[Senate Hearing 109-737]
[From the U.S. Government Publishing Office]
S. Hrg. 109-737
HEALTH CARE LEGISLATIVE INITIATIVES
CURRENTLY PENDING BEFORE THE U.S. SENATE COMMITTEE ON VETERANS' AFFAIRS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
MAY 11, 2006
__________
Printed for the use of the Committee on Veterans' Affairs
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senate
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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
Bill Brew, Minority Staff Director
C O N T E N T S
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May 11, 2006
SENATORS
Page
Craig, Hon. Larry, Chairman, U.S. Senator from Idaho............. 1
Akaka, Hon. Daniel K., Ranking Member, U.S. Senator from Hawaii.. 3
Salazar, Hon. Ken, U.S. Senator from Colorado.................... 5
Jeffords, Hon. James M., U.S. Senator from Vermont............... 21
Burr, Hon. Richard, U.S. Senator from North Carolina............. 23
Thune, Hon. John, U.S. Senator from South Dakota................. 24
WITNESSES
Kussman, Michael, M.D., M.S., M.A.C.P., Principal Deputy Under
Secretary for Health, Veterans Health Administration;
accompanied by Jack Thompson, Deputy General Counsel,
Department of Veterans Affairs, and Thomas J. Pamperin,
Director, Policy for Compensation and Pension Service, Veterans
Benefits Administration........................................ 6
Prepared statement........................................... 9
Responses to written questions submitted by Hon. Daniel K.
Akaka...................................................... 15
Shaw, Robert, National Legislative Chairman, National Association
of State Veterans Homes; Administrator, State Veterans Center,
Rifle, Colorado................................................ 27
Prepared statement........................................... 28
Melia, John, Executive Director, Wounded Warrior Project,
Roanoke, Virginia.............................................. 31
Prepared statement........................................... 33
Blake, Carl, Senior Associate Legislative Director, Paralyzed
Veterans of America, Washington, DC............................ 35
Prepared statement........................................... 36
Response to written questions submitted by Hon. Larry E.
Craig...................................................... 40
Lara, Juan, Assistant Director, National Legislative Commission,
The American Legion............................................ 41
Prepared statement........................................... 43
Atizado, Adrian M., Assistant National Legislative Director,
Disabled American Veterans..................................... 46
Prepared statement........................................... 47
Response to written questions submitted by Hon. Larry E.
Craig...................................................... 50
APPENDIX
Obama, Hon. Barack, U.S. Senator from Illinois, prepared
statement...................................................... 59
Cullinan, Dennis M., Director, National Legislative Service
Veterans of Foreign Wars of the United States, prepared
statement...................................................... 60
HEALTH CARE LEGISLATIVE INITIATIVES CURRENTLY PENDING BEFORE THE U.S.
SENATE COMMITTEE ON VETERANS'
AFFAIRS
----------
THURSDAY, MAY 11, 2006
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m., in
room 418, Russell Senate Office Building, Hon. Larry Craig,
Chairman of the Committee, presiding.
Present: Senators Craig, Burr, Thune, Akaka, Jeffords, and
Salazar.
OPENING STATEMENT OF HON. LARRY E. CRAIG, CHAIRMAN,
U.S. SENATOR FROM IDAHO
Chairman Craig. Good morning, ladies and gentlemen. The
Committee on Veterans' Affairs will come to order.
Today, the Committee meets to receive testimony on several
pieces of legislation concerning health care matters that have
been referred to us for consideration. Our legislative agenda
is fairly long, and we will have a number of witnesses to hear
from this morning, so I will try to be very brief and ask my
colleagues to do the same.
First, of course, I want to welcome all of our witnesses,
and thank you for being with us today. We have a very large
group on Panel II, so I will ask all of you to be mindful of
the clock as you give your oral testimony. And, of course, as
most of you know, your written comments will be included in the
record and will be available for review by all Members.
Second, as I have noted, we have many bills on the agenda.
Of course, I would like to direct your attention to two bills
that I have introduced. One bill would make changes in the term
limits now imposed on VA Under Secretaries for Health and
Benefits. The other is a bill that I have sponsored along with
my distinguished colleague, Senator Danny Akaka, and that is
Senate bill 2736.
My first bill, S. 2634, would repeal the term limits on the
two Under Secretaries at VA that I have just mentioned.
Further, the bill would eliminate the requirement that there be
a search commission to identify candidates for the President to
consider for nomination to those positions. On the term limits,
I just believe that the executive branch officials should serve
at the pleasure of the President once confirmed. That means
they are subject to removal for poor performance, a very
important part of the accountability, or they can continue to
serve until such time as their services are no longer needed.
As for the search commission, I know some of our witnesses
today from the veteran service organizations oppose that
portion of the bill, partly because they have a role in the
search commission's process, and partly because they believe
the commission makes the position apolitical. I understand
that, and I respect that it is an important process for your
organizations and others. I hope we can work together to see if
we can find some common ground in that area.
My second bill, introduced along with Senator Akaka, would
direct VA to designate at least five amputation and prosthetic
rehabilitation centers across the country to help coordinate
care and services for veterans with amputations.
As all of you know, many of the men and women serving in
our Armed Forces today are surviving injuries that they would
not have lived through just 20 years ago. Most of that is
attributed to amazing battlefield medicine. When I visited Iraq
with Secretary Nicholson last year, I was struck by the
assertion of a doctor in Germany, when we were there at
Landstuhl, who told me that servicemembers that would be
treated in that hospital in Germany that very night had not yet
been injured in Iraq. Of course, the high survival rate also
brings significant challenges. Challenges for men and women who
survive these debilitating injuries and challenges for our
medical system. Coordinating the medical, rehabilitative and
psychological needs of our heroes with amputations are among
the greatest of those challenges.
My hope is that the Craig-Akaka bill will create regional
facilities that can serve as the specialty centers for the
treatment and the rehabilitation of servicemen and women with
amputation. I know VA is making tremendous strides in the care
and treatment of these patients. The legislation is not
intended to take those accomplishments away from VA. But I also
think that the model we have employed for spinal cord injury
and blind rehabilitation has fostered developments in the
technology and treatment of those conditions that simply could
not have been imagined at the outset of those endeavors. I also
think the same will be true for these centers.
Today's newest veterans can live very active and productive
lives even with their injuries. Activities like skiing, and
kayaking, and mountain climbing, and employment, are well
within the reach of these young men and women with amputations.
The question is not whether they will do these things, it is
whether their prosthesis, training and confidence will be up to
the challenges of those activities.
These centers will help us answer the question or develop
products that will answer the questions. I welcome VA to work
with me and our Ranking Member to enhance this legislation, if
necessary, so in the end we can have wide support for these
centers.
Finally, I want the Senators to know that as the Chairman
of the Committee, I truly appreciate the active engagement of
so many Members of the Senate on matters that they believe are
important to the care and treatment of America's veterans. I
know every one of the bills on our agenda today was submitted
with the intention and goal of bettering the lives of our
veterans or the system that provides benefits and services for
these deserving citizens.
That said, I want to make my colleagues aware that in
putting this agenda together today, we have erred on the side
of listing bills for testimony and comments. But I want to
caution everyone that their presence on the agenda would not be
taken as a signal that I support all of the provisions of all
the bills. In fact, I have concerns with many of the bills on
today's agenda. We will work out our differences. Some of them
may not be able to move forward past the point of the Committee
process without minor, or in some cases, substantive changes.
My concern centers on both cost and policy. I am committed to
ensuring that we do not add significant new costs to the
operations of VA health care system this year unless these
costs are directly related to providing care and service to
service-connected veterans, or will enhance the services
provided to those returning from Iraq and Afghanistan.
I know many of you have heard my comments about VA's large
budget increases, so I will not restate them. I just want to
simply say that I do not wish to make our budget difficulties
even worse next year. I hope Members will be willing to work
with us, the Ranking Member and our staffs, to make changes
where necessary so that we can move this legislation forward.
With that, let me turn to my colleague, the Ranking Member,
Senator Danny Akaka.
Senator.
STATEMENT OF HON. DANIEL K. AKAKA,
RANKING MEMBER, U.S. SENATOR FROM HAWAII
Senator Akaka. Thank you very much, Mr. Chairman, for
holding this important hearing on our health care legislation.
As we have a full legislative agenda before us today, I want to
thank the Chairman for his work in preparing this, and also our
staff for doing it.
I would like to just take a minute or so to highlight some
key initiatives. Over the last few months, I have introduced
several pieces of legislation, and they do share a common
theme. The goal of each is to make sure that both returning
servicemembers, as well as veterans already in the system, get
the care they need and the care they deserve.
I am very pleased to have the opportunity to work closely
with our Chairman on a bill that will create at least five
amputation and prosthetic rehabilitation centers within the VA
system. As he already discussed, these centers will provide
cutting edge care and assistance to Veterans who have suffered
from an amputation. With the current conflicts abroad resulting
in a higher rate of amputations than any others before, it is
imperative that VA move in this direction. We are ready to do
our part to assist VA in this endeavor.
We also have legislation before us to specifically address
the demand for long-term care. As the veteran population ages,
the demand for long-term care has increased accordingly. As we
all know, this trend will only continue as our Vietnam-era
veterans get older. Within the goal of encouraging more and
smarter long-term care, I have introduced two bills.
One bill is specifically designed to give VA's local
providers an incentive to develop creative ways to help
alleviate the burden on caregivers while expanding services to
veterans. This approach is based on a very successful mental
health grant program launched by our Committee 7 years ago as
part of the Millennium Act. Ensuring caregivers have the
support and tools they need to care for their family members
makes economic sense, and more importantly, makes policy sense.
I would like to thank the Coalition to Salute America's Heroes
for bringing this innovative idea to my attention.
The second long-term care bill is directed at State homes.
These facilities are universally regarded as providers of high
quality and cost-effective care to veterans, yet the
Administration's proposals last year would have decimated the
state-owned program by reducing its reimbursement. Through a
bipartisan effort, we were able to stop those cuts. I want to
make sure that such a proposal could never be advanced without
more input from Congress and more thought by the
Administration.
In addition, I believe we need to address some inequities
that exist in the state-owned program. I also think there are
ways we can use the State homes model to address gaps in
nursing home care without building large new nursing homes,
which do not make sense in certain small rural areas.
In January of this year, Chairman Craig and I held field
hearings in my home State of Hawaii. The hearing on the island
of Kauai focused exclusively on long-term care in rural
settings. We heard testimony about an innovative approach to
fill significant gaps in long-term care services to veterans
due to the nature and geography of certain States. Bob Shaw,
the National Legislative Chairman for the National Association
of State Veterans Homes, who is here with us today, testified
at the time that large State homes are not appropriate for the
more remote locations in Hawaii. Instead, he argued, we should
look to how Alaska has managed the challenges.
Rather than building new large homes, the State of Alaska
is using its own Pioneer homes, which provide nursing care to
older Alaskans, to provide care for veterans. Similarly, Hawaii
could use existing beds in the community and deem such beds as
part of the State Home program. Doing so would trigger per diem
payments from the VA to help defray the cost of nursing home
care.
Accordingly, my legislation would authorize VA to provide
construction grants and per diem payments for small long-term
care units, approximately 10 to 30 beds, in pre-existing health
care facilities. Such units would address gaps in long-term
care services for veterans living in the remote and rural
regions, including Alaska, Wyoming, Idaho, Montana, Kansas, and
other large rural States.
Mr. Chairman, I look forward to working with you in the
days ahead to move this agenda forward. I look forward to
hearing from all the witnesses today.
Thank you very much, Mr. Chairman.
Chairman Craig. Senator Akaka, Thank you very much. We have
been joined by our colleague, Senator Ken Salazar, of the great
urban-rural State of Colorado.
Senator Salazar. I think more rural than urban, but I will
say Idaho is still more rural than Colorado.
STATEMENT OF HON. KEN SALAZAR,
U.S. SENATOR FROM COLORADO
Thank you very much, Chairman Craig and Ranking Member
Akaka, for your graciousness, for your leadership, and for your
example on bipartisanship here in the U.S. Senate. I appreciate
your leadership on veterans' issues.
The VA health care system is a critical component, both of
our Government's obligation to veterans and of our Nation's
health care system as a whole.
The legislation we will consider today is important in a
number of respects. We will not only be discussing ideas for
specific means we can improve the way we deliver health care to
veterans, but we will also be talking about the fundamental
shape and nature of the VA health care system, and whether and
how we can take it to exciting new directions.
I often go out on the trail, as I was in Craig, Colorado,
up in Moffat County, in the northwest part of the State,
talking to over 200 veterans there this weekend, and extolling
the virtues of what has been accomplished with VA health care.
I am very proud of the efforts that we have already put on the
table and have been a real example for others to follow.
Given the fiscal constraints we know we face in the coming
years, we all know that we need to make some difficult
decisions on how to weigh the health care needs of our veterans
against the myriad of other very important Federal programs.
Today's hearing, hopefully, will lay the groundwork for many of
the decisions, and I am honored to have the opportunity to
participate.
I want to extend my gratitude to the Chairman and Ranking
Member for including my Rural Veterans Care Act as part of
today's agenda. This legislation is based on many of the
findings from last year's hearing of this Committee in Grand
Junction, Colorado, where I heard about the challenges that
many of our veterans in rural America face.
In 2004, a study of over 750,000 veterans residing in rural
America was conducted by the VA which was headed by Dr. Perlin.
The study found, in its essence, that veterans living in rural
areas are in poorer health than their urban counterparts. That
key finding is something that, I think, should have every
Member of this Committee and every member of the VA concerned
about, because at the end of the day, about 25 percent of the
veterans of America live in the rural parts of our country. We
ought not to have a disparity like that because it is a
dishonor to the commitment that we all make to ensure that we
honor the sacrifices that the veterans have made for our
Nation.
The bill that I have proposed will take a series of steps
to enhance the VA's ability to deliver care to rural veterans
by helping veterans get to and from existing facilities and
explore ways to bring VA health care services to their
communities and homes, and improve the quality of care they
receive. Most importantly, it will ensure VA policies are
sufficiently focused on the needs of rural veterans by creating
a new position within the Department, an Assistant Secretary
for Rural Veterans Affairs.
I want to thank my good friend and colleague, Senator
Thune, for his work on this legislation, and for helping us
craft it. I want to thank Senator Akaka and Senator Burr and
Senator Murray, Members of this Committee, for their
participation and their sponsorship of the legislation. In
addition, my colleague from Wyoming, Senator Enzi; and other
colleagues, Senators Lincoln, Dorgan, Conrad, Johnson,
Murkowski, Burns, and Baucus. All of whom recognize the reality
that the disparity that exists between veterans health care in
urban and rural areas ought to be something that we make
something of the past.
I know that there are some issues and concerns that have
been raised about the legislation that we have proposed. I am
looking forward to working with the VA, as well as the Members
of this Committee and the staff, to see how we can work through
those issues and make the Rural Veterans Health Care Act a
reality this year.
Thank you very much, Mr. Chairman.
Chairman Craig. Ken, thank you very much.
Now let us turn to our witnesses, and our first panel, Dr.
Michael Kussman, Deputy Under Secretary for Health, Veterans
Health Administration, Department of Veterans Affairs here in
Washington. He is accompanied by Jack Thompson, Deputy General
Counsel, Department of Veterans Affairs, along with Tom
Pamperin, Director of Policy for Compensation and Pension
Service, VBA.
Dr. Kussman, again, welcome before the Committee. Please
proceed.
STATEMENT OF MICHAEL KUSSMAN, M.D., M.S., M.A.C.P, PRINCIPAL
DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH
ADMINISTRATION; ACCOMPANIED BY JACK THOMPSON, DEPUTY GENERAL
COUNSEL, DEPARTMENT OF VETERANS AFFAIRS; AND THOMAS J.
PAMPERIN, DIRECTOR, POLICY FOR COMPENSATION AND PENSION
SERVICE, VETERANS BENEFITS ADMINISTRATION
Dr. Kussman. Good morning, and thank you, Mr. Chairman,
Ranking Member Akaka, and Senator Salazar. It is an honor for
me to be here today to present the Administration's views on
several bills that would affect the Department of Veterans
Affairs programs that provide veterans benefits and services. I
am accompanied, Mr. Chairman, as you mentioned, by Mr. Thompson
and Mr. Pamperin.
I would like to submit my written statement for the record.
Chairman Craig. Without objection, it will be.
Dr. Kussman. Mr. Chairman, I would like to start by
discussing S. 1537, which would require VA to establish six
Parkinson's Disease Research Education and Clinical Centers,
also known as PADRECCs, and two Multiple Sclerosis Centers of
Excellence. The bill prescribes detailed requirements for the
centers.
First, I want to assure the Committee that the VA is fully
committed to providing high-quality patient care to all
veterans who suffer from Parkinson's Disease and other movement
disorders, and we appreciate the efforts of House Veterans'
Affairs Ranking Member, Lane Evans, for his strong support for
the PADRECCs and their activities, and veterans in general.
I testified before the House Veterans' Affairs Subcommittee
on Oversight and Investigations in 2004. The VA took major
steps toward improving patient care and outcomes, while over
the longer term, pursuing a cure for Parkinson's Disease when
the PADRECCs were started in fiscal year 2001. VA now supports
PADRECCs at six sites across the country, caring for 18,500
patients in fiscal year 2004. To ensure that the sites are
effectively achieving their missions, we are currently
evaluating the PADRECCs and expect to complete this evaluation
and share the results with Congress in late fiscal year 2007.
Because the Department is currently working to achieve many
of the objectives of the proposed legislation, we ask that the
Committee defer action until after the evaluation results are
available so they can be considered. This is especially true
since one of the original goals of the PADRECCs was to evaluate
deep brain stimulation as a modality of therapy for Parkinson's
Disease. During this time, DBS, or deep brain stimulation, has
been accepted as a mainstream treatment and is no longer
experimental.
The VA is also concerned about the statutory mandates for
disease specific centers, such as PADRECCs and MS Centers of
Excellence--the PADRECCs and the MS Centers of Excellence were
based on the successful Geriatrics Research, Education and
Clinical Centers, the GRECC, and Mental Illness Research,
Education and Clinical Center, the MIRECC models. The GRECCs
and the MIRECCs focus on a wide scope of conditions facing a
significant portion of the veteran population from a
multidisciplinary approach. The VA is concerned that disease
specific centers may work to fragment care which is otherwise
well designed in our well designed world class integrated
health care system.
Bill S. 2433, the Rural Veterans Care Act of 2006 is an
ambitious measure to improve access to VA health care and other
veterans benefits for veterans living in rural and remote
areas. We share your commitment to provide veterans who live in
these areas with adequate access to VA health care and
services. However, we do not agree that this bill would
effectively achieve this. The written statement outlines
specifics about our concerns.
Nonetheless, we are very sensitive to the needs of
Americans who live in rural areas for many of the same reasons
that Senator Salazar mentioned. It is a national concern. Many
rural areas throughout the United States lack professionals who
can provide specialized service, and in some cases, even
primary care. It is important to note that this situation is
not unique to the VA.
We have taken special efforts to improve patient care for
veterans living in rural areas with the establishment of
community-based outpatient clinics, attention to care
coordination, and expansion of tele-health initiatives. By
leveraging new advances in technology, we expect to be able to
expand our capability to provide services in veterans' homes
and decrease the need for long and arduous travel to a
facility.
In addition, we regularly cooperate and collaborate with
veteran service organizations, the Indian Health Service and
the Department of Health and Human Services, to serve veterans
who live in rural areas. For example, many facilities partner
with VSOs to provide an external transportation system, which
is vital to many veterans obtaining their health care at VA
facilities in remote, rural or frontier areas. Also, a primary
focus of the CARES process has been to consider how to best
serve veterans in rural areas.
I would also suggest that it is important to consider this
perspective in regard to veterans receiving health care. While
it is important and is reported that 23 percent of enrollees
live in rural areas, based on the census definition of rural
health, only 4 percent of enrollees live in a rural area that
necessitates travel for more than 60 minutes to a VA facility
for care.
I do want to note that we believe that the demonstration
projects and pilot projects included in the legislation could
be achieved to a large extent within the current VA structure
and existing authority.
Bill S. 2500, the Healing of Invisible Wounds Act of 2006,
would prohibit the VA from implementing any modification of the
manner in which VA handles the ratings for Post-Traumatic
Stress Disorder compensation claims until 6 months after the
Secretary submits a report to VA's authorizing committees on
such modification. As VA currently has no plan to change this
procedure for handling ratings for PTSD claims, we believe that
legislation in this area is unnecessary at this time.
The bill would also require the VA, in consultation with
the Department of Defense, to provide each member of the
National Guard and Reserves who serves in active duty in a
combat theater with readjustment counseling services within 14
days of their return from deployment in a combat theater. From
a clinical perspective we have learned that mental health
treatment must be individualized. We also know that 14 days may
not be sufficient time for returning combat veterans to
recognize their needs for readjustment counseling and related
mental health services. We believe mandating this evaluation
violates the basic principle of allowing patients to choose
when, how and where to seek medical care. In addition,
mandating evaluation and treatment could be counterproductive
if the servicemember is not ready or is unaware of their
potential problems.
Furthermore, to address the need for follow-on evaluation,
DOD has initiated the post-deployment health risk assessment,
the PDHRA program, that is designed to identify and offer
individuals a full gamut of mental and physical services, 90 to
180 days post-deployment. The VA utilizes our Vet Centers'
services as well as our full medical center services in support
of this program.
Mr. Chairman, you and Senator Akaka have introduced Bill S.
2736, with the goal of enhancing rehabilitation services to
veterans with amputations and prosthetic devices. I want to
assure you that the VA shares your concerns and is committed to
provide high-quality amputation care involving
interdisciplinary amputation clinic teams, prosthetic and
orthotic laboratories, and preservation amputation care and
treatment programs. Providing this type of care throughout our
system and closer to the veterans homes is one of our goals. In
many instances amputation care and prosthetic services are only
part of the needs of the wounded warrior. In this vein, you are
aware of our four polytrauma centers, which have been heroic in
providing the interdisciplinary care needed for seriously
injured servicemembers.
We have identified a need for a further dissemination of
this expertise in areas closer to where the veterans live. As a
result, we are in the process of developing 17 more network
sites, one per network, the 4 polytrauma centers and 17 more,
to provide similar but less intensive care to the veteran to
include expanded prosthetic and amputation services. Teams at
these sites are or will be trained to provide the
rehabilitation services across the full spectrum of impairments
commonly associated with combat injury. We believe that the
work of these centers will meet the requirements of your
proposed legislation. We invite and strongly encourage you to
visit these centers to see for yourself the progress that has
already been made, and to learn more about VA's plans to extend
this care.
