A publication of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress

April 2001/May 2001

VA Secretary Anthony Principi Goes One On One With VVA

On March 26, VVA Government Relations Director Rick Weidman and VVA Veteran staff met with the new Secretary for Veterans Affairs, Anthony Principi. What follows is that conversation.

VVA: What are your top three objectives for the next four years? How do you expect to achieve them?

Anthony Principi: The only reason I returned was to see if I could make a difference. My top three priorities are: first, to reduce the enormous backlog of claims that are currently pending before the Veterans Benefits Administration--before the VA, I should say, because I view this as a VA crisis, not just a VBA crisis. Clearly, reducing that backlog to a point that at any given time we have no more than 200-250,000 claims in process is of utmost importance to me. That should allow us to achieve a high quality rate and a timeliness of around 90 to 100 days. I think that is a workable solution and my highest goal.

My second highest priority is to assure high-quality health care for the largest number of veterans as possible. We need to maintain our leadership role in specialized services: spinal cord injury, mental health, homelessness, drug and alcohol abuse programs. But at the same time we need to insure that we have a high-quality acute care and surgery system. We donít have the advocates for those programs--other than the medical schools--like we do in mental health and spinal cord injury. But clearly, making sure that we have good programs in acute care and extended care is terribly important.

My third highest priority is putting in place the infrastructure--the information technology systems--that will allow us to be more effective, more efficient, and more productive.

How do I intend to achieve these objectives? Clearly in the claims backlog, it's a very complex issue. Thereís no one easy answer. But there are a number of things we can do immediately.

First, we need to hire more people and hire the right people. Iíd like to see more people with military backgrounds and medical experience: medics, corpsmen, RNs. Get them on board, get them certified in the medicine so that we can dispense with that portion of the training, and get them training immediately on the complexities of Title 38 and the regulations.

We need to take a good, hard look at some of the programs that have been implemented over the past year or two. While I do not question the motivation and the vision that has been brought to bear, it has in some respects put a stranglehold on day-to-day rates. We have a lot of people who have been taken away from rating claims to do other things. Iím very, very concerned about that.

Iím very concerned about the software that has been brought on line. Although theoretically an important tool, it has reduced productivity significantly, rather than improving productivity. I intend to take steps in the very near future to see that we get back to getting ratings specialists doing what they do best, and that is rating claims.

In the area of health care, clearly budget, budget, budget. Thatís first and foremost. You have to have an adequate baseline to start with. Health care is expensive. We all know that. When we have a system the size of the VA, it becomes terribly expensive. So you need to start with an adequate budget.

But some of the dramatic changes that have taken place over the past eight years in VA health care-- transitioning from a very traditional hospital-based system to a more contemporary veteran-focused health-care system--came about in part because we didnít have all the dollars we needed. We had to start changing the way we practiced health care in the VA. The good old days werenít going to work anymore: long hospital stays far in excess of what was done in the private sector, doing inpatient surgery when it could be done outpatient. We needed more outpatient clinics. We needed to go where health care was going in America.

Part of those changes came about not only because of the dynamic leadership like Ken Kizer, but also because all the dollars werenít there. We had to practice like they do in the private sector and bring a business model approach to health care, as well as a compassionate medical approach to health care. So sometimes you have to be more cost-effective in the way you do things. We need to continue that trend.

So we need to get all the dollars we can get, but at the same time we need to exercise more of a business mindset, if you will, in some of the business operations we do. The Medical Care Costs Recovery Fund is a good example. Clearly, if you look at the costs to collect, if you look at the net collections, if you look at collections per FTE, you will see that VA is way behind the private sector.

Recognize that there are differences between the private sector and VA. We canít collect from Medicare or Medicaid, whereas the private sector can. We have to collect from a host of smaller insurance companies, which is much more difficult. But clearly we need to look at best practices to insure that our programs are generating as much revenue as possible. So you have to look at the different stages in MCCF--from intake to utilization review to billing to collections--to make sure that weíre doing this correctly.

Supervision of residents and interns. We need to insure that we have adequate staffing to insure uniform access to health care, so that at one VISN it doesnít take 180 days to get an appointment when at another VISN it takes 30 days.

With the third priority, information technology, I have to hire the best and brightest CIO. I have to find someone whoís willing to come to work for the VA as an assistant secretary for information technology who can bring the respect, leadership, and the management skills to tie together this vast array of systems we have, both in computers and telephony, and also link it to DOD, someone who has respect over at DOD. It will be very, very difficult for me to attract someone from the private sector, obviously. To find that kind of person with what we pay an assistant secretary is very difficult. Our pay scales do not allow for that, unless you can find someone who really wants to come into public service.

