derstand that they calculate that a larger number of those are service connected than you do. Now, what is the difference between your standards of service connection, in neuropsychiatric cases, as compared to the State of California's standards, if you can give us that. If I understand it. Dr. Tolman, of the Department of Mental Hygiene of the State of California, and his aides calculate there are many more patients in State mental institutions who allocate a service connection to the psychoses or neuroses than you do.

Now, what is the reason for that difference in standard? Do you have a very strict standard of service connection in these cases, or what is the reason?

Mr. BIRDSALL (Guy H. Birdsall, Assistant Administrator for Legislation, VA.). I would like to introduce a representative of the Assistant Administrator for Claims, who will answer that.

Mr. PURKS. As to the standards for service connection, they would get the information from us. They would have no business saying it was service connected unless we told them that.

Public Law 239 gives a 2-year presumption on psychotic disabilities. That is for service connection for hospitalization purposes only.

We require a 1-year presumption for compensation purposes. We will rate these cases under Public Law 239, 82d Congress, and grant service connection for hospitalization only. Some of those cases that are institutionalized in the State hospitals could be maintained from VA funds.

Mr. HAGEN. Oh, there is reimbursement there?

Mr. PURKS. If the VA authorizes such care in a State institution, VA will pay for it.

Mr. HAGEN. This is something I probably should know, but every- . one that gets a medical discharge from the service automatically gets a pension, and he is considered service connected; is that true?

Admiral BOONE. That is another matter that the gentleman will

answer.

Mr. HAGEN. If a man is given a medical discharge from the service, it is automatic that he has a service-connected disability; is that correct?

Mr. PURKS. Not necessarily; no, sir.

Mr. HAGEN. But in the absence of a showing of existence prior to enlistment?

Mr. PURKS. That is correct.

Mr. HAGEN. And he does not have the burden of proving a service connection. Do you think that policy should be revised?

Mr. PURKS. The present policy appears to be fairly liberal. It will take care of the boys.

Mr. SPRINGER. Doctor, this whole thing, as I see it, seems to be that you have not got enough money to take care of the various people that apply. I want to go back to just review a minute, because that was covered rather shortly a few days ago. I want to get these categories straight.

First, you have got service connected. Right?

Admiral BOONE. Right.

Mr. SPRINGER. Now, as to that, you have got a mandatory law. Am I right?

Admiral BOONE. That is right. That is the primary requirement, to take care of those patients.

Mr. SPRINGER. That is something you cannot evade.
Now, let us go to the second category. What is that?
Admiral BOONE. Under, I think, Public Law 312.
Mr. SPRINGER. What category does that cover?

Admiral BOONE. We take care, under the provision of that law, of the non-service-connected, if there are beds available for them over and above our requirements for the service connected, and if the individual certifies in a signed statement that he cannot afford to pay. Mr. SPRINGER. Now, then, is that mandatory?

Admiral BOONE. That is mandatory, if the bed is available. We are required by law to accept that statement of inability to pay for medical care.

Mr. SPRINGER. Then you are required to accept them. It is mandatory.

Admiral BOONE. That is right, if the bed is available.

Mr. SPRINGER. If the bed is available. I understand.

Now, were there not some intervening categories in here, though, which do not cover that? Do you not care, for instance, for the medical cases and TB under different classifications?

Admiral BOONE. No. I enumerated the following categories in the list when I said approximately 65 percent were non-service-connected.

Group of patients

Percent of total patients

1. Had service-connected disabilities; hospitalized for treatment of other disabilities which had apparently not directly affected their serviceconnected disabilities__

2. Were permanently and totally disabled and were receiving VA pensions for such disabilities; hospitalized for treatment of permanent and total disabilities and/or other disabilities__

3. Had no service-connected disabilities and had filed no claim for compensation or pension; hospitalized for treatment of non-service-connected tuberculosis or psychosis--

4. Had no service-connected disabiilties and had filed no claim for compensation or pension; hospitalized for treatment of other long-term disabilities requiring hospital care for more than 90 days_-.

5. Disabilities not yet adjudicated but had filed claim for compensation for service-connected disabilities___

6. Disabilities not yet adjudicated but had filed claim for pension for permanent and total disabilities_

7. Nonveterans (United States Armed Forces personnel, humanitarian cases, etc.) ___.

8. Had no service-connected disabilities and had filed no claim for compensation or pension; hospitalized for treatment of general medical and surgical disabilities requiring hospital care for less than 90 days‒‒‒‒ 9. Status not determined___

Total above groups.

11

25

8

3

2

4

1

10

1

65

Mr. SPRINGER. Take that last category. That is the one I am interested in.

How many people in the program are in that category?

Admiral BOONE. Ten percent of the patient load. And I was just going to say, Mr. Congressman, that this gives entitlement under certain codes of the statutes.

Mr. SPRINGER. That is right.

Admiral BOONE. Down to this 10. And that is the 10 percent of the 65 percent non-service-connected.

Mr. SPRINGER. All right. That, roughly, then, would be about 13,000; would it?

Admiral BOONE. About 10,000, I believe.

Mr. SPRINGER. Now, read that category over again, so that the committee can hear it.

Admiral BOONE (reading):

Have no service-connected disabilities and have filed no claim for compensation or pension; hospitalized for less than 90 days as of date of report, for treatment of general medical or surgical disabilities.

Mr. SPRINGER. All right. Now let me ask you this. If that category were removed altogether, your solution would be complete; would it not-if you removed that category entirely? Let me ask you: Does neuropsychiatric go under that clause?

Admiral BOONE. No, that is general medical and surgical.

