the supply troops behind our lines?
Do you have any comment about that situation?

Dr. ROSWELL. Well, Congressman Evans, I share your concerns.
As many as 8 percent of VA personnel could be deployed with a full
deployment, and that would create a critical shortage of very vital
health care professionals at a time when we most need them. I
don’t have any solutions, but I can tell you that we are eager and
ready to begin an active recruitment program. If we receive the
2003 appropriation in the near future, we will activate that full effort
to bring on a substantial number of additional nurses, as many
as 1,300 additional nurses this fiscal year, as many as 500 additional
physicians.
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