[House Hearing, 106 Congress]
[From the U.S. Government Printing Office]




                               before the


                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION


                             APRIL 10, 2000


                           Serial No. 106-190


       Printed for the use of the Committee on Government Reform

  Available via the World Wide Web: http://www.gpo.gov/congress/house

70-278                     WASHINGTON : 2001

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                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       ROBERT E. WISE, Jr., West Virginia
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
STEPHEN HORN, California             PAUL E. KANJORSKI, Pennsylvania
JOHN L. MICA, Florida                PATSY T. MINK, Hawaii
THOMAS M. DAVIS, Virginia            CAROLYN B. MALONEY, New York
DAVID M. McINTOSH, Indiana           ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
JOE SCARBOROUGH, Florida             CHAKA FATTAH, Pennsylvania
    Carolina                         ROD R. BLAGOJEVICH, Illinois
BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
DAN MILLER, Florida                  JOHN F. TIERNEY, Massachusetts
ASA HUTCHINSON, Arkansas             JIM TURNER, Texas
LEE TERRY, Nebraska                  THOMAS H. ALLEN, Maine
JUDY BIGGERT, Illinois               HAROLD E. FORD, Jr., Tennessee
GREG WALDEN, Oregon                  JANICE D. SCHAKOWSKY, Illinois
DOUG OSE, California                             ------
PAUL RYAN, Wisconsin                 BERNARD SANDERS, Vermont 
HELEN CHENOWETH-HAGE, Idaho              (Independent)

                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
           David A. Kass, Deputy Counsel and Parliamentarian
                    Lisa Smith Arafune, Chief Clerk
                 Phil Schiliro, Minority Staff Director

Subcommittee on National Security, Veterans Affairs, and International 

                CHRISTOPHER SHAYS, Connecticut, Chairman
MARK E. SOUDER, Indiana              ROD R. BLAGOJEVICH, Illinois
ILEANA ROS-LEHTINEN, Florida         TOM LANTOS, California
JOHN M. McHUGH, New York             ROBERT E. WISE, Jr., West Virginia
JOHN L. MICA, Florida                JOHN F. TIERNEY, Massachusetts
DAVID M. McINTOSH, Indiana           THOMAS H. ALLEN, Maine
    Carolina                         BERNARD SANDERS, Vermont 
LEE TERRY, Nebraska                      (Independent)
JUDY BIGGERT, Illinois               JANICE D. SCHAKOWSKY, Illinois

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
              Kristine McElroy, Professional Staff Member
                           Jason Chung, Clerk
                    David Rapallo, Minority Counsel

                            C O N T E N T S

Hearing held on April 10, 2000...................................     1
Statement of:
    Martineau, Jean-Guy, director of Veterans Services, city of 
      Salem; Donald T. Welsh, director of Veterans Services, city 
      of Gloucester; Michael G. Ingham, director of Veterans 
      Services, city of Haverhill; and Robert C. Hogan, director 
      of Veterans Services, town of Burlington...................    45
    Murphy, Dr. Frances M., Acting Deputy Under Secretary for 
      Health for Policy and Management, Department of Veterans' 
      Affairs; Dr. Jeannette Chirico-Post, Director of Veterans' 
      Integrated Service Network 1; and William Conte, director, 
      Edith Nourse Rogers Memorial VA Medical Center.............    16
    Restani, Neil F., director of Veterans Services, town of 
      Lynnfield..................................................    84
Letters, statements, etc., submitted for the record by:
    Hogan, Robert C., director of Veterans Services, town of 
      Burlington, prepared statement of..........................    64
    Ingham, Michael G., director of Veterans Services, city of 
      Haverhill, prepared statement of...........................    58
    Martineau, Jean-Guy, director of Veterans Services, city of 
      Salem, prepared statement of...............................    47
    Murphy, Dr. Frances M., Acting Deputy Under Secretary for 
      Health for Policy and Management, Department of Veterans' 
      Affairs, prepared statement of.............................    19
    Restani, Neil F., director of Veterans Services, town of 
      Lynnfield, prepared statement of...........................    86
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut, prepared statement of............     3
    Tierney, Hon. John, a Representative in Congress from the 
      State of Massachusetts, prepared statement of..............     7
    Welsh, Donald T., director of Veterans Services, city of 
      Gloucester, prepared statement of..........................    53



                         MONDAY, APRIL 10, 2000

                  House of Representatives,
       Subcommittee on National Security, Veterans 
              Affairs, and International Relations,
                            Committee on Government Reform,
                                                       Peabody, MA.
    The subcommittee met, pursuant to notice, at 10 a.m., at 
the Peabody Memorial Veterans High School, 485 Lowell Street, 
Peabody, MA, Hon. Christopher Shays (chairman of the 
subcommittee) presiding.
    Present: Representatives Shays and Tierney.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Kristine McElroy, professional staff member; Jason 
Chung, clerk; and David Rapallo, minority counsel.
    Mr. Shays. This hearing will come to order and welcome our 
witnesses and guests and ladies and gentlemen, I invite you to 
please rise as the Peabody Air Force Junior ROTC Color Guard 
posts the colors.
    Today, we came here to listen and to learn from those with 
a direct stake in the future of veterans' health care in New 
    This is our third hearing on the impact of reorganization 
and funding shifts on the availability and the quality of care 
in Department of Veterans' Affairs [VA] facilities. Earlier 
testimony described long waits for access to specialists, 
lapses in health care standards and funding inequities within 
and between regional Veterans Integrated Service Networks 
(VSNS). VA officials said facility restructuring here in VISN-1 
and refinements in the Veterans Equitable Resource Allocation 
[VERA] system would, in time, bring improvements.
    But last July, Congress' auditing agency, the General 
Accounting Office [GAO], concluded VA could be wasting $1 
million or more every day critical health care restructuring 
decisions are delayed. Today, more than 8 months, or $263 
million later, GAO still reports the VA ``has been unsuccessful 
. . . in its efforts to design a capital asset realignment 
    So a significant portion of the $1.7 billion Congress added 
to the Veterans Health Administration budget this year may be 
spent operating and maintaining unneeded facilities, rather 
than enhancing access and improving the quality of needed 
health care for veterans.
    The effects of delaying the hard decisions in Washington 
are felt acutely here in New England. An older veterans' 
population, declining in numbers, but now in need of more 
extensive, more expensive, health interventions, cannot wait 
years, or drive hundreds of miles, for the basic care to which 
they are truly entitled. Today we need to talk candidly and 
objectively about how the VA can sustain and improve a health 
care system in New England that will meet veterans' needs in 
the new millennium.
    I want to thank Congressman John Tierney for inviting the 
subcommittee to the Sixth Congressional District of 
Massachusetts. We value his participation in this committee as 
an equal partner with the chair. We value this opportunity as 
well to discuss these important issues with those most directly 
involved, and we look forward to the testimony of all of our 
    John, I would like to personally thank you for asking us to 
come here and this committee oversees all of the VA, all of 
DOD, all of FEMA, all of terrorist activities at home and 
abroad and when I asked John what hearing was most important he 
said we needed to talk about the VA and to meet in his district 
and that is why we are here. We will do a lot of good listening 
    [The prepared statement of Hon. Christopher Shays follows:]

    [GRAPHIC] [TIFF OMITTED] T0278.001
    Mr. Tierney. Thank you, Mr. Chairman, and I want to thank 
everybody that has taken the time today to join us here at the 
    I want to be the first to officially welcome Congressman 
Chris Shays to join us in this particular district and I can 
say that we have a Congressman here as chairman of this 
committee who is truly a person that we can work with and who 
understands these issues and works very hard on them.
    I want to also welcome our witnesses from the Veterans' 
Administration, Dr. Murphy, Dr. Post and Mr. Conte with whom we 
worked with many, many times, as well as the veterans' agents 
from the surrounding areas who will also be testifying in the 
second panel. I am glad that you could all be with us and join 
us today.
    Let me also welcome all the veterans in attendance and the 
veterans service organizations who have provided written 
testimony for the record. It is imperative that we hear your 
concerns and your viewpoints today. I look forward to listening 
to your comments after the first two panels have concluded and 
you will see that we have microphones in the aisles and that we 
will have an opportunity for folks to make comments and ask 
some questions.
    Mr. Chairman, I have a written a statement from 
Representative Anthony Vera, the State Representative from 
Gloucester that I would like to ask be presented in the record. 
And I also have a written statement from Mayor Nicholas J. 
Costello, the mayor of Amesbury which I would like to ask be 
put in the record, as well as a written statement from 
Congressman Thomas Allen of Maine, which I believe is already 
in there and ask that you enter that in the record.
    Mr. Shays. Without objection, so ordered.
    Mr. Tierney. I would like to acknowledge and welcome Mayor 
William Scanlon from the city of Beverly who is also with us in 
the audience today who has been a great friend of veterans and 
a number of other veterans' agents who will not be testifying, 
but with whom my office works on a regular basis and provide 
great service to the veterans in this District.
    In Washington, veterans' health care is often analyzed as 
an issue of national scope, focusing on the processing, 
reengineering, streamlining initiatives and appropriations 
debates. Discussing the issue in this way sometimes removes and 
detaches policymakers from the concerns of individual veterans, 
veterans who live with the system on a daily basis, veterans 
who rely on the system for their most essential health care 
    That is why I am particularly gratified today to have a 
hearing analyzing the local point of view. In many ways, health 
care is rooted in local systems and infrastructure, so it 
behooves us to extract ourselves from the daily Washington 
processes to come here today and to analyze the issues from a 
different perspective, yours.
    For veterans in the Sixth Congressional District of 
Massachusetts, the facility that provides the primary and 
specialized medical care is the Edith Nourse Rogers Memorial VA 
Medical Center in Bedford. This institution has been providing 
care to veterans since 1929. It has always been a VA facility 
and last year it handled more than 186,000 visits.
    Today we have with us Mr. William Conte, the director of 
the facility who will provide additional background on the 
facility's capacity and his efforts to deal with shrinking 
    A recent development, and one in particular that I am very 
excited about is the establishment of community-based out 
patient clinics. We now have two, one in Lynn and one in 
Haverhill. They greatly increase veterans' access to health 
care. These clinics are important to the effort to reach out to 
veterans and to serve them in the communities in which they 
live. We have helped to move forward the application of a third 
CBOC in Gloucester.
    Last year, the Lynn and Haverhill CBOCs handled more than 
5,600 visits and I know the representatives on the panel will 
be able to respond to questions about those clinics.
    Although these are positive developments, there are also a 
number of challenges, both for veterans and the system that 
serves them. Transportation, to and from VA facilities is a 
primary concern. Again, the clinics are extremely valuable in 
extending VA's outreach to other areas, but for veterans who 
need specialty care or report for multiple visits, 
transportation hurdles may be too great to overcome.
    I understand that if veterans go to one or two clinics, 
they can catch a shuttle to the Bedford facility if they need 
x-rays or other services not provided at the clinics. If they 
need more specialized services, however, such as an upper GI 
endoscopy, they may have to take another shuttle still into 
    For veterans, the current transportation process can be 
insurmountable, especially if it involves anesthesia or other 
procedures that complicate traveling alone. I hope we can 
discuss transportation concerns today, both at the regional and 
the local levels.
    Long term care is also an issue that is gaining 
significance. VA has highlighted outpatient solutions and in-
home care, which have their own advantages. If VA can assist 
veterans without uprooting them from their homes, this solution 
benefits everyone involved. My concern, however, relates to 
veterans with degenerative and other conditions that eventually 
may require hospitalization and inpatient treatment.
    VA is now in the process of downsizing its inpatient 
capacity as it redirects assets toward outpatient care. So how 
will short-term shift affect the extended term outlook? How 
will VA be able to deal with the increasing demand of long-term 
care when the baby boom generation moves into this stage? And 
how do these concerns relate to VA's ability to comply with the 
Millennium Health Care and Benefits Act?
    These are just a few of the issues I hope our witnesses 
will address today, and although I know there are many more of 
interest to the veterans in attendance, I look forward to 
hearing their testimony also.
    Before concluding, let me just extend my thanks to several 
people from Veterans Memorial High School here in Peabody who 
have helped to make this hearing possible: Principal Joe 
Patuleia, Elaine Kirby, Richard Carey, Major Grover, of course, 
and the students of the culinary arts and the Air Force Junior 
    In addition, I would like to thank the Peabody Police 
Department and Temple Beth Shalom for allowing us to use their 
parking lot.
    I would also like to recognize Michael King, who is the 
director of the North Shore Veterans Counseling Services, for 
his dedicated service to our country and for keeping our North 
Shore veterans informed about the timely issues in his 
veterans' column in the Salem Evening News.
    Finally, I would like to thank Chairman Shays again for 
calling this hearing. As I mentioned, I think this type of 
local focus adds immeasurably to our ability to address these 
issues. It is a special privilege to have the opportunity for 
the subcommittee to address issues specific to my own district.
    I appreciate your willingness, Mr. Chairman, to hold this 
hearing today in Peabody. I especially commend you for all the 
work that you do in addition to veterans' issues with the very 
serious matter of terrorism and preparedness in this country 
for any event that may occur and I look forward to today's 
    Thank you.
    [The prepared statement of Hon. John Tierney and the 
information referred to follow:]










    Mr. Shays. I thank the gentleman and we will just get some 
housekeeping taken care of.
    Pursuant to House rules and committee rules I note for the 
record that the subcommittee requests that all witnesses 
appearing in this hearing in a nongovernment capacity provide a 
resume and a disclosure of Federal grants and contracts 
received and further ask that all testimony be submitted for 
the record and remarks by our colleagues be submitted for the 
record as well.
    Without objection, so ordered.
    I would also like to say that before calling our panel that 
this committee has had an excellent working relationship with 
the Department of Veterans' Affairs and we realize this is a 
partnership, so this is not a committee that is just standing 
in judgment of the VA. We also look at how Congress and the 
administration play a role in providing better health care for 
our veterans.
    At this time, I am not sure if my mic is on all the time. 
Mine is not on at the time. I am not bringing the mic closer. I 
need the people in the back to get it better.
    At this time, we will call Dr. Frances M. Murphy, Acting 
Director, Under Secretary for Policy and Management, Veterans' 
Health Administration, Department of Veterans' Affairs, 
accompanied by Dr. Jeannette Chirico-Post, Director of 
Veterans' Integrated Service Network I; and Mr. William Conte, 
Director, Edith Nourse Rogers Memorial VA Medical Center. I 
invite them all.
    Remaine standing and I will swear you in.
    [Witnesses sworn.]
    Mr. Shays. Note for the record that the witnesses have 
responded in the affirmative.
    Dr. Murphy, you have the testimony, but we are going to 
invite both of our guests as well to respond to questions. That 
is why you are all three under oath. I will note this committee 
swears every one under oath. The only one who has ever gotten 
away without being sworn in was Senator Byrd. All other 
Senators and Representatives have been willing to cooperate.
    Thank you, Dr. Murphy.


    Dr. Murphy. Good morning. Mr. Chairman, Mr. Tierney, Mayor 
Scanlon, and honored guests. I appreciate the opportunity to 
appear before you today to discuss VA Health Care in the New 
Millennium. With me today are Dr. Post and Mr. Conte from the 
Edith Nourse Rogers Memorial VA Medical Center in Bedford, MA.
    I would like to take the opportunity to compliment the Air 
Force ROTC and say it makes me proud to see our young people do 
so well.
    The past decade has been characterized by dramatic change 
in the delivery of health care services in the United States. 
In the past 5 years, the VA health care system has also had a 
tremendous transformation. VA has transformed itself from a 
disease-oriented, hospital-based health care system to an 
integrated system providing a continuum of accessible, 
coordinated, patient-centered, prevention-oriented care.
    We have seen demonstrable improvements in our capacity to 
achieve consistent, reliable, accessible, satisfying and high-
quality care. We also continue to face challenges of reducing 
medical errors in health care and meeting the needs of an aging 
population, of incorporating the explosive growth of scientific 
knowledge into daily practice and of incorporating expensive 
new medical and information technologies, and of realigning our 
infrastructure to more effectively support current health care 
    Structurally, ``New VA'' is composed of 22 Veterans 
Integrated Service Networks [VISNs]. Each VISN forms a regional 
health care system that provides a continuum of health care to 
veterans who reside in a geographic area.
    More than at any other time in our history, VA more closely 
mirrors--and in many cases exceeds--the best in private sector 
health care. Indeed, the structural transformation underpins a 
quality transformation. Significant organizational changes 
include: closing more than 52 percent of all hospital beds 
since July 1994; reducing inpatient admissions by 34 percent 
between 1994 and 1999; providing health to over 700,000 more 
veterans in 1999 than in 1994.
    That is a 31 percent increase in the number of veterans 
cared for by the VA. Within the networks we consolidated 
managements and operation of 48 hospitals or clinics into 23 
locally integrated health care systems since September 1995. 
Also we approved and brought 388 new community-based outpatient 
clinics into operation since 1995. We will establish more than 
60 this year and that means that VA will have more than 1,200 
sites of care across this Nation in bringing health care 
services into more veterans' communities.
    Over that same period of time, we increased the rate of 
selected surgeries and procedures which are safely provided in 
the ambulatory setting to 92 percent of surgeries that are 
    Especially notable in clinical achievements are reduced 
avoidable hospitalizations and lowered mortality, resulting in 
cost-savings through reductions in avoidable health care 
    For example, the rates of pneumonia and influenza 
vaccinations provided to VA patients far exceed U.S. Public 
Health Service Healthy People 2000 goals and available 
benchmarks. Also, life-saving beta-blocker medications after 
heart attacks are provided at VA hospitals at rates that exceed 
all available benchmarks in the private sector. These two 
actions alone have saved, Mr. Chairman, an estimated 5,000 
lives since instituted. That is an incredible accomplishment in 
quality health care for veterans.
    Similar improvements have been seen in other areas of 
preventative health services such as screening for cervical and 
breast cancer and in the treatment of prevalent diseases such 
as diabetes and mental illnesses. Simultaneously, patient 
satisfaction has increased. In fact, VHA scored 79 on the 
externally conducted American Customer Satisfaction Index. This 
is significantly above the score obtained by the private sector 
health institutions who scored only 70 on that scale. Loyalty 
and Customer Service scores are even higher at 90 and 87, 
    Mr. Chairman, the VA New England Health Care System has 
shared in the accomplishments of the VA health system and in 
some instances has led the way. Network 1 also faces the same 
challenges that confront many other areas of the country.
    I would like to take the opportunity briefly to discuss the 
accomplishments and challenges that are facing the New England 
Healthcare System (Network 1). Network 1 is an integrated and 
comprehensive health care system that delivers care to all six 
New England States, Maine, New Hampshire, Vermont, 
Massachusetts, Rhode Island and Connecticut.
    Twenty-five community-based outpatient clinics are 
strategically located throughout New England and provide 
increased access to health care services for veterans. Network 
1 has significant and long standing affiliations with some of 
the most prominent medical schools in the country. These 
include Boston University, Brown, Dartmouth, Harvard, Tufts, 
Yale, Universities of Connecticut, Massachusetts and Vermont 
Medical Schools and the University of New England. Funded 
research programs are another strong suit in Network 1 with the 
third highest research funding in VHA.
    Over the past 5 years, from 1995 to 1999, VHA faced a very 
challenging budget situation. Our budget in real dollars 
decreased by 23 percent over that time period. However, I am 
pleased to tell you that with the $1.7 billion increase that 
appropriated for VHA in 2000 and a $1.3 billion increase that 
has been proposed in the Presidential budget for fiscal year 
2001, we believe that we will be able to increase the access 
and decrease waiting times for veterans, further increasing the 
quality of care delivered by the Veterans Health 
    Network 1 has seen several changes in leadership during the 
past year. Mr. Fred Malphurs was appointed as the Interim 
Network Director, following the retirement of the former 
Network Director. Mr. Malphurs has been instrumental in setting 
a course that promotes teamwork, ``open book management,'' and 
greater participation in network committees and strategic 
    Recently, Dr. Jeannette Post was appointed as the Network 
Director after serving as the Acting Clinical Manager for 6 
months. I am pleased to tell you that she brings to this 
position excellent management and clinical credentials and a 
passion for delivering quality health care services to the 
veterans of New England. We will provide effective leadership 
and expand the initiatives to provide quality, accessible 
health care services in an integrated delivery network.
    I would like to turn the microphone over to Dr. Post at 
this point to let her tell you about the initiatives that will 
take place in Network 1 over the next several months.
    Dr. Post.
    [The prepared statement of Dr. Murphy follows:]