Mr. SPRINGER. In other words, this is just anybody who wants to get some medical care, who is a veteran, and who goes to the hospital. Am I right on that?

You

Admiral BOONE. Yes, but it might be the emergency case, medical or surgical too, an accident or any one of many other reasons. know, if an accident occurs on the street, a policeman comes along, finds he is a veteran, and he is rushed right to a VA hospital, if one is in the vicinity. Specifically, this group is described in the following table. Accidents are only a part of the next to the last group.

Diseases and conditions for which 9.6 percent of the patient load in VA and non-VA hospitals is receiving treatment

[All patients who have no service-connected disabilities and have filed no claim for compensation or pension, who are hospitalized for less than 90 days as of date of report for general medical or surgical disabilities]

Diseases and conditions for which 9.6 percent of the patient load in VA and non-VA hospitals is receiving treatment-Continued

Diseases of genito-urinary system--

Diseases of kidneys and ureters_

Diseases of prostrate-

Other

Diseases of bones and organs of movement_-

Arthritis and rheumatism___.

Displacement of intervertebral disk_

Other

Diseases resulting from accidents, poisonings, and violence.

Fractures of limbs__.

Other fractures_.
Other

All other diseases and conditions____

712

270

230

212

976

428

206

342

1, 110

476

156

478

1, 538

The above cases must meet the requirements of Public Law 312 as to availability of a bed and the signed statement of the patient of his inability to pay for hospitalization.

Mr. SPRINGER. That would not be any percentage of 10,000 though; would it, Doctor?

Admiral BOONE. No; but it is a large percentage. We have a lot of those cases, although they are only a small part of the total.

Mr. SPRINGER. Do local hospitals handle accident cases? They do in my town. We do not send any veterans to a veterans' hospital. Admiral BOONE. If some driver driving a car takes him, a passerby, or the policeman, or the fireman. We will say he has a fractured skull or a serious illness or injury. It certainly would not be humane to remove him immediately from one hospital to another.

Mr. SPRINGER. I understand that. But as to this 10,000 group of people, I am inclined to believe a full 90 percent are people who go there to get their tonsils out, their adenoids removed, their appendixes removed, or their operation for something internal. That is the category to which I think there is a strong public resistance, Doctor, at the present time-taking care of people who really ought to go to private hospitals. Those are the people who are taking up these beds that should be going to other people. Now, that is my general reaction. And I am wondering if, in this sense, it would not help us to clarify this a whole lot. Most of these categories and codifications took place before 1936! did they not? These categories?

Admiral BooNE. 1946 was the year the modern medical program was initiated, when General Bradley was Administrator.

Mr. SPRINGER. Now, practically all of your authorities on these were inaugurated before 1936; were they not?

Admiral BoONE. About 1935.

Mr. SPRINGER. That is what I was thinking. This is before World War II. And you have not had any recodification or reclassification of veterans generally to determine who should be admitted to hospitals since 1935?

Admiral BOONE. No changes in the law. May I say this, Mr. Congressman. There was a period in 1933, I think it was-when a new administration came in, that they did not apply the law as

to the non-service-connected. Then there was such a furious public reverberation, I think in 1934, that they went back and reapplied the law.

Mr. SPRINGER. That is right. I remember that.

Now, the thing I am wondering about is this: Certainly there is a duty upon the Government to take care of all of these classifications, and it seems to me that you can and should go ahead, except in the case of this class of people that just want to go to a hospital to be taken care of under the VA program merely because they have been veterans. I fail to understand why I should go over to the veterans' hospital here in Washington and be taken care of at Government expense just because I happen to be a veteran and to have served years in the Navy. I do not believe that is the feeling now of people who come out of World War II. I realize that this was largely done before World War II took place. But that would be a solution which would relieve this entire pressure you have got under this program at the present time, is it not, if that group were eliminated entirely? Mr. EDMONDSON. Would the gentleman yield?

4

Mr. SPRINGER. I will yield to you in just a second, Mr. Edmondson. Admiral BOONE. I grant, Mr. Congressman, it is that 10 percent, that zone, where there lies the greatest criticism. There is no question about that. It is in that 10 percent zone; whether they should, except in these emergencies, be admitted.

Now, in that connection, and I think this would be very informative to the Congress. And it is something that I am critical of, as Chief Medical Director. When a man has insurance covering him for a portion at least of his hospitalization, up until about a year and a half ago, the insurance companies wrote in that they would pay the Government. Some insurance companies, including the Blue Cross and Blue Shield, have now stricken us, the VA, off, so that the American taxpayer is being deprived of money to which he is entitled. The insurance company receives the premium payment from the individual, and when the veteran is hospitalized in our hospital, for one reason or another, the taxpayer is not always getting that payment from the insurance company. He is paying the premium out in his policy for medical and hospital care, and the Government gets nothing many times when the man is hospitalized. That needs correction, I think. Mr. SPRINGER. That is why I come to this fundamental question of making a change at this point. I think Mr. Hagen, the gentleman from California, raised a point a moment ago. It seems to me that our emphasis in care should be on service connections. And I am talking about the TB cases and the neuropsychiatric whether or not they are service-connected-that great group of people that cannot be taken care of by local medicine, plus your service connections. It seems to me wrong to be doing all this for these 10,000 people here at the same time you are cutting off another group. Maybe it is only dental care, but it is service-connected. It seems to me the serviceconnected should be taken care of first of all.

In other words, if it is necessary to eliminate any group, eliminate that group, and take care of the people who pay the price in war, not the people who are going to the hospitals to be taken care of just because they are veterans.

I do not know whether that strikes the rest of the committee, but that is a reaction, I feel, among the public at large.