[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


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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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.]
  

                                  
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