Furthermore, VA is partnering with DOD at the Intrepid
Center in San Antonio, and the new Walter Reed Amputation
Center, to do what your legislation proposes. We fear that to
add new centers of excellence, as described in the legislation,
will be redundant, and replicate already existing services. We
owe the 450 servicemembers who have suffered an amputation in
this conflict the very best.
Consequently, we ask that you defer action on this
legislation so we can form a partnership and work jointly to
achieve the best care for these amputees. We believe that the
21 centers are better than 5.
VA supports S. 2634, which will eliminate the statutory
limits for the Under Secretaries of Health and Benefits. This
bill is important to provide the Secretary with needed
flexibility as well as decrease the time required to fill these
vacancies.
Mr. Chairman, we are still in the process of clearing views
on S. 2753 and S. 2762, and we are in the process of doing cost
estimates for these and most of the bills discussed. Once we
do, we will supply those for the record.
I am pleased to see that while we may differ in our
approach to some of the issues, the VA and the Committee both
have the same conviction and dedication to meet the health care
needs of our veterans and to provide the best care for all the
veterans throughout the Nation.
This concludes my oral statement, Mr. Chairman, and I will
be happy to answer any questions that you or other Members of
the Committee have.
[The prepared statement of Mr. Kussman follows:]
Prepared Statement of Michael Kussman, M.D., M.S., M.A.C.P, Principal
Deputy Under Secretary for Health, Veterans Health Administration
Good Morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on several bills that would affect Department of
Veterans Affairs (VA) programs that provide veterans benefits and
services.
S. 1537
Parkinson's Disease Research Education and Clinical Centers; Multiple
Sclerosis Research Education and Clinical Centers
Mr. Chairman, I will begin by addressing S. 1537. This bill would
require VA to establish six Parkinson's Disease Research, Education,
and Clinical Centers (PADRECCs) and two Multiple Sclerosis Centers of
Excellence (MS Centers). The bill prescribes detailed requirements for
the centers. It would provide that any such center in existence on
January 1, 2005, must be designated as a PADRECC or MS Center under
this law unless the Secretary determines that it does not meet the
bill's requirements, has otherwise not demonstrated effectiveness in
carrying out the purposes of a PADRECC or MS Center, or has not
demonstrated the potential to carry out those purposes effectively in
the reasonably foreseeable future. The centers would also need to be
geographically distributed. Finally, the Secretary could designate a
facility as a new PADRECC or MS Center only if a peer review panel
finds that the facility meets the requirements of the law, and
recommends designation.
VA does not support S. 1537 because it is unnecessary; the
Department is already in full compliance with the substantive
requirements of this bill. VA recommends that Congress await an ongoing
evaluation of the existing PADRECCs before it considers whether to
mandate that VA either continue their operation or designate new
centers. Additionally, VA is concerned that statutory mandates for
these ``disease specific'' centers have the potential to fragment care
in what is otherwise a well-designed, world class integrated health
care system. I am increasingly concerned about the proliferation of
this disease specific model and its impact on patient care and VA's
integrated health care model. As it relates to a particular disease, I
believe that it is much more important for VA to disseminate the best
in evidence based practices across its health care system than to
establish centers that provide care for a particular disease. VA
currently has PADRECCs at six sites--San Francisco, California;
Richmond, Virginia; Philadelphia, Pennsylvania; Houston, Texas; Los
Angeles, California, and Puget Sound/Portland, Oregon (a combined
site). Those sites served a total of 18,500 patients in fiscal year
2004. We are currently conducting an evaluation of PADRECCs'
effectiveness in disseminating best practices, impact on patient
outcomes, and the types of organizational structures that contribute to
effectiveness. The study will be completed in 2007. Until this study is
complete, VA believes that it would be unwise to mandate continued
operation of these or additional PADRECCs . VA will, of course, share
the results of the evaluation with Congress to assist in determining
the need for legislation in the future.
For similar reasons, VA also does not support establishing new
specialty centers for the care of veterans with multiple sclerosis. VA
is well aware that Parkinson's disease and multiple sclerosis are
prevalent in the veteran population, particularly among aging veterans.
However, the nature of battlefield injuries is changing, and VA is now
treating many new veteran patients with complex polytrauma syndromes,
including brain injuries, limb loss, and sensory loss. Treating such
disorders, and the mental and emotional disorders that accompany them,
requires an interdisciplinary approach that moves beyond the focus on a
single disease. By mandating new ``education, research, and clinical
centers'' that are disease-specific, flexibility to respond to changing
combinations of related conditions is reduced. It is also important to
note that the ``models'' on which PADRECCs and MS Centers are based,
the successful Geriatric Research, Education and Clinical Center
(GRECC) and Mental Illness Research, Education and Clinical Center
(MIRECC) programs, were not as narrowly focused on a disease process
but addressed a wide gamut of issues facing a significant portion of
the veteran population.
S. 2433, RURAL VETERANS CARE ACT OF 2006
Mr. Chairman, S. 2433 is an ambitious measure to improve access to
VA health care and other VA benefits by veterans living in rural and
remote areas by creating a new Assistant Secretary who would be
responsible for formulating, coordinating, and overseeing all VA
benefits, policies, and procedures affecting such veterans. This would
include overseeing and coordinating personnel and policies of the three
Administrations (i.e., Veterans Health Administration (VHA), Veterans
Benefits Administration, National Cemetery Administration) to the
extent such programs affect veterans living in rural areas.
Section 2 of the bill would establish a new Assistant Secretary for
Rural Veterans (AS) to formulate, coordinate, and implement all
policies and procedures of the Department that affect veterans living
in rural areas. It would require the new Assistant Secretary to
oversee, coordinate, promote, and disseminate research into issues
affecting veterans living in rural areas, in cooperation with VHA and
the centers that would be established under section 6 of the bill, as
well as ensure maximum effectiveness and efficiency in the provision of
benefits to these veterans in coordination with the Departments of
Health and Human Services (HHS), Labor, Agriculture and local
government agencies.
In addition, section 2 would require the Assistant Secretary to
identify a Rural Veterans Coordinator in each VHA Integrated Service
Network (VISN), who would report directly to the Assistant Secretary
and coordinate all the functions authorized under section 2 within his
respective VISN. It would also require the Assistant Secretary, under
the direction of Secretary, to supervise the VA employees who are
responsible for implementing these policies and procedures.
Section 3 of the bill would require the Assistant Secretary to
carry out demonstration projects to examine alternatives for expanding
care in rural areas. In so doing, the Assistant Secretary would have to
work with the Department of Health and Human Services to coordinate
care that is delivered through the Indian Health Service, Critical
Access hospitals, or Community Health Centers. One such program would
have to involve expanded use of fee-basis care for veterans living in
rural or remote areas. Not later than 1 year after the date of
enactment of this Act, the Assistant Secretary would be further
required to re-evaluate VA policy on the use of fee basis care
nationwide and to revise established policies to extend health care
services to rural and remote rural areas.
Section 4 of the bill would require the Secretary to conduct a 3-
year pilot program in 3 VISNs to evaluate various means to improve
access to care in highly rural or geographically remote areas for all
enrolled veterans and those with service-connected disabilities who
live in such areas. In carrying out the pilot, the Secretary would be
required to provide these veterans with acute or chronic symptom
management, non-therapeutic medical services, and any other medical
services jointly determined to be appropriate by the individual
veteran's VA primary care physician and the respective VISN Director.
The Secretary would also have to allocate 0.9 percent of the
appropriated medical care funds to carry out this section before
allocating any other medical funds.
Section 5 would amend VA's authority to provide beneficiary travel
benefits to require that covered lodging and subsistence be determined
at the same rates that apply to Federal employees. It would also
require that VA's mileage allowance be determined in accordance with
the rates that apply to Federal employees.
Finally, section 6 of the bill would require the new Assistant
Secretary to establish up to five Centers of Excellence for rural
health research, education, and clinical activities. These centers
would be required to: conduct research on rural health services; allow
for use of specific models of furnishing services to this population;
provide education and training for health care professionals; and,
develop and implement innovative clinical activities and systems of
care.
We share the concern that rural veterans have adequate access to VA
health care and other VA services; however, we do not agree that the
bill would effectively achieve this and, so, oppose S. 2433.
First, the Under Secretaries of the three VA Administrations are
responsible for formulating and implementing program policy in their
respective areas. The proposed Assistant Secretary could have no direct
authority over them or their organizations. The proposed role and
responsibilities of the Assistant Secretary, as provided for in this
legislation, would cause significant confusion and disruption across
organizational lines--both among, and within, the Administrations.
Assuming there were some way to operationalize the responsibilities
of the Assistant Secretary, the ability of the Under Secretaries to
manage their employees and respective programs efficiently and
effectively would be significantly reduced. The bill would dilute
control from the Administrations with respect to specified activities,
personnel, and resources. This would increase the potential for
fragmented services, waste, and inconsistent, if not unequal, treatment
of veterans based solely on their geographic location. For instance, 23
percent of enrollees live in rural areas based on the Census'
definition of a rural area. However, only 4 percent of enrollees live
in a rural area and travel more than 60 minutes to a VA facility. Under
the bill, a disproportionate share of health care resources would be
directed to this population. The planning and delivery of services to
rural veteran-enrollees would be inconsistent and incoherent with
respect to the total population of enrolled veterans. The possibility
of fragmentation in the delivery of benefits cannot be overstated.
Second, S. 2433 would adversely dilute the ability of the Under
Secretary for Health to manage not only the delivery of VA health care
to rural veterans but also the delivery of health care to all veterans
because of the significant costs associated with enactment of this
bill. The proposed demonstration projects would cost $225 million based
on the President's Budget for fiscal year 2007. The additional
beneficiary travel benefits would cost approximately $550 million
(based on current employee-related rates), and that estimate accounts
only for the proposed increase in VA's mileage allowance. Providing per
diem (lodging and subsistence) at the proposed rates in addition to the
mileage allowance would raise the estimate to well over $1 billion.
Moreover, these increases would assist only the limited categories of
veterans who are eligible for beneficiary travel benefits. We believe
medical care funds are better directed to the delivery of direct health
care for all eligible veterans.
We note that the mandate to expand the use of fee-basis care in the
proposed demonstration projects may not be possible, because VA's
authority to provide fee-basis care (meaning contract care other than
care furnished under a sharing or scarce-medical-specialist agreement)
is limited by statute. Further, the mandate ignores the economic impact
of expanding the use of fee basis care. The cost of care in fee
settings is typically significantly greater than the cost of the same
care provided in VA settings. As a result, while fee-basis expansion
may make care accessible for some rural veterans, it would
disproportionately reduce the resources available for care of all other
veterans. Moreover, we do not understand the mandate to provide non-
therapeutic medical services as part of the pilot program and would
question the wisdom of providing such service from the three medical
care appropriations.
Finally, the demonstration projects and pilot project could be
achieved, to a large extent, within the current VHA structure and
existing authority. It does not require an organizational
restructuring, which, again, would create significant risk of
fragmentation and lack of continuity of care and benefits.
S. 2500, HEALING THE INVISIBLE WOUNDS ACT OF 2006
Section 2 of S. 2500 would prohibit VA from implementing any
modification of the manner in which VA handles ratings for post-
traumatic stress disorder (PTSD) claims for purposes of the payment of
compensation until 6 months after the Secretary submits to the Senate
and House Committees on Veterans' Affairs a report on such
modification. We do not support enactment of this section of the bill
for several reasons. First, VA believes that this legislation is
unnecessary because VA currently has no plan to change its procedures
for handling ratings for PTSD claims. Second, the bill would represent
an unwarranted restriction on the Secretary's Congressionally delegated
authority to issue regulations governing veterans' benefits matters,
which must be based upon statutory authority, and to manage the
implementation of statutorily authorized benefit programs. Finally, VA
is already required to report to Congress on its rulemaking. Under 5
U.S.C. S. 801, before a rule can take effect, VA must submit to both
Houses of Congress a report on the rule.
Section 3 of this bill would require the Secretary of Veterans
Affairs, in consultation with the Secretary of Defense, to provide each
member of the National Guard and Reserves who serves on active duty in
a combat theater with readjustment counseling services within 14 days
of their return from deployment in a combat theater. Such services
would have to be provided through VA's Vet Centers. Services would have
to include group counseling, a 1-hour session of private counseling,
and outreach concerning VA readjustment counseling services and mental
health services. Section 3 would also require that the National Guard
member or reservist be retained on active duty until receipt of the
readjustment counseling services required under the section.
VA does not support section 3 of S. 2500. A returning combat-
veteran's need for readjustment counseling and related mental health
services will be case-specific. Mandating that all such servicemembers
receive this counseling and related mental health services is counter-
productive and inefficient in the absence of an individual needs
assessment being conducted by an appropriate VA professional. It also
violates a fundamental liberty of the servicemember to be able to
choose whether to receive such services, thus violating the hallmark
bioethical principle of patient autonomy. Further, we object to
legislatively mandating the type of counseling to be provided,
including the treatment milieu. Not all of these servicemembers would
want or benefit from group sessions, for instance. Indeed, such
sessions might be contraindicated in particular cases. We strongly
believe that only VA's health care and counseling professionals can and
should determine who among the cohort of returning combat soldiers
needs readjustment counseling and/or other appropriate related care.
Finally, as to the proposal that they retain their active duty status
until receipt of VA services, we must defer to the Department of
Defense (DoD).
S. 2634, ELIMINATING STATUTORY TERM LIMITS OF UNDER SECRETARY FOR
HEALTH
AND UNDER SECRETARY FOR BENEFITS
Mr. Chairman, S. 2634 would eliminate the current statutory 4-year
term limit that applies to both the Under Secretary for Health and the
Under Secretary for Benefits position, as well as the currently
mandated search-commission processes for identifying candidates to
recommend to the President for these positions. VA supports S. 2634 as
it would provide the Secretary with needed flexibility as well as
decrease the time required to fill these vacancies.
S. 1731, REDESIGNATION OF VAMC MUSKOGEE, OKLAHOMA
This bill would designate the Department of Veterans Affairs
Medical Center in Muskogee, Oklahoma as the ``Jack C. Montgomery
Department of Veterans Affairs Medical Center.'' We defer to Congress
in the naming of Federal property in honor of individuals.
S. 2736 AMPUTATION CENTERS OF EXCELLENCE
S. 2736 would require the Secretary to establish not less than five
centers that provide enhanced rehabilitation services to veterans with
amputations and prosthetic devices. Each such center would provide
special expertise in prosthetics, rehabilitation with the use of
prosthetics, treatment, and coordination of care for veterans with any
amputation. They would also be responsible for providing information
and supportive services to all other Department facilities concerning
the care and treatment of these veterans. Each center would have to
meet specific staffing and resource requirements set out in the bill.
Finally, these centers would not be able to duplicate the services
currently being provided by the Department's polytrauma centers.
The Department does not support S. 2736 because it is unnecessary
in light of the recent and notable progress VA has made to address the
needs of patients with amputations and more complex injuries. VA
recognizes the Committee's concern regarding this important issue, not
only as it relates to veterans already in the healthcare system but
also as it relates to returning OIF/OEF combat veterans. We would like
to work with the Committee Members to make sure their concerns are
addressed and plans to keep the Committee apprised of the progress we
make as we continue to integrate the amputation system of care with the
polytrauma system of care. VA first developed the amputation system of
care in 2004, but as the war progressed and VA saw the dramatic
increase in patients with complex, multiple injuries as a result of
Improvised Explosive Devices (IEDs), VA developed a comprehensive,
integrated system of care to provide rehabilitation to these patients
with severe and lasting injuries. Teams at these sites are being
trained to provide rehabilitation services across the full continuum of
impairments commonly associated with combat injury including
prosthetics and amputation. Given our recent decision to open up the
additional 17 Level II Polytrauma Network Sites, we believe this
legislation is unnecessary, but would be pleased to continue the
discussions with the Committee on this important subject.
I would now like to address some of the specific clinical,
educational, and research initiatives that are currently underway that
obviate the need for this legislation.
CLINICAL CARE
VA has a long-standing history of providing amputation care, which
involves interdisciplinary amputation clinic teams, prosthetic and
orthotic laboratories, and Preservation-Amputation Care and Treatment
Programs (PACT). We are enhancing our delivery of amputation care to
address the needs of returning combat injured veterans who have
suffered amputations. These veterans are younger, were previously
active and healthy, and have high expectations and goals for life after
amputation. Such enhancements include: addition of staff; advanced
specialized training for staff; use of advanced prosthetic devices,
equipment, and techniques in the rehabilitation process; and, long-
range case management services to provide care coordination.
These enhancements are being developed as a complement to, and in
coordination with, the polytrauma system of care--not as duplicative
efforts. This coordination is necessary because many of the returning
amputee-veterans have additional injuries, such as traumatic brain
injury, PTSD, or hearing loss, requiring expanded rehabilitation
services. The polytrauma system of care is designed to provide lifelong
rehabilitation services across the full continuum of care. Four
Polytrauma Rehabilitation Centers (PRC) and 17 Polytrauma Network Sites
(PNS) have been established. The PRCs are located in Tampa, Florida;
Richmond, Virginia; Minneapolis, Minnesota; and, Palo Alto, California.
These Centers provide acute inpatient rehabilitation services to
veterans with multiple impairments, including amputation. The
interdisciplinary teams at the Centers include: physicians; physical
therapists; occupational therapists; prosthetists; social workers; case
managers; nurses; psychologists; speech therapists; and, recreation
therapists.
The 21 Polytrauma Centers (4 PRCs and 17 Network Sites), one in
each VISN, address long-range care needs and case management. PNS sites
were identified based on specific amputation, rehabilitation, and
mental health expertise including:
1. Comprehensive Physical Medicine and Rehabilitation Service;
2. Inpatient Rehabilitation Unit accredited by the Rehabilitation
Commission (CARF);
3. Prosthetic/Orthotic Lab accredited by ABC or BOC; certified
prosthetist on staff;
4. Surgical expertise in the area of amputation care and
polytrauma;
5. Specialized PTSD programming;
6. Presence of Driver's Training Program; and
7. Access to telerehabilitation technology.
These sites provide access to specialized services either directly,
or via consultation, within a reasonable geographic distance of
veterans' home. This interdisciplinary approach is used throughout the
continuum of care not just in the patient's acute rehabilitation
setting.
As servicemembers progress from the acute care setting to their
home environment, their needs for services will change. To meet these
demands, our clinical teams must be well versed in evaluation
techniques, rehabilitation methods and prescription of equipment.
To that end, VA is working closely with Walter Reed Army Medical
Center and Brooke Army Medical Center (BAMC) to provide advanced
training in amputation care to VA clinicians. For example, VA has
entered into a Memorandum of Agreement with BAMC to provide advanced
rehabilitation for patients with amputations at BAMC's newly designed
Center for the Intrepid (CFI). The agreement provides for VA staff to
be based at the CFI. This staff will have access to state-of-the-art
equipment and techniques for amputation rehabilitation. Their duties
will include providing regular training sessions to other VA employees.
Veterans and military servicemembers will have access to this
specialized center for high level rehabilitation.
EDUCATION AND TRAINING
Specialized training for prosthetists and therapists in the
Polytrauma System of Care has been provided in a number of venues. VA
clinicians have received advanced skills training though Walter Reed
Army Medical Center and BAMC. At present, VA has 12 teams of
prosthetists and physical therapist scheduled to attend the Military
Amputation Advanced Skills Training, on May 10-12, 2006. (Teams
attended similar training at WRAMC 1 year ago.) Finally, a joint DoD-VA
Amputation Clinical Practice Guideline is being developed to provide
guidance to the field in the area of amputation rehabilitation.
RESEARCH
VA has three research Centers of Excellence related to amputation.
These Centers address state-of-the-art discoveries in prosthetic
equipment, biohybrid limbs, microelectronics and nanotechnology. By
collaborating with Rehabilitation Research and Development, the Centers
and PNSs will be on the cutting edge of new technology in amputation
care. The three Centers are identified below.
Seattle
Limb Loss Prevention and Prosthetic Engineering.
Providence
Tissue Engineering to Rebuild, Regenerate and Restore Function
after Limb Loss.
Cleveland
ADVANCED PLATFORM TECHNOLOGY
Elsewhere, the Miami VAMC has established a Research Center for
Amputation Rehabilitation. Professionals at Miami are actively involved
in the development of advanced rehabilitation strategies in amputation
care and provide excellent outreach and education to the larger VA
community. In addition, the Salt Lake VAMC and the University of Utah
have recently been given grants to evaluate strategies related to
osseointegrated implants.
OTHER BILLS
Mr. Chairman, we do not yet have cleared views on S. 2753 or on
Senator Akaka's draft bill on State Homes. Nor do we have cost
estimates for these and most of the bills we have discussed. Once we
do, we will supply those for the record.
This concludes my prepared statement. I would be pleased to answer
any questions you or any of the Members of the Committee may have.
______
Responses to Written Questions Submitted by Hon. Daniel K. Akaka
to Dr. Michael Kussman
Question 1. With regard to Vet Centers and S. 2500, you mentioned
in your statement that while VA appreciates the intent of the
legislation, it is not necessary to mandate post-deployment mental
health counseling. Yet, we have seen tremendous results from the work
done by Vet Centers in conjunction with the Reunion and Re-entry
Program in New Hampshire. We are all aware of the recent GAO report
which raised the concern that soldiers screened may not be getting the
care they need. What is being done to replicate the success of the New
Hampshire model at other sites across the country?
Answer. Failed to respond before publication.
Question 2. While I understand that VA did not have time to submit
formal views on my caregiver assistance bill, S. 2753, I would like to
inquire about a related program that VA recently implemented. As you
know, last year's $100 million set aside for mental health initiatives
was distributed to incentivize providers in the field to come up with
innovative proposals for treating veterans who require mental health
services. We saw great success from that effort, and I am proud that
Hawaii's veterans were able to benefit as well. I think we all know
that there are gaps in VA non-institutional care, as GAO has previously
found. In that case, why not try a similar program for long-term care?
Answer. Failed to respond before publication.
