[Senate Hearing 109-109]
[From the U.S. Government Publishing Office]
S. Hrg. 109-109
BACK FROM THE BATTLEFIELD: ARE
WE PROVIDING THE PROPER CARE
FOR AMERICA'S WOUNDED WARRIORS?
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
MARCH 17, 2005
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Larry E. Craig, Idaho, Chairman
Arlen Specter, Pennsylvania Daniel K. Akaka, Hawaii, Ranking
Kay Bailey Hutchison, Texas Member
Lindsey O. Graham, South Carolina John D. Rockefeller IV, West
Richard Burr, North Carolina Virginia
John Ensign, Nevada James M. Jeffords, (I), Vermont
John Thune, South Dakota Patty Murray, Washington
Johnny Isakson, Georgia Barack Obama, Illinois
Ken Salazar, Colorado
Lupe Wissel, Majority Staff Director
D. Noelani Kalipi, Minority Staff Director
C O N T E N T S
----------
Thursday, March 17, 2005
SENATORS
Page
Craig, Hon. Larry E., U.S. Senator from Idaho.................... 1
Akaka, Hon. Daniel K., U.S. Senator from Hawaii.................. 3
Obama, Hon. Barack, U.S. Senator from Illinois................... 4
Burr, Hon. Richard, U.S. Senator from North Carolina............. 5
Salazar, Hon. Ken, U.S. Senator from Colorado.................... 6
Prepared statement........................................... 7
Ensign, Hon. John, U.S. Senator from Nevada...................... 7
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia.... 30
Thune, Hon. John, U.S. Senator from South Dakota................. 32
Letter from Paula Hatzenbuhler............................... 32
WITNESSES
Duckworth, Major L. Tammy, U.S. Army National Guard.............. 8
Prepared statement........................................... 11
Costello, Joseph J., M.A., Team Leader, Vista Vet Center,
Department of Veterans Affairs................................. 13
Prepared statement........................................... 15
Hosking, David J., Global War on Terrorism Outreach Readjustment
Counselor, Madison Wisconsin Vet Center, Department of Veterans
Affairs........................................................ 17
Prepared statement........................................... 19
Farmer, Major General Kenneth L. Jr., M.D., Commanding Geneeral,
North Atlantic Regional Medical Command and Walter Reed Medical
Center......................................................... 36
Prepared statement........................................... 38
Perlin, Jonathan B., M.D., Ph.D., MSHA, FACP, Acting Under
Secretary for Health, Department of Veterans Affairs,
accompanied by Robert Epley, Deputy Under Secretary for Policy
and Program Management, Veterans Benefits Administration....... 41
Prepared statement........................................... 43
Response to written questions submitted by Hon. Daniel K.
Akaka...................................................... 62
Response to written questions submitted by Hon. John Ensign.. 65
Department of Veterans Affairs, example of letter sent to
Veterans................................................... 58
Bascetta, Cynthia A., Director of Veterans Health and Benefits,
U.S. Government Accountability Office.......................... 52
Prepared statement........................................... 54
BACK FROM THE BATTLEFIELD:
ARE WE PROVIDING THE PROPER
CARE FOR AMERICA'S WOUNDED WARRIORS?
----------
THURSDAY, MARCH 17, 2005
United States Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:06 a.m., in
room SR-418, Russell Senate Office Building, Hon. Larry E.
Craig, Chairman of the Committee, presiding.
Present: Senators Craig, Burr, Ensign, Thune, Akaka,
Rockefeller, Murphy, Obama, and Salazar.
OPENING STATEMENT OF HON. LARRY E. CRAIG, CHAIRMAN,
U.S. SENATOR FROM IDAHO
Chairman Craig. Good morning, ladies and gentlemen, and
welcome to the Veterans' Affairs Committee. This hearing will
be convened.
We are here this morning in a hearing we call, ``Back from
the Battlefield: Are we Providing the Proper Care for America's
Wounded Warriors?'' I have called this hearing of the Senate
Veterans' Affairs Committee to receive testimony on and review
the experiences of our service men and women as they leave
active duty in the Army, Navy, Air Force, Marine Corps and
Coast Guard and transition back to civilian life in the big
cities and small towns all over this great Nation.
And as the panel of witnesses suggest, I am not only
interested in hearing about this experience from those who are
charged with operating it from a managerial standpoint, but I
also, want to hear from those who have gone through it
themselves or even still going through it as we speak. I am
particularly interested in two distinct, but equally important,
populations of servicemembers.
First, for obvious reasons, I am interested in learning
about the care and services provided to those who are
physically injured fighting in the war on terror, in Iraq,
Afghanistan and other dangerous places around the globe. I
hasten to point out that many of them want to and may, in fact,
return to active duty and continue their extraordinary service
to this country. Others, however, may be faced with the reality
of a transition to civilian life that is, sadly, involuntary.
By that I mean some of those injured may be discharged from the
Armed Services as a result of the serious injuries sustained in
battle. Yet I am hearing, albeit anecdotal, that for many of
those who are ultimately discharged, life in the months and
weeks leading up to that discharge consists of time spent away
from home, families, children and the very support structure
they will need to truly recover.
I am not suggesting that rushing the injured out of the
Armed Services is an answer to our desire, but I am suggesting
that perhaps the current practice of treating these
servicemembers only in a medical treatment facility in
Washington, DC., Georgia or Texas while they await medical
board review may not be right either. I hope those here today,
representing the military and VA, can begin to think about ways
to use their many facilities smarter to bring these men and
women closer to home for recovery services.
We must ensure that those highest-priority veterans are
given all the tools, service and assistance necessary to
seamlessly transition back to civilian life.
And, second, as I said, equally important, groups of
servicemembers the Committee will hear about today are those
who return from war whole, in body, but perhaps troubled in
mind by the experiences they had while overseas protecting our
freedom.
All of us are aware our country is relying more than in
recent past on the activation of the National Guard and the
Reserves to serve on the war on terror. Seventeen hundred of my
fellow Idahoans with the Army National Guard's 116th Cavalry
Brigade are now serving overseas in Iraq. In fact, next month,
I will visit the regional medical center in Germany, as well as
Iraq, with the Secretary of Veterans Affairs, to see firsthand
the work done by these men and women.
These guardsmen and reservists who are fortunate to come
back to us safely do not return to Army base in Georgia or an
Air Force base in Colorado or Idaho, for that matter. Instead,
they return to a Guard unit or Reserve unit in their home
State, and most likely they go right back to work or they are
expected to and go right back into their homes with their
families. I need to know that the Department of Defense and the
VA are working closely together to identify not only these men
and women, but where they live and how we can reach out to them
to ensure their transition is a smooth one.
We are privileged today to have two panels of witnesses to
speak about all of our concerns and any concerns they may wish
to express or concerns other Members of our Committee will
have.
Our first panel is really a microcosm of those I have just
spoken about in my statement. We have two distinguished
veterans who now work for the Department of Veterans Affairs in
a Veterans Readjustment Counseling Service. Mr. Joseph
Costello, welcome, a veteran of Operation Enduring Freedom, who
was awarded a Bronze Star, and David Hosking, a veteran from
the Vietnam War and Operation Iraqi Freedom, who was also
awarded the Bronze Star.
Also, joining us on Panel One is Major Tammy Duckworth, of
the Illinois National Guard. She is accompanied by her husband
Bryan Bowlsbey; is that correct? Major Duckworth is a Blackhawk
helicopter pilot who was injured November 12th, in 2004, when
the helicopter she was flying in Iraq was struck by a rocket-
propelled grenade. Clearly, Major Duckworth's story of bravery
and courage will inspire each and every one of us here in this
room. But just as important, her experience since sustaining
her injuries will enlighten us on the difficult process of
moving from the battlefield to our medical facilities overseas
and I hope educate us on the grueling process of rehabilitation
and recovery, once a servicemember returns to the United
States.
Major Duckworth, we are honored by your presence this
morning, and we thank you very much for being with us.
Joining us on the second panel will be Major General
Kenneth Farmer, Commanding Officer at Walter Reed Army Medical
Center, right here in Washington, DC; Ms. Cynthia Bascetta, the
Director of Veterans' Health and Benefits at the U.S. General
Accounting Office; Dr. Jonathan Perlin--and many of you are
getting to know Dr. Perlin, the Acting Under Secretary of
Health at the Department of Veterans Affairs--who is
accompanied by Robert Epley, the Deputy Under Secretary of
Benefits at the Department of Veterans Affairs.
Well, ladies and gentlemen, this will make up our panelists
of the day and today's testimony. But before we hear from them,
let me ask if there are any amongst us who would like to make
opening comments. Let me turn to the Ranking Member, Senator
Akaka.
Danny?
OPENING STATEMENT OF HON. DANIEL K. AKAKA,
RANKING MEMBER, U.S. SENATOR FROM HAWAII
Senator Akaka. Thank you very much, Mr. Chairman.
I am so pleased that we have this opportunity to talk about
what our Government is doing to care for those who have served,
and this is our effort this morning. It is a subject that
deserves our most serious attention, and we are giving it that
attention.
I, also, want to say that it was a pleasure to work with
Chairman Craig in developing this hearing today. As Ranking
Member, I appreciate the opportunity to provide input to the
Chair on the topic at hand and on the witnesses we will hear
from today.
VA and DOD seem to be doing a good deal to ensure a
seamless transition for the men and women who serve. I applaud
that, and I am sure we will hear much more about that this
morning. My focus is very simple--to make sure that both
departments are doing everything possible to guarantee that
each and every soldier, whether Active duty or Reserve or Guard
member, is receiving high-quality care without having to work
to get it. All servicemembers, including the men and women who
are coming back from Iraq and Afghanistan, should have nothing
less than a seamless reintegration into society and their
lives. It is my view that we need to be particularly attentive
to the challenges faced by the Guard and Reserve in this
transition.
Why am I so adamant about this? Because without a seamless
transition, we will be failing our veterans. We have witnesses
who will give us the macro view, how things should be working
according to VA, DOD and the General Accounting Office, but our
first panel of witnesses will provide the micro view. This is
especially important, given that some experts have calculated
that one in every eight soldiers reported symptoms of PTSD.
But, first, we will hear from Major Tammy Duckworth, a
member of the Illinois National Guard, who is receiving care at
Walter Reed. On a personal note, the State of Hawaii can claim
her as one of its own. At this time, our esteemed friend and
Senator from Illinois can, also, do the same.
[Laughter.]
Senator Akaka. Once her story is told, you will see why I
am so proud. I look forward and welcome her testimony.
Thank you very much, Mr. Chairman.
Chairman Craig. Danny, thank you.
So we have dueling jurisdictions this morning over you,
Tammy. Let me introduce, next, for any comments that he would
like to make, the Senator from Illinois, Senator Obama.
STATEMENT OF HON. BARACK OBAMA,
U.S. SENATOR FROM ILLINOIS
Senator Obama. Thank you very much, Mr. Chairman, Ranking
Member Akaka. I congratulate you on setting up this important
hearing and very much appreciate the opportunity to be here at
least for a portion of it.
As of yesterday, 11,285 men and women have been wounded in
Operation Iraqi Freedom. That is 11,285 husbands, wives, sons
and daughters who will be returning home with scars that may
change their lives forever. They are our heroes. They deserve
our deepest gratitude and support. It is very much appreciated
that Mr. Costello and Mr. Hosking are here to help us talk
about how we are providing appropriate care not simply to heal
wounds, but, hopefully, to also allow those who are returning
home to continue to grow and prosper, whether they decide to
remain in active duty or not.
I hope that we are setting a very high bar. I do not think
it is sufficient for us simply to try to help our veterans
achieve some semblance of normalcy. We want to be a service
that is providing them the kind of care that allows them to
thrive over the long term.
Yet we have, also, obviously, here today Major Duckworth
and her husband, Bryan. As Senator Akaka mentioned, she is a
helicopter pilot with the Illinois National Guard. She made her
way to Illinois from what I understand was a pretty diverse set
of homes. We were speaking beforehand, Senator Akaka, and it
turns out that not only did she spend time in Ohio, but she
also spent time in Southeast Asia, where I also lived in
Indonesia for a time. So I have got you beat on this one.
[Laughter.]
Senator Obama. I have got the Illinois connection, I have
got the Hawaii thing going, I have got Southeast Asia. Me and
Major Duckworth, there is some cosmic thing going on here.
Four months ago, while piloting a Blackhawk helicopter over
Iraq, Major Duckworth lost both her legs when a rocket was shot
through the floor of her aircraft. Today, she sits before us by
the grace of God. She does not just tell people that she hopes
to fly again. She will fly again someday. I am just in awe of
her courage and her contribution to our country. We are so
grateful to you. I am very much looking forward to hearing your
testimony. I have had the opportunity to read it, and I am
confident that you will be sharing a constructive, positive
outlook on what significant achievements are already taking
place in the VA system, but also areas where we can achieve
some significant improvements. I think we should not feel
defensive or embarrassed about the fact that even as we are
doing a good job, we can always do a better job and figure out
how to do that.
It is our obligation. The one thing I would point out
before the testimony takes place, that we, in Congress, provide
some oversight, but we also provide you the resources. One of
the frustrating things, I assume, if I were in the VA system,
would be insisting on performance and then not always getting
the resources needed for performance. So part of what I hope is
accomplished here today is, to the extent that there are things
that are not happening, that you can tell us why they are not
happening, and how we can fix them and how Congress can
potentially provide help on that.
The only other comment I would make would be that I do hope
that Ms. Duckworth's story and the story of thousands of others
serve as a mandate for this Committee. We need to guarantee
that these men and women will receive the care and services
they need to carry on their lives. That means DOD and VA
working together to provide more efficient vocational
rehabilitation services. It means ensuring that we have the
capacity to treat specific needs like soldiers returning with
post-traumatic stress disorder. It means focusing on prosthetic
research and innovation so the Armed Services can keep heroes
like Major Duckworth in their ranks.
Mr. Chairman, again, I thank you for holding this hearing.
Chairman Craig. Senator, thank you very much.
Now, let me turn to Senator Burr. Richard, do you have any
opening comment?
STATEMENT OF HON. RICHARD BURR,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Very quickly, Mr. Chairman. I am not sure I
can compete with my two colleagues on this tie to the Major,
but very few individuals will come through this Committee in
uniform that will testify that have not spent some memorable
experience in North Carolina, I can assure you.
[Laughter.]
Senator Burr. Mr. Chairman, the good news I think, today,
for all of us is the VA is preparing. The VA is not within a
shell. They are looking at the changing world not only of the
mission that we are currently involved in, but the changing
world of health care. Health care is a challenge to those of us
that are legislators as it relates to seniors and to
individuals who tend to fall through the cracks of coverage,
but it is also a challenge to us from a standpoint of those who
have the luxury of coverage.
Success will not be judged based upon funding alone.
Success, as it relates to how we respond to those who come
back, I truly believe is going to be a combination of the level
of compassion and innovation, the level of funding and
outreach, the level of access and education that not just the
VA is going to do, but all of us are going to do.
I think that Barack said it very well. These are heroes,
and they deserve the most focused effort on the part of all
concerned to make sure that we do everything that we can to
prepare for it. It is unfortunate sometimes that we cannot
accelerate technology past where it has the capability to go,
but certainly 2 years from now we will have options we do not
have today, and it will be because of the preparation of this
Committee and of the VA that we are able to take advantage of
those technological breakthroughs when they are available.
The Major's testimony brings out one thing that I want to
highlight, and it is not any of the points that she suggests
that we need to go through. I think it was her testimony. But
it was these are young lives that have a long life to live, and
I think that is something that we cannot lose focus of. In many
cases, we are dealing with young lives that have a long
fruitful time that they will spend with us and our ability to
address it, the ability of this Committee to make sure that not
just the resources, but the blueprint is there to address this
is ultimately the thing that will impact these lives.
I thank you, Mr. Chairman.
Chairman Craig. Richard, thank you very much.
Senator Salazar, any opening comment you would like to
make?
STATEMENT OF HON. KEN SALAZAR,
U.S. SENATOR FROM COLORADO
Senator Salazar. I will submit my opening comment for the
record, but I would like to just make a brief comment here, if
I may, Mr. Chairman. Thank you.
Major Duckworth, I very much applaud you for your courage
and what you have done for our country. Shortly after I got
sworn in, in the first week of January, I had the pleasure and
honor of meeting you at Walter Reed Army Hospital. I can tell
you that you not only inspired me that day, but you inspire me
here again today. Your bravery over the skies of Iraq, and your
return back to the United States and to be here before the
Veterans' Affairs Committee of the U.S. Congress is just
another indication of how courageous you are and how determined
you are to make a difference.
So your contribution to this Committee, as we deal with the
issues of veterans, is very important, and I think especially
in the context of where we are today, for we know that in
Afghanistan and in Iraq we now have had some 11,000 men and
women who have been injured. What we do here in the Veterans'
Affairs Committee will, obviously, very much affect their
lives. As Senator Burr said, it is, in many cases, many years
of your lives that we will be affecting.
So I very much look forward to your testimony, and I also
know that Ambassador Nicholson, now Secretary Nicholson, who is
heading up the Veterans Administration, is also looking very
much forward to figuring out ways in which we can make sure
that we have the right kind of transition between DOD and the
VA, with respect to information sharing that I think is very
important to make sure that we are taking care of our veterans
in the veterans system.
So, again, I thank you for being a part of this panel
today.
[The prepared statement of Senator Salazar follows:]
Prepared Statement of Hon. Ken Salazar,
U.S. Senator from Colorado
Thank you Mr. Chairman, Senator Akaka, Members of the Committee and
our panelists.
The issue of smoothing the transition from active duty service to
veterans' care has always been an administrative challenge, but now,
with the large number of seriously injured soldiers returning home, it
has the potential to become a crisis.
More than 11,000 troops have been injured in Iraq and Afghanistan.
More than 6,000 of these were unable to return to duty within 3 days.
During Korea, Vietnam and the 1991 Gulf War, about one servicemember in
four died from their wounds. Today's battlefield-wounded are surviving
at twice the rate, but many are coming back with very severe
disabilities, including missing limbs.
One of the first things I did when I was sworn in as a Senator this
year was visit Walter Reed Army Medical Center to say thank you to the
courageous men and women there who have given parts of themselves so
that our country can remain strong. These injured soldiers represent
the best in America and we owe them more than our gratitude.
The VA offers outstanding rehabilitative services, and the sooner
this treatment begins, the more successful injured veterans are in
their recovery. Unfortunately administrative gaps have led to delays
and many veterans have fallen through the cracks.
The VA has recognized this problem and has done its best to make it
better. The VA has set up task forces and dispatched case workers to
military medical treatment facilities. They have tried to reach
incoming veterans earlier and better coordinate with the DOD.
These efforts have done a lot of good. As we will hear from those
who have been through the system, it does work for many people. But
independent analysis has consistently shown that there are still huge
gaps.
The VA is having trouble getting the information they need from the
DOD. The sharing of information and quality of casework management
varies greatly from region to region. In some cases the DOD only gives
the VA the names of new patients, with no information on severity of
injury. In other cases, injured soldiers who do not apply for VA
services immediately are lost to the system.
This is an administrative problem with huge implications for our
fighting men and women. It is also a problem that will not be fixed
with half-measures.
It is clear that the DOD needs to work more closely with the VA to
share medical information. The VA also needs to redouble its efforts to
fill the gaps in its outreach to make sure that seriously injured
veterans are never lost to the system.
I look forward to the testimony of the panelists today. I want to
share a special thank you to Major Duckworth, who is appearing after a
recent family tragedy. Your bravery in the skies above Iraq is matched
by the courage and strength you are showing here today. Thank you for
your service.
Chairman Craig. Thank you very much.
Senator Ensign, any opening comment you would like to make?
STATEMENT OF HON. JOHN ENSIGN,
U.S. SENATOR FROM NEVADA
Senator Ensign. Just very briefly, Mr. Chairman. Thank you
for holding this hearing, and I thank all of you for being here
and your service to our country.
I had a personal experience not too long ago over at Walter
Reed. We had a soldier from Nevada, returning home from Iraq.
Wounded, he had been hit in the leg and had an open abdominal
wound. I asked him, ``How are you being treated? How is the
care? How is the support system? How are they dealing with the
emotional, mental aspects, as well as the physical aspects?''
It seems to be, at least from his reports, he had a wonderful
experience.
I guess the purpose of this hearing, Mr. Chairman, is to
determine if we are really taking care of our veterans and do
we have the resources required. I also want to caution us that
there is a lot of focus on this issue right now. What is it
going to be 2 years, 3 years, 4 years, 10 years from now? We
can never afford to neglect the people who have sacrificed for
all of us, those of you who have sacrificed for all of us. When
the cameras are on and the bright lights are shining, everybody
wants to step up to the table, but are we going to continue
that physical, emotional, mental support that seems to at least
be there at this current time? That is one of the things that I
hope that we continue looking at this into the future.
Thank you, Mr. Chairman, for holding this hearing.
Chairman Craig. John, thank you very much. That is the
ultimate challenge. You have said it well.
With that, let us turn to our first panel. Again, we thank
you all so very much for being here. We would ask Major Tammy
Duckworth, United States Army National Guard, if she would lead
off the panel this morning.
STATEMENT OF MAJOR L. TAMMY DUCKWORTH,
UNITED STATES ARMY NATIONAL GUARD
Major Duckworth. Good morning. Mr. Chairman, Senior Ranking
Member Akaka, and distinguished Members of the Committee, thank
you for the opportunity to come before you today to discuss the
care of wounded servicemembers injured in Operations Enduring
Freedom and Iraqi Freedom and our efforts to facilitate the
transition between the military and Veterans' Affairs health
care facilities and between military and veteran status.
The medical efforts at Walter Reed Army Medical Center, as
well as the medical team at Landstuhl, the Combat Area Surgical
Hospital, and the in-theater Medevac helicopter crew have been
extraordinary. In any previous conflict, I would not be alive
today. It is a testament to the superior protective equipment
that I was wearing and to the medical care pipeline from the
front lines to Walter Reed that I can be here.
I would like to take a moment to stress the unique nature
of the military health care system. While civilian
professionals are an important component in that system, there
is no substitute to being treated by and recovering with fellow
soldiers. Only a fellow servicemember can understand the
stresses and wounds of combat. The CASH in Baghdad is the
target of frequent rocket attacks. I have met physicians and
nurses at Walter Reed who were there. They know, on a personal
level, what the foot soldier faces. Additionally, I doubt that
doctors at a stateside civilian hospital would be as familiar
with the damage caused by rocket-propelled grenades, improvised
explosive devices or the dangers of theater-specific bacterial
infections. Soldiers, whether they are physicians or other
wounded soldiers, understand the warrior ethos that drives my
recovery.
As disabled soldiers transition to veteran status, we will
look to the VA to provide continued access to health care,
health technology, assisted living devices and social services.
The VA will have to face a challenge of providing care at the
high level set by the military health care facilities. This is
a challenge that the VA can meet if it is given enough
resources, and if it listens to disabled servicemembers, and
puts forth the effort to put our needs.
The first most easily identified need that the VA will have
to support is continued access to technology. Disabled veterans
will require access to different devices as they age and as the
technology undergoes innovation. The VA will need to track
ongoing changes in medical technology such as in prosthetics
research and inform the veteran of the availability of the new
technology.
I am certain that while the American people are focused on
injured soldiers from the global war on terrorism, the funds to
aid those soldiers will continue to be forthcoming. I am
concerned that during peacetime, funds for research, such an in
the fields of prosthetics, will be reduced. The VA needs to
continue to support the cutting-edge research that is underway
as a result of the current conflict's wounded. In order to do
so, the VA itself will need continued funding earmarked for
this purpose.
Second, as I look around at the other wounded soldiers, it
is clear that the majority of them are young with long lives
ahead of them. Whether we will continue to have the honor of
serving in uniform or return to productive civilian lives, we
will require continued access to high-quality VA services as we
age. The VA will need to support this need over the long term,
as currently wounded soldiers will be accessing its programs
over a lifetime.
Third, in order to provide ongoing care to veterans, the VA
will have to identify and develop specific programs and
cultivate professionals to implement them. Experience is, as we
say in combat terms, a force multiplier. The technologies that
make recovery possible from such severe wounds require
experienced professionals to assess and apply them to the
veteran. Patients benefit from long-term relationships with
highly trained and experienced specialists. This is especially
true of the therapists that specialize in amputee care who grow
to know the peculiarities of residual limbs and the use of
prosthetics. The level of care provided by the VA will be
enhanced by a commitment to the programs and professionals who
will interact with the patient.
Fourth, disabled soldiers will need access to assisted
living devices such as high-tech prosthetic care; orthopedic
care and rehabilitation; home modifications; vehicle
modifications; specialty equipment such as wheelchairs,
bathroom equipment, hand cycles, adaptive sports equipment,
specialty equipment for blinded soldiers, such as talking
appliances or computers, and smart home technology.
Fifth, the VA will need to provide access to social
services, such as job counseling and psychological support.
Many of the young, wounded soldiers today need advice on which
jobs or educational programs will be most suited to them. Such
career counseling will allow the soldier to maximize the
educational and job-training benefits provided by the VA.
Additionally, those that sustained brain injury as well as
those that develop psychological trauma will need long-term
counseling and support.
Finally, it does the disabled veteran no good if he or she
is unable to access the various programs provided by the VA.
While still assigned to Walter Reed, I have immediate access to
the prosthetics care that is part of my recovery process. This
access will continue for me through the new amputee center.
However, for disabled veterans living in areas far from VA
hospitals and facilities, travel itself is a significant
obstacle to their continued care. These disabled veterans will
need regular, easy transportation support from the VA.
I applaud the VA and the Department of Defense partnership
that assists military servicemembers who have served in combat
and aims to provide them with a seamless transition to civilian
life and veteran status.
Those select individuals from amongst the American people
who would willingly serve in the Armed Services are a limited
resource. Our warriors are expensive and indispensable. I
believe we must jealously guard this resource, retaining as
many as possible in the service, and sparing little effort to
return one of them to service. For example, the cost to make
another Military Police Captain in order to replace a wounded
one is prohibitive when compared with the medical costs to fix
wounded soldiers and return them to duty.
