Dr. ROBINSON. To the best of my knowledge, that has not been activated, as yet. There presently are legal barriers to expansion, but if S. 59 becomes law, dental care for ambulatory patients could be greatly expanded.

Senator CRANSTON. Then, (b) that the VA set an immediate priority for the full utilization of auxiliaries in its facilities to increase the efficiency, practicability and economy of its dental services, and that staffing patterns be developed to assure that by 1975 the team approach to dental health care is fully operational in all VA dental services. Any action?

Dr. ROBINSON. Lack of funds has impeded action. And, I would like to point out, Senator, that this is one of the most important areas because, again, it would reduce the cost of care, expand the utilization of the dentists, and rather than having a 1-to-1 ratio—we don't even have now of assistants to dentists, we should have 2-to-1 and a hygienist with every dentist. This forms a team that can operate in a much .more economical fashion. And, it's funds that have prevented this, not personnel. A start has been made but progress is slow. The TEAM program is now in operation in some 10 dental schools. At least in the VA hospitals affiliated with those schools the team approach could be utilized, but it would require renovation of dental facilities in those hospitals.

Senator CRANSTON. Recommendation (c) was that the VA immediately establish recruitment and training programs for dental auxiliaries, with special emphasis on veterans with experience as dental auxiliaries during their military service.

Dr. ROBINSON. Again, lack of funding. There are places ready to go, and they just need funding. The VA has tried on-the-job training for veterans, but I do not believe that is the answer, for these veterans have had practical experience in the service. I believe they need special programs for "retreading" them and upgrading their background knowledge.

Senator CRANSTON. Recommendation (d) was that support be provided to the Dental Service for immediately expanding its research and development activities, and that those activities be directed toward the solution of oral and related health problems that are most prevalent in the patients in the VA system but which have direct applicability to the private sector.

Dr. ROBINSON. This has not yet been done. Again, here is a matter of it being economically more feasible to carry out research and prevention rather than care of disease after it has occurred.

Senator CRANSTON. In each of these cases where you come back with almost that universal answer, "no funds, no action," could you supply for the record the funds you think are required to get action? Dr. ROBINSON. Again, I would like to put that in the record.

Senator CRANSTON. Further, it was recommended (e) that a strong public and professional educational program be implemented to educate the public about the mission, activities and potentials of the VA Dental Service.

Dr. ROBINSON. The report of the advisory council has been published and the VA personnel have appeared before some organizations but in my opinion this is almost totally inadequate and is not the strong program the council members envisioned.

Senator CRANSTON. Same reason?

Dr. ROBINSON. Funding.

Senator CRANSTON. It was recommended that the VA Dental Service immediately embark on a series of studies and demonstrations to develop and test new ways of providing care to patients and to improve the use of dental manpower facilities.

Dr. ROBINSON. Again, this would require funds.

Senator CRANSTON. Finally, the Council suggested that its membership be more representative of all aspects of dentistry and be more integrated with other areas of health care facilities.

Dr. ROBINSON. The Council has been dissolved because of the restrictions on councils within the Federal Government.

Senator CRANSTON. Why is that necessary?

Dr. ROBINSON. I understood it was because they would have to get Executive permission to have the Advisory Council as such, and this would be difficult. This is only what I know as a civilian on this particular question.

Senator CRANSTON. How valuable is the Council, and what do you think of that action?

Dr. ROBINSON. I think the report speaks for itself, and I think it would be very valuable to be able to continue this Council.

Senator CRANSTON. Has the medical counterpart been abolished, SMAG?

Dr. ROBINSON. SMAG has not yet been abolished.

Senator CRANSTON. Is it going to be abolished?

Dr. ROBINSON. To the best of my knowledge, it is not.
Senator CRANSTON. Does it have any dental representation?

Dr. ROBINSON. It has had a dental representative, and I understand there is an appointment of a new dental representative pending. Senator CRANSTON. Is that adequate?

Dr. ROBINSON. It would not replace the Dental Advisory Council. If there is no replacement of the advisory council in dentistry, I think there should be two or three dentists on SMAG to represent the various sectors, the practicing sector, the educational sector and the research sector.

Senator CRANSTON. Would you give this further thought and a recommendation on how many representatives of the dental community should be on SMAG, should the Dental Advisory Council not be reestablished?

Dr. ROBINSON. I think three would be a minimum to adequately represent these three areas.

Senator CRANSTON. We will print the full report of the Council in the hearing record at the conclusion of your testimony.

Over the last 3 fiscal years, one recurring problem has been a growing backlog of Vietnam veterans' needs for dental care under the VA fee-dental program.

What is the status of that backlog at this point?

Dr. ROBINSON. I would have to get that from the Assistant Medical Director for Dentistry for the record.

Senator CRANSTON. Is there adequate provision of funds in the fiscal 1974 budget for fee-dental care?

Dr. ROBINSON. I don't believe there is, if there is any additional demand for dental care.

Senator CRANSTON. What kind of problems occur when a veteran has to wait 6 months to receive dental care under the fee program?

Dr. ROBINSON. The disease has advanced to the stage where rather than having a relatively early lesion to treat and preserving the teeth, he may lose his teeth and get into the situation of need for further, expensive treatment.

Senator CRANSTON. Could you give us an estimate on the adequacy of funding for fee dental in the budget?