Question 3. VA did not submit formal views on my State Veterans
Home legislation, S. 2762. I would like to ask about the per diem rates
that VA allocates to State Homes for the care of veterans. Can you
please explain the rationale behind the current policy of only
partially reimbursing State Homes for the cost of caring for service-
connected veterans? It is my understanding that VA pays community
nursing homes almost three times as much per day to care for the same
veteran patients.
Answer. Failed to respond before publication.
Chairman Craig. Dr. Kussman, thank you very much for that
detailed testimony, and we trust you will get positions on S.
2753 and S. 2762 to the Committee as soon as possible.
We have been joined by two of our colleagues. If you do not
mind, I will allow you to make any opening and additional
comments you wish to make inside the questioning period. Is
that fine with both of you?
Let us proceed then with questions. Dr. Kussman, I
understand that the Administration opposes--and you have just
stated so--the legislation introduced by Senator Akaka and
myself to create the amputation and prosthetic rehabilitation
centers on the grounds that the centers are not necessary in
relation to the work you are currently doing. Your argument is
the VA generally has greatly expanded its services to these
veterans. Witnesses on our second panel today argue that the
care for amputees is still hit or miss, depending upon where
you live. How does VA approach, work toward ensuring that the
care and treatment of amputees, especially those with service
connected disabilities, will be topnotch and consistent across
the country?
Dr. Kussman. Thank you, Mr. Chairman, for the question. Let
me say it is an awesome challenge to come here and basically
say, no, to most of the legislations that were initiated, but I
hope you understand that we are in support of much of what was
done, it is just the manner in which we should do this.
The answer to your question, the VA, in order to
specifically talk about the hit and miss, I will be the first
one to say that we are not perfect. That there are challenges
in a large system like ours to be sure that we provide as much
care as we can throughout the system, and that is really the
purpose of a lot of the things that we are doing.
However, in order to maintain quality, we have mandated
that all VA prosthetic and orthotic laboratories become
accredited by either the American Board of Certification, the
ABC, or the Board of Orthotics and/or Prosthetics
certification, the BOC. The process of accrediting labs ensures
that the state-of-the-art equipment and educated employees are
able to meet the quality standards of what our veterans need.
This ensures that we are comparable to anything that is
going on in the civilian community. And working with DOD, we
are sending teams to Brooke Army Medical Center, and Walter
Reed Army Medical Center to brush up on the new technologies
and the state-of-the-art equipment that really only exist at a
place like Walter Reed where the research is being done, and it
does not exist anyplace else in the country. Irrespective of
the VA, it does not exist in the civilian community. But we
want to be sure that working with DOD, we can provide that full
gamut of care.
Chairman Craig. Does a clinician treating an amputee in
Boise, Idaho or in Lake City, Florida know where to send a
veteran with a prosthetic complication that is beyond the
expertise of the local facility to treat? That would be my
first question.
And do they know who to call for information on the latest
prosthetic devices for specialized amputations?
Dr. Kussman. Yes, sir. Thank you. I believe that the
clinicians treating the amputees, whether it is in Boise or in
Lake City or in any place in our system, have access to the
prosthetic personnel in each of these facilities, who are
readily available to help the clinician if they have questions
on how and where to provide the information and care to any of
our veterans, new or old, for prosthetic care.
As far as who to call for information, Mr. Fred Downs, I
think whom you know, runs our prosthetics and orthotics system,
has a very intensive and involved network, where anybody who
has any questions can call him directly. As I said, we are
training our people with Walter Reed and Brooke Army Medical
Center, and will participate directly in the care at the
specialized centers at Walter Reed and the Intrepid Center, so
we believe that information will be disseminated throughout the
system.
Chairman Craig. As you know, it is not just Iraq and
Afghanistan. We have hundreds, if not thousands, of veterans
from previous wars who have prosthetic devices for amputations.
The devices wear out and they break down over time, or
literally just break. It is my understanding that replacement
services can be lengthy. What system does VA employ today to
track all of those veterans, on a regular basis, to ensure that
they are seen in regular intervals for prosthetic assessments
and/or replacements of aging or broken devices? And, of course,
you, as well as most Members of this Committee, are witness to
this new generation of devices that are phenomenally better,
and will these veterans have those devices made available to
them?
Dr. Kussman. Yes, sir. Thank you for the question. I would
be the first one to admit that as far as a tracking mechanism,
we have not put in place a tracking mechanism as thorough as we
would like to see. That has been a challenge to our PACT
program that is actually establishing a registry that we will
be able to track both new and old--I don't mean old in age,
although I am getting older every minute--but as far as
previous wars' veterans. And we will know where they are and
how often they are being seen and what devices they have. Each
veteran is assigned a primary care provider who would see them
clinically and refer them to whatever specialty clinics or
prosthetic services that they need.
As far as replacing aging and broken devices, again, the
system is not perfect, but all service connected amputees are
provided a prosthetic or orthotic device, and they are given a
prosthetic service card. This card allows the veteran to seek
repairs of his or her device at the point of service or
emergencies without any prior authorization. They can just go
to whoever has serviced them, wherever they are in the country.
Should the determination be made at the point of service that
additional services are needed, these cards contain the VA
point of contact to get additional authorization.
Veterans who are not service connected may call their local
prosthetic service vendor and authorization can be provided to
the vendor via purchase card. Veterans who live within close
proximity of the VA can simply report to the prosthetics
department, and repairs are processed immediately.
We are very anxious to learn about situations where the
system does not work well, and that we would commit ourselves
to making sure that there are not long delays and frustrations
for veterans who need our services.
Chairman Craig. Dr. Kussman, thank you very much. You are
correct, you and I are not aging.
[Laughter.]
Chairman Craig. I once Chaired the Aging Committee here. We
are maturing.
Dr. Kussman. I do not really mind getting older,
considering the alternative.
[Laughter.]
Chairman Craig. Thank you very much. Let me turn to my
colleague, Senator Akaka.
Dan.
Senator Akaka. Thank you very much, Mr. Chairman.
Dr. Kussman, of all items on the agenda, only one bill
garners VA support. I would like to add that the one bill you
support is an Administration bill, and with a smile, I want to
commend you for your courage.
[Laughter.]
Dr. Kussman. You notice who is here today.
[Laughter.]
Senator Akaka. Am I to infer that there is nothing the
Administration has or needs from Congress other than authority
for higher copayments. I would like to think that Congress has
valuable input to be made, especially in those areas where the
GAO and others have found shortcomings, like long-term care,
mental health, and seamless transition.
Today, GAO came out with findings which showed that the
majority of soldiers at risk to PTSD were never referred by
clinicians for further help. We have long pressured DOD to
screen returning soldiers with the assumption that care be
forthcoming. From your perspective, doctor, is the interaction
between VA and DOD working to reach and treat veterans in need
of mental health care?
Dr. Kussman. Thank you for the question. Yes, having had a
previous career on the south side of the Potomac, and now being
on the north side, I think I have a little bit of perspective
on--I have been encouraged, and I think most of us who
understand the dynamic feel that partnership is as good as it
has ever been.
In reference to your comments about the GAO report that was
in the Washington Post this morning, if I remember the
statistics exactly, they looked at 179,000 people who came
back, and 9,000 or so were ones that with the post-deployment
questionnaire that is done on everybody who redeploys, answered
three of the critical questions enough that they would
potentially need--that is 5 percent of the total number of
people. Of that 5 percent, only 22 percent got direct follow
up, and 78 percent they could not document.
It is not clear from that, the GAO study--and we have been
aware of that--of how many are active duty that are still
staying on active duty of that 179,000 or the 9,000 who filled
out the questionnaire. And they would be picked up potentially
later in the active duty component. The ones that I think you
are most interested in are the National Guard and Reserves, who
are leaving active duty. That has been a challenge all along
with our partnering because many of these--particularly the
National Guard and Reserves--after deployment, want to go home.
Some of them refuse to get the evaluation because they know
that they have to stay. That is why the post-deployment health
risk assessment program was established by DOD, partnering with
us, where we leverage our Vet Centers and our traditional
facilities in support.
So I believe that there is ample opportunity for people to
get the care that they need, but to some degree the
servicemember has to acknowledge and be willing to get some
help. The problem with this is that they do not want to, or
they do not see it as a problem.
We are well aware of the challenges of getting people in
for mental health, but we give them wallet cards and all kinds
of information when they leave the post-deployment arena to
allow us to help them when they need care.
So I believe we are working very closely with DOD on
multiple levels and multiple arenas to provide mental health
services. This is very important to us.
Senator Akaka. Yes. And this is the reason why this
Committee has stressed a seamless transition because of this
kind of need. And you are correct that we are also concerned
about the National Guard and Reserves, because those are the
troops that when they go home, they go back to work instead of
continuing in active service at a base, and therefore, may need
some attention that we cannot give them.
Mr. Chairman, my time has expired, and I will continue with
questions.
Chairman Craig. Senator, I am pleased you brought that up,
and I am glad, Dr. Kussman, you commented on the GAO study. We
will spend some time with this to better understand it. The
good news/bad news part of this, if it is accurate, the good
news is that a substantially lower percentage are recognizing
or having to deal with PTSD, that 5 percent versus some talked
about 30 plus percent. The bad news is the discrepancy in
referral and follow up. And, of course, some of your
explanation for it, we all understand is a reality, but this is
also, in the long term, very serious business for these
veterans who might experience this.
Let me turn to Senator Salazar.
Ken.
Senator Salazar. I want to return to the Rural Veterans
Health Care Act which you say you oppose for a number of
reasons on the part of the VA. Let me ask you a question with a
prefatory comment here.
It seems to me that what you are seeing out of the Senate
and what you will see out of this Senator, for as long as he
has a breath in him, is that we need to put a spotlight on the
problems that we face with veterans in rural America. For those
of us who come from rural States, we recognize that sometimes
the golden curtain drops at the end of the largest suburban
city in our State, and that a great part of rural areas of our
States is forgotten.
When I look at the findings of the VA itself, and recognize
that there was a study very comprehensively done on 767,000
veterans, and the basic conclusion of that study was that our
rural veterans were not receiving the same kind of health care
as their urban counterparts. To me, that says that we have a
problem. I recognize that there are 6 million veterans who live
in rural America and who are receiving a second-class health
care because of the place where they reside. That means that we
have a problem. When I look at the dozen or more Senators that
have signed up, including Senator Burr, Senator Thune, Senator
Murray, Senator Akaka, and others who have signed up to say
that this is an issue, that we have a problem, it tells me that
we need to do something about it.
I recognize that for other groups of veterans, including
minority veterans and women veterans, we have created an office
within VA. I wholeheartedly support those offices. It seems to
me that with 6 million veterans living in rural America, that
we ought to figure out a way of shining a spotlight on them by
creating some kind of an organization within VA that does that.
And yet, the response in your opposition to our modest
legislative proposal is that it would create chaos and
confusion among VA. I, frankly, do not believe that, because it
seems to me that VA is the kind of organization that has shown
its quality and its ability to respond to the special
challenges that face our rural veterans. I would hope that the
VA can work with me and with my Democratic and Republican
colleagues to figure out a way of putting a spotlight on that
issue.
My question to you is, do you have some thoughts on how we
might be able to put that spotlight on the challenges faced out
in rural America?
Dr. Kussman. Thank you, sir. I couldn't agree more with our
partnering. We need to do this. I mean, please, I hope you
understand that my comments were not in any way try to diminish
the issue. The bill itself, the way it was written for an
Assistant Secretary to do that, would be significantly
different than the offices that you described with women's or
minority health issues. There are not Assistant Secretaries, I
do not believe, at that level.
But I think that we will commit ourselves to work with you
and the other Senators that are supporting this bill, to try to
work out a system that will put spotlight on these rural
veterans, and to maximize our ability to provide them the best
level of care.
Senator Salazar. Let me ask you a question relating to the
costs associated with the disparity of health care provided to
veterans in rural America versus urban America. In places like
Craig, Colorado, where I met with 200 veterans on Saturday, one
of the concerns that was raised by some veterans, some of the
World War II generation, was that their travel to receive
health care some several hundred miles away, would actually
result them in getting into a worse health condition than if
they did not go to the VA itself. And so part of the problem we
have is that veterans in rural America are not getting access
to the kind of preventive health care that they need. And also
the difficulty in accessing health care service where it
actually exists is something that creates a great burden on
them.
How would you respond to how the VA should address that
reality?
Dr. Kussman. Yes, sir. As I mentioned, I think this is a
reality for the country. There are non-veterans who live in
those rural areas that have equal problem in getting care. As
mentioned, we believe that we want to make it easy for them to
travel if they have to, maximize with technology our care
coordination program, tele-medicine, make it as easy as
possible for them to get care, preventive medicine services,
even in their own home and not to have to go anywhere, with the
technology that is available.
As mentioned--and numbers can be used any way they want, it
is our understanding that 96 percent of veterans do not have to
travel more than 60 minutes to a site of care, whether it is a
CBOC or whether it is a facility, and it is not that those 4
percent of veterans are not important. We will continue to work
with you to try to maximize the ability, because we certainly
do not want a subsegment of our veteran population to get
substandard care.
Senator Salazar. I know my time is up, and I appreciate
that comment, Dr. Kussman. I do not believe the 4 percent
number, and I know that it is far different from having a CBOC
in someplace in a remote part of Colorado versus having some of
the other facilities we have in places like Grand Junction. I
can only assure you and Secretary Nicholson--if you will pass
this on to him--that I think for Senators, like Senator Thune,
who know what it is like to live in those broad stretches of
the Dakotas, or the other colleagues that we have on this
legislation, that this is not an issue that is going to go
away. We need to find a way to put a spotlight on the issue and
make sure that we are not creating two Americas with the kind
of health care system that we are providing veterans in rural
areas.
Dr. Kussman. Yes, sir. Thank you.
Chairman Craig. Senator, Thank you very much.
Let me turn now to Senator Jim Jeffords.
Jim.
STATEMENT OF HON. JAMES M. JEFFORDS,
U.S. SENATOR FROM VERMONT
Senator Jeffords. Thank you, Mr. Chairman.
Dr. Kussman, you state in your testimony, regarding Senator
Salazar's rural health bill, that 23 percent of enrollees live
in rural areas as defined by the census data, yet only 4
percent of enrollees live more than 60 miles from a VA
facility. The VA objects to the legislation because it focuses
too many resources on too small a percentage of the veteran
population. Could this objection to the legislation easily be
overcome by choosing a pilot site that would involve delivery
of care to the more typical rural veteran, a veteran who lives
in a rural area where access to care is diminished and where a
fee-basis approach might provide some significant benefits to
care for specialized or tertiary services?
Dr. Kussman. Thank you, sir. Just as a point of
clarification, I think that we said 4 percent would have to
travel more than 60 minutes to care, not 60 miles.
But as I mentioned in my testimony, I think that there are
pilot projects that we can do with the existing infrastructure
and existing things that are necessary with the legislation.
Issues related to fee-based care are very complicated and
somewhat limited for us to do under the existing rules of
engagement, but I might ask Mr. Thompson to comment on that.
Mr. Thompson. Well, yes. Our authority to pay for care is
quite limited under current law. Essentially, it can be
authorized only where VA lacks the ability to perform a certain
procedure such as an organ transplant, for example, or when it
would be more costly for VA, in terms of the beneficiary travel
reimbursement it would have to pay the veteran, then we could
do the care ourselves. In other words, where it would be more
economical for the Department to contract for the care
elsewhere than to perform it itself. So current law authorizing
fee-basis care is quite limited, and so some of the provisions,
for example, for the pilot that would require us to expand our
use of it, we would be limited by current law from performing.
Senator Jeffords. Dr. Kussman, in the next few months
Vermont will welcome home some 300 National Guard members known
as Task Force Saver. This Guard unit is currently stationed in
Ramadi, and has had a very high casualty rate. I think that
these men and women are going to need significant help with
readjustment upon their return. Unless we put more money into
these programs, I am worried that the servicemembers who do not
live near any military installations will fall through the
cracks.
Do you have a plan for treating these veterans within
existing funding levels?
Dr. Kussman. Yes, sir. We have worked very hard with our
Seamless Transition Office, and coordinating with the different
States. I think that one of your neighbor States, New
Hampshire, had a very good program that was put together with
the State Adjutant General and the State Veterans' Affairs
people, when the unit came back, very quickly when they had
their first organization, the families were brought in, the Vet
Centers were there, members of the VBA and VHA were there from
our regional centers, as well as the hospitals, to provide them
the full depth and breadth of services. This is regularly being
coordinated. I think we have been reasonably successful in
other States.
This is something that is new to us. Each war has different
things in it that we have to learn. One is what the Chairman
mentioned about the survival and the polytrauma that we are
seeing. I think the number is, if you do not die on the
battlefield and you can get to somebody beyond your buddy, you
have a 98.7 percent chance of survival, unheard of. The only
unfortunate thing related to it is that many people who would
have died from chest and abdominal wounds are not, and are
surviving with that.
And the other things that we are learning is how to deal
with large numbers of National Guard and Reserves, and how we
assist people dealing with the full spectrum of readjustment
issues. Most people do not get PTSD, but most people have some
readjustment issues that are normal responses to abnormal
situations. And we have to provide the infrastructure and the
people to allow people to get to whatever they need. Most
people seem to do fine, when they reintegrate themselves,
having a supportive family, clergy, friends, and they do get by
after a short period of time of maybe some lack of sleep or
adjustments. Myself, from my previous life, I had the same
things.
There are others along that spectrum who need some
specialized assistance with psychologists, social workers,
psychiatrists. But they frequently only need one or two short
interventions to realize that the symptoms they are having do
not mean they are sick, and the last thing we want to do it
stigmatize it. And then along that spectrum, there are people
who have true major issues related to PTSD, and we certainly
have to be ready to treat that.
We spent a lot of money and effort putting together
infrastructure to adjust this. And actually, I think that we
are very proud of what we have put together to take care of the
readjustment issues related to the full spectrum of
servicemembers.
So we will stand ready to help Vermont, just like we have
with any other State in the union.
Senator Jeffords. Thank you. I have another question, but--
--
Chairman Craig. Go ahead, proceed.
Senator Jeffords. Dr. Kussman, Senator Salazar's rural
health legislation would establish up to five Centers of
Excellence for rural health research. I am sure you are aware
that some of the research that has illuminated the problems
comes from a paper authored by the VA's on Dr. Jonathan Perlin,
and Vermonter Bill Weeks, at the White River Junction VA Center
for Outcomes Research.
In 1999, Dr. Kaiser realized that delivery of care to
veterans in rural areas was a problem for the VA. He set aside
$7.25 million each year for several years to fund the Rural
Health Initiative Study, this problem, and provided suggestions
for addressing it.
The significant work that has been produced by Dr. Weeks in
the Center for Outcomes Research is now invaluable as the VA
focuses on the gap in care. It seems to me that creating the
centers as designed in Senator Salazar's legislation would
augment the work that has already been done by VA, and bring
this research into sharper focus.
Are you aware of the work done by the Rural Health
Initiative? And if the VA does not plan to support Senator
Salazar's entire bill, would you support the creation of these
Centers of Excellence?
Dr. Kussman. Thank you for the question. Yes, I am aware of
the study, and Senator Salazar mentioned it several times
already. I think that the issues that have come out of that
study are important things. They are the focus of what we need
to do in support of rural health. I think that the concept of a
Center of Excellence--I do not know whether it is 5 or 1 that
we need--is certainly something that we could work together on
to move forward in assisting this, and trying to solve issues
related to this issue.
Chairman Craig. Jim, Thank you very much.
Let's now turn to Senator Richard Burr.
Richard.
STATEMENT OF HON. RICHARD BURR,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Dr. Kussman, I find it quite intriguing that
there are five pages of testimony as it relates to S. 2433, but
Mr. Thompson summed it up in one sentence. He said, ``We do not
have the authority to do what you have suggested in this
bill.'' But there are five pages in your testimony that suggest
the reasons why the VA could not be supportive or should not be
supportive of this. Let me read some of them.
``This would cause significant confusion and disruption
across the organizational lines, both among and within the
Administration.
``This bill would dilute control from the Administration
with respect to specific activities, personnel, resources.
``This would increase the potential for fragmented
services, wastes, inconsistency, if not unequal treatment of
veterans based solely on their geographical location.''
The bill was written because of their geographical
location. That is, in fact, what the whole thing is about.
Clearly, the second panel does not share the confidence of the
Veterans' Administration either on prosthetics, which the
Chairman is interested in. I would hope there would be some
that would express some concerns about our inability to provide
an equal level of care to the rural veterans.
Now, we may not have it perfect. I am not sure that we are
off by five pages. Let me assure you, Mr. Thompson, if it is
the authority that you need, you are in the right spot for us
to be able to fix it.
But I would ask you to focus, for just a second, on the
veteran that lives in the rural area, not on your
organizational flow chart and whether we screw that up. I would
ask you to focus on the veteran and ask yourself: are we
providing them the level of care that we are providing
everybody else? Inequality may exist today, but not after
implementation of this legislation. I think that is why, in
fact, we have raised the question.
You went into great depth to talk about the cost of
implementation of this, and I think you ended up with a final
cost of well over $1 billion. That very well could be the case.
I mean, I, as much as anybody in here, respect the progress
that the VA has made, the passion that each one of you puts
into the job, what I truly think is the focus on the population
that you are charged with servicing. What I do not see is a
cost estimate on what happens if we do not deliver the care to
those individuals in a preventive way. If in fact, because they
cannot travel to where they get that preventive care at the
earliest stage of a problem, they become an inpatient
participant for an extended period of time, and it was all
because they could not get there. They did not have the
resources. They did not have the means.
Let me suggest to you that I think we can do a better job
with rural veterans. 60 minutes is 60 miles where I live. That
is how rural it is. You are not dodging stoplights. But I see,
literally, every time I go home, individuals that tell me they
cannot get to the VA facilities. I am in a State that has the
fastest growing veteran retiree population in America. It
probably will not be rural tomorrow, or 10 years from now. It
is all going to be urban if it continues the way that it is
going to. But I take a little bit of offense that any of the
points of why this legislation would be inappropriate is
because it would screw up the organizational flow chart at the
VA.
I give you those words to share with you a little bit of
frustration in the points that you have brought up. And I
challenge you, and Dr. Perlin, and the Secretary, that if you
do not like this, come back to us with something that does
address what we think is a real concern. Don't just come up and
suggest you are not going to be supportive of the legislation
because it changes things in a way that people might be
uncomfortable with inside the Veterans' Administration, because
our focus, day in and day out, are the people on the outside of
the Veterans' Administration.
