Testimony
OF JOHN
C. BOLLINGER, DEPUTY EXECUTIVE DIRECTOR PARALYZED
VETERANS OF AMERICA BEFORE
THE HOUSE COMMITTEE ON VETERANS’ AFFAIRS, HEALTH
SUBCOMMITTEE CONCERNING THE CURRENT STATE AND FUTURE CHALLENGES
OF THE VA HEALTH CARE SYSTEM APRIL 3, 2001 Chairman
Moran, Ranking Democratic Member Filner, members of the Subcommittee,
the Paralyzed Veterans of America (PVA) is pleased to present our
views on the current state and future challenges of the Department of
Veterans Affairs’ (VA) health care system.
As we stated in our Annual Testimony, which we presented last
month, the provision of health care to veterans is our primary
mission. To our members,
the existence of a viable system that provides the highest quality of
health care directed toward the special needs of veterans is a matter
of life and death. We
could spend days and weeks discussing the current state, and the
future challenges facing this system, but the long and the short of it
can be summed up in a quote from a congressional report from 1951:
that the VA health care system “represents an attempt on the part of
Congress to partially discharge our obligation to the men and women
who have offered their lives in defense of our country.” PVA
members utilize VA health care at a higher percentage than any other
veterans service organization. All
of PVA’s members are veterans with spinal cord injury or
dysfunction. Due to the
complex nature of these disabilities PVA members must rely on a
lifetime of specialized health care and continuing rehabilitation
services. Fortunately for us, since World War II, the VA has developed
an extensive network of spinal cord dysfunction care second to none.
Specialized services, such as spinal cord dysfunction care, are
the core of the VA’s mission and responsibility to veterans.
VA’s specialized services are incomparable resources that
often cannot be duplicated in the private sector. An
independent study released last Spring produced by the widely
recognized consulting firm Booz-Allen & Hamilton compared VA’s
SCI services to SCI services funded by Medicare, Medicaid, Aetna,
Kaiser, Alliance, Blue Cross/Blue Shield and the Swedish medical
systems. The
study found that the VA provided more comprehensive coverage for SCI
than any other health care program.
It determined that the VA’s benefits met, or exceeded, those
provided by each of the plans reviewed.
It concluded that VA’s services were uniquely organized and
that no other health care provider was as involved in the full
continuum of care for SCI patients. To provide this high-quality health care it is essential that a spinal cord injury center be operated in the venue of a tertiary medical center. The clear advantage of the SCI system is that it incorporates the multi-disciplinary team approach of many medical specialties, from neurology to social work, from initial stabilization post injury to long-term care. These are services that can only be found in the hospital setting, and only provided by highly trained and highly motivated health care professionals. Likewise, for the VA to reap the full benefits of its restructuring efforts over the last number of years, and to realize its efforts to provide cutting-edge 21st century health care, it is essential that the integrity of the hub and spoke method be maintained, and strengthened. This model relies upon the tertiary care facility serving as the hub, with outpatient clinics and other facilities that ease access into the system serving as the spokes. Without the hub, the spokes will fail. The
VA has undergone extraordinary change in recent years, marked
primarily by a major shift from inpatient to outpatient services.
This change in the direction of care has been brought about by
the need to cut costs. It
also has had the intended result, through the opening of hundreds of
outpatient clinics, of bringing primary care services closer to the
communities where veterans live.
This trend, the shifting of resources away from medical
centers, will continue as the VA attempts to realign and, potentially,
to close many medical centers. This
trend, absent coordinated planning, represents another major threat to
the SCI system unless resource allocation remains in balance and
continues to support the medical center approach to health care. VA
Secretary Principi stated recently in an interview, in regards to the
sentiment that it was time to close the VA system, that this “would
be such a tragedy because I do believe that the VA is part of the
safety net in this country for people who have few other options.
We are a leader in specialized programs, and without a robust
health care system around them, they will collapse and die.”
PVA could not agree more.
It is clear, that PVA members cannot find the specialized care
they need at a community-based outpatient clinic that provides only
basic general primary care services. We have discovered that some of these community-based clinics
are not even wheelchair accessible.
These clinics may provide ice packs and aspirin, but they
cannot provide the health care needed by PVA members – health care
provided in specialized settings supported by tertiary care hospitals. A
crucial component of maintaining and improving the VA’s ability to
provide specialized services, is that the VA must retain its essential
capacity to provide these services.
Congress recognized the importance of maintaining capacity with
the passage of P.L. 104-262, the “Veterans Health Care Eligibility
Reform Act of 1996,” which required the VA to maintain its SCI
capacity by statute. Even
with this statutory mandate it has been an on-going struggle for us to
see that VA Veterans Integrated Service Network (VISN) and local
managers live up to the requirement to maintain SCI beds and staffing. Last
year we were able to finally reach agreement with the VA on a template
for the entire SCI system. This
template sets numbers for beds and staff at each SCI center.
This template can serve as a benchmark for maintaining
capacity. Although we are
encouraged by this agreement, we are ever mindful that the numbers are
only as good as the good faith required by local hospital managers and
VISN directors to see that these beds are in place and properly
staffed. In addition,
this agreement will only work with the direct supervision of top VA
leadership and the oversight of this Subcommittee.
We look forward to working with you to see that the promises
made to protect spinal cord medicine are kept. PVA
members cannot find the quality services within the general community
as well, either by contract or by any vouchering scheme that would
send PVA members to places where specialized care services do not
exist. What could be
looked at as a boon to some veterans strikes at the heart of the VA
inpatient specialized services we rely upon.