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    Dr. Post. Thank you for the opportunity to discuss the 
accomplishments and challenges that are facing the VA New 
England health care system. Network 1 is an integrated and 
comprehensive health care delivery system that delivers care in 
the six New England States. Twenty-five community-based 
outpatient clinics are strategically located throughout New 
England and provide increased access to health care services 
for veterans.
    Network has a significant and longstanding affiliation with 
nine of the most prominent medical schools in this country. We 
are the third highest research funding in VHA. Network 1 is 
committed to provide quality health care services to the 
veterans throughout New England. The goal is to provide the 
right care at the right time and at the right level required to 
safely and compassionately meet the unique needs of each 
    A major Network 1 initiative has been the development of 
this integrated health care system based in primary care. This 
primary care model has resulted in improved continuity, 
improved satisfaction and an increase in the number of patients 
    The Network opened a new CBOC in southern Maine on March 17 
and we expect to open 12 new CBOCs this year. Feedback from 
patients is one of the most significant measures of quality. We 
are currently No. 1 in the country in overall quality of care 
as rated by ambulatory care patients.
    Network 1 was the first network to obtain the joint 
commission of accreditation, network accreditation with 
commendation. It was recognized for meritorious achievement as 
a finalist for the kinds of quality achievement recognition 
grant last year.
    Network 1 has embarked on a new mission to communicate more 
often and in more detail with veterans, employees, affiliates, 
congressional offices, local unions and other stakeholders. A 
number of communication tools have been developed that are 
responsive to the needs of patients, employees and stakeholders 
and enhance the understanding of network initiatives.
    All nine VA Medical Centers are utilizing the computerized 
patient medical record. We have implemented a state-of-the-art 
information technology called Webtop which will allow a 
clinician anywhere in New England to access the electronic 
medical record for any enrolled patient. Both of these systems 
will foster communication and consultation among physicians 
throughout New England.
    One of the greatest challenges facing Network 1 is the need 
to come together as one network instead of its current, 
parochial orientation of nine individual medical centers. 
Network needs to move from a hospital-centered system to a 
Network patient centered system which provides health care 
services along the entire health care continuum. The Network 
must re-engineer its business processes and implement clinical 
practice guidelines to ensure there is a single, consistent 
standard of quality health care regardless of geographic 
location of care and delivery.
    Another strategic goal of Network 1 is to integrate health 
services by fully implementing Care Line management. Care Lines 
are intended to enhance the provision of uniform, high quality 
services throughout the network by reducing variations in care 
and standardizing availability and coordination of services. 
This allows for improved management of patients along a 
seamless continuum of care.
    Another major initiative is the consolidation of the local 
Boston facilities, Jamaica Plain, West Roxbury and Brockton. 
The consolidation will reduce duplicate clinical services and 
business processes. The Bureau of Resource Allocation System 
was developed to match resources with patient needs across the 
country. Although the network received reductions in resource 
allocations in the first 2 years, in fiscal year 2000 Network 1 
received a 5\1/2\ percent increase or $43 million more than the 
prior year. It is projected that our next year's funding will 
be a 2.9 percent increase equated to $24 million.
    Network 1 has a cost per unique patient that is 
approximately $400 greater than the national need and has 
staffing ratios that are some of the highest in the country. We 
have made strides to reduce overall cost per patient, however, 
we need to gain additional efficiencies through reorganization 
of health care delivery systems. These efforts will improve the 
network's ability to deliver high quality care and serve more 
patients at a reduced cost in the future.
    Thank you for the opportunity to discuss the achievements 
of Network 1.
    Mr. Conte. For those who do not know the scope of the 
Bedford Hospital, it is basically a long term care facility 
psychiatric care with rehab focus, a large Alzheimer's 
component and a primary care clinic around the eastern 
Massachusetts area and a large research component.
    Since this hearing today is being held in Peabody, MA, I 
will provide you with information of a few of the many 
successful local initiatives. VHA Network 1 appreciates the 
support and encouragement of the New England Congressional 
Delegation in the opening of new community based outpatient 
    Congressional support was instrumental in the success of 
the clinics in Lynn and Haverhill, and to the proposed clinic 
for Gloucester. The clinic in Haverhill is located with the 
Hale Hospital, a facility owned and operated by the city of 
Haverhill, creating a mutually beneficial partnership with the 
community. The clinic in Lynn is located in a private sector 
medical building. Both the Lynn and Haverhill clinics provide 
primary care services and have expanded recently to include 
mental health counseling.
    The Edith Nourse Rogers Memorial Veterans Administration 
Hospital in Bedford operates an Alzheimer's care program that 
is nationally known for its comprehensive quality care. It is 
comprised of an Outpatient Program, an Adult Day Care Center 
and an Inpatient Program.
    The Alzheimer's care program is fully integrated with the 
Geriatric Research Education and Clinical Center known as a 
GRECC in the VA facility. The Bedford GRECC program is a unique 
program in that it is fully integrated with clinical care, a 
full partner with its academic affiliate, Boston University, 
and designated by VHA Headquarters as a National Center to 
facilitate cooperative efforts between the VA, private sector 
health care organizations and pharmaceutical companies.
    To enhance the continuum of health care services provided 
to veterans, the Bedford VA Medical Center has embarked on two 
innovative projects utilizing the Enhanced Use leasing 
authority. The first proposal is to establish a cooperative 
venture with a private sector organization for construction and 
operation of an Assisted Living Center at the Bedford VA 
Medical Center with an emphasis on Alzheimer's.
    In return for the ability to utilize VA property, the 
private sector organization will provide bed space for VA 
patients at no charge. This proposal is expected to be approved 
and construction started in 2001. The second proposal would 
establish a cooperative venture with the New England Shelter 
for Homeless Veterans, a nonprofit organization for 
construction and operation of 40 units of Single Residency 
Housing at Bedford. In return for the ability to utilize VA 
property, the New England Shelter will lease the building and 
this will help us offset some of our operational costs. This is 
a change in the testimony. This proposal is expected to be 
approved and construction started in the near future.
    Another example of a VA-private sector partnership is in 
the area of health care services to homeless veterans. A 
private sector homeless services provider, Ms. Leslie 
Lightfoot, has received a VA Grant to obtain, equip and operate 
a health care van in the greater Worcester, MA area. This 
program will provide the van at scheduled, designated locations 
to perform basic health screenings and followup.
    The Bedford VA Medical Center will provide expertise in the 
planning phases of this project and will provide equipment, 
supplies and personnel to support this important homeless 
outreach effort which is expected to be operational by this 
    Thank you.
    Mr. Shays. At this, Mr. Tierney, I invite you ask any 
questions you would like.
    Mr. Tierney. Thank you very much, Mr. Chairman, I thank the 
members of the panel for their testimony.
    I want to ask Mr. Conte a question first, but I think I 
would be remiss if I did not share with the folks that are 
here, as well as with the chairman, just the wonderful work 
that the folks at the VA Hospital in Bedford have done and the 
cooperation that they have given my office and the veterans' 
councils and agents throughout the district.
    We have had a number of health fairs that probably could 
not have happened without Mr. Conte and his staffs volunteering 
considerable amounts of their time on several days in this past 
couple of years in Haverhill, in Lynn and out in Gloucester 
where people gave their time to run the tests, to sign people 
up to make sure that we had appreciation for the number of 
veterans who would, in fact, utilize those services.
    And so I want to thank you publicly and your staff through 
you for the cooperation that you have had. And it went beyond 
that. Once the CBOCs were actually cited first on the North 
Shore and then in Haverhill. The staff worked with local 
veterans' councils and gave them a voice in where they would be 
located and how they would be established and how they would be 
staffed and that continues to go on, so we are very, very 
appreciative of that.
    Last, let me just say we gave you a major headache at one 
point in time when we put out a veterans' newsletter that 
indicated that there was a prescription drug benefit to which 
veterans were entitled and I think the next day you had over 
500 phone calls rushing into the clinics and your office was 
good natured and gracious about building those and making sure 
that the veterans, in fact, got the benefit of those services 
so on behalf of veterans I would thank you for making sure that 
they were well served with the right disposition and attitude 
when that increase of calls came in.
    As you know, Mr. Conte, I am very much a proponent of the 
community-based outpatient clinics. Can you tell us roughly 
what resources these clinics that are in this district have had 
and how many physicians and nurses they have and what type of 
care they are generally provided?
    Mr. Conte. Yes. I will start with Lynn. Lynn was originally 
staffed with the positions of a physician and a nurse 
practitioner and administrative support and that would be 
roughly in the area of about $350,000 worth of personal 
services and then in the Lynn area we contracted with a medical 
building there and I believe the lease was in probably the 
$30,000 range, so we are looking at about $400,000 roughly that 
goes into that clinic when it started a year and a half ago.
    We have increased services. At this point we have mental 
health practitioners going up there now, so I would say we are 
well up over $500,000, according to that clinic. That does not 
count all the new patients or the new prescription drugs and 
all the services we provide back at the Bedford facility. 
Haverhill was brought up the same way.
    Both of these clinics were brought up as a startup 
initiative, let it grow and let us meet the demand. Haverhill 
is very similar in terms of its original start. It was a nurse 
practitioner, physician and administrative support, again in 
the $300,000 to $500,000 range at this point in time.
    Mental health services are expanding in both those areas as 
we speak.
    Mr. Tierney. Does the entire budget for those facilities 
come from the Bedford facility?
    Mr. Conte. In the past, yes, that has been true and the 
issue was that if we did get an outpatient clinic we would 
generate those dollars within the facility and the VA facility 
at Bedford, we have been very dynamic in rearranging, 
reprogramming dollars.
    We have done a lot of sharing with other facilities. We 
have done a lot of consolidations for things like 
administrative services. For example, a good example, we used 
to have a large kitchen staff, now we do cook/chill which is 
basically cooked in West Roxbury, the food is prepared there, 
it is brought to the veterans facility and that saves us a lot 
of dollars and that provided the dollars to expand to those 
    The Haverhill staff are part of the Bedford facility and so 
are the Lynn staff, so is the Winchendon staff. There is 
another group out in Winchendon that people do not realize has 
been there for many years. Also the VCC in the Lowell area, 
Veterans' Community Care Center.
    Mr. Tierney. And despite, has the Bedford facility been 
able to maintain its patient case load, the waiting time has 
been about the same and not increased?
    Mr. Conte. Two questions. The waiting time, 5 years ago, we 
have a member of the GPRA, Government Performance Review Act. 
We are a pilot site. We establish times that were in the range 
of 7 days and less than 30 minutes to be seen in a primary care 
clinic. Over those 5 year periods, I do not think we have 
exceeded those times four or five times. We have a strong QA 
program that monitors that, so we have been working with that 
for many years, so yes, we have been able to maintain our times 
by shifting staff in the ambulatory care.
    The other issue is that the dollars that we have taken from 
programs have enhanced that ability to expand those clinics. We 
have expanded some clinics and have been able to maintain those 
times, yes.
    Mr. Tierney. One of the issues I expect me hear about 
something today, but I heard about it quite frequently in our 
offices is transportation. I understand there is shuttle 
service to the Bedford facility, but I would like for you to 
take a moment, if you would to describe how often the shuttle 
runs and what is entailed in participating in that 
    Mr. Conte. Difficult question. They change quite a bit. 
There is shuttle that runs from the Worcester clinic, excuse 
me, from the Lynn clinic to Bedford and back, I believe four 
times a day, a morning run and the afternoon run. There is also 
a shuttle that runs to the Haverhill clinic back to Bedford and 
then there is part of a consolidated transportation network 
that is working out of Boston that the VISN initiative startup 
was a VISN initiative about a year and a half ago when they 
were working the transportation network.
    We, ourselves, at the Bedford facility decided to run this 
shuttle to try to get people back to the Bedford facility when 
they need that kind of care and I think it has been reasonably 
successful. As the clinic expands, there may be need for more 
transportation. Obviously, you identified that earlier.
    Mr. Tierney. How is the staff of these programs being paid? 
Are they being paid by the clinics themselves or?
    Mr. Conte. Out of our operating dollars at the veterans 
facility, certainly.
    Mr. Tierney. Are there any other plans for that network 
transportation concern in the future?
    Mr. Conte. At the VISN letter there is a Boston 
consolidated transportation network and actually there was a 
contract let out about a year and a half ago and there was an 
evaluation period. We are going through that right now, for the 
private sector vendor who was coordinating that transportation 
network in the Boston area. Lynn and Haverhill are not included 
the initial startup of that, so we ran the vans ourselves, but 
we have to look at that, yes.
    Mr. Tierney. With the indulgence of the chair I would like 
to continue. I am beyond my time for a couple of seconds.
    Can you describe how someone who wanted to go to the clinic 
in Haverhill would actually get to say Jamaica Plain or Bedford 
or West Roxbury if they needed to get there, how that works?
    Mr. Conte. I believe there is a van that is going down to 
Jamaica Plain, but it is not as regular, I believe, as the one 
we have running back from Bedford, but you could take two 
routes, obviously, public transportation being another option, 
but you could take a van from the Lynn clinic to Bedford and 
then from Bedford into Jamaica Plain which makes it a little 
difficult sometimes and I believe we are starting an initiative 
to run a van from those clinics because they have gotten to the 
point where you have enough demand. In the past there has not 
been that demand.
    Mr. Tierney. Is the demand for the service of the clinics 
actually helping our budget here locally, the way the current 
funding situation is going?
    Mr. Conte. I would think so. Our numbers alone have gone 
from about 9,700 veterans to over 11,000 and we have been 
trying to put a finger on that, if they were coming to Bedford 
and now to Lynn or if they were new at Lynn and I would 
strongly support the idea that more people are coming to the 
Lynn and Haverhill clinics because of access and therefore we 
are earning more dollars under this VERA model, yes.
    Mr. Tierney. Now a lot of veterans have asked questions 
about the plans to implement the new millennium bill, maybe you 
could help us first by telling us a little bit about the 
requirements of the bill or Dr. Murphy or Dr. Post or whoever, 
just give a brief outline about the millennium bill and then 
maybe I think somebody was a little perplexed about the lack of 
funding, a vital functioning of that particular bill and all 
that it calls for and I would like for you to tell us what your 
approach is going to be in dealing with that.
    Dr. Murphy. I will start and then I will turn it over to 
Dr. Post. The millennium bill is a rather complex piece of 
legislation. The millennium bill provides for a continuum of 
long-term care. In fact, it provides long-term care to veterans 
who are greater than 70 percent service connected and allows VA 
to provide that care on a more consistent basis.
    It also gives us the ability to provide noninstitutional 
long-term care by allowing us to set up pilots for assisted 
living and to do more home-based, long-term health care. It 
also changes some of the provisions for the State homes.
    As you can imagine, the implementation of this legislation 
requires many policy decisions and publication of regulations. 
We are well into that process and expect to be able to move 
forward relatively quickly. In fact, Dr. Post spent last week 
down in Leesburg, VA leading one of the seven subcommittees 
working on the implementation plan for that bill. It is a 
complex piece of legislation, but it does give veterans more 
access to the long-term care that they are going to need in the 
    Were there specific aspects of the bill?
    Mr. Tierney. I was interested in the funding of it which I 
think is problematically probably more on our level than yours, 
but I am curious to know what your approach is going to be.
    Dr. Murphy. We did put specific funding into the 2001 
budget that will allow us to fully fund the long term care 
piece of that legislation.
    In addition, the legislation set out VA authority to charge 
copayments for some long-term care and so part of what will pay 
for that is some of the co-payments that we will collect from 
veterans who use the long-term care.
    Mr. Tierney. Does that also include--I was concerned that 
as that bill was coming through Congress with the prescription 
drug aspect of that. I was very concerned at the beginning, but 
there is now an allowance for an increase in the co-pay on 
that. Do you anticipate that that is going to a severe 
increase, moderate increase, no increase?
    Dr. Murphy. We do not believe that there will be a very 
large increase in the pharmacy co-payments. The problem was 
that the level of co-payment the VA was charging was not even 
paying for the administrative costs of sending out the bills 
for the copayments. I think the copayments are likely to be 
under $10 and probably closer to $5 per monthly medication 
    Mr. Tierney. Thank you.
    Dr. Post. I just wanted to add to the comments that Dr. 
Murphy just gave you about the implementation of the millennium 
bill. If you believe that all health care should be local I 