I would urge you to think of the efforts of the Army
Medical Department and the VA as a force multiplier for two
reasons. First, these organizations can help us retain good
soldiers, Marines, airmen and sailors who would have otherwise
not been able to continue to physically accomplish their
missions and remain in the service of the United States. These
wounded have already been trained at great expense, as well as
been tested and gained invaluable experience in the crucible of
combat.
Further, I believe we want to ensure that our warriors are
secure in the knowledge that, when and if their comrades are
hurt, we will take care of them. The front-line soldiers should
not expend a moment of time to worry about a fallen comrade. We
must ensure that he knows ``My buddy made it to Walter Reed, he
will be OK, they have the best doctors and cutting-edge
technology there.''
We will maintain the optimal morale and performance from
our soldiers through ensuring that these medical facilities are
adequately funded.
I have experienced firsthand the excellence of the Army's
medical system for the combat wounded. Because of the type of
injuries and the geographic location of my home, I have been
treated at Walter Reed. Had I been burned badly, I would have
been sent to a different facility. For example, an amputee
center has been opened at Fort Sam Houston's Brooke Army
Medical Center. I believe it is just as important to fund all
of those facilities. I can only hope and implore that the VA
steps up to receive disabled veterans as we transition into its
care from the military medical system. In order to continue to
provide care at the level provided by the military health care
system, these programs will have to be funded into the future.
On behalf of our injured, wounded or ill servicemembers and
their families, I thank members of this great institution for
providing us with the funding and resources to take care of
some of the finest citizens of this Nation. These are the men
and women in uniform who have committed their lives and well
being to the defense and protection of this great Nation. Thank
you for the funding that provides invitational travel orders
for family members, allowing my husband and mother to be at
Walter Reed. They are an important part of my rehabilitation
team.
The AMEDD, with Walter Reed Army Medical Center on the
cutting edge, has provided world-class health care to the
injured and wounded members of all the services. A strong
partnership between the military health care system and the
Department of Veterans Affairs will provide the optimal care
for the needs of our servicemembers and their families.
Thank you.
[The prepared statement of Major Duckworth follows:]
Prepared Statement of Major L. Tammy Duckworth,
United States Army National Guard
Mr. Chairman and distinguished Members of the Committee, thank you
for the opportunity to come before you today to discuss the care of
wounded servicemembers injured in Operations Enduring Freedom (OEF) and
Iraqi Freedom (OIF) and our efforts to facilitate the transition
between the Military and Veteran Affairs (VA) Health Care Facilities,
and between military and veteran status.
The medical efforts of Walter Reed Army Medical Center, as well as
the medical team at Landstuhl, the Combat Area Surgical Hospital and
the in-theater Medevac helicopter crew have been extraordinary. In any
previous conflict I would not be alive today. It is a testament to the
superior protective equipment that I was wearing and to the medical
care pipeline from the front lines to Walter Reed that I can be here.
I would like to take a moment to stress the unique nature of the
military healthcare system. While civilian professionals are an
important component in that system, there is no substitute to being
treated by, and recovering with fellow soldiers. Only a fellow
servicemember can understand the stresses and wounds of combat. The
CASH in Baghdad is the target of frequent rocket attacks. I have met
physicians and nurses at Walter Reed who were there. They know on a
personal level what the foot soldier faces. Additionally, I doubt that
doctors at a stateside civilian hospital would be as familiar with the
damage caused by a rocket propelled grenades, improvised explosive
devices, or the dangers of theater-specific bacterial infections.
Soldiers, whether they are physicians or other wounded soldiers
understand the warrior ethos that drives my recovery.
As disabled soldiers transition to veteran status, we will look to
the VA to provide continued access to healthcare, health technology,
assisted living devices and social services. The VA will have to face
the challenge of providing care at the high level set by the military
healthcare facilities. This is a challenge that the VA can meet if it
is given enough resources and if it listens to disabled servicemembers
and puts forth the effort to meet our needs.
The first, most easily identified need that the VA will have to
support is continued access to technology. Disabled veterans will
require access to different devices as they age and as the available
technology undergoes innovation. The VA will need to track ongoing
changes in medical technology such as in prosthetics research and
inform the veteran of the availability of this new technology.
I am certain that while the American people are focused on injured
soldiers from the Global War on Terrorism, the funds to aid those
aoldiers will continue to be forthcoming. I am concerned that during
peacetime, funds for research such as in the field of prosthetics will
be reduced. The VA needs to continue to support the cutting edge
research that is underway as a result of the current conflict's
wounded. In order to do so, the VA itself will need continued funding
earmarked for this purpose.
Second, as I look around at the other wounded soldiers, it is clear
that the majority of them are young with long lives ahead of them.
Whether we will continue to have the honor of serving in uniform, or
return to productive civilian lives, we will require continued access
to high quality VA services as we age. The VA will need to support this
need over the long term as currently wounded soldiers will be accessing
its programs over a lifetime.
Third, in order to provide ongoing care to veterans, the VA will
have to identify and develop specific programs and cultivate
professionals to implement them. Experience is, as we say in. combat
terms, a force multiplier. The technologies that make recovery possible
from such severe wounds require experienced professionals to assess and
apply them to the veteran. Patients benefit from long-term
relationships with highly trained and experienced specialists. This is
especially true of the therapists that specialize in amputee care who
grow to know the peculiarities of residual limbs and the use of
prosthetics. The level of care provided by the VA will be enhanced by a
commitment to the programs and professionals who will interact with the
patient.
Fourth, disabled soldiers will need access to assisted living
devices such as:
High tech prosthetic care.
Orthopedic care and rehabilitation.
Home modifications e.g. ramps, thresholds, lifts and wide
doors.
Vehicle modifications/hand controls.
Specialty equipment such as wheelchairs, bathroom
equipment, hand cycle, adaptive sports equipment.
Specialty equipment for blinded soldiers such as talking
appliances or computers.
Smart home technology:
Fifth, the VA will need to provide access to social services such
as job counseling and psychological support. Many of the young wounded
soldiers today need advice on which jobs or educational programs will
be most suited to them. Such career counseling will allow the soldier
to maximize the educational and job training benefits provided by the
VA. Additionally, those that sustained brain injury as well as those
that develop psychological trauma will need long term counseling and
support.
Finally, it does the disabled veteran no good if he or she is
unable to access the various programs provided by the VA. While still
assigned to Walter Reed I have immediate access to the prosthetics care
that is part of my recovery process. This access will continue for me
through the new amputee center. However, for disabled veterans living
in areas far from VA Hospitals and facilities, travel itself is a
significant obstacle to their continued care. These disabled veterans
will need regular, easy transportation support from the VA.
I applaud the VA and Department of Defense (DOD) partnership that
assists military servicemembers who have served in combat and aims to
provide them with a seamless transition to civilian life and veteran
status.
Those select individuals from amongst the American people who would
willingly serve in the armed services are a limited resource. Our
warriors are expensive, and indispensable. I believe we must jealously
guard this resource, retaining as many as possible in the service, and
sparing little in the effort to return one of them to service. For
example, the cost to ``make'' another Military Police Captain in order
to replace a wounded one is prohibitive when compared to the medical
costs to fix wounded soldiers and return them to duty.
I would urge you to think of the efforts of the Army Medical
Department (AMMED) and the VA as a force multiplier for two reasons.
First, these organizations can help us retain good soldiers, Marines,
airmen and sailors who would have otherwise not been able to continue
to physically accomplish their missions and remain in the service of
the United States. These wounded have already been trained at great
expense, as well as been tested and gained invaluable experience in the
crucible of combat.
I believe we want to ensure that our warriors are secure in the
knowledge that, when and if their comrades are hurt we will take care
of them. The frontline soldier should not expend a moment of time to
worry about a fallen comrade. We must ensure that he knows, ``My buddy
made it to Walter Reed, he will be OK, they have the best doctors, and
cutting edge technology there.'' We will maintain the optimal morale
and performance from our soldiers through ensuring that these medical
facilities are adequately funded.
I have experienced first hand the excellence of the Army's medical
system for the combat wounded. Because of the type of injuries, and the
geographical location of my home, I have been treated at Walter Reed.
Had I been burned badly I would have been sent to a different facility.
For example, an amputee center has been opened at Fort Sam Houston's
Brooke Army Medical Center. I believe it is just as important to fund
all of those facilities. I can only hope and implore that the VA steps
up to receive disabled veterans as we transition into its care from the
military medical system. In order to continue to provide care at the
level provided by the military health care system these programs will
have to be funded into the future.
On behalf of our injured, wounded or ill servicemembers and their
families, I thank members of this great institution for providing us
with the funding and resources to take care of some of the finest
citizens of this Nation. These are the men and women in uniform who
have committed their lives and well being to the defense and protection
of this great Nation. Thank you for the funding that provides
invitational travel orders for family members, allowing my husband and
mother to be at Walter Reed. They are an important part of my
rehabilitation team. The AMEDD, with WRAMC on the cutting edge, has
provided world class health care to injured and wounded members of all
the Services. A strong partnership between the military healthcare
system and the Department of Veterans Affairs will provide the optimal
care for the needs of our servicemembers and their families.
Chairman Craig. Major, thank you very much for that
testimony. It is truly appreciated.
Now, let me turn to Joseph Costello, Team Leader, Vets
Center, Vista, California.
Joe, welcome. We will need to have you bring that
microphone over to you and be sure it is on.
STATEMENT OF JOSEPH COSTELLO, M.A., TEAM LEADER,
VET CENTER, VISTA, CALIFORNIA
Mr. Costello. Mr. Chairman, and Members of the Committee,
Senator Akaka, I am privileged to appear you today to discuss
the role of the Vista Vet Center in providing care and services
to veterans returning from Operation Enduring Freedom and
Operation Iraqi Freedom. Although this statement will focus on
the activities of the Vista Vet Center, our efforts are typical
of the 206 Vet Centers nationwide.
Under the leadership of Dr. Alfonso Batres, Chief of
Readjustment Counseling Service, and Mr. Richard Talbott, the
Pacific Western Regional Manager, the Vista Vet Center, located
in Vista, California, endeavors to provide the highest-quality
readjustment counseling and outreach services in an expeditious
and cost-effective manner to eligible veterans and their
families, especially to those who are suffering from
readjustment problems related to combat trauma or military
sexual trauma experienced while on active duty.
The services we provide for veterans include community
outreach, referral to Department of Veterans Affairs medical
and benefits providers; individual, group and family
readjustment counseling; military sexual trauma counseling; and
onsite employment assistance and vocational rehabilitation
counseling via out-stationed ancillary staff. Vista Vet Center
staff provides ongoing outreach to newly returning veterans of
combat operations in Iraq and Afghanistan. Additionally, for
more than a year, Vista Vet Center counselors have provided
bereavement counseling to family members of military personnel
killed on active duty in Iraq or Afghanistan.
The Vista Vet Center is located approximately 10 miles from
the Camp Pendleton Marine Corps Base. We serve the communities
of North San Diego County and Southern Riverside County. This
community-based location of the Vista Vet Center provides
maximum accessibility for our veteran clients. The Vista Vet
Center is co-located with a VA Community-Based Outpatient
Clinic. Many of our veteran clients also receive VA medical
care at this facility. We are fortunate to have a close and
cooperative relationship with our colleagues in the San Diego
VA health care system, a relationship we nurtured by providing
office space for medical staff before the CBOC was actually
established.
The Vista Vet Center maintains non-traditional hours in an
effort to ensure that veterans, whether employed or not, have
access to services at a time that is convenient for them. The
center is staffed from 7 a.m. until 8:30 p.m., Monday through
Thursday, and from 7 a.m. until 4:30 p.m. on Friday. We, also
provide outreach assistance to newly returning veterans and
family members and participating community activities on
weekends. If a military or veterans service organization
requests our presence at a function during non-traditional
hours, it can be assured of our enthusiastic participation.
The Vista Vet Center has a core staff of four persons, a
team leader, two counselors and an office manager. The staff
has also been augmented by the addition of one half-time
military sexual trauma counselor, one full-time global war on
terrorism outreach worker. All of the team members are
veterans, and four hold various mental health licensure and/or
certifications to include social work, psychology, marriage and
family therapy and alcohol and drug abuse counseling.
Ancillary staff members onsite weekly at the Vet Center
include a full-time licensed psychiatric nurse clinical
specialist volunteer, a County of San Diego Veterans Services
representative who provides benefits assistance to our
veterans, a VA vocational rehabilitation counselor, a VA
homeless outreach counselor, and employee assistance counselors
from the State of California. The Vista Vet Center also
participates in the VA work study program. This program allows
recently discharged veterans an opportunity to earn money doing
supportive work for veterans and the Vista Vet Center staff
while attending school. Two of our current work study staff
members are also Operation Iraqi Freedom veterans. All of the
members of the ancillary staff are instrumental to the success
of the Vet Center mission.
The Vista Vet Center continues to provide readjustment
counseling and supportive social services to a large percentage
of Vietnam veterans. At the same time, we provide readjustment
counseling services to all combat veterans who request our
services who include an increasing number of OEF and OIF
veterans and to victims of military sexual trauma. Over the
past year, we have also provided bereavement counseling for
three family members of two marines and one soldier killed in
action in Iraq. During fiscal year 2004, the Vista Vet Center
served 635 individual veterans and had 6,849 visits from
veterans and family members. Nearly 50 percent--or 312--of the
individual veterans served in fiscal year 2004 were either OEF
or OIF veterans.
The Vista Vet Center provides intense and comprehensive
counseling opportunities for North San Diego County veterans
and their families. Our goal is to assist combat veterans and
veterans who have suffered military sexual trauma to achieve a
productive transition from military to civilian life.
Counseling services available through the Vet Center include
individual, couples, family and group centers. Specific,
focused group counseling activities include anger management,
stress management, trauma-focused group therapy, post-traumatic
stress disorder process groups, spouse and significant other
groups, and family education groups. The Vista Vet Center staff
also coordinates with Veterans Benefits Administration locally
to participate in weekly transitional assistant program
briefings at Camp Pendleton and Naval Station San Diego.
In August 2004, the Vista Vet Center became the first Vet
Center in the Pacific Western Region to hire a global war on
terrorism outreach counselor. This counselor immediately
implemented an aggressive outreach effort. To date, Vista Vet
Center has conducted outreach and provided information on Vet
Center services to every National Guard, Armory, and Reserve
Center in San Diego County.
The Vista Vet Center also conducts outreach activities to
nearly every veterans' service organization and college campus
in the county. These organizations, as well as military and the
veteran community, have enthusiastically embraced our efforts.
We have also developed an effective working relationship with
the Family Readiness Program of the California National Guard
and with various Army Reserve Units. Vet Center staff members
participate in family presentations and recreational activities
with family members of deployed National Guard troops.
Our outreach efforts, also extend to active duty military
activities in San Diego County. Of particular note is a recent
collaboration undertaken with Naval Medical Center, San Diego.
Naval Medical Center personnel have agreed to provide Vet
Center staff with office space one day a week to assist OEF/OIF
veterans in achieving seamless transition from military to VA
care. The Vista Vet Center also has an excellent collaborative
relationship with Naval Hospital Camp Pendleton and the Family
Service Center at Camp Pendleton. We are discussing similar
``office space'' arrangements with these military providers to
enhance further collaborative support for newly returning
veterans.
The intent of the Vista Vet Center's aggressive outreach
effort is to ensure that all veterans in San Diego County are
aware of the services they are entitled to receive at the Vet
Center. We will continue to strive to serve our veterans on
their terms. A cup of coffee is always available and veterans
are always welcome to stop by with or without an appointment. I
can state without reservation that the Vista Vet Center staff
is uniformly dedicated to helping all veterans who seek
assistance through our center.
Mr. Chairman, Senator Akaka, this concludes my statement. I
look forward to answering any questions you or other Members of
the Committee might have.
[The prepared statement of Mr. Costello follows:]
Prepared Statement of Joseph J. Costello, M.A., Team Leader,
Vista Vet Center, Department of Veterans Affairs
Mr. Chairman and Members of the Committee: I am privileged to
appear before you today to discuss the role of the Vista Vet Center in
providing care and services to veterans returning from Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Although this
statement will focus on the activities of the Vista Vet Center, our
efforts are typical of the 206 Vet Centers nationwide.
Under the leadership of Dr. Alfonso Batres, Chief of the
Readjustment Counseling Service, and Mr. Richard Talbott, the Pacific
Western Regional Manager, the Vista Vet Center, located in Vista,
California, endeavors to provide the highest quality readjustment
counseling and outreach services in an expeditious and cost-effective
manner to eligible veterans and their families, especially those who
are suffering from readjustment problems related to combat trauma or
military sexual trauma experienced while on active duty.
The services we provide for veterans include community outreach;
referral to Department of Veterans Affairs (VA) medical and benefits
providers; individual, group and family readjustment counseling;
military sexual trauma counseling; and onsite employment assistance and
vocational rehabilitation counseling via out-stationed ancillary staff.
Vista Vet Center staff provides ongoing outreach to newly returning
veterans of combat operations in Iraq and Afghanistan. Additionally,
for more than a year, Vista Vet Center counselors have provided
bereavement counseling to family members of military personnel killed
on active duty in Iraq or Afghanistan.
The Vista Vet Center is located approximately 10 miles from the
Camp Pendleton Marine Corps Base. We serve the communities of North San
Diego County and Southern Riverside County. The community-based
location of the Vista Vet Center provides maximum accessibility for our
veteran clients. The Vista Vet Center is co-located with a VA Community
Based Outpatient Clinic (CBOC). Many of our veteran clients also
receive VA medical care at this facility. We are fortunate to have a
close and cooperative relationship with our colleagues in the San Diego
VA Healthcare System, a relationship that we nurtured by providing
office space for medical staff before the CBOC was actually
established.
The Vista Vet Center maintains non-traditional hours in an effort
to ensure that veterans, whether employed or not, have access to
services at a time that is convenient for them. The center is staffed
from 7 am until 8:30 pm Monday through Thursday, and from 7 am until
4:30 pm on Friday. We also provide outreach assistance to newly
returning veterans and family members and participate in community
activities on weekends. If a military or veterans service organization
requests our presence at a function during non-traditional hours, it
can be assured of our enthusiastic participation.
The Vista Vet Center has a core staff of four persons: a Team
Leader, two Counselors, and an Office Manager. The staff has also been
augmented by the addition of one half-time Military Sexual Trauma
Counselor and one full-time Global War on Terrorism (GWOT) Outreach
Worker. All of the team members are veterans, and four hold various
mental health licensure and/or certifications, to include social work,
psychology, marriage and family therapy, and alcohol and drug abuse
counseling.
Ancillary staff members onsite weekly at the Vista Vet Center
include a full-time licensed psychiatric nurse clinical specialist
volunteer, a County of San Diego Veterans Services Representative who
provides benefits assistance to our veterans, a VA Vocational
Rehabilitation Counselor, a VA Homeless Outreach Counselor, and
Employment Assistance Counselors from the State of California. The
Vista Vet Center also participates in the VA Work Study program. This
program allows recently discharged veterans an opportunity to earn
money doing supportive work for veterans and the Vista Vet Center staff
while attending school. Two of our current work-study staff members are
also Operation Iraqi Freedom veterans. All of the members of the
ancillary staff are instrumental to the success of the Vet Center
mission.
The Vista Vet Center continues to provide readjustment counseling
and supportive social services to a large percentage of Vietnam
veterans. At the same time, we provide readjustment counseling services
to all combat veterans who request our services (who include an
increasing number of OEF/OIF veterans) and to victims of military
sexual trauma. Over the past year, we have also provided bereavement
counseling for three family members of two Marines and one soldier
killed in action in Iraq. During fiscal year 2004, the Vista Vet Center
served 635 individual veterans and had 6,849 visits from veterans and
family members. Nearly 50 percent (312) of the individual veterans
served in fiscal year 2004 were either OIF or OEF veterans.
The Vista Vet Center provides intense and comprehensive counseling
opportunities for North San Diego County veterans and their families.
Our goal is to assist combat veterans and veterans who have suffered
military sexual trauma to achieve a productive transition from military
to civilian life. Counseling services available through the Vet Center
include individual, couples, family, and group sessions. Specific,
focused group counseling activities include anger management, stress
management, trauma-focused group therapy, post-traumatic stress
disorder (PTSD) process groups, spouse and significant other groups,
and family education groups. The Vista Vet Center staff also
coordinates with Veterans Benefits Administration locally to
participate in weekly Transitional Assistance Program (TAP) briefings
at Camp Pendleton and Naval Station San Diego.
In August 2004, the Vista Vet Center became the first Vet Center in
the Pacific Western region to hire a GWOT outreach counselor. This
counselor immediately implemented an aggressive outreach effort. To
date, the Vista Vet Center has conducted outreach and provided
information on Vet Center services to every National Guard Armory and
Reserve Center in San Diego County.
The Vista Vet Center also conducts outreach activities to nearly
every veteran's service organization and college campus in the county.
These organizations, as well as the military and veteran community,
have enthusiastically embraced our efforts. We have also developed an
effective working relationship with the Family Readiness Program of the
California National Guard and with various Army Reserve units. Vet
Center staff members participate in family presentations and
recreational activities with family members of deployed National Guard
troops. Our outreach efforts also extend to active duty military
activities in San Diego County. Of particular note is a recent
collaboration undertaken with Naval Medical Center (NMC) San Diego. NMC
personnel have agreed to provide Vet Center staff with office space 1
day a week to assist OEF/OIF veterans in achieving seamless transition
from military to VA care. The Vista Vet Center also has an excellent
collaborative relationship with Naval Hospital Camp Pendleton and the
Family Service Center at Camp Pendleton. We are discussing similar
``office-space'' arrangements with these military providers to enhance
further our collaborative support for newly returning veterans.
The intent of the Vista Vet Center's aggressive outreach effort is
to ensure that all veterans in San Diego County are aware of the
services they are entitled to receive at the Vet Center. We will
continue to strive to serve our veterans on their terms. A cup of
coffee is always available and veterans are always welcome to stop by
with or without an appointment. I can state without reservation that
the Vista Vet Center staff is uniformly dedicated to helping all
veterans who seek assistance through our center.
Mr. Chairman, this concludes my statement. I look forward to
answering any questions that you or other Members of the Committee
might have.
Chairman Craig. Joe, thank you very much.
Let us turn now to David Hosking, a Counselor at a Vet
Center, Madison, Wisconsin.
STATEMENT OF DAVID J. HOSKING, GLOBAL WAR ON
TERRORISM OUTREACH READJUSTMENT COUNSELOR, MADISON WISCONSIN
VET CENTER
Mr. Hosking. Mr. Chairman and Members of the Committee, it
is an honor to come before you today to speak about my role as
a Global War on Terrorism Outreach Readjustment Counselor. With
the guidance of the Vet Center program's leadership, we have
created a much-needed link between the returning veteran and
the support systems that will help them readjust to their life
at home with their loved ones. My assigned duties perfectly
exemplify the Vet Center program's statement of purpose:
``We are the people in VA who welcome home war veterans
with honor by providing them quality readjustment counseling in
a caring manner. Vet Centers understand and appreciate
veterans' war experiences while assisting them and their family
members toward a successful postwar adjustment in or near their
community.''
Now, I would like to provide you some specific examples of
what I do as a GWOT counselor. Most weeks I start with a trip
to Fort McCoy, Wisconsin, where I am part of a demobilization
process for troops returning from overseas. Some weeks I may go
to McCoy two or three times. I always start my presentations
and briefings with, ``Good morning, veterans,'' or ``Good
afternoon, veterans.'' My heart fills with pride when I see the
look on their faces as they smile and they look at each other.
I ask them, ``Am I the first person to refer to you as
veterans?'' They say, ``Yes,'' and I tell them what an honor it
is for me to have that privilege. I go on to tell them that I
have sat in the chairs they are sitting in, that I am a Vietnam
veteran and an Iraqi Freedom veteran, and it is my privilege to
provide them with a PowerPoint presentation and a Vet Center
briefing to make them aware of what is available to them in
benefits and counseling if they should want or need our
service. Yes, I like to tell them my standard joke, which I
must say gets a laugh, and I always say laughter is the fuel
for morale.
In the last 8 weeks, I have provided outreach to 3,500
veterans returning from the war through Fort McCoy, Wisconsin.
The veteran population processing through Fort McCoy includes
veterans returning home to the States of Wisconsin, Minnesota,
Tennessee, Illinois, Alabama, Kentucky, Pennsylvania, Iowa,
Michigan, Ohio, and more. My outreach responsibility is my
first priority. When the troops are coming home through Fort
McCoy, I reschedule all my other appointments. Do I get tired
of doing that same thing over and over? Never. There are always
new faces from new places. They have new things to tell me that
make me glad that I was there on that day to meet them.
The military behavioral staff person at Fort McCoy told me,
after my first presentation, ``Wow, Dave, you sure bond easily
with these troops.''
I told her, ``Ma'am, I am a veteran. It is veteran-to-
veteran. It is like trucker-to-trucker or biker-to-biker. We
are on the same level from the word go. We know how each other
feels and what we have been through. We do not have to explain
it. We just know.''
At Fort McCoy, the soldiers do evaluations of our
briefings, and I get to see how they feel about them. Based on
these outcomes, I am happy to report that our outreach effort
is effective. Here are some examples of what they have to say:
``Do not change a thing.''
``The VA briefing was great.''
``The best I have ever had. He was funny, and it was nice
to have a briefing from someone who was over there.''
``Outstanding. He took the time to help us and give us a
welcome home.''
``He was too long.''
``It was too short.''
[Laughter.]
Mr. Hosking. So I guess that tells me it is not perfect,
and I will keep working on it.
On the first 2 weekends of the month, depending on their
drill schedule, I travel to National Guard and Reserve units
throughout the State. As of March 1st, I have visited 20 units.
Over 1,500 additional troops are to be visited at 14 other
units not counting the ones that are still deployed. It makes
no difference whether they are Navy, Air Force, Marines or
Army--a veteran is a veteran. We also have units who returned
before my outreach position was created. So I try and make sure
to get to every veteran and make them aware of the Vet Centers
and the VA benefits they may need.
