    [House Hearing, 110 Congress]
    [From the U.S. Government Publishing Office]

                  LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853,

                  H.R. 1925, H.R. 2005, H.R. 2172, H.R. 2173,

                 H.R. 2192, H.R. 2219, H.R. 2378, and H.R. 2623

    =======================================================================

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JUNE 14, 2007

                                   __________

                               Serial No. 110-27

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                            U.S. GOVERNMENT PRINTING OFFICE

    37-465                         WASHINGTON : 2008
    ----------------------------------------------------------------------
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    Washington, DC 20402-0001

                         COMMITTEE ON VETERANS' AFFAIRS

                        BOB FILNER, California, Chairman

    CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
    VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
    MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
    STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
    Dakota                               HENRY E. BROWN, Jr., South
    HARRY E. MITCHELL, Arizona           Carolina
    JOHN J. HALL, New York               JEFF MILLER, Florida
    PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
    MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
    SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
    JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
    CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
    JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
    JERRY McNERNEY, California           VERN BUCHANAN, Florida
    ZACHARY T. SPACE, Ohio
    TIMOTHY J. WALZ, Minnesota

                       Malcom A. Shorter, Staff Director

                                     ______

                             SUBCOMMITTEE ON HEALTH

                      MICHAEL H. MICHAUD, Maine, Chairman

    CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
    VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
    PHIL HARE, Illinois                  JERRY MORAN, Kansas
    MICHAEL F. DOYLE, Pennsylvania       RICHARD H. BAKER, Louisiana
    SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South
    JOHN T. SALAZAR, Colorado            Carolina

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                                C O N T E N T S

                                   __________

                                 June 14, 2007

                                                                       Page
    Legislative Hearing on H.R. 1448, H.R. 1853, H.R. 1925, H.R.
      2005, H.R. 2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378,
      and H.R. 2623..................................................     1

                               OPENING STATEMENTS

    Chairman Michael Michaud.........................................     1
        Prepared statement of Chairman Michaud.......................    53
    Hon. Jeff Miller, Ranking Republican Member, prepared statement
      of.............................................................    53

                                   WITNESSES

    U.S. Department of Veterans Affairs, Hon. Michael J. Kussman,
      M.D., MS, MACP, Under Secretary for Health, Veterans Health
      Administration.................................................    38
        Prepared statement of Hon. Kussman...........................    80

                                     ______

    American Legion, Shannon Middleton, Deputy Director for Health,
      Veterans Affairs and Rehabilitation Commission.................    23
        Prepared statement of Ms. Middleton..........................    62
    American Veterans (AMVETS), Kimo S. Hollingsworth, National
      Legislative Director...........................................    25
        Prepared statement of Mr. Hollingsworth......................    65
    Disabled American Veterans, Adrian M. Atizado, Assistant National
      Legislative Director...........................................    26
        Prepared statement of Mr. Atizado............................    68
    Herseth Sandlin, Hon. Stephanie, a Representative in Congress
      from the State of South Dakota.................................     6
        Prepared statement of Congresswoman Herseth Sandlin..........    53
    Hodes, Hon. Paul W., a Representative in Congress from the State
      of New Hampshire...............................................    14
        Prepared statement of Congressman Hodes......................    60
    Lowey, Hon. Nita M., a Representative in Congress from the State
      of New York....................................................    17
        Prepared statement of Congresswoman Lowey....................    61
    Miller, Hon. Jeff, a Representative in Congress from the State of
      Florida........................................................    18
        Prepared statement of Congressman Miller.....................    58
    Moran, Hon. James P., a Representative in Congress from the State
      of Virginia....................................................     3
        Prepared statement of Congressman Moran......................    55
    Paralyzed Veterans of America, Carl Blake, National Legislative
      Director.......................................................    28
        Prepared statement of Mr. Blake..............................    72
    Rodriguez, Hon. Ciro D., a Representative in Congress from the
      State of Texas.................................................     2
        Prepared statement of Congressman Rodriguez..................    54
    Salazar, Hon. John T., a Representative in Congress from the
      State of Colorado..............................................    16
        Prepared statement of Congressman Salazar....................    56
    Veterans of Foreign Wars of the United States, Dennis M.
      Cullinan, Director, National Legislative Service...............    30
        Prepared statement of Mr. Cullinan...........................    76
    Vietnam Veterans of America, Barry Hagge, National Secretary.....    31
        Prepared statement of Mr. Hagge..............................    77
    Watson, Hon. Diane E., a Representative in Congress from the
      State of California............................................     5
        Prepared statement of Congresswoman Watson...................    56