So I hope to find perhaps a retired military person who commanded a large organization in the military, who has an engineering background, who has the respect of DoD, because I believe we can do veterans a great service if we can link our information systems together. Without the information from DoD, we canít provide any health care, we canít evaluate disability claims, we canít even bury a veteran. So I'm looking very, very diligently for someone who recently retired from the military who can bring that expertise.

VVA: Youíve stated that one of your key aims is to ease or eliminate the backlog of claims in the Veterans Benefits Administrationís Compensation and Pension Service. VVA has stated publicly that the only way to do this is for the regional offices of VBA to get it right the first time and to hold managers and supervisors accountable for how accurately and fairly claims are developed and adjudicated that first time. Do you agree, and how can this be accomplished in four years?

Anthony Principi: I certainly do agree that getting it right the first time does cut back on your workload over the long period. We should always have a zero defect policy and strive for quality. That should always be our goal. I think it can be accomplished in four years. I think it starts with hiring good people and training them appropriately.

I think we may have missed the mark a little bit. Iíve only been here eight weeks and Iíve got a lot to learn, but it seems to me that we now have implemented all these programs which are "designed to give us high quality," and I donít think that's the case.

Itís become more of a defensive mechanism for cases that are going to go up on appeal. Today, any rating decision can be about a 20-25-page legal brief thatís so thick you canít even put it in an envelope. Itís gotten to the point where weíve just gone too far to one side, given the fact that a very, very small percentage of cases are appealed. This is further exacerbating an already difficult situation with the backlog.

Quality starts at the very beginning. It starts at the medical evaluation; it doesnít start in VBA. It starts with doing a good medical exam and making sure you have the expert systems that can allow a physician--whether an experienced C&P physician or a brand-new resident--to insure that all of the issues required by the courts are addressed.

It starts at that point. I think that expert systems can allow that medical evaluation to be converted into a medical report and into a diagnostic code summary. That can aid the ratings specialist in doing the evaluation.

I think it can be done. You do it through smart systems. And you link VHA and VBA together. This is not a VBA problem; this is a VA problem. The folks at VBA shouldnít be the only ones losing sleep over this crisis. VHA senior leadership should be losing sleep, IT people should be losing sleep, and the general consul should be losing sleep. I donít think they are losing any sleep over this situation because it's never been viewed as a VA crisis. I think thatís the real tragedy.

VVA: VVA and many of our good friends in the Congress have advocated a much more rigorous application of the Government Performance and Results Act. What steps do you intend to take to systematically hold VA personnel accountable, especially those in key posts?

Anthony Principi: It starts with good measurements, good metrics. People have to know what is expected of them, and we need to have good measurement tools to be able to determine whether in fact theyíre meeting those performance standards. Thatís the starting point.

Then it requires tough leadership to review those measurement standards weekly, monthly, semiannually, and hold people accountable for accomplishing those objectives. Senior leadership has to determine our objectives and our goals and then make sure people are doing their jobs. If theyíre not doing their jobs, then they have to be moved or relocated. Because, again, we don't exist to serve ourselves; weíre here to serve the customer. If the customerís needs are not being met, then thereís got to be a reason for it.

People need to be held accountable. They need to be supported, they need to be motivated, there needs to be high morale. We shouldn't manage through intimidation or fear. But when we put people in positions of authority, just like a captain of a ship, if something goes wrong, then youíre held accountable for it. Strict accountability is very, very important. We need to bring that sense of responsibility to the VA.

VVA: Some of our lay leaders have alleged that thereís a problem within VA that the top leadership--VISN directors and hospital directors--never get fired, they just get transferred. Will the task force that you are forming on veterans benefits, be taking a look at these kinds of accountability practices?

Anthony Principi: Sure. Theyíre going to be looking at management, process, and organization. I would certainly encourage them to look at that and performance standards and training. Youíre absolutely right. You canít just hold the GS-7s and -9s and the -11s accountable. You have to look at the top. I agree with that. And I will do so.

VVA: The Veterans Eligibility Reform Act of 1996 requires that the VA maintain a medical capacity for the specialized services--PTSD, spinal cord injury treatment, blind and visual treatments, substance abuse, recovery treatment--at least at the same level that existed in FY96. Since the VA has not maintained capacity in this area, what is your plan to document your efforts and to restore the organizational capacity so that thereís no question that it's there in every sector of the nation?

