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THE LEGISLATIVE PRIORITIES OF

THE BLINDED VETERANS ASSOCIATION

PRESENTED BY THE NATIONAL PRESIDENT

ELIZABETH R. CARR

BEFORE THE HOUSE AND SENATE

VETERANS’ AFFAIRS COMMITTEES

FEBRUARY 26, 1998

I. Introduction

Mr. Chairman, Members of these distinguished Committees, I am very proud to have the opportunity as the first woman president of the Blinded Veterans Association (BVA) to present our 1998 Legislative Priorities. As you may recall, in 1995 BVA celebrated its 50th Anniversary of continuous service to our nation's blinded veterans and their families. In our written statement we presented a brief history of BVA and detailed some of our accomplishments during the last five decades. We are extremely proud of our contributions to improving the welfare of blinded veterans. All too frequently, we hear BVA is the best kept secret in the veterans’ community. Consequently, we utilized our annual testimony as an excellent opportunity to share BVA's story with these Committees, especially the new members.

II. Background on Hines Blind Rehabilitation Center

Mr. Chairman, 1998 is another very special year. It marks the 50th anniversary of both the establishment of the first VA Blind Rehabilitation Center (BRC) at the Veterans Affairs Hospital, Hines, Ill., and of VA Blind Rehabilitation Service (BRS). If I may Mr. Chairman, I would like to take a moment to briefly relate the history of the Hines BRC. It is important these Committees are aware of the tradition of excellence established at Hines and ultimately introduced to eight other VA facilities around the system. The Hines BRC has made astounding contributions to the field of blindness. Congress and particularly these committees can be very proud of the rehabilitative care authorized and funded for our nations blinded veterans.

At the end of World War II, neither the VA nor the military provided comprehensive blind rehabilitation for the service men and women blinded in combat. They medevaced most soldiers blinded in the European theater to either Valley Forge Army Hospital in Valley Forge, Pa. or Dipple Army Hospital in Calif. In the absence of any formalized program for the blind, these facilities could only experiment with the notion of blind rehabilitation. Following recovery from their wounds, they transferred many blinded soldiers from Valley Forge to Avon Old Farms Army Convalescence Home in Avon, Conn. for rudimentary blind rehab training. Again, a comprehensive approach to rehabilitating these veterans was not in place. It was during this time that approximately one hundred blinded veterans assigned to Avon Old Farms organized BVA. From our inception, BVA strongly advocated the establishment of a comprehensive blind rehabilitation program. Our efforts culminated in VA accepting the responsibility for the care and rehabilitation of blinded veterans. These efforts led to the establishment of the first comprehensive residential blind rehabilitation center at Hines VA Hospital.

When the Hines Blind Rehabilitation Center opened in July 1948, it was a small nine beds residential center. The first chief of the new center, charged with the task of developing a comprehensive rehab program, was a war blinded veteran himself. Armed only with his experiences with blindness and a thorough understanding of what a newly blind person’s rehabilitative needs, he carefully selected his staff from therapists assigned to the Corrective Therapy section of Physical Medicine and Rehabilitation Service. Although the applicants had no knowledge or experience with blindness, these individuals voluntarily applied for positions working with blinded veterans. It is important to note here most of these individuals were veterans themselves from WW II. From a nucleus of five therapists, the new chief developed and refined the techniques still used today safe and independent blind travel using a long white cane. This small and dedicated staff also worked to provide the necessary services to rehabilitate blinded veterans. They developed, tested and perfected many new and innovative techniques that significantly enhanced the lives of newly blinded veterans. Gradually new services were added to the program including other ancillary professional disciplines such as psychologists, social workers and nurses. These pioneers understood from the outset that adjustment to sight loss was psychological and physical. Furthermore, they were sensitive to the devastating impact of sudden and traumatic vision loss. Therefore, they created a rehabilitative environment that would be responsive to both the physical and psychological components of blindness. They quickly discovered that the most effective methodology was an intensive course of rehabilitation in residential setting.

From this modest beginning, the comprehensive residential Blind Rehabilitation Center featured an interdisciplinary team approach to service delivery. They found that this method was the most effective method for helping blinded veterans in overcoming the handicap of blindness. Most of these blinded veterans were young and needed employment following rehabilitation, so they developed a prevocational training model of blind rehabilitation.

The Korean War resulted in a large number of newly blinded service men and women entering the VA system, increasing the demands on the Hines BRC. To cope with the influx of patients, Hines was expanded. As the capacity of the program began to grow to meet the demand, so did the level of knowledge, expertise and innovation to more effectively assist blinded veterans through successful rehabilitation. Although the increased work load placed greater pressure on the professional staff, they continued to perfect and refine adaptive techniques and validate the effectiveness of the comprehensive residential rehabilitation concept. In fact, the model proved to be so successful that non-VA programs around the country and the world adopted the VA model for blind rehabilitation. They invited many Hines pioneer staff to foreign countries as consultants to assist in establishing blind rehabilitation programs similar to that of VA.

The mid-60s and the Vietnam war again placed new pressures on the VA blind rehabilitation system. Consequently, it became necessary to expand capacity to provide essential services. As a result, they established a new BRC at the VA Hospital in Palo Alto, Calif. in 1967 and at the VAMC, West Haven, Conn. in 1969. Additional facilities have been added during the years to reach the present total of nine.

It is important to note that the legacy of Hines has resulted in the establishment of university programs in blind rehabilitation. In the early 60's, Western Michigan University was interested in beginning a graduate program in Orientation and Mobility, the discipline to teach blind people to travel safely and independently with the long cane. As mentioned previously, this was a profession literally created and developed at Hines. It was only fitting therefore that one of the pioneer mobility instructors from Hines was chosen to head the new graduate level program. Subsequently, a similar graduate degree program was developed to train blind rehabilitation teachers. These are the professionals who teach braille, typing, and independent living skills such as cooking and other communication techniques for the blind. Soon after the graduate program was operational, an academic partnership with VA was created. VA now trains through academic affiliations, many rehabilitation specialists serving blind people in America.

Despite the incredible successes the residential rehab programs were experiencing, many blinded veterans were not taking advantage of these outstanding services. VA learned that blindness can often be an extremely isolating disability and veterans do not actively seek assistance but rather remain in their home dependent on others for their care. Frequently, they have been stripped of all self confidence and worth, feeling completely overwhelmed, not knowing where to turn. Seeking a solution to overcoming this aspect of blindness, VA engaged in a pilot project with the American Foundation for the Blind (AFB) and the BVA establishing an aggressive outreach program. That effort has become known as the Visual Impairment Services Team (VIST), an interdisciplinary team approach to the delivery of comprehensive services to blinded veterans and their families. Much more will be said about this vital program later, but It is important to note the historical significance of another example of the pioneering efforts undertaken by VA to help blinded veterans overcome the handicaps of blindness is important.

Thanks to the commitment of Congress and the Department of Veterans Affairs, VA is the premier provider of blind rehabilitation services in the world. More important, this success story is largely due to the extraordinary commitment and dedication of the pioneer staff at the Hines Blind Rehabilitation Center 50 years ago. They represented everything that was good in our country and the VA system. Those of us who have benefited from the services provided by VA will be eternally grateful.

