Testimony OF JOY
J. ILEM ASSISTANT
NATIONAL LEGISLATIVE DIRECTOR OF
THE DISABLED AMERICAN VETERANS BEFORE
THE HOUSE
VETERANS’ AFFAIRS COMMITTEE SUBCOMMITTEE
ON HEALTH April
3, 2001 Mr. Chairman and
Members of the Subcommittee:
I am pleased to present the views of the Disabled American
Veterans (DAV) regarding the current state and future challenges
facing the Department of Veterans Affairs (VA) health care system.
Many severely disabled veterans utilize VA’s health care
services and are directly affected by the quality of care they
receive. Therefore, this
issue continues to be one of our foremost concerns and is of great
importance to the DAV’s more than one million members and their
families.
The Veterans Health Administration (VHA) operates the largest
health care system in the United States, with 173 medical centers, 771
ambulatory care and community-based outpatient clinics, 134 nursing
homes, 42 domiciliary-care facilities, 206 readjustment centers, and
72 comprehensive home-care programs.
In fiscal year 2000, VA provided care to nearly 3.8 million of
the 4.8 million enrolled individuals, the vast majority of whom have
service-connected disabilities or qualify on the basis of low income.
VHA provides a wide range of services, including specialized
services and treatment for blind rehabilitation, spinal cord injury,
brain trauma, post traumatic stress disorder (PTSD) and amputations.
The DAV, in concert with the other Independent Budget
Veterans Service Organizations (IBVSOs), AMVETS, Paralyzed Veterans of
America, and Veterans of Foreign Wars, have expressed serious concerns
about the current state of VHA. The
system is experiencing serious difficulties in providing quality and
timely care and the specialized services veterans need consistently
nationwide. We believe
that adequate funding is the central issue governing VA’s ability to
deliver high-quality and accessible services to veterans. Three
years of flat-line appropriations have taken their toll on VA’s
medical care system and threatened its viability.
Repeated budget shortfalls have had a direct impact on
veterans’ ability to access care.
As the Nation’s largest direct provider of health care
services, VA’s programs must be adequately funded to support its
congressionally mandated missions. We
acknowledge and sincerely appreciate the efforts of the House
Veterans’ Affairs Committee in recent years to provide additional
funding for VHA. However,
years of inadequate budgets have negatively impacted the system and
prevented VHA from delivering the continuum of health care services
veterans need. VA health
care is a Federal responsibility that must be met fully by Congress
and the Administration through adequate appropriations. Appropriately
managing the VA health care system is understandably a difficult task,
given its size and variability. It
faces ever increasing problems as funding shortfalls continue, new
laws are passed, and additional demands are placed on the system.
Unless VHA is provided sufficient resources, it will be unable
to fulfill its primary mission. Below,
we address some of the problems VHA is facing and briefly outlines
areas of major concern to DAV. WAITING TIMES
A significant increase in demand for care has resulted in many
veterans being denied access to timely health care services at VA
facilities. We repeatedly
hear complaints from veterans that they have to wait too long for the
health care they need. VHA
has set reasonable timeliness goals for itself but has fallen short of
providing equal and timely access to routine and specialty care for
its enrolled veteran population throughout the system.
Unacceptable waiting times in many cases are directly related
to resource limitations.
DAV asks its Hospital Service Coordinators to provide
information on a monthly basis concerning waiting times for routine
primary care visits, follow-up appointments, and specialty clinic
appointments in VA facilities nationwide.
We have received notice that many facilities have a 30-60 day
waiting period for primary care and specialty care appointments. The
DAV feels that VA management at headquarters and in the field should
be held accountable for identifying and addressing problems related to
delivery of timely quality care at VA facilities. LONG-TERM CARE
The
Veterans Millennium Health Care and Benefits Act was signed into law
on November 30, 1999. This
legislation expanded VA’s mission to maintain capacity for
specialized care for aging veterans.