                                     ______

                           SUBMISSIONS FOR THE RECORD

    National Rural Health Association, Andy Behrman, Chair, Rural
      Health Policy Board, statement.................................    85
    Reyes, Hon. Silvestre, a Representative in Congress from the
      State of Texas, statement......................................    87
    United States Ombudsman Association, Ruth Cooperrider, President,
      and Deputy Ombudsman, State of Iowa--Office of Citizens' Aide/
      Ombudsman, letter..............................................    89

                       MATERIAL SUBMITTED FOR THE RECORD

    Hon. R. James Nicholson, Secretary, U.S. Department of Veterans
      Affairs, to Hon. Bob Filner, Chairman, Committee on Veterans'
      Affairs, letter dated August 19, 2007, views on H.R. 2623 and
      H.R. 2699......................................................    91
    U.S. Department of Veterans Affairs, Veterans Health
      Administration, report entitled: ``Plan to Increase Access to
      Quality Long-Term Care and Mental Health Care for Enrolled
      Veterans Residing in Rural Areas,'' January 10, 2008...........    96
    Job Description for Program Analysis Officer, Office of the
      Assistant Deputy Under Secretary for Health for Policy and
      Planning, Veterans Health Administration, U.S. Department of
      Verterans Affairs..............................................   103

    LEGISLATIVE HEARING ON H.R. 1448, H.R. 1853, H.R. 1925, H.R. 2005, H.R.
         2172, H.R. 2173, H.R. 2192, H.R. 2219, H.R. 2378 AND H.R. 2623

                                  ----------

                            THURSDAY, JUNE 14, 2007

                U. S. House of Representatives,
                                Subcommittee on Health,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.

        The Committee met, pursuant to notice, at 10:00 a.m., in
    Room 340, Cannon House Office Building, Hon. Michael Michaud
    [Chairman of the Subcommittee] presiding.

        Present: Representatives Michaud, Brown of Florida, Snyder,
    Hare, Miller, Brown of South Carolina.

                 OPENING STATEMENT OF CHAIRMAN MICHAUD

        Mr. Michaud. This hearing will now come to order. I'd like
    to thank everyone for coming today. I ask unanimous consent
    that all written statements be made part of the record. Without
    objection, so ordered.
        I also ask unanimous consent that all members be allowed
    five legislative days to revise and extend their remarks.
    Without objection, so ordered.
        Today's legislative hearing will provide members of
    Congress, Veterans, the U.S. Department of Veterans Affairs (VA
    and other interested parties the opportunity to discuss
    legislation within this subcommittee's jurisdiction in a clear
    and orderly process. While not necessarily in agreement or
    disagreement with the bills before us today, I do believe that
    this is an important process that will encourage frank
    discussion and new ideas.
        We have ten bills before us that seek to improve healthcare
    for the Nation's veterans and I look forward to hearing the
    views of our witnesses. I also look forward to working with
    everyone here to continue to improve the quality of care
    available for our veterans.
        There are two draft discussions that are not before us
    today. There is a discussion draft on homelessness, and a
    discussion draft on mental health services. Congressman Patrick
    Murphy of Pennsylvania has also introduced H.R. 2699. I'd ask
    that the members of the third panel, the veterans service
    organizations (VSOs), and the fourth panel, VA, provide
    comments and views on these three items for the record once
    they are made available. We'd like to have the written comments
    submitted to the Committee by June 21st of this year.
        We may as well begin, starting off with Mr. Rodriguez.
        [The prepared statement of Chairman Michaud appears on p.
    53.]

       STATEMENTS OF HON. CIRO D. RODRIGUEZ, A REPRESENTATIVE IN
       CONGRESS FROM THE STATE OF TEXAS; HON. JAMES P. MORAN, A
      REPRESENTATIVE IN CONGRESS FROM THE STATE OF VIRGINIA; HON.
    DIANE E. WATSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
           CALIFORNIA; AND HON. STEPHANIE HERSETH SANDLIN, A
         REPRESENTATIVE IN CONGRESS FROM THE STATE SOUTH DAKOTA