Before concluding my reflections on the 50 years of outstanding rehabilitative service provided by the Hines Blind Center, I want to explore the future of that wonderful facility. As some of you may recall, several years ago, a Chicago Network Strategic Plan was surfaced that proposed relocating the HBRC to VAMC Westside Chicago. The basis for this recommendation was a very suspect architectural firm space evaluation report that indicated the buildings housing the HBRC would not be suitable for patient care after the year 2003. A firestorm of protest erupted from not only the BVA but the Hines Blind Center Alumni and hundreds of blinded veterans who had received their rehabilitative training at the Hines facility. As a result that plan was scrapped but to our knowledge no definitive plans have been developed to address the problems identified in the flawed structural review. Several committees have been appointed to review the situation and make recommendations but it appears a conflict exists between the needs of the Hines VA Hospital and Veterans Integrated Service Network (VISN) 12. BVA has participated in the committees that have studied the potential problems but is frustrated with the lack of formalized planning. Mr. Chairman, the blind center does not just serve one medical center or just one VISN. Typically, they serve multiple networks and all the facilities within those networks. Therefore, decisions regarding staffing, space and general support for any BRC must be made in the larger context of a national program. Moreover, funding of the specialized programs must also take these factors into consideration when allocating resources to support such critical programs.

Several options have been placed on the table for review with respect to addressing the need for new space at Hines for the BRC. It should be noted that Spinal Cord Injury Service (SCI) has also been involved in these deliberations because of similar space needs. The first and most desirable option would be to construct a new replacement facility on the Hines campus to house the BRC. A second option would be to construct a new multipurpose building housing the BRC, SCI Rehabilitation Research and Development activities and possibly neurology. A third option would be to move the BRC into existing available space somewhere else in the hospital. The final option would be to renovate the existing BRC buildings bringing them up to code. The third and fourth options do not seem workable. Trying to move the BRC program into non contiguous space as has been mentioned, would fragment the therapeutic environment that has proven so successful in the past. The renovation option would probably be cost prohibitive and extremely disruptive to the program.

We are very skeptical if a single network or a single facility within a network will be willing or capable of the planning or decision making that is needed for specialized programs that service multiple Networks and facilities. It does not appear strong centralized direction and support exist to insure that the national scope of the programs are protected and enhanced when necessary. In our view the management of the specialized programs is an over-arching issue within the context of the Network concept characterized by decentralized decision making. From the onset of the VHA Reorganization, BVA has questioned the feasibility of managing the special disability programs within a managed primary care model of health care delivery. As the network concept draws nearer to full implementation, our concerns are only heightened given recent decisions made at the local and network level.

III. NEW VHA

Mr. Chairman, one of the primary goals of BVA in presenting our legislative priorities before these Committees is to provide an update on the status of blinded veterans in America. The fundamental challenges confronting the Department of Veterans Affairs (DVA) to provide high quality benefits and health care services in a timely manner as we approach the 21st century are truly profound.

Like all other federal departments and agencies the fiscal environment in which VA will be required to operate causes great concern. The prospect of diminishing resources accompanied by an increase in the demand for service will make it increasingly more difficult for VA to provide essential services to our nation's veterans. Along with our sister Veterans Service Organizations (VSOs), BVA recognizes the need for and applauds the efforts of VA to re-engineer and reorganize itself to become more cost efficient and effective in the delivery of services. Clearly, failure to accomplish meaningful streamlining and reorganization will surely result in the total breakdown of the VA system as we know it. Reorganization, however, should not result in the dismantling of essential programs and services that have proven their value. We realize this presents significant challenges for VA managers who must find substantial savings and efficiencies without crippling VA's ability to meet the special needs of veterans.

BVA has been generally supportive of VA efforts to move away from the old organizational stove pipe mentality. It is imperative, the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA) and the National Cemetery Service (NCS) work closely to insure the smooth delivery of benefits and services. VA must have the capacity for the various elements of the department to communicate quickly and efficiently if the overall goal of efficient quality service delivery is to be achieved. Fundamental to this effort is integrating state of the art technology and information management systems throughout the department. Each element of the department must have the ability to communicate electronically as well as work closely together on a personal basis. Failure in the past to plan strategically by anticipating the needs for change and the increased dependence on state of the art Information resources Management systems has clearly impaired the most efficient utilization of resources frustrating Congress and veterans alike. Finally, it appears VA is progressing in a cohesive integrated manner towards achieving strategic goals but cannot afford to have resources withdrawn or severely constrained at this crucial juncture. Failure to provide adequate funding will certainly insure that VA fails to complete the necessary re-engineering and reorganization provide those benefits and services veterans have earned and so richly deserve.

Blinded veterans, possibly more than any other segment of the veterans population, are very upon the VA system of benefits and services. Unemployment among the blind is extremely high despite the Americans With Disabilities Act (ADA). Consequently, disability compensation and pension are absolutely vital to financial security for these veterans. Additionally, access to high quality health and rehabilitative services are essential if severely disabled veterans are to be fully integrated into their families as contributing members of society. It is for these reasons BVA is so vitally interested in and concerned over many of the contemplated or implemented changes in VA programs that directly impact of blinded veterans.

As we have testified in the past, BVA has been very supportive of VHA reorganization. We shared the view that if VHA did not change the manner in which they delivered health care, VA would be unable to continue providing health care to our nation's veterans. Dependence on an acute hospital based delivery system was not only contrary to preferred medical practice, but extremely cost inefficient, especially in light of diminishing financial resources. Therefore, the decision to transition from the antiquated hospital based acute medical care to managed primary care was long overdue. The goal of increasing access to higher quality and quantity of health care for veterans as articulated by Dr. Kenneth Kizer, Under Secretary for Health, seems to command a lower priority for local managers. Unfortunately, it appears many of their decisions are being driven solely by the bottom line rather than increased access to improved quality care. Achieving cost savings seems to be their only mantra. Before detailing specific examples effecting specialized programs and services for blinded veterans, Mr. Chairman, let me say again, BVA supports the goals of the reorganized VHA and believes substantial cost savings can be realized without dismantling or otherwise destroying effective programs.

VHA is clearly receiving appropriated dollars to operate its health care system. Consequently, VHA must be accountable to the Congress and ultimately the tax payers. As a result of the balanced budget agreement achieved last year between the administration and Congress, VA will be forced to operate with a straight line budget in the out years of that agreement. There is no question that VA officials as well as veterans have great concerns about whether VA will be able to survive in that fiscal environment. In anticipation of that diminished level of funding support, VHA managers, particularly those in the field, are striving to identify major cost savings. Various working groups at the facility as well as the network level have been convened to find cost savings in all programs and services. The problem with this approach is that number crunchers, not clinicians are making programmatic decisions without any knowledge of the programs or services they are proposing to reduce or eliminate. In most cases, program officials are not consulted with or involved in the decision making process. They are not asked for input into the process but expected to implement mandates regardless of the impact on their programs. As if this wasn't bad enough, these same program officials are branded as not being team players if they question program changes mandated by management. Management by intimidation will not result in high quality programs and services and surely will only foster low employee morale and apathy toward VA's mission.

BVA does not argue that a concerted team effort must be undertaken to achieve desired goals and objectives provided it is truly a team effort. This means all team members must have equal opportunity to have input in the decision-making processes effect any VA service. Management cannot ignore or exclude program officials or subject matter experts when programs are subject to review for the purpose of uncovering cost savings. Program managers, and we include blind rehabilitation officials, must be challenged to engage in an honest concerted effort to identify cost savings without compromising quality care. We cannot emphasize enough that latter statement about compromising the quality of the program.

