I appreciate this opportunity of appearing before the subcommittee. Mr. McKenzie and I will be happy to answer any questions you may have regarding these matters.

Mr. BYRNE. General, on page 6, No. 2, you said dependents of military personnel in the lower enlisted ranks had serious difficulties in obtaining dental care.

Now I have found that out myself, by visits to Europe and right here at home. Can you explain that, why they have such difficulties in getting dental care for their children and themselves?

General HAYES. One is distance from where they are stationed to an appropriate civilian facility. One is expense. The expense is high relative to the actual money that the lower rank enlisted man has. When he has a problem of equating his budget to proper care of the teeth in the preventive sense, that is evaluation every 6 months or a year, versus buying food, the money goes for food. This is the problem he faces.

Mr. BYRNE. You are not answering my question. Take John Jones, an enlisted man; he has two or three children. And he is stationed somewhere in Germany, at an installation, and the child has a toothache and needs teeth fixed, and he can't find a dentist.

My argument is there should be a dentist at each installation to take care of these problems. When he has to go on the economy in the city, they take him over as you well know.

Now I don't know how many cases we found like that. That is why

we asked for this.

General HAYES. I am not familiar with that problem in an overseas situation.

Mr. BYRNE. The same thing with glasses. They have trouble getting glasses.

General HAYES. There is a different problem for glasses. We have not, in our survey, seen a particular problem in dental care in overseas situations because the dependents are authorized routine care on our posts. That is the difference between care, for instance, here and

overseas.

It is in the CONUS base

Mr. BYRNE. Yes.

General HAYES (continuing). That the dental care problem has had the greatest impact.

Now in some areas overseas we had a shortage of dental specialists such as orthodontists. Orthodontists are in short supply all over. Mr. BYRNE. That is right.

General HAYES. But that has been a problem. But even overseas-I just recently returned from Japan where I had a medical commandwe worked out a triservice agreement where the Air Force did the orthodontic work for the whole Konto Plain area.

On the other hand, in some of the outlying places, we did contract to civilian orthodontists who were not near the central concentration. I think each area tries to do the best it can in things like that, where they are short personnel, and when I say short of personnel, this is a nationwide civilian shortage and not just a service shortage.

Mr. BYRNE. I know what you are talking about when you talk about orthodontists. But that is not my point. When you have a toothache in the middle of the night and you are in a faraway land and you just have a few pennies and there is no dentist around and you have

to take the kid and go into the city and look up a dentist, especially in Paris where they charge you 16 bucks to look at you, and you don't know you are paying it until you go out of the hotel the next morning.

We have found that all over. Even in Vietnam, we have heard complaints about dental care. I don't know what is wrong with us. If we want to have these boys in the service we should give them the best.

When you have a toothache, a bad tooth, you need help. That was our argument when we went around to the bases. We saw kids sitting around in hospitals waiting for glasses 3 months, and a kid with his face up like that [indicating] waiting for a dentist. The dentist was off for 2 days.

So our committee thought that we should look into it and that is what we are trying to do. I am not here to badger you, but to try to get some help from you. As they say, General Hayes knows how to do it. So let's move, General, and get them some help.

General HAYES. Well, I am glad you brought this to our attention, because I agree with you that if we are not delivering service, we should know about it. We will try to do something about it.

Mr. BYRNE. Thank you.

Mr. BRINKLEY. Mr. Chairman.

General Hayes, in the last paragraph on page 2, where you talk about the care in our facilities, the general medical care for beneficiaries other than active duty members being on a space-available basis, provided it is within the framework consistent with the military mission. Well, this really seems not to tell us a great deal because it would seem that it would accommodate any situation at all and could be a policy which is a convenient device to limit care.

It would seem that this policy might be a device to limit services, medical services, provided dependents based on the budgetary squeeze, based on the monetary situation, and if this is true we certainly ought

to correct it.