                  STATEMENT OF HON. CIRO D. RODRIGUEZ

        Mr. Rodriguez. Mr. Chairman, thank you very much. And
    members of the Committee thank you for this opportunity to be
    here before you. I have my bill, H.R. 2173, a bill introduced
    by myself and my colleague Congresswomen Grace Napolitano,
    provides for increase in the capacity for mental health
    services through contracts with qualified community health
    centers.
        This is an opportunity for veterans in rural communities,
    especially to be able to get access to services, not to mention
    in those areas where we don't have access to mental health
    services within our VA system. It's also a great opportunity to
    follow up on individuals that need the services.
        Recent surveys show that one in eight returning Iraqi war
    veterans report symptoms of post traumatic stress disorder
    (PTSD). The same studies also report high incidents of major
    depression and anxiety disorders among returning members of the
    Army and Marine combat unit. As a member of this Committee, we
    have long identified mental health services as a major issue
    facing returning soldiers as well as the Department of Veterans
    Affairs.
        Experts note that the manifestation of clinical symptoms of
    post traumatic stress disorder and other mental health
    disorders often occurs over several years. With the increase of
    active duty, guardsman and reservists returning from combat,
    the necessary capacity to provide mental health services is
    relatively unknown. It is difficult to know if our large number
    of returning veterans will need mental health services beyond
    what the VA is capable of providing.
        My bill, H.R. 2173, authorizes the VA to contract with
    community mental health centers to increase the capability. In
    my opinion the need has out paced the capacity of the VA to
    provide mental health services in out patient clinics.
    Contracting out to the community mental health centers is
    already been done successfully in some States, and could serve
    as a model for the VA-wide implementation.
        Mr. Chairman, in my previous career, I worked as a mental
    health field social worker. I am fully aware of the great
    services provided by the community health centers. And if there
    is any doubt of the quality of the care they can provide, I can
    tell you of the hundreds of families who's lives have been
    changed by the treatment received during my professional career
    in the field, but you don't have to take my word.
        Each year community health centers have nearly six million
    children, adults, families and communities across this country
    the chance to recover and lead productive lives. Our returning
    soldiers deserve nothing less and we hope that we can provide
    them with that opportunity.
        As I mentioned before, it is clear that our soldiers
    returning with an increased need for mental health services,
    but after this long war, it is unclear what the VA capacity to
    fulfill this need will be. It is my hope that H.R. 2173 can
    provide the VA with the tools to continue to provide top notch
    mental health services to our veterans in their own
    communities.
        Mr. Chairman, once again I would like to thank you for
    allowing me this opportunity, and I urge your support, and just
    indicate that this piece of legislation, I think, will help
    enhance the quality of care for our veterans especially in
    rural communities and in those areas, urban areas, where
    there's a large number of our veterans.
        Thank you.
        [The prepared statement of Chairman Rodriguez appears on p.
    54.]
        Mr. Michaud. Thank you very much. As you know I am very
    concerned about access to healthcare benefits for veterans
    particularly in rural areas that need that access.
        Mr. Moran?