I thank the Chair.
Chairman Craig. Thank you.
Let us now turn to Senator Thune.
John.
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Thank you, Mr. Chairman, and I appreciate as
well the panel for being here and the veteran service
organizations that are represented here today and that will
testify later. I appreciate your input. And, Mr. Chairman,
having a hearing on these pieces of legislation that Members of
this Committee have introduced, I echo what my colleague from
North Carolina in many respects said about the criticisms of
the bill that he and I and Senator Salazar have introduced
regarding rural veterans. The only thing, I think, I would say
maybe is in South Dakota 60 minutes is about 80 miles, perhaps,
instead of 60 miles in North Carolina.
Chairman Craig. That is all depending on who is watching,
isn't it?
[Laughter.]
Senator Thune. Exactly. But, in any case, the distances are
vast, and one of the things that I am concerned about, too,
being from a very rural State--in fact, South Dakota is within
the largest and most rural VISN in the country, and it is an
area that is made up of a lot of veterans. We have a high
proportion of our population that have served the country in my
State, and many of these veterans do live in very rural,
geographically remote areas. And one of the things that I hear,
probably more often than anything else from veterans as I
travel across South Dakota, is access to facilities. And we
have been working for an amendment to the supplemental last
week that would have put more money into facilities so that we
could do a better job of building some of the community-based
outpatient clinics which have served as, I think, a very
effective model when it comes to outpatient care in rural
areas.
But we still have an awful lot of people who travel several
hours to access care, and I think that there are measures
proposed in some of these bills that would address that. With
respect to Senator Salazar's bill--and as I said, Senator Burr
and I are cosponsors of that--one of the criticism that has
been leveled--and I agree, I cannot imagine that a criticism of
that would be that it somehow messes up an organizational
chart. But one of the arguments or criticisms that has been
leveled is the cost, that it would cost about $1 billion to
enact that legislation. And one other issue that has been
raised is the issue of fee-basis care. I know that veteran
service organizations are concerned about a provision in the
bill that would strengthen the use of fee-basis care because it
runs counter to the principle of reducing the amount of funding
that the VA spends on higher cost contracted services.
But I am interested in hearing, I guess, in greater detail
a little bit about some of those criticisms. First, with
respect to the issue of cost, could you perhaps explain to us
how you arrived at that additional $1 billion cost associated
with Senate bill 2433. And then perhaps second, why, when it
comes to serving the needs of veterans in very rural areas,
giving them access to contract care would not make some sense?
When you get out in rural parts of South Dakota or Colorado, or
North Carolina, for that matter, certainly in Idaho, it seems
to me that would be a reasonable, sensible approach to take.
So I am interested in hearing your reaction both to the
issue of cost, the $1 billion cost that you have said this
would entail; and, second, your thoughts on the issue of
contract services.
Dr. Kussman. Thank you, Senator. The specifics of how this
was generated, it had to do with the demonstration projects and
the additional beneficiary costs as well as fee-basing. And I
don't have the specifics with me, but I would be happy to get
those to you of how that was specifically developed.
You know, both from your questions and Senator Burr's
questions, I don't--and, again, I feel a little awkward because
we are not against dealing with rural health, and we are not
insensitive to the needs of all the things that you have
articulated. The question is how to go about doing that.
I don't think that any of us are hung up on wire diagrams,
but the issue is how do we maximally benefit the veteran with
our ability to do our job. Developing an Assistant Secretary at
the VA level would not be perceived by us as a form and
function that would be advantageous to the veteran. This is the
responsibility of the Under Secretaries to the Secretary of VBA
and the VHA. So if it appears that we are against it on the
basis of some arbitrary and capricious wire diagramming, that
is not the case. The question is how do we provide our mission
and maximally utilize our ability to meet the mission.
As far as fee-basing, clearly that is an issue, and we
again would appreciate the opportunity to work with you and
Senator Salazar and Senator Burr to work on some of the
strengths of the bill and some of the things that we find that
would not be exactly where we would find the best way to do the
job.
Senator Thune. Well, I appreciate that, and any detail you
can provide on the cost estimates that you have done associated
with the bill would be helpful, if you could. And I would
accept that offer to work with you, but with an eye toward the
veteran out there and what can we do to improve quality of
services to veterans across this country and making sure that
all have good access to care rather than, again, how it might
impact the organizational structure in Washington. Ultimately,
we want to do what is in the best interest of the veteran. We
want to have an eye on the veteran out there across the
country. But we would certainly welcome your input on how we
might address the concerns that you have raised within our
bill. But clearly, I think that this is an effort which is
based upon a very valid concern raised by veteran constituents
that we have, that we represent in some of the more rural areas
of the country, and a need that I think we would like to see
more fully addressed.
So that was the purpose of the legislation, and we look
forward to working with you on it.
Thank you, Mr. Chairman.
Chairman Craig. Dr. Kussman, I would like to do another
round, but I think time is going to be limited, so we are going
to hold the record open a certain period of time. If any of our
colleagues have additional questions to ask, we will be
submitting them to you in writing. These are obviously very
important issues. You can hear the concern and passion
expressed here as it relates to at least one area, our rural
veterans. I think it is something that, obviously, this
Committee and Members will pursue in working with you so that
we can make sure we get it right and those services are
delivered.
Gentlemen, thank you very much for your time. We will
dismiss you and ask the second panel to come forward.
Dr. Kussman. Thank you, sir.
Chairman Craig. Dr. Kussman, thank you.
Gentlemen, thank you very much. If the Committee would come
to order, please.
Our second panel is made up of Robert Shaw, Legislative
Chairman, National Association of State Veterans Homes from
Rifle, Colorado. Robert, we are pleased to have you with us.
John Melia, Executive Director, Wounded Warrior Project, from
Roanoke, Virginia. Carl Blake, Associate Legislative Director,
Paralyzed Veterans of America here in Washington. Juan Lara--
Juan, welcome--Assistant Director, National Legislative
Commission, the American Legion, here in Washington. And Adrian
Atizado, Assistant Legislative Director, Disabled American
Veterans.
Gentlemen, thank you for being with us today.
Mr. Shaw, we will start with you.
STATEMENT OF ROBERT SHAW, NATIONAL LEGISLATIVE CHAIRMAN,
NATIONAL ASSOCIATION OF STATE VETERANS HOMES; AND
ADMINISTRATOR, STATE VETERANS CENTER, RIFLE, COLORADO
Mr. Shaw. Chairman Craig, Ranking Member Akaka, Senator
Burr, Senator Salazar, Senator Jeffords, and other
distinguished Members of the Senate Veterans' Affairs
Committee, thank you for inviting me to testify today on behalf
of the National Association of State Veterans Homes. As the
Legislative Chair of NASVH, I want to express our strongest
support for Senate bill 2762, the Veterans Long-Term Care
Security Act of 2006.
Mr. Chairman, I have testified before the Committee earlier
this year at a field hearing that you and Senator Akaka
conducted in Hawaii looking at that State's particular health
care needs for veterans. At that time, I raised several issues
of concern for the State Home system, in general, and also
offered a possible model to help improve delivery of long-term
care services in States like Hawaii, where you have a veterans
population that is dispersed over a large rural area.
Over the past several months, we have been working with
both your staff and Senator Akaka's staff in a bipartisan
manner to assemble legislation that would address these
concerns. In that spirit, we are grateful to Senator Akaka for
introducing Senate bill 2762, the Veterans Long-Term Care
Security Act of 2006, earlier this week, and to you, for
including it on today's agenda.
Mr. Chairman, the State Home program is an essential
partnership between the Federal Government and the States, both
of whom have made major and lasting investments in providing
benefits and services to veterans. The Veterans Long-Term Care
Security Act respects that commitment, enhances it, and extends
continuing support for the work done by the State Homes. Let me
briefly highlight why this legislation is so important to
veterans.
S. 2762 would help protect the State Home program per diem
from sudden and disruptive reductions by requiring the VA
Secretary to consult with stakeholders and report to Congress
before implementing such changes to the per diem program. Mr.
Chairman, as I am sure you will recall, last year the
Administration made budget proposals that would have
dramatically reduced Federal support for the State Home
program, changes that would have drastically altered the
current system of State home care. We are pleased that those
proposals were wisely rejected by Congress and not resurrected
this year in this year's budget submission. Given the
significant and growing long-term care needs of veterans, as
well as the significant investment in the State Home program
made by the States, we believe it is prudent to ensure that
significant reductions of support of the State Home program
should only be made in coordination with the States as well as
with full and informed consent of Congress.
S. 2762 would also help provide equity of access to VA
resources for service-connected veterans residing in State
Homes. Currently, VA is not authorized to place or pay for
service-connected veterans in State Homes, nor provide them
with prescription medications. This legislation would authorize
but not require the VA to place service-connected veterans in
State Home facilities, specifically those who need long-term
care due to a service-connected disability or who have a
service-connected disability rating of 70 percent or greater.
The bill would then require VA to reimburse State Veterans
Homes the same amount VA pays to private nursing homes when VA
places service-connected veterans in those facilities.
To correct a similar inequity, S. 2762 would authorize VA
to furnish prescription medications to service-connected
veterans residing in State Veterans Homes for service-connected
conditions and for any conditions of veterans rated 50 percent
or more disabled. Currently, this benefit is denied to service-
connected veterans residing in State Homes, even though non-
service-connected veterans who are housebound or in receipt of
aid-and-attendance benefits do receive them.
Finally, S. 2762 includes provisions designed to address
gaps in State home care, particularly in rural and remote areas
such as the Neighbor Islands of Hawaii, Idaho, Alaska, South
Dakota, North Carolina, Wyoming, Kansas, and other rural
States. In order to fill in these gaps and provide additional
options to veterans and flexibility to States, S. 2762 would
allow VA the option to deem an existing facility to be a State
Home for purposes of product in the VA per diem grant program.
This would allow a State to create smaller long-term care units
within larger health care facilities when this would better
serve the needs of veterans in that State. The bill contains
safeguards to ensure that no State would use this deeming
authority to exceed its allotted ceiling of State Home beds
under the Millennium Health Care Act regulations.
S. 2762 would build upon the successful model employed by
Alaska through their ``Pioneer Homes'' system. It would allow
States to pursue innovative collaborations with existing health
care systems in order to expand availability of long-term care
services for veterans when such States are unable to cost-
effectively justify the establishment of large, stand-alone
State Veterans Homes in remote areas.
Mr. Chairman and Members of the Committee, we look forward
to working with you to strengthen veteran's long-term care
services administered by the State Veterans Home network and
VA. The quality care provided by our members in our association
is an indispensable, cost-effective, and successful element of
the Nation's provision of comprehensive health care to
veterans, and S. 2762, the Veterans Long-Term Care Security
Act, would help ensure the continuation of this vital State-
Federal partnership.
Mr. Chairman, this concludes my statement. Thank you for
permitting me to testify today on behalf of the National
Association of State Veterans Homes. I am pleased to answer any
questions that you may have.
[The prepared statement of Mr. Shaw follows:]
Prepared Statement of Robert Shaw, National Legislative Chairman,
National Association of State Veterans Homes; and Administrator, State
Veterans Center, Rifle, Colorado
Chairman Craig, Ranking Member Akaka and other distinguished
Members of the Senate Veterans' Affairs Committee, thank you for
inviting the National Association of State Veterans Homes (NASVH) to
testify at this legislative hearing. As the Legislative Chair of NASVH,
I am honored to be here with you this morning to express our support
for legislation that we believe would significantly contribute to
strengthening the delivery of long term care services to veterans.
Our Association is an all-volunteer, non-profit organization
founded over a half-century ago by administrators of State Veterans
Homes to promote the common interests of the Homes and the elderly,
disabled veterans and their family members that we serve. The
membership of NASVH consists of the administrators and senior staffs of
119 state-operated Veterans Homes in 47 States and the Commonwealth of
Puerto Rico. We will soon add a new home in a 48th State, which happens
to be the State Veterans Home in Hilo, now under construction on the
Big Island of Hawaii.
State Homes provide nursing home care in 114 homes, domiciliary
care in 52 locations, and hospital-type care in five of our homes. Our
State Homes presently provide over 27,500 resident beds for veterans,
of which more than 21,000 are nursing home beds. VA supports State
Homes through payment of a per diem allowance for each veteran VA
certifies to be in need of the types of care we provide.
Earlier this year on January 9th, I was honored to testify at a
field hearing the Committee held in Hawaii looking at that State's
particular health care needs for veterans. Since that time, we have
been working with Senator Akaka's staff and the Committee's staff to
assemble a bill that would address many of the concerns we raised at
that hearing. I will not repeat all those concerns in detail here, but
I invite the Committee to review our legislative goals discussed during
that hearing; goals that were recently confirmed by resolutions adopted
unanimously at our association's mid-winter conference held here in
Washington, DC this past March.
Mr. Chairman, we have always appreciated the bipartisan spirit of
the Veterans' Affairs Committee, and we are pleased to see that
longstanding tradition continue under your leadership. In that spirit,
we are grateful to Senator Akaka for introducing the ``Veterans Long
Term Care Security Act of 2006.'' This legislation offers three
important changes in VA long term care policy that we hope the
Committee will favorably consider:
Essential communications and planning with stakeholders;
Equity of access to VA resources and benefits; and,
An alternative model to traditional construction of new
State Homes.
The State Home program is a partnership between the Federal
Government and the States, both of whom have made major and lasting
investments in providing benefits and services to veterans. The
Veterans Long Term Care Security Act respects that commitment, enhances
it and extends continuing support for the work our Homes do for elderly
and disabled veterans and their dependents. The bill certainly confirms
what the Senate itself expressed in passing S. RES. 417 earlier this
year, a bipartisan resolution introduced by Senator Lautenberg with 35
cosponsors, and we want to thank you, Mr. Chairman, Senators Akaka,
Isakson, Hutchison, and Salazar, as well as Majority Leader Frist and
several former Members of this Committee for your cosponsorship of this
resolution. We sincerely appreciate that support and expression of
trust in what we do for veterans.
Mr. Chairman, let me briefly explain the major provisions of the
Veterans Long Term Care Security Act, which we believe will help to
stabilize and strengthen the State Home program.
The first policy enhancement would protect the per diem program
from sudden cuts that could prove extremely disruptive to providing
care to elderly veterans. This provision would require the Secretary of
the Department of Veterans Affairs to consult with stakeholders and
report to Congress before implementing any reductions of Federal
support for per diem payments. The bill would require VA to consult
directly with those most responsible for the management of State Home
programs--the Governors of the States, the State Homes themselves, and
other national veterans' service organizations with expertise. The
Secretary would then have to submit a report to the Veterans Affairs'
Committees in the Senate and House explaining the reasons for, and
affect of, such proposed reductions at least twelve months prior to
their taking affect.
Mr. Chairman, as you will recall, last year the Administration made
several budget proposals to dramatically reduce Federal support for the
State Home program; cuts that would have had severe and lasting
negative consequences for long term care services for veterans. Those
ill-fated proposals, which were wisely rejected by Congress, would have
drastically altered the current system of State Home care as authorized
in Chapters 17 and 81 of Title 38, United States Code. Given the
significant and growing long term care needs of veterans, as well as
the significant investment in the State Home program by the States, we
believe it is prudent to ensure that significant reductions of support
for the State Home program should be made in coordination with the
States, and with the full and informed consent of Congress. The
proposed consultation and reporting requirements contained in the
legislation would help ensure just that and we strongly support these
provisions.
The second policy would help to provide equity of access to VA
resources for service-connected veterans residing in State Homes.
Currently, VA is not authorized to place or pay for service-connected
veterans in State Homes, nor provide them with prescription
medications. For several years we have discussed with VA officials our
interest in both these issues, but VA has not taken any actions to
remedy these inequities. The legislation would authorize--but would not
require--VA to place service-connected veterans in State Home
facilities; specifically those who need long term care due to a
service-connected disability or who have a service-connected disability
rating of 70 percent or greater. The bill would also require VA to
reimburse State Veterans Homes the same amounts VA pays to private
nursing homes when VA places veterans in those facilities under the
authority of section 1720 of Title 38, United States Code.
To correct a similar inequity, the bill would authorize VA to
furnish prescription medications to service-connected veterans residing
in State veterans homes who need such medications for those service-
connected conditions, and for any conditions of veterans with service-
connected disabilities rated at 50 percent disabling or higher. These
service-connected veterans are denied that benefit today in State
Homes, even though nonservice-connected veterans who reside in our
Homes for whom VA has granted a ``housebound'' adjudication or who are
in receipt of VA regular aid-and-attendance benefits, do receive their
continuing VA medications. We believe service-connected veterans should
receive equitable benefits compared to nonservice-connected veterans
and strongly support this change in policy.
The third policy change in the bill is designed to address gaps in
State home care coverage, particularly in rural and remote areas such
as the Neighbor Islands of Hawaii, or parts of Idaho, Alaska, Montana,
Wyoming, Kansas and other large rural States. Given the current system
for funding construction of new State Homes, care is too often
unavailable to many veterans as a practical matter due to sparse
populations, long travel distances, remoteness and even cultural
barriers. In order to fill in these gaps and provide additional options
to veterans and flexibility to States, the bill would allow VA to deem
a preexisting health care facility to be a State Home for purposes of
participation in the VA per diem program. This would allow a State to
create smaller long term care units within larger health care
facilities when this would better serve the needs of veterans in that
State. The bill contains safeguards to ensure that no State could use
this deeming authority to exceed its allotted ceiling of State Home
beds under the Millennium Act regulations.
Mr. Chairman, you will recall that we offered extensive testimony
supporting this concept at your January 9, 2006 hearing where we
reported this model had been successfully employed in Alaska through
Alaska's ``Pioneer Homes.'' I testified then, and want to reiterate
now, that this concept could be applied directly to the Hawaiian
Neighbor Islands and possibly to other remote areas in other large,
rural States. This provision would allow some States to pursue
innovative collaborations with existing health care systems in order to
provide long term care services for veterans where they are needed, and
we strongly support this provision of the bill.
Mr. Chairman, NASVH is committed to doing our part to help meet the
long-term care needs of veterans, whether they live in major
metropolitan areas or in geographically dispersed, rural and remote
places such as Idaho, Hawaii, Alaska, and States. Although a rural
State may not be able to cost-effectively justify the establishment of
large, stand-alone State veterans' nursing home, other creative
solutions such as the ``Pioneer Homes'' model we have described are
worth pursuing in existing health care facilities that meet all other
VA standards for State Home care. If enacted this legislation could be
an effective tool to bring about innovative new ways of meeting these
veterans' needs.
Mr. Chairman and Members the Committee, we look forward to working
with you to strengthen veterans' long-term care services administered
by the State Veteran Homes network. The quality care provided by our
member Homes is an indispensable, cost-effective, and successful
element of the Nation's provision of comprehensive health care to
veterans. We want to continue the very successful partnership between
our State Veterans Homes and VA in order to meet the needs of veterans
who are going to need long-term care in the years ahead. We want to be
sure that the State Veterans Home program remains an important partner
and viable option to help VA meet their obligations and the Veterans
Long Term Care Security Act would move us forward in that direction.
Mr. Chairman, this concludes my statement. Thank you for permitting
me to testify today on behalf of the National Association of State
Veterans Homes. I will be pleased to answer any questions.
Chairman Craig. Thank you very much.
Now let us turn to John Melia.
John.
STATEMENT OF JOHN MELIA, EXECUTIVE DIRECTOR, WOUNDED WARRIOR
PROJECT, ROANOKE, VIRGINIA
Mr. Melia. Chairman Craig, Ranking Member Akaka, and
Members of the Committee, I thank you for convening this
hearing and for allowing me to comment on various pieces of
legislation pending before you. I would like to limit my
remarks to Senate bill 2736, which would create five Department
of Veterans Affairs Amputee and Prosthetic Rehabilitation
Centers. Wounded Warrior Project recently proposed the creation
of these centers, and we strongly support this bill. We commit
to you our assistance to seeing this bill through to passage
and enactment.
The Wounded Warrior Project assists the men and women of
the United States Armed Forces who have been severely injured
during the ongoing global war on terror.
In assisting these wounded warriors as they reintegrate
back to civilian life, we have the opportunity to observe
systems in place and to identify where these systems may need
improvement to meet the growing patient needs. Our
conversations with literally hundreds of new amputees have led
us to one conclusion: The VA system of providing amputee
rehabilitation and prosthetic devices such as limbs,
wheelchairs, and adaptive equipment, is in dire need of
modernization and restructuring if VA is going to have any
chance of achieving its goal of providing quality health care
and fostering employability for seriously wounded veterans.
The system must be revamped in order to ensure these men
and women will have the opportunity to live full and productive
lives, including joining the modern workforce without being
hindered, by long waits for equipment, endless fittings and
refittings, and consultations with outside vendors.
The VA health care system currently finds itself, for the
first time in many years, inundated with young servicemembers
who have lost limbs in the war and who are looking to VA for
their long-term health care and prosthetic and assistive device
needs. This new amputee population is made up of people, who
just months or years ago, were in peak physical condition.
Rightfully, many still consider themselves warriors and
athletes and are determined to live active and productive lives
that include a myriad of recreational activities including
skiing, kayaking, hunting, and more. Unfortunately, unless the
VA changes the way it offers these services, it will not be
able to provide the level of care that these soldiers need and
now expect.
Let me tell you about the experiences of Staff Sergeant
Heath Calhoun and his difficulty in accessing prosthetic
services and equipment from his local VA Medical Center. On
November 7, 2003, Heath, a member of the 101st Airborne, lost
both of his legs in Iraq when his convoy was hit by a rocket-
propelled grenade. This past summer Heath rode a hand-cycle
over 4,200 miles as part of a cross-country bike ride called
Soldier Ride, which raises public awareness and support for
severely wounded servicemembers. At the completion of the ride,
Heath's hand-cycle was in desperate need of repairs, and in
late 2005, he took his bike to the local VA for repair. Heath
did not receive his bike back from them until 2 weeks ago,
meaning he was unable to ride it for 5 months.
Heath is also an active skier, and in early December of
2005, he attempted to procure a ``sit-ski'' through the VA so
that he could participate in several skiing events between
December and April, the prime ski season. Heath was told that
the first appointment he could schedule was not until February
1, 2006. Additionally, he was informed that should the doctor
approve his request for the equipment, it would take an
additional 10 days for VA approval before the purchase could be
made. And he was then told that it would take an additional 4
to 6 weeks from that point until the equipment could be
provided, in essence killing any chance that he would be able
to participate in ski activities this past winter.