think VA has moved in the right direction by establishing an 
increasing number of access points or CBOCs and in our network 
alone with the additional 10 to 12 that will happen in this 
year, that will be a plus.
    The millennium bill affords us the opportunity to make all 
long term care local and that includes not only the 
institutional care, but the noninstitutional care and we in New 
England have already started to move to enhance that access, 
our relationships with the State Veteran Homes, the further 
development of the geriatric and long-term care on that. We 
have additional development of 24 hour day, 7 day a week 
contact with us from the emergency room.
    Mr. Tierney. Can you tell me how that will work? Are you 
going to reduce bed space now and bring it more out to the 
community and more outpatient based. What about the long term 
care inpatient demand? When that increases in the future, will 
we have what we need to address that?
    Dr. Post. I think that is part of the process for us. Part 
of the process is to decide where is the right level for the 
patient to be maintained for the longest period of time for the 
patient to maintain his functional independence.
    Mr. Conte talked about our Alzheimer's unit at the Bedford 
VA which maintains the patient from an ambulatory care through 
a day care and then up through institutional care. I think that 
over time the issue for us is to have the right size and I do 
not know if I can predict the numbers that are there for right 
    Mr. Tierney. Are you in the process of doing any sort of 
survey or determining what the likely demand for in-patient 
care is going to be for baby boomers?
    Dr. Post. I think that is part of our geriatric/long term 
care line to make an assessment of where we should be and then 
to address, as Dr. Murphy has said, through the millennium 
bill, the additional placement of those patients that are 70 
percent or greater.
    Mr. Tierney. Thank you. Mr. Chairman, why do not I let you 
have a few questions.
    Mr. Shays. Thank you. I am going to ask these questions as 
if I were in Washington and not be concerned that I am asking 
them in Massachusetts, but the purpose is to understand the 
challenges and to give you an opportunity to respond to it.
    In Connecticut, we felt we did our duty by consolidating 
Newington and West Haven and making it one system which is 
referred to as the Connecticut Health Care System. You have a 
facility in Vermont. You have a facility in New Hampshire. You 
have a facility--I am talking major facilities, not community-
based health care clinics, a major facility in Rhode Island as 
well. And you have four facilities in Massachusetts, I believe, 
and now you have consolidated two and I just want to sense, is 
there going to be eventually one Massachusetts Health Care 
System coordinating the major hospitals?
    Dr. Post. The process to look at the delivery of health 
care in Massachusetts was thoroughly reviewed. That review 
process began some 2 to 3 years ago as we came to be an 
integrated delivery system. And actually, Mr. Conte and I were 
on one of the first groups to look at what we should do in the 
network for those two locations, 5 miles apart, Jamaica Plain 
and West Roxbury. West Roxbury had already been joined with the 
Brockton VA I think some 10 years prior to----
    Mr. Shays. How many major facilities are we talking about 
in community based health care clinics?
    Dr. Post. Bedford, JP, Jamaica Plain, West Roxbury and 
    Mr. Shays. Five facilities. I am sorry, four.
    Dr. Post. Four facilities.
    Mr. Shays. Right, consolidated into how many?
    Dr. Post. No, Bedford is still unique. The Jamaica Plain, 
West Roxbury and Brockton have been in the process of 
consolidating and integrating into a single health care system.
    Mr. Shays. And it will have one so then you will have two 
    Dr. Post. Right.
    Mr. Shays. And the savings from that, it seems to me can 
then be poured into--it does not go back down to Washington, it 
stays up in District 1?
    Dr. Post. Correct, in VISN 1.
    Mr. Shays. When will that consolidation be concluded?
    Dr. Post. It is projected to be finished within the next 3 
to 4 years.
    Mr. Shays. So right now we have five community based health 
care clinics in Connecticut. Is there any plan to open any 
others, do you know?
    Did I ask the wrong question? [Laughter.]
    Dr. Post. And I did not even answer yet.
    Mr. Shays. Is that your final answer? I would just be 
interested in knowing how the transcriber records that event. 
    I saw some veterans actually dive for--as they are trained.
    Dr. Post. If I may answer the question, as we as a network 
look at where care is delivered and I said it before and I will 
repeat my phrase of health care is local, so there are 
additional CBOCs planned for Massachusetts as well as 
    Mr. Shays. Will any of these go through--you have 5 in 
Connecticut, 6 in Maine, given the size of the State, 2 in 
Vermont, 10 in Massachusetts, 2 in New Hampshire and none in 
Rhode Island, community based health care clinics. Do I have 
old information?
    Dr. Post. No, that is correct.
    Mr. Shays. Now do you have plans to increase the number in 
Connecticut, in Massachusetts? Are there any specific ones that 
you can mention?
    Dr. Post. I would be happy to mention some of them. We 
actually have just submitted, I think it is four or five that 
have gone into headquarters for the technical review that is 
required and I will check on the site of the Connecticut one. I 
just cannot remember. I think it is Danbury.
    Mr. Shays. I think you are right.
    Dr. Post. OK, and in Massachusetts, it is the Gloucester 
clinic, it is Quincy, two sites, Turners Falls in the western 
part of the State of Massachusetts and additional ones in 
Massachusetts to be considered. And in Rhode Island, there is 
one in Newport, Martha's Vineyard in Massachusetts as well is 
being considered.
    Mr. Shays. Massachusetts now has three community based 
health care clinics?
    Dr. Post. That is correct.
    Mr. Tierney. This is a powerful man.
    Mr. Tierney. These clinics have enabled you, it seems to 
me, to provide a better service for those particular needs at a 
reduced cost, is that correct?
    Dr. Post. That is correct and as I mentioned in my opening 
testimony that as an integrated delivery system, as we move 
toward an ambulatory care or primary care service line, we will 
develop as a network a standard of care across the network that 
is to the best practice so that the care that is rendered in 
Lynn and Haverhill is the same that is rendered in Newington 
and West Haven clinics in Connecticut. We can, as an integrated 
delivery system, then grow in terms of meeting the needs of our 
    As Mr. Conte said, the majority of care that is delivered 
in our CBOCs is primary care. Good primary care can meet 80 to 
85 percent of the needs of our veteran population. Following 
that, the specialty services, the mental health services. As we 
know the population that we are managing, then we need to 
provide the additional support for both the mental health and 
the specialty clinics.
    Mr. Tierney. Now the way the system works, as you service 
more veterans, you get more resources provided, correct?
    Dr. Post. Correct.
    Mr. Tierney. So it is based on the number of veterans 
    Dr. Murphy. Correct.
    Mr. Tierney. And it strikes me that by expanding community-
based health care clinics you are reaching more veterans as 
they get older who need this service who do not have to go into 
a larger facility with the bureaucracy sometimes associated 
with the larger facility. It is more personal and so on. I 
think the next hearing that I want to know is why does one 
Member of Congress get three in a State with only 10 Members, 
but that is for another hearing.
    Mr. Shays. Let me just ask you another question. One of the 
tragedies of our failure to properly--is there someone who is 
kicking the mic that we do not know about? It is a shocking 
    Let us give it a try. Our failure to properly protect our 
blood supply resulted in the HIV virus working--that pathogen 
working into our blood supply, but one of the silent killers 
was hepatitis C and in the course of our hearings we learned 
about hepatitis C a number of years ago.
    My sense is that the VA has done a better job than almost 
any other health care network in terms of dealing with 
hepatitis C and I would just like to know if, Dr. Murphy, you 
could give us a sense of what is happening there?
    Dr. Murphy. I would be happy to. Thank you for the 
compliment on our hepatitis C program. I think VA has been very 
proactive on this issue. And one of the reasons for that is 
that VA or veterans have a higher rate of hepatitis C than the 
general population. The population in the United States has a 
rate of about 1.8 percent of hepatitis C and veterans at least 
by our estimates from a 1-day screening program have a rate of 
about 6.6 percent, so it is significantly elevated in the 
veteran population.
    In our drug treatment programs it can be up to 40 percent 
of the IV drug abusers being treated, so it is a very important 
problem for veteran.
    Hepatitis C can cause chronic liver disease, including 
cirrhosis and liver failure and sometimes result 20 or 30 years 
down the line in liver cancers. So it is important to identify 
the infection by screening veterans and the risk factors 
include exposure to infected blood products from transfusions 
or from IV drug abuse and also other blood exposures.
    If you go into a VA medical center the physicians and 
health care providers will ask you about risk factors for 
hepatitis C and offer you a blood test that can rule out 
hepatitis C. Prior to 1992 there was not a blood test that 
could be done and so individuals who received blood 
transfusions prior to that date may have received infected 
blood products.
    We have screened several hundred thousand veterans, in our 
health care system and have found about 60,000 individuals who 
are infected with hepatitis C. We have provided our health care 
providers with guidelines for treatment. There are drugs 
available, very good drugs that can help treat hepatitis C and 
prevent the complications and so I would encourage any of you 
who might be worried about being exposed to this infection to 
go into your local VA medical center and get screened.
    We are also providing a lot of education to our providers. 
We will have done three national training programs, face to 
face conferences with our health care providers as of the end 
of this year. We have done national teleconferences. We have 
participated with NIH in training programs and with the 
American Liver Foundation. So VA has been a leader in this 
    Mr. Shays. Thank you. Would you tell me what veterans have 
been most exposed to hepatitis C, what era veteran?
    Dr. Murphy. It appears that there was an epidemic that 
occurred in the 1960's and early 1970's and the highest rate of 
hepatitis C appears to occur in Vietnam Era veterans. However, 
any veteran who is exposed to infected blood products would be 
at risk for hepatitis C.
    Mr. Shays. Let me go to Mr. Tierney in just 1 second. I 
want to ask these two questions for the record and I would like 
to know how are the allocations distributed to the facilities 
in VISN 1? How do you decide what, how they are allocated?
    Dr. Post. The process that has been used in the past is the 
historical information of workload that was done in the prior 
year and then an adjustment made to that for various incentives 
that may on in the facility. That has been the allocation up 
through this fiscal year.
    Mr. Shays. And is it likely to change in the next few 
    Dr. Post. It is our intent as we move toward better 
definition of an integrated delivery system to have the 
resources delivered, some of it will continue to go to the 
facilities, but the majority of it will be through our care 
    Mr. Shays. Last question. What is the timeframe which VISN 
1 hopes to achieve the goals of increasing the number of 
veterans' users by 5 percent and to decrease the cost by 5 
    Dr. Post. This year. We hope to make that achievement this 
    Mr. Shays. Thank you.
    Mr. Tierney.
    Mr. Tierney. Thank you. I know how good we are getting 
because we are not letting the interruptions bother us now. We 
just go straight through.
    Let me just say I understand some veterans need to obtain 
replacement copies of their discharge forms from the National 
Veteran Center in order to obtain various services and although 
turn around time has significantly improved, I understand, 
there is still quite a backlog. Could you tell us whether or 
not there are efforts under way to address this particular 
    Dr. Murphy. I cannot answer the question specifically about 
providing the DD214 form, but I will find that information and 
get back to you.
    Mr. Tierney. Thank you. Also, the average processing time, 
I guess, the original compensation claim is about 204.8 days. 
And I am just curious, are there ways that we can reduce this 
for veterans. Sometimes these two problems interact and create 
a significant difficult and I just see that issue coming up 
over and over again.
    Dr. Murphy. All three of us are with the Veterans Health 
Administration and the claims processing is administered by the 
Veterans Benefits Administration which is administratively 
separated from VHA. However, I know that Joe Thompson, the 
Under Secretary for Benefits has been taking VBA through a 
reengineering process.
    The waiting times have actually gone up slightly in the 
past year as they have been training more rating specialists 
and they knew that their performance would get worse before it 
got better because as you are training it takes more time and 
more resources to process a claim, but they expect that with 
the increased number of rating specialists that are being 
trained that in a very short period of time processing time for 
claims should come down. So we are wishing them great luck and 
we hope that their performance does improve in the very near 
    Mr. Tierney. Let me just ask you one last question, you 
mentioned that the network has a cost per unique patient, as 
you phrased it. It is approximately $400 greater than the 
national average. Would you define for me that unique patient?
    Dr. Post. You would like to know the actual cost?
    Mr. Tierney. When you said that you have one type of 
patient that was approximately $400 greater than the national 
mean you mentioned that it was pertaining to a unique patient. 
What constitutes a unique patient?
    Dr. Post. Actually, that term is referring to a unique 
Social Security number, so it is per individual and the way we 
calculate the cost per patient by network is to take the total 
resource allocation, the number of dollars for Network 1 and 
divide it by the number of veterans that are being served. So 
that is the unique veteran.
    The allocation is actually done as a basic and a complex 
patient and the complex patients get almost 10 times the number 
of dollars that the basic care patients do, so we do make some 
adjustment for the complexity of the medical care required.
    Mr. Tierney. Thank you for clarifying that. Let me end, Mr. 
Chairman, with just a couple of questions about proposed 
    During your statement you described the new communications 
council and you mentioned several electronic means of 
communication. Do we have an estimate of the number of all the 
veterans that actually use computers? Do we have any statistics 
on that?
    Dr. Post. I do not have the number of veterans who have 
access to computers. I can tell you that in many of our 
facilities we are trying to provide them that opportunity.
    Mr. Tierney. And you have some idea, you must have an idea 
of how many veterans actually receive your printed newsletter?
    Dr. Post. I am sure that we have that number. I just do not 
have it off the top of my head. I apologize.
    Mr. Tierney. Since this is going to be the cornerstone of 
the new VHA where else can veterans obtain information related 
to the new services, charges of existing services, is there 
anything else that veterans here and others ought to know 
about, ways that they can access information?
    Dr. Post. Other than the printed material, there is access 
on the Web to the VISN 1 Website which has lots of information 
on it about the CBOCs, the services that we provide and what is 
available to them.
    Mr. Tierney. Thank you very much. I would like to thank all 
three of you for your testimony here this morning and for 
joining us.
    Mr. Shays. I would just conclude by making this comment. I 
think the most significant complaints we have from our veterans 
tend to be with the major facilities, the waits, the 
bureaucracy and so on. I think and I may find it is different, 
so I am sharing it with all of you to get your comments when 
you take to the mic, but I think the biggest area of compliment 
comes with the community based health care clinics, so it will 
be interesting to see from our veterans if that holds up. Is 
that something, is that consistent with what you are hearing?
    Dr. Murphy. That is actually very consistent with what we 
hear from veterans at the national level and at the local 
level. In fact, that is why we chose access and waiting times 
as a major initiative that we will take on in 2000 and 2001.
    Veterans want to be able to get in to see their physician 
in a short period of time. We have made a commitment that every 
veteran who calls for a first time primary care appointment 
will be seen within 30 days and they will be seen for a 
specialty appointment within 30 days. We know that in many 
facilities we are not meeting those goals at this point.
    Sometimes for services like orthopedic consults or 
ophthalmology consults or hearing testing, the waits are 
considerably longer. And in order to help us understand how we 
can reduce the waiting time for appointments, we have actually 
worked with the--we have an IHI initiative and it is amazing 
what we have learned through that.
    We have looked at how we have organized clinics. We have 
found about even changing the number of nurses or doctors 
assigned to that clinic. In one case we were able to reduce the 
waiting time from 159 days down to 7 days, just by changing the 
way the clinic was organized. That is astounding.
    So that kind of reengineering and improvement process can 
provide better service to veterans and it really did not take 
any increased dollars. It just took a focus on making a change.
    Mr. Shays. We are preparing to go on to our next panel, but 
if any of you would like to just make a closing comment, I 
would be happy to have you do that.
    Mr. Conte. I would just like to thank John and the rest of 
the people that work with John for the support and we have 
brought on these clinics. I really do not think we could have 
done it without the support of congressional people and working 
with the community and I think that is a real example how the 
VA should do this in the future.
    Mr. Shays. Thank you. Dr. Murphy.
    Dr. Murphy. I also want to thank the chairman and all the 
members of the subcommittee. You have been extremely supportive 
of the re-engineering process and the transformation of VHA. 
You have been clear with the Department that what they want to 
see is better health care to more veterans in a timely way and 
we thank you for your efforts on behalf of veterans.
    Mr. Shays. Thank all three of you.
    At this time we would call our next panel.
    All four of our next panelists are directors of Veterans 
Services. We have Mr. Robert Hogan, town of Burlington; Mr. 
Michael Ingham, city of Haverhill; Mr. Donald Welsh, city of 
Gloucester, and Mr. Jean-Guy Martineau, city of Salem.
    Will all four of you gentlemen raise your right hand, 
    [Witnesses sworn.]
    Mr. Shays. Thank you. Note for the record, all four of our 
witnesses have responded in the affirmative. And I am going to 
have you testify in the reverse order I gave you, so Mr. 
Martineau, I will have you go first, then Mr. Welsh, then Mr. 
Ingham and Mr. Hogan, in that order.