On the other weekends we go to Family Readiness meetings.
The Family Readiness group is made up of families from the
National Guard and Reserve units whose service men and women
are deployed. The Family Readiness is under the National Guard
Bureau, though it consists of both Guard and Reserve families.
We have attended eight of the meetings so far. When I say ``we
go,'' I am referring to my wife and I. My wife is a Vet Center
volunteer. She has been asked by the Readiness groups to come
along so the wives of the deployed soldiers can ask her
questions. She can relate to what they are dealing with.
My role is to provide information about VA health care and
benefits, be with soldiers' families, tell them how important
they are and what a great job they do caring for the homes and
families of the deployed service men and women. I find that
family members write down and keep good notes on any
information you may give them and make sure that the
information is shared with their veterans.
In my outreach program, I also regularly speak to VFWs,
American Legions, County Veterans Service Officers, as well as
other civic groups. I like to network with these organizations,
which may have our new veterans as their members and can
contact us if one of them should need our help. We also know
that these groups and organizations include moms, and dads, and
other relatives or friends of returning veterans who can serve
as resources to give those veterans support and direction if
they should need our help. I like to post Vet Center
information in the community to promote the Vet Center's
services, to make more people aware of the support we have for
veterans.
As you can see, I have a very active and fulfilling job,
where working a weekend is not like working a weekend, where
talking to veterans is like meeting a new friend, and where
Family Readiness meetings are like a family reunion.
I would like to conclude by telling you that outside of my
family, this is the most gratifying thing that I have ever had
the pleasure of being part of.
I thank you, Mr. Chairman, and your Committee for allowing
me to talk about the greatest job a veteran like myself could
ever have. Thank you.
[The prepared statement of Mr. Hosking follows:]
Prepared Statement of David J. Hosking, Global War on Terrorism
Outreach Readjustment Counselor, Madison Wisconsin Vet Center,
Department of Veterans Affairs
Mr. Chairman and Members of the Committee: It is an honor to come
before you today to speak about my role as a Global War on Terrorism
(GWOT) Outreach Readjustment Counselor. With the guidance of the Vet
Center program's leadership, we have created a much needed link between
the returning veteran and the support systems that will help them
readjust to their life at home with their loved ones. My assigned
duties perfectly exemplify the Vet Center program's statement of
purpose:
We are the people in VA who welcome home war veterans with honor by
providing quality readjustment counseling in a caring manner. Vet
Centers understand and appreciate veterans' war experiences while
assisting them and their family members toward a successful post-war
adjustment in or near their community.
Now I would like to provide you with some specific examples of what
I do as a GWOT Outreach Counselor. Most weeks I start with a trip to
Fort McCoy Wisconsin., where I'm part of the de-mobilization process
for troops returning from overseas. Some weeks I may go to Fort McCoy
two or three times. I always start my presentation and briefing with
``Good morning, veterans'' or ``Good afternoon, veterans.'' My heart
fills with pride to see the look on their faces as they smile and look
at each other. I then ask them if I'm the first person to refer to them
as veterans. They answer ``Yes!'' and I tell them what an honor it is
for me to have that privilege. I go on to tell them that I have sat in
the chairs they are sitting in, that I am a Vietnam veteran and an
Iraqi Freedom veteran and it is my privilege to provide them with a
PowerPoint presentation and Vet Center briefing to make them aware of
what is available for them in benefits and counseling if they should
want or need services. Yes, I also like to tell them my standard joke,
which I must say gets a laugh, and I've always said ``laughter is the
fuel for morale.''
In the last 8 weeks, I have provided outreach to over 3,500
veterans returning home from the wars through Fort McCoy, Wisconsin.
The veteran population processing through Fort McCoy includes veterans
returning home to the States of Wisconsin, Minnesota, Tennessee,
Alabama, Kentucky, Pennsylvania, Iowa, Michigan, Ohio and more. My
outreach responsibilities are my first priority. When the troops are
coming home through Fort McCoy, I reschedule all my other commitments.
Do I get tired of doing the same thing over and over? Never! There are
always new faces from different places. They have new things to tell me
and make me glad that I was there on that day to meet them.
The military behavioral health staff person at Fort McCoy told me
after my first presentation ``Wow, Dave, you sure bond easily with
these troops.'' I told her ``I'm a veteran; it's veteran-to-veteran
like trucker-to-trucker or biker-to-biker. We're on the same level from
the word go. We know how each other feel and what we've been through.
We don't need to explain it, we just know.
At Fort McCoy, the soldiers do evaluations of our briefings and I
get to see how they feel about them. Based upon these outcomes, I am
happy to report that our outreach efforts are effective. Here are some
examples of what they have to say:
``Don't change a thing!''
``The VA briefing was great!''
``The best I've had yet; he was funny, and it was nice to have a
briefing from someone that was over there.''
``Outstanding, he took the time to help us and gives us a WELCOME
HOME!!!''
``He was too long!''
``It was too short.''
So, I guess that tells me it's not perfect, and we'll keeping
working on it.
On the first two weekends of the month, depending on their drill
schedule, I travel to National Guard and Reserve units throughout the
State. As of March 1, I have visited 20 units. Over 1,500 additional
troops are to be visited with another 14 units, not counting the ones
that are still deployed. It makes no difference whether they are from
the Navy, Air Force, Marines, or Army, a veteran is a veteran. We also
have units who returned before my outreach position was created; so I
try and make sure we get to every veteran and make them aware of Vet
Centers and of any VA benefits they may need.
On other weekends we go to family readiness meetings. The Family
Readiness Group is made up of families from National Guard and Reserve
units whose service men and women are deployed. The Family Readiness in
under National Guard Bureau, though they consist of both Guard and
Reserves families. We've attended eight meetings.
When I say ``we go,'' I'm referring to my wife and me. My wife is a
Vet Center volunteer. She has been asked by the readiness groups to
come along so the wives of the deployed soldiers can ask her questions.
She can relate to what their dealing with. My role is to provide
information about VA healthcare and benefits, be with soldiers'
families, and tell them how important they are and what a great job
they do caring for the homes and families of the deployed service man
or woman. I find that family members write down and keep good notes on
any information you have for them and they make sure the information is
shared with the veterans.
In my outreach program, I also regularly speak to VFW, American
Legion, and County Veterans Service Officers, as well other civic
groups. I like to network with these organizations, which may have our
new veterans as their members and can contact us if one should need our
help. We all know that these groups and organizations include Moms,
Dads, and other relatives or friends of returning veterans who can
serve as resources to give those veterans the support and direction if
they should need our help. I like to post Vet Center information in the
communities to promote the Vet Center services and make more people
aware of our support to the veteran. As you can see, I have a very
active and fulfilling job, where working a weekend is not like working
on a weekend, where talking to veterans is like meeting new friends,
and where family readiness meetings are like family reunions.
I would like to conclude by telling you that outside of my family,
this is the most gratifying thing that I have ever had the pleasure of
being a part of. I thank you, Mr. Chairman, and your Committee for
allowing me to talk to you about one of the greatest jobs a veteran
like myself could ever have.
Chairman Craig. Well, David, thank you very much. I thought
in that concluding moment you were going to tell us your
standard joke. Is it suitable for mixed company?
[Laughter.]
Mr. Hosking. I have three. I will give you the shortest
one.
Chairman Craig. Give us the shortest one. You have already
run over time.
Mr. Hosking. I will give you the shortest.
Some soldiers came in from Kentucky--I love this one
because I do not start off the same all the time. I go up front
very seriously, and I introduce myself and I say, ``Veterans, I
have a very serious topic, and I would like you to be
serious.'' Boy, they all sit up very stiff and everything. I
say, ``Did I tell you about the guy from Kentucky that went in
the bar, and he ordered four shots of booze? The bartender set
them out, and he drank them one after the other very quickly.
``And the bartender said, `Wow. You drank those awful
fast.'
He said, ``Yeah, you would, too, if you got what I got.''
The bartender said, ``What have you got?''
He said, ``Fifty cents.''
[Laughter.]
Mr. Hosking. The next morning I was talking to a group from
Minnesota, and my friends--I call them my friends now because
once I meet them, they are my friends--they came walking
through to go in to have their blood taken or whatever, and
this great big guy looks around the corner and said, ``Dave, I
have only got 50 cents.'' We all knew what it was about. It was
funny.
Chairman Craig. All right. Well, thank you very much. We
appreciate all of your testimony.
Let us start our questioning round. We will stick to a 5-
minute rule for all of us, and then we can return if necessary
for a second round.
Major Duckworth, your presence and your statement are
certainly inspiring to all of this panel or all of this
Committee, and your outlook toward the future is also
tremendously inspiring. I know you are in the Illinois National
Guard, and I also know that you are recovering right here at
Walter Reed Army Medical Center.
You heard my opening statement, and in that I made some
probative comments that I would like to continue to pursue with
you and potentially other witnesses this morning. If it were
possible, would you prefer to be treated at a facility closer
to your home? You might want to combine that statement or
comment back. Would it make any difference to you if that
facility was a VA facility? Of course, I trust you will be very
honest and frank with us as we seek to find out the kinds and
levels of service that are being provided. We think those are
very, very necessary. In other words, if you could receive
comparable rehabilitative services, and they were in a VA
facility closer to your home, would that be preferable or are
you satisfied, certainly, with that service and the situation
at Walter Reed?
Major Duckworth. Mr. Chairman, of course, being closer to
home----
Chairman Craig. Is your microphone on? Thank you.
Major Duckworth. Being closer to home is always going to be
better. However, I am concerned that it is very difficult to
reach the level of service and the level of care that is
available for me at Walter Reed. There are several components
in this.
One, I am with a group of patients that have similar
experiences, and just being together and going through the
rehabilitation together is an inspiration, it is comforting, it
is a way to force yourself to work a little bit harder because
the guy on the mat next to you is working just as hard. I
always say the third floor of Walter Reed, where the
occupational therapy and the physical therapy labs are, is the
most inspirational place I have ever been. Once I got myself
out of the hospital bed and down to that floor, I am down on
the third floor with other soldiers, there was no looking back.
My recovery only increased in speed from that point on.
I also wonder what the likelihood or what the effects would
be of being more isolated in my hometown, even though it is at
the local VA Center. I am not around the same larger population
of fellow soldiers of professionals who deal on a regular basis
with fellow soldiers.
One of the things that happened to me in Iraq was that I
became positive with the Acinobacteria, which approximately 90
percent of the soldiers coming back from Iraq are testing
positive for. If we were all to come home and then be farmed
out to civilian hospitals or VA Centers across the country, you
now have all of these soldiers with an infectious disease that
is peculiar to that theater, something that the expertise is
not there, I do not think, other than in some place like Walter
Reed that deals on a regular basis with this specific
population.
So, yes, sir, it would be nice to be home, but I would like
to get healthy quickly, get to the point where I can stay in
the Army and fly again, and to do that is to be at Walter Reed
at this point.
Chairman Craig. I mentioned in my opening statement that
oftentimes the process of review by the Physical Evaluation
Board can be a long one for our service men and women, and it
can sometimes be frustrating. How has that process worked for
those you have rehabilitated with at Walter Reed? In a general
sense, how do you feel that is working?
Major Duckworth. I feel it is working well, sir. The staff
at Walter Reed are very good at working with you, at setting
your goals. And if your goals are to leave the service and go
back to civilian life, then they help you to prepare your
packet for the Board and for the evaluation for whether or not
you should be retained. If, however, you would like to stay in
the military then, there are counselors and people that help
you prepare your case to stay in. In either case, the Board
seems to be responsive to what the soldiers are trying to do,
whether it is to get out or to come back in, and there is help
for us as we pursue those goals.
Chairman Craig. Thank you very much.
The Ranking Member is not back yet, so let me turn to
Senator Obama.
Senator Obama. Thank you very much, all of you, for your
testimony. I have just got a couple of quick questions.
Major Duckworth, with respect to the process of
recuperation for you, I know that you have the benefit of a
caring husband who is also in the services and so has some
sense, I think, of what is going on here. Are we giving
sufficient training to the spouses and families of our wounded
veterans in terms of helping them achieve a full recuperation,
and are there areas where we could be making improvements?
Major Duckworth. Yes, sir. I do benefit from having a
spouse who is also a military member, and he understands the
military bureaucracy and a lot of the finer points in
negotiating through that bureaucracy. I think that there is
room for improvement, in terms of helping the spousal member.
Oftentimes, the servicemember does everything in terms of the
paperwork and handles the military bureaucracy, but then when
you are unable to do that and everything falls on the spousal
member, it is difficult for them to do so.
We have actually talked with and tried to advise spouses of
other injured soldiers who are new to the process and give them
tips on what it is they should be looking at, especially if the
servicemember is very young. They are very inexperienced, and
they themselves do not know what some of the paperwork actually
implies for them.
An example that I can think of is there was a very young
servicemember--I think he is 19 years old--filling out
paperwork for the VA that asked him questions about chemical
agents he might have been exposed to in Iraq, whether he was
exposed to industrial pollutants, those types of things. The
servicemember was having his mother fill these things for him
because he could not write. His arms were injured. So she asked
him, ``Were you exposed to industrial chemicals?'' and his
response was, ``No,'' because he was not anywhere near any
factories. But I knew, as a helicopter pilot flying into
Baghdad every day, there is a cloud of dark smoke, pollution
hanging over that city and that there were factories just
outside of his perimeter that he never saw, but he was
certainly exposed to the pollutants coming out of there.
Senator Obama. Right.
Major Duckworth. And I advised him and said you need to say
yes to this because, yes, indeed, you were exposed to these
pollutants. And if you do not put that down, somewhere down the
road, if you develop respiratory issues, this may become a
problem for you in claiming your VA benefits because, on this
statement, you are saying, no, you were not exposed to
anything.
So there is that type of counseling, guidance that is
needed for the family members who may not be as savvy to the
military bureaucracy.
Senator Obama. Well, I think that is a terrific point. I
guess what I am wondering then is whether there some sort of
ombudsman or somebody who is walking our injured vets through
the process as they are filling out paperwork or the families
are filling out paperwork, as far as you can tell? As you said,
you and the Captain have the benefit of experience. You guys
look pretty young to me, but you are not 19, and so you
probably have a better grasp of this stuff. Did you get a
sense, and this is something I can direct to the next panel,
obviously, but I am interested, from the perspective of a user
of the facility, whether there is sufficient hand-holding,
walking people through the process so that they can focus on
recovery, as opposed to focusing on other things. My impression
is, then, we need to improve that a little bit.
Major Duckworth. There is definitely a presence. There was
a VA rep by my hospital bed speaking with my husband while I
was still just coming out, just regaining consciousness. So the
VA is definitely there and dropping off booklets of the VA's
services that are available.
I think there could be room for improvement in terms of, as
you said, the hand-holding process or perhaps coming up with an
actual road map. What happens now is you have VA
representatives come through and speak with you and offer help
and guidance and all of those things, but it might be easier if
there were more of a checklist approach, a more systematic
approach. It is wonderful. I see representatives from the VA
all the time, but sometimes when the servicemember is ill and
the spouses are trying to help, it is so overwhelming. There
are so many people coming through your hospital rooms that have
great intentions, and want to work with you, and help you and
do all of these things, and you get so many business cards that
sometimes there is almost a flood of help available, and it is
hard to sort through that help. Maybe some more of an
organization, allowing the VA to direct how they will provide
you with the support that you need.
Senator Obama. That is very helpful.
Thank you very much, Mr. Chairman.
Chairman Craig. Senator, thank you.
Let me turn back to our Ranking Member, Senator Akaka.
Danny?
Senator Akaka. Thank you very much, Mr. Chairman.
Messrs. Hosking and Costello, let me say at the outset
thank you so much for joining us today. We are looking forward
to your testimony. Your being here today I know takes you away
from what you so obviously love to do, and that is to help
veterans, and we look forward to your returning to that.
I am curious about each of your personal experiences with
your transitions from DOD to VA. Tell me how you found the
process. Were you given appropriate and helpful information by
VA and DOD?
Mr. Hosking. When I first came back, as I came through, I
was kind of in this want-to-get-home mode. I must say that it
was a great education for me, because now when I go back up
there, I learned from that, and it was like a long, drawn-out
process. I must say at Fort McCoy, they are constantly trying
to streamline the process. They understand the soldier wanting
to get home, but, they also understand the importance of
getting all of the data correct as far as their financial
benefits or whatever.
So I would just say, as I came back through compared to
now, I think the process is vastly improved, and I think the
people, where I came through, which was Fort McCoy, have done a
very good job of trying to show that feeling toward the soldier
and what he is going through in that process, not being cold to
them, but being very warm, but also making sure that they do
everything very accurately and on a timely manner. So I would
say, as they are coming through there right now, it is very
much improved.
Senator Akaka. Joseph Costello?
Mr. Costello. Yes, sir, Mr. Akaka. I came back through Fort
Bragg, North Carolina, and I had the benefit of being a VA
employee before I went overseas and being a VA employee upon my
return. Even with that experience and having had the experience
of providing presentations at the various TAP presentations at
military bases in San Diego, I was amused with myself because I
was not listening. I really just wanted to get home. That is,
generally, the case with most of the soldiers and other
servicemembers. You want to get home. So, yes, VA
representation was there, and I did not pay attention to a
thing. I was just thinking about my wife, and my kids, and
driving back to the West Coast.
So one of the issues that I try to press strongly with my
global war on terrorism outreach counselor is that repetition,
hitting these folks as soon as they come back, but then going
back, again, when they get back into a drill status and hitting
them, again, a few months later and a constant participation
because, yes, representation is there and, no, most people do
not listen to a thing. They just want to go home. So you can
catch bits and pieces, but I think as someone who is employed
by the Department of Veterans Affairs, it is important that we
continue the effort and do not just let it go with one contact.
Senator Akaka. Thank you.
Major Duckworth, I also want to add my aloha and welcome to
Captain Bryan Bowlsbey. I met him when I came in, but I want to
say aloha, again.
Now, I asked for your appearance here, Major, before our
Committee because I believe your experiences will be very
beneficial to us as we try to address how DOD and VA can best
serve you during the rest of your military career as a veteran.
I understand that other injured servicemembers at Walter Reed
are looking to you for guidance. Do you have a feel for how
returnees perceive the care at Walter Reed and their future
care at VA facilities?
Major Duckworth. Senator Akaka, I do. I think that, as Mr.
Costello was saying, repetition is necessary. The hospital
staff, as well as the VA staff and volunteers who also work for
the VA, come through and are always there to talk with the
soldiers, at this point, I do not know if some of the younger
servicemembers really understand all of the benefits that are
available to them and all of the resources that are available
to them. We get the little book with the VA services, and that
has been a great resource to have to go through and read
through that. But I still think that there is still some lack
of understanding, especially younger servicemembers or those
that are not as familiar with the military system, lack of
understanding of what benefits are available to them and what
they can access and when can they access those things.
It would be nice to have a counselor or a checklist or
something that you could go back to and use as a reference to
guide you through the process later on, because right now you
have personal contact, but then you have all of the information
that is available to you, but you do not have a road map, per
se, as to how you transition from one status to the next and
what services are available to you. It would almost be nice to
have a counselor assigned to you to sort of review your case as
you are still going through the rehabilitation process.
Senator Akaka. Have you had any contact with VA, direct
contact with VA personnel, during your recovery?
Major Duckworth. Oh, yes, sir, definitely. They were there
even just as I was coming out of anesthesia within the first
weeks.
Senator Akaka. Thank you.
Chairman Craig. Danny, thank you very much.
Now, let us turn to Senator Salazar.
Ken?
Senator Salazar. Thank you, Mr. Chairman.
Let me ask this question of Mr. Hosking. You, obviously,
visit with thousands of veterans returning from Iraq and from
Afghanistan, and you probably hear a lot of their stories about
what happens when they return back here to this country. So, if
you were king for the year, and somebody were to ask you what
is it that you would do, if anything, to improve the transition
from being an active member of the military to being a veteran,
what would you do to improve it? What recommendations would you
give to this panel?
Mr. Hosking. Well, I can really only speak on the outreach
part because that is what I do. But what I see in the outreach
part is this--they constantly look to upgrade, and we get that
appraisal from those soldiers I told you about, which really is
very, very helpful in the transitional period.
I find out that the soldiers coming through right now are
telling me that, wow, this is going rather quickly. When we
talk about their benefits, I list their benefits. I tell them
who to contact about their benefits, County Veterans Service
Office. ``Do me a favor, if I have helped you at all today, do
me the favor of taking your DD214, go down and meet your County
Veterans Service Officer, and get it registered. That is your
ticket to your benefits and not only Federal benefits, there
are State benefits.''
So that is where you start. I try to tell them where to
start and how to go through that process of talking to the
specialists who will deal with the benefit they need. As far as
outreach goes, all I would ask is just please let me keep doing
my job.
Senator Salazar. Let me ask a question with respect to
those who come back from the war more seriously injured. I
think some of my colleagues on the panel mentioned we are
talking about young lives with many, many years ahead of them.
I look at Major Duckworth, and I am inspired not only by her
history before her combat injuries in Iraq, but also with
respect to her future.
For those men and women who are coming back from Iraq or
from Afghanistan who have the kind of serious injuries that
will stay with them for an entire lifetime, can you comment on
what you think we might be doing to make sure that that
transition from the life that they used to know to the life
that they are going to be facing in the future, how that is
going and whether there are things we might be able to do to
improve that future for them.
Mr. Hosking. From the earlier question talking about where
they would get their care at, I think it would be nice if they
had a choice. I think there are some of us who like to stay
with our Guard, with our unit. I am a helicopter crew chief.
Going with my unit, I have that support from my friends within
my unit, which I never had when I came home from Vietnam. I
feel like I had that support.
I think maybe having a choice on where they have their
care--maybe there are some who would rather be closer to home,
where they feel that support from their wife and family, and
others who would rather do as the Major said, maybe stay right
here where that top-quality care is and be with other soldiers
who, naturally, we get support from our comrades. So maybe
choices like that would make it easier for them to make that
adjustment.
Senator Salazar. Just one more question. In terms of making
that initial choice about where they go I understand is
something that could be helpful for many families that come in,
the kinds of worries, though, that you hear anecdotally in
terms of long term, whether it will be 10, 20, 30, 40 years
from now, is that something that is commonplace, and do you
think that we as a national Government are doing enough to make
sure that veterans with serious injuries are going to be taken
care of in the way that they ought to be taken care of?
Mr. Hosking. It is a difficult question, sir, because a lot
of these young people are focusing on tomorrow, what is going
to happen tomorrow, but I do see concern as to whether I can
stay in the military. There are a lot of young people who love
that military, and they want to stay with that military, and
they want to stay with their comrades, if they can, maybe not
in their unit, but maybe a different unit. I think that is one
thing I do hear: ``Why can't I stay in the military, maybe in
another position?'' So that is maybe something we would like
you to look at.
Senator Salazar. Thank you, Mr. Hosking.
Chairman Craig. Ken, thank you very much.
We have been joined by Senator Patty Murphy, of Washington.
Patty, welcome. You did not make an opening statement. If you
want to extend your time a bit longer, with any additional
comments and, of course, questions of the panelists, please
proceed.
Senator Murray. Thank you very much, Mr. Chairman. I really
appreciate you having your hearing and having us get a chance
to talk with you about this really critical issue. Major, thank
you especially for your courage and willingness to be here
today to help us understand how we can do a better job.
Following up on the question that was just asked, I hear,
as you do, from our military who are coming out, that they feel
like they are being discharged too fast. They really do want to
remain part of the military. They want to be part of the
service, particularly those that I have talked to who are
amputees or who have serious brain injuries that they are
recovering from. In particular, I am hearing from them that
they believe that they are being discharged too soon simply to
save DOD money and to be sent to the Veterans for care. Is that
anything any of you have been hearing as well?
Mr. Costello. No, ma'am. I would not be able to speak for
DOD on those issues. I could speak for VA, but I have not been
hearing much of that, not from the veterans that come to our
center.
Chairman Craig. Mr. Hosking?
Mr. Hosking. As I said before, I have heard from a couple
of soldiers who would have liked to have kept their career
going maybe in a different field. I think if you have a soldier
who has knowledge, I would like to retain that knowledge as
long as I can, especially this could be someone in finance who
knows everything about finance, and do we want to let that
resource get away if he wants to be in there, if he wants to be
a good soldier? I would like to see us look at that closely.
Senator Murray. Major, have you felt any pressure to leave
the service?
Major Duckworth. No, ma'am. Actually, I have had the
absolute opposite experience. When people sat down with me to
talk to me about what I wanted to do and set my goals for my
recovery, I told them that I wanted to stay in the service, and
I wanted to fly helicopters for the Army once again. Nobody
laughed at me. Nobody looked at me like I was insane. They all
just said, ``Well, let us sit down and see what we need to do
to help you fight that fight.''
There have been a few other soldiers ahead of me who have
fought the fight to stay in and have been allowed to stay in. I
am learning from them and their blueprints for how they were
able to accomplish that goal. There is not really anybody who
can be my counselor and tell me, ``OK, if you want to stay in,
these are the steps you have to take.'' It is something that I
have to take my own initiative and go talk to the other
soldiers and then find out what that road map is.
I can see if somebody were unsure of themselves and not
quite sure whether or not they wanted to stay in that they
might end up out of the service by nature of not having mounted
an effort to stay in. That is really what you need to do is you
really have to mount an effort when you go before the Board,
and you will be rejected the first time, and then you will have
to be ready to appeal. It is only on appeal do you then win the
fight to stay in.
Senator Murray. So it takes tremendous effort to stay in.
Major Duckworth. Yes, ma'am.
Senator Murray. Major, you were at Walter Reed, correct?
Major Duckworth. I still am.
Senator Murray. You still are. I understand that everyone
is assigned an Army counselor to help them get through the
process, but some of the VSOs are telling us that they are
having trouble getting access to patients at Walter Reed. Has
that been your experience?
Major Duckworth. I have not had any problems with accessing
any help that I have needed, and I do not know of any other
soldiers who have said that they have had that experience. Most
of us actually have so many people talking to us that it can
become a little bit bewildering.
