with and held to be aggravating service-connected disabilities, since such associated conditions should be regarded as being in the same general category as the service-connected disabilities involved for the purposes of adjunct treatment.

RECOMMENDATION NO. 9

"That the veteran should assume a liability to pay for care of his non-service-connected disability if he can do so at some reasonable time in the future. Such a debt should be without interest. Congress should pass appropriate laws providing for the collection of such obligations."

Comments of Veterans' Administration

Amendatory legislation would be required to implement this recomdation. Hospitalization for non-service-connected disabilities is provided under the authority of section 6, Public No. 2, 73d Congress, approved March 20, 1933, as amended. This basic law contemplates the furnishing of hospital care and treatment on a gratuitous basis to veterans who are eligible under its provisions. In this respect, the program of hospitalization, both for service-connected and non-service-connected cases, is a part of the overall pattern of benefits, including compensation, pension, and readjustment aids for war veterans, which has been established for the assistance and relief of eligible veterans as a measure of the Government's obligation and therefore at the expense of the Government.

Aside from the questionable policy of placing the Veterans' Administration in the position of providing hospital care for pay in competition with private and other institutions, it would seem directly contrary to the spirit and purpose of this benefit program to require a veteran to assume a burden upon his future of the kind proposed by recommendation No. 9.

As indicated in connection with recommendation No. 8, the House of Representatives declined to adopt a somewhat similar provision as a rider to the second independent offices appropriation bill for 1954 (H. R. 5690, 83d Cong.), and an extensive later study conducted within the Committee on Veterans' Affairs resulted in a resolution by that committee endorsing continued hospitalization for non-service-connected conditions, where beds are available, for veterans not having the ability to pay for private hospitalization. It is believed that there was implicit in this conclusion a rejection of the idea that veterans should be burdened with a liability to pay for such hospitalization when able to do so.

The whole question of the extent to which hospital and medical care should be provided for veterans with non-service-connected disorders is one of high policy for Presidential and congressional consideration. However, it is seriously doubted that any limitation of the policy now in effect should involve such a drastic change in the basic purpose of the veterans' hospital program as that proposed in this recommendation. It may be mentioned, also, that this proposal would be administratively expensive and unwieldy. The followup procedures, both with respect to determination of when the veteran might have attained an economic position enabling him to make payment and with respect to collection procedures, could be most cumbersome and would tend

to emphasize the commercial aspects of a governmental activity in behalf of a large group of persons hitherto regarded as having a special claim on the Government by reason of their service in time of war in the Armed Forces.

It should be noted that the Commission's comments with respect to collecting from insurance companies are rather misleading and unrealistic. The insurance companies have very largely written their policies to exclude reimbursement for hospital care afforded at public expense. The Commission's recommendation would not affect this nonassumption of liability, and it is beyond the power of the Congress to require change of these insurance policies on this matter or to prohibit private persons from entering into such contracts. Legislation on this aspect would probably have to take the form of prohibiting hospitalization for veterans who have purchased policies containing such an exclusionary clause or, possibly, a provision requiring that such an applicant be placed in an inferior position in the order of admissions.

RECOMMENDATION NO. 10

"That outpatient care, whether prior to or following hospitalization, be furnished to indigent veterans with non-service-connected disabilities. (This does not include neuropsychiatric cases prior to hospitalization.) Such patients should also assume a liability to pay for their care if they can do so at some reasonable time in the future." Comments of Veterans' Administration

In general, there is no authority under the present law for outpatient care except for service-connected disabilities. The Veterans' Administration has gone as far as is legal under the existing law, and amendatory legislation would be required to accomplish the purpose of this recommendation.

The intent of the recommendation is to reduce the length of stay in Veterans' Administration hospitals and thereby decrease hospital costs. However, the extent to which this would be realized is speculative. Unless accomplished by an orderly curtailment of hospital facilities, a plan for outpatient care for non-service-connected disabilities to indigent veterans could easily add to rather than diminish existing expenditures for the medical care and treatment of veterans. The intent of the recommendation is understood and may be worth congressional exploration in conjunction with the whole problem of the limits, if any, which should be prescribed for the hospital and medical care of veterans with non-service-connected conditions. The qualifications to the recommendation are, however, subject to serious question. It would not cover the area in which possibly the greatest benefits could be realized the field of neuropsychiatry-and would involve the highly doubtful procedure envisaged by recommendation No. 9, that of requiring beneficiaries of the proposed outpatient care to assume a liability to pay for their care if they can do so at some reasonable time in the future.

RECOMMENDATION NO. 11

"That the Veterans' Administration emphasize its program of medical care and rehabilitation services for the aging veteran eligible for care, in order to reduce the number of chronic bed cases.'

Comments of Veterans' Administration

The principle of this recommendation is sound and the policy of the Veterans Administration for the past several years is consistent with it. There are a number of studies currently in progress on the matter of medical and rehabilitation services for the aging veteran, and more are planned on this important phase of the program of the Veterans' Administration. The legal authority to provide medical rehabilitation services already exists, within reasonable limits, and it is assumed that this recommendation does not comprehend vocational training, as provided for under other governmental programs.

RECOMMENDATION NO. 12

"That the medical-care functions of Veterans' Administration regional offices be consolidated with, and where practicable physically located within, nearby Veterans' Administration hospitals.' Comments of Veterans' Administration

The consolidation of the medical-care functions of regional offices with nearby Veterans' Administration hospitals, where practicable, represents the current policy of the Veterans' Administration which has been approved by the Administrator. Ten clinics have already been moved to hospitals, and studies are continuing for further consolidations as soon as feasible.

RECOMMENDATION NO. 13

"(a) That the responsibility and authority to establish and maintain medical criteria for disability, both initial and continuing, should be transferred from the Compensation and Pension Branch of the Department of Veterans' Benefits, to the Department of Medicine and Surgery.