    Mr. Martineau. Thank you, Mr. Chairman.
    With well over 1,000 visits to the VA I feel qualified to 
tell you what has taken place in the VA health care system here 
in the Northeast. Within the past 9 years I have had a first 
hand look at the Department of Veterans' Affairs health care 
    Daily, the Salem Veterans Services Department provides 
transportation to local VA medical centers. This includes the 
VA in Boston, Bedford, West Roxbury, Causeway Street clinic as 
well as the clinics in Lynn. My visits to these health care 
centers has brought me into contract with a great number of VA 
administrators and VA health care providers. I have also worked 
with VA social workers and patient representatives at the 
Chelsea Soldiers Home and the New England Shelter for Homeless 
Veterans in Boston.
    The impact of health care restructuring and reallocation of 
funding priorities has had the ``down sizing'' effect on the 
quality of care for veterans. Once a veteran has completed the 
eligibility process and enrolled in the health care system, he 
or she will not be seen by a primary care doctor for a month or 
more. Once they are assigned a primary care doctor, the veteran 
finds that the doctor is not experienced or is a medical 
student. I have found this to be particularly true in the 
mental health clinic in Bedford. Also, with so many foreign 
doctors, especially in the J.P. hospital, many veterans cannot 
easily communicate with their doctors. Real communication and 
patient confidence in their doctors is lacking.
    Also medical tests, which are required for proper doctor 
diagnosis in many cases cannot be given on a timely basis. 
Recently, one veteran I transported to the VA in February could 
not get an MRI until this coming May, a 3-month waiting period. 
I do not think that is good medical care. Beyond the inadequate 
medical care mentioned, personnel and administrative problems 
exists, morale among workers is at a long term low.
    Down sizing has resulted in many good experienced personnel 
retiring or having to do two or three additional jobs. This is 
especially noticeable in the social services and patient 
support groups. Another major problem caused by ``down sizing'' 
is the complete ``inaccessibility'' of existing medical units.
    Long term, in patient nursing home care is for all intents 
and purposes unavailable. I have one veteran who filed for 
nursing home care 4 years ago. He is 100 service connected and 
we are still waiting for him to be admitted. Unfortunately, 
this case is a good example of the lack of any nursing home 
care for our veterans.
    I have some recommendations. As an experienced and 
concerned veterans advocate, I would be wrong not to take 
advance of this opportunity to offer some recommendations to 
improve the VA health care system.
    Reallocate funding to allow for Bedford VA to provide 
timely and appropriate nursing home care for all veterans who 
are 50 percent service connected.
    Target increased funding to the directors of Bedford and 
Boston to make sure that the existing administrative staffs 
have the funds to provide proper qualified and more experienced 
doctors and medical care providers.
    Provide more bed availability for the in-patient study and 
inpatient care in the GRECC unit which deals with dementia and 
Alzheimer health care.
    Increase the funding for existing outpatient clinics as 
well as providing for more neighborhood VA clinics.
    Gentlemen, you have only given me 5 minutes to provide 
testimony on 9 years of travel and first hand knowledge of the 
VA health care system. Five days of testimony would not be 
enough. So let me summarize by saying that I would never 
subjugate myself, a Vietnam veteran, or any member of my family 
to the VA health care system.
    I have always, in the past, in all my work's challenges, 
where I have spoken or testified had one model and that is 
``better to light one candle than to curse the darkness,'' so 
if I see one hope it is in the newly opened and ever increasing 
VA clinics in Lynn and in Haverhill.
    In ending, I would be remiss if I did not thank Mr. Conte, 
the director of Bedford and his staff. Although Mr. Conte and I 
have in many cases agreed and in many cases disagreed, he has 
always and his staff have always made themselves available to 
    I want to thank Congressman Tierney. I have worked my 9 
years with previous Congressmen Marvoulas, previous Congressman 
Torkelson and now with Congressman Tierney and he is one of the 
bright stars that represent us in Washington insofar as being a 
champion of veterans' issues and veterans' concerns and I want 
to thank Congressman Tierney for that.
    And one guy I want to thank that is in the audience and 
there are many people that I could single out, but you know, 
with the downsizing of the VA, to get immediately health and 
direct care, to make a difference, you can it right away if you 
go to New England Shelter for Homeless Veterans.
    Thank you, Tommy Lyons and your staff and also the Chelsea 
Soldiers' Home. I don't see anybody here from the Chelsea 
Soldiers' Home, but God bless them too. And I want thank all of 
you and the chairman and the congressional staff that is here 
for allowing the veterans to have this opportunity to listen to 
you, for you to come to us and I want to thank all of the 
veterans that come here that show enough concern to listen what 
you have to say. God bless the veteran.
    [The prepared statement of Mr. Martineau follows:]