When asked about his struggle, Heath had these words: ``As
an amputee I can't just take off jogging down the street to
keep in shape. I get my exercise by skiing and cycling and
using adaptive equipment provided by the VA. By making it hard
to get my equipment and exercise, it was like my doctor was
taking away my gym pass for 6 months. These people are supposed
to encourage my health and fitness, not stymie it.''
We know for a fact that Heath is not our only constituent
who has found himself frustrated as a result of seeking VA
prosthetic and rehabilitation services. Others have attempted
to access prosthetic care from their local VA medical centers
and found themselves completely dissatisfied with their
experience. Unless VA reconfigures its prosthetic system, it
runs the risk of alienating this new amputee population and
having them seek their care from non-VA providers.
Additionally, the current system runs the risk of
precluding these men and women from reentering the civilian
workforce as no employer is going to give the employee the
necessary time off necessary to navigate VA's prosthetic system
in its current structure. The VA's goal of veteran reemployment
will be seriously hindered for these wounded warriors should
they be required to spend such long periods of time navigating
the system.
The biggest problem VA's prosthetic program is facing is
that there is no systemwide consistency and coordination from
medical center to medical center. Some centers are well
equipped to evaluate the needs of servicemembers with fully
functioning prosthetic laboratories, a full range of
occupational and physical therapies, and a well-versed
prosthetic staff. Others are simply not able to evaluate or
provide for their prosthetic needs. In many cases, today's
advanced prosthetic and assistive device technology has left
local VA employees in need of substantial retraining, and these
employees often find themselves heavily reliant on the limited
expertise of outside vendors or, worse yet, salesmen.
All of this means that a wounded servicemember's ultimate
success in having a positive VA experience hinges upon their
proximity to a location with a strong prosthetic program and a
knowledgeable prosthetic representative. The creation of
amputee and prosthetic rehabilitation centers will rectify many
of these issues.
While Wounded Warrior Project is seeking these new centers
on behalf of the new generation of injured servicemembers, it
should be noted that creating these centers will greatly assist
the entire population of veterans with amputations, including
those injured in previous conflicts or later in life. All
veterans in need of prosthetic and amputee rehabilitation,
regardless of age, will benefit as a result of the legislation.
Again, we thank Chairman Craig and Ranking Member Akaka for
their sponsorship of this bill, and we pledge to work with you
on seeing this through to enactment.
[The prepared statement of Mr. Melia follows:]
Prepared Statement of John Melia, Executive Director,
Wounded Warrior Project, Roanoke, Virginia
Chairman Craig, Ranking Member Akaka, and Members of the Committee,
I thank you for convening this hearing and for allowing me the
opportunity to comment on various pieces of legislation pending before
the Committee. I would like to limit my remarks to Senate Bill 2736 (S.
2736) which would create five Department of Veterans Affairs Amputee
and Prosthetic Rehabilitation Centers. Wounded Warrior Project recently
proposed the creation of these centers and we strongly support the
bill. We commit to you our assistance to seeing this bill through to
passage and enactment.
The Wounded Warrior Project (WWP) is a nonprofit organization aimed
at assisting the men and women of the United States armed forces who
have been severely injured during the war on terrorism in Iraq,
Afghanistan and other hot spots around the world. Beginning at the
bedside of the severely wounded, WWP provides programs and services
designated to ease the burdens of these heroes and their families, aid
in the recovery process and smooth the transition back to civilian
life. We strive to fill the vital need for a coordinated, united effort
to enable wounded veterans to aid and assist each other and to readjust
to civilian life.
In assisting these wounded warriors as they reintegrate back to
civilian life we have the opportunity to observe various systems in
place and to identify where these systems may need improvement to meet
the growing patient needs that have arisen as a result of the ongoing
war on terror. One program in need of modernization and restructuring
is the system through which the Department of Veterans Affairs (VA)
provides all veterans who have lost limbs, including newly injured
servicemembers from the ongoing military conflicts, with the necessary
long term physical and occupational therapy as well as their prosthetic
appliances. These appliances include all of the prosthetic limbs,
wheelchairs, and adaptive sports equipment these injured heroes rely on
to help put their broken lives and bodies back together.
As a result of the current Global War on Terror the VA Healthcare
system finds itself, for the first time in many years, inundated with
young servicemembers who have lost limbs in the war and who are looking
to the VA for their long-term health care and prosthetic and assistive
device needs. This new amputee population is made up of young men and
women who, just months ago, were in peak physical condition on the
battlefields of war prior to the traumatic event that has taken their
limbs. Other than their amputations, many are still in, or are close
to, that prime physical conditioning and they are now looking to the VA
to maintain that lifestyle as they move forward. Rightfully, many still
view themselves as warriors or athletes and they are more determined
than ever to live active and productive lives that include a myriad of
recreational activities such as skiing, kayaking, hunting, etc.
Unfortunately, unless the VA changes the way it offers the full range
of prosthetic devices and rehabilitation services, it is simply not
going to be able to provide the level of care that these soldiers are
in need of.
I would like to tell you about the experiences of wounded warrior
Heath Calhoun in accessing prosthetic services and equipment from his
local VA Medical Center as an example of the struggle that severely
injured servicemembers are facing as they transition out of the
Department of Defense medical system and into the VA health care
system. On November 7, 2003, Heath, a Staff Sergeant in the United
States Army, lost both of his legs in Iraq when his convoy was hit by a
rocket propelled grenade. This past summer Heath rode a hand-cycle over
4,200 miles as part of a cross country bike riding program called
Soldier Ride which raises public awareness and support for severely
wounded servicemembers. Upon completion of the ride Heath's hand-cycle
was in need of repairs so, in late December 2005, he took his bike to
the VA Medical Center in Salem, VA. Heath did not receive his bike back
from the VA until 2 weeks ago, meaning that he was unable to ride for 5
months.
Heath is also an active skier. In early December of 2005, Heath
attempted to procure a ``sit-ski'' through the Salem VAMC so that he
could participate in several skiing events that run between December
and April which is prime ski season. Upon reaching out to the VA for
this equipment, Heath was told that the first appointment he could
schedule was not until February 1st, 2006. Additionally, he was
informed that upon his appointment, should the Doctor approve his
request for this equipment, it would then take an additional 10 days
for full VA approval to be obtained before the purchase could be made.
Heath was then told it would take an additional 4-6 weeks from that
point until the equipment would be provided, in essence killing any
chance he would be able to participate in any of that season's ski
events.
When asked about his struggles with his local VA, Heath said,
``As an amputee I can't just take off jogging down the street
to keep in shape. I get my exercise by skiing and cycling. By
making it hard to get my equipment and exercise it was like my
doctor was taking away my gym pass for 6 months. These people
are supposed to encourage health and fitness, not stymie it.''
Fortunately for Heath, WWP was able to put him in contact with a
high-ranking VA prosthetic specialist who assisted him in obtaining the
equipment in just 5 weeks. Heath was then able to ski in several events
in February, March and April. Not all wounded servicemembers will be
that fortunate and we know for a fact that Heath is not the only one of
our constituents who has found himself frustrated as a result of
seeking VA prosthetic and rehabilitation services. VA must reconfigure
its prosthetic system in order to meet the needs and expectations of
Heath Calhoun and his fellow amputees or it runs the risk of alienating
this population and having them seek all of their care from non-VA
providers.
The biggest problem facing the VA's prosthetics program is that
there is no system wide consistency and coordination from medical
center to medical center. Some centers are well equipped to evaluate
the needs of the individual servicemember with fully functioning
prosthetic laboratories, a full range of physical and occupational
therapies, and a well-versed prosthetic representative or prosthetist.
Others simply are not able to evaluate or provide the prosthetic needs
of the newly injured servicemember. Therefore, a wounded
servicemember's ultimate success hinges upon their proximity to a
location with a strong prosthetic program and a knowledgeable
prosthetic representative.
The creation of Amputee and Prosthetic Rehabilitation Centers, as
proposed in S. 2736, would rectify many of these issues. While these
Centers would in no way replace the current prosthetic system at each
medical center, they would be responsible for the system-wide
coordination of the physical and occupational therapy and prosthetic
care provided to veterans with amputations and would ensure the quality
of care regardless of where the patient was physically located. They
would be the central location for the development and implementation of
standardized referral protocols for servicemembers in need of higher
levels of physical or occupational therapy as well as higher level
prosthetic needs. They would be responsible for the standards of
education and training of the prosthetic representatives and
prosthetists at all of the VA Medical Centers around the country and
would ensure they were able to easily refer patients to the Amputee
Centers whenever appropriate. It is also our hope that much of the
amputee or prosthetic related research and development projects will be
facilitated at these Centers to ensure the projects are consistent with
the needs and issues of the related patient population.
With respect to infrastructure and construction we believe these
new centers can be created using existing VA infrastructure with the
realignment of certain facilities. Startup funding would be utilized
for minor construction projects, establishment of Gait Labs, new
equipment, recruitment, new salary dollars, continuing education, and
travel dollars for staff and potential patients.
Finally, while Wounded Warrior Project is seeking these new centers
on behalf of the new generation of injured soldiers it should be noted
that creating these centers will greatly assist the entire population
of veterans with amputations, including those injured in previous
conflicts or later in life. All veterans in need of prosthetic and
amputee rehabilitation, regardless of age, will benefit as a result of
this legislation. Again, we thank Chairman Craig and Ranking Member
Akaka for their sponsorship of this bill and we pledge to work with you
on seeing it through to enactment.
Chairman Craig. John, thank you.
Now let's turn to Carl Blake. Welcome before the Committee
again. Good to see you.
STATEMENT OF CARL BLAKE, SENIOR ASSOCIATE LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA, WASHINGTON, DC
Mr. Blake. Thank you, Mr. Chairman, Ranking Member Akaka,
and Members of the Committee, PVA would like to thank you for
the opportunity to testify today on the proposed legislation.
PVA opposes the provisions of S. 2634 that would repeal the
term of office and the appointment commission for both the
Under Secretary for Health and the Under Secretary for
Benefits. We are particularly concerned about the provision in
the draft bill to eliminate the role of the appointment
commission. The commission was created as a buffer to isolate
the political process from the selection process by allowing
the commissioners to screen and actually select the core
candidates. By eliminating this commission, there would be no
counterbalance at all in a future Secretary's choice or a
future White House's choice in seeking appointment purely by
partisan objective or potential preconceived disinterest in the
mission of the VA.
PVA is fully aware of the challenge that the VA faces in
trying to address the health care needs of rural veterans. We
have no objections to the establishment of an Assistant
Secretary as outlined in S. 2433. We do, however, have some
concerns about the pilot program authorized by this
legislation.
The program would give VA additional leverage to broadened
contracting out of health care services to veterans in
geographically remote or rural areas. We believe that this
pilot program could set a dangerous precedent, encouraging
those who would like to see the VA ultimately privatized.
Current law limits VA in contracting for private health
care services to instances in which VA facilities are incapable
of providing necessary care to a veteran; when VA facilities
are geographically inaccessible to a veteran for necessary
care; when emergency medical services prevents a veteran from
receiving care in a VA facility, or to complete an episode of
VA care. The VA could better meet the demands of rural veterans
if it was more judicious in its application of the fee-for-
service program that it already has the authority to do.
We also believe that the VA could address the needs of
veterans through broad application of the hub-and-spoke model
used by other services within the VA. A veteran can get his or
her basic care at a community-based outpatient clinic. However,
if the veteran requires more intensive care or a special
procedure or needs some other type of care, he or she can then
be referred to a larger VA medical center. Even spinal cord-
injured patients within the VA rely on the hub-and-spoke model.
PVA strongly supports S. 1537, a bill that would codify the
Parkinson's Disease and Multiple Sclerosis Centers of
Excellence. We would like to express our sincere thanks to
Senator Akaka for introducing this legislation, and to you,
Senator Craig, for placing it on the agenda today. This
proposal appropriately recognizes the successful strategy of
the VHA to focus its systemwide service and research expertise
on two critical care segments of the veteran population.
Since 1997, PVA has worked closely with VA MS clinicians
and administrators, as well as with private MS providers and
advocates, to address the patchwork service delivery for
veterans with MS.
The designation of two MS Centers of Excellence located in
Baltimore and in the Seattle/Portland area provides open access
to centers engaged in marshaling VA expertise in diagnosis,
service delivery, research, and education. Furthermore, these
programs are made available across the country through the same
hub-and-spoke model which I have spoken of.
PVA supports S. 2500, a bill that would enhance the
counseling and readjustment services provided by the VA. It
only makes sense that National Guardsmen and reservists, who
are playing a significant role in the combat operations
overseas, would have access to this counseling.
PVA also supports the creation of the Amputation and
Prosthetic Rehabilitation Centers outlined by the proposed
legislation. We must emphasize, however, that additional real
dollars will likely be needed to establish these centers.
We would also like the Committee to consider going a step
further as these centers are created. VHA should be required to
partner with manufacturers, dealers, payers, and advocates to
develop performance test standards for amputee and prosthetic
devices. An example of these types of test standards is the
American National Standards Institute (ANSI) and Rehabilitation
Engineering and Assistive Technology Society of North America
(RESNA) Wheelchair Performance Standards. These standards are a
collaborative effort with specific impacts on wheelchair
research and development, consumer disclosure, and payer
decisions. PVA believes that these centers could be the
spearhead for development of evidence-based performance test
standards for amputee and prosthetic devices.
PVA supports S. 2762. We believe that this legislation is
both timely and necessary to preserve and protect the State
Veterans Home program and the thousands of veterans who depend
on it. PVA urges the Committee to preserve VA per diem rates
and construction funding for State Veterans Homes.
Mr. Chairman, I would like to thank you again for the
opportunity to testify today, and I would be happy to answer
any questions that you might have.
[The prepared statement of Mr. Blake follows:]
Prepared Statement of Carl Blake, Senior Associate Legislative
Director, Paralyzed Veterans of America, Washington, DC
Chairman Craig, Ranking Member Akaka, and Members of the Committee,
Paralyzed Veterans of America (PVA) would like to thank you for the
opportunity to testify today on the proposed legislation. We are
particularly pleased that this Committee is considering legislation
that would help veterans with special needs, particularly veterans with
Parkinson's disease and Multiple Sclerosis.
S. 2634
PVA opposes the provisions of S. 2634 that would repeal the term of
office and the requirement for a commission on appointment for both the
Under Secretary for Health and the Under Secretary for Benefits of the
Department of Veterans Affairs (VA). Currently, each Under Secretary
serves for a specific 4-year term. PVA believes that the 4-year term
requirement serves a very valuable function. Under current law, once
the Under Secretary has served the 4-year term, that individual,
wishing to continue service, must be re-confirmed by the U.S. Senate.
The advice and consent of the Senate Committee on Veterans' Affairs and
the Senate as a whole provides additional oversight over the conduct of
the Under Secretaries. The reconfirmation also provides an opportunity
for others with interests in the operation of the Veterans Health
Administration and the Veterans Benefits Administration and their chief
administrative officers to have the ability to opt into this process
too and re-visit the qualifications and track record of the
individuals. Just as initial confirmation at the beginning of the Under
Secretary's term serves an outside objective oversight function, so
does this 4-year end-of-term look-back process let the office holder,
and all others, know that the position is beholden to more than just
one Secretary and one White House.
For many of the same reasons we oppose the provision in the draft
bill to eliminate the role of the appointment commission. Under current
law, once there is a vacancy in the Under Secretary position, the
Secretary of Veterans Affairs is required to appoint a commission drawn
from specific individuals and interest groups, including veterans'
service organizations. The commission is called on to screen all
candidates for the job, select three of the top candidates, forward
those names through the Secretary to the White House where one will be
chosen from that group.
We are as convinced today, just as those who created this process
in the original legislation were, that the selection of these Under
Secretaries, because of their direct roles over the health care and
benefits of millions of veterans, must be as objective as possible. The
individual must be chosen on the merits without a hint of political
considerations. The commission was created as a buffer to isolate the
political process from the selection process by allowing the
commissioners to screen and actually select the core candidates. We
have no qualms about the current Secretary's ability and sincerity in
choosing, basically on his own, a candidate for submission to the White
House who would certainly meet all the qualifications we could expect
in an Under Secretary. But who knows what lies down the road in future
Administrations and with future Secretary's of Veterans Affairs. By
eliminating this commission there would be no counter balance at all in
a future Secretary's choice, or the choice of some future White House
seeking appointment purely by partisan objective or potential
preconceived disinterest in the mission of the VA. We strongly urge the
Committee not to support changing their role and this process.
S. 2433, THE ``RURAL VETERANS CARE ACT''
PVA is fully aware of the challenges the VA faces every day to
provide timely access to quality health care for veterans who live in
rural areas of the country. However, we are concerned that in
addressing the problem of access for these veterans, the long-term
viability of the VA health care system may be threatened. PVA members
rely on the direct services provided by VA health care facilities
recognizing the fact that they do not always live close to the
facility. The services provided by VA, particularly specialized
services like spinal cord injury care, are unmatched in the private
sector. If a larger pool of veterans is sent into the private sector
for health care, the diversity of services and expertise in different
fields is placed in jeopardy.
We have no objections to the establishment of an Assistant
Secretary for Rural Veterans. We recognize the need for a senior
administrator in the VA that can address the needs of rural veterans as
policies are formulated for the larger veterans population. The
requirement to consult with other Federal, State, and local agencies is
particularly important. Agencies such as the Indian Health Service have
dealt with rural health care issues for quite a long time.
PVA has serious concerns about the pilot program authorized by this
legislation. This program would give VA additional leverage to broaden
contracting out of health care services to veterans in geographically
remote or rural areas. If you review the early stages of VA's Project
HERO, it is apparent that this is a direction that some VA senior
leadership would like to go. We believe that this pilot program would
set a dangerous precedent, encouraging those who would like to see the
VA privatized. Privatization is ultimately a means for the Federal
Government to shift its responsibility of caring for the men and women
who served.
Current law limits VA in contracting for private health care
services to instances in which VA facilities are incapable of providing
necessary care to a veteran; when VA facilities are geographically
inaccessible to a veteran for necessary care; when medical emergency
prevents a veteran from receiving care in a VA facility; to complete an
episode of VA care; and, for certain specialty examinations to assist
VA in adjudicating disability claims. The VA could better meet the
demands of rural veterans through more judicious application of its
fee-for-service program.
We also believe that the VA could address the needs of veterans
through broad application of the ``hub-and-spoke'' principle. A veteran
can get his or her basic care at a community-based outpatient clinic
(CBOC). However, if the veteran requires more intensive care or a
special procedure, he or she can then be referred to a larger VA
medical center. This would ensure that the veteran continues to get the
best quality care provided directly by the VA, thereby maintaining the
viability of the system.
Ultimately, we believe that in order for the VA to best meet this
demand, adequate funding needs to be provided for health care. As we
have stated in the past, we recognize that the Administration made a
significant step forward this year with its funding request. However,
it still does not go far enough. In order to avoid the problems
experienced last year, and to address the access issues for all
veterans, including those veterans who live in rural areas, Congress
must appropriate a minimum of $32.4 billion as recommended by The
Independent Budget.
Finally, we realize that it is an extremely difficult task to
establish a standard for when a veteran's home is considered to be
rural. This legislation attempts to do so by stating that if a veteran
lives more than 60 miles from the nearest VA health care facility then
they live in a rural area. However, this is very much a subjective
idea. Access to VA health care is subject not only to distance, but
time and population density as well.
S. 1537
PVA strongly supports S. 1537, a bill that would codify the
Parkinson's Disease, Research, and Educational Centers as well as the
Multiple Sclerosis (MS) Centers of Excellence. We would like to express
our sincere thanks to Senator Akaka for introducing this legislation.
This proposal appropriately recognizes the successful strategy of the
Veterans Health Administration (VHA) to focus its system-wide service
and research expertise on two critical care segments of the veteran
population.
Since 1997, PVA has worked closely with VA MS clinicians and
administrators, as well as with private MS providers and advocates, to
address the ``patchwork'' service delivery for veterans with MS. From
the beginning, we realized that within that ``patchwork'' existed vital
elements that, when brought together, could best serve veterans with
MS.
The designation of two MS Centers of Excellence located in
Baltimore and the Seattle/Portland area provides open access to centers
engaged in marshaling VA expertise in diagnosis, service delivery,
research and education. Furthermore, these programs are made available
across the country through the ``hub and spokes'' approach. The mid-
term evaluation of these two centers acknowledged the success of VA's
strategy.
With regards to the Parkinson's disease centers, PVA recognizes
that these centers are a specific approach to focus health care
services and research. The very delicate surgical and treatment
breakthroughs developed in recent years must be localized so that they
might be better assimilated into VA-wide practice. PVA supports this
approach for Parkinson's disease just as we support the strategy for MS
veterans.
S. 1731
PVA generally concedes to the wishes of our local chapters, as well
as other local veterans' service organization members and State
Congressional delegations on issues involving naming VA facilities. We,
as the National Office of PVA, support, in concept S. 1731.
S. 2500, THE ``HEALING THE INVISIBLE WOUNDS ACT''
PVA supports S. 2500, a bill that would enhance the counseling and
readjustment services provided by the VA. PVA realizes the motivations
behind Section 2 of this legislation. In light of the efforts by the VA
last year to review some 72,000 veterans' claims for service-connection
for Post-Traumatic Stress Disorder (PTSD), we believe that this
provision is necessary. Veterans who experience serious mental health
conditions should not face the prospect of a reduction of benefits
simply because the VA does not believe that they are truly disabled.
PVA also supports Section 3 of the legislation that would require
the VA to provide readjustment counseling to servicemembers in the
National Guard or Reserves who return from a combat theater. It only
makes sense that these men and women who are playing a significant role
in combat operations around the world have access to counseling. We
recognize that when National Guardsmen and Reservists demobilize they
generally just want to go home. However, readjustment counseling may
ultimately be in their best interest as they may face difficulties down
the road.
To that end, we also support the authorization of $180 million for
the Vets Centers. The Vet Centers managed by the VA provide vital
readjustment services to the men and women who have placed themselves
in harm's way and to their families. Vet Centers offer various types of
readjustment counseling, including bereavement counseling, as well as
related mental health services. The mental health services are
especially important as the men and women returning from Iraq and
Afghanistan seek to cope with the stress and related difficulties they
faced while in combat. Moreover, their value is enhanced by the fact
that they are located close to veterans and that they exist within a
non-institutional environment.