It seems perfectly clear that when facility or Network fiscal managers are tasked with achieving cost saving review budgets, they only look at the bottom line figure in the aggregate and by individual programs. When any program stands out as being expensive, such as blind rehab, it is targeted for cost savings. The only objective is to reduce the cost of the particular program without any knowledge or understanding of how the program operates, what its objectives are, what outcomes are being or expected to be achieved or what professional resources are necessary to provide those services. Two specific examples come to mind: one, a blind rehab center has been told that must reduce the average length of the program by eight days. The justification for the requirement is to reduce cost regardless of whether the rehabilitative needs of the veterans are being met. How long a blinded veteran needs to be in a blind center is a clinical decision that must be made by competent blind rehab professionals not budgeteers or unqualified administrative officials. The length of stay is also directly determined by the individual veteran, his capacity to learn new skills and gain confidence in his ability to integrate these skills into his daily activities. As we all know, everyone does not learn at the same rate. Historically, the VA Blind Rehabilitation Program has provided blinded veterans with sufficient time and repetition in training to allow the veteran not only to acquire but master a given skill. As I am sure you can imagine, being introduced to an adaptive technique or skill is not the same as mastering its application sufficiently to gain a reasonable level of confidence in one's ability to utilize that skill on a daily basis. The other major contributing factor to length of stay is now quickly a veteran is able to make the emotional or psychological adjustment to sight loss. Acquisition of skills is of no value if the veteran has not achieved a healthy level of adjustment. A blinded veteran who remains chronically depressed about his blindness or cannot accept himself/herself as a blind person will certainly not utilize learned skills. These individuals tend to return home and resume a very withdrawn and dependent life style. The adjustment aspect of the residential Blind Rehabilitation Program in many ways is the most critical factor. Unfortunately, it is also the most intangible in terms of measurement. From a cost benefit stand point, artificially reducing the length of stay in the program will only result in veterans not making the necessary adjustment to sight loss or acquire the essential adaptive skills to assist in overcoming the handicap of blindness. It has been proven during the years, blinded veterans having the opportunity to live with other blinded veterans on a daily basis while undergoing intensive rehabilitation optimize that individuals adjustment to his visual loss. The intensity of the residential program clearly facilitates adjustment along with skill acquisition. One Network director has been quoted as saying VA blind rehab is antiquated. We believe he is referring to the residential or inpatient model. He seems to be insisting that blind rehabilitation services should be provided on an outpatient basis consistent with the transition to outpatient based managed primary care.

Dr. Kizer has repeatedly stressed that his vision of the VA health care system is one that is driven by outcome measures. Decisions, therefore on clinical programs should be based on outcome measures which validate the effectiveness and quality of that program. BVA subscribes to this approach for validating program effectiveness. VA BRS has developed Outcome Measures for the residential Blind Rehabilitation Program. Unfortunately, data has been collected for less than a year so sufficient data is not yet available for management officials to determine the effectiveness of programs and drive decisions regarding reductions of resources when appropriate. The outcomes data is potentially very powerful. The VA Rehabilitation Research and Development Center at VAMC Decater, Ga is coordinating the collection of this data and is working in collaboration with the private sector in the development and refinement of appropriate instruments for data collection.

We are confident that when sufficient data is available, it will validate the value of the residential blind rehab program in terms of desired outcomes as well as cost effectiveness. Preliminary data suggests that veterans with multiple medical problems are more capable of independently managing those problems, following Blind Rehabilitation Training thus reducing their dependency on VA for acute medical care. BVA has argued for years that blinded veterans who had access to blind rehab would be less likely to require hospitalization or nursing home care because of their blindness. Older veterans particularly are more susceptible to falling and incurring serious injuries that are expensive to treat. Providing proper rehabilitation training, however, woul significantly diminish the likelihood and frequency of falling.

The same BRC referred to above was advised to assist in achieving shorter lengths of stay, they should complete initial evaluations of blinded veterans over the phone prior to admission. This suggestion is blatantly absurd. Most blinded veterans have additional disabilities and or medical conditions that require management and monitoring during the rehab process. These additional complications affect the veterans ability to learn, adjust or acquire skills. Fine or gross motor coordination cannot be assessed or evaluated on the phone. Similarly, tactile discrimination, critical to learning braille or other adaptive skills, cannot be assessed over the phone. The VA Blind Rehabilitation Program is staffed primarily by Master Degree Blind Rehabilitation specialists. These professionals are extensively trained to evaluate and assess a blinded person's needs and potential for rehabilitation. These same professionals also provide the training that will enable that individual blinded veteran to acquire the necessary skills to maximize his/her independence. I ask you, who should be making this kind of clinical decision, rehabilitation specialists or number crunchers? We believe the answer is obvious, but Mr. Chairman, it does not seem so obvious to field managers. The same facility managers are also strongly suggesting to the BRC manager that all applications for rehab be very closely scrutinized in an effort to screen out veterans just described above who might require a longer length of stay or utilize more medical resources during the rehab process. This sound to me like the private sector, for profit mentality, that is enroll only young, healthy people in the health care plan who will be unlikely to need or demand health care services.

As mentioned before, BRS managers should be challenged to try and identify or develop programmatic changes that might result in cost savings without compromising quality. I submit Mr. Chairman, BRC managers have undertaken this challenge and the statistics verify they have achieved significant changes resulting in substantial cost savings without compromising rehabilitation. Blinded veterans attending the residential BRC programs are evaluated and a individualized rehabilitation treatment plan is especially designed to address their needs. There is no mandated length of stay applicable to all blinded veterans. The length of stay is driven solely by need and the rate of progress necessary for the individual to acquire essential skills.

Another example of the kind of mentality operating in the field in pursuit of cost savings, is the BRC chief at a different facility was contacted by the facility Personnel Officer asking why the BRC could not hire two G.S. 5 blind rehab technicians rather than a G.S. 11 blind rehab specialist. I ask you Mr. Chairman would you want a physicians assistant performing open heart surgery on you? Of course not and why should blinded veterans be asked to have less qualified individuals providing essential rehabilitative training.

Still in another Network, local facilities are being encouraged not to refer blinded veterans to VA blind rehab programs in other networks but to refer these veterans to local providers. They apparently hope to accomplish two goals. One is to reduce the costs by forcing veterans to receive their training, presumably less expensive, outpatient basis rather than in an inpatient residential program. The other motivating factor may be an attempt to manipulate or game the Veterans Equitable Resource Allocation (VERA) model. While the examples sighted above are comparatively few, and do not appear to be systemic yet, we are deeply concerned they could very well represent a trend. If one facility or Network is successful in circumventing basic policy or guidelines disseminated by Dr. Kizer, it will not be long before others implement the same policies or practices. This view may sound overly cynical but we have had a lot of experience with this kind of resistance to national guidelines or directives from VA Headquarters. All too often, Network or facility managers have expressed their strong opposition to being micro-managed by Headquarters. Now that that decision making authority has been decentralized they can do whatever they believed to be in the best interest of their facility or Network. There clearly appears to be an adversarial relationship between the field and Headquarters. This relationship is nurtured by the field and seems to stem from long standing perception of being micro-managed by Headquarters.

Mr. Chairman, local or Network decisions that have adversely affected programs and services for blinded veterans are not limited to the residential blind centers as outlined above. Two outpatient programs critical to service delivery have been severely curtailed at some stations. Again this could suggest the onset of a unacceptable trend. The two programs in question are the Visual Impairment Services Team (VIST) and the Blind Rehabilitation Outpatient Specialist (BROS) program. I will provide more detail on each of these programs further in this statement, but suffice it to say decentralized decision making is clearly having adverse effects in a number of program areas.