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    Mr. Shays. God bless the veteran and thank you.
    Mr. Shays. Mr. Welsh, if you would just get that mic and 
just lower it down a bit.
    Mr. Welsh. Mr. Chairman, Congressman Tierney, fellow 
veterans, ladies and gentlemen, good morning.
    My name is Don Welsh, as has been mentioned. I am the 
director of Veterans' Services for the beautiful city of 
Gloucester, MA and I do appreciate the opportunity to address 
this committee about the State of VA health care in my area of 
Massachusetts which I will refer to as Cape Ann. Having spent 
24 years in the Marine Corps I can tell you I thoroughly enjoy 
taking care of veterans and the more we can do for the veteran, 
the better.
    Let me start by saying the status of VA health care for the 
veterans I represent is generally speaking not good and it is 
getting worse. But I have a reason for saying that. It is 
because of the difficulty for veterans of Cape Ann to get to VA 
health care facilities. There are none in Cape Ann. Thus, these 
veterans have to travel many miles to the nearest facility 
after waiting a lengthy period for an appointment and often 
have to go back for a second or third time to complete 
    What we need is a community based outpatient clinic [CBOC], 
in my area. You have heard a lot about that already this 
morning. I am well aware of the CBOCs that in recent years were 
opened in Haverhill and Lynn and the great relief they provided 
for the veterans in and near those cities. And as you have 
already heard, thanks to Congressman Tierney and his staff, 
application for a CBOC in my area has been made. How great it 
would be to open a VA clinic in Gloucester to service our aging 
veteran population which finds it more and more difficult to 
get around.
    Let me point out that in my city of Gloucester there is a 
higher percentage of veterans per capita than anywhere else in 
Massachusetts. It has been calculated that the average number 
of veterans in relation to the overall population of each city 
in Massachusetts is about 11 percent. In Gloucester, the 
veteran population is about 21 percent.
    And as I have mentioned it is an aging population. World 
War II veterans are in their late 70's or 80's and the Korean 
War Era vets are not far behind. It is very difficult for them 
to travel long distances for VA treatment. Many of them just go 
without much needed services, rather than make repeated trips 
to a VA facility.
    As Tom Brokow so eloquently wrote in his book, ``The 
Greatest Generation,'' which was about World War II veterans, 
``They persevered through war . . . and then went to create 
interesting and useful lives in the America we have today . . . 
They answered the call to save the world from the two most 
powerful and ruthless military machines ever assembled . . . 
but they did not protest. They won the war; they saved the 
    Now, these veterans and veterans of other conflicts need 
our help. They need better health care services and the VA can 
and should be the instrument for those services. Let us not let 
our veterans down.
    As everyone knows, HMOs are cutting back on providing 
prescription drugs and this is becoming a real burden for many 
of our veterans, particularly those who are on fixed incomes. 
This is an area where the VA can pick up the torch and provide 
relief. But in order to do so we need more facilities, staff 
and dollar resources.
    Another area that should be addressed is the need to 
provide dental care for our veterans. Today, that service is 
almost nonexistent. I get inquiries every week from veterans 
about availability of dental care, but very few veterans are 
eligible under current rules for such VA health care. With 
skyrocketing dental costs and again with an aging veteran 
population, a more liberal dental policy should be adopted by 
the VA.
    I will close with a request for another area to be 
addressed by this committee. It concerns communication by or 
about VA health care services. What I am experiencing these 
days with veterans who are being discharged from active duty is 
that many are not informed about the VA services available to 
them. It should be a mandatory policy that every member of the 
Armed Forces be given a Veterans' Affairs briefing prior to 
release from active duty. If that is a policy, it is not 
working in many cases. As a result, veterans are missing out on 
benefits, particularly in the health services area.
    Thank you very much.
    [The prepared statement of Mr. Welsh follows:]

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    Mr. Tierney. Your last suggestion is something that we will 
just separate right now and we will write a letter to the 
Secretary of Defense and those who have direct responsibility. 
It is an excellent idea. If it is happening, I am not sure if 
it is a requirement. I agree, I am not sure it is happening. 
And we will make sure that that is something we deal with right 
away when we get back. It is an excellent suggestion.
    Mr. Welsh. Thank you, Mr. Chairman.
    Mr. Shays. Mr. Ingham.
    Mr. Tierney. I have already tasked one of my task. I will 
have her announce her name later, so if it does not happen, you 
will know who to call.
    Mr. Ingham. Congressman Shays, Congressman Tierney, fellow 
veterans, the ROTC students here--I just left 2 weeks at the 
Air Force Academy, the Air Force Reserves and hopefully, you 
students will attend that college and serve.
    As the Veterans Services director for the city of 
Haverhill, MA, one of the most common requests from veterans of 
my office is assistance with medical care and prescriptions.
    With this in mind, I was very fortunate to meet William 
Conte, the director of the Bedford VA and formulate plans for 
health care services for veterans outside of the Bedford 
Hospital. These were dramatic steps for the VA to go outside 
the traditional system of providing care and bring health care 
services directly to the veterans in their community.
    The first step was to develop a survey to define the health 
needs of the veterans and what issues that might be preventing 
them from using the VA health care service. Along with local 
organizations, the Veterans Council of Haverhill, we held a 
health day with medical teams from the Bedford VA Hospital. 
Over 700 veterans and their families attended.
    The results of the survey indicated that a lack of 
knowledge of the VA system and services that were available was 
the primary reason for not using the VA. The second problem 
identified was transportation as many of the veterans were 
elderly, driving to distant VA facilities was too difficult. 
The survey also showed priorities of care that the veterans 
would utilize. The most overwhelming need was assistance with 
prescriptions. An interesting point of the survey was the 
income level; many veterans earn under $25,000 annually. Many 
veterans identified needs that related directly to age such as 
ophthalmology, cardiology, urology and rheumatology.
    With the health needs established, transportation issues to 
address and education priorities outlined, we brought our 
findings to Dr. Fitzgerald, the director of the New England 
Health Care System for submission to the VA for congressional 
    Thanks to the support of Congressman Tierney, local and 
State officials, veterans organizations, the Veterans Outreach 
Center and Veterans Services of Haverhill, we were able to 
approve as a site for a veterans community based outpatient 
    With staffing from the Bedford VA Hospital and site work 
completed, the Haverhill Clinic opened in November 1998 at the 
city-owned Hale Hospital. The staff members, half of whom work 
part-time out of the Bedford VA, the clinic is now serving over 
1,200 veterans. With new patients enrolling daily, staff and 
services continue to increase with the demand.
    Substance abuse and psychological care is now available 
twice a week and plans are to expand the service with added 
space when available. Issues such as agent orange and the Gulf 
War Syndrome, as well as assistance with VA compensation claims 
can be addressed at the clinic. The Haverhill Clinic staff 
often assists agents with placement for substance abuse, Post 
Traumatic Stress Disorder treatment, often while the veteran is 
in the Veterans Services Office and in need of immediate help.
    The clinic is only primary outpatient care, but importantly 
the Haverhill Clinic is tied into a network of extensive health 
care between the Bedford VA and the Boston VA hospitals. The 
clinic provides accessibility to a coordinated and a continuity 
of care with courtesy, family involvement and patient 
education. In a new era of health care, the VA must reach 
veterans and educate them on their benefits, and we in the 
service of veterans are responsible to do the best we can to 
see that they receive the benefits available.
    The Haverhill Community Based Outpatient Clinic has 
dramatically impacted the veterans of Haverhill as well as 
other communities in the Merrimack Valley and lower New 
Hampshire. The overwhelming response of the veterans using the 
clinic is that they are totally satisfied with the treatment 
they received, both personally as well as physically.
    Dr. Balse and his staff have done an outstanding job 
providing health services to veterans that should be used as an 
example for future clinics throughout the country. I have had 
veterans tell me how much their lives have changed with the 
care they are now receiving at the Haverhill Veterans 
Outpatient Clinic.
    Some feel their lives were saved as a direct result of 
visiting the clinic. I know of one veteran that thought he was 
in good health, and upon a visit to the clinic found he had a 
life threatening heart condition that resulted in cardiac 
surgery that was performed by the VA doctors at Jamaica Plains, 
    The pharmacy program is probably the most used service at 
the clinic. Medications are requested by the primary doctor and 
filled by mail from the Bedford pharmacy. Veterans are saving 
substantially on medications enabling them to lead healthier 
lives as well as a better standard of living.
    Bedford, Lynn and Haverhill, due to the marriage of health 
care services provided over 190,000 visits to veterans in 1999, 
in these hospitals alone. That equals to approximately three 
visits per veteran in the system. This is a dramatic result for 
1 year in business and we have only reached approximately 15 
percent of the 36,000 veterans in the Merrimack Valley.
    As I mentioned earlier, transportation is a primary reason 
veterans are not taking advantage of the VA health care system. 
Many veterans with illnesses depend on family members to take 
them for medical treatment. This is a stress on the entire 
family, not just the veteran.
    With the clinic centrally located in the Merrimack Valley, 
many veterans are able to take advantage of care they often 
went without. Haverhill is very fortunate to have a van and a 
driver under the Department of Veterans' Services to take 
veterans to the VA hospitals. The Northeast Veterans Outreach 
Center is also under the Department of Veterans' Services, 
provides transportation to the clinic with a van donated by the 
Massachusetts Department of Disabled American Veterans.
    Haverhill also provides transportation through the 
Department of Human Services. This is free transportation for 
Haverhill's elderly, handicapped and veteran residents. 
Transportation is available from the Haverhill Clinic to the 
Bedford VA with a daily shuttle. Haverhill also has the MVRTA 
bus system.
    The problem for veterans outside of Haverhill is getting to 
the clinic as well as transportation to VA hospitals in Boston. 
Expanded public transportation, discounts for existing 
transportation, or grants to towns and cities to provide 
limited transportation for veterans will make it possible for 
them to take advantage of the health services available.
    It is in our best interest to see that veterans are made 
aware of the advantages of the New England health care system. 
Prevention and treatment will ensure healthier and more 
productive lives and save on taxpayers in the future. Many 
veterans have service related injuries both physically, as well 
as psychologically, the Haverhill Clinic fulfills and 
obligation to them for their service to our Nation with the 
best health care we can provide.
    We are here today to request of you to express to 
Washington that it is imperative to maintain the quality of our 
VA health care system and to see that adequate funds are there 
in the new millennium for a generation that preserved the 
freedom of this country that all of us in the 21st century will 
hopefully enjoy.
    I wish to close by thanking you for listening to our 
comments today and commend you for your efforts to best serve 
all veterans of the U.S. Armed Forces.
    Thank you.
    [The prepared statement of Mr. Ingham follows:]

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    Mr. Shays. Thank you, Mr. Ingham.
    Mr. Hogan.
    Mr. Hogan. Chairman Shays, Congressman Tierney, Mr. Conte, 
ladies and gentlemen and fellow veterans, thank you for 
allowing me the opportunity to discuss the impact of VA health 
care service restructuring and resource allocation in the 
delivery and quality of health care.
    I have three areas that I intend to address here today, one 
being long term care for our veterans, another is continued 
access to VA health care services for all veterans, and finally 
and briefly, some comments on hepatitis C care and funding.
    We need to make sure that the VA health care system is 
sound enough and funded well enough, not for the healthy among 
us, but for those among us that hope for quality health care 
during their journey through this life and at the end of our 
life. We need to live up to the promises and expectations of 
our elderly veterans who need the coverage that the VA health 
care system promised them, over the five, six or seven decades.
    That coverage may take several forms, such as VA nursing 
home care, community based nursing home care, and nursing care 
for the veterans in their own home. But we cannot be told that 
there is no room at the inn or that specific alternative care 
that is promised has not yet be established or funded.
    The funding for the new Millennium Health Care and Benefits 
Act should be applauded for its beginnings, but it must 
continue to grow and expand with the very increasing needs of 
our veterans as they age and need proper medical care.
    In the March edition of VFW Magazine, Republic Congressman 
Bob Stump stated that this health care package is a blueprint 
for the next century. Well, that sounds good, but without the 
required funding, the blueprint will sit and collect dust and 
the lack of funding can in no way diminish the VA's obligation 
to maintain and deliver proper and appropriate health care to 
our veterans. And it is the responsibility of every Member of 
Congress to help the VA meet this obligation. In that same 
edition, Democratic Congressman Lane Evans reaffirmed Congress' 
proud support for our Nation's veterans.
    Now comes the difficult task of trying to wed that concept 
to reality. The passage of the Veterans Millennium Health Care 
and Benefits Act in November of this past year has good 
direction, but there needs to be significant plans on how to 
get to the goals stated, and money is one key component in that 
    The bill directs that the VA operate and maintain a 
national program of extended care services including geriatric 
evaluations, nursing home care, both in-house and contract, 
adult day care, domiciliary care and respite care. With a 
national nursing home crisis we are seeing nursing homes 
closing due to cutbacks in Federal funding. In Massachusetts 
alone, 93 of the State's 580 nursing homes are already in 
bankruptcy with 13 homes closing over the past 2 years.
    The VA should not depend on there being enough good quality 
nursing homes available and with there being almost 5,000 
complaints against nursing homes sin this State alone last 
year, the good quality part of that equation is also in doubt. 
The VA should not be dumping its veterans out to lesser quality 
    The Millennium Health Care Act requires the VA to develop 
and begin to implement a plan for carrying out the 
recommendations of the Federal Advisory Committee on the Future 
of Long Term Care, and that the VA increase both home care and 
community based care options.
    The elderly veterans who need this care now are the 
builders of this great society. They sacrificed in war and they 
sacrificed in peace and now just because they have aged does 
not mean the VA and this country can forget them. They are an 
important part of this great society and they have earned the 
right to expect to be treated with dignity and be accorded the 
care any decent society can afford, not years from now.
    Throughout the 20th century, brave young men and women, 
young boys and girls actually, who gave up their youth and the 
comfort of their home and the safety of their families 
volunteered and were drafted to serve their country and on many 
occasions either died or were injured because of that service 
to their country. And what is not in the testimony, Mr. 
Chairman, if I could just remember the 19 Marines who passed 
away this weekend and note that service to this country can be 
hazardous both here and around the world, both in peace and in 
    Throughout America's history, American veterans have served 
and served well. They saw democracy challenged, here and around 
the world and they defended it. They saw civilization 
threatened here and around the world and they rescued it. They 
saw human rights endangered and they sought to restore them.
    Their heroism was prompted by faith in the fundamentals 
that have guided this Nation from its beginnings. The idea was 
that liberty must be protected, whatever the cost. And the VA 
health care system owes that same dedication to those men and 
women, whatever the cost.
    And the VA must consider itself a supplier of a service and 
that customer satisfaction is their top priority. The VA must 
develop a communication plan so that anyone and everyone at the 
VA who answers the telephone or sits at a desk must know what 
the game plan is and where the resources are for the veterans 
and their families and the VA must be user friendly. The VA 
must be veteran friendly.
    And Congress to guarantee permanent funding for all 
veterans. We cannot continue to inflict emotional distress upon 
the veterans who quality for VA health care, that they will not 
have this taken away from them based simply on cost 
    There is a health care prescription medicine crisis in the 
broader health care structure that affects the VA health care 
system. Many veterans who have private health insurance have no 
prescription coverage for the drugs they need. Even in our most 
extensive public insurance program, Medicare, three out of five 
seniors in this country do not have dependable drug coverage.
    According to a recent report from the House Government 
Reform Committee of which both Congressman Tierney and 
Congressman Shays are members, drug companies charge older 
Americans discriminatory prices. Seniors in many parts of this 
country, including New England, are being forced to pay on 
average, more than twice as much for prescription drugs than 
other customers.
    Health care is one of the most important issues in this 
country today. And it is so because of the explosion of health 
care crises around the country. President and future health 
care crises will send veterans to the VA in droves to secure 
the proper health care. The VA will need to be ready to handle 
that need and the VA must continue to provide care to the 
veterans that has been promised to them, that VA health care 
must provide quality care to the right patient at the right 
time and at the right level of care.
    If we do not take dramatic steps now to address these 
issues, it will only be harder for us down the road to be more 
diligent to ensure good quality care for our aging veterans.
    And finally and quickly I would like to comment about 
hepatitis C care and funding. Hepatitis C is a fairly new, yet 
very disturbing medical risk and the veterans are on the high 
side of the curve when it does come to those infected, as you 
heard us talk earlier. It is also very costly and it will be a 
major impact on the VA budget line item. Treatment can be 
expected to run a minimum of $10,000 per year for each veteran 
infected with the disease and future prevention and treatment 
to try and prevent additional damage to one's liver are also 
considerable. It is on the radar screen for one very good 
reason. It is important.
    Thank you for allowing me this opportunity to address these 
    [The prepared statement of Mr. Hogan follows:]