However, more than a year has passed since the passage of the
law and we are still waiting for implementing regulations. Some
facility administrators are apparently reluctant to fulfill the
Millennium Act’s mandate and restore inpatient long-term care
programs. In the
meantime, lengths of stay in inpatient long-term care units are
limited and veterans in most need of this service are shuffled out of
the system. Additionally,
because of the reduction in inpatient long-term care capacity,
enrolled veterans are not confident that VHA will be able to provide
the long-term care services they need. The
shift to primary care has negatively impacted on specialized care
programs for age-related conditions such as dementia, psycho-geriatric
evaluation and treatment, and end of life care.
These programs associated with advanced age are essential in
providing a full continuum of health care services.
Given a rapidly aging veteran population, VHA should address
the likely increase in demand for these types of services. VHA
must meet its obligations and ensure that the Millennium Act is fully
implemented in fiscal year 2001.
Congressional oversight is necessary to ensure VHA is
maintaining capacity of its in-house extended care staffing and
services. Additionally,
new appropriations are needed to cover the costs of long-term care
mandated by Public Law 106-117. EMERGENCY CARE
The
1999 Veterans Millennium Health Care and Benefits Act also authorized
VA to reimburse veterans for the cost of emergency care services
provided at non-VA facilities if they lack health insurance and are
enrolled in the veterans health care system.
However, no implementing regulations have been issued, nor has
information been disseminated informing eligible veterans of access to
these services. Speedy
implementation of emergency care regulations mandated by the
Millennium Bill are imperative to ensure that veterans are well
informed about access to emergency care and receive reimbursement when
appropriate for such care. SPECIALIZED SERVICES
The
DAV views VHA’s programs for veterans with special needs as the core
of the VA health-care system. Many
VA programs, directed at certain disability groups affected by
blindness, serious mental illness, traumatic brain injury, spinal cord
injury, amputation and post traumatic stress disorder, are unmatched
in excellence. Unfortunately,
there has been a continuing erosion of VHA’s specialized services
for veterans suffering from these severely disabling conditions. Despite
statutory requirements that VHA maintain the capacity to provide
specialized services, many specialized programs have been dismantled
or severely compromised by staff shortages or reorganization.
Mental Health/Substance-Use Disorders
VHA
has not maintained its capacity to provide services to veterans with
serious mental illness, post traumatic stress disorder, and
substance-use disorders. We
have seen cutbacks and closures of many of VA’s specialized
inpatient programs. The shift to
primary care has had an erosive effect on VA’s premiere mental
health programs. Although
VA has provided better access to community-based primary care, many
community-based outpatient clinics (CBOCs) do not provide mental
health care services. There
has not been adequate development throughout the system of necessary
mental health services to replace traditional inpatient programs.
Some seriously mentally ill patients may be at risk without the
structured support of an inpatient program and routine monitoring by
mental health professionals. Without
appropriate VA services, these patients may experience homelessness
and other related problems and have to rely on other community
resources for assistance. It
is essential for VHA to maintain equal access to a full continuum of
mental health services across the VISNs for veterans. Additionally,
outpatient care is not always appropriate for all veterans with
specialized needs. In the past, VA was well known for its excellent programs for
veterans dealing with substance-use disorders.
These lengthy and intensive inpatient programs were highly
successful and helped many veterans to overcome their addictions and
once again lead productive healthy lives.
However, due to cutbacks many of these programs are no longer
available. Some
counselors believe that veterans seeking treatment for substance-use
disorders are at a higher risk for relapse if they do not have access
to traditional long-term inpatient programs.
Likewise, shifting serious chronic mentally ill veterans to
primary outpatient care settings is not always providing satisfactory
care/treatment for these patients. Decisions
about specialized services must be based on patient need and
appropriateness of care rather than cost driven.
Adequate funding is necessary to staff specialized programs
with qualified individuals. Congressional
oversight to maintain these specialized services is necessary to
protect our Nation’s most vulnerable veterans.
Prosthetics and Sensory Aids
Veterans
who require prosthetics and sensory aids continue to encounter
obstacles to receiving timely and appropriate services and equipment,
despite program enhancements. We
applaud the decision to centralize and fence VHA’s entire
prosthetics budget and impose accountability on key personnel for
budget execution decisions. These
measures help to alleviate the inappropriate pressures placed on
clinicians to find cost-savings at the expense of disabled veterans.