Anthony Principi: Itís clear to me that in some areas we have not maintained capacity at the threshold that we've been directed to by legislation. In other areas weíve exceeded capacity. But clearly the law is the law, and we need to abide by it.

The first thing we need to do is: How do we measure what our current capacity is? Iím not sure we know. There are so many variables in this very, very large health care system. But I intend to insure that if Congress says that we have to have "X" number of beds in spinal cord injury, that we have a model that shows us on any given day how many beds weíre maintaining. It fluctuates sometimes. We may have a nursing shortage in some parts of the country that causes us for good medical reasons to lower the number of spinal-cord-injured beds. Itís a very volatile situation.

But by and large, I intend to insure that we have the ability to monitor all the specialized programs to insure weíre meeting capacity. If weíre not meeting capacity, I expect Dr. Garthwaite, the undersecretary, to explain to me why. I assume there will be a good explanation for it, and weíll communicate that to the Hill and to our stakeholders.

VVA: VVA is a strong proponent of the concept of "in-country effect." Basically, this view of the veteran's service-related disability maintains that the in-country Vietnam experience--or in-country wartime experience during any war--including toxic exposures, herbicidal agents, traumatic, stressful experiences, exposure to endemic diseases, parasitic infections, et cetera, has an overall impact on the personís physical and psychiatric health. Under this concept, the VA would consider the total effect on the veteranís health as a whole and compare that to a baseline of a nonveteran cohort group. The VVA would take action where there are discrepancies or anomalies in the combat theater group, rather than trying to treat disabilities one at a time.

Thatís a basic overall holistic view of veteranís health, instead of us continuing to bicker over particular diseases and causality, whether itís Agent Orange, PCBs, or whatever else people may have been exposed to in the military.

Anthony Principi: Thatís an interesting question and one that I would like to spend some time thinking about and getting briefed by the experts on. From my first days on the Hill when I met with my first group of veterans on ionizing radiation, I really saw the importance of breaking out of the current mold we were in and looking at these environmental hazards in a different way.

Iíve come to appreciate and understand how exposure to environmental hazards is not very different, if at all, from a more traditional bullet wound, cannon shell wound, or bayonet cut, and that we have to be very, very proactive in this. On the other hand, I think the science needs to be clear.

I'm not sure you ever have 100 percent of the science tell you that this disease is associated with that exposure, whether it be Agent Orange or ionizing radiation. Science can help show causality, but for every scientist proposing one theory, you have someone proposing another theory. So I think at some point itís a judgement call, and you have to give the benefit of the doubt to the veteran. Because Iím not sure you'll ever have 100 percent of the science and the medicine tell you this is absolutely the right thing to do or not to do. It just doesnít work that way.

The in-country effect is an interesting concept. I guess Iím not sure how it would work. I would want to study this more carefully. Certainly some lifestyle decisions I made were not the wisest decisions from a health perspective. How would that impact on a disability rating I might receive, vis-ŗ-vis my exposures and my traumas in Vietnam. But it's something worth discussing, because weíre evolving in this area of environmental hazards.

Weíve come a long way in the past twenty years. Weíre still learning, and certainly the Persian Gulf syndrome is the latest in that evolution. The VA has always, I believe, been very revolutionary in some of the things that we have done since 1944 in benefits and service delivery. I think the manner in which weíre dealing with environmental hazards and chemical exposures has been a lesson for all America, not just for the military.

VVA: The veterans health initiative, undertaken by Dr. Garthwaite and his staff, to take complete militaries history of all veterans who comes to the VA and test them for all the maladies and diseases that veterans may have been exposed to due to duty station, branch of service, dates of service, MOS, and what actually happened to them, thatís one thrust. The other thrust is to reward VA clinicians who become proficient in understanding those special health-care problems of each generation of veterans, as well as particular things having to do with their discipline.

We want to know whether or not you are fully committed to implementing this initiative.

Anthony Principi: Itís an area, again, I havenít been able to focus on. But it certainly goes a long way toward what I hoped to accomplish when I directed the establishment of a Persian Gulf registry, so we would have a complete medical record on people who served in a given area at a given time. We could build upon it and draw some conclusions.

Iíve always believed that we are a veterans health care system, as opposed to a more generic health care system. One of our great strengths is that we have a system thatís somewhat closed and provides us the opportunity to build a wonderful database upon which to make decisions in health care and peopleís lives.

The veterans health initiative--was that something that was generated in-house by the VA or by the service organizations or by VVA in particular?