Having detailed the above examples of decentralized management decisions, Mr. Chairman, BVA goes on record once again, by strongly urging the centralized management and funding of special disability programs be. We encourage and support the establishment of "National Guidelines" and "Performance Standards." If these programs cannot demonstrate through "Outcome Measures" and "Patient Satisfaction Surveys" that they are meeting expectations and functional outcomes then and only then should decisions be made to reduce or dramatically alter or eliminate the service delivery model. As stated above, VA BRS should and must be challenged to explore and develop new and innovative approaches to service delivery that might serve as an appropriate alternatives to the current model. Dismantling or forced reductions in the current rehabilitation methodology imposed by non-clinicians, are totally unacceptable in the absence of appropriate alternative delivery models. Following the publication of Dr. Kizer's "Vision For Change", BVA questioned the feasibility of operating the special disability programs in a managed primary care environment. We were assured however, this was possible although there were no examples in the private sector upon which to base this assurance. Given the examples outlined above, we now believe integrating these programs into the managed primary care model is proving more difficult than originally anticipated. At the very least Mr. Chairman, we recommend a moratorium be placed on any decisions that directly impact in the specialized programs such as reductions in resources or changes in service delivery until the VHA transition to outpatient care had been completed. Further, we believe any such decision should be delayed until functional outcome measures are developed, implemented and sufficient data is available to support any such decisions.

Although decentralized management authority may be the preferred management style by Headquarters’ officials, it does not exempt them from being accountable for how appropriated dollars are being utilized. All too frequently, Headquarters’ officials indicate they cannot be directive to the field nor interfere with the local or Network decisions. BVA does not believe this approach is responsive to the statutory mandates contained in the Eligibility Reform Act adopted by Congress last year. As you well know, that legislation is very specific in terms of the VA responsibility for maintaining the capacity to provide specialized services for disabled veterans. BVA applauds the hard work of these committees in crafting the ERA legislation including the provision to preserve and protect the special disability programs. We caution however that we are very suspicious of the reports you are receiving from Headquarters demonstrating they are in compliance with the law. We have received indications that critical definitions such as "capacity" previously agreed upon after consultation with the Secretary's Advisory Committee on Prosthetics and Special Disabilities Programs, are now being changed to support data being forwarded to these committees suggesting compliance. There continues to be great disparity in the manner in which data is collected from station to station and how that data is being reported to Headquarters. Unfortunately, data collection within VHA historically has experienced serious systemic problems. Genuine efforts are underway through enhanced technological capability to refine and validate this process. Our concern remains that decisions are being made in the absence of valid outcome data that have and will continue to have a devastating affect on the special programs. Most of these decisions, especially those reducing resources, will be irreversible. Once resources are eliminated they will never be restored.

IV. VA BUDGET

Before discussing the President's Fiscal Year 1999 budget request for the Department of Veterans Affairs, I would first like to comment on the FY '98 Budget for VA. BVA along with the other major VSOs were strongly opposed to the administration proposal, ultimately adopted by Congress, that reduced the VA core appropriation for health care. Contained within this request was a proposal to allow VA to retain all third party collections. The reduction of the core appropriation would then be offset by the retention of third party collections. While we are not opposed and indeed favor VA being allowed to retain collections from insurance companies for the provision of VA Health Care for the treatment of non service connected conditions, we are opposed to substituting these collections for appropriations. Our position regarding retention of third party collections is and always has been those receipts should be a supplement to not a substitute for core appropriations. We were grateful when Congress adopted a provision to safeguard VA in the event that collections did not reach the projected level resulting in a serious short fall in revenue for health care. That safeguard was legislated for only the FY '98 budget as we understand the process.

Turning to the Presidents FY '99 budget request for the Department of Veterans Affairs, BVA is extremely disappointed that for the third consecutive year health care is flat lined. We find this particularly disturbing given all the proposed new programs the President showcased in his State of the Union message. In fact, the word "veteran" or "VA" did not appear once in that statement. How can we consider making new promises and commitments to various segments of the American population without first assuring commitments already made are honored? We argue that should there in fact be a budget surplus, the VA core appropriation should be restored allowing VHA to retain third party collections as a necessary supplement. Arguably, many of the problems we outline in this testimony regarding specialized services, may indeed be directly related to inadequate funding levels forcing facility and Network managers to make more draconian reductions than otherwise would be necessary to achieve improved efficiencies. Forcing VA to rely on their a ability to collect from third party payers in order to provide earned benefits and services certainly does not represent a grateful nation.

Much attention has been focused on the processing of veterans’ claims and the tremendous backlogs. Congressional Hearings repeatedly seek answers to this chronic problem and have been stimulated by inquires at the district levels from frustrated veterans’. Each year, VA tries to report improvement in reducing the backlogs and progress towards modernization of the their information technology. Yet, the backlogs continue. Despite the continued existence of these delays in claims processing and the unacceptably high number of remands, the administration again fails to provide the necessary resources and manpower, to correct the problem. Disabled veterans, their surviving spouses and dependents deserve better. In an atmosphere of budget surpluses, more timely and accurate claims processing and adjudication must command a higher priority.

Although the budget request does provide a modest increase for the National Cemetery Service (NCS) it falls far short of current and future needs for a rapidly aging veteran population. Those Americans who have served honorably and indeed sacrificed for their country should have the opportunity for burial with dignity and honor in a national cemetery. This budget clearly does not provide that guarantee.

V. INDEPENDENT BUDGET

BVA is very proud to once again endorse the Independent Budget (IB), prepared by four of the major VSO's; Disabled American Veterans (DAV), Paralyzed Veterans of America (PVA), Veterans of Foreign Wars (VFW) and AmVets. BVA, along with many other endorsements, had an opportunity to participate in many of the preparatory sessions and had input into the formulation of this extremely important document. We trust these committees will read this document carefully because it contains many important and constructive suggestions regarding DVA and VA health care delivery. The IB outlines a clear blueprint for addressing VA medical care delivery, including reorganization and funding. BVA believes these suggestions are very sound and should receive serious consideration as the budget process moves forward.

VI. BLIND REHABILITATION SERVICE (BRS)

Mr. Chairman, I have already detailed many problems we believe exist within VHA BRS particularly as they relate to the comprehensive residential Blind Rehabilitation Centers. To date, all VA BRC programs are operating all their authorized beds. However this does not suggest that serious difficulties are not looming on the horizon. Several programs have lost Full Time Employee Equivalent (FTEE) blind rehabilitation specialist positions. Should additional reductions or freezes be imposed it is very likely capacity will be diminished. It is the high quality professional blind rehabilitation staff that has distinguished VA as the premier provider of comprehensive Blind Rehabilitation Services. Unfortunately, as mentioned above these are the positions management officials target for reduction to achieve cost savings. Maintaining a high quality program resulting in favorable outcomes is directly related to the quality of the professionals providing the care.

More blinded veterans have received comprehensive blind rehabilitation last year than ever before. Moreover, the length of stay has been significantly reduced to the point that length of wait is no longer an issue. These are truly remarkable achievements and have resulted in cost savings. At the same time the services have become more accessible to blinded veterans. For the most part, this has been achieved largely through the initiative of the BRS staff and not the result of artificially imposed limits. The unconscionable backlogs, we have complained about in the past, have been virtually eliminated. Much of this improvement can be attributed to changes in the blinded veteran population being served in the BRCs and the effectiveness of the professionals formulating individualized rehabilitation plans responsive to changing needs. They also reflect advancements made in technology available and adapted for blind people to enhance independent living. The residential blind rehabilitation program has evolved during the past fifty years to respond to changing needs. VA BRS retains the same pioneering spirit that produced the premier service model in the world. Clearly they cannot rest on their laurels and must continually be challenged to respond to changing needs with innovative high quality services. If this is to occur, the subject matter experts must be the architects of new delivery models not managers concerned only with the bottom line.