However, we still have concerns about the prosthetics programs. Facility
directors must be held accountable for ensuring that prosthetic
services within their VISNs are appropriately supported and staffed.
Additionally, VHA officials must remain diligent to ensure that
national prosthetic policies are properly followed.
Quality and accuracy of prosthetic prescriptions must take
precedence over cost-saving measures. Veterans
continue to report that orders for prosthetic devices are not being
delivered in a timely manner. Staff
shortages and excessive workloads have resulted in a delay in filling
orders. Delayed
prosthetics orders can potentially lead to grave or morbid outcomes
for at-risk patients. Congress
and the Administration must provide adequate resources to ensure there
are appropriate staffing levels in prosthetic departments and
qualified representatives who have the requisite training and
experience to fill critical positions.
VHA must provide oversight and guidance on the restructuring of
its prosthetics programs to ensure consistency nationwide. Blinded Veterans
VA’s Blind Rehabilitation Service (BRS) is a
comprehensive program to rehabilitate our nation’s blinded veterans.
Unfortunately, because of funding reductions, this excellent
program is in danger. Funding
for critical staff positions have been frozen, postponed indefinitely,
or eliminated. These and
other factors have resulted in delayed access to this specialized
service for some veterans. Existing
comprehensive programs must not be dismantled until other alternative
models of service delivery are identified and tested.
VHA must restore the bed capacity in blind rehabilitation
centers to the level that existed at the time of the passage of Public
Law 104-262. VHA must
ensure appropriate staffing levels are maintained and rededicate
itself to the excellence of programs for blinded veterans. Spinal Cord Dysfunction
The comprehensive care provided at VA’s specialized centers
for spinal cord injury/disease (SCI/D) is second to none.
Unfortunately, these programs have been seriously degraded over
the past five years by substantial staff reductions.
Despite a congressional mandate to maintain system capacity,
local officials reduced staff and were only able to operate 65 percent
of the SCI/D beds reported as operational in 1996.
This has resulted in delayed or denied care to veterans with
SCI/D and threatens the quality of care these veterans receive.
Last year local managers were required to identify the
additional resources necessary to restore mandated staffing levels for
SCI/D centers. However, this objective has not been accomplished.
VHA must provide sufficient funding for additional extended
care beds and the more than 400 additional medical professionals
required to restore capacity of the SCI/D health care system. Homeless Veterans
It is
estimated that, on any given night, approximately 275,000 veterans are
homeless. Access to VA
benefits and specialized services is essential for many homeless
veterans to regain and hold steady employment.
A comprehensive care approach, including specialized programs
for mental health care and substance abuse problems, offer homeless
veterans a hand up and an opportunity to break the cycle of
homelessness. We
need an accurate assessment from VHA as to the staffing and funding
levels dedicated to homeless services in each medical center and the
types of programs currently functioning to address the complex needs
of the homeless veteran population. Women Veterans
Since
the restructuring of the Veterans Health Administration and
implementation of a primary care model throughout the system, we have
seen the discontinuation of several dedicated women’s health
clinics. The DAV is
seriously concerned about the incidental impact of the primary care
model on the quality of health care delivered by VHA to some women
veterans. Information
from a January 2000, VA conference report noted that women veterans
comprise less than 5 percent of VA’s total population and, as a
result, VA clinicians are generally less familiar with women’s
health issues and less skilled in routine gender-specific care.
With the advent of primary care in VA, clinicians see a reduced
ratio of women. Therefore,
it is unlikely that they will gain the clinical exposure necessary to
develop and maintain expertise in women’s health. Women’s
clinics should be maintained to ensure women veterans are not
subjected to lower standards of clinical expertise in their health
care, and VA Women Veterans Health Programs must be adequately funded
to avoid a decline in services. We
also have concerns about privacy issues at VA facilities for women
veterans, and about their ability to access specialty care services
for mental health disorders, sexual trauma, and eating disorders.
Gulf War Veterans
Many
Persian Gulf War (PGW) veterans have suffered tremendously for the
last decade with ill-defined health problems.
