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tal and medical care on a given day. We will provide care for one million veteran patients this year—an increase of 130,000 over last year.

Similarly, the 11 million outpatient visits to be funded by VA this year is an all-time high-over 2.1 million more than last year. We have activated 12 new Drug Dependence Treatment Centers since the start of this Fiscal Year, bringing to 44 the number of these specialized units put into operation in a little more than a year, and enabling VA to care for 40 per cent more patients than the 20,000 treated last year. By the end of this Fiscal Year, we will have increased the number of personnel in VA's hospital and medical care program to a record high 154,000, up 8,000 over last year and 19,000 over Fiscal 1971.

VA hospital staffs have grown from 117 employees for each 100 patients in Fiscal Year 1968 to 146 for each 100 in Fiscal Year 1972. VA's 1974 request now before Congress asks for an increase to 150 employees for each 100 patients.

The number of full-time VA physicians increased from 5,085 in 1968 to 5,374 in 1973.

Despite the fact that nurses are in generally short supply, the VA has done well in the recruiting market and now has more nurses on duty than ever before in history. There are now 21,279 nurses in the VA, approximately 30 per cent above the 16,399 in 1969.)

Medical training this year in VA's 168 hospitals will be provided to 62,000 people, the greatest number in VA history, and an increase of 10 per cent over a year ago. These medical and paramedical personnel will be trained in 60 professional and technical categories.

Other positives of VA medicine in 1973 are the addition of 248 specialized medical units in our hospital system, and the more than 5,000 research projects that will be conducted by upwards of 5,400 Research Investigators.

Looking forward to Fiscal Year 1974, the President's overall budget has been guided by his promise to the American people to do everything in his power to avoid the need for a tax increase. He considers this to be a solemn commitment, and he is very serious about remaining within a spending ceiling for this Fiscal Year 1974.

Even within these restraints, the VA has fared very well for 1974.

Of our total appropriation requirements for 1974, $2,761,600,000 or approximately 23 percent is for medical programs. Our estimates provide for improvement in both inpatient and outpatient programs, increases in the number of inpatients treated and outpatient medical visits, activation of additional medical and research facilities, and augmentation of the continuing educational program for medical personnel. A total 1974 increase of $48 million over 1973 is requested for medical appropriations.

For the Medical Care appropriation, we are requesting $2,656,000,000, an increase of $49.9 million over 1973. On a program basis, however, this represents an increase of $114.0 million over the obligations level for 1973. This program increase will provide for:

Inpatient treatment for a total of 1,108,900 beneficiaries, an increase of 27,500 over 1973 and 164,711 over 1972 experience.

Outpatient medical visits totaling 13,549,000, an increase of 1,916,079 over 1973 and 4 million or 42 percent higher than 1972.

A total of 275,000 outpatient dental examinations and 264,000 outpatient dental treatments.

The training of 62,000 physicians, dentists and other health service personnel in VA facilities.

Activation funds for 6 hospitals and other new facilities and systems.

A composite VA hospital staffing ratio of 150 employees per 100 patients, an increase of 1 over 1973 and 4 over 1972. Our request of $71 million for the Medical and Prosthetic Research appropriation is $5.8 million less than for 1973. However, the total program level for 1974 will be $78.4 million or $2.6 million higher than for 1973, taking into account the use in 1974 of funds available from 1973 appropriations.

This program increase of $2.6 million will provide for an average employment increase of 100 which, coupled with responsive shifts in emphasis, will permit:

Initiation of research programs in new and replacement hospitals and other expanded laboratory facilities.

Expansion of VA cooperative studies in areas such as hypertension, sickle cell disorders and alcoholism.

Expansion of prosthetic research and development activities—particularly the strengthening of biomedical engineering activities.

We are requesting $32.6 million for Medical Administration and Miscellaneous Operating Expenses in 1974, as compared to $28.7 million for 1973. This increased of $3.9 million will provide for an employment level of 810, or 75 over 1973 of which 50 relates to medical automatic data processing activities previously funded under the General Operating Expenses appropriation.

In addition to strengthening and improving management appraisal and evaluation activities and program development, the increase will provide for additional tuition and other educational support funds for medical-administrative personnel ; expansion of the Exchange of Medical Information program; and additional studies or projects related to improved health services delivery and medical program effectiveness and economy.