VVA: We had recommended it to Dr. Garthwaite, and he undertook it. There was a separate educational part having to do with raising a base salary for three years if people passed proficiency examinations.

Anthony Principi: And are they doing it, to your knowledge?

VVA: It hasn't been implemented yet.

Anthony Principi: Oh. It hasn't been implemented at all.

VVA: The education part is done, but theyíre working on the first test with radiation veterans. And then the others will be proceeding apace.

Anthony Principi: It certainly sounds like something we should pursue. But I would want to get more information.

VVA: One of the charges against the VA has to do with quality of care across the system. One of the things thatís come to our attention is that apparently it's up to the discretion of the VISN directors whether to implement clinical best practices or protocols for any area of medicine in their network. Many feel that this has resulted in a situation where whether a veteran gets any treatment at all for a particular malady, much less proper treatment, depends on where in the country he or she happens to live.

Anthony Principi: Your observations are generally correct. Weíre now in the process of putting borders on the amount of discretion the field has. I think at one point when the VISNs were first established it was complete delegation of responsibility. I believe now the pendulum is beginning to swing back. Perhaps more needs to be done.

I believe in having decisions made close to the patient, close to the veteran. At the same time, I believe it's very, very important that there be uniform policies and procedures across the system to insure that veterans, wherever they reside, have equal access to the system. Youíll have some degree of difference across the nation. A system this large cannot have absolute uniformity and consistency. But we can certainly have a lot more than we do today.

We have a policy that says these programs have high priority: spinal cord injury, mental health, homelessness, screening for hep C, and things of that nature. I expect that those policies will be carried out. I will hold people accountable for doing so.

VVA: As all health care--like all politics--is ultimately local, VVA believes that requiring each hospital director to meet with all the veterans service organizations at least every 4-6 weeks in a formal manner would help very much in this regard. Do you agree and do you plan to mandate this act at the local level?

Anthony Principi: I certainly believe that itís absolutely critical to our success to meet with the stakeholders at all levels. Clearly, one of the cornerstones and hallmarks of my tenure will be close working relationships and partnerships with the veterans service organizations. If itís good for me, it's good for the VISN director and the medical center director to do so as well.

I will mandate this act of partnership at the local level as well. Whether itís every four, six, or eight weeks, I'll leave that up to the medical center directors. But it certainly shouldnít be once or twice a year. But I would certainly think no more than quarterly. I would hope that the vast majority of medical center directors and VISN directors have quarterly meetings with the leadership of the veterans organizations.

Most of the folks I've met in the field reach out to a lot of our stakeholders. But I intend to remind people how important that is. It breaks down a lot of the cynicism and the distrust. The vast majority of people donít expect that you can agree on every point. Thatís not the way it works in any area. But you can certainly go a long way to achieving that rapport, and itís just good for everybody to do so.

VVA: VVA is very concerned about the promulgation of regulations affecting vital needs of veterans. These regulations include declaring hepatitis C to be a presumptive disability and declaring Type II diabetes to be a presumptive disability for veterans exposed to Agent Orange anywhere in the world. Would you please give us your thoughts on these two matters as well as pending regulations regarding veterans exposed to radiation, payment for emergency care for veterans at non-VA facilities, and the rewrite of the hepatitis C ratings schedule?

Anthony Principi: These--like the others--are very important questions. There are a lot of components to your question. Exposure to environmental hazards is very, very important to me. We need to move out and provide presumptive service connection where it is warranted by the science and the medicine and in areas where weíre having difficulty finding answers to questions.

I defer to the committee; the committee on the Senate side indicated a preference for doing the legislating on service connection for ionizing radiation. I told them that I would like to move forward on ionizing radiation and get the regulations over to OMB. They posed no objection. Itís just a matter of getting my signature and getting them over to OMB.

I hope to have the emergency care for veterans at non-VA facilities done very, very quickly. I had some concerns there. I wanted to make sure that this is something we should do, that was needed. My concern is that I was told it would cost between four and five hundred million dollars to go to basically community hospitals. Thatís an unfunded mandate. The law is discretionary: It says I may go ahead and do this, not that I shall do it.

But I intend to move forward with it. At the same time, itís going to take four to five hundred million dollars out of our health care system. Thatís a lot of money. I want to make sure the regulations protect against abuse, that this is indeed emergency-care treatment; and that lengths of stay in emergency rooms are reasonable and adequate.