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    Mr. Shays. Thank you very much. I should have asked. I make 
an assumption and maybe incorrectly that all of you have served 
in the military and I would love for you to each just share 
where you served and what branch.
    Mr. Hogan. All of us have served. I served in the U.S. Army 
and I served in Vietnam in the late 1960's.
    Mr. Shays. Thank you for your service. Mr. Ingham.
    Mr. Ingham. Yes, I served in the U.S. Air Force. I was 
there during the Vietnam Era. I served in Germany and in the 
United States. I was activated for Desert Storm. Again, I 
served here in the States at Westover Air Force Base and I am 
currently in the Air Force Reserves as a Senior Master 
Sergeant. I have approximately 26 years and still going.
    Mr. Shays. Sergeant, thank you for your service. Mr. Welsh.
    Mr. Welsh. Twenty-four years in the Marine Corps, starting 
with Tet Offensive in Vietnam, finishing up with Desert Storm.
    Mr. Shays. Thank you. Mr. Martineau.
    Mr. Martineau. I served from 1968 to 1972, U.S. Navy with 2 
years in Vietnam.
    Mr. Shays. Thank you, sir. Thank you all for your service.
    Mr. Shays. I am going to recognize Mr. Tierney, but I am 
going to ask you a question now that I would like you to just 
think about, if he is not asking you a direct question. And I 
would like you, I want to make the assumption that the clinics 
tend to be more user friendly and that they are a relatively 
new innovation of the VA that you are pleased with, but I would 
like to know if that is true.
    I would like to know the best and the worse VA clinic and I 
would also like to know the best and the worse of the major 
facilities, what you think, so for instance, Mr. Martineau, I 
am going to force you to think of something really good about 
the major facility and we will get to it later. I will get the 
answers to my questions when Mr. Tierney is finished. Thank 
    Mr. Tierney.
    Mr. Tierney. Thank you. As Irish as I look, part of me is 
French so I know for sure that it is Martineau on that and I 
hope, I see that you have so much to say and so little time to 
say it, it is always easy to speak for about an hour when you 
are passionate on an issue, but not quite as easy to speak for 
5 minutes. So the next time you turn to C-SPAN you will see 
Chairman Shays and I struggling to get our thoughts in in 1 
minute and you will know of the difficulty that is there.
    Let me just say, Mr. Chairman, as I waive the deduction, 
you see four of our veterans' agents who I am proud to have in 
our District and work with and they are just an example of the 
great veterans' agent that we have in this District and that 
make our job that much easier and they represent the veterans 
so well. So I want to thank you publicly for the work that each 
of you do and for those that are in the audience that also work 
with us.
    Jean-Guy, I know you are busy thinking of Chris' question, 
the chairman's question, but I do want to ask you, I know for a 
fact the amount of time that you spend on transportation, you 
personally, take any number of veterans where they have to go 
and Mr. Ingham, I am going to ask you the same question because 
I know you do a lot of the same and I suspect that the others 
do also.
    What can we do to improve the transportation situation 
between the veterans' homes and the clinics and the clinics and 
the hospitals in Jamaica Plain, in West Roxbury and in Bedford?
    Mr. Martineau. That is a very complicated question. 
Basically, it is almost impossible to really improve the 
immediate needs of transportation because the majority of the 
veterans that we transport to hospital, the reason why we do it 
is because they cannot take public transportation because they 
cannot even go to the clinics because they are either in 
wheelchairs or they have walking problems and they have to use 
    So we have to literally get them from their doorstep to the 
door of a parking lot over at the VA Clinic in Lynn and we do 
transportation, of course, as we told you at the Chelsea 
Soldiers' Home as well as the VA Clinic in Boston and the one 
in Bedford.
    And again, many of these elderly veterans are World War II 
veterans and now Korean War veterans do have mobility problems. 
So to improve the transportation I think what you would have to 
do is guarantee funding for transportation that is more 
personal and more accessible to those veterans who cannot walk 
on their own. They cannot even get up from a wheelchair on 
their own without assistance.
    So it is nice to have a car. It is even nicer to have a DAV 
van and I compliment the DAV. I can go on complimenting other 
organizations. However, unless you have someone who can 
physically assist the veteran out of his wheelchair or help him 
with his walker, he or she with his walker, it will not really 
make an immediate difference, but again, any support in funding 
that you can give on the short term and the long term directly 
to the cities and towns, veteran funding directly targeted at 
the clinics to provide transportation would be a definite 
    Mr. Tierney. Thank you.
    Just by way of note I am going to talk to the chairman 
about this at some point in time and the committee members, 
probably trying to establish some sort of a pilot program, but 
I do not know just where we are going with it yet.
    Mr. Ingham, maybe you can give us some suggestions too 
about what we might think of in terms of trying to get together 
an idea of how we go about this and also tell me if you would 
about Mass. Ride and whether or not positively impacts or gives 
you any assistance in this area?
    Mr. Ingham. One of the important issues is not so much as 
getting the vehicles. There are many organizations out there 
who are willing to donate vehicles. It is finding drivers. 
Volunteer drivers are very difficult to get. I deal with a lot 
of volunteer drivers for elderly transportation as well as for 
veterans and it is more a funding issue.
    If you make it through either grants or through the 
government, really any kind of forms of funding where you make 
this affirmative position for driving is probably the largest 
improvement that you could do for help getting veterans into 
the hospitals.
    As far as the outreach center, they looked for quite a 
while to get a volunteer driver. They had a van donated from 
the DAV, but again, the most difficult part was finding a 
volunteer driver. So I think if there is any way that you could 
push for funding, through grants or whatever forms you can to 
get a permanent driver that would basically be the best 
    Mr. Tierney. Thank you. Mr. Hogan and Mr. Welsh, I would 
like to talk to you a little bit about the communication 
    Mr. Hogan, you indicated that not every veteran is aware of 
his rights, what might be available to him or her within the 
health care, VA health care system. Can you tell us what you 
believe is the most used source of information by veterans, at 
least from your information?
    Mr. Hogan. I have most access in my community to the local 
newspaper, the local cable and I work very well with Mr. Conte 
and Mr. Bill Davis from the Bedford VA and for the chairman's 
information, my proximity to the Bedford VA is rather close, so 
I have a different perspective than the other gentleman.
    I think if the VA and its representatives were to continue 
to do that, to work with the agents and the service 
organizations within the communities to have them disseminate 
the information, when I came on board as a veterans' agent, I 
was surprised at how little so many of the veterans knew about 
what was available to them through the VA. So I think the VA by 
itself putting out a newsletter on a Website is one thing, but 
I think they have to network just as well with the agents and 
the service offices within the communities.
    Mr. Tierney. What sort of information you get as veterans 
agents when you are dealing with the Veterans' Administration?
    Mr. Welsh. You mean----
    Mr. Tierney. The Veterans' Administration, how do they 
communicate with you and how often do you meet with 
representatives, how often do you get either e-mails----
    Mr. Welsh. The Website is a good source. There is also a 
book, we call our bible so to speak. It is ``What Every Veteran 
Should Know.'' I use the 800 number a lot. There is no problem 
with communication between an office like mine or the other 
veterans' offices across Massachusetts. Massachusetts is unique 
with this veterans' benefits, the agents that we are.
    I think there is only one or two other States that have the 
same system, so the veterans in our communities can come to our 
office and ask any question whether it is a State-related 
question or Federal VA and we have all sorts of way to get this 
information, as I mentioned, not only by the literature that is 
put out, the Website, but also the regional number and I have 
had no problem in getting good feedback from the VA system and 
in particular, the health care system.
    I want to make a little pitch here in case I am not asked 
about the Bedford system. I think they are super. They provide 
a great service and I know the veterans from Gloucester, at 
least the majority of them and have never had one complaint 
about the VA system in Bedford.
    Mr. Tierney. While I have you at the mic, I know that you 
believe strongly in traditional clinics, community based 
outreach clinics. Could you take just a moment to put on the 
record what that would mean to the average Gloucester veteran 
    Mr. Welsh. A lot. As I mentioned there are so many veterans 
in Gloucester and particularly from the World War II area, many 
on oxygen. There is no transportation system to the other 
facilities, something that I know your office and I will be 
working on. And particularly for those World War II veterans, 
just to be able to go down the street to a clinic if we had one 
in Gloucester, I would be happy to go pick them up at their 
door and take them because it is just so difficult for them to 
get out. We have facilities in Gloucester and I know again for 
the older veterans it would just be a tremendous thing.
    And even the younger veterans, many of them do not have the 
ability to drive. They have problems that keep from even taking 
public transportation, but particularly for the older veteran 
it would be a tremendous thing.
    Mr. Tierney. Thank you very much for that. Let me just ask 
one last question, Mr. Ingham. I am gratified that so many 
veterans find the community clinics helpful as you indicated, 
but in the course of your testimony described as key to the 
earlier detection and prevention as well as life saving 
capabilities, things that have talked about, do you have a 
specific example in mind when you mentioned those issues?
    Mr. Ingham. I have a specific case. An individual came into 
my office. He was having a hard time in trying to get health 
insurance and he came and asked me how could I help him out and 
that was right when we started the clinic, he was probably one 
of the first ones to get in. He was the individual I was 
talking about that had the heart condition. So he went in, got 
into the system, saw Dr. Balse, was found to have a heart 
condition, went through the VA system, was treated and still 
comes in to see me regularly.
    We did have another individual, Walter Hamal, who is our 
last World War I veteran. He was also one of the first into the 
clinic, as our first customer, basically. Unfortunately, he 
just passed away, but he did take quite advantage of the system 
and was very happy for it.
    I want to bring up one point brought up earlier by 
Congressman Tierney, two, possibly three. I think it is because 
of his commitment and a stronger point was education. We 
throughout the veterans organizations in Haverhill, we all as 
veterans' councils, came together very closely as a unit to get 
the clinic into Haverhill and because I think of that we are 
able to get more education out there and there was more 
information brought into the community. So that is a big reason 
that we do have the clinic.
    Mr. Tierney. Well, you lobbied it last night, the staff 
tried to get me lost in Boston, trying to explain how difficult 
it is to get into Boston from here, so it never ends. They work 
on everyone.
    One last question. This is just a curiosity question, Mr. 
Welsh. I want to know if it is ever been determined why we have 
the higher concentration of veterans in Gloucester?
    Mr. Welsh. Fishermen. Many of them are natives.
    Mr. Tierney. Last, let me just reiterate as some of our 
witnesses have said before, we have an excellent homeless 
shelter here and Tom Lyons is in the audience and does a great 
deal of work with that. We have spent a lot of attention in 
Congress trying to deal with special veterans' issues, that is 
one of them, obviously and I just want to add my commendations 
to Tom and people who work with him for the great work they do.
    Mr. Shays. I hope he will address the committee so we will 
have him on record as well.
    Mr. Tierney. Thank you, Mr. Chairman. Thank you, witnesses.
    Mr. Shays. I am wanting to know the best and worse of both 
the clinics and the primary VA facilities. And Mr. Hogan, I 
will start with you.
    Mr. Hogan. The best part of it, I think, is the care, once 
you get into the door.
    Mr. Shays. Which facility?
    Mr. Hogan. I am with the Edith Nourse Rogers, again, I am 
the director which is next door to Bedford.
    Mr. Shays. So you do not really utilize the clinics?
    Mr. Hogan. No. But the care in the facility, I think, is 
wonderful once you get through the door. The worse part 
sometimes is beds, there is not enough time and with the aging 
population, an awful lot more people with education are trying 
to use the facility, so I think sometimes the weight could be 
the worse part, but I think the care, once we get through the 
door is the best Bedford has to offer.
    Mr. Shays. Mr. Ingham.
    Mr. Ingham. I think the best of the care dealing with the 
CBOC. A comment was made that their staff should be commended, 
Dr. Balze, the nurses, nurse practitioners, everybody there is 
just excellent and willing to work with the veterans. It has 
been a unique experience to start just developing the clinic 
and where we went with that and getting the organizations 
together with a letter of writing and calling of Congress and 
    But the work of the facility, like the Bedford VA is so 
advanced to look ahead into the future as Mr. Conte did, we 
started out with really nothing and got health care into 
Haverhill. It is just an amazing event.
    Mr. Shays. What about the larger facilities?
    Mr. Ingham. I think the problem with the larger facilities 
is transportation, getting into them. A lot of the older 
veterans, especially, are intimidated trying to take the 
services to get in there. And I think our future too with the 
geriatric type situations. We were just told as agents at our 
last meeting that there is a high rate of Alzheimer's with 
veterans and they do not really know why. It seems that in the 
general population that veterans----
    Mr. Shays. What would be the best that you would see in the 
larger facilities?
    Mr. Ingham. Probably just the overall care. They can handle 
anything from cardiac, heart conditions, all type of care. It 
is there, it is available and it is a shame that many are not 
taking use of it.
    Mr. Shays. Mr. Welsh.
    Mr. Welsh. As I have already mentioned I believe the 
Bedford Medical Center is the best in the area. I am not very 
familiar with Haverhill because people do not go from 
Gloucester to Haverhill, but those that have gone to the Lynn 
outpatient clinic seem to be satisfied. The worse is the clinic 
on Causeway Street in Boston, that is my----
    Mr. Shays. So your point rather than saying what is the 
best or the worse of the clinics, you are actually saying which 
clinic you think needs the most improvement?
    Mr. Welsh. Yes sir.
    Mr. Shays. Let me just quickly, why do you think that needs 
the most improvement? Just in terms of the interaction or 
parking or what, the facility itself?
    Mr. Welsh. When we talk about the outpatient clinic?
    Mr. Shays. Yes.
    Mr. Welsh. In Lynn, there is no problem with parking. You 
cannot get to Lynn from Gloucester. It is one of those tough 
things, but there is adequate parking. I think the people are 
very courteous and that is why I do not have many complaints 
about the Lynn outpatient clinic. Causeway is a big problem 
because there is no parking and there seems to be a different 
attitude at the Causeway----
    Mr. Shays. Do they have more queuing up there? Is it more 
like the traditional motor vehicle department?
    Mr. Welsh. I think there is more of a downsizing of 
Causeway. Someone else could answer it better than me, but it 
seems as though it is going away.
    Mr. Shays. OK, Mr. Martineau.
    Mr. Martineau. Mr. Chairman, I am not here to throw hand 
grenades, maybe a few rocks and pebbles, but not hand grenades.
    Mr. Shays. He says that because he is a veteran not only of 
the service, but a veteran of the city council and they know 
how to do this. [Laughter.]
    Mr. Martineau. I am a good Republican, Mr. Chairman. 
    Mr. Shays. I want to give you special time. I have not met 
a Republican in Massachusetts, so this is--[laughter.]
    Mr. Martineau. I knew we had something in common, Mr. 
Chairman. You know, I just want to preface my remarks by saying 
that I find my responsibility with the veteran initially is to 
give him the best first visit he can get at a VA health care 
    This is why I personally take that veteran to the hospital, 
clinic myself, so I know what I am talking about. I do this 
almost on a daily basis. So I had some initial problems with 
the Lynn clinic as the Congressman knows, and his staff. He is 
got a fantastic staff. And they have ironed those problems out.
    The good part about the Lynn clinic is many of our veterans 
will go there on their own. It is a short ride today and it 
lessens their transportation time. The bad part about the Lynn 
Clinic is many of the veterans will travel to the Lynn Clinic 
and then will find that they will have to leave the Lynn 
Clinic, take a shuttle and go to Bedford of JP for testing.
    Mr. Shays. So these are services they are not really going 
to get?
    Mr. Martineau. And I will be at Bedford or I will be at 
Jamaica Plain and once I get there and transport my veterans 
there, some of the veterans will recognize me who are on a 
shuttle from Lynn, will ask me to take them home from Bedford 
and take them back to Lynn because it is really on our way back 
to Salem.
    So as far as the Lynn Clinic goes, my hats off to the 
decisionmakers to go that route. I think the neighborhood 
clinics as Lynn and elsewhere are very important because 
generally speaking it does save time in the veterans' traveling 
    Mr. Shays. How about the primary major facilities? What is 
the best and the worse?
    Mr. Martineau. I can speak for a long time on Bedford and 
Jamaica Plain and the Causeway Street clinic, but let me just 
generalize, because--I do not understand communication between 
Bedford and Boston. There is none. I have had one veteran as 
recently as a couple of months ago who had been treated in the 
JP Clinic in Boston, the Jamaica Plain for years and it took 
him 4 hours administratively eligible for medical care in 
Bedford, 4 hours. So here is a guy that had VA health care in 
Boston and going to Bedford he had to be re-enrolled all over 
    Mr. Shays. Fair enough, so communication----
    Mr. Martineau. Computer linkup, Mr. Chairman.
    Mr. Shays. And common sense.
    Mr. Martineau. Yes, there is no--I do not know what the 
computer linkup is, but as far as I can see, there is not any.
    The other problem that I have experienced is going in with 
the veterans, the doctors are not experienced for the most 
part. You have too many foreign doctors and you have too many 
doctors that are really not experienced. They are students who 
are practicing medicine on our veterans and I do not think that 
is right.
    Mr. Shays. OK.
    Mr. Martineau. Insofar as the administrative staffs, I 
think that now too many of our administrators, health care 
providers, social workers and patient representatives are doing 
two and three jobs and I do not think--it is because of the 
downsizing effect and I think that is a drawback.
    Let me just say some good comments that I would like to 
make about Bedford and Jamaica Plain. Accessibility to the 
administrators and the social workers in these hospitals is 
excellent. I have never been refused on a moment's basis. They 
have always taken time from their day. I do not know if it is 
because I will go to their bosses.
    Mr. Shays. But it is a very important positive and it is 
nice that you are expressing that. So access is there and that 
is great to hear.
    Mr. Martineau. Also Bedford provides terrific adult day 
care and especially their branch office over at the Chelsea 
Soldiers Home. I think that could be expanded, but I 
congratulate Bedford for their adult day care and the services 
that they provide with their staff at the Chelsea Soldiers 
Home, that is really great. But you know what is really 
fantastic about both Bedford and Jamaica Plain and that is 
their detox.
    A lot of homeless veterans can get detox in Bedford and 
Jamaica Plain and when you take them they immediately get the 
care that they need.
    They have teams of people that surround themselves with 
these veterans and take care of their emotional needs, their 
physical needs, their rehabilitation needs, getting them back 
on their feet, both personally, professionally, medically and 
also followup. So as far as detox goes in Bedford and Jamaica 
Plain. They are the best. So that is about it.
    Mr. Shays. Thank you very much. I have some questions that 
I would just love to get on the record. I am going to look for 
shorter answers because I do want to hear from the veterans 
that are going to speak. By the way, I would invite you all to 
stay up there if you like while the veterans are making 
comments and if it is not abused invite you to make short 
comment periodically about what you have heard, if you would 
    I would like to first ask have you noticed an increase in 
veterans taking part in the VA health care system? If the 
answer is yes, why do you think this is the case? If no, what 
can be done to encourage veterans. I not looking for long 
answers, but are you seeing the increase and then respond why 
you think your answer is what it is.
    We will go with you, Mr. Martineau, first since you have 
the mic.
    Mr. Martineau. As it has been stated by my fellow veterans' 
advocates up here, we have definitely seen an increase in 
people going to the VA because of the downsizing of the HMOs 
and the downsizing of their private health services.
    Mr. Shays. OK, the reason I am having trouble with a French 
name is because I am married to a French woman named Deraine so 
there is no excuse.
    Mr. Welsh. Definitely an increase in veterans signing up 
because we have had some great health fairs, thanks to 
Congressman Tierney's office. Also, our veterans' services 
organizations in Gloucester, AMVETS, VFW, American Legion, they 
have gotten the word out, so communication, publicity, we have 
newspaper articles from time to time, veterans say I can sign 
up and they do.
    Mr. Shays. I know Mr. Martineau was responding, nodding the 
head as you made that point too, so Mr. Ingham?
    Mr. Ingham. Yes, definitely, the CBOC in Haverhill is 
seeing an increase close to approximately 50 a month. I said 
1,200 over the year. I think most of it is due to education and 
the biggest is on word of mouth. Veterans talk to veterans. 
That is one of the biggest ways of getting it around.
    Mr. Shays. Mr. Hogan.
    Mr. Hogan. I agree also. I think there is an increase of 
use going on right now. A lot of it has to do with the 
publicity that we are able to get out through veterans' 
newsletters, newspaper articles. Once the veterans realize that 
they are eligible now and I think one of the big issues right 
now is that there is a pharmacy use and the hospitals because 
of the explosion of co-payments and insurance problems with 
medications and pharmaceuticals, they are going to the VA and 
they are signing up.
    Mr. Shays. Let me do this, let me--if you do not mind 
staying up there you are welcome if you have to leave for a 
second and want to come back. We will invite from our audience 
anyone who wants to make some comments and this is how it is 
going to work.
    I am going to ask, Karen, I am going to ask you to get 
their name and address on a file card after they have spoken so 
we can get the transcriber the exact spelling of your name. We 
are going to want to know if you served, where you served, what 
branch you served in and where you served. We can use the 
portable mic if that works.
    Jason, you have the mic. Let us do that.
    Mr. Tierney. Mr. Chairman, just 1 second. I think it should 
be noted for those that might not already know it, several of 
the veterans service organizations have representatives here, 
but they have also been invited by the chairman to submit for 
the record. We would like to have that and it will all be 
entered on the record.
    Mr. Shays. It will all be entered into the record. So sir, 
I see you are standing up and we will invite you on that side.
    Let me ask you, are there mics on both--we do not need the 
portable mic--do the mics work that are there? Can you turn the 
floor mics on to see if they are--would you see if that one 
works? Just speak into it a second. Yes, both of them work, so 
we will use that, Jason, so we do not need you to hold the mic 
there, but Karen, when they are done, get the full name and 
address so we will be able to have it on the record.
    OK, and if you would state your name, if you served, the 
branch of service and where you served.
    Sgt. Bryan. My name is Staff Sergeant Edward J. Bryan. I am 
still active in the Massachusetts National Guard. I joined the 
service in 1974, U.S. Army.
    Mr. Shays. Let me say this. I am going to do 2 minutes a 
statement. Is that all right?
    Sgt. Bryan. Yes. I only have a few basic questions, they 
are kind of loaded ones, but I am not throwing hand grenades.
    Mr. Shays. You have got a lot of pages, that is why I am 
    Sgt. Bryan. I already submitted them for the record.
    Mr. Shays. OK, sir, again your name.
    Sgt. Bryan. Edward J. Bryan.
    Mr. Shays. Mr. Bryan, thank you.
    Sgt. Bryan. I served with the 1173rd Transportation 
Terminal Unit in Boston. Went to Saudi Arabia. I am now retired 
from the fire department because of my Gulf war service and I 
am disabled from the National Guard from my Gulf war service.
    I have a couple of questions. I know you are here, there is 
a $1 million plus a day that you are worried about from the 
GAO, you stated that in your statement. I know it is a problem 
with the U.S. Government and going to combat like World War II 
veterans, Vietnam veterans, Korea, Gulf war and other 
conflicts, I think the budget should be either level funded or 
increased. I got an increase of $25 billion in the statement 
that I submitted. The reason why is because we just had a 
conference in Washington on April 5th and the next hall over 
was asking for $600 billion for infectious diseases. That is a 
    The first question I wanted to ask today was on the program 
up here in Bedford. Are the biopsies sent to the Armed Forces 
Institute of Pathology? Now how are we going to get to the 
bottom of Alzheimer's Disease if nobody is recording it? I 