An appropriation of $100 million is requested for construction of hospital, nursing home and research and educational facilities in 1974. This provides $61.299,000 for Construction-Major Projects, and $38,701,000 for Construction -Minor Projects. It provides funds totaling:

$37.0 million for hospital replacement and modernization consisting of: construction funds for new clinical support facilities at Boise, Idaho, and partial construction funding of the replacement hospital at Bronx, New York; the new hospital bed building at Columbia, South Carolina ; the relocation hospital and nursing home at Loma Linda, California ; the Los Angeles replacement hospital, and the West Roxbury spinal cord injury rehabilitation center and modernization.

$37.0 million for other hospital improvement projects.
$5.7 million for research and educational facilities.
$10.5 million for nursing home care projects.

The remaining $9.8 million is for operating expenses of the Office of Construction which is responsible for facility design and construction. Mr. Chairman, this will give you and the Members of the Subcommittee an idea of the operation of our hospital and medical care program during the past several years and our plans for the coming year.

Senator CRANSTON. Dr. De Bakey has informed us that he cannot stay, so we will proceed very briefly with Dr. DeBakey.

Doctor, can you summarize very briefly your written statement for us?



Dr. DEBAKEY. I would be glad to, Mr. Chairman.

Senator CRANSTON. Your full statement will of course go in the record, and I apologize for the lateness of the hour, but I know you are aware of the fact that we had to ask those questions.

Dr. DEBAKEY. I understand. I am just sorry I can't change my plans, but unfortunately I can't, as I must take a flight this after


I do want to thank you for the opportunity to appear before you.

And, to summarize, let me say that the testimony which I have formally submitted for the record and which you have very kindly agreed to accept for the record, has indicated my own personal interest.

I think you will find that I have a very personal interest in the research training program, and in the whole VA program. This emanated from the time that I was in the Surgeon General's Office in 1946, and it is as a consequence of my experience there that I made a proposal to the Surgeon General that a VA research program be started to follow up medical observations on all the veterans returning, and to establish a program that would develop an inquiry into matters relating to the medical problems of the veterans.

This proposal went to the National Research Council, which set up the committee, and I was transferred to the National Academy of Sciences to work there for another 6 months at the end of the war. I was still on active duty, and we established the Veterans Follow Up Agency, which really began the first research program in the Veterans Administration.

In 1955 they started the intramural research program, which was a great addition to the research program.

In brief, let me say that I think the Veterans Administration research activities have contributed enormously to the medical care for veterans themselves, but also to the quality of the general medical care in the Nation.

It is very difficult, I think, to set a size to the whole veterans program, and particularly the veterans—not only medical care program, but the veterans research and training program, and to separate it from the whole national program. It is an integral part of the total national activity in this area. That is why it assumes great importance.

Now, to illustrate this importance is to illustrate its relation to our own program. In our own institution, as well as in many other parts of the country, we have a very close relationship between the Veterans Administration program, not only medical care program, but research and training program with our own Baylor College of Medicine program.

We expanded our enrollment beginning 3 years ago, but 2 years ago in a very active development of doubling our enrollment of our medical students, largely because Veterans Administration hospital was a closely affiliated hospital with our program. That was the only basis for being able to enlarge our class to be able to use more doctors. The Veterans' Administration hospital in Houston assumes a very important role in our total academic activity.

The cutbacks that are taking place and projected in research and training from the Federal Government, and particularly for the National Institutes of Health will actually affect our academic program by something on the order of about a $9 million reduction of our total expenditures, which means about a one-third reduction in our faculty personnel.

We are going to be very hard put to make up this deficit in the Veterans Administration hospital, which we are making up now because of the lack of funds in the Veterans' Administration hospitals to support these activities.

The funding that they provide us, or which is provided for research in the Veterans Administration hospital, is of course a very important source of research, but because of the lack of adequate funds, the patient care suffers, and we have had to make this up from our budget, the Baylor College of Medicine budget in order to provide the proper level and quality of medical care and training.

This is a very critical time because I doubt seriously that the quality of medical care that we have been able to provide the veterans can continue into next years' activities with this much cut in the overall budget. I am afraid this is going to take place across the country, so it is all very well and good to hear about the high qual

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ity of medical care you want to provide the veterans coming back home, and particularly the increasing number of veterans we are now having to assume following the Indochina war. It is not going to be possible to maintain that level if we have to continue at the funding level that we now have, and projecting for the next year in almost every area of special activity in our hospital (and we are one of the hospitals that has the special activities such as kidney dialysis, renal transplantation), it is not possible to do renal transplantation at our Veterans Administration hospitals despite the fact that we are a dialysis center. If it were not for the fact that we had Baylor supporting the renal transplantation, and if it was up to the VA, they simply couldn't do it, because they don't have the funds to provide it. So, we have to provide the personnel that does it. This is true in almost every other specialized areas.