For example, at Fort Benning, Ga., I think we are going to encounter more limited services to a great many dependents based on the economics that we are encountering. If this is so, the responsibility of the Congress of the United States is to provide for money and to insist, I think, to the Defense Department that the services which we provide to the dependents of the military ought to be rather definite, rather than as general as you say on the bottom of page 2.

General HAYES. I see your point, and I think it is a good one. With the Vietnamese war going on, however, some of our hospitals have been so overcrowded with casualties that they have not been able to accept nonactive duty dependents or beneficiaries. This really had nothing to do with budgeting. It was just the space

Mr. BRINKLEY. The priority situation.

General HAYES. That is right, the space and the available medical personnel were not adequate to handle so many people.

I agree with you that there could be a trap in this from the point of view of budgetary restrictions.

Mr. BRINKLEY. Yes. Well, thank you. I certainly agree that our soldiers should have priority. I appreciate your clearing that up for

me.

Mr. BYRNE. Mr. Hunt.

Mr. HUNT. Mr. Chairman. You were talking about the problems that you uncovered in your visit overseas. Of course I wasn't with you, so I am a little curious. And you referred to some kid with his face all swollen up. Did you mean a serviceman?

Mr. BYRNE. A child of a serviceman.

Mr. HUNT. A dependent of a serviceman.
Mr. BYRNE. Yes; a dependent.

Mr. HUNT. I just wanted to get that clarified.
General, what is a nonactive duty dependent?

General HAYES. Dependent of a retired individual.

Mr. HUNT. Retired.

General HAYES. Or deceased.

Mr. HUNT. Or deceased.

In the majority of the cases, don't they have access to a veterans' hospital?

General HAYES. No.

Mr. HUNT. For in- and out-patient care?

General HAYES. No.

Mr. HUNT. They don't?

General HAYES. Not the dependents.

Mr. HUNT. Not the dependents. You still handle all of them at the post?

General HAYES. They are either handled in our hospital system or under CHAMPUS.

Mr. HUNT. But they are quite restricted, are they not, at the present time due to the influx of the casualties from Vietnam?

General HAYES. Yes; but the CHAMPUS program looks after that. And I must say that in some rare instances dependents have been handled in veterans' hospitals, but that is not a matter of regular policy or action.

Mr. HUNT. Yes; I know of some that have. That is the reason I raised the question.

General HAYES. But this is a peculiar, special situation.

Mr. HUNT. Some of them have been handled in veterans' hospitals, have they not?

General HAYES. Yes.

Mr. HUNT. Through arrangements made between the military and the veterans' hospitals?

General HAYES. That is correct.

Mr. HUNT. Yes. That is all.

Mr. BYRNE. Mr. Ford.

Mr. FORD. General Hayes, your statistics about the number of outpatient visits and hospital beds and so on are quite impressive. I guess, with the exception of the VA, you have the largest medical program in the world in operation. I think, perhaps, the record should show, while we hear a lot of complaints about one thing or another, we hear very few complaints about the quality of care in the military service, and as far as we know the quality of care is excellent.

From your office, from your standpoint, do you have any concern about the quality of care, or is there any area in which you feel that you have inadequacies which are affecting the quality of care?

General HAYES. At the particular moment, no. We are concerned in a few specialty areas where there is a shortage of people.

If we continue to have the problems of retention of our hard-core career medical officers, there is a possibility that the quality of medical care will deteriorate.

Mr. FORD. Would you say this retention of your career medical officers is your No. 1 problem?

General HAYES. I would say that is the biggest medical problem the Armed Forces face.

Mr. FORD. Have you made any recommendations to the Department of Defense for solution to the problem?

General HAYES. We have a number of recommendations. I would like to take the first one, which I think, for the long range and the long pull, is going to probably have a great impact, and that is Mr. Hébert's H.R. 1. Our office supports Mr. Hébert's bill and has developed an implementation plan that we think would be acceptable to the American medical community at large. It would favorably affect retention of our military medical officers because of the opportunities it affords for academic recognition, for academic status, and expanding their professional knowledge.