Scientists and medical researchers continue to search for
answers and contemplate the various health risk factors associated
with service in the Persian Gulf.
However, no single cause has yet been determined.
Some PGW veterans face challenges in obtaining appropriate
health care and many are dissatisfied with what they consider limited
treatment regimes/options available at VA to treat their chronic
debilitating symptoms. These
veterans must have access to health care services and treatment
regimens that will help them regain their good health and mental
well-being. VA must
tailor its health care services to meet the unique needs of PGW
veterans. CONSTRUCTION/MAINTENANCE
VA has neglected its health care facilities nationwide to the
point that the system’s infrastructure has fallen into decay.
Annual appropriations for major and minor construction projects
have decreased sharply, from $600 million in fiscal year 1993 to only
about $200 million in fiscal year 2000.
Additionally, there has been a resistance to funding any major
projects before the Capital Assets Realignment for Enhanced Services
(CARES) process has been completed.
We fear that continued neglect of the system’s facility
assets may compromise the quality of veterans’ medical care.
VA must maintain and improve its existing health-care
infrastructure. As the
House Veterans' Affairs Committee has pointed out, the CARES project
will take many years to bear fruit.
In the meantime, VHA must protect its assets and ensure that
the delivery of health care services to sick and disabled veterans is
not interrupted or that that their lives are not put at risk because
of needed repairs, outdated structures, or unsafe buildings.
We appreciate the recent action taken by the full Committee on
the Veterans’ Hospital Emergency Repair Act (H.R. 811).
This legislation would authorize immediate measures to begin a
course to reverse the deterioration of facilities and the inevitable
consequent decline in the quality of health care for veterans.
While we believe this is a good first step, more must be done
through regular appropriations in the annual budget for VA
construction. BILLING ISSUES
We
continue to receive complaints from disabled veterans regarding
billing problems within VHA. Veterans
and insurers are constantly frustrated by inaccurate and inappropriate
billing for health care services.
We are especially troubled about reports of billing for care
that is secondarily related to a service-connected condition.
Some facilities have used these unscrupulous methods to
compensate for inadequate funding and less than satisfactory
collection practices. To
function properly and efficiently, VHA must adopt and adhere to
appropriate billing practices. Inappropriate
billing practices for care of conditions directly associated with
service-connected conditions is unacceptable and must stop
immediately. Billing for
secondary conditions forces veterans to reopen their claims and causes
an unnecessary burden on the Veterans Benefits Administration. NURSING SHORTAGES
There
are simply not enough nurses to care for the growing number of VA
patients. Failure to
address the impact of inflation has led to serious problems with
recruitment and retention of vital health care professionals,
especially VA’s registered nurse staff.
The long overdue pay raise provided to VA nurses by Congress
last year will help to ease the shortage of this critical VA resource.
However, the impact of a stressful work environment on an aging
nursing workforce, coupled with mandatory overtime requirements, cross
training, and other factors, could have a serious effect on the
quality of care registered nurses are able to provide to our
Nation’s veterans. VHA must act responsibly and address these concerns. CONCLUSIONThe
DAV recognizes that VA has made a genuine effort to address problems
associated with management of its health care system.
But clearly, more needs to be done.
VHA must honestly assess and request accurate funding levels
needed to fulfill its mission of providing quality and timely health
care services to our Nation’s veterans. VHA
will continue to face the same problems in the future if adequate
resources are not provided. In
fact, its problems will most likely be compounded in the future unless
aggressive steps to correct deficiencies are taken now.
It is truly disgraceful that the Nation’s largest health care
system has been allowed to fall into a state of disrepair and overall
decline. We may be
serving our veterans, but are we serving our veterans well? Once again, veterans’ priorities face serious competition for Federal resources. The new Administration and Congress have the opportunity and the ability to make good on the Nation’s historic obligation to those who served in the Armed Forces. We need to not only strengthen but improve the quality and efficiency of services delivered to our Nation’s veterans. To do less is counter to the very reason the department was established “To Care For Those Who Have Borne the Battle.” Back to Witness List |