medicine, long term care, and preventive medicine. Allied health workers developed specifically to assist the physicians and the dentists with these modalities of care can function with great efficiency and safety. They take a shorter period to train and they are less costly to produce. With their assistance, each physician and dentist can serve more veterans than before and thus expand his own utility.

(b) The provision calls specifically for the development of inter-disciplinary approaches. One of the major problems facing the organizers of health care systems today is the central difficulty of deploying health care personnel in the most efficient fashion-so that each profession can make a maximal contribution to the production of health care which is effective, efficient, less costly and more personalized than is now the case. Much experimentation is needed in redeploying the manpower we now possess and in devising new categories when necessary.

In this respect, the veterans hospitals have a unique opportunity to develop new models for the use of all health manpower. The system is a large one; it is well organized, and it is possible to set up carefully studied models of patient care to explore the new uses of health professionals much more effectively than is possible in community or university hospitals. Many of the obstacles of self-interest and conflicting prerogatives which stand in the way of newer patterns of manpower utilization in the civilian sector are obviated in the veterans hospital system. With the new provision, the veterans hospitals could use their unique potential to the fullest for the benefit of the veterans they serve and for the improvement of health manpower utilization for the entire nation.

(4) SOME GENERAL COMMENTS ON THE VETERANS' ADMINISTRATION HOSPITALS AS NATIONAL RESOURCES FOR EDUCATION OF HEALTH MANPOWER

I would like to emphasize that my support for the specific provisions of S 59 I have discussed and elements of 92-541 now awaiting funding is based on my conviction that they will improve the care of veterans and especially those veterans in the category for which we have the greatest moral responsibility as a nation. These measures if enacted and funded as the case may be will bring certain aspects of medical care delivered to all veterans closer to optimal than is now the case. Surely, the veteran should not receive inferior care when a comprehensive pattern is available (to the non-veteran) in the community. But these measures will also enable the veterans hospitals to develop and provide improved methods of care. Thus, in selected areas of care, the veterans hospitals can take a role of leadership for the benefit of those "they serve and all others, as well.

It happens also that these measures will also enhance the already great contributions of the veterans hospital system to the production of health manpower for its own future needs of the nation at large. Our veterans hospitals constitute a unique resource for medical, dental and health professional education of all types. They are now assuming an ever greater importance for the universities with which they are affiliated. They have a mandate to participate in education as well as patient care; they provide examples of settings in which good care must be the prime objective. But good care is also the first requirement for good education. The veterans hospitals also permit easier and better controlled opportunities for developing newer kinds of health manpower, for better models and patterns of delivery of care, and utilization of personnel. The veterans hospitals provide an economical means for enlarging the number of students who can be educated in any university. In some communities they are or can become the major clinical base for new medical and health professional schools. The return in benefits to patient care and education for the money expended for certain types of education can be higher in a veterans hospital than in comparable institutions under private auspices.

Current recommendations for federal expenditures for education of health professionals impose considerable restraint to health manpower production. This may not have dire results immediately. If some form of national health insurance is enacted-then the demands for medical care will surely increase. With the demands will come the requirement for more health manpower of all types. The actualization of the full potentialities of the veterans hospitals for education and patient care can and will provide a resource for clinical education ready to respond to future expanded needs and to provide a steady flow

of health manpower at a time when other systems will be forced to curtail their efforts.

Moreover, the largest capital and operating cost of establishing a new medical school is the university hospital. The veterans hospitals, if they can extend their roles as S 59 and P.L. 92-541 and their provisions promise to do, can compete in quality with university hospitals and obviate the attendant costs of building and maintaining a whole new set of university hospitals.

All of us in medical education now realize that we must tie education more closely to health care delivery. It is only through our impact on production of adequate numbers and kinds of health care personnel and through our efforts to improve the patterns of health care delivery that we can justify our educational and research efforts. This close inter-penetration of service, education and research is a feature of the mandate of the veterans administration hospitals which will make them progressively more important resources for the welfare of all citizens as well as the veteran population.

The funding of 92–541 should be considered a necessary adjunct to the passage of S 59. The veterans administration system can thereby extend its capacities in clinical education and by doing so to facilitate the care of more veterans. These measures will further encourage the essential mix of patient care, education, and research which provides the best ground for the development of newer types of health personnel and patterns of health care delivery the veteran and the entire nation need.

