[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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                     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

                              ----------                              

                              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.
  

                                  
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