                    STATEMENT OF HON. JAMES P. MORAN

        Mr. Moran. Thank you Mr. Chairman, and Mr. Miller, Mr.
    Salazar, Mr. Brown. I want to thank you for holding this
    important hearing today and commend the Subcommittee for the
    work that it has already undertaken on behalf of our Nation's
    veterans.
        The problem of suicide among our veterans is one of the
    most serious issues that we have to address as we care for our
    older veterans and prepare for a new generation of returning
    soldiers.
        The Centers for Disease Control recently released very
    troubling statistics. Each year approximately 115,000 veterans
    attempt suicide. This accounts for nearly 20 percent of all
    suicide attempts, and yet the veteran population only accounts
    for 11 percent of the entire population. So in other words,
    veterans are much more likely to attempt suicide as other
    groups of our society.
        This disproportionate prevalence of suicide among veterans
    suggest that in addition to our overall national strategy on
    suicide prevention, particular attention should be paid to
    preventing suicide among this special population.
    Unfortunately, I expect this trend to continue as more of our
    brave men and women return from multiple deployments with the
    symptoms of post traumatic stress disorder.
        As we have learned, the staggering 20 percent of soldiers
    returning from Iraq are experiencing depression, sleep
    depravation, anxiety, and other symptoms of PTSD. I am proud
    that this Congress has already acknowledged the growing problem
    of PTSD and dedicated substantial resources to it. Still, I
    believe as scientific evidence suggests, that as our returning
    soldiers are increasingly susceptible to PTSD, they are at an
    elevated risk for suicide attempts.
        My bill, the ``Veterans Suicide Prevention Hotline Act of
    2007,'' would create a 24-hour National toll-free hotline to
    assist our Nation's veterans in crisis. It would be staffed
    predominately by veterans trained to appropriately and
    responsibly answer calls from other veterans. The hotline would
    follow the models of the national suicide, sexual assault, and
    domestic violence hotlines who have volunteers trained in
    active listening and crisis de-escalation respond to a variety
    of crisis calls.
        I believe that this cultural competency, the ability to
    connect to another veteran who understands what the caller may
    be experiencing can make a real difference in crisis
    counseling. It is difficult to connect on this level with
    anyone else, even trained doctors or other professionals.
        So to build this capacity nationwide, my bill calls for a
    3-year competitively awarded grant for two and a half million
    dollars in the next three fiscal years. The funding will be
    made available to a qualified non-profit crisis center to
    establish, publicize, and operate the hotline including
    developing curricula to train and certify volunteers.
        We have reached out to the Department of Veterans Affairs
    and are encouraged that the Veterans Health Administration
    (VHA) is undertaking new efforts to establish a suicide hotline
    and address mental health needs. Their plan is to divert
    callers from the national suicide prevention hotline to a VA
    facility staffed by doctors, psychologists, and other certified
    counseling professionals. On the surface, the VHA's effort may
    appear duplicative of what I am proposing, but there are some
    very important differences that I feel need to be highlighted.
        First, my legislation requires that the people answering
    the phones, those dealing directly with the veterans are
    veterans themselves. There are times when speaking with someone
    who has the cultural competence and the empathy to really
    understand the experiences of veterans in crisis can help make
    the difference between successful integration to mental health
    treatment and failure to reach a veteran in dire need of
    services.
        Second, the VHA has many responsibilities for providing the
    highest quality of healthcare for our veterans. However, they
    have experienced stressed budgets and staffing shortages in
    recent years. Because the demands placed on any veterans
    hotline may be much greater as our Nation redeploys from Iraq
    in the future, I have concern that the VHA may not have the
    capability and commitment to the hotline that a non-profit
    organization dedicated to suicide prevention as its sole
    purpose might be able to provide.
        Third, there are times when a person in crisis doesn't want
    to talk to a doctor. They want to talk to a volunteer. Mentally
    ill individuals all face societal stigmas associated with
    seeking care. Research from the Air Force's suicide prevention
    effort suggest that this is perceived to be even more profound
    in the military and veteran communities. Fear of the system, of
    an un-friendly mental health establishment or of potential job-
    related consequences keep many from seeking care. One of the
    motivations behind the National Suicide Hotline and this bill
    is to give people in crisis another option, an anonymous
    hotline that can respond to their immediate crisis.
        To conclude, our vets deserve as much support when they
    return from combat as they receive while in battle. Too many of
    our veterans are struggling to make the difficult adjustment
    back to society and need someone they can talk to, someone who
    has walked a mile in their shoes. This legislation will offer a
    caring voice at the end of the line when it feels that there is
    no where else to turn.
        Thank you, Mr. Chairman.
        [The prepared statement of Congressman Moran appears on p. 5
    5.]
        Mr. Michaud. Thank you very much. Ms. Watson?