Senator CRANSTON. Our next witness, changing the order, is Col. Herbert M. Houston, director, National Legislative Service, Veterans of World War I.

We are delighted to have you with us and we appreciate your patience in waiting.

STATEMENT OF COLONEL HERBERT M. HOUSTON, DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF WORLD WAR I OF THE U.S.A., INCORPORATED

Colonel HOUSTON. Thank you very much, Mr. Chairman.

For the sake of the pressure of time, I would like to submit the written statement.

Senator CRANSTON. Thank you very much. That will go in the record. We appreciate that.

Colonel HOUSTON. I would also like to submit five letters as a part of this, with three appendices.

Senator CRANSTON. They will go in the record following your prepared statement at the conclusion of your testimony.

Colonel HOUSTON. I can state briefly, in summary, the objectives we have, Mr. Chairman, and that is to get our people into a Veterans Hospital for post-hospital care, which is nursing homes. Those are the two critical areas to which I would summarize the written statement.

Turning briefly to some of the appendix letters that we have referred to, we have sought to get some information for you on particular cases and instances that we could point out to you the need for hospitalization for our aging veterans.

We continue to receive letters of individuals who sought to get admittance, who are put on a waiting list or were sent home without hospitalization. So, we sent out some inquiries to get some letters back or cases back. We didn't have time to receive them before this hearing, so I called some service offices to get some letters and statements from them.

We have been trying to get patients in the hospitals or nursing homes to get their reactions from them. There are two letters in this group from individual cases.

I would like to address myself now to some of these letters from the service offices, and I will just quote a few sentences from some of these letters.

This particular one is from a county service officer, where he states that he had a number of cases where the hospitalization was refused to the veteran, but he did not have time to go into his record and get this to me to present the names for you.

Now, he raises a problem that I have not heard raised in any of this testimony. The sentence "Our problem in Cleveland is the doctors will not accept a service-connected patient, because they say the VA will not pay the fees."

This has reference to the outpatient care. With this letter is a letter from the medical association of that county, which is very critical. It may be found in the record. He apologizes for not being able to give us names-I was restricted as to time, I had 2 days to get this for

you.

Another case in another county, another service officer makes this complaint with regards to getting veterans in the hospital:

The complaints that I have for the Veterans' Administration Hospital is that when a veteran makes application for hospitalization, it will take the Doctor 10 days to review this application and then he will be scheduled for hospitalization from 30 to 40 days in the future.

The VA tells us that there is no waiting list. I think this man is on a waiting list until he is admitted to the hospital.

These are quotations from the service officer.

Another complaint is the VAH will notify a veteran to report to the VAH for admission, when he arrives he is examined and told to go home and come back for admission next week.

The veterans in the community where this gentleman lives to which he is referring, is 150 miles from the Veterans' Administration hospital. These veterans are on a limited retirement income and do not have the funds to go to these hospitals. If it is an ambulance case, it will cost the community from $110 to $125 in ambulance fees to travel and transport him to the hospital.

If he is able to ride in a car, that means that someone must donate his time and a car or send him in a taxicab, which will cost $50. This is very critical, a very critical indictment of that situation.

He goes on to state, "If this man needs hospitalization next week, why does he not need it now?"

Just briefly, I have a letter here from an individual who said he made application to go to the Veterans' Administration hospital three times unsuccessfully, and the reason given him, no beds.

Senator CRANSTON. Do you know what his problem was, do you know what his health problem was?

Colonel HOUSTON. He had been in the VA hospital on three previous occasions at different places, and he had moved to this place. Senator CRANSTON. What was his illness, do you know?

Colonel HOUSTON. He just says serious ailments, he does not classify it.

Those are the hospital cases. Our problem there is getting our people in the hospital.

Now, we receive hundreds of letters that back up the statements of these service officers throughout the year. Now, I would like to call your attention, Mr. Chairman, in regards to nursing homes. I heard you ask the question if there is any place in the VA budget where money could be saved. Right here, I think, is one place that money can be saved if the law is changed or the regulations of the VÅ were changed. I have a letter here

Senator CRANSTON. What would you do to make a savings there? Colonel HOUSTON. I was going into that a little later, but I will mention it now. If the VA would accept the recommendation of the veteran physician at home to go directly to the nursing home instead -having to be hospitalized and kept there for a period of time and then transported to the nursing home. I think it would be a penitence, but it would be a savings in money and time, and the hours of service at the VA while they were processing them at the Veterans' Administration hospital.