found that out at Walter Reed Institute last summer. I am doing 
research on Alzheimer's itself because there is an interaction 
between Gulf war veterans, Vietnam veterans and ADD people.
    Question No. 2, Persian Gulf war appointments are not being 
done in Massachusetts. They are not being followed, according 
to Public Law 103-446. I got a letter from Colorado with a 
gentleman having problems. We are seeing this all across the 
Nation. This is a national problem.
    I am a member of Merrimack Committee here, VISN 1 and we 
are trying to address that problem with a basic test versus a 
full screen test. We are trying to get that through all the way 
to VISN 1 and all the way to the Network Director, Mr. Clark, I 
think it is.
    Mrs. Murphy stated on HIV and hepatitis C, but she did not 
mention leishomeniosis or other infectious diseases. Whatever 
the cost----
    Mr. Shays. Mr. Bryan, I am going to interrupt you a second. 
I am just going to have--we do not have so many people here 
that I maybe can adjust the time. We are going to try to get 
out of here by 1:15 at the latest and I would like to just ask 
how many people would like to speak and then I am going to--
keep your hands up nice and tall. I am going to be real strict 
    I am going to say 3 minutes at most and the questions are 
going to be rhetorical in the sense that we are going to have 
them in the record and then we are going to try to get some 
answers for them and we will make the answers part of the 
record as well. OK, is that something we can do.
    So yes, you have about a minute left and thank you.
    Sgt. Bryan. Because I found out that doctors are not doing 
the tests because the VA, thanks to the VA in Washington put 
out these big booklets that all of the doctors are supposed to 
review, but they are only reviewing the little booklet and they 
are doing the tests. They have to look at the whole spectrum. 
So that is a big national problem.
    A lot of the times you will look back at these suffering 
Gulf war veterans and Public Law 103-346 is not fully enforced 
and I think that is a key question, enforcement of it. I got 
that in the documentation and I want to--I know there are State 
issues here also, but there are major problems. You are going 
to be hearing from me and a few other Gulf war veterans 
throughout the Nation, your committee, within the next several 
months to another year because we need much more treatment 
trials and the two treatment trials that are out in the VA are 
not very promising.
    We need at least 10 more before September and I want to be 
trying to work with Dr. Pughsner. I am having troubles, but it 
is an IG complaint, but I want to see if I can step through 
your committee to get that accomplished.
    Thank you.
    Mr. Shays. I would be happy to have you work through our 
committee. I will invite you all, just take notes and at the 
end when they are done I will invite just brief comments from 
all of you on any comments you want to say that you have heard. 
Thank you, Mr. Bryan.
    Sgt. Bryan. Thank you, Congressman Shays for sticking your 
neck out. Thank you.
    Mr. Shays. Thank you, sir. Sir?
    Mr. Hart. Good afternoon, sir. Mr. Chairman, Congressman 
Tierney, my name is Terry Hart. I am the veterans' service 
agent, director of Veterans' Service from Ipswich.
    Mr. Shays. Excuse me, I am just going to interrupt you just 
a second. Karen, are you doing it? I want to make sure that the 
names are totally verified with the individual after you get 
them. OK, thanks. I am sorry, sir.
    Mr. Hart. No problem, sir. Seeing as the veterans' agents 
up here represent the Army, Air Force, Marine Corps and Navy, I 
wanted to let you know that I represent that fifth service, 
having spent 27 years in the U.S. Coast Guard.
    Mr. Shays. Yes sir. As did my brother.
    Mr. Hart. I am adjacent, my area, four towns, adjacent to 
Gloucester, the towns of Ipswich, Essex, Hamilton and Wedham 
and I have been using the clinic at Haverhill significantly in 
the last year that I have been a veterans' agent, sending 
people there right, left, up and down. Would also very strongly 
support the concept of a clinic at Gloucester.
    I have a lot of people who drive very little and being 
stuck in the middle there between major cities of Gloucester 
and Haverhill, major for our area anyway, we have some of our 
senior veterans who will go to Haverhill, will not go to 
Gloucester. Others who will go to Gloucester, will not go to 
Haverhill. So we like the idea of having a clinic in Gloucester 
as well.
    I would also like to make a couple of comments with respect 
to what has gone on this morning. Dr. Post indicated that there 
will be an increase probably in the cost of co-pays for 
pharmaceuticals through the VA clinic. I would like to go on 
record as stating that I hope (a) we can extend that then to a 
90-day prescription in terms of the co-pay cost because I think 
that is a logical extension.
    Right now, it is $2 per 30-day supply per prescription. If 
somebody can get a 90-day supply for whatever the co-pay goes 
up to, I think that would be a logical way of doing it since 
you said the cost is based on the administrative costs.
    By the same token, you should know that that is one of the 
key drawing cards for us to send people to your clinics is the 
idea that those costs to pharmaceuticals going down is a big 
factor in people wanting to use the VA clinics. I would also 
like to praise Mr. Conte. As a member of the Northeast 
Veterans' Service Officers Association we met at Bedford a 
month or so ago and the suggestion was made by me that they 
ought to have some of us on their board of advisors. Mr. Conte 
now has four of us, including myself on his board of advisors 
for Bedford VA and I think that improves the communication 
tremendously in our area.
    And communication is the key. What we find, of course, is 
many service organizations represented here, each of them have 
members. They have their own newsletters. We all go through the 
newspapers to try to get our word out to people. The Department 
of Veterans' Services provides word as well as they can, but 
until we get some sort of linkage in communication. We are 
still not reaching all the veterans and that is a key part of 
what we are doing, sir.
    Mr. Shays. Thank you very much.
    Mr. Callanan. Good morning. My name is Dan Callanan. I was 
born in 1924, joined the Marines on my 18th birthday. Three 
years later I was lucky enough to come back from the Pacific 
without a scratch on me. I was told that the Veterans' 
Administration was for people with disabilities. I did not know 
anything about anything to the contrary, but I visited many of 
my old mates at VA hospitals, people without arms and legs, 
people I had known, people I got to know.
    Recently, thanks to you people in Congress, you have passed 
a law which provides prescription drugs and I came out here 
today to thank you for that and to leave with you a bunch of 
eyedrops which cost me a small fortune in the past year and a 
    I say a small fortune, but I had a detached retina. I do 
not know what caused it. It happened in August a year ago while 
I was mowing my lawn. I thought it was just another fleck of 
dust that comes out of this power plant in Salem which is soot 
all over the neighborhood, but maybe it was a bee that bit me, 
but before the day was over a retina surgeon at the Lynn Clinic 
told me it was detached retina. I went almost a whole year 
without being able to read a newspaper, spending a lot of money 
on eyedrops. Now I am getting them for $2 each. According to 
the letter that I received last week, it is on file here. Thank 
you for this opportunity.
    Mr. Shays. Thank you very much.
    Mr. Cascella. My name is Craig Cascella. I am a retired 
sergeant in the Marine Corps. I served as a Military Police 
Officer in Quantico, VA and I was also stationed in Washington, 
DC. I served as Presidential Security Guard. Mr. Chair and 
members of the committee----
    Mr. Shays. You know what, we have a problem. And that is we 
need to get you on tape. So I am going to let you start over 
again? We will insert the written statement in the record then. 
The reason I said that this is not just an exercise in 
futility. We actually transfer this transcript. Then the staff 
studies it. Then we make recommendations and so this is not 
idle chatter that you are participating in. This is a 
congressional hearing in which what you say we hope to have 
some impact in what happens in government.
    Let me just do this. I am going to have, I am going to see 
if we can solve the problem of you being on the mic and I am 
going to just interrupt. I am going to have someone else speak 
and let me, see, Karen, you put your head together and think 
how we can do that. If you do not mind, I am just going to have 
you wait a sec and have this gentleman speak.
    Are you going to be here later, sir? Will you be here for a 
    Mr. Cascella. Yes.
    Mr. Shays. OK, let us see if we can solve the problem 
getting you on the transcript. Yes sir?
    Mr. Bowers. Thank you, Mr. Chairman and Congressman 
Tierney. I am Alan Bowers, third national junior vice commander 
of the Disabled American Veterans [DAV]. I was medically 
retired from the Air Force in 1974 after I injured my spine 
when I ejected from an aircraft in Vietnam. I am here to 
present the views of the nearly 45,000 members of the DAV and 
auxiliary who reside in Massachusetts.
    We have submitted to you, sir, a written text and we 
respectfully request that that text become part of the record.
    Mr. Shays. That will be part of the record.
    Mr. Bowers. Thank you, sir, and I will just make a couple 
of quick comments to highlight a couple of points.
    Since 1985, the buying power of VA medical care 
appropriations has fallen because of inflation. The total 2000 
VA medical care appropriation is worth only 82 percent of the 
1985 appropriation. That decreased buying power has adversely 
affected the Department's ability to provide safe, quality 
assured care.
    In 1996, VISN 1 had $856 million. In 2000, it has $867 
million. That equates to a 1.21 percent increase in allocations 
and MCCF receipts over 5 years. I note from a fax that I 
received from the National Office of the DAV Friday afternoon 
that on April 7th in the morning, the Senate passed the Johnson 
amendment which would add $500 million to President Clinton's 
proposed $1.4 billion increase. That is completely in line with 
what the DAV independent budget requests and we would hope that 
the House would go along with that effort and match that 
effort. It would go a long way to helping the VA have the 
dollars they need to give quality care.
    With respect to the hepatitis C, Dr. Murphy mentioned the 
1-day test sample where approximately 6.6 percent of the 
veterans tested came up positive for the virus. Under VERA, 
veterans who have the virus are considered basic care patients. 
As I understand it, that means that the VA or the VISN gets 
$3,249 a year for that patient. We suggest that a health care 
diagnosis should be reimbursed at the rate of a complex 
    One of the individuals testifying this morning mentioned 
high staff ratios in VISN 1. But in fact, the DAV has heard 
testimonials from frustrated and demoralized health care 
providers, including physicians and nurses, when they are 
working with sicker patients and they are working longer shifts 
or perhaps even double shifts, both the patient and the 
provider are at risk. So we ask you to take a very hard look at 
the staffing levels and make sure that they are adequately 
staffed so that there is quality care and there are no medical 
    Mr. Shays. I am going to extend your time a little bit 
here. How much longer do you need?
    Mr. Bowers. One final comment. I just want to say thank 
you. The Disabled American Veterans has one purpose, to build 
better lives for disabled veterans and their families. We rely 
on you and the VA to help us provide safe care, adequate care, 
accessible care. The DAV pledges to work with you and I am 
confident that together we can build better lives for the 
individuals who fought for America's freedoms.
    Thank you very much.
    Mr. Shays. Thank you for your service. It is wonderful to 
have you up front so I can see your smiling face in the light.
    Mr. Cascella. It is great to be down here.
    Mr. Shays. Is this mic on now?
    Mr. Cascella. Do you want me to start with my intro again 
or do you know who I am?
    Mr. Shays. Yes, I want you to start all over again. Thank 
you for your cooperation.
    Mr. Cascella. It is no problem, Mr. Chairman. My name is 
Craig Cascella. I am a retired military--from the Marine Corps. 
I was a sergeant from 1988 to 1992, stationed in Quantico, VA 
and also in our Nation's Capital, Washington, DC. I was a 
military police officer and also served as a Presidential 
security guard for Presidents Reagan and Bush, respectively.
    I am currently the secretary of the New England Chapter of 
the Paralyzed Veterans. On behalf of our members, I would like 
to thank you, Mr. Chairman, and members of the committee, for 
holding this hearing in our area and allowing us to provide 
this statement.
    I have submitted copies of my written statement and I hope 
that they have been distributed to you. If not, I would be more 
than happy to give you another one.
    First, I would like to comment on the fiscal year 2001 VA 
budget that was submitted by the administration. For the first 
time in many years, a reasonable increase has been proposed for 
veterans health care. The $1.5 billion total increase including 
the $1.355 billion for health care is a good and welcome 
beginning, although it is less than the $1.9 billion increase 
that is recommended by PVA.
    It is our understanding that the $1.9 billion increase is 
more in line with what the VA requested to pay for all existing 
and new programs. The PVA recommendation is based on careful 
analysis of present and future health care trends and includes 
the costs of the new initiatives such as emergency care, 
hepatitis C and long term care provisions called for in the 
Veterans Millennium Health Care and Benefits Act.
    The PVA has recommended a $20.66 billion appropriation for 
medical care. This amount represents a $1.8 billion increase 
over the amount provided in fiscal year 2000. The PVA has 
recommended a $386 million appropriation for medical and 
prosthetic research. This represents a $65 million increase 
over the administration's flat line request. The PVA recommends 
a $71 million appropriation for the medical administration and 
miscellaneous operating expenses account. This represents a $6 
million increase over the administration's request.
    In total, the PVA has recommended a total increase for 
Veterans' Health Administration of $1.9 billion, $555 million 
over the administration's requests which includes nearly a $1 
billion increase just to meet the routine escalating costs such 
as salary increases and inflation.
    Mr. Chairman and members of the committee, we ask that you 
support the recommendations of PVA. We also ask for your 
assistance to insure that the VA receives the funding that it 
needs to insure that veterans who rely upon the VA for their 
health care needs are accorded adequate and quality health 
    Let us work together, building upon the accomplishments of 
last year to secure for a solid budget base for health care in 
the years ahead.
    We ask you to reaffirm our Nation's covenant to veterans 
and to remain faithful with generations of promises.
    Last, I would like to comment on a local issue.
    Mr. Shays. If you could just bring it to a conclusion.
    Mr. Cascella. Yes, Mr. Chairman. Analysis showed that 
millions of dollars could be saved if the West Roxbury at 
Boston VA Medical Centers were consolidated. In order to 
complete a successful consolidation, some construction and 
renovations were needed at approximately a cost of $30 million. 
At first it was thought the VA Central Office would provide all 
funds needed for construction and renovations. That thinking 
proved to be wrong.
    The VISN will have to provide the funding for the entire 
consolidation. We have learned that in order to fund the cost 
of construction and renovations, the VISN will have to use all 
of their minor construction funds and equipment purchasing 
funds for the next 3 years. We believe that this is the wrong 
way to fund the consolidation.
    Overall, quality of health care provided and quality of 
care in not purchasing replacement equipment or new equipment 
will be sacrificed. We believe that the VA Central Office must 
provide the necessary funds to complete the consolidation.
    Mr. Chairman and members of the committee, we ask that you 
look into this matter and encourage the VA Central Office to 
provide the necessary funding to complete the consolidation 
that will eventually save significant resources.
    Mr. Chairman, that concludes my statement. Again, I thank 
you for coming to our area and allowing us to present our 
comments to you all. Thank you.
    Mr. Shays. Thank you. And I appreciate you being flexible 
with us in coming up front like this so we could record your 
    Mr. Cascella. Thank you for being flexible.
    Mr. Shays. Thank you. Who would like to speak at this 
    Ms. Maguire. My name is Hilary Maguire representing the 
Veterans Northeast Outreach Center in Haverhill, MA. I also 
served on the 782nd Maintenance Battalion under the 82nd 
Airborne Division during Desert Storm.
    Just for a real quick note to clarify, our van was donated 
by the VFW of Massachusetts and also Congressman Tierney, just 
so you know in regards to your question about 214s. There is a 
number in Boston. It needs some revamping, but it is another 
option for those that live in Massachusetts trying to get their 
    My question today and I hope at some point there will be 
some clarification, I have had several women come into my 
outreach center who suffered from sexual trauma while on active 
duty. I have read the law. It is my understanding that they are 
eligible for sexual trauma counseling, but I do not know if it 
needs to be clarified or if they are eligible for health care 
    Two women have come into my center and have been denied 
benefits due to their time while on active duty. It is my 
understanding that they need to serve a minimum of 2 years. I 
am hoping that maybe this could be addressed and the 2-year 
eligibility requirement dropped.
    Mr. Shays. If they have served less then 2 years, they are 
not entitled to benefits?
    Ms. Maguire. Yes, that is the answer that they have been 
    Mr. Shays. I am seeing a shaking of the head of someone who 
is in a position to know, so let us say this. We will get the 
answer and hopefully respond to it to you before we leave 
    Ms. Maguire. Thank you.
    Mr. Shays. Thank you. Will you make sure that happens, 
    Mr. Daley. Good morning, Congressmen, Tom Daley, State 
Adjutant for the DAV. And I just want to say on that DD 214, 
Congressman, in Massachusetts, anybody who has received a bonus 
in Massachusetts going all the way back to the first World War, 
the Department of the Adjutant General's Office will have a 
copy of that discharge.
    Mr. Shays. Thank you.
    Mr. Daley. And also I would like to present this written 
testimony concerning the hepatitis C, Gulf war veterans 
compensation and DIC entitlement which I will----
    Mr. Shays. Excuse me, 1 second. Do we have a tape problem 
here? No problem. We will take care of it. We want it on the 
record. I have to tell you this is my most favorite part of the 
    Mr. Daley. I will be submitting written testimony on long 
term care, hepatitis C, Gulf war and veterans issues and 
conversations with DIC, means testing, etc.
    I just want to say we have good working relationship with 
the veterans agents in Massachusetts. They are very supportive 
of us and we work together on case loads. Dan Stack, a 
supervisor here for the DAV National Service Office, so we do 
work together.
    Roughly 15 of the 20 percent of the veterans across this 
country belong to veterans organizations and the rest of the 
veterans do not even know what is going on in this country. 
That is the problem.
    In Massachusetts, to be a veteran in Massachusetts, you 
have to have 1 day wartime, 90 day service. We have a lot of 
veterans in--I know that is not a Federal issue, but it is 
important to us because we are trying to get legislation passed 
in Massachusetts to pick up all what we call old war veterans 
and we want to make sure that they are included in the benefits 
across the Commonwealth because that will enhance, that will 
bring in issues, that will bring more people and more 
penetration into the VA system. We are trying to work on that 
    So again, concerning the veterans issues in the 
Commonwealth. On that 90-day, 1 day wartime, they are not 
entitled to benefits because they are not entitled to real 
estate exemptions. They are not entitled to Chapter 115 
benefits administered out of the Department of Veterans Affairs 
and they are not entitled to Civil Service preference.
    But my own opinion is if anybody who puts the uniform on in 
this country is entitled to benefits, so I would like to see 
that happen. We are working on it in Massachusetts, the DAV and 
all the veterans organizations to pick up all the old war 
veterans and I am sure that it will help the VA long term care 
down there, more veterans penetrating the system into the VA 
health care system.
    That is all I have to say, thank you very much.
    Mr. Shays. Thank you very much.
    Mr. Boutin. Mr. Chairman, Congressman Tierney, my name is 
Gerard Boutin. I am Commandant for the Marine Corps League for 
the Department of Massachusetts and I have two very quick 
questions. The first concerns the screening for the 
establishment of the Lynn Clinic which I think is a great 
    At that time they were looking for members to sign up so 
they could have a large member on their rolls. I just recently 
have been re-enrolled and one of the things that they state is 
what if I am sick when I am traveling. It says you may receive 
health care at any VA health care facility in the country, 
well, that is really not true.
    Recently, I was in Florida last February and I noticed a 
sign for a VA clinic so I went in and I presented my card and 
said if I needed medical assistance could I come into the 
clinic and their answer was no. You are not in the system. And 
they proceeding then to give me a whole bunch of paperwork that 
I would have to fill out and which I brought home.
    Shortly thereafter, I went over to St. Petersburg and had 
to take a blinded veteran to the VA hospital and I did the same 
thing. I asked if I had to take care of any medical problems 
and I presented my card again, I said could I come to this 
facility and the answer again was no. You are not in the 
    So I really do not understand if we are in the VA and we 
are not in the system, as I understand in asking questions when 
I get back, we are here in the system in Wheaten and that is 
about it, but it does not take care of when we travel and I 
think a lot of the veterans, that is what they need. We will 
look for the benefit if we are traveling.
    Second, I am receiving bills from the VA because the VA 
cannot bill Medicare for services and maybe you know all about 
that and I would like to bring that up as a point. The VA, as I 
understand cannot bill Medicare for services. Therefore, any 
services that I get in the VA hospital in Bedford, I have to 
pay out of my own pocket.
    Mr. Shays. I was under the impression that services were 
available wherever you are and so I would like to nail that one 
down and maybe that can be dialogued before we leave directly 
with Dr. Murphy or our other two panelists who were there.
    Mr. Boutin. Incidentally, you asked, I was in the Marine 
Corps from 1946 to 1952. I served as a Staff Sergeant with the 
2nd Marine Division.
    Mr. Shays. Thank you for your service, sir. Yes sir?
    Mr. Becker. My name is Bernard Becker. I am a past State 
commander and past regional commander of Jewish War Veterans. I 
served in the Air Force from 1950 to 1954. VISN 1 as far as I 
am concerned stinks. We are closing up wards at hospitals. We 
are closing buildings at Brockton VA and then people who have 
the Alzheimer's cannot find a place to go. They are told by 
their families, take them to a private place and they will take 
care of them.
    As far as I am concerned they should keep these buildings 
open, keep the wards open and take care of the veterans in the 
facilities. Holyoke, Chelsea Soldiers Home, there are waiting 
lists. They cannot put any more in there, but when they are 
closing up these buildings, I cannot see why they cannot keep 
them open and put the veterans in those buildings and I also 
have from my national organization, they did send me a fax on 
veterans issues.
    Mr. Shays. Thank you.
    Mr. Calomo. Thank you for letting me speak today. I am a 
past Vietnam combat medic and I served in the Army in the 
199th. I am from Gloucester, MA and I support Colonel Welsh, a 
veterans' agent, because of the veterans, I am the past city 
council of Gloucester, and many----
    Mr. Shays. You are not a Republican?
    Mr. Calomo. No, I am a Democrat. [Laughter.]
    I am sorry, I am a Democrat. I have had many veterans also 
call me and tell me they cannot get transportation to Bedford 
or Boston and I myself go to Bedford and Boston. I go to 
Jamaica Plain and I have a lot of trouble driving into Boston, 
so I do not do that. I take the train and I spend the whole day 
trying to get to my appointment and get back to Gloucester.
    Also a lot of the veterans cannot get a ride from Boston to 
Bedford. They have tried. A lot of time the drivers are 
unavailable through the DAV. They do have vans, but a lot of 
times the drivers are unavailable. So it is hard to meet 
scheduled appointments.
    I also work for a home health service and I have had 
clients that ask me to take them and I have done that. So at 
this point I reemphasize a real need for us to have something 
in Gloucester, a medical facility.
    Thank you very much.
    Mr. Shays. Can you say your name into the mic?
    Mr. Calomo. Samuel Calomo. Thank you.
    Mr. Shays. Thank you, sir.
    Mr. Gonzalez. Good morning, Mr. Chairman and Congressman 
Tierney. My name is Salvatore Gonzalez and I am from Chapter 
3240, the name of it is General John S. Patton, Jr. from 
Beverly and I am here to request information from you, if I 
    We have a member of our chapter who has been very sick and 
lives on the second floor and he needs assistance because he 
cannot negotiate the stairs. He has to sit down two to three 
times before he can out to the second floor.
    I went to make an initial contact in Jamaica Plain about 
what we could do to help him out as far as getting an electric 
chair. The doctor had to recommend then to the Rehab Medicine 
in the fourth floor so that they could approve the 
recommendation before he could be eligible to receive an 
electric chair. By the way, this veteran is 50 percent service 
connected for the Second World War.
    I made the initial contact in March and the closest I could 
get a doctor to see him at the VA, it is May 17th, so the guy 
is still trying to get off the second floor which is very hard 
for him.
    My question is this, what does a person like that have to 
do when he has to go out and get help? Where does he go from 
    Mr. Shays. We are not going to take any questions right 
now, but we are going to have your question on the record and 
we have staff here that can respond to the question.
    Mr. Gonzalez. Thank you, sir.
    Mr. Shays. Thank you.