A lot of private-sector hospitals are in difficult financial situations, and I donít want this to be abused. This money is too important to veterans. Before we just jump in and do things, letís keep in mind that a half a billion dollars is a lot of money. Nobodyís throwing another half a billion dollars at this health care system. And itís not going into the VA health care system, itís being taken away and going to private-sector hospitals.

So I want to make sure that those regulations protect the VA, protect veterans who have no choice but to go to a community hospital, and that if they have insurance, the insurance is going to pay for it. If they have Medicare, Medicare is going to pay for it. If they have Medicaid, Medicaid's going to pay for it. The VA is not going to be seen as the deep pocket here to bail out hospitals that should be going somewhere else.

With regard to hepatitis C, that is a very difficult one. It is difficult because I need to understand the science and the medicine a little better. I read the report of an epidemiological study that was conducted by the University of Florida, the Navy Medical Research Center, and the VA, which had some interesting findings. I donít have the exact percentages in front of me. But it was a small cohort of veterans who sought treatment at the VA. This was a microcosm of the population that came to VA for health care. So you can't draw conclusions about the entire VA population.

About 20 percent were Vietnam veterans. Most of the veterans with hep C joined the service subsequent to 1974. So the vast majority of veterans who were shown to have the hep C virus came on active duty after 1974. The majority of those found to have hep C were either Vietnam veterans or came on active duty subsequent to 1974.

However, it also showed no correlation between hep C and blood transfusions. The vast majority of those with hep C were self-reported IV drug abusers. A quite high percentage were incarcerated, about 27 or 28 percent. So we see that those who served in Vietnam in combat--and do not have any reported drug abuse or incarceration--have a very low incidence of hep C compared to those who, regrettably, may have had an IV drug abuse problem or something of that nature.

It concerned me, reading this epidemiological study, because once you grant a presumption of service connection you cover the vast array. Iíve asked for an analysis of this study. Is it scientifically valid?

Itís taking me a little bit longer to understand the ramifications of hepatitis C and the various studies that have been done to make sure Iím consistent with the science and the medicine, and also taking into consideration the role of IV drug abuse and other behavioral lifestyle decisions. We need to help men and women who served their nation in uniform and because of that service are inflicted with this terrible, terrible disease. Equally importantly, we need to make sure that we have the programs in place--the screening programs, the centers of excellence in hepatitis C. The VA can make a difference.

So itís not only an issue of disability compensation, itís also equally important--and Iím sure for many, more important--that the treatment and the research be there to take care of that. Weíre doing a lot. We reimburse hospitals for men and women who are being treated for hepatitis C. So there is an incentive to screen; there is an incentive to treat. The reimbursement is a lot higher--about $42,000 per patient--than it might be to actually treat that patient even with these expensive drugs.

If I thought there was a disincentive to treat then Iíd be really concerned. But if a hospital knows that it will be reimbursed this amount of money to make sure that this veteran gets the care he needs, then I feel a lot better.

But again, in these eight weeks Iím just trying to get up to speed and understand the various issues. With regard to emergency care moving forward, and Iíll probably move forward hep C at some point, hopefully not in the too distant future. Ionizing radiation I'm moving forward.

VVA: Of deep concern to us is that 87 percent of the folks whoíve tested positive for hepatitus C are not deemed good candidates for treatment for one reason or another. Weíre deeply concerned about the case management of that 87 percent. Weíre afraid of a train wreck ten years down the line, with veterans needing liver transplants that arenít available and the enormous strain in costs that that will bear on the system, given that there's already 75,000 positive, that we've only scratched the surface in terms of testing.

Anthony Principi: Thatís a difficult issue. We have all of these special programs for treatment of hep C. Sometimes you don't have all the resources you need. You do have these mandates, we do have priorities, the secretaryís priorities in some of these areas and others. Just balancing this entire workload and this breadth of workload is a tough issue. But Iím optimistic we're going to get there.

VVA: VVA believes that the VA may not spend enough in some areas, but it does spend billions to assist in the rehabilitation, restoration, training and education of veterans, including homeless veterans. Yet much of this effort will not make a long-range difference in the lives for many of these veterans, particularly homeless veterans, unless the veteran is assisted to obtain and sustain meaningful employment at a living wage. Can you please comment on this whole-veteran concept?

Anthony Principi: Youíre absolutely right about homeless veterans in need of sustained employment. Clearly, thatís the key to success: allowing these veterans to reenter our society as productive members whose respect, self-dignity, and self-worth are greatly increased.