Above, I mentioned one Network director who suggested that VA BRS was antiquated and out of touch with modern medicine. We strongly disagree with this opinion but recognize the potential need to identify local providers that might supplement VA programs. Not every blinded veteran will agree to leave home to attend a residential blind rehab center or because of medical problems will not be able to leave home. An additional deterrent to attending a BRC is that more and more blinded veterans have spouses that have become disabled or ill and depend on the veteran who now has become the care-giver. These veterans continue to have needs however that must be addressed if the individual is to sustain a reasonably independent life style. To this end, it is incumbent on VA to identify qualified local providers to meet those needs. Before VA begins contracting such services, however, the local providers must be evaluated and determined to be capable of meeting VA standards for blind rehab and similarly achieve VA Outcome Measures. While we acknowledge that contracting for services might become necessary occasionally, we caution against large scale contracting for service. The inherent danger is wholesale contracting as another attempt to reduce cost without regard to the quality of service provided.

A. Visual Impairment Services Team (VIST) Program

The fundamental vehicle of service delivery to blinded veterans in the VA system is the Visual Impairment Services Team (VIST) program. VIST is an interdisciplinary team approach to the delivery of comprehensive services developed by VA more than 30 years ago. The program was the result of a pilot project sponsored by BVA, the American Foundation for the Blind (AFB) and VA. The failure of blinded veterans to utilize the benefits and services they wer entitled to precipitated this aggressive outreach effort. The isolating effects of blindness accompanied by the depression and feelings of being overwhelmed induced these veterans to remain in their homes..

As a direct result of this outreach effort, newly blinded veterans learned that programs and services were available to assist them in working through the trauma of vision loss. Exposure to a full range of benefits and services, including rehabilitation, instilled hope for resuming a meaningful and productive life.

The primary reason for the success of this vital program is the VIST coordinator. The coordinator is the key member of the interdisciplinary team responsible for coordinating the delivery of comprehensive services. When the program was first established, the coordinator was a part time position usually filled by the social worker assigned to the Team. Shortly after its inception, it became evident that this position required a full time coordinator to manage the emerging work load. It took nearly ten years before VA recognized this need and provided six full time centralized VIST Coordinator positions. Over the years that number has increased to 92. This would not have been possible without the intervention by these committees from time to time to encourage VA to provide more full time positions. We have always maintained that any station that had at least 100 eligible blinded veterans on their roles, could support a full time VIST coordinator. Mr. Chairman, this program has been extremely successful in identifying blinded veterans not previously known to VA and coordinating the delivery of comprehensive services to these needy veterans.

As the program has evolved, a significant body of knowledge about blindness has been developed and shared among these professional providers. They have become the subject matter experts at VA facilities regarding blindness and appropriate services to assist in coping with the problems associated with vision loss.

Over the years, VIST Coordinators organizationally have been very vulnerable in that they were essentially one person services. That vulnerability has become even more pronounced in the new organizational structure. There is no consistency throughout the system with respect to their organizational alignment. As a consequence they have become targets for cost savings reductions. Several stations have arbitrarily decided these positions were not full time and VIST responsibilities have been assigned as collateral duties to existing social work staff. As VIST Coordinator vacancies developed at these stations management could not resist the opportunity to eliminate one full time FTEE and withdraw support for this vital program. Only one station attempted to submit statistical documentation to support the decision. However, the numbers sighted were irrelevant and unrelated to the purpose of the basic program. The other stations made no effort and in fact had no data, such as outcome measures or patient satisfaction surveys to justify the elimination of the full time position. All stations insisted however they would provide all necessary services and blinded veterans would not experience any reduction in the level or quality of service. This has simply not proven to be the case. If allowed to continue, other stations will not be far behind. Dr. Kizer has repeatedly indicated that before any decisions are made in the field impacting the special disability programs, field managers are to consult with program officials at VA Headquarters. This has not occurred and in fact, the field is extremely resistant to talking with program officials in Headquarters. On the rare occasions they have made contact, it is only to inform officials what their decisions are regardless of that professional’s knowledge or experience. It seems apparent field managers have been given mixed messages. On the one hand, they are told they have decentralized decision making authority and are free to manage their Networks or facilities as they see fit given the available resources. On the other hand however, they are being told in some areas such as special disability programs, they do not have authority to independently make decisions impacting those programs. Dr.Kizer's confidence that field managers will do the right thing on behalf of the special disabilities programs certainly is not shared by many of the VSOs including BVA. The increasing pressures on these programs may be symptomatic of the continual erosion of resources for health care.

These decisions are also difficult to understand in light of the emphasis Dr. Kizer has placed on VA moving towards case management. VIST coordinators are exactly that, Case Manager. The VIST program has employed this methodology for thirty years with great success and we applaud Dr. Kizer for moving in this direction for all veterans. It seems entirely consistent that these coordinator positions should be maintained and more added where appropriate.

The transition to managed primary care does not preclude the need for the VIST program either as some in the field are attempting to maintain. The primary care team does not possess the knowledge, expertise or frankly the time to become experts in the field of blindness. Without doubt, the blinded veterans’ medical needs can be addressed by the primary care team but issues more directly related to blindness should be referred back to the VIST Coordinator to insure appropriate VA and non VA resources are mobilized on behalf of the blinded veteran and his family. Yes the family is directly impacted by the veterans vision loss and if not properly educated regarding the ramifications of sight loss can often sabotage the rehabilitation or adjustment process. This can and does occur despite the best of intentions on the part of family members. Family training is another area in which VA BRS has made pioneering advancements. It is essential the family has realistic expectations for the blinded veteran upon completion of rehabilitation. Primary care teams just cannot be expected to possess all the knowledge associated with vision loss, rehabilitation, family adjustment, community resources and the full range of VA services available to blinded veterans and their families. Additionally, VIST Coordinators review the blinded veterans VA disability ratings annually insuring they are properly rated either for disability compensation or pension purposes. As you all know, the VA disability rating schedule is complex to say the least. Coordinators are extremely familiar with those sections of the Code pertaining to blindness. Even more importantly in this regard, they have become familiar with those areas of the Code which allow for Special Monthly Compensation (SMC) and increases that may be associated with combinations of disabilities. Knowledge of the latest prosthetic devices, sensory aids and appliances for the blind enhance the Coordinator’s ability to assist blinded vets. Again, primary care teams do not possess this knowledge or expertise. Can there be any question that to facilitate the delivery of comprehensive services to this special group of veterans it is imperative highly qualified and skilled professional must be dedicated on a full time bases to achieve the desired outcomes?

Mr. Chairman, if the VIST program did not embrace the concepts currently being implemented in VHA and did not have a proven track record of success, we could understand the attempts to either curtail or eliminate this program. Again, we are painfully aware of the necessity to identify cost savings but strongly disagree that the VIST program is the place to cut. This program provide a blinded veteran with access to essential services such a preventive primary care that can be scheduled by the medical center thus controlling work load. The absence of such workload management will certainly result in blinded veterans appearing in the emergency room with acute episodes that are much more costly to treat. In addition the available of the full continuum of service available throughout the VIST clearly enhances the blinded veterans opportunity to maximize his level of independent functioning. History has demonstrated that the ability for a blinded veteran to receive quality health care, essential information about his blindness, the latest in prosthetic devices for the blind, comprehensive review of VA disability rating and community resources enables blinded veterans to lead much more meaningful and productive lives.