AMPUTATION AND PROSTHETIC REHABILITATION CENTERS
PVA supports the creation of Amputation and Prosthetic
Rehabilitation Centers outlined by the proposed legislation. The need
for these centers is amplified by the number of veterans of Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who have
amputations. As we stated with regards to the Parkinson's disease and
MS Centers of Excellence, the VA has the essential expertise to focus
dedicated services on a wide range of medical conditions. It then
transfers learned approaches for specific care to the broader VA health
care system. However, the Veterans Health Administration (VHA) often
times lacks the financial wherewithal to create a needed focal point or
center. This legislation calls for the creation of these focal points
and the need for resources to actuate that goal. We must emphasize,
however, that additional real dollars will likely be needed to
establish these centers.
We would also like the Committee to consider going a step further
as these centers are created. VHA should be required to partner with
manufacturers, dealers, payers, and advocates to develop performance
test standards for amputee and prosthetic devices. An example of these
types of test standards is the American National Standards Institute
(ANSI) and Rehabilitation Engineering and Assistive Technology Society
of North American (RESNA) Wheelchair Performance Standards. These
standards are a collaborative effort with specific impacts on
wheelchair research and development, consumer disclosure, and payer
decisions. PVA believes that these centers could be the spearhead for
development of evidence-based performance test standards for amputee
and prosthetic devices.
THE ``VETERANS LONG-TERM CARE SECURITY ACT''
PVA believes that this proposed legislation is both timely and
necessary to preserve and protect the State Veterans' Home program and
the thousands of veterans who depend on it. During debate over the
fiscal year 2006 VA budget, the Administration proposed cutting the per
diem rate for State Veterans' Homes by two-thirds and proposed placing
a moratorium on construction funding as well. Fortunately, Congress
refused to support those recommendations. PVA urges the Committee to
preserve VA Per Diem rates and construction funding for State Veterans'
Homes. Daily per diem funding is vital to the preservation of these
programs.
The most recent Government Accountability Office (GAO) report
concerning State Veterans' Home (GAO-06-264) release in March points
out that 52 percent of VA's nursing home workload is currently being
provided by State homes. In contrast, 35 percent is provided in VA-
operated nursing homes and about 13 percent is provided in privately
operated nursing homes. Protective legislation is necessary to
safeguard the largest segment of VA's three-pronged approach to
providing nursing home care.
PVA supports Section 2 of this legislation that would require the
VA to provide a report to Congress prior to implementation of a
reduction in per diem rates. We believe that in order for the VA to
provide a comprehensive report they should follow the GAO
recommendations to collect necessary data that will accurately reflect
the impact of proposals to reduce per diem rates and construction
funding. The report should include information on the number of
veterans affected, their age, their VA priority status, their gender,
their length-of-stay, and local alternatives to care.
We also support Section 3 of the legislation that would require the
VA to pay the full cost of nursing home care to eligible veterans
residing in State Veterans' Nursing Homes. It is VA's obligation to pay
for nursing home care for eligible veterans regardless of the venue of
care. PVA likewise supports Section 4 that requires VA to furnish
prescription medicines in State Veterans' Homes.
PVA is uncertain about Section 5 of the legislation that would
allow VA to deem certain health care facilities as State homes. We have
concerns about allowing the VA to deem any private nursing home as an
eligible State home. How would VA and the individual States oversee
issues regarding appropriate staffing, quality of care, safety, and
cleanliness? PVA is concerned that ``deeming status'' could
dramatically increase the number of State Veterans' Homes without
requiring proper checks and balances. The VA and individual States must
have the capacity to monitor quality in any ``deemed status'' facility.
PVA is also concerned that ``deemed status'' could allow the VA to
reduce the number of VA-operated nursing homes. VA nursing homes
provide a higher quality of nursing home care than is available in
private sector. We would not support ``deemed status'' if it results in
a loss of VA-operated nursing homes. At the same time, we recognize the
fact that additional ``deemed status'' on State Veterans' Homes, that
does not sacrifice VA facilities, and that can be successfully
monitored, may help solve the problems associated with a rapidly aging
veteran population and the increasing demand for nursing home care.
Mr. Chairman, PVA would like to thank you once again for providing
us the opportunity to comment on these important issues. We look
forward to working with the Committee to ensure that meaningful
legislation that best benefits veterans is enacted. I would be happy to
answer any questions that you might have.
______
Response to Written Questions Submitted by Hon. Larry E. Craig
to Carl Blake
Question 1. One of the real practical problems I have with the
commission process is that people other than the elected President and
Senators identify the executive branch officials. But, once those
officials are nominated and confirmed, the public holds Senators and
the President accountable for the executive branch officials' action.
Does it not strike you as just a little unreasonable, frankly, that
we are being held accountable for the performance of an official who
was chosen by members of your organizations? Without getting too
unserious, why shouldn't we hold you accountable since you picked them?
Answer. The recommendation from the search commission to the
Secretary of Veterans Affairs (VA) does not come solely from
representatives of veterans' service organizations. Title 38 U.S.C. S.
305 states that only two persons representing veterans served by the
Veterans Health Administration (VHA) shall be made part of the search
commission to select the Under Secretary for Health. The remaining
members of the selection commission include: (1) three persons
representing clinical care and medical research and education
activities affected by the VHA; (2) two persons who have experience in
the management of veterans health services and research programs, or
programs of similar content and scope; (3) the Deputy Secretary of
Veterans Affairs; (4) the Chairman of the Special Medical Advisory
Group established under 38 U.S.C. S. 7312; and (4) one person who has
held the position of Under Secretary for Health (including service as
Chief Medical Director of the Department), if the Secretary determines
that it is desirable for such person to be a member of the commission.
Correspondingly, 38 U.S.C. S. 306 indicates only two persons
representing veterans served by the Veterans Benefits Administration
shall be made part of the commission to select the Under Secretary for
Benefits with similar remaining staff requirements as those established
for the Under Secretary for Health. In both cases, of the ten person
search commission, only two are representatives from veterans' service
organizations.
Furthermore, the recommendations of the search commission are
forwarded to the VA Secretary for review. The Secretary then has
responsibility to forward the recommendations to the President with any
comments that he deems necessary. If the President does not agree with
the list of persons provided by the Secretary, the President may
request that additional individuals be recommended from which he can
choose a nominee. Ultimately, none of the recommendations made by the
commission are binding to the President.
Clearly, members of our organizations do not pick the individuals
for the positions of the Department of Veterans Affairs (VA) Under
Secretaries for Health or Benefits. In the end, it is the President's
prerogative to choose whomever he wishes, and responsibility rests with
the Senate to confirm or deny that choice. Representatives from
veterans' service organizations who serve on the selection commission
act as advisors and nothing more. We find it disappointing that you
would seem to imply that you should not be held responsible if you
confirm an unsatisfactory choice for one of the Under Secretary
positions.
Question 2. Mr. Blake, in your testimony you mention that the
Amputation and Prosthetic Rehabilitation Centers should focus some
attention on partnering with manufacturers, dealers, and payers of
amputation devices to develop some standards of care and service. You
mention specifically your experience with wheelchairs and how that
program has been successful.
Can you talk a little more about PVA's role in the program
pertaining to wheelchairs and how improvements in the evaluation
process and standards have really revolutionized care for spinal cord
injured veterans and the wheelchair industry?
Answer. In the early 1980s, PVA became involved with a number of
likeminded advocates for the development of ``performance'' standards
for wheelchairs. Working with academic rehabilitation engineers,
manufacturers and the VA, PVA recognized that the development of tests
to examine various performance features of a wheelchair could improve
everyone's ability to determine just what a wheelchair could do. For
example, we discovered that not all manufacturers measured the
components of a wheelchair the same. Not all manufacturers recognized
the turning radius of a wheelchair with cambered wheels. Not all
electrical components provided the same power. It was a consensus of
these advocates that the development of performance standards could
bring some uniformity to the field of wheelchairs. For example, when
someone asks about measurement of the foot pedals from the seat on
different chairs, there might be some comparability.
Today, wheelchair performance standards are listed as ANSI/RESNA
wheelchair standards. Compliance with these tests are required in the
marketplace if a manufacturer wishes to report to consumers,
professionals or payers how their product stacks up against other
chairs available in the marketplace. These standards apply to manual
chairs, power chairs, scooters and mobility platforms. The standards
address endurance, temperature, seating, tires and all components. It
is important to note that these are ``performance'' standards;
therefore, they do not have a predetermined answer. Rather, they tell
the manufacturer how to measure or test the chair or component and how
to report the results of the test or measurement. These individual
results are the basis for comparison with similar chairs. It is not a
goal of these standards that every chair be identical. Instead, the
desired outcome is standardization of the calculation or test
procedures so answers can be compared.
The outcome of wheelchair standards has been uniformity in the
description of products in the marketplace. This achievement works for
consumers, manufacturers and payers alike. Each party derives from the
ensuing disclosure what the performance and suitability of a product
for an individual's needs are as expressed by the consumer,
manufacturer or payer.
PVA believes that the development of performance testing standards
for amputation devices would stimulate the consumer, manufacturer and
payer fields to know what products deliver. Presently, we hear that the
field needs a better device, and we ask ``better than what?'' Since
performance testing standards do not currently exist, what is the basis
for comparison among products? What would need to be improved if we
don't know what current products are capable of doing? PVA believes
that the development of scientifically based performance test standards
would revolutionize the entire field as consumers seek information,
manufacturers test their products and payers recognize what performance
they can expect for their funding.
Chairman Craig. Carl, thank you very much.
Juan, we will now turn to you.
STATEMENT OF JUAN LARA, ASSISTANT DIRECTOR, NATIONAL
LEGISLATIVE COMMISSION, THE AMERICAN LEGION
Mr. Lara. Thank you, Mr. Chairman.
Mr. Chairman, Ranking Member Akaka, Members of the
Committee, thank you for the opportunity to present the
American Legion's views on the veterans' health care
legislation before us today. It is indeed an honor and a
privilege to present these views on behalf of the Nation's
largest veterans service organization.
The American Legion does not support the proposed changes
in S. 2634. The American Legion has concerns regarding the
changes in the appointment process and the suggested repeal of
term limits. The American Legion wants to ensure that the
appointment process is adequate in determining that only the
most highly qualified individuals are selected.
The American Legion would like to support the creation of
additional polytrauma centers to meet the increased demand by
severely injured veterans located across the Nation. Our
concern is that in the funding of any new center, we would like
to see real dollars, as Mr. Blake previously stated. We also
would like to see more details on how the new prosthetic
centers will fit in to the existing medical system.
The issue of providing safe and adequate health care to
rural veterans is not a small one. S. 2433, Section 2 would
establish the position of the Assistant Secretary for Rural
Veterans within the VA to address this problem. The American
Legion supports the establishment of this position, but
adequate resources must be allocated in order to meet the
health care needs of all veterans. We are concerned with the
current health care model and methodology used to fund VA,
which is clearly flawed. This fact was apparent when faulty
assumptions and questions cost projections forced Congress to
secure an additional $1.5 billion in an emergency spending bill
to cover the VA health care shortfall for fiscal year 2005.
We support the measures outlined in Sections 3, 4, 5, and
6. However, there must be clear-cut objectives and details on
the measures for success or failure of the projects.
S. 1537 would require the Secretary of VA to designate at
least six VA health care facilities for Parkinson's disease
research and at least two for multiple sclerosis if sufficient
funding is appropriated. We support the VA's research because
it serves the veteran population and is a natural step toward
improving veterans' health care.
Under the Veterans Long-Term Security Act, Section 2 would
require the VA to submit a detailed report to Congress before
implementation of a reduction in per diem rates for care
provided to veterans in State homes.
The American Legion supports stronger oversight of VA's
handling of payments to State homes and the requirement that
the Secretary will report in detail a justification for
reducing payments and that VA will consult with the appropriate
State officials and local agencies responsible for the
supervision of State homes in each State.
Section 3 would increase payment rates for nursing home
care provided in State homes to veterans with service-connected
disabilities. The American legion has long supported full
reimbursement of nursing home care furnished to 70 percent
service-connected veterans or higher, if the veteran resides in
a State home.
The American Legion is pleased to support the provision in
Section 4 which would allow for the provision of prescription
medicines for veterans with service-connected disabilities
receiving care in State homes. Currently, they are required to
travel unnecessarily to VA facilities to receive their
prescription medications.
Section 5 authorizes certain health care facilities to be
treated as State homes. The American Legion supports the
measure for more State homes to meet the needs of veterans.
These facilities must meet the proper guidelines with proper
oversight and should have sufficient funding. The VA should be
prudent in the approval of any applications submitted.
THE AMERICAN LEGION HAS NO OFFICIAL POSITION ON S. 1731
S. 2500, Section 2 requires the VA to submit a report to
the Committees on Veterans' Affairs in the Senate and House on
proposed PTSD modification ratings for service connection for
compensation payments and wait 6 months after the report is
submitted before a change is implemented.
The American Legion supports stronger congressional
oversight, especially in matters involving PTSD and other
psychiatric conditions, given the increased volume of these
types of cases in the VA. The American Legion would welcome an
opportunity to present its views if a report is submitted to
Congress and to comment on the impact that any change may have
on the veterans' community before it is actually implemented.
Section 3 would require the Secretaries of VA and Defense
to extend mental health care services to National Guard and
reservists who served on active duty in a theater of combat.
The current conflicts in Afghanistan and Iraq are producing a
new generation of veterans. These conflicts have necessitated
the call-up of the National Guard and Reserves in record
numbers. The prevalence of mental health problems is well
documented within the ranks of these servicemembers. Many of
the Guard and Reserve are slipping through the crack of the VA
safety net due to a myriad of factors. These injured veterans
and their families and the American Legion would support and
welcome the mental health care services. We believe this
legislation will address some of the transition problems that
the Guard and Reserve encounter due to the uniqueness of their
situation.
Section 4, of course, authorizes $180 million to be
appropriated to the VA for fiscal year 2007 for readjustment
counseling and other mental health services. The American
Legion appreciates, welcomes, and supports the additional
funding in this measure which would help the Vet Centers carry
out this important mission.
Caregivers are a critical part of the continuum of care for
the VA. The American Legion supports S. 2753.
Mr. Chairman, Ranking Member Akaka, and Members of the
Committee, the American Legion would like to thank you and the
Committee for putting forth very comprehensive legislation to
address some of the monumental problems the VA faces today in
providing quality, accessible health care to the Nation's
veterans. We look forward to working with this Committee and
its Members in the future.
I would be happy to answer any questions the Committee may
have.
[The prepared statement of Mr. Lara follows:]
Prepared Statement of Juan Lara, Assistant Director, National
Legislative Commission, The American Legion
Mr. Chairman and Members of the Committee:
Thank you for the opportunity to present the American Legion's
views on the veterans' health care legislation before us today. It is
indeed an honor and a privilege to present these views on behalf of the
Nation's largest veterans service organization.
s. 2634, repeal term limits and simplify appointments for the offices
of under secretary for health and under secretary for benefits
This legislation seeks to amend sections 305 and 306 of title 38,
United States Code, by eliminating subsections that set terms of office
and establish procedure for filling vacancies in the positions of Under
Secretary for Health and Under Secretary for Benefits for the
Department of Veterans Affairs (VA).
The American Legion does not support any of the proposed changes to
the existing law that governs the appointments for the offices of the
Under Secretary for Health and Under Secretary for Benefits. Having
participated in the selection process, the American Legion has concerns
regarding the changes in the appointment process and the suggested
repeal of term limits outlined in this legislation. The American Legion
wants to ensure that the appointment process is adequate in determining
that only the most highly qualified individuals are selected.
While the American Legion cannot support either elements of this
proposed legislation concerning on the offices of Under Secretary of
Health and the Under Secretary of Benefits as a result of this
legislation.
S. 2736, AMPUTATION AND PROSTHETICS REHABILITATION CENTERS FOR VETERANS
This legislation requires the Secretary of the VA to establish at
least five regionally dispersed centers that would provide
rehabilitation services to veterans with amputations or prosthetic
devices. These centers would have expertise in prosthetic,
rehabilitation, treatment and coordination of care for veterans with
amputations of any functional part of the body; and provide information
and supportive services addressing care and treatment of veterans with
amputations to all facilities of the VA.
The American Legion would support the creation of additional
Polytrauma Centers to meeting the increased demand by severely injured
veterans located across the Nation. This would greatly improve
accessibility and convenience.
S. 2433, RURAL VETERANS CARE ACT OF 2006
This bill seeks to improve services available to veterans residing
in rural areas.
If enacted, Section 2 of the proposed legislation would establish
the position and responsibilities of the Assistant Secretary for Rural
Veterans within VA.
The American Legion does not object to the establishment of this
position. The issue of providing safe and adequate health care to rural
veterans is not a small one. The creation of an Assistant Secretary for
Rural Veterans will allow VA to directly and thoroughly address the
problem. The provision of health care to the rural veterans population
needs that type of undivided attention. The current health care model
and methodology used to fund VA is clearly flawed. This fact was
apparent when faulty assumptions and questionable cost projections
forced Congress to secure an additional $1.5 billion in an emergency-
spending bill to cover the VA health care shortfall for fiscal year
2005. We do not object to the addition of this post to the VA, but
adequate resources are critical in order to meet the health care needs
of all veterans.
Section 3 of this measure would mandate that the Assistant
Secretary for Rural Veterans conduct demonstration projects exploring
alternatives for expanding care in rural areas, including creating
partnerships with other Federal health care providers under the
Department of Health and Human Services (HHS), as well as, private
health care providers.
The American Legion would also recommend including the Department
of Defense (DoD) since there are a number of military installations in
rural communities. This would be consistent with the recommendations
from the President's Task Force to Improve the Delivery of Health Care
for America's Veterans with called specifically for increase
collaborative efforts between VA and DoD health care delivery systems.
However, there must be clear-cut objectives and details that will be
used to measure the success or failure of the projects.
Section 4 of the bill would require the Secretary of VA to conduct
a pilot program to evaluate the feasibility and advisability of
utilizing various means to improve access to health care services for
veterans who reside in highly rural or geographically remote areas. The
program will be conducted in three VISNs chosen by the Secretary, based
on recommendations made by the Assistant Secretary for Rural Veterans.
Section 5 of this measure would authorize veterans to receive
travel reimbursement equivalent to the rate set for Federal employees.
Section 6. Section 6 would mandate the Assistant Secretary for
Rural Veterans establish up to five Centers of Excellence for rural
health research, education and clinical activities; geographically
disperse the health care facilities throughout the United States; and
define selection criteria.
S. 1537, PARKINSON'S DISEASE RESEARCH AND EDUCATION CLINICAL CENTERS
This legislation requires the Secretary of VA to designate at least
six VA health care facilities as locations for centers of Parkinson's
Disease Research, Education, and Clinical activities and at least two
facilities as locations for Multiple Sclerosis Centers of Excellence,
if sufficient funding is appropriated to do so. It also requires that
existing (as of January 1, 2005) facilities operating as such be
designated as Centers of Excellence, unless the Under Secretary of
Health advises otherwise. Funding will be appropriated from the VA's
medical services account and medical and prosthetics research account
as appropriate.
One of the recruitment and retention tools for physicians is the
robust research program that VA has and the affiliation VA enjoys with
many medical schools throughout the country. VA's research not only
serves the veteran population, but also contributes to the Nation as a
whole. Expansion of research centers such as for Parkinson's and
Multiple Sclerosis is a natural step forward toward the betterment of
veterans' health care. It is also the sign of a healthy and viable
program.
VETERANS LONG-TERM CARE SECURITY ACT
This legislation would ensure appropriate payment for the cost of
long-term care provided to veterans in State veterans homes.
Section 2 would require VA to submit a detailed report to Congress
before implementation of a reduction in per diem rates for care
provided to veterans in State homes.
The American Legion welcomes stronger oversight of VA's handling of
payments to State homes. The most critical aspect of this section is
the requirement of the Secretary to report in detail a justification
for reducing payments and that VA will consult with the heads and
appropriate officials of the State and local agencies responsible for
the supervision of State homes in each State.
Section 3 would increase payment rates for nursing home care
provided in State homes to veterans with service-connected
disabilities.
The American Legion has long supported full reimbursement of
nursing home care furnished to 70 percent service-connected veterans or
higher, if the veteran resides in a State home.
Section 4 would allow the provision of prescription medicines for
veterans with service-connected disabilities receiving care in State
homes.
The American Legion is pleased to support the provision for
prescription medicines. Veterans with a rating of 50 percent or greater
service-connection receive VA pharmaceutical benefits at no cost.
Currently, pharmaceutical services are available at the State veterans'
homes for these veterans, but they are required to unnecessarily travel
to VA facilities to receive their prescription medications.
This legislation will help to alleviate that unnecessary and
sometimes undue hardship on the veteran.
SECTION 5 AUTHORIZES CERTAIN HEALTH FACILITIES TO BE TREATED AS STATE
HOMES.
The American Legion believes VA has the responsibility to provide
long-term care to America's veterans. Along with that comes the
responsibility of ensuring the quality and effectiveness of the
treatment provided by facilities that are not necessarily under VA's
jurisdiction. The American Legion also believes VA should be prudent in
the approval of the applications submitted by the States with respect
to the health facility.
S. 1731, JACK C. MONTGOMERY DEPARTMENT OF VETERANS AFFAIRS MEDICAL
CENTER
This legislation renames the VA Medical Center in Muskogee,
Oklahoma as the Jack C. Montgomery Department of Veteran Affairs
Medical Center in honor of Medal of Honor recipient Jack C. Montgomery
for his service and dedication to the military and the VA.
The American Legion has no official position on this legislation.
S. 2500, HEALING THE INVISIBLE WOUNDS ACT OF 2006
Section 2. requires that the Secretary of VA, before modifying the
manner in which post-traumatic stress disorder (PTSD) is handled with
regards to rating of service-connection for compensation payments,
submit a report on the proposed modification to the Committees on
Veterans' Affairs in the Senate and House of Representatives and wait 6
months after the report is submitted before the change is implemented.