Senator Murray. They might not know who they are talking to
as well.
Major Duckworth. Right.
Senator Murray. Have either of you heard of VSOs having
difficulty accessing patients at Walter Reed to help them?
Mr. Hosking. No, I have not, not in my area.
Mr. Costello. Nor have I. I am in California, so I really
would not be able to answer that.
Senator Murray. One other question, and it is a difficult
one. Major, I will ask you, and I know it is a tough one. But I
am hearing from some of our soldiers who are coming back and
being discharged, particularly from Guard and Reserve, that
they have deep concerns about the issue of being asked about
sexual assault while they have been deployed, coming back and
not feeling comfortable answering questions regarding that,
being put into situations where they do not feel comfortable
answering those questions, being discharged.
The reason I am concerned about that is because if they are
discharged without having talked about it beforehand, and then
they get out in their community and there is either mental
problems associated with it, which is often, or physical
problems associated, which is often as well, because they were
not asked correctly, in a comfortable situation, that they may
not get the services they need, and we are not treating them
fairly.
I just wonder if you have heard any of that or have any
concerns about women, in particular, being discharged without
having the proper ability to be asked about sexual assault
while being deployed.
Major Duckworth. I have not had that experience, ma'am, and
I have not heard of that. If anything, at Walter Reed, the
counseling teams that come through are of varied mixture of
gender types, ethnic groups coming through, so that if I were
uncomfortable with talking, for example, with a male
psychologists, there were female psychologists and counselors
that also came through that I could have spoken with.
Senator Murray. I understand Walter Reed may be different,
unlike some of the discharges that occur out across the
country.
Have either one of you heard this concern expressed at all?
Mr. Costello. My personal opinion is it continues to be an
under-reported issue and an under treated issue. One of the
things that the Vet Center--and I am very proud of the Vet
Center for providing military sexual trauma counselors
specifically. That is their only role in our center is to
provide care for those who have been sexually traumatized. It
is a big issue because I think with this new theater of
operations we have many people who have combat trauma and
military sexual trauma, so it is quite an issue, and it is
challenging.
We have a female licensed psychologist who is also a Naval
Reserve officer, and it seems to be more comfortable for both
men and women--and men are, clearly, underreported, even more
so than women--but both genders feel more comfortable with a
female, I think, because the perpetrators are usually male. We
work very, very hard to address that issue. I will say it is
challenging. It is challenging, even in the most sensitive
manner, it is very challenging to ask that question and to also
receive an answer the first time. So we try to leave the door
open. When they are ready to talk, we are there for them.
Senator Murray. Mr. Hosking?
Mr. Hosking. I also speak about that when I do my
demobilization. I also point out the fact that we have female
and male counselors, whether it be for them or their children
or whatever. So we try to do our best to make them aware of
that and make them aware that we are in a community setting
where they can come in and talk to us. So I guess we work at
it, but you are right, it is a very sensitive area, and we need
to keep working at it.
Senator Murray. I appreciate that response. It is a
difficult one, Mr. Chairman, but I am concerned, particularly
for Guard and Reserve who just want to answer the questions and
get home, that if we do not provide the correct counseling, the
correct atmosphere, that we are causing some severe damage to
women and men who have served us, and we have to be very
sensitive to how we do this.
Thank you.
Chairman Craig. Well, I thank you for those questions, and
I think that was a most appropriate one to be asked. Thank you
very much.
Now, let me turn to Senator Rockefeller. Jay, welcome
before the Committee. You are a long-time senior Member of this
Committee. I have been on it a while, but you have been here a
while longer, and we appreciate always your presence and your
questions.
STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
U.S. SENATOR FROM WEST VIRGINIA
Senator Rockefeller. Thank you, Mr. Chairman, very much.
Last Saturday, I went to Keyser, West Virginia, which is
kind of a rural area, to welcome a Guard group returning home.
That region covers Pennsylvania, Maryland, and West Virginia.
It was the 101st Battalion. The whole crowd was about 400, but
there were about 45 veterans who were returning that day. The
whole town--it is not a big community--they all turned out.
There was an enormous amount of celebration, and then they were
introduced one-by-one, the returning soldiers as they came in.
It was very interesting to me. I looked at it in two ways.
One is that, although two of them had been wounded, they had
not been wounded severely. I was glad about that. The second
thing is that all of these strapping young folks that came back
who looked so healthy, there are two kinds of ways of measuring
health, and that is if you get an injury that is physical, and
the other is if you get an injury internal to you which nobody
sees. Patty made reference, obviously, to one of those.
I try to go back to the first Persian Gulf War and the
difficulty we had on this Committee trying to prove that the
DOD was literally withholding information on the Persian Gulf
War Syndrome, and Pyridostigmine bromide, and DEET, and all of
that kind of stuff. The doctor who was in charge of
stonewalling us then is still there now, and I do not know that
he stonewalled us on anything, but he sure did on that. I had
hundreds and hundreds in West Virginia, soldiers, men and women
whose lives just sort of collapsed, and the old pattern was to
tell them to take an aspirin and get a good rest.
Now, I would like to ask each of you, from a wounded
soldier's perspective and a counselor's perspective, what are
the kinds of effects upon those young men and women who came
in, in a line, all robust, young, glowing, families running
toward them, did we not see--injuries that were there, but we
did not see?
Major Duckworth. Senator Rockefeller, well, of course,
soldiers over the long term, especially those that were in
high-combat stress positions, on foot patrols, soldiers who
conducted daily convoys were exposed to tremendous amounts of
stress that may not appear or begin to affect them long term
until after they have left the service. I am not in the health
care profession, so I will leave the concerns on how that
develops to medical professionals.
I do know, though, that when I came home on R&R leave,
prior to being hit, the first 3 or 4 days I had a very
difficult time slipping back into my old life and being with my
husband. Just driving on the Interstate was very nerve-wracking
for me because as cars cut in and out in front of me, my
instinct was to just run them over because if that happened--
which, if you know Chicago traffic, it is like DC traffic, it
is probably a good instinct----
[Laughter.]
Major Duckworth. But in Iraq that means that somebody with
an IED or a car bomb is trying to get into your convoy, and
every bit of training that we received and how we drove over
there taught us to be very aggressive. So I think you might see
more aggression.
I was very skittish. I came from a world where the world
was shaded in different colors of sand, and tan and brown, and
I came here and everybody was in bright colors, and there were
men and women in different--and I was just very nervous for
quite a few days, and it was hard to settle back in.
For soldiers that face stress on a regular, daily basis, I
can see how that, long term, could be come an issue.
Senator Rockefeller. I am, obviously, thinking of matters
like post-traumatic stress disorder and a variety of other
things. I talked to several of the soldiers afterwards, and
they said that they were really having a hard time just getting
back into their family, which you have indicated, which is an
injury of sorts, or can be. Maybe the transition works and
maybe it does not. But I think I am right in saying that 50
percent--and tell me if I am wrong--that 50 percent of our
soldiers who are in Iraq for a period of 2 years that they will
go through or consider the process of divorce during the course
of those 2 years. That has to have an enormous effect.
So PTSD, stress, readjustment, and I am putting this in the
context of, I would say to you, that we have about 5,800
returning troops so far, with many more to come, in West
Virginia, and we have one outreach counselor. So that will be a
second question. But what would you see as the unseen
injuries--psychological, physical, whatever?
Mr. Costello. Well, probably the greatest unseen injury
would be referring to post-traumatic stress disorder. From a
psychological perspective, I think that every veteran--and I
may be wrong--but just as Major Duckworth said, when I
redeploy--because I am still in the Reserves--I am not taking
R&R, because you come back and you are all of those things--
skittish, uncomfortable, it is not OK to not have your weapon,
and you lose a bit of an edge when you return.
When people finally return from theater, that can last for
quite a bit of time. Discomfort with not having your weapon is
what I hear most commonly, not feeling that they fit in, and
things are different, and it is difficult to sleep, and all of
those things, difficult to readjust to the family. People
change in a year, and situations change in a year, and even
under the best of circumstances, if you were going on a year
with some private company and you returned, there would be
readjustment issues.
So my belief is that everybody has readjustment issues.
Some of those are more pervasive and chronic, and that is what
the Vet Centers are there for, is to provide that long-term
care. We do not have a time limit. We have been doing this
since 1979 and continue to see those Vietnam veterans who need
readjustment counseling and treatment for more chronic issues,
such as post-traumatic stress disorder or other diagnosed
mental illnesses. But that is what we are there for. We are
there for the duration.
But, yes, you are right. Those issues will continue, and we
hope to be there to continue to address them.
Senator Rockefeller. Mr. Chairman, I have another question,
but I will defer.
Thank you very much.
Chairman Craig. Senator Rockefeller, thank you very much.
Now, let me turn to Senator Thune.
John, any questions?
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Thank you, Mr. Chairman.
I also want to thank our panel and thank the Major for your
service to your country. That is powerful, powerful testimony
to the courage of our young men and women. Thank you for being
here, and thank you, gentlemen, for the work that you do to
support our veterans across this country.
A couple of questions. If I might, Mr. Chairman, I would
like to submit for the record a statement or a letter from a
lady in my home State of South Dakota, who, incidentally, I
just met with in the hallway, whose father recently died of
Agent Orange. I think it pertains, in some measure, to what we
are talking about here today--people who come back and the
service that they get from the VA and some of the issues that
they deal with subsequent to that service. I would like to
include that in the record.
Chairman Craig. Without objection, that will be a part of
the record.
[The letter referred to follows:]
March 14, 2005
Hon. Senator John Thune,
United States Senate,
Washington, DC 20515
Dear Senator Thune: General William T. Sherman said, ``War is
hell.'' This takes on an additional meaning for my family and I'm sure,
for thousands of other families across the country. My father was
diagnosed with multiple mylomia in September 1995. He and our entire
family went through the steps of being diagnosed with a terminal cancer
and later, with the realization that this cancer was a direct result of
Agent Orange and his military service in Viet Nam.
Several years after diagnosis, my parents bought a fifth wheel
camper and headed to California to visit my brothers. My father's
health took a turn for the worse while there, and I arranged for an
emergency flight home. When my father left South Dakota, he was driving
a forty-foot fifth wheel and when I picked him up at the airport, he
was in a wheel chair.
In a matter of weeks, my father's condition worsened and we had to
put my father in a nursing home, as the Veterans Administration
Hospital had no facilities for patients suffering from dementia. In a
very short time, I watched my father go from a 200 pound independent
man to a 90 pound can't-sit-up, roll-over, do-anything-for-himself man.
I watched him be physically and mentally abused in the nursing home. I
watched him fall, writhing in pain and I watched my father die with no
dignity.
My father ate, drank, and breathed the Navy. He always gave 200
percent to the military and served for 20 years. Several months before
my father passed away, I had asked Governor Rounds to check into his
service record and see if he were eligible for benefits because his
medical condition was related to Agent Orange. The Veterans
Administration (VA) then informed us that my father was indeed eligible
and was awarded $2,300 per month. Unfortunately, within days of this
ruling, my father died and this money was never awarded to his
``survivor,'' my mother.
On September 1, 2003, my father died and I stood over him, crying
and looking at his narrow, sunken face. As I slowly pulled the sheet up
over his body, I thought to myself that his sharp, protruding bones
could still be seen through the sheet. I watched a movie clip play
through my mind, remembering playing hide and seek with my father,
tagging along with him to Moffet Field Air Base, opening presents on
Christmas day, teaching me how to drive stick shift, and holding me
when something or someone made me cry. I remembered how he and my son
were inseparable. I grieved thinking how my father would never see me
graduate from college or his grandson graduate from high school. He
would never see his grandson get married or see any great-
grandchildren.
My father's mother had to bury her son. I have been deprived of my
father. My son has been deprived of his grandfather and my mother
deprived of her friend and husband. Most of all, my father has been
deprived of his life.
Since my father's death, I have been contacting my congress people
to reinstate my mother's claim to the money promised my father through
his Agent Orange-related illness. Although the Veteran's Administration
provides my mother with a small pension, she does not receive the
survivor's benefits as the full amount of what was promised my father
before his death. The response from Congress to this request is that
because my mother did not ``live the war,'' she is not entitled to this
monthly benefit.
Yes, it is true that my father ``lived the war''; he served in the
Korean War and in Viet Nam. But so did my mother--she ``lived the war''
when Internet and satellite communications were nonexistent. She
``lived the war'' by moving to whichever base the United States Navy
asked her to move to. She ``lived the war'' when my brother was born in
Africa, another brother in Tennessee and I was born in Florida. My
mother ``lived the war'' as she watched the ill effects of Agent Orange
take the life of her husband. What part of this can you say, my mother
did not live?
Just as the military has support units back at the bases to help
the soldier accomplish the mission, so too was my mother a support unit
to my father and the Navy, helping ensure that all was taken care of at
home, including all financial business, moving the family to different
bases without the help of her husband, and with little or no support
from the Navy. Is her contribution any less than that of the military's
support units?
Besides the mental anguish, the pain and suffering, which our
family has suffered, there has been a monetary impact as well. My
mother has had to sell the truck, the van and other personal
possessions to help meet monthly bills. After two strokes, the doctors
have told her she needs to alleviate as much stress from her life as
she can. But how can she do that when the monthly cost of living bills
are far greater than her pension each month?
At the very least, the Veterans Administration should pay my mother
the back pay due the family for the time of illness my father endured.
This would be from September of 1995 to the time of his death in
September 2003. This alone would make a real difference in the quality
of my mother's life. It wasn't until my father's dementia and he began
to relive his Viet Nam days that we realized Agent Orange was the cause
of his illness. A dedicated Navy man to the end, he had honored his vow
of secrecy given to the Navy about his involvement in the war.
Our country is generous in its gifts to others throughout the world
who are suffering. But, what about our own soldiers and their
families--those who are willing to lay down their lives for the
freedoms we enjoy? The United States asks people to join the military
and fight for our country, but when they are wounded, or killed, then
what? What about the families of those who serve? Veterans and their
families are often pushed aside and forgotten. When my father died, we
received a letter with a stamped signature from President Bush. We
received word that my mother would receive a small pension, but was not
entitled to the $2,300 survivor's benefits. And we continue to hear
throughout each and every legislative session how money is being cut
from veteran programs and how families of veterans are often unable to
meet the costs of living.
I remember so well how my father looked up at me while he was
suffering in the nursing home and with tears in his eyes, he said,
``The military promised me they would always take care of me medically
and financially for the rest of my life if I re-enlisted.'' These words
came back to haunt me this week as I was talking with an Army vet. He
told me that for re-enlistment, he too, had been told that the Army
would take care of him for the rest of his life. These promises were
made to soldiers willing to serve their country in times of need and
they require a commitment from the American people to honor these
promises.
I ask you to support legislation that would add dignity to the
lives of survivors of soldiers who faithfully served our nation. We can
do this by providing financial compensation to the widows of military
personnel in a manner commensurate with their great sacrifice. This
comes with the full recognition that no monetary gift can ever replace
a person's life, yet financial compensation can provide a token of
respect and honor for our veterans and their families.
Sincerely,
Paula Hatzenbuhler
Senator Thune. Thank you, Mr. Chairman.
I guess I am interested, in particular, and we have a lot
of National Guard people in South Dakota who have been
deployed--in fact, 74 percent of the members of the South
Dakota National Guard have been deployed to Iraq or Afghanistan
or are involved in some aspect of those operations, and I also
have a number of active duty personnel in South Dakota as
well--and we want to make sure that as they return that they
are able to transition, and those who have been injured in
either of those theaters, that we are doing everything we can
to address the health care needs that they have, both in the
military setting and then also later in the VA.
Just one question with respect to that, and it kind of goes
back to the question that Senator Rockefeller was asking,
because I think, in many cases, there are these issues that
crop up that may be theater-specific, that may be related to
particular aspects of these conflicts, that when they come
back, are there things that we could be doing to better
anticipate those types of things, illnesses that might be
created as a result of things that they are exposed to areas. I
am thinking, of course, in the Vietnam era to the conversation
I just had with my constituent about Agent Orange.
But are there things that our VA facilities could be doing
better here to anticipate some of the issues that we are going
to be dealing with as a result of people coming back? That is
sort of a follow-up I think to the question Senator Rockefeller
was asking. I direct that I guess to you, Major, first, and
then perhaps maybe the other panelists.
Major Duckworth. Not having to access the VA services thus
far, I am just doing the rehabilitative process at Walter Reed,
I cannot say what the experience would be through my local VA
center. I do think it is important to make the distinction. I
have come up with a good definition of what health is. Being
healthy is not the absence of disease. I am healthy. I was very
healthy before I was injured, and I did not contract an illness
or catch any disease. I lost my limbs, and now as I am
recovering, I am becoming healthy again, but I will still need
the VA to help me access my environment and especially with the
youth of the injured soldiers today, a quality of life, a
healthy life will mean sports and those types of things and the
adaptive equipment they will need for that.
Just because somebody does not have a particular disease
does not mean that they are healthy. They can develop PTSD or
those types of things later on. We need to understand that
there are other needs beyond the immediate sickness that you
may undergo.
Senator Thune. It kind of ties into the question that you
were referring to with PTSD, Mr. Chairman, but I guess I am
just, as sort of a preemptive measure, thinking ahead of things
that we need to be doing to be prepared for folks as they are
coming back in. I realize you are not accessing the VA yet.
We have, in my State, benefited--I am a rural State, a lot
of geography--from the community-based outpatient clinics has
given some of our veterans access to facilities, but just in
terms of the treatments, and the therapies and all of the
things that are going to be necessary when people return home,
and because of some of the unique things that I think they are
exposed to in each of these different operations, that was I
guess my line of thinking with respect to that question.
I have got one other quick question if I might ask, and
that has to do with is health care, and benefits, and those
types of things. Is it a deterrent to young people today, when
it comes to signing up, either recruiting for the first time or
getting them to re-up and stay in? Do you hear that when you
talk with people who come back and are considering or
contemplating whether or not they want to stay in the National
Guard, for example? Are there things that, as a political body
here, we ought to be doing differently to continue to provide
the incentives for people to stay in the services? A very open-
ended question.
Mr. Costello. Yes, it is, but I appreciate the question,
Senator. I will speak as a soldier in that regard.
As a soldier, certainly I would love to see medical
benefits increased via DOD. I think that would be great. As a
Reservist, any greater access would be a wonderful thing. It is
not the thing that keeps us in. In fact, I have never heard
anybody talking about, you know, I would reenlist if they gave
me more medical benefits. Bonuses are nice, but it is not what
keeps people in.
You get something in military service that you just cannot
get elsewhere, and you are either committed or you are not and
particularly as a Reservist. Reservists stay in because of the
brother- and sisterhood, and commitment to mission and the
team. That is why we stay in. But, sure, that would be nice.
[Laughter.]
Mr. Hosking. I guess, on behalf of my brothers and sisters
in the National Guard, I concur totally. But Joe is exactly
right. I took what is called a Try-1 that turned into Try-28. I
always said the National Guard is kind of a trap. I never
missed the National Guard until the day after I retired. It is
a very close group of people, and that is why they stay because
it is hard to walk away. When you have got friends by the name
of Zeke, and Bear, and Treehugger and things like that, you
just do not walk away from them.
But as far as taking care of them and doing more for them
in the Guard and Reserve, yes, by all means.
Senator Thune. Thank you, Mr. Chairman. It is a discussion
that I hear a lot about when it comes to our efforts to recruit
and retain people who are serving and making sure. And we had
the discussion about Tricare access for National Guard members
and that sort of thing, and it is something that we are
debating again here in the context of the DOD authorization
bill this year. So I appreciate your comments.
Thank you for your testimony.
Chairman Craig. I wish we could assume another round. I am
going to ask our colleagues to be tolerant so we can get to our
second panel, but there may be some questions we would submit
to you all in writing. You have been an extremely valuable
panel to us as we build what I think is an increasingly
important record.
Certainly, Major, to you, you are an example of a great
generation of young Americans who are currently serving. You
are also an example of a generation of veterans coming that we
recognize, we recognize we must serve, and will serve and be
prepared to serve, and I think you have made extremely valuable
points this morning. One of them, obviously, is your youth and
the youth of those young men and women who are serving who are
coming home not physically whole and yet are anticipating a
full life. So it is certainly our commitment to assure that
that happens. It is part of the reason we are holding these
kinds of hearings and will continue to pursue it, attempting to
get it as right as we possibly can.
Gentlemen, your service is, obviously, extremely valuable.
That transition, we are developing a phrase here that has been
used, but I am not sure is yet perfected, and that is called
``seamlessness.'' So we are going to study that a long while to
make sure that it is a seamless transition from military to
civilian life, and the roles you are playing in it are
extremely valuable.
Thank you all very much. We appreciate it.
Now, we would ask our second panel to come forward, please.
To our second panel, welcome. We thank you for your
patience, but I trust, I watched, you were all listening very
intently, and I appreciate that. I think we all have a lot to
learn in all of these experiences, and so we appreciate you
being here.
Let me, first, turn to Major General Kenneth Farmer,
Commanding General, Walter Reed Army Medical Center and North
Atlantic Regional Command.
General, thank you very much for being with us today. You
are a very important person to a lot of active military and
soon-to-be veterans.
Please proceed.
STATEMENT OF MAJOR GENERAL KENNETH L. FARMER, JR., M.D.,
COMMANDING GENERAL, NORTH ATLANTIC REGIONAL MEDICAL COMMAND AND
WALTER REED ARMY MEDICAL CENTER
General Farmer. Thank you, Mr. Chairman and distinguished
Members of the Committee, for this opportunity to come before
you today to discuss the care of our wounded servicemembers and
especially those from Operations Iraqi Freedom and Enduring
Freedom and our efforts to facilitate the transition between
military and Veterans Affairs health facilities and between
military and Veterans Status. Our efforts have been
extraordinary in this area.
The VA-DOD partnership has made generational advances over
the past efforts to synchronize military health care treatment
and transitions between DOD and VA and has sought to ensure
that the process of moving patients from one health care system
to the other is as seamless as possible. As part of the VA's
seamless transition program, the Veterans Health Administration
has assigned several full-time employees to DOD casualty
treatment facilities, including two social workers at Walter
Reed Army Medical Center, to serve as liaisons between our
hospital and VA facilities.
Each VA facility has also selected a specific point of
contact who works closely with these liaisons to assure a
seamless transition to the most appropriate plan and place for
care. They work closely with the treatment teams at Walter Reed
to provide ongoing consultation regarding complex discharge
planning issues as well as to identify and access health care
benefits and resources.
Once our discharge planning staff refers a servicemember
for VA care, the liaisons meet with a servicemember and family
to orient them to the VA system, to provide an overview of the
veteran's health care benefits, to address current medical
issues identified as part of the servicemember's treatment
plan, and in collaboration with our Walter Reed staff, they
also coordinate referral information, enrollment, identify
treatment needs and transfer of medical records with a
receiving VA facility to assure that the health care delivery
remains uninterrupted during a transition.
The success of this collaborative effort is evident in the
case of Specialist Lance Geiselman, a soldier from Fort Hood,
Texas, who sustained severe injuries when his M1A2 tank
detonated an improved explosive device or IED. Specialist
Geiselman's injuries consisted of a left above-the-knee
amputation and a lower spine fracture, and that spine fracture
left him with significant neurologic deficits in both legs.
Because of the cooperation between VA and the DOD, two
synchronized treatment teams were able to efficiently and
effectively coordinate the transfer of Specialist Geiselman
from Walter Reed to the Memphis VA Hospital to begin his
neurological rehabilitation for his spinal injury.
After several months in the Memphis VA, Specialist
Geiselman was able to walk, with some assistance, and he then
was transferred back to Walter Reed to complete his prosthetic
fitting for his amputation, with aggressive rehabilitation at
our amputee center. With his family and our staff cheering him
on, he was able then to walk with minimal assistance. I think
this shared responsibility for care was a textbook case of
excellent teamwork with an optimal outcome.
But this type of collaboration with the VA is not a new
phenomenon for Walter Reed. In fact, the Defense and Veterans
Brain Injury Center, which integrates clinical care, clinical
follow-up with applied research, treatment and training, stands
as another shining example of the benefit of our partnership.
This program was created after the first Gulf War to
address the need for a systematic program for the provision of
care and rehabilitation within DOD and VA facilities specific
to brain injuries. The Brain Injury Center is headquartered at
Walter Reed, but operates through the cooperation of seven
military and VA hospitals across the United States. These sites
work collaboratively to provide evaluations and expert case
management to help active duty military veterans and other
eligible beneficiaries with traumatic brain injury to return to
work, duty and their community.
Our goal is to ensure individualized evidence-based
treatment for each patient as well as to provide educational
programs for patients, their families and the community. In
fact, the Director of the Defense Veterans Brain Injury Center,
Dr. Deborah Warden, is participating in the Congressional Brain
Injury Task Force Brain Injury Awareness Month lecture series
today here on Capitol Hill.
The center is uniquely situated for seamless transition due
to its 12-year history of DOD-VA collaboration. An example of
this collaborative work is with Warrant Officer John Simms, who
was injured in a Blackhawk helicopter crash in Iraq 15 months
ago. Initially, not expected to live, he was treated on the
USNS Comfort and was transferred to Walter Reed for intensive
care. He was then sent to the Richmond VA Hospital, one of four
VA centers for treatment of traumatic brain injuries and
difficulty of speech. From Richmond, Simms was sent to Virginia
Neuro Care, the Brain Injury Center's civilian partner, for
community reentry. He is no longer piloting an aircraft, but he
is able to fully care for himself and live independently in the
community.
In the attempt to interview early and reduce the emotional
stress associated with a transition between DOD and veteran
status, the Veterans Benefit Administration has also assigned
benefits counselors to Walter Reed full time to provide
comprehensive education and assistance to these seriously
injured combat veterans.
We also provide full-time vocational rehabilitation and
employment counseling services onsite. They make initial
assessments of the servicemember's abilities, interests, and
aptitudes and forward them to a counselor in the home State or
area. The counselors use this information to help the
servicemember prepare resumes and arrange interviews for those
planning to go into the workforce and enable some
servicemembers to volunteer in various VA jobs while awaiting
discharge.