"(b) That the Department of Medicine and Surgery should also develop and maintain a mechanism for review of disability allowances based on the possibility of increase or decrease in disabilities." Comments of Veterans' Administration

Both parts of this recommendation could be carried out, if a redistribution of functions is indicated, by administrative action on the part of the Veterans' Administration. However, the discussion preceding the recommendation tends to indicate a misunderstanding by the Commission of the existing provisions and limitations of law respecting the assignment of percentage disability ratings for purposes of establishing and revising the schedule of disability ratings and for purposes of individual adjudications. The Commission states (H. Doc. 99, 84th Cong., p. 41) that disability compensation is "presumably equated to impairment of earning power" and urges that "disability ratings be based on true medical criteria and be more realistically related to loss of earning capacity."

The governing provisions of Veterans Regulation No. 3 (a), which was promulgated pursuant to title I of Public No. 2, 73d Congress, and which assumed the character of permanent law perforce of section 19 of the same act, provide that the Administrator shall adopt and apply a schedule of ratings of reductions in earning capacity from specific injuries or combination of injuries and that ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. Thus the impairment of earning capacity involved is not impairment precisely related to the individual case, but rather "average impairment" as related to a large class of individuals, which does not permit the reduction of percentage rating in an individual case where the person has been successful in overcoming the handicap. This statutory criterion corresponds to the principle which was incorporated in the War Risk Insurance Act Amendments of October 6, 1917, when the compensation system for the great World War I group was established. Consideration of "average impairment" in civil occupations similar to the occupation of the individual at time of enlistment was authorized by the World War Veterans' Act, 1924, but the "average impairment" concept, without reference to preservice occupation, was reverted to in the enactment and implementation of Public No. 2, 73d Congress.

Any assumption that a transfer within the Veterans' Administration of responsibility for the rating criteria would result in a change in the rating policy so as to relate the percentage rating in the individual case to the exact degree of impairment in that case, irrespective of what might be the situation in the average case, is therefore based on a misapprehension of the nature of the compensation benefit as defined by law.

It may also be noted that the one example used by the Commission of an excessive disability rating in the lower brackets is described in such a way as to reflect a misunderstanding. It is, in effect, stated that amputation of a great toe is rated at 30 percent, for which the veteran is entitled to a minimum of $50 per month, regardless of his other income. In fact, the uncomplicated amputation of the great toe entitles to a rating of only 10 percent. When it is associated with removal of the metatarsal head and consequently with the loss of muscle tone of both arches of the foot, it entitles to 30 percent. This is not high in relation to 10 percent for the simple loss of the toe or 40 percent for the loss of the foot. In any event, the question of whether such a rating or any category of rating in the schedule for rating disabilities is realistic can be authoritatively determined only by a survey of the resultant average impairment in earning capacity and not solely on the basis of medical opinion, no matter how well informed.

It is not entirely clear as to how far the recommendation would go in vesting responsibility in the Department of Medicine and Surgery concerning disability criteria. The Commission's discussion concerning the relationship between ratings assigned and actual impairment of earning capacity suggests that by Recommendation No. 13 (a) it is sought to transfer basic functions of the rating schedule board, now within the Department of Veterans' Benefits, to the Department of Medicine and Surgery

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With respect to the rating schedule itself, it should be stated that in its preparation and the preparation of amendments the advice of the medical authorities within the Department of Medicine and Surgery is freely sought and the final product is coordinated with them, to the end that each revision or amendment will represent the most current medical knowledge at the time. The membership of the rating schedule board includes two physicians. Thus, while the organizational responsibility for the schedule is that of the Department of Veterans' Benefits, its development and change results from a cooperative proceduce with the Department of Medicine and Surgery. As previously indicated, the question of whether the schedular evaluation of disabilities resulting from various types of diseases and injuries is realistic does not by any means depend solely on medical opinion or medical criteria, but rather upon average impairment of earning capacity in civilian life, which is determinable on the basis of factual studies, including medical considerations.

The rating boards at the field station level, each of which has a physician as a member, determine the proper degree of average impairment of earning capacity to be assigned in a given case. They deal with a wide variety of medical, legal, and other technical questions in adjudicating compensation and pension claims. Their determinations include a consideration of the reports of physical examinations as well as lay evidence. The criteria governing their operations are formulated in the Department of Veterans' Benefits as a staff function of the compensation and pension program. The action of physicians within the Department of Medicine and Surgery plays an important part in the adjudicative process, in that the Veterans' Administration physical examinations are conducted by physicians of that department and their findings, along with other pertinent facts, are used in making the determination of the degree of disability under the rating schedule itself. Appealed claims are passed upon by the Board of Veterans' Appeals, which also has physicians, including specialists, among its members.

As a predicate for recommendation No. 13 (b), the Commission states that there is a tendency to assume that disability is continuing and progressive and to avoid reexaminations. Unless the examination by medical personnel of the Department of Medicine and Surgery indicates that the disability is static, reexaminations are required until the disability has remained at the same level as shown by examination over a period of 5 years. Although there may have been some justification for criticism that in some instances disabilities have been prematurely classified as having reached a stationary level, efforts have been made to correct this situation and it is believed that the reexamination. policy is fundamentally sound. The answer to the question of what should be the policy on reexaminations and the "mechanism" for periodic review is not, in any event, one which hinges on a transfer of responsibilities, as proposed.

It should be noted that at one time the medical service of the Veterans' Administration's predecessor, the United States Veterans' Bureau, had the responsibility for the rating schedule and for the rating policy generally. During the period 1924-26 this responsibility was transferred by administrative action to the service having charge of the compensation program, and this has been the situation