This boon could very well be the disguised death knell that we
so very much fear. The
threat to the VA health care system represented by the push to voucher
the VA health care system is ever-present.
PVA remains deeply opposed to these efforts.
Well-meaning attempts to address the problems faced by veterans
who do not reside near VA facilities could very well have the
practical effect of destroying the VA system.
We hope that this is not the purpose of those who support these
vouchering efforts. We
need to find solutions for these veterans, but the solutions we find
should not fundamentally subvert the system. PVA
is troubled by legislation put forth in the last Congress that would
have created a pilot program to shift medical services and veteran
patients from the VA to the private sector. The care afforded these veterans would have been paid for by
the veteran’s own private or public insurance with the VA acting
only as a secondary payer. It
is important to note that we are not opposed to contracting out
medical services when there is a demonstrable lack or availability of
certain services within the VA. What
we do oppose, and oppose strongly, are efforts that would turn the VA
into an insurer of health care rather than a provider of health care.
These efforts would not only represent a major departure from
the usual delivery of VA health care services, but would provide
disparate treatment of veterans depending on whether or not they have
private insurance, undermine the VA’s ability to maintain its
specialized services programs by eroding the VA’s patient and
resource base, and endanger the well-being of veteran patients. Efforts
to voucher the VA would strike at the core of the structure of the VA
health care system, the structure of the VA hospital serving as the
hub, or locus, of inpatient services, and the outpatient clinics
serving as the spokes of the wheel, feeding patients to that hub.
Proposals, such as those from the last Congress, do just the
opposite. They would
attract veterans to the VA outpatient clinic, only to send them out of
the VA system for their care. Veteran
patients would be lost to the system, undercutting the VA hospital’s
patient base, its budget and resource requirement justification, and
any potential benefit the veteran’s third party reimbursement could
bring to the system if that care had been provided in a VA facility.
These proposals set a very dangerous precedent which, if
allowed to expand, could endanger the viability of a VA facility
maintaining its full range of specialized inpatient services for all
other veterans in the area as those resources go elsewhere. Although
the final version of a vouchering proposal in the last Congress
included language calling for the inclusion of a certain percentage of
veterans without private insurance, we have grave concerns over how
such a mandate would be carried out.
Even with the inclusion of such language, these provisions
would effectively allow only veterans who have the means to pay for
their own health insurance to be referred from VA or VA contracted
outpatient clinics to private sector facilities for inpatient care.
The vast majority of those without health insurance,
potentially those with the most financial need, would still have to
travel to the VA hospital to get their care.
By authorizing non-service connected care in private sector
facilities, proposals such as those brought forward in the last
Congress would create an entirely new eligibility category.
Veterans’ groups and Congress worked for years to reform the
patchwork eligibility system then in place.
This would represent a step backward. Finally,
vouchering proposals represent the abrogation of the VA’s, and the
federal government’s, direct responsibility to discharge the
obligation to provide health care to veterans.
The VA, in sending the patient to the private sector to use the
veteran’s own health insurance, would be washing its hands of the
veteran patient. As a
payer of only co-payments and deductibles, the VA would have very
little recourse to monitor the quality of the care provided.
It would not have the responsibility to provide any follow up
care or continuing treatment. Even
though the proposal forwarded in the last Congress contained language
stating that the VA would coordinate care through the provision of
case management, PVA believes that, lacking a formal contractual or
regulatory relationship with the providing hospital or the private or
public insurer, the VA would have no right or even incentive to
monitor, evaluate or influence the care provided once that patient has
been referred. In
addition, veterans would lose all recourse to the VA for the
consequences of the care they receive once they are referred out of
the system. Another
challenge facing the VA system, the challenge of a crumbling
infrastructure and a lack of investment in the system was recognized
by this Committee, and acted upon by the House of Representatives.
For too many years, the VA has faced dwindling construction
budgets. This pattern is
an explicit indication of poor stewardship over the medical system’s
facility assets. The VA
must remain flexible in order to provide the highest quality of care
to veterans and to protect the provision of specialized services, but
a health care system that lacks safe structures, that has been allowed
to “realign through neglect,” is a health care system in name
only. It
is easy to be lulled into believing that veterans are dying off and
that there is no need for a VA health care system.
This is undoubtedly false.
It is true that we are facing, in a demographic sense, an
increasingly graying population of veterans, but the simple fact
remains that as long as we have a military we will continue to have
veterans. The VA must
look to meeting the specialized health care needs of all veterans. This is especially true in meeting the needs of elderly
veterans, and why it is essential that the VA implement the long-term
care provisions of the “Veterans Millenium Health Care and Benefits
Act,” P.L. 106-117. The
VA can be a tremendous asset as we, as a Nation, begin to address the
long-term care needs of all of our citizens. Earlier,
I quoted from a congressional report from 1951.
That report also states that at that time “the quality of
medical care available to the beneficiaries of the [VA] has been
raised to a point where it unquestionably represents the best medical
care available anywhere in the world at any time in the world’s
history.” This
statement should remain our goal, and light the path of our efforts to
face the promises and challenges of the present, and the uncertainty
of the future. PVA appreciates this opportunity to present our views on the current state and future challenges confronting VA health care. I will be happy to respond to any questions. Back to Witness List |