In closing, I have only mentioned a few of the things that
we are doing together on behalf of our injured, wounded and ill
servicemembers and their families. I want to again thank the
members of this great institution for providing us with the
funding and resources to execute our mission, which is to take
care of some of the finest men and women of this Nation who
have committed their lives to our well-being and defense.
Finally, I would like to point out that the Army Medical
Department at Walter Reed and elsewhere is providing world-
class health care to our injured and ill members of all
services and will continue to do so. We have established a
strong partnership with the Department of Veterans Affairs,
facilitated by an unwavering spirit of cooperation in our
efforts to provide a holistic approach to taking care of the
needs of our servicemembers and families.
I look forward to your questions and, Mr. Chairman, I would
especially be happy at that time or now, if you prefer, to
respond to your question about the ways that we are getting
casualties close to their home for care.
[The prepared statement of General Farmer follows:]
Prepared Statement of Major General Kenneth L. Farmer., Jr., M.D.,
Commanding General, North Atlantic Regional Medical Command and Walter
Reed Army Medical Center
Mr. Chairman and distinguished Members of the Committee, thank you
for the opportunity to come before you today to discuss the care of
wounded servicemembers injured in Operations Enduring (OEF) and Iraqi
Freedom (OIF) and our efforts to facilitate the transition between the
Military and Veterans Affairs (VA) Health Care Facilities and between
military and veteran status. The efforts of my regional medical
facilities and the VA have been extraordinary in this arena.
Let me begin by addressing the VA and Department of Defense (DOD)
partnership that assists military servicemembers who have served in the
Global War on Terrorism (GWOT) in obtaining health care and other
services from the VA. The VA/DOD partnership has made generational
advances over past efforts to synchronize health care treatment and
transitions between DOD Medical Treatment Facilities (MTFs) and the VA
health care facilities. This partnership has sought to ensure the
process of moving patients from one health care system to the other is
as seamless as possible. Prime examples of this are the exchanges of
experienced clinical and administrative staff members to serve as
liaisons between the MTFs and VA facilities. The VA has provided
dedicated social workers and nurse case managers that serve as the VA
representative that can assist with the multi-disciplinary coordination
required to ensure the most effective treatment regimen for patients is
harmonized prior to Servicemembers being transferred from the MTF to
the VA. Furthermore, these case managers collaborate with TRICARE in
order to synchronize medical issues between the patient, their family
members and the TRICARE benefit counselor. The results of these moves
have been notable improvements in obtaining TRICARE authorized benefits
for both the Servicemember and their family. In addition, the WRAMC
staff is coordinating with VA on the separation of traumatically
injured Servicemembers, to ensure VA disability benefits can be awarded
days after separation. The VA has stationed several VA/DOD liaisons at
the major DOD health care facilities, along with the creation of the VA
Office of Seamless Transition (which provides policy guidance on
improving the clinical and administrative processes between our two
agencies). In collaboration with these initiatives, the Army Medical
Department (AMEDD) has assigned dedicated social work and nurse case
managers to coordinate patient transfers between the MTF and the VA.
Furthermore, the AMEDD is assigning active duty liaisons to support all
four of the VA's Poly Trauma Centers on a trial basis. The goal of this
initiative is to maintain the lines of communication between the
agencies to ensure priority placement and access to VA health care
services. These moves provide for clear, comprehensive and early
intervention and overview of VA health care services and benefits for
Servicemembers and their families. Because of this relationship between
our two organizations and by virtue of early assistance intervention,
the transition from the MTF to the VA has been much improved.
Since last summer, NARMC has transitioned over 54 Servicemembers
from our MTFs to the VA. This process replicates itself throughout the
AMEDD and the VA. But I also want to expand on the benefits of this
partnership to include more than just the seamless transition of
Servicemembers from one health care system to another. Our reengineered
relationship is energized at the grass root level between the major
MTFs and the VA health care centers. These programs allow VA benefit
counselors to access Servicemembers and their families before they are
transferred to the VA. The VA has stationed seasoned rehab, benefits
and vocational counselors at Walter Reed Army Medical Center (WRAMC)
and other major MTFs within DOD to assist Servicemembers and their
families. These counselors provide crucial information and education
related to the network of VA benefit program available to
Servicemembers and their families. They work with the MTF, VA case
managers and the other various DOD/MTF patient initiatives to arrange
for the full breadth of patient care and family assistance. This care
and benefits coordination has proven to be instrumental to the success
of the Defense and Veterans Brain Injury Center as servicemembers
transition between Walter Reed Army Medical Center and the four Poly
Trauma Centers located in Richmond, VA, Tampa Bay, FL, Minneapolis, MN
and Palo Alto, CA. But the partnership is more than this; it also
focuses on the needs of the Servicemember and their families beyond the
boundaries of immediate, direct health care. It takes on a more
holistic approach by expanding the scope of assistance to
Servicemembers and their families once integrated into those
communities. The VA intercedes at the earliest point possible to
discuss the many benefits they can offer. One snapshot of these
initiatives is the pastoral care services of the Tampa VA under
Chaplain David Lefavor, a Chaplain in the Traumatic Brain Injury
Center. He works very closely with WRAMC's social work service center
by coming to WRAMC and visiting Servicemembers and their families prior
to their transition to the Tampa VA.
Let me take a few minutes to relate some of the many other
initiatives and programs that the MTF, in conjunction with DOD and
other players, have brought into existence to assist and serve our
Servicemembers and their families. WRAMC recognized at the outset of
the war that it was not fully equipped to handle the many needs of the
family members of Servicemembers injured or wounded in Afghanistan and
Iraq. Thus the Medical Family Assistance Center (MEDFAC) was created to
address the needs of family members and Servicemembers. The MEDFAC's
primary objective is to provide for comprehensive support to those
family members and next-of-kin who would travel from across the country
to be with their loved ones injured in support of operations in Iraq.
The MEDFAC was activated on 4 April 2003 and since its inception, the
MEDFAC has provided services to over 4,000 patients and their family
members/next-of-kin. The MEDFAC operates on a 24 hour basis and a
representative from this cell meets every Servicemember evacuated to
WRAMC upon their arrival. They assist Servicemembers and family with a
barrage of issues or concerns ranging from family and Servicemember
travel, reception of both family members and Servicemembers,
arrangements for lodging, and financial assistance for those in need.
Between April 2003 and March 2005, the MEDFAC arranged over 1,200
invitational travel orders (ITOs) for family members of sick, wounded
or injured Servicemembers. They coordinated and arranged for an
assortment of referral services for Servicemembers and their families
(such as grief/mental health support, legal consultation, crisis
counseling, etc). They have established a network of lodging facilities
that include the WRAMC Mologne House, the Fisher House and various
hotels in the local community that have accounted for over 20,000 room
nights for OIF/OEF patients and family members. In support of this, the
MEDFAC has arranged for over $400,000 in grants for lodging and food
assistance. They have arranged for the disbursement of over 400 airline
tickets for family members at no cost to the family member. The MEDFAC
serves as the focal point for family assistance with the myriad of
organizations that are friends and supporters of the military community
(American Red Cross, United Services Organizations (USO), Fisher House
Foundation, Fallen Patriot Fund, Soldiers' Angel Foundation, Walter
Reed Society, VA, Disabled Soldiers Support System just to name a few).
The MEDFAC can and will continue to broaden its role into peacetime
family support operations with the goal of maintaining a ready,
responsive organization with available resources for immediate response
and activation in crisis situations.
I want to personally thank the Members of Congress for working to
amend statutes that restricted our ability to provide appropriate, time
sensitive support to our GWOT Servicemembers and their families. The
authority granted by this body for injured or wounded GWOT
Servicemembers to receive up to $250 for the procurement of civilian
attire has had positive effects on soldiers and their families. In
addition to seeking statutory changes from Congress, the military is
also revising its own regulation to make certain that we have the tools
and procedures in place to expeditiously address and assist military
personnel and their families during time of uncertainty and bereavement
at the injury or loss of a loved one. In late 2003, WRAMC's Staff Judge
Advocate established an Expedited Personnel Claims Program (under the
Military and Civilian Personnel Claims Act). Soldiers returning from
Operation Iraqi Freedom/Operation Enduring Freedom who are combat
causalities, or who have otherwise suffered from an in-theater injury
or illness, sometimes have had personal property destroyed, or are
forced to leave their personal property behind in the care of their
units. The expedited personnel claims program simplifies the process by
minimizing documentation which allows the majority of claims to be
settled in one working day. Reimbursement is speeded by treating the
claims as ``emergencies'' and arranging for electronic funds transfer.
Well over 600 claims have been filed, settled and paid under these
procedures, with disbursements in the past 15 months in excess of $1M.
In order to facilitate the medical and non-medical needs of our
Servicemembers and family members, WRAMC has teamed up with a
combination of Federal and State agencies, private sector employers,
service-providers, veteran service organizations and DOD support staffs
to address four core objectives; (1) identify challenges and solutions
to transitioning servicemembers and their families; (2) identify
special services that organizations and agencies will provide; (3)
identify ways to effectively implement services; (4) insure integration
and collaboration. As a result, DOD liaison offices are being
established at WRAMC to coordinate the delivery of services to our
Servicemembers and their families. Two of the primary HQDA/DOD agencies
that have or will have liaison offices at WRAMC are the Disabled
Soldier Support System (DS3) and the Military Severely Injured Joint
Support Operations Center. The Army's DS3 program is on the cutting
edge of providing assistance to soldiers and their families. In April
of 2004, the Army introduced DS3, providing severely disabled soldiers
and their families with an advocate to support America's sons and
daughters as they transition from military service back into their
civilian communities.
DS3 provides soldiers and their families with a personal DS3
advocate, called a soldier/family management specialist. This
specialist ensures soldiers understand the numerous support programs
available to them and provides the soldier with assistance in
completing administrative requirements to receive support that is so
well deserved. DS3 maintains contact with the Department of Veterans
Affairs, Department of Labor and other organizations that assist
veterans. Additionally, private sector employers have agreed to
routinely sponsor career events at WRAMC; and for the first time at
WRAMC, both Department of Labor and the VA will work along with Army
Career and Alumni Program Counselors (ACAP) to facilitate Transition
Assistance Program workshops. The intent is to better integrate
existing programs to provide holistic support services for our severely
disabled soldiers and their families from initial casualty notification
to the soldiers' return to his or her home station and final career
position. DS3 will also use a system to track and monitor severely
disabled soldiers for a period up to 5 years beyond their medical
retirements to provide appropriate assistance through an array of
existing service providers.
Each of the Services has initiated similar efforts to ensure that
our seriously wounded Servicemembers are not forgotten--medically,
administratively, or in any other way. To facilitate a coordinated
response, DOD has established the Military Severely Injured Joint
Support Operations Center. The Joint Operations center is
collaborating, not only with the military Services, but also with other
departments of the Federal Government, non-profit organizations, and
corporate America to assist these deserving men and women and their
families. Twenty-four hours a day, 365 days a year, the Joint Support
Operations center is a toll-free phone call away.
In closing I have pointed out only a few of the things that we are
doing together on behalf of our injured, wounded or ill Servicemembers
and their families. I want to again thank members of this great
institution for providing us with the funding and resources to execute
our mission which is to take care of some of the finest citizens of
this Nation. These are the men and women in uniform who have committed
their lives and well being to the defense and protection of this great
Nation. Finally, I would like to point out that the AMEDD, with WRAMC
on the cutting edge, has provided world class health care to injured
and wounded members of all the Services and will continue to do so. We
have established a strong partnership with the Department of Veterans
Affairs facilitated by an unwavering spirit of cooperation in our
efforts to provide a holistic approach to taking care of the needs of
our Servicemembers and their families.
Thank you.
Chairman Craig. Thank you, General. I will be back to you,
and you can anticipate that question.
Thank you very much.
Now, let me turn to Dr. Jonathan Perlin, Acting Under
Secretary of Health, U.S. Department of Veterans Affairs. As I
mentioned earlier, he is accompanied by Robert Epley, Deputy
Under Secretary for Policy and Program Management, Veterans
Benefits Administration.
Doctor, welcome, again, before the Committee. Please
proceed.
STATEMENT OF JONATHAN B. PERLIN, M.D., Ph.D., MSHA, FACP,
ACTING UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY ROBERT EPLEY, DEPUTY UNDER SECRETARY
FOR POLICY AND PROGRAM MANAGEMENT, VETERANS BENEFITS
ADMINISTRATION
Dr. Perlin. Good morning, Mr. Chairman and Ranking Member
Akaka. Thank you, both, very much for the opportunity to appear
today and for the privilege of submitting a written statement
for the record.
I would also like to introduce our own example of seamless
transition. I am accompanied as well by Dr. Michael Kussman,
Major General, Retired, but former Commander of Walter Reed
Army Medical Center.
Let me begin by telling you how humbled my colleagues and I
are by the heroism of Major Tammy Duckworth. She personifies
the point of VA's commitment, our mission to care for those who
have borne the battle and our pledge to constantly improve and
do our best for America's newest heroes.
Mr. Chairman, the Veterans Health Administration has no
higher calling, no more important mission, than to provide
exemplary health care to our Nation's combat disabled veterans.
Providing true care means more than providing health services
that are technically sufficient. True care means that we must
honor these heroes and their families by providing them with
compassion and dignity and by coordinating every possible
service and support activity that may help improve their
functioning and restore them to their rightful place in our
society.
VHA, the Veterans Benefits Administration and the entire
department are reaching out to all new combat veterans in
unprecedented ways. Since fiscal year 2002, we have spoken to
more than 700,000 active duty servicemembers, members of the
Reserves and National Guard in discharge planning and
orientation sessions. Secretary Nicholson and Secretary
Principi have sent more than 230,000 thank you letters, with
information brochures, to each OIF and OEF veteran identified
by DOD as having left active duty. We have prepared videos,
wallet cards and websites to assure that they are aware of
their eligibility for VA health care and benefits.
Each VA medical center has identified a point of contact to
coordinate activities locally and to assure the transition from
military to veterans health care not only provides clinical
data, but also conveys a full picture of the person we care
for. To assure this, VA has also assigned full-time social
workers and benefits counselors to seven military treatment
facilities to facilitate immediate, comprehensive and
compassionate care and family support. They have coordinated
more than 1,900 transfers of OIF and OEF servicemembers and
veterans to VA medical centers.
Forty-eight thousand seven hundred and thirty-three
veterans, out of approximately two hundred and forty-five
thousand separating servicemembers, have sought VA care as of
December 2004. In general, the medical issues that we see are
those we might expect to see in a young, active military
population--musculoskeletal, dental and psychological. However,
one of the harshest realities of modern warfare is the number
of servicemembers returning with major and multiple trauma,
including amputation, spinal cord injuries, traumatic brain
injuries or combinations of all of these.
We are expanding the scope of VA's four regional Traumatic
Brain Injury Centers and creating true Polytrauma Centers, with
additional clinical expertise to address the special problems
that multi-trauma, combat-injured patients face. Our goal is to
coordinate these services across traditional disciplinary lines
and, to the extent possible, meet all rehabilitative needs
simultaneously, not sequentially.
Another reality is that some of those who serve in combat
will return home with mental health issues requiring treatment.
Veterans and their families, as well as Members of Congress and
GAO, may be concerned about the potential for high incidence of
post-traumatic stress disorder or PTSD among returning OIF and
OEF veterans. They may also be concerned with VA's ability to
properly care for veterans with PTSD. While some adjustment
problems are normal and can be treated successfully at VA's Vet
Centers, PTSD differs from other adjustment disorders in that
it is not necessarily time-limited.
This fiscal year, we have allocated $100 million more to
implement initiatives contained in the Department's Mental
Health Strategic Plan. The President's fiscal year 2006 budget
proposes to supplement this with an additional $100 million.
These initiatives will benefit not only veterans with PTSD, but
all veterans receiving mental health care from VHA.
As of December 2004, 6,386 OIF and OEF veterans--only about
2 percent of VA's total number of PTSD patients--have been
referred for evaluation or diagnosed with potential PTSD at VA
facilities. I am confident that the President's budget contains
sufficient funding to allow us to provide world-class care for
veterans with PTSD and to meet all of the health care needs of
OIF and OEF veterans.
In conclusion, Mr. Chairman, VA has embraced the
opportunity to serve this newest generation of returning war
heroes by reinventing existing programs, enthusiastically
creating outreach initiatives, enhancing specialized clinical
services and collaborating with our DOD partners to share
access to health records.
I have had the privilege of meeting many of these heroes
and discussing their needs with them and their families.
Although I am very proud of what VA has done before and
already, I know that we can never do enough. We have an
opportunity to heal their wounds and restore them to their
rightful place in our society. I promise you, and I promise
them, that we will make the very most of that opportunity.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Perlin follows:]
Prepared Statement Jonathan B. Perlin M.D., Ph.D., MSHA, FACP, Acting
Under Secretary for Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee, I appreciate the
opportunity to appear before you today to discuss efforts of the
Department of Veterans Affairs (VA) toward effecting a seamless
transition for separating servicemembers from the Department of Defense
(DOD) health care system to the VA health care system.
First, let me assure you that interest in this issue comes from the
highest reaches of the Department. Though only recently taking office,
Secretary Nicholson has reaffirmed VA's determination to assure that
maximum efforts to serve the needs of newly returning servicemembers
are undertaken by the Department. These issues include health care,
rehabilitation adjustment and mental health care.
Deputy Secretary Mansfield is also deeply engaged in this endeavor.
The Deputy co-chairs VA/DOD Joint Executive Council (JEC) with the
Under Secretary for Defense for Personnel and Readiness. Last week, he
addressed the Joint DOD/VA Conference on Post Deployment Mental Health.
I will, in my statement, address the Department participation, on
two major aspects of the transition program and on one aspect that
concerns the more ``administrative'' efforts we have undertaken to
achieve a seamless transition, such as coordination and outreach to
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
veterans and their families. The second aspect involves the clinical
care we have provided, the numbers we have seen, and the education and
clinical tools we have developed for our health care providers. I will
also discuss coordination with DOD and the Department's responses to
the reviews of the Government Accountability Office (GAO) on VA's PTSD
program and other aspects of transition.
Before I do that, however, let me just say that the Department is
well positioned to receive and provide health care to returning OIF and
OEF veterans. As the largest integrated health care organization in the
United States, we can meet their needs through nearly 1,300 health care
facilities throughout the country, which include 696 community-based
outpatient centers that provide access to health care at points closer
to the veterans' homes. We also have 206 Vet Centers which are often
the first contact points for returning veterans seeking VA assistance.
Because the extent and complexity of our network of facilities may
seem daunting to some severely injured veterans, we have taken steps to
ensure a smooth transition from DOD health care to VA health care.
Therefore, we have assigned VA social workers and benefits counselors
to intercede on behalf of injured OIF and OEF veterans and assisting
them in negotiating the challenges associated with transition. I will
address this initiative in more detail later in my testimony.
VA offers comprehensive health care benefits to our enrollees,
including the full range of primary care services and specialty care
services. The quality of our care is second to none. In fiscal year
2004, we led the Nation for 18 health-care quality indicators in
disease prevention and treatment where comparable data are available.
We set the benchmark in patient satisfaction in the American Customer
Satisfaction Index. The recent RAND study demonstrated that VA leads
the Nation for preventive health services and chronic disease
management. This study, which appeared in the December 21, 2004, issue
of Annals of Internal Medicine, found that VA patients received higher-
quality care than comparable patients receiving care from other
providers.
We are an acknowledged leader in providing specialty care in the
treatment of such illnesses as post-traumatic stress disorder (PTSD);
spinal cord injury (SCI); and traumatic brain injury (TBI). We are now
leveraging and enhancing the expertise already found in our four TBI
centers to create Polytrauma centers to meet the manifold needs of
certain seriously injured veterans. We anticipate full implementation
of the Polytrauma Center initiative by the end of this fiscal year, and
we will provide the services of the centers to veterans from all parts
of the country. Again, I will discuss the Polytrauma Centers in more
detail later in my statement.
The TBI centers also collaborate with three military treatment
facilities (Walter Reed Army Medical Center, Wilford Hall Air Force
Medical Center, and San Diego Naval Medical Center) in the Defense and
Veterans Brain Injury Center (DVBIC). Through DVBIC, VA and DOD provide
state-of-the-art clinical care, conduct research, and provide
educational initiatives in the area of brain injury. A specialized
referral network has been developed to facilitate smooth transitions
both from military treatment facilities to VA and between VA
facilities.
As part of VA's seamless transition process, we have greatly
increased the number of outreach activities to returning servicemembers
and new veterans, including producing numerous pamphlets, brochures,
and videos to more than 209,000 returning servicemembers. VA has
increased the overall briefings on VA benefits to returning
servicemembers, including Reserves and National Guard members, from
5,300 briefings with 197,000 attendees in fiscal year 2003 to 7,200
briefings to over 261,000 attendees in fiscal year 2004. In January
2005, we have already provided 2,260 briefings to 79,000 returning
servicemembers.
With the activation and deployment of large numbers of Reserve/
Guard members following September 11, 2001, and the onset of military
actions in Afghanistan and Iraq, VA outreach to this group has been
greatly expanded. National and local contacts have been made with
Reserve/Guard officials to schedule pre- and post-mobilization
briefings for their members. Returning Reserve/Guard members can also
elect to attend the formal 3-day Transitional Assistance Program (TAP)
workshops provided by VA personnel.
va/dod joint executive council
Overall support and guidance for joint VA/DOD initiatives detailed
throughout my statement are provided VA/DOD Joint Executive Council
(JEC). This council, co-chaired by the Deputy Secretary of Veterans
Affairs and the Under Secretary for Defense for Personnel and
Readiness, ensures high level attention from both Departments to
maximize opportunities to improve service to our mutual beneficiaries.
JEC supported initiatives enhance resource utilization and sharing
arrangements to produce high quality cost effective services for both
VA and DOD beneficiaries. Through this forum, VA and DOD have achieved
significant success in improving interagency cooperation in areas such
as deployment health, pharmacy, medical-surgical supplies, procurement,
patient safety, clinical guidelines, geriatric care, contingency
planning, medical education, information management/information
technology, financial management and benefits coordination.
The revised VA/DOD Joint Strategic Plan (JSP), issued in
conjunction with the 2004 Annual Report to Congress, highlights data-
exchange opportunities and specifically identifies Seamless
Coordination of Benefits as one of its six major goals. As a result of
the JSP, enhanced efforts to educate active duty, reserve and National
Guard personnel on VA and DOD benefits programs, eligibility criteria
and applications processes are underway.
The VA/DOD Joint Executive Council Joint Strategic Plan supports
the expansion of the Benefits Delivery at Discharge program. This
effort includes the development of a cooperative physical exam process
that would be valid for Military Service separation requirements and
would also be acceptable for VA's disability compensation requirements.
These efforts should further ease the transition for active duty
service persons into civilian life.
va/dod electronic data exchange
Our ability to provide care to returning OIF and OEF servicemembers
is enhanced to the extent that we can obtain accurate health care
information from DOD in the shortest timeframe possible. VA and DOD
have made significant progress toward development of interoperable
electronic health information systems that allow appropriate data
sharing in compliance with applicable privacy protections.
In 2002, VA and DOD gained approval of their Joint Electronic
Health Records Interoperability Plan HealthePeople (Federal). VA began
implementation of Phase I of the plan, the Federal Health Information
Exchange (FHIE) that same year.
The highly successful FHIE supports the one-way transfer of
electronic military health data on separated servicemembers to the VA
Computerized Patient Record System (CPRS) for viewing by VA clinicians
treating veterans. Since FHIE implementation in 2002, DOD has
transferred records for over 2.4 million unique patients to the FHIE
repository, where more than 1 million records have been viewed by VA
clinicians. FHIE improves care and enhances patient safety for veterans
by providing VA clinicians access to pertinent DOD healthcare data.
FHIE, implemented jointly by VA and DOD in 2002, provides
historical data on separated and retired military personnel from the
DOD's Composite Health Care System to the FHIE Data Repository for use
in VA clinical encounters and potential future use in aggregate
analysis. Data being shared, through one-way transmission from DOD to
VA, include laboratory and radiology results; outpatient pharmacy data
from military treatment facilities, retail network pharmacies, and DOD
mail order pharmacy; allergy information; discharge summaries;
admission, disposition, and transfer information; consult reports;
standard ambulatory data records; and patient demographic information.
In October 2004, the Departments released Cycle 1 of the
Bidirectional Health Information Exchange (BHIE), permitting DOD
Military Treatment Facilities and VA Facilities to share patient
demographic data, DOD and VA outpatient pharmacy data, and allergy
information when a shared patient presents for care. BHIE Cycle I is
operational at Madigan Army Medical Center (Tacoma, WA) and VA Puget
Sound Healthcare System.
Work on BHIE Cycle II functionality, which adds other categories of
data, began on November 1, 2004, with scheduled implementation by the
3rd Quarter of fiscal year 2005 in El Paso, Texas.
VA and DOD are now developing interoperable data repositories that
will support the bidirectional exchange of computable data between the
DOD Clinical Data Repository (CDR) and the VA Health Data Repository
(HDR), known as Clinical Data Repository/Health Data Repository (CHDR).
In September 2004, VA and DOD successfully demonstrated a CHDR pharmacy
prototype in a lab environment that supported the capability to conduct
drug/drug and drug/allergy interaction checking across VA and DOD
systems. The Departments are actively developing CHDR for production
and anticipate completing the interface by October 2005.
seamless transition
Although I have chosen to discuss our transition program in two
parts, these two aspects of transition are tightly intertwined. The
success of our coordination and outreach efforts will affect what we do
clinically. In turn, our clinical encounters with OIF and OEF veterans
will inform and guide our future activities in coordination and
outreach for these veterans to offer them all needed assistance.
coordination efforts and oversight
In August 2003, VA's Under Secretary for Benefits and Under
Secretary for Health created a new VA Taskforce for the Seamless
Transition of Returning Servicemembers. This taskforce was composed of
VA senior leadership from key program offices and the VA/DOD Executive
Council and focused initially on internal coordination efforts to
ensure that VA approached the mission in a comprehensive manner. The
task force was charged with:
Improving communication, coordination, and collaboration,
both within VA and between VA and DOD, in providing health care and
benefits to returning veterans of Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF);
Ensuring that VA staff is educated about the needs of OIF/
OEF veterans; and
Ensuring that policies and procedures are in place to
enhance the seamless transition and veterans' access to health care and
benefits.