We, The American Legion, supports stronger congressional oversight,
especially in matters involving PTSD and other psychiatric conditions,
given the increased volume of these types of cases in VA. The American
Legion would welcome an opportunity to present its views if a report is
submitted to Congress and to comment on the impact that any change may
have on the veterans' community before it is actually implemented. The
American Legion voiced concerns over VA's initiative to conduct a major
case review regarding PTSD in response to the May 2005 VA Inspector
General (IG) report on variances in VA's disability compensation
payments. While they did not complete the review, the handling of the
situation caused undue hardship and anxiety for an untold number of
veterans with serious psychiatric conditions and needlessly exacerbated
their illness.
Section 3 prescribes that the Secretary of VA, in consultation with
the Secretary of the Defense, extend mental health care services to
National Guard and Reservists who served on active duty in a theater of
combat.
The current conflicts in Afghanistan and Iraq are producing a new
generation of veterans who will be forever changed because of their
service to this Nation. These conflicts have necessitated the call up
of the National Guard and Reserve in record numbers. The prevalence of
mental health problems is well documented within the ranks of these
service men and women. Further, many of the Guard and Reserve are
slipping through the cracks of the VA safety net due to a myriad of
factors. These injured veterans and their families would welcome the
mental health care services.
The American Legion believes this legislation will address some of
the transition problems that the Guard and Reserve encounter due to the
uniqueness of their situation.
Section 4 authorizes $180,000,000 to be appropriated to the VA for
fiscal year 2007 for readjustment counseling and other mental health
services through the Vet Centers.
The American Legion appreciates the additional funding requested in
this legislation for the Vet Centers to carry out this important
mission.
S. 2753, CAREGIVER EXPANSION
This legislation would require VA to make $10 million available as
a grant program to expand the services available to veterans for non-
institutional care services.
The American Legion supports the intent of this legislation.
Mr. Chairman, The American Legion would like to thank you and the
Committee for putting forth very comprehensive legislation to address
some of the monumental problems VA faces today in providing quality,
accessible health care to the Nation's veterans. We look forward to
working with you in the future. Thank you.
Chairman Craig. Juan, thank you very much.
And our last witness, Adrian, please proceed.
STATEMENT OF ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Mr. Atizado. Chairman Craig, Ranking Member Akaka, Members
of the Committee, on behalf of the more than 1.5 million
members of the Disabled American Veterans and its Auxiliary, I
wish to express our sincere appreciation for the opportunity to
present our views on health care legislation before the
Committee.
Beginning with S. 2634, which would repeal the 4-year term
limits of both VA Under Secretaries for Health and Benefits and
repeal the search commission requirements for both positions
under current law, while the DAV is not opposed to eliminating
the term limits, we have some concerns with repealing the
provision for a search commission. And while current law merely
formalizes the search for prospective candidates, it does
enhance this process by involving a select group of recognized
individuals who are from various fields and interests
particularly relevant to VA and its mission. And, equally
important, it isolates the process from political influences.
It is for these reasons that we urge the Committee not to
support the provision of this bill.
DAV does support S. 2500, Healing the Invisible Wounds Act
of 2006. However, we do recommend some modification of Section
1 as it may be limiting for any change in rules or standards
for the purpose of expanding entitlement or providing for more
liberal disability ratings.
S. 2433, the Rural Veterans Care Act of 2006, is a
comprehensive and thoughtful bill which clearly attempts to
address complex issues surrounding rural veterans' access to VA
health care. We support Section 5, which would increase travel
reimbursements to veterans seeking VA care. In fact, DAV
Resolution 183 urges the VA to include a line item in its
budget for the cost of increasing the travel reimbursement rate
to a more reasonable amount so that it can make the needed
adjustments without reduction in funds for direct medical care.
With respect to the remaining provisions in this bill,
though beneficial to an underserved veteran population, the DAV
has serious concerns about its impact on the VA health care
system. DAV does not believe VA has been provided sufficient
funding to care for the veterans currently enrolled in the
system. It has a growing list of thousands of veterans waiting
to be seen by a health care provider, as we speak. Until
Congress is willing to guarantee full funding for such a
comprehensive initiative as proposed, we cannot support this
measure.
Existing VA research and education clinical centers and
Centers of Excellence have proven to be a valuable resource to
educate sick and disabled veterans as well as VA health care
providers on new and effective treatment regimes. DAV does
support S. 2763 and S. 1537, which would create two Multiple
Sclerosis Centers of Excellence and Centers for Clinical
Research and Education specific to veterans suffering from
amputations and Parkinson's disease.
DAV fully supports S. 2762, the Veterans Long-Term Care
Security Act of 2006, which seeks to curb untenable attacks to
limit the provision of institutional extended care services to
service-connected disabled veterans in State Veterans Homes.
While DAV does not have a specific resolution to support S.
2753, we would like to take precious time to highlight the need
for this legislation. It is critical to note that families, not
government, provide 80 percent of long-term care for older
persons in the United States. With VA's increased emphasis to
provide non-institutional extended care services, caregivers
become a crucial element for success in caring for our Nation's
sick and disabled veterans. The aging veteran population is
causing more and more families to face the stress and financial
difficulties that come with caring for veterans who are not
only old but young as well, particularly the veterans from this
current war.
This bill would move VA in the direction to meet
caregivers' needs who endure emotional and personal health
strains by providing VA facilities and frontline health care
providers the seed to produce high-quality, cost-effective
approaches in providing the much needed relief to caregivers.
Mr. Chairman, this completes my testimony. I would be happy
to answer any questions this Committee may have.
[The prepared statement of Mr. Atizado follows:]
Prepared Statement of Adrian M. Atizado, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman and Members of the Committee:
On behalf of the more than 1.3 million members of the Disabled
American Veterans (DAV) and its Auxiliary, I wish to express my
appreciation for this opportunity to present the views of our
organization on health care legislation before the Committee.
These measures cover a range of issues important to veterans and
their families. The DAV is an organization devoted to advancing the
interests of service-connected disabled veterans, their dependents and
survivors. For the past eight decades, the DAV has been devoted to one
single purpose: building better lives for our Nation's disabled
veterans and their families.
S. 2634
This legislation would repeal the 4-year terms for the Department
of Veterans Affairs (VA) Under Secretaries for Health and Benefits and
repeal the search commission requirements for both positions under
current law.
While the DAV is not opposed to eliminating the term limits for
both Under Secretary positions, we are concerned that repealing the
provision for a commission would be detrimental to the fundamental
process. Whether the process is formal or informal, it is fundamental
in the search and selection of a candidate for any position. In the
case of either of the Under Secretary positions, the search commission
is formalized under current law. Moreover, the search commission's
process of selection involves careful deliberation, examination, and
consideration by a selected group of recognized individuals who are
from various fields and interests particularly relevant to VA and its
mission. Not only does current law regarding the search commission
enhance the selection process, but equally important, isolates the
process from political influences. The DAV urges the Committee not to
support the provision of this bill that would abolish the search
commission.
S. 2736
The DAV supports this legislation, which would require VA to
establish five Amputation and Prosthetic Rehabilitation Centers to
address a gap in VA's specialized services for the newest generation of
veterans with amputations. The growing number of Operation Iraqi and
Enduring Freedom veterans who survive these debilitating injuries
should be allowed every advantage that equals their desire to integrate
into civilian life and become a productive member of society.
Veterans who seek medical care from VA and require prosthetics to
enhance their quality of life consist of two distinct populations: our
newest veterans with technologically advanced prosthesis and veterans
of past wars utilizing older prosthetics devices. The new level of
service such centers could provide, coupled with the research,
development, and innovation in this area of medicine would be an
invaluable resource to disabled veterans of today and tomorrow.
S. 2433
The Rural Veterans Care Act of 2006 is a comprehensive bill to
improve the care provided to veterans living in rural areas. It would
establish an Assistant Secretary for Rural Veterans in the Department
of Veterans Affairs (VA) to: (1) formulate and implement all policies
and procedures that affect veterans living in rural areas; (2) identify
a Rural Veterans Coordinator in each Veterans Integrated Service
Network (VISN); (3) coordinate demonstration projects to examine
alternatives for expanding care in rural areas; (4) establish
partnerships with other Federal agencies to coordinate health care
services for veterans living in rural and geographically remote
locations; (5) reevaluate directives and procedures related to the use
of fee-basis care nationwide and strengthen the use of fee-basis care
to extend health care services to rural and remote areas; (6) conduct a
pilot program in three VISNs to evaluate the feasibility of utilizing
various means to improve access to care for veterans living in highly
rural or remote geographical areas dedicating an amount equal to 0.9
percent of the total health care appropriation in that fiscal year for
each year of the program; and (7) establish one to five Centers of
Excellence dedicated to rural health research, educational and clinical
activities.
S. 2433 is a very thoughtful bill which clearly attempts to address
the complex issue of rural veterans' access to VA health care. Without
question, this measure is the most comprehensive plan put forward to
date to fully address the health care needs of veterans living in rural
areas. Although we acknowledge it would be beneficial to veterans
living in remote areas of the country, we have serious concerns about
the impact it would have on the VA health care system. Most likely,
this bill would dramatically increase contracted or fee-based care
based on the provision in Section 4 of the measure which relates to
veterans approximate driving distance to the nearest VA facility and
sets out parameters for care under this initiative. There is also the
provision in Section 3 of the bill that calls for reevaluating the VA's
fee-basis program on a nationwide basis and to revise established
policies to strengthen the use of fee-basis care to extend health care
services to rural and remote areas. Although S. 2433 proposes to
explore various alternative means to provide care for veterans living
in rural areas of the country, it is likely most of such care would
have to be provided on a contract basis in the private sector. This
appears to be in conflict with another demonstration project VA is
moving forward with, project HERO, an initiative aimed at reducing the
amount of funding it spends on higher cost contracted services.
DAV's position on contracted or fee-based care is well known. In
general, current law limits VA in contracting for private health care
services to instances in which VA facilities are incapable of providing
necessary care to a veteran; when VA facilities are geographically
inaccessible to a veteran for necessary care; when medical emergency
prevents a veteran from receiving care in a VA facility; to complete an
episode of VA care; and, for certain specialty examinations to assist
VA in adjudicating disability claims. VA also has authority to contract
for the services in VA facilities of scarce medical specialists. Beyond
these limits, there is no general authority in the law to support any
broad contracting for populations of veterans. DAV believes that VA
contract care for eligible veterans should be used judiciously and only
in these specific circumstances so as not to endanger VA facilities'
ability to maintain a full range of specialized inpatient services for
all enrolled veterans. We believe VA must maintain a ``critical mass''
of capital, human, and technical resources to promote effective, high
quality care for veterans, especially those disabled in military
service and those with highly sophisticated health problems such as
blindness, amputations, spinal cord injury or chronic mental health
problems. We are concerned that the contracted care element as provided
for in this bill (particularly if it were focused on acute and primary
care to significant populations) would inevitably grow over time, and
place at risk VA's well-recognized qualities as a renowned and
comprehensive direct provider of health care.
Specifically, we do not believe VA has been provided a sufficient
funding level to care for the veterans currently enrolled in the
system. Waiting lists are once again growing and timely access to
services is delayed for thousands of veterans. Putting additional
budget pressures on the system would only exacerbate the problem. Until
Congress is willing to guarantee full funding for such a comprehensive
initiative as proposed in S. 2433, we can not support this measure.
Section 5 of S. 2433, would increase travel reimbursements to
veterans traveling to VA facilities for treatment. DAV would support
this provision in the bill in accordance with DAV Resolution 183, which
urges VA to include a line item in its budget for the cost of
increasing veterans' beneficiary travel reimbursement rate to a more
reasonable amount so that it can make the needed adjustment without
reduction in funds for direct medical care to sick and disabled
veterans.
S. 1537
The DAV supports S. 1537, which would direct VA to designate,
establish, and operate at selected VA Medical Centers at least six
centers for Parkinson's disease research, education, and clinical
activities, and at least two Multiple Sclerosis Centers of Excellence.
Additionally, it would require the Under Secretary for Health to assure
appropriate geographical distribution of such facilities, and establish
a panel to assess the scientific and clinical merit of proposals
submitted by a facility for the establishment of such a center.
The VA annually cares for over 40,000 veterans suffering from
Parkinson's disease; however, the incidence of Parkinsonism increases
with age. While there is currently no cure for Parkinson's disease and
despite advances in treatment, relentless progression of neuronal
damage frequently leads to total disability. Further research into
fundamental mechanisms of neuronal degeneration is needed for the
development of improved diagnostic and treatment regimens.
Multiple Sclerosis (MS) is a chronic, unpredictable neurological
disease that affects the central nervous system. Like Parkinson's
disease, there is no cure for MS yet, although pharmaceuticals can help
slow the course of the disease or ease symptoms in some patients. The
symptoms of MS are highly variable, depending on the areas of the
central nervous system that have been affected. An MS Center of
Excellence contemplated in this legislation would take advantage of
VA's strengths. As a system of medical facilities linked through
technology with academic affiliations, these centers provide an
opportunity for significant progress toward understanding and treating
MS.
Existing VA research and education clinical centers and Centers of
Excellence have proven to be a valuable resource to educate sick and
disabled veterans as well as VA health care providers on new and
effective treatment regimes. Following this successful template, the
proposed centers would not only attract an array of world class health
care providers and researchers to VA, they would also provide fertile
ground for collaboration and development in the areas of clinical care,
scientific research, and educational outreach. They would ensure
specialized care will be embedded throughout the continuum of care
provided by the VA health care system.
STATE HOME LEGISLATION (SEN. AKAKA)
Mr. Chairman, we applaud Ranking Member Akaka and Senator Burr for
the draft legislation to help both service-connected veterans and the
State Veterans Home system, and we appreciate the Committee considering
it today.
Section 1 of this bill would require a future VA Secretary to
consult with the Governors, State Homes, and other stakeholders in
long-term care, such as the DAV and other veterans service
organizations, if a proposal were being considered that would
jeopardize the future of the State Veterans Home system. The Committee
will recall, in the fiscal year 2006 budget, the Administration made
just such a proposal--to revamp eligibility by greatly restricting
admission to State Veterans Homes and to propose a moratorium on the
construction grant program to support those homes, without any prior
warning or communication with those most affected. Thankfully, these
ill-advised proposals were rejected by Congress but they certainly
could be made again. If so, we believe stakeholders have a right to
expect consultation before the fact and assistance from VA in preparing
for any such significant changes.
For the purpose of equity, we believe sections 2 and 3 of the Akaka
bill are especially important. Providing service-disabled veterans a
State Home placement option to meet their long-term care needs, and
providing their necessary prescription medications for service-
connected disabilities, are overdue extensions of support for veterans
who have made great sacrifices due to injuries or illnesses incurred in
military service.
Section 4 of the bill would enable a State and VA to establish
small State Home bed units in pre-existing health care facilities where
a full-blown State Veterans Home could not be justified under current
regulatory criteria. We believe this provides a reasonable option for
states such as Hawaii and other parts of the country that have remote
and rural environments. In summary, the DAV fully supports the purposes
of this bill.
S. 1731
This bill would rename the VA Medical Center in Muskogee, Oklahoma,
as the Jack C. Montgomery Department of Veterans Affairs Medical
Center. The DAV has no resolution on this issue, but we do not oppose
its enactment.
S. 2500
This measure would enhance the counseling and readjustment services
provided by the VA for members of the National Guard and Reserves.
Section 3 and 4 of the ``Healing the Invisible Wounds Act of 2006,''
would ensure that these men and women receive the readjustment
counseling and mental health services necessary to transition into what
we hope will be a full and productive life after return from a combat
theater. Specifically, the bill provides for greater cooperation
between VA and the Department of Defense, through the expansion of
Reunion and Reentry activities of Vet Centers. A report from VA is
required that includes, among other things, the cost and effectiveness
of the program as well as an assessment of servicemember satisfaction.
Additional funds would be authorized to provide these services.
In general, the DAV supports this measure; however, we recommend
modification of language in section 1 of this bill to include standards
for service connection of post-traumatic stress disorder, and to permit
any change in rules or standards for the purpose of expanding
entitlement or providing for more liberal disability ratings.
Mr. Chairman, this completes my testimony. I'll be happy to answer
any questions the Members of this Committee might have.
______
Response to Written Questions Submitted by Hon. Larry E. Craig
to Adrian M. Atizado
Question. One of the real practical problems I have with the
commission process is that people other than the elected President and
Senators identify the executive branch officials. But, once those
officials are nominated and confirmed, the public holds Senators and
the President accountable for the executive branch officials' actions.
Does it not strike you as just a little unreasonable, frankly, that
we are being held accountable for the performance of an official who
was chosen by members of your organizations? Without getting too
unserious, why shouldn't we hold you accountable since you picked them?
Answer. The recommendation from the search commission to the VA
Secretary does not come solely from representatives of veterans service
organizations. As is reflected in your floor statement when introducing
this measure, ``the Secretary of Veterans Affairs must establish a
commission made up of various interested individuals . . .'' Moreover,
title 38, United States Code S. 305, prescribes only two persons
representing veterans served by the Veterans Health Administration
shall be made part of the search commission. Correspondingly, S. 306
indicates only two persons representing veterans served by the Veterans
Benefits Administration shall be made part of that commission. In both
cases, of the ten person search commission, only two are
representatives from veterans service organizations. It is worthwhile
to note that the legislative language for the search commission
originated from the amended text of S. 533 as a substitute to H.R.
3471, which was then passed by the Senate. Specifically, the conference
report filed in the House (H. Rept. 100-1036) describes that the
conferees ``agree to follow the Senate amendment with regard to the
establishment of a Commission to recommend individuals to fill
vacancies in the Chief Benefits Director and the Chief Medical Director
positions.'' The statutory language has remained relatively unchanged
in nature or purpose regarding the issue at hand since passage of H.R.
3471 (Public Law 100-527).
Furthermore, the recommendation of not less than three persons by
the search commission is sent to the VA Secretary who then forwards the
recommendation to the President with any comments the Secretary
considers appropriate. If the President does not agree with the list of
persons provided by the Secretary, the President may request that
additional individuals be recommended from which he can choose a
nominee. Undoubtedly, the search commission's recommendation is non-
binding to the President.
Clearly, members of our organizations do not ``pick'' the
individual for the positions of the Department of Veterans Affairs (VA)
Under Secretaries for Health or Benefits. As portrayed in my written
testimony, one of the many strengths of the search commission is the
actual process of selection, which involves careful deliberation,
examination, and consideration among a group of individuals selected
from various fields and interests particularly relevant to VA and its
mission. Unlike the information before the search commission such as
the candidate's curriculum vitae, the President and Senate Committee on
Veterans' Affairs have the benefit of additional pertinent information
on the candidate such as the Federal Bureau of Investigation background
check of their employment, professional, personal, travel, medical,
financial, legal, military and educational histories from which to
decide. The Senate has the final say in whether to confirm the nominee.
Chairman Craig. Thank you very much, Adrian, for that
testimony, and, again, to all of you, thank you for your time
and your preparedness, because we handed you a fairly full
slate of different legislative initiatives by this Committee.
Mr. Melia, let me ask you a couple of questions. I think
all of us are concerned by your testimony and by the experience
that our veterans who are amputees are having. You noted that
there is a huge difference in service provided to veterans with
amputations, depending on VA's medical facility he or she
happens to be the closest to. Clearly, we should strive for
greater consistency.
You have given us one example. Can you give us an example
of the types of services an amputee can receive at one of the
``good facilities'' and what type of trouble he or she is
likely to encounter in a less adequate facility?
Mr. Melia. Thank you, Senator. Thank you for that question.
I think what we are finding is that this is a system that
is essentially run by human beings and run by budgets, and that
anytime that you have those two things mixed together, there is
a recipe for inconsistency. The people that are getting the
money and the people that are getting the best people are
providing the best service.
My feeling and the feeling of the Wounded Warrior Project
is that we have seen big disparities in things like access to
care, the amount of time that it takes servicemembers to access
the system. Practitioner skill level is a major problem.
Earlier testimony spoke of certification for prosthetic
representatives. We have found that is highly inconsistent
throughout the system and that there is really no system in
place for continuing education of prosthetists and prosthetic
representatives. Some of the certification statistics were
spoken of earlier, including the ABC certification, is nothing
more than a sign-off by the chief of prosthetics in a
particular department and does not require anything like
continuing education in an institution of higher learning like
we may find with doctors and lawyers. Obviously, our
servicemembers deserve much more than that.
Also, things like gait labs and occupational therapy and
physical therapy are also very important and having the best
people doing that. This is a very small population, Senator;
450-some servicemembers have been wounded. If we cannot provide
excellence to this group in the VA system, who do we provide
excellence to? The VA right now has a problem with marketing
and with public relations within this group. It only takes one
or two servicemembers having a bad experience for most of them
to hear it and move on to another system. These folks have
choices through TriCare. Many of them are allowed to use fee-
basis, and Heath Calhoun, whom I spoke of previously, had to be
refitted for his prosthetics recently. And at that smaller
site, a VA site, he actually was referred to an outside vendor
for that service. So the service was not even provided within
the VA system. Possibly he may be brought back for physical
therapy and occupational therapy, but not in that site. He
would actually have to go to Richmond, Virginia, some 3\1/2\
hours away.
My biggest concern is employability and, you know, 10 to 15
appointments a year is what the standard new amputee is faced
with. As an employer of four combat wounded disabled veterans
of this conflict, I can tell you that 15 days is too much for
most employers in this country to give people off. It does not
leave them much time for vacation either. When they have an
appointment, it is not for an hour. It is for a day.
So I think that the hub-and-spoke model that Mr. Blake
spoke about earlier that is used within the VA system--within
the SEI system--is really the type of system we need here where
there is a Center for Excellence, where somebody goes for a
yearly review, and then maybe is referred back to the smaller
facility.
Chairman Craig. We certainly appreciate your testimony,
your focus on it, along with Carl Blake's testimony and focus
on it. We do not disagree with you. That is why the legislation
is here. We cannot provide this level of expertise in every VA
facility. It simply would not be cost-effective, but it has got
to be there. It has got to be reasonably accessible as
adjustments and changes occur. I think that with these new
modern devices, older veterans are going to be great
beneficiaries of it, too, clearly, as these devices become more
available and as they are constantly refined and tuned, if you
will, of the kind that I have certainly seen and viewed over
the last several years. So we thank you for that testimony.
Let me turn to Senator Akaka.
Danny.
Senator Akaka. Thank you very much, Mr. Chairman.