Dr. ROBINSON. I believe that in the absence of additional benefits the amount budgeted may be adequate.

Senator CRANSTON. I have to go to the floor for a vote. Would you mind waiting? I will be back as quickly as possible, because I do have a few more questions.

Dr. ROBINSON. Certainly.

Senator CRANSTON. We stand in recess. [Whereupon, a short recess was taken.]

Senator CRANSTON. The hearing will reconvene.

I apologize for the delay.

Doctor, regarding your comments on Public Law 92-541, I regret the exclusion from subchapter I, of the establishment of new dental schools. The original Senate-passed bill, S. 2219, which I authored in the last Congress, did provide authorization for the establishment of new dental and other health training schools, as well as medical schools.

Unfortunately, the House insisted on limiting the new school provisions in the subchapter I of the bill to medical schools, which I think is an unfortunate decision.

However, I would like to point out that the $50 million authorized to be appropriated annually to carry out subchapters II, III, and IV, providing for the expansion of existing training at affiliated institutions, is available for expenditure, if appropriated, at the VA's discretion, to carry out activities under any of the subchapters.

The legislative authority in subchapter III, which does cover dental schools, is equally as broad as the authority in subchapter II, which covers only expansion of medical schools. Thus, there is no cause for concern in terms of expansion of training at dental schools being fully authorized by Public Law 92-541.

In my opening statement, I said I was interested in finding where savings could be made in present budget items as well as where more money is needed. If we could get our attentions and efforts on places where we could make some savings, it might help us then get funds for programs that so definitely need them.

Where would you recommend that we cut the fiscal 1974 budget, if you can make any such recommendation, for, first, the Department of Medicine and Surgery, and, second, other VA programs, and, third, the rest of the Federal budget?

Dr. ROBINSON. That's a little broad. I think we can save money. I'm certainly not going to suggest cutting the budget. We can produce care more effectively by better utilization of auxiliaries, and this would mean putting money into the utilization of auxiliaries. As I pointed out in my testimony, the team approach, where dentists, dental assistants and dental hygienists work together is a much more economical method of dental practice than the method used in the past. The second one, which would save a great deal of money, and I think practically no expense, would be the use of qualified dental students,

where such are available, as we have done in our community hospitals. There is no reason why these highly-qualified dental students, who often do some of their finest work, maybe a little slower than later, but some of their finest work, under supervision, could be produced on veterans and result in very effective treatment.

Then, the other thing I think, of course, that the Veterans' Administration Department of Medicine and Surgery should take a very careful survey to reduce any duplications that might exist. I would be very happy to see if I could help identify any of those.

Senator CRANSTON. Does the VA have any regulations which make it difficult or impossible to use the supervised dental students properly? Dr. ROBINSON. They do not make it impossible, they make it difficult at the present time. I would hope those regulations could be made much simpler.

Senator CRANSTON. Could you submit those regulations, with any comments about what we might do about them?

[Dr. Robinson subsequently supplied the following information:]

After further exploration I have determined that VA regulations will have enough flexibility so that guidelines can be developed to permit properly supervised dental students to render dental care to veterans in VA hospitals and in school clinics. I would urge the earliest development of such guidelines and their distribution to the affected stations.

Senator CRANSTON. Do you have any other thoughts on savings, after thinking about it?

Dr. ROBINSON. Another resource is the dental research facilities in dental schools. With present limitations of NIH funding I believe cooperative use of those facilities would be welcomed by many dental schools and would save the cost of duplicating expensive scientific equipment.

Senator CRANSTON. Could you look for that?

Dr. ROBINSON. I would be happy to.

Senator CRANSTON. I would like to say, in response to my own more general question, that in the Federal budget, as proposed by the President, I believe such potential savings exist and that they are very substantial. I believe we can make some cuts, and that Congress will make some cuts in other programs that will enable us, then, to seek to get adequate funding for programs like the one we have been discussing this afternoon, without increasing the overall spending level of the Federal Government, and, therefore, without any threat of a tax increase or a broader deficit. I have been working very hard at the present time to find ways in which this can be done.

Dr. ROBINSON. I think the people in my sector think of the importance of health care and the need for this is something we owe the people. We think that is more important than some of the things that have been put into defense and things far away from our own domestic

scene.

Senator CRANSTON. I agree. Defense and foreign and military aid, military spending on overseas aspects of the military budget are exactly the areas where I believe we could make substantial cuts and help the value of the dollar at the same time.

Dr. ROBINSON. It might be presumptuous for me to say this, but for the last couple of years, we in the health education areas and health professions, in general, have heard, "once the war is over, there will

be money available for the programs that we need. All of the people deserve health care." It is over, and we would like to see it now, because we have been prepared for it.

Senator CRANSTON. That's not the way it appears in the budget that was submitted by the White House to the Congress. As far as the medical care aspects relating to veterans, I think that is a constant priority, and we have to meet it and can't avoid it. I thank you very much for your very helpful testimony.

Dr. ROBINSON. Thank you very much, again, and I thank you for appearing at the 50th anniversary meeting of the American Association of Dental Schools last week.

Senator CRANSTON. Thank you. It was a pleasure to have you. Please thank the university on my behalf for enabling you to be here. Dr. ROBINSON. Thank you.

[The previously mentioned report and a letter subsequently submitted follows:]