In January of this year, VA established a permanent Seamless
Transition Office. Composed of representatives from the Veterans Health
Administration (VHA), the Veterans Benefits Administration (VBA), as
well as other offices within VA, the Seamless Transition Office now
coordinates all activities related to the transition of returning
servicemembers. The office reports to the Acting Deputy Under Secretary
for Health. The original Taskforce has been retained, however, and will
serve the Seamless Transition Office in an advisory capacity.
Over the last 18 months, VA has achieved many successes in the
areas of outreach and communication, trending workload, data
collection, and staff education. We have worked hard, both internally
and with DOD, to identify OIF and OEF veterans and to provide them with
the best possible health care and access to benefits. VA has put into
place a number of strategies, policies, and programs to provide timely,
appropriate services to these returning servicemembers and veterans.
Throughout the process, we have greatly improved dialog and
collaboration between VA and DOD.
Many servicemembers are returning from combat with severe injuries,
requiring extensive hospitalization and rehabilitation. We must be
situated where these veterans are to provide them immediate and
continuing assistance as they are separated from active duty and enter
the VA health care system.
To that end, VA has assigned full-time social workers and benefits
counselors to seven major military treatment facilities (MTFs),
including Walter Reed Army Medical Center (WRAMC) and National Naval
Medical Center (NNMC) in Bethesda. They work closely with MTF treatment
teams to ensure that returning servicemembers receive information and
counseling about VA benefits and programs. They also coordinate the
transfer of active duty servicemembers and recently discharged veterans
to appropriate VA health care facilities and enroll them into the VA
health care system. Through this collaboration, we have improved our
ability to identify and serve returning servicemembers who have
sustained serious injuries or illnesses while serving our country. VHA
staff have coordinated more than 1,900 transfers of OIF/OEF
servicemembers and veterans from an MTF to a VA medical facility. VBA
benefits counselors are also stationed at MTFs to provide benefits
information and assistance in applying for these benefits. These
counselors are generally the first VA representatives to meet with the
veteran and family members. From October 2003 through mid-March 2005,
VBA benefits counselors have interviewed almost 5,000 OIF/OEF
servicemembers hospitalized at MTFs. It is important to note that there
are benefits such as the specially adaptive automobile grant and the
specially adapted housing granted that can be authorized while the
servicemember is still on active duty. For the most seriously injured,
the military services now work with VA to determine the discharge date
(usually 3 days prior to the end of the month), so that the separating
military member can be awarded VA disability entitlement effective the
first of the following month and paid at the end of that month.
For veterans whom we do not encounter in the MTFs, we have adopted
other outreach strategies. These individuals may not have the same
serious combat-related injuries we have seen in the MTFs; however, they
may have other health care, readjustment issues, or benefits needs that
require assistance. We must also reach out to these veterans to let
them know that we are here to help them.
Each VA medical center and regional office has identified a point
of contact to coordinate activities locally and to assure that the
health care needs and benefits needs of returning servicemembers and
veterans are met and that additional contact is made should the veteran
relocate. VA has distributed guidance on case management services to
field staff to ensure that the roles and functions of the points of
contact and case managers are fully understood, and that proper
coordination of benefits and services takes place.
VA is also working with DOD to obtain a list of servicemembers who
enter the Physical Evaluation Board (PEB) process. The PEB list will
identify those individuals who by virtue of their service sustained an
injury or developed an illness that precluded them from continuing on
active duty and resulted in medical separation or retirement. The list
will enable VA to contact these servicemembers to initiate benefit
applications, and transfer of health care to a VAMC Medical Center
prior to discharge from the military. Although the Seamless Transition
initiative was initially created to support servicemembers who served
in OIF/OEF, it is intended to become an enduring process that will
support all servicemembers who, as a result of injury or illness, enter
the disability process leading to medical separation or retirement.
outreach
VA has developed and distributed pamphlets, brochures, and
educational videos designed for returning servicemembers, VA employees,
and others involved in this important effort. Working with DOD, we
developed a brochure entitled ``A Summary of VA Benefits for National
Guard and Reserve Personnel.'' The brochure summarizes the benefits
available to this group of veterans upon their return to civilian life.
We have distributed over a million copies of the brochure to ensure the
widest possible dissemination through VA and DOD channels. It is also
available online at http: // www.va.gov / environagents / docs /
SVABENEFITS.pdf and http: // www.defenselink.mil / r2 / mobile / pdf /
va--benefits--rs.pdf.
VA also actively participates in discharge planning and orientation
sessions for returning servicemembers, and we have expanded our
collaboration with DOD to enhance outreach to returning members of the
Reserves and National Guard. Since fiscal year 2002 through the 1st
quarter of the fiscal year 2005, VBA military services coordinators
have conducted more than 19,000 briefings, reaching a total of more
than 700,000 active duty servicemembers. These briefings include 1,795
pre- and post-deployment briefings attended by over 88,000 activated
Reserve and National Guard servicemembers. During fiscal year 2004
alone, VBA military services coordinators provided more than 7,200
benefits briefings to separating and retiring military personnel,
including briefings aboard some Navy ships returning to the United
States. Almost 1,400 of these briefings were conducted for reserve and
guard members.
Other outreach activities include the distribution of flyers,
posters, and information brochures to VA medical centers, regional
offices, and Vet Centers. VA has, in fact distributed more than 1.5
million brochures to DOD demobilization sites and USOs. VA has also
produced and distributed one million copies of a VA health care and
benefits wallet/pocket card. The card lists a wide range of VA
programs, and provides relevant phone numbers and email addresses.
VA has also produced media aimed specifically at OIF and OEF
veterans. Examples of these include:
The first issue of the ``OIF & OEF Review.'' This provides
a wide range of information about health and other benefits issues to
veterans and their families. The first issue was only distributed to
medical centers (VAMCs), Regional Offices (ROs) and Vet Centers. The
upcoming issue will be mailed out to all returning OIF/OEF veterans.
Two information sheets, one each on OIF and OEF,
summarizing health issues for those two deployments were published.
These were distributed to all VAMCs, RO, and Vet Centers.
A video targeted at OIF/OEF veterans returning home from
overseas titled ``We're by Your Side.'' The video thanks servicemembers
for their service and introduces some of the services VA can provide as
they readjust to civilian life. The video can be used in a variety of
settings such as waiting rooms, new employee orientations, and at
offsite functions such as health fairs.
As servicemembers separate from the military, VA contacts them to
welcome them home and explain what local VA benefits and services are
available. Furthermore, in order to make a wide selection of general
information available to OIF and OEF veterans online, we have created a
direct ``Iraqi Freedom'' link from VA's Internet page (www.vba.va.gov/
EFIF). This website provides information on VA benefits, including
health and mental health services, DOD benefits, and community
resources available to regular active duty servicemembers, activated
members of the Reserves and National Guard, veterans, and veterans'
family members.
Last year, VA began sending ``thank-you'' letters together with
information brochures to each OIF and OEF veteran identified by DOD as
having left active duty. These letters provide information on health
care and other VA benefits, toll-free information numbers, and
appropriate VA websites for accessing additional information. The first
letters and information brochures were mailed in April 2004, and thus
far, VA has mailed letters to more than 230,000 returning OIF/OEF
servicemembers through this medium. Secretary Nicholson has
enthusiastically agreed to continue this valuable initiative.
A critical concern for veterans and their families is the potential
for adverse health effects related to military deployments. VA has
produced a brochure that addresses the main health concerns for
military service in Afghanistan, another brochure for the current
conflict in Iraq, and one that addresses health care for women veterans
returning from the Gulf region. These brochures answer health-related
questions that veterans, their families, and health care providers have
about these military deployments. They also describe relevant medical
care programs that VA has developed in anticipation of the health needs
of veterans returning from combat and peacekeeping missions abroad.
These are widely distributed to military contacts and veterans service
representatives; they can also be found on VA's website.
Another concern is the potential health impact of environmental
exposures during deployment. Veterans often have questions about their
symptoms and illnesses following deployment. VA generally addresses
these concerns through such media as newsletters and fact-sheets,
regular briefings to veterans' service organizations, national meetings
on health and research issues, media interviews, educational materials,
and websites, like www.va.gov/environagents.
employee education
The distribution of information, however, must not stop with
letters, and brochures, and websites aimed at the returning veterans.
We must ensure that our commitment is understood and shared at every
level of the Department as well. Therefore, we have developed a number
of training materials and other tools for our front line staff to
ensure that they can identify veterans who have served in a theater of
combat operations and take the steps necessary to ensure the veterans
receive appropriate care.
To aid VA employees in their efforts to assist OIF/OEF veterans, we
produced and distributed a video in DVD format entitled ``Our Turn to
Serve'' to all VHA and VBA field facilities. The video helps VA staff
better understand the experiences of military personnel serving in
Operations Iraqi Freedom and Enduring Freedom, and explains how they
can provide the best possible service to these newest combat veterans.
We have also provided copies of this video to Military Treatment
Facilities. Additionally, we have created a web page for VA employees
on the activities of VA's seamless transition initiative. Included are
the points of contact for all VHA health care facilities and VBA
regional offices, copies of all applicable directives and policies,
press releases, brochures, posters, and resource information.
va health care
Up to this point, Mr. Chairman, I have focused on the
accomplishments we have achieved to effect a seamless transition from
DOD health care to VA health care. I would now like to turn my
attention to the clinical side of the transition issue.
general data
Veterans who have served, or are now serving in Afghanistan and
Iraq, may enroll in the VA health care system and, for a 2-year period
following the date of their separation from active duty, receive VA
health care without co-payment requirements for conditions that are or
may be related to their combat service. Following this initial 2-year
period, they may continue their enrollment in the VA health care system
but may become subject to any applicable co-payment requirements.
As of December 2004, 244,054 OIF and OEF veterans had separated
from active duty. Approximately 20 percent of these veterans (48,733)
have sought health care from VA. A very small number (930) have had at
least one episode of hospitalization. Reservists and National Guard
members make up the majority of those who have sought VA health care
(27,766, or 57 percent). Separated active duty troops have accounted
for 43 percent (20,967). Thus, OIF/OEF veterans have accounted for only
slightly more than 1 percent of our total veteran patients (4.7 million
in fiscal year 2004); however, many of them will, of course, have
suffered much greater acute trauma.
OIF and OEF veterans have sought VA health care for a wide variety
of physical and psychological problems. The most common health problems
have been musculoskeletal ailments (principally joint and back
disorders) and diseases of the digestive system, with teeth and gum
problems predominating. No particular health problem stands out among
these veterans at present. The medical issues we have seen to date are
those we would expect to see in young, active, military populations.
However, we caution that these data are health care utilization data.
They do not represent a formal epidemiological study. Consequently,
recommendations cannot be provided for particular testing or
evaluation. These war veterans should be assessed individually to
identify all outstanding health problems. We will continue to monitor
the health status of recent OIF and OEF veterans to ensure that VA
aligns its health care programs to meet their needs.
mental health issues
As you are aware, Mr. Chairman, there has been particular interest
about mental health issues among OIF and OEF veterans and VA's current
and future capacity to treat these problems. At the outset, let me make
clear that nearly every servicemember who is exposed to the horrors of
war comes away with some degree of emotional distress. Many will have
some short-term adjustment reactions. But, thankfully, the majority of
them will not suffer long-term consequences from their combat
experience. Moreover, in view of the current efforts at early
identification of the wide range of adjustment reactions by DOD and VA
clinicians, it may be possible to lower the incidence of long-term
mental health problems through a concentrated effort at early detection
and intervention.
As of December 2004, the most frequent mental health diagnosis we
had seen at VA health care facilities was adjustment reaction, which
was diagnosed in 6,268 patients. Our data also indicate that 13,657
OIF/OEF veterans have received Vet Center services for readjustment
counseling. Allowing for those veterans who have been seen at both Vet
Centers and VAMCs, a total of 19,070 OIF/OEF veterans sought VA care
for issues associated with readjustment to civilian life.
Adjustment reaction is, in fact, the mental health diagnosis that
we would expect to find most often in troops returning from Iraq and
Afghanistan. The disorders in this category may result in temporary
impairment in social or occupational functioning or in symptoms and
behaviors that are beyond normal expected responses to stressors.
Adjustment disorders resolve either when the stimulus is removed or
when the patient reaches a higher level of adaptivity through
supportive therapy. Post-traumatic stress disorder (PTSD) is itself
classified using the same code as adjustment disorders. However, PTSD
differs from other adjustment disorders in that it is not necessarily
time-limited in its course and almost always requires a higher level of
intervention. As of December 2004, 4,783 patients at VAMCs were coded
with a diagnosis of suspected PTSD. In addition, 2,082 veterans
received services for PTSD through our Vet Centers. Allowing for those
who have received services at both VAMCs and Vet Centers, a total of
6,386 individual OIF/OEF veterans had been seen with potential PTSD at
VA facilities following their return from Iraq or Afghanistan.
I am often asked whether VA has the capacity required to care for
``all the OIF and OEF veterans with PTSD.'' To assess that, we must put
the number of OEF and OIF veterans with potential PTSD in perspective.
In fiscal year 2004, we saw approximately 279,000 patients at VA health
care facilities for PTSD and 63,000 in Vet Centers. Thus, OIF and OEF
veterans account for only about 2 percent of VA's PTSD patients.
So, it is in that context that I assure the Committee that VA has
the programs and resources to meet the mental health needs of returning
OIF and OEF veterans. Furthermore, to position VA for future needs,
this fiscal year we have allocated $100 million to implement
initiatives contained in the Department's Mental Health Strategic Plan.
The President's fiscal year 2006 budget submission proposes to
supplement this with an additional $100 million. These initiatives will
benefit all veterans receiving mental health care from VA. We are, in
fact, confident that the President's fiscal year 2006 budget request
contains sufficient funding to allow us to continue to provide for all
the health care needs of OIF and OEF veterans. Meeting the
comprehensive health care needs of returning OIF and OEF veterans who
choose to come to VA is one of the Department's highest priorities.
treatment
VA's approach to the provision of health care, in general, is
guided by an emphasis on the principles of health promotion and
preventive care. It focuses on supporting the patient's autonomy and
self-determination through an inclusive process of education and good
health practices.
In caring for veterans with mental health problems, VA applies
concepts of rehabilitation that address a patient's strengths as well
as his or her deficits. We emphasize recovery of function to the
greatest degree possible for each patient. This approach is designed to
identify and resolve problems in readjustment to civilian life, before
they progress to problems requiring more intensive clinical
intervention. VA's Readjustment Counseling Service frequently takes the
initial lead in providing this level of care through our 206 community-
based Vet Centers located throughout the United States. Intervention at
this local level is often all that is needed to resolve a veteran's
symptoms and allow a return to normal functioning.
Vet Centers have played an important role in providing outreach and
assistance to veterans since 1979. The Vet Centers see approximately
130,000 veterans every year and provide more than one million visits to
veterans and family members. They continue to perform this critical
function for OIF and OEF veterans. More than 15,000 OIF and OEF
veterans have made more than 35,000 visits to Vet Centers. VA has hired
50 outreach workers from among the ranks of recently separated OIF and
OEF veterans to help meet the needs of their fellow veterans at
targeted Vet Centers across the country. In concert with VBA's Casualty
Assistance Program which offers personalized outreach services to
surviving family members, the Vet Centers provide bereavement
counseling for the families of OIF and OEF servicemembers who have died
as a result of combat.
For veterans with mental illness who require more intensive or
specialized clinical intervention, VA provides comprehensive care
through a continuum of services designed to meet the patients' changing
needs. The intensity of care ranges from acute inpatient settings, to
residential services for those who require structured support prior to
returning to the community, to a variety of outpatient services.
Outpatient care includes mental health clinics; ``partial
hospitalization'' programs such as day hospitals and day treatment
centers that offer care 3-5 days a week to avert the need for acute or
extended inpatient care; and intensive case management in the
community. Long-term inpatient or nursing home care is also available,
if needed.
VA's specialized mental health programs include programs designed
to meet the needs of patients with disorders such as schizophrenia,
major depression, PTSD, and addictive disorders. To take one example,
VA provides care through 144 specialized PTSD programs located in every
state. These programs consist of specialized inpatient PTSD units,
Residential Treatment units, and Outpatient PTSD clinical teams (PCTs).
Providing care for mental disorders comprises two core elements of
treatment, evidence-based psychotherapy, psychosocial rehabilitation,
and state-of-the-art psychopharmacology. Evidence-based practices are
outlined in joint VA/DOD clinical practice guidelines (CPGs) on major
depression, serious mental disorders, substance use disorder, and PTSD.
VA has also incorporated an OIF/OEF clinical reminder tool in our
computerized patient record system (CPRS). This reminder advises
clinicians that they are seeing an OIF or OEF veteran who needs to be
screened for both medical and mental health problems associated with
deployment to Iraq and Afghanistan. VA's guidance for prescribing
medications recommends that physicians use their best clinical
judgment, based on clinical circumstances and patients' needs.
polytrauma centers
One of the harshest realities of combat in Iraq and Afghanistan is
the number of servicemembers returning from Iraq and Afghanistan with
loss of limbs and other severe and lasting injuries. We recognize that
we must provide specialized care for military servicemembers and
veterans who have sustained severe and multiple catastrophic injuries.
Since the start of OIF/OEF, VA's four regional Traumatic Brain Injury
(TBI) Lead Rehabilitation Centers (located in Minneapolis, Palo Alto,
Richmond, and Tampa) have served as regional referral centers for
individuals who have sustained serious disabling conditions due to
combat. These programs are specially accredited to provide
comprehensive rehabilitation services and TBI services. Patients
treated at these facilities may have a serious TBI alone or in
combination with amputation, blindness, or other visual impairment,
complex orthopedic injuries, auditory and vestibular disorders, and
mental health concerns. Because TBI influences all other areas of
rehabilitation, it is critical that individuals receive care for their
TBI prior to, or in conjunction with, rehabilitation for their
additional injuries.
In accordance with section 302 of Public Law 108-422, we have
developed a plan to expand the scope of care at these four centers and
create Polytrauma Centers. This plan builds on the capabilities of the
regional referral centers but adds additional clinical expertise to
address the special problems that the multi-trauma combat injured
patient may face. Such additional services include intensive
psychological support treatment for both patient and family, intensive
case management, improvements in the treatment of visual disturbance,
improvements in the prescription and rehabilitation using the latest
high tech specialty prostheses, development of a clinical data base to
track efficacy and outcomes of interventions provided, and provision of
an infrastructure for important research initiatives. Additionally, the
plan addresses services for patients in the outpatient setting for
ongoing follow-up care not requiring hospitalization. The plan provides
for enhancements to existing rehabilitation outpatient clinical
services to ensure that necessary services can be provided within
easier access to the patient's home.
We currently are anticipating full implementation of the Polytrauma
Center initiative by the end of this fiscal year.
clinical tools
If we are to provide effective health care, we must first provide
our clinicians with the tools necessary to do the job. I have alluded
to two of these tools above, the clinical reminder tool in our CPRS and
the clinical practice guidelines on mental health issues. In addition
to the guidelines on mental health, VA and DOD have developed two post-
deployment guidelines, a general purpose post-deployment guideline and
a guideline for unexplained fatigue and pain. These evidence-based
clinical practice guidelines give health care providers the needed
structure, clinical tools, and educational resources that allow them to
diagnose and manage patients with deployment-related health concerns.
Our goal is that all veterans will find their VA doctors well informed
about specific deployments and related health hazards.
Another important clinical tool is the Veterans Health Initiative
(VHI), a program designed to increase recognition of the connection
between military service and certain health effects; better document
veterans' military and exposure histories; improve patient care; and
establish a data base for further study. The education component of VHI
prepares VA healthcare providers to better serve their patients. A
module was created on ``Treating War Wounded,'' adapted from VHA
satellite broadcasts in April 2003 and designed to assist VA clinicians
in managing the clinical needs of returning wounded from the war in
Iraq. Also available are modules on spinal cord injury, cold injury,
traumatic amputation, Agent Orange, the Gulf War, PTSD, POW, blindness/
visual impairment and hearing loss, radiation, infectious disease risks
in Southwest Asia, military sexual trauma, and traumatic brain injury.
VA's National Center for PTSD has also developed an Iraq War
Clinician's Guide for use across VA. The website version, which can be
found at www.ncptsd.org, contains the latest fact sheets and available
medical literature and is updated regularly. The first edition was
published in June 2003, and the second edition was published in June
2004. These important tools are integrated with other VA educational
efforts to enable VA practitioners to arrive at a diagnosis more
quickly and accurately and to provide more effective treatment.
gao reports
I will now turn my attention to recent GAO reports.
gao study on implementation of special committee recommendations
First I will discuss GAO's study, ``VA Health Care: VA Should
Expedite the Implementation of Recommendations Needed to Improve Post-
Traumatic Stress Disorder Services,'' (GAO-05-287).
GAO conducted this review to determine whether VA has complied with
recommendations of the Under Secretary for Health's Special Committee
on Post-Traumatic Stress Disorder (Special Committee) to improve VA's
PTSD services. GAO concluded that VA had not fully met any of the 24
recommendations reviewed related to clinical care and education. GAO
recommended that VA should work with the Special Committee to expedite
VA's timeframes for fully implementing the recommendations needed to be
in compliance.
VA strenuously disagrees with this report and has not concurred
with its conclusions and recommendation. It should be noted that while
this report acknowledges that VA is a world leader in treating PTSD.
The report data do not allow extrapolation to any statements on
capacity of the PTSD program. The report also does not address the many
efforts undertaken by VA to improve PTSD care.
Rather, this report is one of limited focus, measuring only the
literal comportment with the Special Committee recommendations to the
Under Secretary for Health. Even in this regard, the report fails to
address the fact that the Under Secretary and the members of the
Special Committee met and agreed upon a plan of action that embodied
the spirit and intent of the Advisory Committee recommendations.
In separate letters, the Co-Chairs of the Special Committee
outlined their support for VA's implementation of the Committee's
recommendations. They expressed their ``discomfort'' at the negative
tone of the GAO report and point out that the report fails to address
the many efforts undertaken by VA to improve PTSD care. We provided
copies of these letters to GAO as part of our initial response to their
report, and wish to submit at this time as part of the hearing record.
Mr. Chairman, we strongly believe that the report leaves a grossly
inaccurate picture of PTSD services and does a great disservice to the
2,700 men and women who provide these important services. To the
average reader, the report implies that VA services for veterans with
PTSD is woefully inadequate and undermines the quality of VA care. This
implication is simply incorrect. GAO's findings and conclusions do not
accurately portray either VA's provision of PTSD services to veterans
over the past 20 years or VA's ability to provide these services to
veterans in the future. For example, as I stated earlier, the number of
OIF and OEF veterans to whom VA has provided PTSD services is but a
small percentage of the total number of veterans treated for PTSD in
the VA health care system. This indicates that VA does indeed have
sufficient capacity to provide care to veterans with PTSD.
gao study on availability of ptsd services
In an earlier study, ``VA and Defense Health Care: More Information
Needed to Determine If VA Can Meet an Increase in Demand for Post-
Traumatic Stress Disorder Services'' (GAO-04-1069), GAO reviewed DOD's
efforts to identify servicemembers who have served in Iraq and
Afghanistan and are at risk for PTSD, and VA's efforts to ensure that
PTSD services are available for all veterans. GAO concluded that VA
lacks the information it needs to determine whether it can meet an
increase in demand for VA PTSD services. GAO found that VA does not
have a count of the total number of veterans currently receiving PTSD
services at its medical facilities and Vet Centers. GAO stated that
without this information, VA cannot estimate the number of additional
veterans its medical facilities and Vet Centers could treat for PTSD.
GAO recommended that VA determine the total number of veterans
receiving PTSD services and provide facility-specific information to VA
medical facilities and Vet Centers.
VA has concurred with this recommendation and in October 2004
consolidated the necessary data into a national report and distributed
the report to all VISNs, medical centers, and Vet Centers to assist
them in estimating potential PTSD workload expansion. VA will update
and distribute this report on a quarterly basis. At the same time, we
caution that this narrow scope of analysis does not account for the
multiple health concerns that are associated with veterans returning
from combat. PTSD cannot be effectively treated in isolation. The
complexity of problems associated with veterans' military experiences
and post-deployment adjustment requires that we focus on all associated
health issues. GAO's study also does not address the resources that VA
subsequently is dedicating through the implementation of its Mental
Health Strategic Plan and the additional $100 million in each of fiscal
year 2005 and fiscal year 2006 to support mental health care, which
includes the $25 million mandated to be available for mental health
programs by Public Law 108-170.
conclusion
A servicemember separating from military service and seeking health
care through VA today will have the benefit of VA's decade-long
experience with Gulf War health issues as well as the President's
commitment to improving collaboration between VA and DOD. VA has
successfully adapted many existing programs, improved outreach,
improved clinical care through practice guidelines and educational
efforts, and improved VA health providers access to DOD health records.
VA's commitment to returning combat veterans is firm.
Mr. Chairman, this concludes my statement. I will be happy to
respond to any questions that you or other Members of the Committee
might have.
Chairman Craig. Doctor, thank you very much. We do
appreciate that statement.
Now, let me turn to Cynthia Bascetta, Director of Veterans'
Health and Benefits at the Government Accountability Office.
Welcome.
STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR OF
VETERANS HEALTH AND BENEFITS, U.S. GOVERNMENT
ACCOUNTABILITY OFFICE
Ms. Bascetta. Thank you. I apologize for this gravelly
voice. I hope you can hear me.
Mr. Chairman, Senator Akaka and Senator Rockefeller, I am
very pleased to be here to provide GAO's perspective today on
these important issues. As you know, Major Duckworth's
experience and the continuing deployment of our military forces
compel us to reaffirm our commitment to ensuring effective and
efficient management of the VA programs on which many of them
will come to rely.