How do we do that? Weíve got some wonderful homeless programs out there. There are lots of great programs out there that strive to get these homeless veterans into jobs. Compensated work therapy is a great program.

As far as the Department of Labor goes, I certainly will be talking to my counterpart, Elaine Chao, to determine how well DOL is doing to find veterans jobs. Especially those who have serious employment handicaps, like homeless vets. The others are pretty easy to find jobs, but it's those with significant employment handicaps, such as the homeless population, that more emphasis needs to be applied.

VVA: Do you think itís likely that the administration will back efforts to significantly reform and hold the grantees under the LVER program more accountable for performance and results?

Anthony Principi: I would certainly hope so. I intend at some point to talk to my counterpart to see if that's something that she would be willing to undertake. I can't really speak for the Department of Labor or for the administration, but I would certainly urge them to do so, and itís consistent with the President's initiatives to hold people accountable in education for our youngsters. Letís work together on mutually agreeable goals and objectives, and then let's measure our performance at the end of the day and make sure we have the resources to get the job done.

We really do spend a lot of money. A lot of money. Fifty-one billion dollars is a lot of money. I like to think a lot of programs work well. But some donít. We shouldnít be spending money on programs that donít work. Thereís plenty of need in other programs that are working--in homelessness for example.

There are some programs that are working wonderfully. They should be funded more, because they have proven track records, and others do not. Letís reward success.

VVA: You recently opened the Center for Veterans Enterprise at the VA and spoke of the need to fully implement the Veterans Entrepreneurship and Small Business Development Act of Ď99. What plans do you have to market and expand the range of services available through this center?

Anthony Principi: I am utterly excited about the new center. Iím going to work very, very closely with the director to determine how we market and expand the range of services. Working with employers, we will insure that veterans understand the services that are offered by the center, educate employers on what we do, insure that we take steps to make sure that the VA is complying with various directives and procurement to insure that weíre given some type of preference allowed by the federal acquisition regulations to veteran-owned small businesses. I will be meeting with the director here this week to begin discussions on the center and what we need to do to make it successful.

VVA: Congress strengthened veterans preference laws in both í98 and í99, yet VVA believes there is much more that needs to be done in the actual doing by the agencies. Do you plan to begin active recruiting?

Anthony Principi: I believe military personnel make the best employees. Bar none. I believe we need to do whatever we can to recruit them into government service. They are skilled, they are dedicated, they are motivated, they are disciplined and mature. They make wonderful, wonderful employees. So we will be actively recruiting at transition assistance programs and other places to get the military personnel to look at service at VA as a viable career choice.

These are the kinds of people we should be going after. They have a sense of mission, about who we are, what we do. Certainly veterans preference is a way for us to get these people into the VA. I strongly support hiring military personnel.

VVA: Currently, the only part of VA that is authorized to treat the whole family is the VA Vet Center program, which is so essential in regard to PTSD treatment and in regard to hepatitis C treatment. Would you favor a change in law that authorizes VA to treat the veteranís family when it is clinically indicated as a vital part of treating the veteran, such as serious mental illness and hepatitis?

Anthony Principi: I certainly believe that such a change is something we should seriously consider. Whether we should go beyond that to open up our doors to dependents of military retirees or some segment of the population we arenít currently seeing: I think there are long-term strategic issues there that we need to consider. Theyíre an important part of our beneficiary population, our patient population. Losing them and the downturn in the World War II population and others, we need to maintain a stable patient population base. The question becomes: Do we need to engage in a discussion with the service organizations and with Congress as to whether we should open our doors? Your question is more in the therapeutic sense.

If itís part of the treatment process and important to the veteran as well, bringing in the family for joint counseling, joint treatment care, then itís something we should look at. I cannot think of why we would not want to do that. But at the same time, we should look at that carefully, and I should obviously talk to the undersecretary of health and obtain his views.

VVA: Any last comment, Mr. Secretary?

Anthony Principi: I appreciate the opportunity to do this, and I look forward to following up with you from time to time to see how well we're doing in some of these areas. Itís important that the American people and veterans understand how truly important we are in health care in this country and build support for the system. Not that weíre perfect; clearly we have lots of things that we have to do. But at the same time, on any given day we're providing a lot of health care to people who have no other option.

I think that's the point I want to make to OMB. I want to educate some of the bureaucrats over there as to what we do and how we do it, and urge them to get out and visit some of our medical centers and see first hand the kind of care and the quality care we provide. I think they have a somewhat skewed view of the VA and donít fully appreciate and understand the magnitude of the work we do.

   

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