Another tool the VIST Coordinator utilizes to assist blinded veterans in their adjustment to sight loss is conducting support groups. These are group consisting of other blinded veterans all struggling with the same kind of adjustment issues, negative feelings and problems within their families and communities. Special knowledge and expertise is required to conduct such a focused therapeutic group. The attitude that exist at certain facilities that blinded veterans are no different than any other veteran seeking care and do not require specialized services or care managers is just not acceptable or compatible with highly proclaimed customer satisfaction.

B. Blind Rehabilitation Outpatient Specialist (BROS) Program

The other highly specialized outpatient program offered by BRS and referenced above is the Blind Rehabilitation Outpatient Specialist program. This is a new approach to the delivery of blind rehabilitation services to blinded veterans who either do not require a residential program of rehab or for what ever reason will not attend the residential program. A major shortcoming of the BROS in the past was the lack of follow up for veterans having completed the residential program. VA BRS did not possess the manpower to carry out effective follow-up to assess how effectively the veteran had transferred the newly learned skills to his home environment. Thanks to Congress earmarking $5,000,000 for BRS in the FY'95 DVA appropriation, BRS was able to establish 14 new BROS positions in 14 different facilities around the system. Although this is a comparatively small number of professionals, it provides VA with an excellent opportunity to evaluate the effectiveness of the rehabilitation approach and with what segment of the overall blinded veteran population is it most effective.

The BROS is a highly qualified professional who ideally is dually certified: that is has a dual Masters Degree both in Orientation and Mobility as well as Rehabilitation Teaching. In the absence of such dually credentialed professionals, Masters level blind rehab specialists selected for these positions undergo extensive cross training at one of the BRC. This prepares these individuals to provide the full range of rehab services in the veterans home environment. The delivery of such outpatient rehabilitative service may prove to be extremely cost efficient for those veterans who have rehabilitation needs but are unable to attend the residential program. VA BRS is currently in the process of developing, testing and refining outcome measure for this new program. Once sufficient data has been collected, decision regarding the effectiveness of this method of service delivery can be more appropriately evaluated. Like the full time VIST Coordinator positions referred to above, two VISNs have failed to fill vacancies in two of these BROS position. One VISN took more than 14 months to make the decision to fill the vacancy. That was only after BVA elevated the problem to Acting Secretary Gober. Previous attempts to have the problem fixed within VHA were unsuccessful. The other Network now apparently has a freeze on all positions and the facility is not allowed to recruit to fill the vacancy. This comes after the Network Director, in a letter to BVA, indicated that position would be filled once approval was sought by the facility. We appreciate the severe fiscal constraints the Networks and facilities are operating under but just one FTEE makes a bold difference in service delivery for blinded veterans.

Mr. Chairman, the outcome measures gradually being implemented and continually refined by VA BRS will eventually provide a wealth of extremely valuable data on VA blind rehab services. Hopefully this data will not only validate the efficacy of these services but provide VA with a profile to determine just what method of rehab intervention is most effective with each type of blinded veteran. Here again VA BRS is engaged in a pioneering effort. This type of data or data collection is unavailable any where in the field of blind services. Having a relatively complete profile outlining the rehabilitative needs of blinded veterans and what training model would be most beneficial in addressing those needs would be an extremely valuable tool for VIST Coordinators as they assess the needs of a given blinded veteran. Such a profile should facilitate making the most appropriate referral. Provided the outcomes data validates the outpatient delivery model, this could result in substantial cost savings. We caution however, outcome measures must be fully implemented with sufficient data collection and analysis before programmatic decisions are made.

While we understand the urgency many Network facility directors feel to complete the transformation of the VA health care system and achieve substantial cost savings, we firmly believe these decisions must be based on solid data. In the case of the special disability programs, those decision must await sufficient data collection.

Currently VA provides only two options in terms of rehabilitative service delivery, residential blinds rehab and the BROS. The latter is not much more than a year old and still under development. Furthermore 14 positions clearly do not provide equity of access to this a model of service delivery. There may be other models of service delivery not yet developed. Further research in this area must be encouraged. VA should not abandon its leadership role in the field of blind rehabilitation services and continue to explore additional alternatives to addressing the needs of blinded veterans. Perhaps a combination of the two existing models might prove effective. Hasty decisions to move to new untested or unproven models should be strongly resisted.

C. Computer Access Training

Until the explosion in computer technology and the more recent advancements in adaptive access technology, blind people were at a distinct disadvantage obtaining essential information previously available only in print. As our society began to enter the information super highway, people with severe visual impairments or blindness were effectively left by the wayside. Adaptive access technology is now beginning to catch up with the information technology enabling people who are blind to access the same information sighted people have had access to from the onset of the electronic revolution. For a number of years, BVA advocated for VA to provide computer evaluation and training for blinded veterans to enable them to have similar access to information as their sighted counterparts. As you well know, employment today almost demands the ability to utilize computers for most entry level positions and certainly is required for upward mobility. When BVA began advocating for this important evaluation and training, qualified instructors equipped to teach adaptive access technology were not available in the local community. Consequently, from our prospective it was imperative that VA BRS provide such services to enable blinded veterans to enjoy greater opportunities to obtain meaningful employment and to access essential information.

As the result of the FY'95 appropriation with the special funds earmarked for VA BRS, monies were made available to establish Computer Access Training (CAT) programs at the five major blind rehab centers. The demand for admission to these programs has dramatically increased to the point that an eligible blinded veteran may have to wait a year or more for admission. Ironically as the waiting time for admission to the basic adjustment to blindness programs has been declining the waiting time for computer training has increased. During the intervening years, the private sector has begun to catch up in terms of having qualified providers who can teach adaptive access technology to the blind. BVA has been working with VA BRS encouraging the referral of eligible blinded veterans, when appropriate, to local resources for this vital training. We believe this approach will dramatically reduce the length of wait for veterans and substantially reduce the cost for VA. Having to admit a blinded veteran into a VAMC, BRC for this specialized training and housing the blinded veteran in a hospital bed is quite expensive. Local training would eliminate this expense while at the same time be more responsive to meeting the veteran’s needs.

As outlined above, quality must be assured if VA is to pursue contracting for this training. To satisfy this objective, VA BRS can and should develop training protocols incorporating VA standards and necessary Outcome Measures that must be achieved to meet the obligations of the contract. We expect some resistance to this service delivery approach both from the VA BRC programs because of turf issues and the local medical centers or Networks when they learn they will be expected to pay for these services. Overall, however, this should result in substantial cost savings for the system. We believe there will continue to be sufficient workload for the CAT programs at the VA BRC because not all blinded veterans will have this specialized training available in their local communities. Therefore they will continue to depend on the VA for these services. Let me be clear Mr. Chairman, we certainly are not recommending wholesale contracting authority but we do feel this is one instance within the blind rehab array of services that could potentially realize cost savings without seriously compromising access to quality service.

D. Beneficiary Travel

Despite all the potential benefits to be realized from participating in blind rehabilitation, many veterans are not highly motivated to after loosing their vision. There are several reasons for this reluctance. One, veterans are not anxious to leave home and their families for a period of six to eight weeks when unconvinced the proposed rehabilitation will be beneficial. Most of us had little or no experience with blindness or blind people prior to loosing our vision. Therefore we were influenced by the negative stereotypes of blindness. Further, we had little confidence rehabilitation would have any positive benefit. Depression, characterized by feelings of being overwhelmed and without hope do not generate a high degree of motivation to reach out for help. Motivating such veterans to receive the rehabilitation that will prove beneficial to overcoming that depression is the primary task of the VIST Coordinator.