My testimony is based on three reports; one on vocational
rehabilitation and employment services for the seriously
injured; and, two, on post-traumatic stress disorder. We
conducted our work at major MTFs, where most seriously injured
servicemembers are initially treated, including Walter Reed, as
well as several VA medical facilities. I would like to
highlight the steps VA has taken and the challenges we believe
it faces in providing services to the seriously injured,
especially those servicemembers transitioning to veteran
status.
I would like to emphasize, first, that VA has placed the
highest priority on serving the seriously injured. Through
collaboration with DOD, servicemembers in some locations are
even receiving services while they are still on active duty.
For example, VA has expedited vocational rehabilitation
services by taking steps such as assigning social workers and
benefits counselors to MTFs in certain locations. Walter Reed
is the model for this approach.
Similarly, VA requires that every returning OEF/OIF
servicemember receive priority consideration for health care
appointments. Notably, in contrast to previous wars, both VA
and DOD are taking steps to screen and provide treatment for
combat-related psychological injuries, particularly PTSD. While
we commend these steps, our work so far indicates that VA may
face significant challenges in achieving its goals.
One inherent challenge is the difficulty VA providers face
in determining when a seriously injured individual may be
receptive to assistance. The uncertainty of the recovery
process is just one of many complicating factors. To ameliorate
this, we recommended that VA establish a policy for maintaining
contact with servicemembers who initially decline vocational
rehabilitation. In the absence of such a policy, some regional
offices reported that they do not stay in contact, while others
reported a variety of methods and timeframes for routine
follow-up. As a result, some who could benefit from services
may be overlooked.
Another challenge is that VA has been unable to obtain
systematic data about seriously injured servicemembers from
DOD. VA requested lists of servicemembers being evaluated for
medical separation who might be likely to turn to the VA. VA
and DOD have been working on a Memorandum of Agreement but, in
the meantime, VA has had to rely on ad hoc regional office
relationships to identify those who might need vocational
rehabilitation. This is particularly troublesome because early
intervention is critical for the most successful outcomes.
DOD officials reported concerns about the potential adverse
effect on retention if servicemembers were informed of their
entitlement to VA benefits. They also cited potential privacy
issues as impediments to sharing health information. Such
information, particularly about psychological injuries, would,
of course, be especially sensitive but, at the same time, VA
would be better-positioned to plan for the projected influx of
at-risk and newly diagnosed veterans with PTSD and other
psychological injuries if it had better data from DOD.
Mr. Chairman, the dilemma is that issues like these, if not
resolved, constitute challenges for the seamless transition
overall, as well as for the health and welfare of individual
servicemembers and veterans. Overcoming these challenges will
require VA and DOD to continue and improve on their efforts to
work closely so that seriously injured servicemembers and
veterans receive the care they need.
In our ongoing work on PTSD, mandated by the National
Defense Authorization Act of 2006, we are assessing the methods
DOD and VA have established to identify and treat those
returning from the OEF/OIF conflicts with or at risk of
developing PTSD.
A critical component of our work will be our continuing
review of the efforts of the two departments to build on the
collaborative efforts they have engaged in so far for the
benefit of the active duty forces as well as veterans.
I would be happy to answer any questions that you might
have.
[The prepared statement of Ms. Bascetta follows:]
Prepared Statement of Cynthia A. Bascetta, Director, Health Care,
Veterans Health and Benefits Issues, U.S. Government Accountability
Office
Mr. Chairman and Members of the Committee: Thank you for inviting
me to discuss the Department of Veterans Affairs (VA) efforts to
provide disability benefits and health care to seriously injured
servicemembers returning from Afghanistan and Iraq. Since the onset of
U.S. operations in Afghanistan in October 2001 and Iraq in March 2003,
more than 10,000 U.S. military servicemembers have sustained physical
and psychological injuries. It is especially fitting, with the
continuing deployment of our military forces to armed conflict, that we
reaffirm our commitment to those who serve our Nation in its times of
need. Therefore, effective and efficient management of VA's disability
and health programs is of paramount importance.
You expressed concerns about servicemembers and veterans who may
seek services from VA. Today, I would like to focus on the steps VA has
taken and the challenges it faces in providing services to those who
have been seriously injured in these conflicts. Specifically I would
like to highlight the findings of our work on VA's disability program
and health care services for seriously injured servicemembers returning
from Afghanistan and Iraq. My comments are based on our reviews of VA's
programs for vocational rehabilitation and employment (VR&E) and health
care, specifically post-traumatic stress disorder (PTSD) services. This
work included visits to four Department of Defense (DOD) major military
treatment facilities (MTF), including Walter Reed Army Medical Center
where most seriously injured servicemembers are initially treated. We
interviewed officials at VA's central office and at 12 of VA's 57
regional offices. We also interviewed officials at seven VA medical
facilities where large numbers of servicemembers were returning from
Afghanistan and Iraq to discuss the number of veterans currently
receiving VA PTSD services and the impact that an increase in demand
would have on these services. We did our work in accordance with
generally accepted Government auditing standards.
In summary, VA is taking steps to provide services to seriously
injured servicemembers as a high priority but faces significant
challenges in doing so. Specifically, VA has taken steps to expedite
VR&E services to seriously injured servicemembers, but challenges such
as the inherent differences and uncertainties in individual recovery
processes make it difficult to determine when an individual may be
receptive to services. VA has also faced difficulties in obtaining
specific data from DOD about seriously injured servicemembers; instead,
VA has had to rely on ad hoc regional office arrangements at the local
level. Because such informal data sharing relationships could break
down with changes in personnel at either the MTF or the regional
office, we recommended that VA and DOD reach an agreement for VA to
have access to information that both agencies agree is needed to
promote servicemembers' recovery and return to work. Similarly, VA
requires that every returning servicemember from the Afghanistan and
Iraq conflicts who needs health care services receive priority
consideration for VA health care appointments, including PTSD services.
VA, however, faces challenges such as developing accurate data on
current workloads and estimating potential PTSD workloads. Without this
information, VA will be unable to accurately assess its capacity to
serve those servicemembers at risk for PTSD. Based on our work, we
recommended ways for VA and DOD to address these issues.
background
VA offers a broad array of disability benefits and health care
through its Veterans Benefits Administration (VBA) and its Veterans
Health Administration (VHA), respectively. VBA provides benefits and
services such as disability compensation and VR&E to veterans through
its 57 regional offices. The VR&E program is designed to ensure that
veterans with disabilities find meaningful work and achieve maximum
independence in daily living. VR&E services include vocational
counseling, evaluation, and training that can include payment for
tuition and other expenses for education, as well as job placement
assistance.
VHA manages one of the largest health care systems in the United
States and provides PTSD services in its medical facilities, community
settings, and Vet Centers. VA is a world leader in PTSD treatment and
offers PTSD services to veterans. PTSD can result from having
experienced an extremely stressful event such as the threat of death or
serious injury, as happens in military combat, and is the most
prevalent mental disorder resulting from combat.
Servicemembers injured in Afghanistan and Iraq are surviving
injuries that would have been fatal in past conflicts, due, in part, to
advanced protective equipment and medical treatment. However, the
severity of their injuries can result in a lengthy transition involving
rehabilitation and complex assessments of their ability to function.
Many also sustain psychological injuries. Mental health experts predict
that because of the intensity of warfare in Afghanistan and Iraq 15
percent or more of the servicemembers returning from these conflicts
will develop PTSD.
va has taken steps to provide services to seriously injured
servicemembers as a high priority
In our January 2005 report on VA's efforts to expedite VR&E
services for seriously injured servicemembers returning from
Afghanistan and Iraq, we noted that VA instructed its VBA regional
offices, in a September 2003 letter, to provide priority consideration
and assistance for all VA services, including health care, to these
servicemembers. VA specifically instructed regional offices to focus on
servicemembers whose disabilities will definitely or are likely to
result in military separation. Because most seriously injured
servicemembers are initially treated at major MTFs, VA has deployed
staff to the sites where the majority of the seriously injured are
treated. These staff have included VA social workers and disability
compensation benefit counselors. VA has placed social workers and
benefit counselors at Walter Reed and Brooke Army Medical Centers and
at several other MTFs. In addition to these staff, VA has provided a
vocational rehabilitation counselor to work with hospitalized patients
at Walter Reed Army Medical Center, where the largest number of
seriously injured servicemembers has been treated.
To identify and monitor those whose injuries may result in a need
for VA disability and health services, VA has asked DOD to share data
about seriously injured servicemembers. VA has been working with DOD to
develop a formal agreement on what specific information to share. VA
requested personal identifying information, medical information, and
DOD's injury classification for each listed servicemember. VA also
requested monthly lists of servicemembers being evaluated for medical
separation from military service. VA officials said that systematic
information from DOD would provide them with a way to more reliably
identify and monitor seriously injured servicemembers. As of the end of
2004, a formal agreement with DOD was still pending.
In the absence of a formal arrangement for DOD data on seriously
injured servicemembers, VA has relied on its regional offices to obtain
information about them. In its September 2003 letter, VA asked the
regional offices to coordinate with staff at MTFs and VA medical
centers in their areas to ascertain the identities, medical conditions,
and military status of the seriously injured.
In regard to psychological injuries, our September 2004 report
noted that mental health experts have recognized the importance of
early identification and treatment of PTSD. VA and DOD jointly
developed a clinical practice guideline for identifying and treating
individuals with PTSD. The guideline includes a four-question screening
tool to identify servicemembers and veterans who may be at risk for
PTSD. VA uses these questions to screen all veterans who visit VA for
health care, including those previously deployed to Afghanistan and
Iraq. The screening questions are:
Have you ever had any experience that was so frightening, horrible,
or upsetting that, in the past month, you have had any nightmares about
it or thought about it when you did not want to:
Tried hard not to think about it or went out of your way
to avoid situations that remind you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your
surroundings?
DOD is also using these four questions in its post-deployment
health assessment questionnaire (form DD 2796) to identify
servicemembers at risk for PTSD. DOD requires the questionnaire be
completed by all servicemembers, including Reserve and National Guard
members, returning from a combat theater and is planning to conduct
follow-up screenings within 6 months after return.
va faces significant challenges in providing services
to the seriously injured
VA faces significant challenges in providing services to
servicemembers who have sustained serious physical and psychological
injuries. For example, in providing VR&E services, individual
differences and uncertainties in the recovery process make it
inherently difficult to determine when a seriously injured
servicemember will be most receptive to assistance. The nature of the
recovery process is highly individualized and depends to a large extent
on the individual's medical condition and personal readiness.
Consequently, VA professionals exercise judgment to determine when to
contact the seriously injured and when to begin services.
In our January 2005 report on VA's efforts to expedite VR&E
services to seriously injured servicemembers, we noted that many need
time to recover and adjust to the prospect that they may be unable to
remain in the military and will need to prepare instead for civilian
employment. Yet we found that VA has no policy for maintaining contact
with those servicemembers who may not apply for VR&E services prior to
discharge from the hospital. As a result, several regional offices
reported that they do not stay in contact with these individuals, while
others use various ways to maintain contact.
VA is also challenged by DOD's concern that outreach about VA
benefits could work at cross purposes to military retention goals. In
our January 2005 report, we stated that DOD expressed concern about the
timing of VA's outreach to servicemembers whose discharge from military
service is not yet certain. To expedite VR&E services, VA's outreach
process may overlap with the military's process for evaluating
servicemembers who may be able to return to duty. According to DOD
officials, it may be premature for VA to begin working with injured
servicemembers who may eventually return to active duty. With advances
in medicine and prosthetic devices, many serious injuries no longer
result in work-related impairments. Army officials who track injured
servicemembers told us that many seriously injured servicemembers
overcome their injuries and return to active duty.
Further, VA is challenged by the lack of access to systematic data
regarding seriously injured servicemembers. In the absence of a formal
information-sharing agreement with DOD, VA does not have systematic
access to DOD data about the population who may need its services.
Specifically, VA cannot reliably identify all seriously injured
servicemembers or know with certainty when they are medically
stabilized, when they are undergoing evaluation for a medical
discharge, or when they are actually medically discharged from the
military. VA has instead had to rely on ad hoc regional office
arrangements at the local level to identify and obtain specific data
about seriously injured servicemembers. While regional office staff
generally expressed confidence that the information sources they
developed enabled them to identify most seriously injured
servicemembers, they have no official data source from DOD with which
to confirm the completeness and reliability of their data nor can they
provide reasonable assurance that some seriously injured servicemembers
have not been overlooked. In addition, informal data-sharing
relationships could break down with changes in personnel at either the
MTF or the regional office.
In our review of 12 regional offices, we found that they have
developed different information sources resulting in varying levels of
information. The nature of the local relationships between VA staff and
military staff at MTFs was a key factor in the completeness and
reliability of the information the military provided. For example, the
MTF staff at one regional office provided VA staff with only the names
of new patients and no indication of the severity of their condition or
the theater from which they were returning. Another regional office
reported receiving lists of servicemembers for whom the Army had
initiated a medical separation in addition to lists of patients with
information on the severity of their injuries. Some regional offices
were able to capitalize on long-standing informal relationships. For
example, the VA coordinator responsible for identifying and monitoring
the seriously injured at one regional office had served as an Army
nurse at the local MTF and was provided all pertinent information. In
contrast, staff at another regional office reported that local military
staff did not until recently provide them with any information on
seriously injured servicemembers admitted to the MTF.
DOD officials expressed their concerns about the type of
information to be shared and when the information would be shared. DOD
noted that it needed to comply with legal privacy rules on sharing
individual patient information. DOD officials told us that information
could be made available to VA upon separation from military service,
that is, when a servicemember enters the separation process. However,
prior to separation, information can only be provided under certain
circumstances, such as when a patient's authorization is obtained.
Based on our review of VA's efforts to expedite VR&E services to
seriously injured servicemembers, we recommended that VA and DOD
collaborate to reach an agreement for VA to have access to information
that both agencies agree is needed to promote recovery and return to
work for seriously injured servicemembers. We also recommended that VA
develop policy and procedures for regional offices to maintain contact
with seriously injured servicemembers who do not initially apply for
VR&E services. VA and DOD generally concurred with our recommendations.
VA also told us that its follow-up policies and procedures include
sending veterans information on VR&E benefits upon notification of
disability compensation award and 60 days later. However, we believe a
more individualized approach, such as maintaining personal contact,
could better ensure the opportunity for veterans to participate in the
program when they are ready.
In dealing with psychological injuries such as PTSD, VA also faces
challenges in providing services. Specifically, the inherent
uncertainty of the onset of PTSD symptoms poses a challenge because
symptoms may be delayed for years after the stressful event. Symptoms
include insomnia, intense anxiety, nightmares about the event, and
difficulties coping with work, family, and social relationships.
Although there is no cure for PTSD, experts believe that early
identification and treatment of PTSD symptoms may lessen the severity
of the condition and improve the overall quality of life for
servicemembers and veterans. If left untreated it can lead to substance
abuse, severe depression, and suicide.
Another challenge VA faces in dealing with veterans with PTSD is
the lack of accurate data on its workload for PTSD. Inaccurate data
limit VA's ability to estimate its capacity for treating additional
veterans and to plan for an increased demand for these services. For
example, we noted in our September 2004 report that VA publishes two
reports that include information on veterans receiving PTSD services at
its medical facilities. However, neither report includes all the
veterans receiving PTSD services. We found that veterans may be double
counted in these two reports, counted in only one report, or omitted
from both reports. Moreover, the VA Office of Inspector General found
that the data in VA's annual capacity report, which includes
information on veterans receiving PTSD services, are not accurate.
Thus, VA does not have an accurate count of the number of veterans
being treated for PTSD.
In our September 2004 report, we recommended that VA determine the
total number of veterans receiving PTSD services and provide facility-
specific information to VA medical centers. VA concurred with our
recommendation and later provided us with information on the number of
Operation Enduring Freedom and Operation Iraqi Freedom veterans that
has accessed VA services in its medical centers, as well as its Vet
Centers. However, VA acknowledged that estimating workload demand and
resource readiness remains limited. VA stated that the provision of
basic post-deployment health data from DOD to VA would better enable VA
to provide health care to individual veterans and help VA to better
understand and plan for the health problems of servicemembers returning
from Afghanistan and Iraq. In February 2005, we reported on
recommendations made by VA's Special Committee on PTSD; some of the
recommendations were long-standing. We recommended that VA prioritize
implementation of those recommendations that would improve PTSD
services. VA disagreed with our recommendation and stated the report
failed to address the many efforts undertaken by the agency to improve
the care delivered to veterans with PTSD. We believe our report
appropriately raised questions about VA's capacity to meet veterans'
needs for PTSD services. We noted that, given VA's outreach efforts,
expanded access to VA health care for many new combat veterans, and the
large number of servicemembers returning from Afghanistan and Iraq who
may seek PTSD services, it is critical that VA's PTSD services be
available when servicemembers return from military combat.
concluding observations
VA has taken steps to help the Nation's newest generation of
veterans who returned from Afghanistan and Iraq seriously injured move
forward with their lives, particularly those who return from combat
with disabling physical injuries. While physical injuries may be more
apparent, psychological injuries, although not visible, are also
debilitating. VA has made seriously injured servicemembers and veterans
a priority, but faces challenges in providing services to both the
physically and psychologically injured. For example, VA must be mindful
to balance effective outreach with an approach that could be viewed as
intrusive. Moreover, overcoming these challenges requires VA and DOD to
work more closely to identify those who need services and to share data
about them so that seriously injured servicemembers and veterans
receive the care they need.
Mr. Chairman, this concludes my prepared remarks. I will be happy
to answer any questions that you or Members of the Committee might
have.
Chairman Craig. Cynthia, thank you very much for that
testimony. Let me start right with you and go forward.
We keep hearing, and I mentioned, certainly, in some of my
comments, an effort to create a seamless transition and you, I
believe by your testimony, are suggesting that if the seams are
there, the threads are not joined in all instances.
Informational flow is critical. Understanding the conditions,
situation, but more importantly the individuals involved.
In your opinion, how has the lack of data, as you have
stated it, sharing agreement or I should say impeded VA's
ability to assist severely injured servicemen or
servicemembers?
Ms. Bascetta. Well, first of all, let me say that there is
total buy-in on the seamless transition. I have not detected an
unwillingness or a lack of commitment.
Chairman Craig. I do not dispute that either.
Ms. Bascetta. It is a work in progress. I would just want
to make that clear from the onset. But I think the risk in not
continuing to make sure that it truly is seamless is that
servicemembers and veterans, as they transition to veteran
status, may be overlooked, may not be able to avail themselves
of all of the benefits, and that is health benefits as well as
vocational rehabilitation to which they are entitled. This is
why we are so interested in following up and looking at not
only the policies for the seamless transition, but the actual
implementation of those policies.
Chairman Craig. Well, thank you. We will follow up, too,
and continue to do so as we proceed through this.
Dr. Perlin, we are going to make it a part of the record.
[The letter referred to follows:]
The Secretary of Veterans Affairs,
Washington, DC, March 8, 2005.
Name of Veteran
Street Address
City, ST, 00000-0000
Dear Veteran: We at the Department of Veterans Affairs (VA) thank
you for your service to our country. We are grateful to all the men and
women who risked their lives to fight terrorism in Afghanistan, Iraq,
and many other places around the world. America is more secure because
of your participation in these hazardous operations.
You received this letter because the Department of Defense notified
VA that you have been released from active duty although you may still
be a member of the Reserves or National Guard. If this is not the case
the information which follows will not apply to you until you are
released from active duty. If you are still a member of the Reserves or
National Guard the following information does apply to you.
VA can offer you a wide range of health care benefits and
assistance to aid in your transition to civilian life. VA can provide
combat veterans with 2 years of free health care for any health problem
that is possibly related to service in a designated area of military
conflict. It can also pay compensation for service-connected
disabilities and provide other benefits.
Information about health care and benefits is provided in the
enclosed brochures:
A Summary of VA Benefits
A Summary of VA Benefits for National Guard and Reserve Personnel
Our benefits offices and medical centers will assist you. If you
have questions about benefits or health care you can contact VA toll-
free by dialing 1-800-827-1000 for benefits information and by dialing
1-877-222-8387 for information on health care eligibility. You may also
visit the VA website at www.va.gov. The VA home page links to the Iraqi
Freedom/Enduring Freedom website that describes benefits for returning
veterans.
If you need help with personal and family concerns following your
return from military service, or with other community readjustment
issues such as finding a job, please contact a Vet Center which you can
locate by calling the toll-free numbers above or by visiting
www.va.gov/rcs.
On behalf of President George W. Bush and a grateful Nation, thank
you for your service.
Sincerely yours,
R. James Nicholson
Chairman Craig. We have a copy of the letter that the
Secretary sends out to veterans that certainly I think has some
valuable information in it as part of that transitional
environment that we are talking about. At the same time, we
want to make sure he is sending them out to all veterans and
that those nameless are complete and that DOD and VA are
appropriately working together to make sure that happens.
Are you confident at this time that you are getting all of
the necessary information, the necessary individuals who are
transitioning out and that you are gaining access to them in
the way you expect to and should?
Dr. Perlin. Well, first, Mr. Chairman, thank you very much
for the opportunity to describe the ongoing process of seamless
transition. This is, as Ms. Bascetta said, a work in progress,
and I am very confident about the work that has been done. I am
extremely appreciative for the 245,000 names that have been
provided to us, but there is work to be done and, under the
aegis of our Joint Executive Council chaired by our Deputy
Secretary and the Under Secretary of Defense for Manpower and
Readiness, we are building toward a joint electronic record, an
interoperable health record, and we believe that will be the
final culmination of seamless information.
We expect initial operation of that in October of 2005. In
the interim, we appreciate any and all efforts from the
Department of Defense to provide information about any
separating servicemembers, particularly those individuals who
are going through the physical evaluation board, so that we can
best anticipate and meet their needs both in terms of benefits
and health services and so we have a plan we have great
confidence in.
We have an appreciation for what has been done. We
recognize that there is additional work that needs to be done.
Chairman Craig. Doctor, there are some in Congress that
suggest we should extend the period from 2 to 5 years during
which a veteran from Operation Enduring Freedom or Operation
Iraqi Freedom may enroll in VA's health care system and be
exempt from copays. We have also heard in the panel just before
you this rush to get home, not all are listening, reality is
not setting in. Do you feel or does VA support such an
extension of time?
Dr. Perlin. Mr. Chairman, thank you for that question. You
recognized absolutely correctly that the servicemember has a
choice between two lines, one that says ``go home'' and the
other that says ``more boxes to check.'' Understandably, they
go for the ``go home.'' This is why it is so important that we
give them materials that are durable, these cards that identify
that 2-year eligibility, which is tremendously important.
The Department does not have an official position on this
yet. I think it is important to note that the individuals who
do present during that 2-year period can continue on for any
care that they might need. If they have service-connected
conditions, certainly, they remain eligible to receive care for
those. Should a veteran ever present to VA, say, 10 years out
with a service-connected condition or a condition that they
feel might be service connected, including something such as
symptoms of PTSD, they certainly can be evaluated for that
condition and could be service connected in perpetuity for the
care that is required.
Unfortunately, we have no Department position. We welcome
those veterans and appreciate your encouragement for veterans
to come seek us out in that 2-year window.
Chairman Craig. I am running out of time. I am going to ask
one more question. I am not confident we will have time for
another round, so, General, I must get to you, and I want you
to answer the question that you have asked or you have
anticipated.
General Farmer. Yes, sir.
Chairman Craig. I think that is most important, and I also
in doing so would ask has DOE considered----DOD considered--
see, I wear another hat, and it is the Energy Committee, so I
am DOD'ing, I suspect sometimes.
[Laughter.]
Chairman Craig. Has DOD considered partnering with VA and
sending severely injured servicemembers to a local VA facility
in their community with friends and family while the PEB
decision is pending rather than keeping them at a military
treatment facility? If you would speak in those parameters,
please.
General Farmer. Yes, Mr. Chairman. I am happy to respond to
that.
First, I would tell you that when we keep a casualty at
Walter Reed or any other military treatment facility, it is
generally because of their wishes or the family's wishes or for
continuity and completion of care.
Second, through invitational travel orders and other means
of assistance to include financial assistance for families,
when we cannot get the soldier there, we are usually getting
the family here. Our Malogne House Hotel on the Walter Reed
campus, the three Fisher Houses and a substantial number of
rooms in other local hotels have turned into that family away
from home, to have the family here with the soldier when it is
not appropriate or possible to get the soldier home.
Third, we do get many servicemembers, and it is our general
approach and policy to get the servicemember to the medical
treatment facility that is closest to their home or to their
duty station, that is appropriate and capable of delivering
their care.
Fourth, as noted in my testimony and in direct response to
the final part of your question, we do get many others to VA
medical centers, even while the medical evaluation board and
physical evaluation board are in progress and while they are
still on active duty and particularly for things where the VA
has a specialty center--I mentioned the spinal cord injury,
traumatic brain injury and a number of other specific niches.
Finally, the Community-Based Health Care Organizations--
CBHCOs--that have been created in response to these casualties
returning from Iraq and Afghanistan, under the oversight of the
National Guard Bureau, offer an opportunity to get many
soldiers back living at home, under a command and control
organization under the National Guard Bureau of State, with
duty at or near their home and getting their care in the local
community and often with the VA. These were established last
year, initially, in Massachusetts, Florida, Wisconsin, Arkansas
and California, and we have recently added Virginia, Alabama
and Utah. And those eight States cover soldiers from all of the
48 contiguous continental States.
So, in summary, I think we are providing a number of
options or choices, when and where appropriate, to get the
casualty to the most appropriate place and a place closest to
their home or duty station.
Thank you, sir.
Chairman Craig. General, thank you very much.
Let me turn to Senator Akaka.
Danny?
Senator Akaka. Thank you very much, Mr. Chairman.
Dr. Perlin, I understand that VA has created a temporary
database to list the servicemembers treated at each military
treatment facility. I do not see how you can ensure seamless
transition without knowing what patients are in the system. I
was surprised to learn that VA did not already have this, and
maybe you can correct me on that. How did you track
servicemembers at MTFs prior to the establishment of this
database?