Coronary artery disease is, as you know, an increasing disease in this country. It affects the veterans as it affects everybody else. So with the newer developments in the treatment of patients for coronary artery disease, and especially with some of the newer developments, we are hard put at the Veterans' Administration hospital, for example, to provide this kind of service and this quality of medical care, because we are short of personnel there, owing to the funding level of the hospital. This is pure medical care.

. We can do this at the private hospitals; we can do it at the city or county hospitals, but we are hard put to give it to the veteran-unless we can transfer him to a private hospital.

The same is true in terms of space. Now, I heard the testimony that was given on construction. I must tell you that I can't understand that testimony in relation to our own requests for additional space at our own hospitals, which has now been in their hands for more than 2 years. Maybe they are phasing it over the next 5 or 10 years, but we need that space right now, and we need it badly, and it is going to be impossible to provide the quality of medical care that we are accustomed to providing the Veterans Administration, and which we are all saying we want to give the veteran population.

We are going to have to continue to operate in the kind of constraints of space and the space limitations that exist in our hospitals today in terms of our population, so, I just don't understand the statement about what they are providing in the way of funds over the next year, as though these are all the funds that can be used.

We can use these funds right now, and unless we get some additional funds in a year from now or 2 years from now, the quality of medical care is not going to be at the same level. And secondly, you are not going to be able to provide all the veterans the medical needs that they will require.

Senator HANSEN. Mr. Chairman, if I could just say a word to Dr. De Bakev.

I think his summarization is extremely good, and I am certain that it will be given very serious consideration by this committee because certainly you are highly regarded, as I needn't tell you. And, I think what you have to say will be given extremely serious and earnest consideration as far as I am concerned.

Dr. DEBAKEY. Thank you very much.

Senator THURMOND. Mr. Chairman, I would just like to express my appreciation as a member of this committee to Dr. DeBakey for his presence here today, and say that I think his comments constitute a very fine contribution to this hearing.

Dr. DEBAKEY. Thank you.

Senator CRANSTON. Dr. DeBakey, I know that you have been in many ways the father of research in the VA, and your leadership in this field has been absolutely tremendous.

We face another problem in the fact that other aspects of the budget mean that affiliated medical schools are also going to be cut back right and left on research, and that in turn is going to affect the research that relates to veterans care.

Would you give us for the record your recommendation as to what the VA research budget should be for 1974? Could you do it for the record ?

Dr. DEBAKEY. Mr. Chairman, I would be hesitant to give you an off-the-cuff figure, but I would be glad to do it for the record.

Senator CRANSTON. We heard this morning that although research support is being reduced, the reduction will not have any impact on the research that can be achieved in the VA hospitals. This statement, I am sure, is rather difficult to support.

Dr. DEBAKEY. I think that statement can be challenged very easily.

Senator CRANSTON. Are you aware of programs which have been eliminated or reduced as a result of these cuts specifically?

Dr. DEBAKEY. Yes, I can supply those for the record, too.
Senator CRANSTON. Would you please do that?

Dr. DEBAKEY. I can also supply for the record some programs that we have been trying to initiate, which we have been unable to initiate because of lack of funds in certain instances.

Senator CRANSTON. I am sure you were glad to hear the VA's assurances that the term "outlay savings" used to describe future research allocations doesn't mean a planned reduction in those programs.

Have you, through your close association with research efforts nationwide, gotten the same impression that no general research reductions are planned in the future?

Dr. DEBAKEY. That is contrary to the experience that I had, and encountered everywhere across this country.

In our own institution we are cutting back, and already we are laying off people. We expect something on the order of about a $9 million reduction, in our overall program around $24 million. It is serious. Now, that money can't be found anywhere else, and the only result will be to have these people laid off and find other sources of work and income, and those research activities will be gone completely.

[Dr. DeBakey subsequently supplied the following information:]




Fulfilling the Nation's obligation to its veterans is a matter of justice and national honor. Meeting their medical needs is one of our highest national priorities. To insure that they are met, I intend to maintain and reinforce the independent system of Veterans Administration health care facilities when and as required. (President Nixon's dedication speech of V.A. Hospital at Columbia, Missouri).

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