Senator CRANSTON. As long as we are on the cuts, is there anywhere else in the budget or is there anywhere else in the VA budget you feel cuts could be made?

Colonel HOUSTON. I can't see it, sir.

Senator CRANSTON. If we have to increase the VA budget and still stay within the spending ceiling, we have to make some cuts somewhere else in the budget, not necessarily in the VA, of course. Do you have any recommendations or ideas as to where we might find that room for cuts?

Colonel HOUSTON. Frankly, sir, I have not studied the overall budget enough to be able to give a good judgment on that. I might arrive at one by a more careful scrunity. But as of now, I would not pass judgment on that.

Senator CRANSTON. The President said that perhaps he would fit within his budget aid to North Vietnam.

Colonel HOUSTON. Well, I would abolish that completely.

Senator CRANSTON. What do you feel about some of the other aspects of our foreign aid, military aid to dictatorships?

Colonel HOUSTON. As long as there are needs for hospital beds for veterans, I think it should come out of that as the number one priority.

Senator CRANSTON. Thank you.

Colonel HOUSTON. May I add this further statement. I have just read an article from-I have forgotten the name of the placewhere the tourists were criticizing the devaluation of the dollar, and the tourists were being penalized for the exchange rate.

In the same news account where this was being discussed-could have been Austin-the appropriation of $17 million to build some roads down there. That $17 million would help some of these veterans obtain a bed or nursing home care or some of the technical work that the previous witnesses has given. That certainly should be

Senator CRANSTON. If, again, we have to choose between cutting the money in the budget for the veterans or cutting something else out, how do you feel about the $30 billion that is going to maintain NATO and other bases overseas, at a cost of $30 billion a year? Five billion of that relates to the collapse of the dollar, because that

is money going out of the country, when our NATO allies do not pay their fair share of the cost of all of that, so that we have to put the money.

up

Colonel HOUSTON. It is a little bit off the question, but I think it is connected with what you are saying. I was in Israel and in the Far East last year, and I went by and observed some of these United Nations camps where we are subsidizing the food and care for these Palestinians in these areas, and comparing them with other natives of the same area. I came away from there with the firm convictions that that should be eliminated, because they were just sitting there waiting for the dole. They were doing nothing to help themselves.

Now, my generation of veterans is firmly convinced that if a man is willing to work he should not ask for anything. These people, we are feeding them, we are clothing them, we are policing them, and I can't see it.

Now, with regard to the question that you raised, I am not in disfavor of it in principal, but in speaking for our organization, we are firmly convinced that as long as the needs of our people are as they are, and we are limited in funds, they should be used at home first. Senator CRANSTON. Thank you.

Colonel HOUSTON. Now, this last paper that I should comment on, it pertains to nursing homes. I didn't get into the text because it only arrived by airmail special delivery this morning.

I am referring to a nursing home now in Cincinnati, Ohio, where the statistics for the month of February_showed that they received 107 applications for nursing home care in February.

One hundred four of those were just being in need of care. Fifty nine were admitted. We are asking why were the others not admitted.

I made an error, I note that further down that none of the 107 did not need care, but the 104 evidently needed, three of them evidently didn't need it as badly.

Now, that goes back to our previous statement of a moment ago, that if the law or ruling could be changed to admit these who do not require hospitalization or nursing homes, they have no homes, they are alone or they are the husband and/or the wife is unable to care for them in the home, either physically or financially. They need immediate care.

Now, as to the nursing home care on a private basis. A private nursing home will cost double the amount that the veteran receives in total income, and that is out. So, there is really only one alternative for these individuals and the number is alarming. I can't give you the number because we have no way of knowing where to obtain an accurate figure.

But, for those individuals who have no home, who cannot get into a Veterans' Administration nursing home, because they are refused admittance into the hospital so that they can go to the VA nursing home, there is only one alternative and that is the charity hospital of the city in which they live.

Now, from my point of view or from our generation of veterans, those are the critical needs.