Dr. Perlin. Thank you, Senator Akaka for the question.
First, let me state that VA, for the first time, actually
has VA personnel located at Walter Reed Army Medical Center,
National Naval Medical Center, Madigan, Eisenhower, Brooke,
Fort Hood, and Fort Carson. And so we actually are very much
aware of those individuals who will be coming from one of the
military treatment facilities into VA.
Our Seamless Transition Task Force, now operationalized as
a full seamless transition office, is the owner of this
database. That office was established, formally, on January 3rd
of this year, but the actual program has been operational now
for 18 months.
So we track each and every individual who is going to come
for VA service, be it a new veteran who has separated from
active duty, Reserve and Guards included, or an active duty
person who is seeking specialized care anywhere within VA under
a Tricare arrangement. So we know each and every individual who
has come into VA. With the advent of the office, we provided
some additional reporting and are pleased to provide to your
office and to the majority side a monthly report, so you really
do see the physical manifestation of that seamlessness of
transition.
Senator Akaka. Well, I was glad to see the letter that the
Chairman shared with me, dated March 8th, that the Secretary is
making this effort directly to veterans as they separate from
active duty.
Major Farmer, I commend you for the many collaborative
efforts and holistic approach utilized by the North Atlantic
Regional Medical Command and also VA. I am pleased to learn
more about the initiatives in place to assist the injured
servicemembers and their families.
Can you tell me what is being done to assist servicemembers
who have what we have been talking about: ``invisible'' wounds,
such as post-traumatic stress disorder? How do they fit into
programs such as DS-3?
General Farmer. Yes, sir. Thank you, Senator Akaka.
There are a myriad of ways in which we have responded to
and started new initiatives to help those with mental and
stress-related concerns. As you are aware, we last year sent in
a Mental Health Advisory Team into theater with psychiatrists,
psychologists, social workers, chaplains, counselors in to talk
with soldiers, to talk with commanders, to talk with others and
to assess the care and the availability of those with concerns
in theater. We have sent that team back recently to do a
relook, and we have actually responded to those concerns.
As you know, we have Combat Stress Control Teams in theater
that are there to practice early intervention before one really
becomes ill with a mental illness and to advise commanders, as
well as having Mental Health Treatment Teams also associated
with our hospitals, and health care organizations, and embedded
in the divisions in the theater.
Back here on this side, a number of things. Our Deployment
Health Clinical Center that was set up at Walter Reed after the
Gulf War, which, in its early days, focused especially on those
with physical symptoms without explanations. That population
which we often refer to as ``Gulf War illnesses,'' has, over
the past year, formed a new track or program called Track 2 to
focus specifically on those with psychiatric, psychologic
trauma concerns and post-traumatic stress disorder, and they
have set up a referral center and a program where we can bring
those in to deal with that.
Finally, I would tell you that the post-deployment health
survey that every soldier coming out of the theater fills out,
either as they exit the theater or as they redeploy here, was
amended last year. The length of that survey was doubled. What
was specifically added were two pieces--one to get more at the
stress-related and mental concerns and, second, to get at the
occupational and environmental exposures.
So, Senator, we have much left to do, but I think we are
doing many new initiatives to get at and respond to those kinds
of concerns.
Senator Akaka. Thank you very much, Mr. Chairman. My time
has expired. I will submit my questions for the record.
Post-Hearing Questions Submitted by Hon. Daniel K. Akaka,
U.S. Senator from Hawaii to Department of Veterans Affairs
Question 1: I am pleased that VA will be spending $100 million on
the Mental Health Strategic Plan. How exactly will this money will be
spent and on which programs?
Response: The Veterans Health Administration has established
priorities for additional funding of programs based on the
recommendations of the Secretary's Mental Health Task Force as well as
the initiatives contained in the Mental Health Strategic Plan. Areas
identified for priority funding are expansion of PTSD services, OIF/OEF
post deployment mental health services, expansion of Substance Abuse
programs, expansion of mental health services in CBOCs, creation of new
Mental Health Intensive Care Management teams and programs for the SMI
(Seriously Mentally III) veteran, new Homeless Domiciliaries, and
creation of case manager positions for the Grant and per diem program.
New CARES projections for mental health services were completed in
Fall 2004 and provided to the field in January 2005. This data is
broken down by mental health program and is specific to the CARES
markets. These data are available to the VISNs who will now be able to
identify where there may be gaps in services within their markets. The
$100 million will be used to correct service gaps once the Networks
provide specific strategic plans on how these gaps need to be
addressed. Priority for funding will be based on service need as
identified by the Networks. The Under Secretary for Health has agreed
to establish a team of mental health experts to continue to work with
the actuarial data to develop a model that attempts to identify the
gap.
VA plans to spend an additional $100 million in fiscal year 2006,
in addition to the $100 million in fiscal year 2005, on mental health
initiatives as outlined in the strategic plan as follows:
1. $29 million for continued expansion of Post Traumatic Stress
Disorder (PTSD) services and Operation Iraqi Freedom/Operation Enduring
Freedom (OIF/OEF) mental health services;
2. $10 million for Homeless Domiciliaries;
3. $20 million for continued expansion of substance abuse services;
4. $20 million for continued expansion of mental health in
Community-Based Outpatient Clinics (CBOCs);
5. $4.5 million for Mental Health Intensive Case Management (MHICM)
teams and Serious Mental Illness Services' expansion;
6. $4.5 million for Homeless Initiatives, which includes an
additional $500,000 to be taken from the $35 million set aside in FY06
for non-recurring residential treatment infrastructure funding;
7. $9 million for Telemental Health (addresses rural mental health
initiatives contained in the Mental Health Strategic Plan);
8. $2.4 million to fund an Inpatient Psychiatry Unit at the
Lexington, Kentucky VA Medical Center (Network 9); and
9. $600,000 for education programs developed by the VHA Employee
Education Service (EES).
Question 2: At both the VA and DOD Committees I have heard that a
joint computerized patient record is on its way any day now. Please
explain what the delay is and what can be done to break the logjam?
Response: VA and DOD are committed to development of interoperable
electronic health record systems. VA and DOD have achieved
interoperability on multiple levels including the Federal Health
Information Exchange (FHIE), the Bi-Directional Health Information
Exchange (BHIE), and the Joint Electronic Health Records
Interoperability Plan--HealthePeople (Federal) Plan (JEHRI), each of
which is described in more detail below. Significant and steady
progress toward this goal is evidenced by having successfully
implemented one-way and bi-directional data exchanges.
FHIE: In June 2002, VA and DOD began implementation of the first
phase of the Plan, the (FHIE), enabling DOD to transmit laboratory,
pharmacy (outpatient and retail), radiology, admission, disposition and
transfer (ADT), consult, discharge summary, allergy and coding data on
separated servicemembers from DOD's Composite Health Care System (CHCS)
to a data repository for use and viewing by VA clinicians in VA's Vista
Computerized Patient Record System (CPRS).
FHIE is fully deployed across all VA medical centers and usage is
monitored closely by the Departments. Since implementation, DOD has
transferred over 10 million clinical records associated with 2.9
million unique patients. Of this number, over 1 million have presented
to the VA for care and treatment. Every month, DOD continues to send
updates that include approximately 10,000 unique DOD patients to the
shared FHIE repository on separating and retiring servicemembers.
BHIE: Having successfully implemented a one-way transfer of
electronic health data, the Departments identified an additional
opportunity to leverage the work and lessons learned as part of FHIE.
In October 2004, the Departments implemented Cycle I of the DOD/VA BHIE
at the Madigan Army Medical Center (Tacoma, Washington) and the VA
Puget Sound Healthcare System. BHIE Cycle I was next implemented
between the William Beaumont Army Medical Center and the EI Paso Texas
VA Healthcare System. BHIE Cycle I permits these facilities to share in
real-time patient demographic, allergy, and pharmacy data. The
Departments are now testing Cycle II of BHIE and preparing for a third
quarter fiscal year 2005 release. Cycle II will add the capability to
exchange in real-time laboratory result data and radiology report text
data.
JEHRI: In addition to BHIE, in 2002 VA and DOD sought and obtained
approval from the Office of Management and Budget to implement the VA/
DOD JEHRI Plan. VA and DOD are implementing Phase II of the JEHRI Plan.
Pursuant to Phase II, VA and DOD will achieve interoperability of next-
generation health information systems, CHCS II and HealthVet-VistA,
through the DOD Clinical Data Repository (COR) and the VA Health Data
Repository (HDR) by October 2005. This interface, which is known as
``CHDR'' will support the bidirectional exchange of computable data. In
October 2004, VA completed a successful CHDR demonstration using a
pharmacy prototype in a lab environment. The Departments are presently
on target to complete the CHDR interface by October 2005. The initial
domains of data that will be shared include pharmacy, allergy,
laboratory, and demographic data. CHDR will also permit the Departments
to perform drug/drug and drug/allergy interaction checking in one
another's health information systems and to implement standards
approved by the interagency Consolidated Health Informatics initiative.
Question 3: In your statement you report the number of veterans
with PTSD utilizing facilities, making the point that this is a
relatively small group. What projections do you have about delayed PTSD
in these returning troops?
Response: VA anticipates that the great majority of OEF/OIF
veterans will not suffer long-term consequences of their war zone
experience, although many will have some short-term reactions to the
horrors of war. Of those who do develop mental/emotional problems, PTSD
will not be the only issue. Major depression and substance abuse are
two issues that can be anticipated. In his July 2004 New England
Journal of Medicine article, Col. Charles Hoge cites an incidence of 17
percent positive screens for PTSD, depression, and anxiety disorders 4
months post-return from combat in an anonymous survey of Army and
Marine troops from the Iraq and Afghanistan theaters.
Studies of Veterans of the Vietnam War, which bears many
similarities to the current conflict especially in Iraq, indicated an
incidence of 15 percent PTSD 5-20 years after the war. Considering the
outstanding efforts of in-theater DOD Combat Stress Control Teams, and
combined DOD/VA efforts at early identification and management of
problems before they deteriorate into established mental disorders, it
is reasonable to anticipate an incidence of 10-15 percent of war zone
troops with mental disorders.
Question 4: GAO argues that VA may not be able to meet an increase
in demand for post-traumatic stress disorder care. Early numbers
indicate that you are going to have major increases in demand for care.
What assurances can you give the Committee that you will be ready for
new veterans and will continue to care for those already in the system?
Response: VA Mental Health is fully prepared and poised to treat
the mental health needs of any of our newest veterans who are returning
from OIF/OEF.
Number of Veterans Served: As of December 2004, 4,783 patients at
VAMCs were coded with a diagnosis of suspected PTSD. In addition, 2,082
veterans received services for PTSD through our Vet Centers. Allowing
for those who have received services at both VAMCs and Vet Centers, a
total of 6,386 individual OIF/OEF veterans had been seen with potential
PTSD at VA facilities following their return from Iraq or Afghanistan.
To put this number in the context of our capacity, in fiscal year 2004,
we saw approximately 279,000 patients at VA health care facilities for
PTSD alone and 63,000 in Vet Centers. Thus OIF and OEF veterans account
for only about 2 percent of VA's PTSD patients.
VA has created a number of tools to assist staff in meeting
returning veterans' needs. A ``pop-up'' screening tool prompts
clinicians to ask a series of questions to assess the possibility of
PTSD, depression and alcohol abuse. VA's National Center for PTSD
(NCPTSD) in collaboration with colleagues at Walter Reed Army Medical
Center created and recently revised an Iraq Clinician War Guide
available as a CD-ROM and on the NCPTSD website. VA has placed skilled
staff in each VA Medical Center and has instituted outreach to
demobilization centers by Readjustment Counseling (Vet Center) and VBA
staff.
For those who have mental disorders, VA's orientation involves the
concepts of rehabilitation that address a patient's strengths as well
as deficits. It embodies a belief in recovery of function to the
greatest degree possible for each patient. For veterans suffering from
PTSD, VA provides state-of-the-art psychotherapy and psychopharmacology
treatments.
VA/DOD Efforts: The joint VA/DOD Clinical Practice Guidelines
direct evidence based care for PTSD and other disorders that may be
associated with PTSD and the stress of war such as major depression and
substance use disorders. VA provides this care through 144 specialized
PTSD programs across the Nation.
There are PTSD programs in all States. The PTSD programs include
specialized inpatient PTSD units, residential treatment units, and
outpatient PTSD clinical teams. VA's ongoing PTSD program evaluation
indicates improvements in PTSD symptoms and functioning in patients
treated by VA for PTSD. In FY04, VA spent more than $3 billion on the
provision of treatment services (medical and psychiatric) to veterans
with a mental illness.
Readjustment Counseling Service (RCS): RCS takes the lead in
providing outreach services through the 207 community based
Readjustment Counseling Centers (RCS), often called Vet Centers,
throughout the United States. Fifty additional Global War on Terrorism
Counselors have been added to these centers to meet this need. In
addition, the Secretary has expanded authority for RCS to deliver
bereavement counseling to those in need.
Mental Health Strategic Plan: To position VA for future needs, as
noted in the reply to Question 1, $100 million in fiscal year 2005 was
allocated to implement initiatives contained in the Department's Mental
Health Strategic Plan. The President's fiscal year 2006 budget
submission proposes an additional $100 million for mental health
initiatives. These initiatives will benefit all veterans receiving
mental health care from VA and include OEF/OIF outreach programs
designed to provide preventive health services that should, in many
instances, identify issues and address them before they require more
extensive clinical intervention.
These enhancements will also address increased clinical needs of
returning veterans and existing veterans who come to VA for PTSD care
and provide funding for substance abuse disorder programs.
As part of VA's overall outreach effort, letters are sent from the
Secretary of Veterans Affairs to all returning troops informing them of
the availability of VA to meet their healthcare and readjustment needs,
including the 2-year eligibility for care provided under Directive
2002-049.
__________
Post-Hearing Questions Submitted by Hon. John Ensign,
U.S. Senator from Nevada, to Jonathan B. Perlin, M.D., Ph.D., Acting
Under Secretary of Health, Department of Veterans Affairs
Question 1: Secretary Perlin: I understand that there were some
comments by Members of the House of Representatives regarding the
status of the future Las Vegas Veterans Hospital. Those comments
alluded to the fact that that hospital was not a ``done deal'' and
caused much concern amongst the Veterans community in Nevada.
Please elaborate on your understanding of the status of the Las
Vegas Veterans Administration Hospital?
Response: The Department of Veterans Affairs (VA) plans to
construct a comprehensive medical center in Las Vegas, as included in
VA's budget request for fiscal year (FY) 2006. Funding for a 120 bed VA
nursing home will be considered for the FY 2007 budget, and the
facility is currently scheduled to open in FY 2010. The total cost of
the comprehensive medical center and long term care facility is $286
million. Construction of the project will begin in 2007.
A parcel of approximately 152 acres, formerly under the control of
the Bureau of Land Management, has been legislatively transferred to
VA. The environmental assessment, a site utility study, as well as
geotechnical and topographic surveys are ongoing.
A project architectural design contract has been awarded to a joint
venture between RTKL Associates, Inc., a national architectural and
engineering firm in Washington, DC, and JMA Architectural Studios in
Las Vegas, NV. Each has significant expertise in health care design.
The schematic design is progressing and a preferred conceptual design
option has been selected. Meetings with medical center staff to develop
department layouts are ongoing. The negotiation for schematics design
development, and construction documents have been completed and a
contract award is being processed.
The first construction contract will be awarded in August 2006 to
include road construction, site grading, off and on-site utility
infrastructure development and construction of a central energy plant.
Additional contracts will be awarded as appropriate.
VA is also planning to lease a minimum of four Community Based
Outpatient Clinics throughout the Las Vegas Metropolitan Area to meet
approximately 50 percent of primary care needs of Las Vegas area
veterans. This will allow many veterans the opportunity to continue to
receive their primary care close to their home.
The Las Vegas Metropolitan Area is one of the fastest growing in
the nation. VA is committed to meeting the growing healthcare demands
of Nevada's veterans.
Question 2: Secretary Perlin: Rural healthcare is of vital
importance to the veterans of northern Nevada. Those who live in Elko
must travel to Salt Lake City, a drive of more than 5 hours to get some
of their healthcare needs met. I know that Elko failed to meet the
CARES Commission population standard of 7,000, but isn't there
something that the VA can do to address this situation?
Response: Elko did not meet the population threshold of 7,000
required to establish a community based outpatient clinic (CBOC) at the
time of the May 2004 Capital Asset Realignment for Enhanced Services
(CARES) Decision. However, the Veterans Integrated Service Network
(VISN) 19 can propose a new CBOCs independent of the CARES Decision. In
addition to veteran population, factors such as veterans' demands,
travel time to VA facilities, and the inherent obstacles that rural
areas face are taken into consideration when submitting their CBOC
priority list to Central Office for review. A CBOC at Elko, Nevada will
likely be a high priority based upon the fact that it is the largest
population area in VISN 19 without a CBOC.
Question 3: Secretary Perlin: John Bright is currently the Acting
Director of the VA Southern Nevada Healthcare System. Every Veterans
organization in my state is anxious to change the ``acting'' to
``permanent.''
What is the status of this appointment?
Response: As of May 1, 2005, John Bright was appointed as the
Director of the VA Southern Nevada Healthcare System.
Chairman Craig. Danny. Thank you very much.
Now, let me turn to Senator Rockefeller.
Senator Rockefeller. Thank you, Mr. Chairman. Mr. Chairman
and Senator Akaka, I hope you will forgive me if I reflect a
little bit on 21 years of history on this Committee with
respect to some of the issues that we are talking about.
I can remember very shortly after I got here that we had
sitting back there in a wheelchair an atomic radiation veteran
who was a victim of the testing that was done in the Pacific in
the 1940s and 1950s, and there were thousands and thousands of
those people. He described what it was like to die, to be in
the process of dying, knowing that his Government was not there
for him and that he could not prove to the Government's
satisfaction that there was a cause between his cancer and his
service, but he knew. That brings up the whole argument of
presumption.
The Government did not really have any interest in what I
had to say at the time, and it was not until years later that
we got some legislation passed that got some help for those
folks back in the 1940s and 1950s. He had long since died, of
course.
Second, I am thinking back to the Agent Orange crisis. I do
not remember the DOD or the Veterans Administration being
anywhere particularly on that issue, and I do not remember the
Congress being anywhere on that issue. I remember the people
who were affected by Agent Orange being somewhere on that
issue, and that was in great pain and great suffering.
In fact, it is ironic and tragic, but thank heavens, it
happened, it really was not, as I remember it until Admiral
Zumwalt came before a committee and pointed out that his son
was dying from cancer from Agent Orange, and then years later
the Congress did something about that. I do not remember
advocacy from the military or the VA community.
I go back later to the Persian Gulf War Syndrome. I
mentioned that, and I will mention it again because I was angry
about it 10 years ago, and I am angry about it today, that the
Defense Department absolutely denied it, fought it. We had
experts on this Committee. I was Chairman at the time. We did a
full investigation of it. They pooh-poohed it, and there was no
recognition. It was kind of, again, you are maybe a little
stressed, get a good sleep, take some aspirin. That made me
very angry then. It makes me very angry now. We may be doing
better on that.
So this has not been what I would call a distinguished
history of automatic sympathy and people reaching out to help
each other. I am going to say something else. I apologize to
the Chairman, but I am speaking from my heart.
Mr. Perlin was asked whether he supported Senator Akaka's
bill to extend care from 2 to 5 years for veterans returning
now from Iraq and Afghanistan. I certainly do, and I think it
is a great piece of legislation. You said you did not have a
position.
That leads me to another thing about, Mr. Chairman, this
whole business of hearings. I do not think that any of the men
and women who have testified--except I suspect you [Cynthia
Bascetta] can say whatever you want. The deal is, when you have
a hearing in Congress, if you are a Senator, do not for a
moment think that people are just talking off the top of their
heads, they sat down the night before and wrote out some
testimony. That testimony has all been vetted by OMB or the
Administration. So that if you do not have a position--Mr.
Perlin, you do have a position, and you are for that
legislation, but you cannot say that. You cannot say that
because you are not allowed to say that because of OMB, because
of the budget crisis, but I think you have a duty to say that.
I do not want you to be fired.
But we cannot accept that he does not have a position, Mr.
Chairman, when there is that kind of--and that is true in all
committees, all Cabinet Secretaries, Assistant Secretaries,
Deputy Secretaries, whenever they come up, every one of their
testimony is vetted and has to be approved by OMB, and if it
does not fit into the President's budget plan or his plans, it
will not be sent. So that brings into question the whole what
is a hearing? What really is a hearing?
So I come at it a little bit with that. I want, profoundly,
to be helpful to Major Duckworth and to the folks that I saw
coming back last Saturday, to the Vietnam vets that I meet when
I go into a Vet Center in West Virginia. You see people that
are sort of dressed like I am, and you think, well, they must
be some group of accountants in to audit the Vet Center. No, I
am sorry. They are Vietnam vets who are there for PTSD
treatment. They just do not happen to look like that is what
they are looking for, but they are. Just like the unemployed
people will often carry a copy of the New York Times under
their arm so that they will not look like they are unemployed.
So this question of what you say, what we can do, I think
says, fundamentally, Mr. Chairman, we need to really have an
expert staff, as I did years ago as Chairman in hiring Diane
Zuckerman, she was fabulous--and we closed that case, as far as
I was concerned, on Pyridostigmine bromide. At that time,
everybody had to take a pill every day. But the pill had never
been approved by the FDA for use in human beings during the
first Persian Gulf War--it had never been approved and yet
people had to take it every day.
The military kept no records, kept no records. I am not
going to ask you now about your position because I have sort of
given a speech. But these are things I think that need to be
said. I think it is very, very important that when we hear
testimony saying about how wonderfully the VA and the DOD are
getting along, I am not sure that is what Cynthia said. You
said there were some areas that you were not getting
information. I know from sitting on the Intelligence Committee
that we do not use the word ``share'' information any more
because you have 15 different intelligence agencies. They all
have their own information. They all want it to be theirs. In
some cases, it may be necessary, but the word is ``access'' to.
If you say ``share information,'' that means you own it, and
you can share it with somebody else. If you have access, it is
a right. Anybody else in that business has a right to have that
information.
If we are dealing with the health care of people, and we
call them heroes, and we do all of these wonderful things
because they absolutely are, but when they come back, do they
get the treatment that they should? I have never been convinced
of that, and I have never been convinced that the budget was
there. You indicated you felt the budget was there for PTSD.
That comes as a surprise to me, and we will see. But I think it
would be very useful for this Committee to take a very
aggressive posture on pursuing the various aspects of returning
men and women from these theaters of war.
Thank you, Mr. Chairman.
Chairman Craig. Senator Rockefeller, thank you.
I suspect I have developed a few reputations over the years
I have been here, but one of them is persistence, and we will
be persistent in pursuing all of the information we think
necessary to allow you--meaning, Senator Akaka and others--to
make the appropriate judgments as it relates to the care that
our veterans and our active military deserve. So we will be
persistent.
Let me close with a couple more questions, if I can, and
maybe one of those is part of that persistence and I ask this
of you, General. Have you or your staff placed any limitations
on VA access to injured servicemembers in an effort to prevent
the loss of military personnel?
General Farmer. No, sir.
Chairman Craig. Do you think this is a little legitimate
concern for the military, considering that these injured men
and women have already given so much?
General Farmer. Sir, I am not aware of that being a concern
because I am not aware that we are doing it in any way. I will
tell you that getting to the genesis of the questions, I think
it goes, in part, back to I think it was Senator Murray's
question earlier about are we pushing people out too early? We
have some, of course, who think we are pushing out, and there
are others who think, ``Hey, look, get me out. You are not
getting me out quickly enough.'' Those are all individual
cases, and what guides us is doing the right thing for the
soldier, sailor, airman, Marine, Coast Guardsman and for their
care not what their status is, and we are certainly not trying
to push anybody out of the VA system for what was asked
earlier, for monetary reasons or otherwise.
Chairman Craig. Well, I will tell you Major Duckworth, and
her condition and her desires challenge us all, but in the
appropriate way. One of my frustrations has been, and I have
shared this I think with Dr. Perlin, we have not adjusted some
of our military standards of service for service, physical
standards, to modern medicine. You have to be perfect in all
ways to be able to do certain things, and modern medicine today
allows people to be as functional, in many respects, as they
are as a whole person, from a physical standpoint.
One of those challenges I think we will all have--because
there is great desire on the part of our military men and women
and the professionalism of them today--to retain them. We
talked of costs, of experience, and all of that and how
valuable it is.
I have heard reference, and it is a frustration, that DOD,
in part, still operates in a bit of a cold war mentality. Cold
war mentality juxtapose a now career military, a professional
military that was not there during the cold war. It is obvious
to me, at least in my effort, and I think the effort of this
Committee and the effort of all of you, that the term or the
phraseology we are using today, and therefore the action you
are taking, ``seamlessness,'' would suggest there is, in no
way, a barrier between DOD and VA.
I am extremely pleased to hear the positioning of VA people
inside military facilities. The Secretary and I will be
visiting one of those soon in Germany. But our men and women
deserve nothing but that. If we are, in fact, honoring them as
career and professional people, that is extremely important I
think not only that we treat them with that kind of respect,
and therefore that kind of organization and system, but
certainly for value of retention and sustaining that over the
years, it is going to be increasingly important that we do
that.
So let me thank you all again for your presence here this
morning. We will stay with you on this. I am one who believes
in persistence and doggedness where necessary.
Cynthia, we appreciate your presence here this morning and
your testimony, and we will continue to make sure that in that
process of crafting a seamlessness environment that the threads
are tightly woven, and consistent and thorough.
Thank you all very much for your presence here this
morning.
Again, Major Duckworth, we thank you. We hope this has not
been too inconvenient for you, and we will look forward to
watching your future and anticipate that you will be able to do
exactly what you want to do.
Thank you so much.
The hearing will stand adjourned.
[Whereupon, at 12:31 p.m., the hearing was adjourned.]