Mr. Lara and Mr. Shaw, I certainly appreciate your support
of the State Home bill and its goal to expand the furnishing of
long-term care. Along those lines, the legislation requires
full cost reimbursement for the so-called Millennium bill
veterans in State Homes. The question is: Is this just a matter
of equity or do you also believe that veterans will benefit
from receiving care in State Homes? Mr. Shaw?
Mr. Shaw. I believe it is both. It is a matter of equity,
and it is a matter of the veteran's individual choice.
Currently, we do have some 70 percent and higher service-
connected veterans who have to pay their cost of care in State
Homes. They choose to be in those State Homes with the
friendship and the families that they have developed there, and
I do not think it is fair or equitable for them to have to
leave those home environments and go to another site to get
their cost paid for by the VA.
So I believe it is both an equity issue and it is a
fairness issue for the veteran to be able to have a right to
choose.
Senator Akaka. Mr. Lara.
Mr. Lara. I concur with his statement, and we believe that
the more choices that the veterans have, the better that will
be. And we definitely agree with your bill, and thank you for
putting that forward, Mr. Akaka.
Senator Akaka. Mr. Lara, regarding the caregivers grant
program, the idea is to incentivize or encourage local VA
providers to develop ways to help caregivers of veterans and to
be innovative in doing this.
What is your view about the manner in which VA is providing
non-nursing home care? In other words, is VA fully complying
with the mandate in the Millennium Health Care Act?
Mr. Lara. We believe that the caregivers are very critical
to the continuum of care for veterans, Senator, and that is a
great question. And it is something that we are closely looking
at. We believe that, so far, the caregivers are not really
getting all the credit that they have because they give a lot
of volunteer hours in providing the care for the veterans. So
we believe that the $10 million grant would be very welcomed. I
think that the only concern would be on how it was going to be
implemented.
As far as what the VA is doing, I think that more can be
done, and the more that we look out for the veterans--their
cares and needs--and the more we improve our delivery of
services to them, I think we are going to have a better end
product for all our veterans.
Senator Akaka. Thank you.
Mr. Shaw, in their testimony, other witnesses expressed
concern about Section 5 of the State Home legislation which
would allow VA to deem unused beds as State Homes for the
purposes of placing veterans in long-term care. In my mind,
this section would ensure that there is a long-term care
capacity in places currently lacking nursing home care. But it
would also obviate the need for building new homes.
There is some concern that quality would not be monitored
in these de facto homes. How is this currently working in
Alaska?
Mr. Shaw. It is currently working in Alaska the same way it
is working in all State Homes. They all have the same set of
rules and regulations for health care delivery.
What we are asking for in the deem status would be no
different. Alaska delivers quality care inside the Pioneer
model, inside the homes they currently have. The VA, once those
are fully certified, will also survey and oversee all the care
that is delivered in those sites. The deem homes would be no
different. There is no separate set of regulatory standards
that would be applied. They would be applied the same all the
way across the board.
So I do not understand the concern, knowing that we would
all live under the same set of regulatory rules.
Senator Akaka. Well, I thank you so much for your response.
Mr. Chairman, if I may ask another question here? My time
has expired.
Chairman Craig. Please proceed.
Senator Akaka. Mr. Atizado, in your testimony, you suggest
changing Section 2 of the Healing the Invisible Wounds Act to
permit any changes in rules or standards to expand PTSD
entitlement for more liberal disability ratings. I want to
thank you for your suggestion, because the purpose of this
section is to protect against any diminishment in PTSD
compensation and not to hinder an expansion of the benefit. And
I agree that this change should be made.
You also recommend a modification of the language to
include standards for service connection of PTSD. Now, my
question to you is: How do you suggest that these standards be
developed?
Mr. Atizado. Ranking Member Akaka, thank you for that
question. The suggested recommendation with regard to standard
service connection primarily deals with protecting the current
standard. It is funny to note that no other title or code
provides for adjudication of a claim that would allow the
Government agency to err on the side of a veteran. And we would
like to make sure that is protected with any modifications of
the bill.
With regard to actual changes or enhancements in standards,
I would be happy to send that back to my office to have our
service staff look at it. But if I were to speculate, I would
assume that they would include some kind of standardization of
training in the area of adjudication for service connection for
PTSD. It would eliminate, I think, quite a bit of subjectivity
that would negate the spirit of the law to err on the side of
the veteran.
Senator Akaka. Well, thank you so much for your response,
and we would look forward to comment from your organization on
that.
Thank you very much, Mr. Chairman.
Chairman Craig. Danny, thank you.
Senator Salazar. Ken.
Senator Salazar. Thank you very much, Chairman Craig, and
to our witnesses, thank you for appearing before us today.
Let me also thank you for having conducted the review that
you did of Senate bill 2433, the Rural Veterans Act. I think
the one thing that we can all agree here is that shining a
light on what is happening with 8 million veterans in rural
America is something that is, in fact, important. You see the
bipartisan support that we have for this legislation with over
a dozen Senators, Republicans and Democrats alike. And I know
that this Chairman and this Ranking Member of this Committee
are very sensitive to the reality of rural veterans. I am
hopeful that this Committee can move forward with legislation
that addresses this disparity. For me, it is un-American to
think that we have essentially two Americas, two systems of
health care with respect to how we provide health care to
veterans in America. If you live in an urban area, you are
going to get one set of health care; if you live in a rural
area, you are going to get a second-class set of health care.
So I appreciate the general comments you have made about
this bill. I know there are concerns that have been raised here
today about some provisions of the legislation. But I look
forward to working with the VA and also with your organizations
to see how we might be able to streamline some of the concerns
that have been raised.
I have a question--I will direct this to you, Mr. Blake, on
the fee-for-service aspect of Senate bill 2433. I have heard
the concerns from people who have said we do not want to
privatize the VA. I understand those concerns. But I also have
heard concerns in places like Craig, Colorado, where some of
the veterans there have said we have great health care
facilities, we are so far removed from Grand Junction some 150
miles away, why can't we just go to the local hospital?
I heard your comment that essentially said that you believe
that under the existing authority of the VA, they could
actually engage in contracting for services for those veterans
that live in those very remote areas.
Can you elaborate on that? Or do you think that the--I
guess your conclusion is the VA does not need additional
authority in those circumstances. But I have heard from others
that perhaps it is important for the VA to examine the
authority that it is using for these fee-for-service programs
in these very far outlying areas.
Mr. Blake. Thank you for that question, Senator Salazar. If
there isn't a tougher issue to deal with, this might be it
because it calls into question--I think we have made clear in
the past our position on the privatization of health care, and
yet we understand that probably the ultimate easiest way to
address this issue for rural veterans is contracting out care
in the most geographically remote areas.
A number of spinal cord-injured veterans who live in rural
areas, as an example, use fee-for-service. Not every spinal
cord-injured veteran chooses to live right near a spinal cord
injury center. Now, granted, the spinal cord injury centers
provide at least some degree of access beyond what some
veterans just in general rural areas have. But there are a
number of spinal cord-injured veterans that choose the fee-for-
service program for access to care. Granted, they also have
access because they have special needs, and so they get some
degree of priority for that reason.
I don't really understand why the VA said they do not have
the authority. What I quoted in my testimony is the exact
language for the different circumstances which would allow them
to use the fee-for-service program. I guess it is all in the
interpretation of the statement ``when VA facilities are
geographically inaccessible to a veteran for necessary care.''
Well, that calls into question maybe the idea of what is
rural, and I address this a little bit in my written statement.
The challenge with trying to determine what is considered
rural, well, as an example, myself, I live down in Virginia. I
would like to believe that I live in a rural area, but 10
minutes away is the hub of suburbia now. I mean, that is just
the way things are in this particular area.
I have seen in the past years how ways of addressing this
issue of rural are done in terms of minutes. There was
discussion earlier about 60 minutes and how far that is. Well,
on the right day at the right time, I work in an office in
downtown DC and it could take 60 minutes to get to the DC VA
Medical Center. That is only 4 or 5 miles in distance. So I
think ``rural'' is a function of many things--time, distance,
population density. So maybe it is just interpretation of what
or how the VA interprets the regulations for what is
geographically inaccessible.
Outside of that, using the parameters that are already
there, I believe that they could open fee-for-service within
reason. We always maintain the concern that privatization
ultimately would harm the greater VA system. But if the fee-
for-service program is the only option or the best option they
have, we certainly could not reject that.
Senator Salazar. I thank you very much, Mr. Blake, and I
would appreciate working with all of your organizations as we
move forward with this bipartisan legislation.
Let me just end by saying that, it is very clear that this
disparity of health services exists. We have this very
extensive study that was conducted by the VA, which the
findings, I think, are glaringly obvious. But it also can
sometimes simply come down to this question of living or dying.
If you have accidents and you are far away from the health care
facilities and you live in a place like my native San Luis
Valley, it may be 3 or 4 hours before you get to the right kind
of medical care. Whereas, if you happen to live in a 2 or 3
million population area, like Denver, Colorado, somehow or
other, you will find the health care within 5 minutes.
And so this disparity of health care is something that is
of great concern to me, and I look forward to working with all
of you, and with the great leadership of Chairman Craig and
Senator Akaka, to address this issue in the future.
Thank you very much, Mr. Chairman.
Chairman Craig. Ken, thank you very much.
Gentlemen, we thank you for being with us. I think, Carl,
you are right. In part, it is how we define ``rural.'' When you
look at the standard Federal definition I think that HUD has
established over the years, rural is in relation to living
inside or outside an incorporated area. With that definition,
probably one of our most rural States is our most urban--
Nevada. It is by definition the most urban State. Pennsylvania
is our most rural State by definition of those living outside
incorporated areas. So it is a challenge for us, and I think
that the questioning today and the comments are extremely
valuable.
I am so disappointed in all of you that you did not jump up
cheering and supporting S. 2634. I hope we can find some ground
there. I understand the purpose of the commission originally. I
am not so sure that it takes politics out of the process. But I
do find that, when you have quality and capable people serving
at the pleasure of a President, that to term-limit them is a
bit arbitrary, at best. They term-limit themselves either by
their failure to act or their actions. This system has a pretty
good record of wringing out those who fail to act or act
inappropriately to meet the services and demands of their job,
whether they be at the level of a Secretary or an Under
Secretary.
Anyway, that was part of the reason why I brought this up
as a form of legislation. I knew it would stimulate rather
vigorous discussion. We will continue that discussion, but I do
appreciate your comments on that.
Again, we will leave the record open for a short time for
any additional questions that may come in writing from our
Members that you may wish to respond to. But, again, we thank
you for your preparedness and the time you have spent with us.
It is appreciated, obviously, as we attempt to work for the
purposes of our veterans with the VA to make sure that which
they provide or that which we will ask them to provide is done
so in an appropriate fashion.
Thank you all very much. The Committee will stand
adjourned.
[Whereupon, at 12:04 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
Thank you, Chairman Craig and Senator Akaka, for pulling together
this hearing on these important pieces of legislation.
I want to focus on a bill that is close to my heart. I remember
when I first started my campaign for the Senate, Congressman Lane Evans
took me around on a tour of his district. Lane was full of energy. By
the end of the day I was worn out. I think it is fair to say that had
he not supported me early in my election campaign, I would not be here
today.
No one has worked harder for this Nation's veterans than
Congressman Evans. When Vietnam vets were falling ill from Agent Orange
exposure, he led the effort to get them compensation. He was one of the
first in Congress to speak out about the health problems facing Persian
Gulf War veterans. He has fought to expand benefits to women veterans,
he's worked to help those veterans suffering from Post-Traumatic Stress
Disorder, and he's also helped to make sure there is a roof over the
head of the thousands of homeless veterans.
In 1995, while he was in a Labor Day parade in Galesburg, Illinois,
Lane noticed that he had trouble waving his left hand. He was diagnosed
with Parkinson's disease, a debilitating illness that attacks the
dopamine producing cells in the brain. As the disease progresses,
patients become unable to control muscles and suffer from stiffness and
tremors. There is no cure for the disease, but symptoms can be managed
somewhat with drug therapy. VA medical centers treat at least 40,000
Parkinson's disease patients every year and some experts believe the
disease affects as many as 150,000 veterans across the country.
Congressman Evans has managed his disease with grace and courage.
And he has been a strong advocate for Parkinson's research and for
treatment of veterans with the disease. He helped the VA open new
Parkinson's centers and introduced numerous bills to expand that
service even further. S. 1537, introduced by Senator Akaka, builds on
legislation Rep. Evans introduced last year that passed the House of
Representatives. This is a good piece of legislation that would
establish six Parkinson's disease research and education clinical
centers across the country. I urge this Committee to approve this bill.
It is a sign of our commitment to veterans with Parkinson's disease and
a fitting tribute to Congressman Evans' legacy of public service.
S. 2433, Senators Salazar and Thune's rural veterans bill, is a
comprehensive approach to improving care for our Nation's rural
veterans. The VA has not focused enough on the particular needs of the
23 percent of veterans who live in rural areas. More than 234,000
veterans live in Illinois' rural counties. This bill would take a
number of steps to improve the VA's bureaucracy and study ways to
extend care. I hope that the Committee will seriously consider this
bill.
Senator Akaka's other bills on long-term care and PTSD would move
the ball forward significantly in addressing these perennially
difficult issues.
One piece of legislation that did not make it onto the agenda is S.
2358, a bill I introduced to establish quality report cards for VA
hospitals. This is a small, but important piece of legislation that
builds on existing data to give those on this Committee and others the
tools to objectively measure quality at VA hospitals.
By measuring and reporting on the quality of care in our VA
hospitals, medical centers would benefit from identification of areas
of need, and opportunities for quality improvement and cost
containment. Greater quality reporting and transparency can facilitate
an honest dialogue about health care quality and how to reform our VA
system.
Several states have already developed and implemented hospital
report card initiatives, and I am proud to say that Illinois began its
own report card initiative in January of this year--an initiative that
I spearheaded when I served in the Illinois State Senate.
The VA Hospital Report Card Act mandates that the Secretary expand
and improve upon current quality reporting provisions for VA hospitals.
The bill requires the Secretary to take steps to ensure that all
reported data is accurate and fairly represents hospital quality. The
VA Hospital Quality Report Card Act will take us one step closer to
improving health care quality and containing costs, and I hope my
colleagues will join me in passing this critical legislation.
__________
Prepared Statement of Dennis M. Cullinan, Director, National
Legislative Service, Veterans of Foreign Wars of the United States
Mr. Chairman and Members of the Committee:
I would like to thank you for the invitation to submit testimony
for this important hearing on veterans' health care legislation. The
VFW is this Nation's largest organization of combat veterans, with over
2.3 million men and women across the country and in our Auxiliaries.
While much of our focus is rightly on the funding and appropriations
side of the debate, these bills under consideration recognize that
there are many complex issues associated with the VA health care
system, and we are happy to provide comments on them.
S. 1537
We are happy to support S. 1537, legislation that would establish
six centers for Parkinson's disease research and two Centers of
Excellence for Multiple Sclerosis.
VA research has been at the forefront of many medical breakthroughs
and an increased emphasis on preventing, treating, and curing these two
diseases is extremely important. This legislation would consolidate
system-wide research being done on these conditions and would help to
streamline research and, perhaps, improve its effectiveness. Since a
large number of highly qualified doctors are drawn to VA, in part, for
the ability to conduct world-class research, these centers could help
recruitment.
We should also keep in mind that any benefits and breakthroughs
that these centers would generate would not just affect this Nation's
veterans, but all of America. It's a win-win for everyone. We thank
Senator Akaka for introducing it, and we would urge this Committee's
approval.
S. 1731
This legislation would name the VA Medical Center in Muskogee,
Oklahoma after Jack C. Montgomery. We are pleased to support it. Jack
Montgomery had a distinguished military record and was a recipient of
the Medal of Honor for his valor in 1944. Naming the Medical Center is
a fitting tribute to this great man and is the least we can do to honor
his memory.
S. 2433
This legislation recognizes the growing access problems that many
rural veterans face, and offers many ambitious solutions. Section 2
would create an Assistant Secretary for Rural Veterans within VA.
Section 3 would mandate demonstration projects for improving access to
care in rural areas by creating partnerships with other government
agencies and private health care providers. Section 4 would create a
specific pilot program to improve care for veterans in highly rural or
geographically remote areas. Section 5 would improve the travel
reimbursement for veterans traveling to VA facilities. Section 6 would
create from one to five Centers of Excellence for rural health
research, education and clinical activities.
We appreciate the intent of this comprehensive legislation. As a
nationwide organization, many of our Members face the problems that
this legislation aims to solve.
We strongly support Section 5, which would increase the travel
reimbursement for veterans seeking care at VA facilities. This is badly
needed as the mileage rate has not been increased in many years, and
the deductible means that most veterans receive no travel assistance at
all. This section would increase the rate to the fair rate provided to
Federal employees. It is the proper thing to do.
We have several concerns, however, with sections 3 and 4. While we
understand that in some areas it is the only alternative, we are
concerned that this bill's reliance on fee-based care is overly broad
and that it could adversely impact VA's budget and its ability to
provide care to all veterans. Although we completely agree that more
must be done to help these underserved veterans, relying primarily on
fee-basis care could be a dangerous precedent, and shirks VA of its
responsibility to care for all veterans equally.
We feel that many of the problems faced by rural veterans are
wrapped up in the larger funding problems that VA has encountered over
the last few years. Although we are appreciative of the budget
increases, sufficient funding has not been provided for all veterans
seeking care. Proper funding, we believe, would fix some of these
problems.
S. 2500, HEALING THE INVISIBLE WOUNDS ACT
We happily support this legislation, which aims to improve mental
health services for veterans, especially those in the National Guard.
Section 2 mandates that any decision that VA makes to change
regulations for Post-Traumatic Stress Disorder (PTSD) would require the
notification of Congress and a six- month wait before implementation.
Section 3 mandates counseling and readjustment services for National
Guard members returning from a combat theater. Section 4 increases
funding for Vet Centers to be used on counseling and readjustment
services.
We strongly support section 2. With VA's ill-fated PTSD review
fresh in our memory, as well as the investigation by the Institute of
Medicine lingering, it seems that VA is predisposed to weakening
veterans benefits with respect to PTSD. This is an intolerable
situation that does more to harm veterans by attaching a stigma, and
discouraging those who truly need help from receiving the care and
benefits they need to lead productive lives.
Sections 3 and 4 are important parts of meeting the needs of
veterans. Despite VA's recent actions, we must encourage more veterans
to avail themselves of VA's services. VA's mission is to make veterans
whole, and effective mental health treatment is an important part of
that. By actively screening returning National Guard members, we can
efficiently help those who need treatment and assist them as they
transition back into daily life. War is certainly difficult, and the
types of conflict our men and women are facing are unique. We need to
ensure policies are in place that are adaptable to the current needs of
veterans, and this legislation is a step in that direction.
S. 2364
VFW supports this legislation, which would repeal the term of
office and the requirement for a search commission for the VA Under
Secretary for Health and the VA Under Secretary for Benefits.
With respect to term limits, we feel that they are not necessary,
and that, in the cases of an Under Secretary who will remain in office,
they are a hindrance. It is noted that the current Under Secretary has
been subject to political pressure from some Senators before they will
commit to reconfirming him, a practice that would go away without term
limits. Additionally, we believe that the Under Secretary should serve
at the pleasure of the President, and that that will, in fact, make him
more accountable. If he is doing a good job, he can remain in office
without facing pressure from the Senate, but if he is doing a poor job,
we can hold the Administration accountable for the Under Secretary's
actions. If the Under Secretary is not performing up to acceptable
standards, he or she cannot hide behind term limits.
We also feel that the search commission is unnecessary. Although we
have played a significant role in the process, we feel that its
elimination is not going to affect our involvement. In fact, we believe
that it may increase our effectiveness. Without a search commission,
there will still be accountability, to the President for his
appointment and to the Senate for its confirmation. We trust in the
Senate's independence and oversight authority, and believe that this
body will hold the officeholder accountable. Our members, who come from
every State, are sure to hold both the Administration and the Senate
accountable for their actions, giving us more direct influence over the
process.
One of our constant refrains is that of accountability. We believe
that this bill will give us more direct ability to hold VA accountable,
and we hope that they continue to improve their responsiveness to the
needs of veterans.
S. 2736
VFW is glad to support this legislation, which would create at
least five VA centers for rehabilitation for veterans with amputations
or prosthetic devices. At a time when war dominates the headlines, it
is clear that this is necessary.
Thanks to improvements in technology, many servicemen and women are
surviving blasts and injuries that would have killed them years ago,
but their survival is coming at a heavy physical price. VA has long
been on the forefront of prosthetics and amputation research, but the
current conflicts are greatly increasing the demand for these types of
services, which allow these servicemembers to easily transition back
into productive society. Losing a limb is not a death sentence, and the
uplifting examples that so many men and women provide is powerful
evidence of that.
We thank you, Chairman Craig, and Ranking Member Akaka for
introducing this important legislation, and we would strongly urge your
colleagues to work for its passage.
S. 2753
We support this legislation, which would authorize a $10 million
grant program for caregiver assistance to expand services available to
veterans for non-institutional care services.
As the veterans' population ages and as there continues to be
reticence to fully fund long-term, institutional care, these types of
assisted services, such as adult-day health care and hospice care, will
prove to be invaluable.
S. 2762
We are pleased to support this legislation, which makes some needed
changes in how VA provides long-term care.
Section 2 of the legislation would require VA to report to Congress
prior to making changes to the per diem program used to help fund State
homes and the long-term care they provide. State homes are an integral
part of VA's total long-term care process, and requiring this report
will hopefully prevent the elimination or reduction of these critical
payments for budget-based reasons. We cannot pinch pennies while the
number of veterans needing these kinds of essential services climbs.
Section 3 would require VA to provide medications for veterans with
service-connected disabilities regardless of whether they reside in a
VA facility or a State Home. While we continue to oppose VA using State
Home beds to supplant its statutory obligation to provide long-term
care, it only makes sense that, if VA is going to use State Home beds
in this way, it affords them the same benefits. It is, in short, part
of the full costs of care.
Section 4 would allow VA to treat certain health care facilities as
State Homes for purposes of providing long-term care to veterans. In
rural or remote areas, especially, this could be helpful to VA. We
support the concept, but we must watch to ensure that the same levels
of care are being provided and that vigorous oversight is maintained to
ensure that these facilities are up to VA's high standards.
Mr. Chairman, we thank you for the opportunity to provide testimony
for this important hearing. If you or any Members of this Committee
have any questions, I would be happy to answer them.