The physical and emotional limitations inherent to sight loss are formidable deterrents for veterans seeking blind rehabilitation. Those limitations severely exacerbated by the veterans inability to travel to the appropriate BRC. Some blinded veterans are not eligible for beneficiary travel and therefore are expected to pay for their own travel to the BRC. In most of these cases air travel is required because of the long distances involved and the price of airline tickets are cost prohibitive for these vets. When motivation is marginal to begin with, the additional financial burden of transportation often proves to be the proverbial straw causing the vet to decline rehabilitation.

When the Beneficiary law was changed particularly to reduce the VA cost for this program, we believe the law and subsequent regulations were intended to address beneficiary travel and are applicable to veterans traveling to their local VA facilities for care. The special disability programs only available at a few facilities around the system require longer and more expensive travel. We strongly believe that if a veteran must be referred to another VA facility, other than the primary station, to receive the care they need, VA then should be required to pay for that travel. Although these veterans are normally outpatients when referred for blind rehabilitation, we believe for beneficiary travel purposes they should be treated as inter facility transfers. This form of transfer is not bound by the General Benny Travel Regulations and relieves the veteran from the burden of pay for his/her own travel. Mr. Chairman, we encourage these committees to consider favorably an amendment to Title 38 governing Beneficiary Travel and exception for Beneficiary travel associated with participation in one of the special disabilities programs. The exceptions should only be granted to veterans who have been accepted for care at the receiving facility. In the case of blind rehabilitation, there is a very formal and detailed application procedure for admission to aBRC. An application must be completed at the veteran's home facility and then forwarded to the appropriate BRC. Clearly, therefore, these are veterans who are patients at one facility, that is unable to provide the necessary care, and who have been accepted by a distant VA facility capable of providing the needed services. The cost to expand the travel eligibility to these veterans would certainly be minimal for VA. If the responsibility continues to fall on the veteran it will surely serve as an effective deterrent to blind rehabilitation or any other specialized program that requires veterans to travel great distances at their own expense.

VII. PROSTHETIC SERVICES

Crucial to the rehabilitation of blinded veterans is the proper prescription of sensory aids and appliances. As outlined above, it is the blind rehabilitation specialist that prescribes the appropriate adaptive equipment to assist in over coming the handicap of blindness. Fundamental to the process is the timely and accurate procurement of these devices. The professional service that manages this activity is Prosthetics and Sensory Aids Service (PSAS).

Nearly eight years ago, this very Senate Committee on Veterans Affairs conducted an oversight hearing on Prosthetic Services because of numerous reports of severely disabled veterans not receiving essential prosthetic devices in a timely manner. Indeed many of these veterans had to wait months for prosthetic limbs and other appliances critical to independent functioning. That hearing exposed the fact that dollars allocated to the local facilities for prosthetics were being utilized for other medical center functions rather than to provide these essential prosthetic services. Many of the major VSOs testified at that hearing reporting on the failure of VA to provide these services and the consequences that was having on the quality of life for our nations severely disabled veterans. We also testified in support of centralized funding for Prosthetics Services to insure sufficient dollars for these services and that the appropriated funds for prosthetics were appropriately utilized to purchase prosthetic equipment rather than supporting other medical center functions. Further, we believed this method of funding these vital services would lend itself to closer monitoring of these appropriated dollars.

As a direct result of that hearing and its findings, VA did in fact implement centralized funding for Prosthetic Services. A dramatic reduction in the number of complaints surrounding delayed orders and difficulties in receiving prosthetic devices was experienced almost immediately. Despite this significant improvement in service delivery, nearly every year thereafter, VA management particularly at a the local level attempted to have the prosthetic funds decentralized once again. Obviously the motivation was to have the opportunity to utilize those funds other than for providing prosthetic services. Clearly this was just another symptom of the magnitude of the under funding of veterans health care. These repeated attempts to decentralized the funding of prosthetics were resisted vigorously by the major VSOs and the Secretaries Advisory Committee on Prosthetics and Special Disabilities Programs.

Mr. Chairman, it appears we have gone back to the future. With the reorganization, prosthetic funding has been decentralized to the Network level. Once again, we are beginning to experience delayed orders for prosthetics which Network and Facility Directors are denying. The most insidious aspect of the emerging problem in addition to the delayed orders, are reports that Prosthetic Representatives are being directed by their Facility Directors not to report delays or that the reason for delays is funding shortages. If in fact this is occurring, it cannot be tolerated and any manager engaging in this behavior should be severely reprimanded.

BVA has become aware that the delivery of quality prosthetic services are being potentially compromised as a result of the streamlining taking place in the field. Here again, cost savings are driving decisions rather than quality service. In several instances vacancies occurred in Prosthetic Representative positions and the stations chose to fill these vacancies with totally unqualified individuals. In one case, the facility selected a nurse whose position had been eliminated. In another case, a dietician was selected for the same reason. Management decisions such as these totally discount the provision of prosthetic services as a professional discipline with a specific body of knowledge requiring specialized education and training. At many facilities the prosthetic function is being transferred to the Office of Acquisition and Material Management, again as a cost saving measure. In these situations, clerks are tasked with performing the functions of a professional prosthetic representative. Substituting unqualified medical personnel for the highly qualified prosthetic professional as a cost saving measure can only result in a serious erosion of quality. To further complicate this situation, PSAS in VA HQ has been severely crippled. The service is grossly under staffed significantly limiting their ability to monitor the Prosthetic program and provide essential advice or consultation. PSAS clearly does not command the priority in the overall scope of service delivery either at the Headquarters or field level. We can only question whether there is a systematic effort in Headquarters to reduce PSAS, monitor their program and facilitate substantial reduction in accountability for the dollars allocated for prosthetic services. As in the cases of what we believe to be abuses of the full time VIST Coordinator positions, the problems in prosthetic services are not all pervasive. We do believe they demand close scrutiny and must be reversed to protect these essential programs. Should these ill advised decision be allowed to stand, other managers will certainly conclude they are free to utilize resources designated for prosthetic and special programs for whatever purpose they deem necessary.

VIII. WOMEN'S PROGRAMS

On a more positive note, I would like to exercise my prerogative and commend the VA on their progress in establishing gender specific services for our nation’s women veterans. Although there is much work to accomplish, dramatic progress has been made to provide essential services to women who have served America as faithfully as their male counterparts. BVA believes now that women veterans have access to VA medical care facilities, there is a great opportunity for those women who are experiencing vision loss to access the valuable services outlined above to assist in over coming this devastating disability. In the past, when a woman veteran applied for service, they were almost always contracted and did not have the opportunity to be referred to the VIST Coordinator. Hopefully that trend will be substantially reduced and the Women's Coordinator can work closely with the VIST Coordinators to insure these eligible veterans can and do receive these vital services

IX. OVERSIGHT

Mr. Chairman, in my comments above, I referred to the Oversight Hearing conducted in 1990 by the Senate Committee on Veterans Affairs and the positive impact that hearing had on service delivery. BVA is absolutely convinced the time has come for another comprehensive Oversight Hearing on Prosthetics and the Special Disabilities Programs. How these specialized services are integrated into the new managed primary model of health care delivery must be thoroughly examined. Additionally, The Veterans Equitable Resource Allocation model must be reviewed in terms of its applicability to the special programs. The major question concerns the appropriateness of a capitated model of resource allocation for these programs. Further, we have maintained the issue of centrally managing and funding should be explored in greater depth. We believe other questions need answers including: what is the role of the program officials in VA HQ? If the special disability programs are national in scope who is responsible for developing and disseminating national guidelines and performance standards for these programs? In the same context, do the special program managers in VA HQ have any real authority or responsibility for the conduct of the programs in the field?