                       TOWN OF LYNNFIELD

    Mr. Restani. Mr. Chairman, my name is Neil Restani. I am 
the director of Veterans Services for the town of Lynnfield. I 
have a statement that I would like to read. Also, I served from 
1942 to 1946.
    Regarding health care at the local level. Our office in 
Lynnfield is very satisfied with the treatment and care that 
our veterans receive at the Bedford health facility. They 
receive excellent care and the cases are handled in a 
professional manner.
    Also, the veterans walk-in clinic at Lynn also provides our 
veterans with much needed assistance. Just last week at our 
American Legion meeting, one of our members was very grateful 
to the treatment that he receives from the Jamaica Plain 
facility regarding his prostate condition.
    I have one concern. My office has this concern. I do 
receive many referrals from veterans who are not eligible for 
many services only because they do not qualify. They do not 
receive any disability. These are veterans of World War II and 
Korea and they are getting up there in years and now they feel 
that they would like some kind of assistance, but they are not 
qualified. I wonder if that matter could be looked into. Thank 
    [The prepared statement of Mr. Restani follows:]
    [GRAPHIC] [TIFF OMITTED] T0278.036
    Mr. Shays. Thank you very much. I am going to try to get an 
assessment of how many more speakers we have, if you would 
raise your hand. Those are the eight speakers, so we are going 
to have to move along. If you can be closer to 2 minutes, it 
would be great, but we will live with 3.
    Yes sir.
    Mr. Ouellette. Mr. Chairman and panel, my name is Joseph 
Ouellette. I am a disabled combat veteran having served with 
the U.S. Army in Vietnam with 173rd Airborne Brigade.
    I am here to represent the Essex County Correctional 
Facility. I am the veterans outreach coordinator and I also do 
the HIV coordination with the hepatitis C virus. So there is a 
link between veterans and the hepatitis C/HIV and there is also 
a tremendous link because 90 percent of the incarcerated people 
are in there because of substance abuse.
    So what I have found for 10 percent being the veterans' 
population, I have approximately 120, 130 veterans. Most of 
them do not know that they have any veterans' benefits at all 
and the crimes committed are because they have a substance 
abuse issue. Most of my connections have been with the Bedford 
VA, the homeless shelter in Boston, and the veterans mansion in 
Haverhill which has been a tremendous asset to help out.
    My question or my concern is in the future let us not 
forget about the incarcerated veteran. OK? Thank you.
    Mr. Shays. Thank you, sir. I am struck, sir, by the fact 
that your comments are very well taken, I mean as are all the 
others, but sometimes that group does get overlooked.
    Mr. Smith. Good afternoon, Mr. Chairman.
    My name is Arthur Smith. I am the past department commander 
for the State of Massachusetts, the American Legion and I would 
ask your indulgence because I have a statement here projecting 
what the American Legion feels about this----
    Mr. Shays. Let me just say though if it is longer than 3 
minutes, it needs to be submitted and you need to summarize.
    Mr. Smith. This is from past national commander, John P.J. 
Komer and past national commander, Anthony T. Jordan. Mr. 
Chairman and members of the subcommittee, the American Legion 
continues to follow the changes in health care delivery in New 
England with great interest.
    The American Legion appreciates the opportunity to submit 
its observations and concerns regarding the impact and 
restructuring and the resource allocation of delivery of 
quality VA health services on the national, regional and local 
level. The American Legion will address the specific issues 
identified in the invitation to submit testimony, the VA budget 
for fiscal year 2001 and the VISN 1 budget for fiscal year 2001 
and access care for the veterans infected with hepatitis C.
    The American Legion has previously acknowledged the 
administration's request of $20.3 billion to veterans' health 
care as reasonable, although the American Legion believes that 
the President's budget requests falls short of the required 
spending level for several reasons. The American Legion 
recommends that the VA health care receive $20.5 billion 
appropriation for fiscal year 2001. First, the American Legion 
questions the VA projections of medical care collection fund, 
called MCCF and sharing other collections.
    The President's fiscal year 2001 budget request is based, 
in part, on the availability of a cost of $600 million from 
MCCF and another $115 billion from sharing in other 
collections. The revenue sources that compromise these funds 
include veterans co-pays, third party insurance and contracts 
with the Department of Defense and Tricare.
    Since the enactment of legislation allowing VHA to transfer 
revenues from MCCF fund, the administration projections have 
been off in each of the past 2 years. National projection fell 
nearly $100 billion short of projections to the fiscal year 
    In VISN 1 alone, the overestimate was $14 million, just 
under 2 percent of its total VERA budget. VHA has made 
adjustments to its formula in projecting collections. Despite 
these adjustments however, the American Legion is not fully 
convinced that the projected collections for fiscal years 2000 
and 2001 by VHA are accurate. This lack of confidence is not 
due to the lack of consideration of VHA's effort, rather it is 
attributed to the unknown ramifications for similar changes in 
policies and operations.
    Mr. Shays. Can I ask you if you could summarize the 
conclusion and we will submit the whole thing?
    Mr. Smith. OK, sir.
    Mr. Shays. Thank you sir, I appreciate your cooperation. We 
are just trying to make sure we get to votes this afternoon, 
there are votes on the floor of the House. That is our 
    Mr. Smith. Finally, the American Legion is committed to the 
issues of the best care to veterans with hepatitis C virus, 
HCV. The American Legion has indicated strong support for VA 
programs geared toward increasing education among both veterans 
and providers that involve treatment of HCV, expanding VA 
treatment and research.
    The national field services of the American Legion 
continues to monitor access to HCV treatment as well as other 
aspects of the HCV issue and a special focus within its 
oversight program.
    Mr. Chairman, if I might be allowed to say on behalf of 
myself, when I entered the U.S. Air Force I raised my right 
hand. The government did not say if you were 10 percent, 20 
percent or 30 percent service connected with a disability that 
we would take care of you.
    The government said that if you needed health care, we will 
take of you and I know earlier this morning they were talking 
about lowering the requirements from 70 percent to 50 percent. 
I do not think that is fair enough to my fellow veterans that 
fought in World War II or my fellow veterans that fought in 
Korea. I think the limit should be down to 30 percent. Thank 
you, Mr. Chairman.
    Mr. Shays. Thank you, sir. Yes sir.
    Mr. Koontz. Ron Koontz. I am the director of Veterans' 
Service for Amesbury. I am also a combat veteran from Vietnam, 
1968, 25th Division and you can stop me after 1 minute.
    What I would like to discuss is with the first panel was 
the disability claim process. I believe it was Dr. Murphy 
talked about the turnaround time for the initial claims. The 
180 days does sound good, but it is once that decision has been 
made, once it goes into the appeal process, there is definitely 
a long term wait on this, anywhere from 18 months to 3 years to 
7 years and probably beyond.
    The other issue would be I have gone through Boston JFK 
Building and I have seen stacks of claims on the floor at least 
3 foot high and I hope this is not indicative of throughout the 
United States, but there does seem to be a backlog on the 
claims process. Thank you.
    Mr. Shays. Thank you very much, appreciate it.
    Ms. Troubetaris. My name is Maureen Troubetaris, I come 
here on behalf of my brother, John Day, served 1967 to 1971, 
United States Air Force Staff Sergeant, served in Vietnam, war 
veteran, served in Bangkok, Thailand as a crash fire fighter. 
My brother has been hospitalized for the past 14 months in the 
veterans hospital and cannot speak for himself. My family are 
his eyes and his ears and his mouthpiece. My greatest concern 
is the money available. You fund it for the veterans who have 
long term health care, health indeed necessities.
    Two weeks ago today I got a call at work out of the clear 
blue sky from the veterans in Jamaica Plain and was told my 
brother ran out of benefits and where do I want him. It is 100 
percent service connected, Vietnam War veteran and this was a 
shock to our family. Where would we place him?
    Once they placed him in a nursing home and they almost 
killed him there. I guess my answer today is quality health 
care for all veterans, quality of where you place your 
veterans. There is no followup after you place your veterans in 
places that you contract out to. Some of these places that you 
have contracted to have great violations. You need to have a 
followup. There needs to be continuity in health care with the 
doctors. With long term health care, you do not have continuity 
in medical health care. Every month there is a new team of 
doctors. The only continuity is in the nursing staff. You need 
to have that for a family to understand.
    I ask that the committee and I thank Congressman Tierney 
for all the help his office has given our family. It is a scary 
thing that my brother cannot speak for himself, but I do ask 
for help that you continue to finance all the veterans programs 
and look at the millennium bill as soon as possible. You cannot 
leave a generation of people, totally unprepared for long term 
health care at the mercy of this kind of treatment. Thank you.
    Mr. Shays. Thank you for being a supportive sister on 
behalf of your brother, ma'am.
    Mr. Tierney. I want to note that Maureen is not only a good 
voice for her brother and family and veterans, but is a 
counselor in the city of Beverly.
    Mr. Passeri. Mr. Chairman, Representative Tierney, Angelo 
Passeri. I am a VA/VS deputy representative for the Vicotira 
Rocky Post and Beverly, a membership of 600 plus. I want to 
thank the panel. They covered every question that was presented 
to me by my membership. You did a fantastic job. You covered 
everything I wanted to cover.
    I just want to augment one thing. When I heard one of the 
objectives that they had was to downsize the in-patient 
complement at the Bedford Hospital. I got a little nervous 
because most of my recourse are to help gain access to that 
facility for our Alzheimer's and no doubt it is probably the 
best institution we have in the Nation.
    I work very close with the first line staff and it is a 
showpiece and it hurts to see that we cannot gain admittance to 
that particular unit. And I just want to hope that you people 
will just keep in mind when we are talking about downsizing in-
patient, that this facility and others like it are definitely 
needed. Please give this a lot of consideration. Thank you very 
    Mr. Shays. Thank you very much.
    Mr. Shays. Yes sir.
    Mr. Boucher. Yes, my name is Gerard Boucher. I entered the 
Marine Corps December 15, 1966 when I was 19. Wounded October 
11, 1967. I am an advocate for the blind and all disabled, 
veterans in quotation. First of all, I want to come up here and 
thank you all for a day like this. The Congressman, the 
Chairperson, all the dignitaries, everybody that had anything 
to do with this assembly. I am just sorry that there are not 
enough veterans here to stick up for themselves.
    I came up here to mention two--one thing I got off my e-
mail the Johnson amendment that just went through the Senate 
for the $500 million, I heard the gentleman mention that 
earlier, I would like to see the House support that, if I 
could, and also this young lady that was up here earlier, just 
before me mentioned about her brother not knowing where to put 
    Now all this space after downsizing these medical 
facilities, Jamaica Plain, Brockton, Broadsbury, what are they 
going to do with all that empty space? Are they going to 
utilize it or sell it or whatever? Would that not be a nice 
place for a nursing home for veterans? That is my suggestion.
    There are a lot of things I would like to say, but I do not 
want the chairman to throw me out. This is what I really want 
to say, it is all in here, but I do not think you are going to 
give me the time.
    Mr. Shays. Let me just say, sir, I would never throw you 
out and it is an honor to have you testify before this 
committee and it is an honor to know you have served so well 
for your country.
    Mr. Boucher. And I want to thank you all again. Today like 
this here is what we need the most. You more you have of this, 
the better. And it is up to us to get the rest----
    Mr. Shays. I have a feeling that when Mr. Tierney asked 
this committee to come up here he was thinking of you.
    Mr. Tierney. This gentleman does a good job and he writes 
to my office at least once a month, always with pertinent 
information and insight and so we thank you very much for that.
    Mr. Boucher. Thank you, sir. Thank you all.
    Mr. Shays. Thank you. Sir.
    Mr. Lyons. Thank you, Mr. Chairman. My name is Tom Lyons. I 
am the executive director of the New England Shelter for 
Homeless Veterans. I want to thank you for being here today and 
also thank my good friend, Congressman Tierney, for allowing me 
to be here today.
    I am a former Marine. I served in 1967 to 1970 with a tour 
of duty in Vietnam in 1968.
    Mr. Chairman, I run probably one of the largest homeless 
shelters in New England, 320-bed facility for men and women. We 
are unique, Mr. Chairman, because we are drug and alcohol free 
and our programs are based on structure and discipline, 
structure and discipline that these men and women had when they 
were in the miliary, we use it as a way of building them back 
to self-sufficiency.
    We have emergency shelter, temporary housing and we also 
have permanent housing right inside our facility. We built a 
new medical clinic with the help of the VA. We are now not only 
providing basic medical care, but we are providing complete eye 
exams as well as dental care.
    We have a training program that over the last 3 years have 
put over 1,100 men and women back into the work force in 
Massachusetts at an average wage of $12. So as you can see, Mr. 
Chairman, we are a program that works and I am proud to say 
that we have been a player within the veterans community over 
the last number of years.
    But the concern I have today, Mr. Chairman, is that the VA 
is talking about doing away with detox programs and are leaning 
toward out-patient detox. As someone who sees 85 percent of our 
clients at our facility who are drug and alcohol dependent, to 
think of an outpatient kind of a detox program scares the hell 
out of me to be quite honest because we have men and women in 
our program 8 months to a year or to a year and a half who are 
drug and alcohol free.
    They were able to do it because of the structure and the 
discipline and the counseling services that we have in our 
    I ask you, Mr. Chairman, and I ask your committee to look 
at whatever the VA has in terms of surveys, whatever, to 
outpatient clinics and see if they actually work or is this 
just another way of creating another out source within the VA 
system. Thank you, Mr. Chairman.
    Mr. Shays. Thank you very much. I would just like to note 
for the record, it is 1:18, so I think we are almost done with 
our speakers. We have one gentleman here. We have three 
speakers all on this side and I do need to limit it to that so 
we have three speakers left.
    I am going to just before you speak, I just want to take 
note that Dr. Frances Murphy has been here the entire time. She 
could have left and she stayed and I appreciate that very much 
as well as Dr. Jeannette Post and I appreciate you staying here 
as a well, Doctor, as well as Mr. William Conte. It is 
important that you hear what the veterans say and I did not 
need to tell you that because you know that. You might be able 
to interact with one or two, but we need to make sure the 
record is straight, particularly on one issue dealing with 
counseling for women and also whether services are available 
throughout wherever you go.
    We have three speakers left. I am also going to allow our 
gentlemen, the panel up here to just make a closing comment if 
they would like if they are short. I think maybe what we will 
do, Dr. Murphy, I am going to have you respond to those two 
questions before we leave so that they are part of the record, 
    Yes sir.
    Mr. Hinds. Good afternoon, Mr. Chairman. My name is John 
Hinds and I would like to put a face behind some of what you 
have been talking about today. I am a disabled Vietnam veteran, 
a career employee in the Veterans Administration and a veteran 
who is suffering from hepatitis.
    I would like to thank Dr. Murphy, Dr. Post, Mr. Conte, Mr. 
Martineau and Mr. Hogan this morning because they were kind 
enough to show me something that I have never seen as a VA 
employee. I am taking annual today from my job in order to come 
here and to thank personally Congressman Tierney for the work 
he does not only on behalf of disabled veterans, but also 
particularly my district. I live in Georgetown.
    Since 1988 I have been an employee of the Veterans 
Administration and I have worked at the VA Regional Office and 
the Kennedy Building in Boston. I have worked at the VA Medical 
Center and Jamaica Plain and I have worked at the outpatient 
clinic in Boston and for the last 9 years I have worked on the 
staff at the Med Center in Boston.
    I have never had anything lower than an outstanding 
performance appraisal on an annual basis and yet I have been 
frustrated in every attempt, despite my education which 
includes a Bachelor of Arts degree and several completions of 
several courses on a master's degree level. I have been 
frustrated because I see what is being given to the veterans on 
the front line basis.
    Thank you, Mr. Martineau for your comments. They are very 
appropriate. I have been thrwarted in my attempts to improve 
myself as a VA employee. I have gone from a grade 5 to a grade 
6 in the 11 years that I have been with Veterans Administration 
and I have been labeled, despite being chosen as 1 of the 12 VA 
employees to give performance training and individual customer 
relations training to fellow employees as angry, troubled and 
frustrated in my attempts to improve myself and improve the 
care of service to veterans.
    So I am the face behind which you have been talking about 
today. I just wanted to thank you for this hearing and I wanted 
to thank you for your help, but I would like to say if you do 
one thing today, please make an attempt to recognize the front 
line employees who are there for the veterans every day and 
yes, they are frustrated because of the inability to improve 
ourselves and to improve the system. Thank you.
    Mr. Shays. Thank you very much, sir. Our second to last 
    Mr. Themes. Good afternoon, gentlemen. I am Charles Themes, 
22 years military service. I am retired military. Three major 
battle scars. I spent 26 months in Korea. There is 1,500 lost 
in Korea. We do not know where they are. We do not know if they 
are prisoners of war. I know Korea better than most of the 
students know this high school. I spent 26 months in Vietnam. I 
was in combat section in Vietnam. I jumped out of helicopters, 
2nd, 3rd, 4th, 5th Corps, Laos and Cambodia borders.
    And so I think a lot of my friends were lost over there. 
What I am saying is that military retirees and some of the 
veterans who were combat veterans have a lot of disabilities. I 
cannot get my teeth cleaned at the Veterans Administration with 
22 years of military service, five honorable discharges and 6 
years reserve. I cannot get my teeth cleaned. When I go to 
Veterans Administration to have my teeth cleaned they say head 
on down the road, that has been gone, Jack. I said that is 
there it was. That is where my helicopter is, taking me to Laos 
and Cambodia.
    But I speak for a lot of men, not only retirees, but the 
veterans. But if they want to know about North Africa, I spent 
3\1/2\ years in North Africa, if they want to know about Cuba, 
I spent 11 months in Cuba. I spent 11 months in the South Pole. 
I spent a lot of places in a lot of other areas. Islands in the 
Indian Ocean and when they look for a demo technician, we need 
you to do the work, you go out and do your job. We came back.
    When I was relieved from the military service they said you 
are all set. I came to VA and they said there is a dental 
office down the street, get going. Thank you very much for your 
time and patience. Have a very nice day.
    Mr. Shays. Thank you, you too, sir, and our final speaker 
from the floor. I am sorry, we have two speakers left.
    Mr. Clark. Good morning, Mr. Chairman, and Congressman 
Tierney. Thank you for giving me the opportunity to speak. My 
name is Larry Clark. I am a disabled Vietnam veteran. I was in 
the U.S. Air Force from 1965 to 1969. For the last 20 years I 
have worked with the veterans an employment specialist in the 
disabled veteran outreach program.
    My statement to you is when we were talking about having 
enough drivers to bring the veterans to and from the hospitals 
it might be appropriate if possibly in the budget you could 
appropriate some funding for van drivers because we do have a 
good CBO program that is coming out of the shelter and that 
would be appropriate, if you could fund that in the budget.
    Mr. Shays. Thank you, sir. Ma'am? You are our final 
    Ms. Zuberek. My name is Eleanor Zuberek. I am not a 
veteran. I am here speaking for my father who is not well 
enough to be here today. Congressman Tierney was kind enough to 
let me know about this in spite of the fact that I am 
frequently consorting with known Republicans.
    I wanted to address the problem of transportation and 
waiting times at the VA hospitals too. I get my dad in and out 
of there myself. I have elected to work part-time so I can be 
there for him. I do not know how many veterans have somebody 
who is willing or able to do that or who is married to a saint 
who is willing to put up with that.
    I want to tell you about 1 day last December, I just 
decided to summarize this into one experience we had. My dad 
called me in the morning and said he was not feeling well so I 
went flying over there and he is 82. He has service connected 
disabilities from World War II. He was having chest pains and 
his lips and his fingernails were turning blue.
    I said let us go to Beverly Hospital. He said no because 
there had been an incident 2 years ago when we had called the 
VA in the middle of the night and they said he is too sick, you 
cannot bring him here from Danvers, it is a 40-mile trip. Take 
him to Beverly, we give you permission. Well, the next day they 
did not know about that.
    And my father got stuck with the bill, so he insisted this 
time that we call Roxbury and I take him down there. We got 
there probably 8:30 and 9 a.m. and we sat in the emergency room 
with a lot of people who were very, very sick until 6 p.m. when 
he could be seen. He had very bad pneumonia and he had been 
released from the hospital the previous week.
    One of the men in the emergency room waiting with him had 
had bypass surgery 8 days before that. He waited longer than my 
father did, at least I think he did. They got there before we 
did. And I do not think this is unusual. We have been in there, 
I was waiting outside in the hall for my Dad to have chest x-
rays and I met two men.
    One came down from Togas to have some simple tests done and 
another one came down from White River Junction. This is to 
West Roxbury. With the distance reversed, my father would not 
have made it up there. He is too fragile to travel that far. 
Never mind, you are providing transportation. And I just want 
to say anything you can do for these guys, when you called them 
to serve their country they did not say let us study it for 60 
days and we will see if it is affordable before we go.
    Mr. Shays. Thank you very much for speaking for your Dad.
    Mr. Shays. In one way it is regretful to have our last 
speaker have such a negative message, but it is an important 
message to hear so I appreciate you sharing your remarks.
    I would like to make sure I do not forget this, so I am 
going to do this now before I just ask for closing comments and 
thank David Rapallo who is the minority staff member who I 
appreciate his presence and always his participation as an 
equal in this committee, with Larry Halloran, the staff counsel 
and also Christine McElroy who I said I would identify as 
ultimately responding, Mr. Welsh, to your suggestion about a 
briefing on VA benefits by DOD before you are discharged.
    She is going to give a card to you today and then we will 
give you the correspondence that we are going to have back and 
forth. It is something that we can easily deal with right away. 
And Gary Batt from Mr. Tierney's staff and Cara Siegel and Tony 
Cooper, as well as from my staff, Karen Shirest and from the 
subcommittee staff as well, Jason Chung and Suzanne French, 
Apex Reporting and also to Richard Carey who is in, fact, and 
Patrick O'Shay the student who has made our sound system work 
quite well.
    Some of the problem was external and we appreciate how they 
have gotten the system to work so nicely. And it is a lot of 
hard work. We appreciate both of your participation. And also 
to Peabody Veteran Memorial High School. Mr. Tierney leaves 
nothing out. He saw the name veteran and he said this is the 
place it had to be.
    I would just encourage, I realize, Dr. Murphy that the 
answer to the sexual trauma answer may be a little more 
complex, but if you do not mind getting to the mike and just 
putting on the record, in general terms, to be followed by more 
extensive remark in writing.
    Dr. Murphy. Congress would pass legislation to make all 
veterans who sustained sexual trauma, whether men or women, 
eligible for counseling and treatment for that in the 
Department of Veterans' Affairs and we work closely with DOD 
and make sure we identify those individuals and get them into 
    The general eligibility rules after eligibility reform are 
that any veteran who served honorably and has an honorable 
discharge for 90 days or more can enroll for VA health care. 
They would undergo a means test, but all priority levels one 
through seven, are eligible to enroll in the VA at this time.
    Mr. Shays. Any area of the country?
    Dr. Murphy. Any area of the country. This is nationwide.
    Mr. Shays. So sometimes the policy may not be followed, but 
that is the rules, so one suggestion is to contact your local 
Congressman or woman to make sure that that service is provided 
and also as well, we are happy to assist, Mr. Tierney, as well 
in any of the work that he has done with his veterans.
    Dr. Murphy. And I am sure the network staff or headquarters 
staff would be happy to help us.
    Mr. Shays. Right. To be aware of that problem and to be 
able to step in. Thank you very much. And gentlemen, I would 
just, very brief comments, I literally need to get a plane soon 
and Mr. Tierney, actually he needs to get on his way because 
you have a meeting on census before you get on the plane.
    Mr. Tierney. And in fact, if you gentlemen might excuse me 
because we are good enough friends that we can talk to each 
other at any time. I am due over in Lynn where the issue of 
census is very important to us and we are taking some efforts 
today to make sure that we get a count so that all of the 
services to all of our citizens will, in fact, reflect our 
    So let me just thank all of our witnesses from the first 
panel very much for not only testifying but for staying and 
listening; to all of our members of the second panel, for all 
the good work that you do day in and day out as well as your 
testimony here today and to all of the veterans who both asked 
questions and made testimony and those that cared enough to 
show up or who were able to show up today and the 
representation that you made for all of those who were unable 
to attend. I look forward to working with all of you. I thank 
you, Mr. Chairman, and staff very much for having the meeting 
held here today.
    Thank you.
    Mr. Shays. And I would be very remiss because everybody in 
this room knows one individual on my staff who does a 
tremendous amount of work with veterans, is himself a retired 
veteran and that is Harry Hoffmander and I want to thank him.
    Mr. Shays. We have not yet adjourned yet. If there is any 
comment that the four of you would like to make, if there is 
not, that is fine.
    Mr. Welsh.
    Mr. Welsh. Thank you, Mr. Chairman. I am from Connecticut, 
like you and if you ask me the question about party 
affiliation, you would like the answer, but I have and always 
will vote for Congressman Tierney.
    Mr. Shays. You know what, in this committee we are 
Americans first and Republicans and Democrats second, just as 
you are when you risked your life for your country.
    I thank all of you. This hearing is adjourned. I will be 
running out very quickly. I hope I do not appear to be rude, 
but I need to get to that plane. Thank you very much.
    [Whereupon, the hearing was adjourned.]
    [Additional information submitted for the hearing record