Now this is the long-range program.

Mr. FORD. Excuse me. Has the American Medical Association taken a position on that yet?

General HAYES. Not officially.

Mr. FORD. One way or the other.
General HAYES. Neither way.
Mr. FORD. Off the record.

(Further statement off the record.)

General HAYES. Now for the short-range point of view toward this business of retention.

Mr. FORD. Yes.

General HAYES. We had a compendium made of all of the studies that affected retention of medical officers. This was finished earlier this year. It was done under Dr. Rousselot's supervision by Lt. Col. Gilbert Jacox. He took all of the studies that had been done since 1956 and abstracted and synthesized the information.

The factors that affected retention were, in descending order of importance, instability of assignment, salary, career management, housing, personal freedom, promotions, professional training and continuing education, assignments, professional leadership, the family life, prestige, undesirable location or facilities, quality of medical care, and physician-patient relationship.

These 14 items were the ones most frequently cited. As you see, the two things that concern us the most are the lowest rated of all reasons for being unhappy with the medical service, quality of medical care, and physician-patient relationship.

I think you can lump these other aspects they talk about-instability, family life, and housing. These really are related subjects, as is salary.

Professional training and continuing education go with professional leadership, and prestige, and this goes back to what we were talking about on H.R. 1; namely, academic recognition and academic position.

These are the short-range problems that we have identified.

Mr. FORD. Well, on the short-term basis, I notice the first item was instability of assignment. You could do something about that administratively right now, couldn't you?

General HAYES. If we didn't have the war going we could. But with the shortage of personnel that we have, we have to move key and skilled people into positions of leadership if we are going to maintain the quality of care of the initially wounded man and the second echelon care as he comes back through the island system in Japan and Guam. We have to fill these positions if the patient is going to get the best care he can initially, which means we then have personnel turbulence back here.

Mr. FORD. I want you to explain to the subcommittee if I can switch subjects on you a little bit I wanted to ask you to explain to the subcommittee briefly the question of continuing health care for dischargees. To explain first, we sometimes have cases where a man's wife is pregnant and he is being discharged from the service, and as you know in most civil health care programs there is a 9-month delay or a year's delay before he can pick up maternity coverage. Chairman Rivers had suggested that the Department try to work out some kind of a program where a man could be covered during this hiatus, between leaving the service and gaining civilian employment where he is covered. I think you have now worked it out. Would you explain it to us?

General HAYES. I would like Mr. McKenzie to explain this because he developed it.

Mr. FORD. All right.

Mr. MCKENZIE. Mr. Ford, as you stated, after Chairman Rivers had made this suggestion to the Secretary of Defense, we entered into negotiations with the health insurance industry to develop such a program. We did succeed eventually in establishing such a program, and it is now being made available, as of September 1, at all of our separation activities. Any person who is being separated from active duty, other than by reason of retirement, is afforded an opportunity during his separation processing to select one of the two health insurance plans that are now available under this program.

Both plans cover a 90-day period following separation. At the end of that period the individual has an option of converting his special short-term plan to a regular health insurance plan offered by the two participating companies, in Blue Cross-Blue Shield and Mutual of Omaha. Both plans offer comprehensive health care benefits. One of the plans includes maternity benefits.

The cost to the individual, if he chooses one of the two plans, varies. For example, if he is single and chooses one plan, the premium for the entire 90 days is $16.50. If, however, he has dependents and wishes family coverage under that particular plan, the amount of the premium, again for the 90 days, is $90.

Under the other plan, for "self only" the premium for 90 days is $30. There is a sliding scale of charges under that plan for family coverage, depending upon the size of the man's family, with the maximum being $103.

As I mentioned, the plan became effective on September 1. During the first month of operation, approximately 2 percent of the individuals who were separated during that month chose one of the two plans.