BVA appreciates what an enormous task VHA experienced in the transition to the new model of service delivery and the need for sufficient time to fully implement the new changes. We do not want to appear to be alarmists regarding the problems we have identified above but feel the new system is far enough along the way to provide some indications as to how the special disability programs are to be treated in the new VHA. Our concern does not lie so much in what Dr. Kizer has prescribed as his vision for the VA health care system but in the manner in which implementation is taking place in the field. Oversight hearings could shed light on these important issues and assist in protecting these programs as intended by the Eligibility Reform Act adopted in the last session of this Congress.

X. LEGISLATIVE PRIORITIES

Other issues BVA believes vital to the survival of the VA and to services and benefits for blinded veterans are outlined below. Some of these issues are unique to veterans and others are applicable to all blind Americans.

A. BVA strongly encourages restoration of full funding for the core appropriation for VA health care. Authorizing VA to retain third party collection should be viewed as a supplement to not a substitute for core appropriations veterans' insurance companies should not be required to pay for veterans health care. This is clearly a responsibility of the Federal Government. At the very least, Congress as it did last year should include safeguard language in the appropriation triggering an automatic supplemental should VA fail to reach its collection targets.

B. BVA strongly supports the provision of a full Cost of Living Adjustment (COLA) for veterans receiving disability compensation and surviving spouses and dependent children receiving Dependency and Indemnity Compensation (DDIC). Further we support this COLA being made effective 12/1/98. It is extremely important that disabled veterans or surviving spouse to be able to keep pace with inflation due to the additional cost associated with severe disabilities. Fortunately, the rate of inflation has been quite low in recent years but costs do continue to rise and place increased pressure on the disabled persons purchasing power.

C. BVA strongly urges members of these Committees to strongly oppose the passage of the Intermodal Surface Transportation Efficiency Act (ISTEA) legislation pending in both chambers. We can appreciate how politically appealing this legislation is particularly in an election year. However, it potentially would have a devastating effect on veteran's health care. The ISTEA bill would transfer the tax revenues collected from the gasoline tax currently going to the treasury for deficit reduction, to the Transportation Trust fund. Should this occur, it would be in violation of the terms of the Balanced Budget Agreement reached last year. Furthermore, it would require spending offsets from other non defense, non transportation discretionary appropriations. Under this scenario, VA stands to loose 2 Billion in discretionary funding over the remainder of the Balanced Budget Agreement. Veterans health care therefore would suffer the bulk of this reduction. Health care is already under funded and this additional loss would be absolutely unacceptable with disastrous results. Your leadership in resisting this legislation will be crucial to the preservation of veterans health care. We applaud all each of you have done over the years to insure the availability of high quality benefits and services. It would be tragic to loose all that has been achieved.

D. Medicare Subvention is an extremely important issue critical to the future funding of VA health care programs. Considerable discussion of this issue has occurred during the years with strong resistance coming particularly from the House Ways and Means Committee. BVA is extremely encouraged by the reported conceptual agreement achieved between Mr. Stump and Mr. Thomas, Chairman of the Ways and Means Subcommittee on Health regarding a pilot Medicare subvention demonstration project for VA. We trust legislative language can be crafted to move this legislation rapidly through this session and obtain prompt Senate action.

Authorizing VA to bill Medicare for services provided to certain veterans seems to be a win win situation. VA benefits from additional revenue to supplement core appropriations and the Medicare trust fund benefits because VA will be reimbursed at a discounted rate. There is no question, VA should be given the opportunity to demonstrate its ability not only to collect these funds but also its ablity to afford the Trust Fund with some real savings.

E. Veterans Preference is another legislative initiative that requires Senate action this session. The House successfully took action last session. Hopefully, the Senate Veterans Affairs Committee will favorably report this important legislation swiftly for full Senate approval.

F. Any settlement by the Federal government with the tobacco industry allowing the government to recover the cost of providing health care services to individuals suffering health related problems associated with the use of tobacco must include the VA. In our view, any funds received through such a settlement should be first used to restore adequate core appropriations for VA health care before any new initiatives are entertained. Additionally, settlement funds should be used to offset costs to the government to pay compensation to veterans determined to have disabilities related to smoking in the military.

G. The debate about how to spend any budget surplus must include veterans. Before any new governmental initiatives or promises are made with these dollars, the promises made in the past to our nations veterans must be met. Many of the problems we have outlined above in the new VHA may be a prelude to systemic problems associated with lack of adequate resources rather than mismanagement or inefficiencies in the system.

H. Last year the Social Security benefits were modified allowing seniors between the ages of 65 through 69 to retain more of their earned income before loosing any of their SS benefits. After five years, this group may earn up to $30,000 per year before they experience any reduction in their SS retirement benefits. Moreover, they only loose one dollar for every three dollars they exceed the earned income limitation. Prior to the change in the law, blind Social Security Disability Insurance (SSDI) beneficiaries had their income earning limitations, known as Substantial Gainful Activity (SGA) levels directly linked to that of seniors. The new law severed that linkage. What is worse is that when a blind SSDI beneficiary exceeds the SGA level by as little as one dollar they loose the total benefit.

It appears that additional reforms of the SSDI will be introduced again this year. BVA strongly urges support for including a provision in any new legislation that would allow blind SSDI beneficiaries an offset similar to the income earning limitations of seniors. In fact the blindness community is requesting a two to one offset rather than a three to one as enjoyed by seniors.

I. Again while not a veterans issue, as members of Congress you likely will be voting on the re-authorization of the Rehab Act currently on a one year extension. Substantial work has gone into re-authorization but amendments can always negatively impact agreements already achieved. Our primary concern is that any re-authorization of the Vocational Rehabilitation Act must protect specialized services for the blind. Blinded veterans know first hand the importance of these specialized services. Additionally flexibility in current laws permitting states to operate separate schools for the blind must be preserved. While main-streaming of disabled children may be a desirable goal, the full continuum of educational options must be available. Moreover, parents of severely disabled children must be permitted a choice as to which is the most appropriate educational setting for their child. One size does not fit all and each child has different and unique needs that may require an educational setting other than the regular school. We urge your insistence that these provisions be included in the final Re-authorized Rehab Act.

XI. CONCLUSION

Once again, Mr. Chairman, I want to thank you and the Committees for this opportunity to present our legislative priorities for 1998. BVA is extremely proud of our 53 years of service to blinded veterans and all the accomplishments we have enjoyed. Our relationship with the VA and Congress, in particular these committees, have been most productive and rewarding. Our priorities, as stated above are the product of the resolutions adopted at our 52nd National Convention held last August in Reno, Nev.

While our membership and indeed all blinded veterans are most appreciative of the programs and services provided by VA, we recognize that change is necessary and believe this may be an opportunity for significant improvements to those services. Hopefully, more blinded veterans than ever before can avail themselves of those services. There is no question, VA services for the blind are the finest in the world and our ongoing efforts will be to ensure they remain the finest. Clearly, we will need the assistance of each of these committees in this worthwhile effort and know we can count on you. Having said that Mr. Chairman, I would be pleased to answer any questions you or other members of the Committee might have.

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