                   STATEMENT OF HON. DIANE E. WATSON

        Ms. Watson. Thank you so much, Mr. Chairman, for holding
    today's hearing and letting me speak on the bill H.R. 1853, the
    ``Jose Medina Veterans Affairs Police Training Act of 2007.''
        I believe this legislation is vital to protect our heroes
    and who have sacrificed their minds and bodies to protect our
    freedoms. And I feel the two previous bills presented will be
    complimented by this legislation.
        Mr. Chairman, too many veterans are suffering from mental
    health problems after returning from combat, and they are not
    receiving the proper treatment they deserve. Congress has a
    responsibility to provide quality healthcare for our veterans.
    We must analyze every aspect of services associated with the
    treatment of post traumatic stress disorder or PTSD for our
    vets.
        So I have introduced H.R. 1853, the ``Jose Medina Veterans
    Affairs Police Training Act of 2007,'' a bill that will force
    the Department of Veterans Affairs to better prepare it's
    police force to interact with patients and visitors at the VA
    medical facilities who suffer from mental illnesses.
        Jose Medina is a constituent of mine. He is a Vietnam vet
    who suffers from PTSD. In January of 2006, Mr. Medina was
    assaulted by two west Los Angeles VA police officers who kicked
    him and forced him to the ground after he isolated himself and
    fell asleep in a hallway at a VA medical center in Los Angeles.
        After a physical altercation ensued, this 56-year-old
    veteran was forced to lay first face down on the hospital
    floor. The officers injured Mr. Medina, and after the
    altercation they did not allow him to use the hospital's
    emergency room. Instead, the officers handcuffed him and
    detained him for an hour before sending him home and gave him a
    loitering ticket.
        This is not the way we should be treating veterans who have
    served and protected this country. What bothers me the most is
    that when we see someone sitting on a hospital floor, one would
    think law enforcement would have hospital staff come and
    question the individual to see if that individual was all right
    or in need of assistance. Instead, in this case, Mr. Medina was
    without medical treatment and was mistreated at the same time.
        This is happening to too many of our brave veterans out of
    sheer ignorance. As we look to the future, thousands of
    veterans will be entering the VA healthcare system. We must
    ensure that the VA has the ability to administer quality
    healthcare services to veterans that suffer from mental
    illnesses. With over 20 percent of the one and a half million
    veterans that served in Iraq or Afghanistan showing signs of
    PTSD, we do not want any of them to endure what Mr. Medina went
    through. They simply deserve better.
        So, Mr. Chairman, the Department of Veterans Affairs
    believes this legislation is unnecessary, but the story of Jose
    Medina and other veterans from around the country who have
    contacted my office with similar problems have confirmed that
    this training is indeed necessary.
        As Congress debates funding strategies and time lines for
    our military missions, we must not overlook the fact that they
    not only--that we not only need for our vets to have the
    resources for results from the battlefield, but they must also
    be treated with dignity and respect once they resume their
    lives after combat. We must ensure that this occurs.
        So, Mr. Chairman, I thank you for this opportunity to
    explain what this bill would do, and I urge the members to
    support H.R. 1853. Thank you.
        [The prepared statement of Congresswoman Watson appears on
    p. 56.]
        Mr. Michaud. Thank you very much. Appreciate your
    testimony. Ms. Herseth Sandlin?

              STATEMENT OF HON. STEPHANIE HERSETH SANDLIN

        Ms. Herseth Sandlin. Thank you, Chairman Michaud and
    Ranking Member Miller. I appreciate the opportunity to discuss
    here today the Services to Prevent Homelessness Act, a bill
    which I introduced May 17, 2007, to provide supportive services
    to very low income veterans.
        The U.S. Census Bureau estimates that 1.5 million of our
    Nation's veterans live in poverty, including 702,000 veterans
    with disabilities and 404,000 veterans in households with
    children. Six hundred and thirty-four thousand of the 1.5
    million poor veterans live in extreme poverty. These poor
    veterans face residential insecurity due to their low income
    levels or their past episodes of homelessness. They also face
    health and vocational challenges and access barriers to
    supportive services, which limit their ability to sustain
    housing and maintain independence for more costly public
    institutional care and support.
        These poor veterans may benefit from flexible and
    individualized support services provided at home based
    settings. The services to prevent Veterans Homelessness Act
    would authorize the Secretary of Veterans Affairs to provide
    financial assistance to non-profit organizations and consumer
    cooperatives to provide and coordinate the provision of
    supportive services that addresses the needs of very low-income
    veterans occupying permanent housing.
        The financial assistance shall consistent of per diem
    payments for each household provided supportive services.
    Supportive services that may be offered include physical and
    mental health, case management, daily living, personal
    financial planning, transportation, vocational counseling,
    employment and training, education, assistance in obtaining
    veterans benefits and public benefits, child care, and housing
    counseling.
        Veterans sub-populations expected to benefit from the
    program include veterans transitioning from homelessness to
    permanent housing, poor disabled and older veterans requiring
    supportive services in home-based settings, and poor veterans
    in rural areas with distance barriers to centrally located
    services.
        While Federal programs exist to help create veterans home
    ownership, there is no national housing assistance program
    targeted to low-income veterans. Permanent housing
    opportunities for veterans ready for independent living are
    limited.
        In addition, the VA currently is not permitted to provide
    grants to create affordable permanent housing and the resources
    that are available for providers are inadequate and highly
    sought by competing housing projects.
        Thank you again for the opportunity to be here today. I
    look forward to continuing to work with the Chairman and the
    Ranking Member to support efforts to meet the housing
    assistance needs of our Nation's low income veterans through
    the establishment of a permanent housing assistance program for
    this population.
        I am happy to take any questions that you may have.
        [The statement of Congresswoman Herseth Sandlin appears on
    p. 53.]
        Mr. Michaud. Thank you very much. I have a couple of
    questions on some of the bills. The first one is to Ms. Watson.
        You so eloquently explained the problem you had with one of
    your constituents at the VA facility. Is this typical? Is this
    the first case or is it really ongoing out there? Have you
    heard from the different VSOs?
        And my second question, what type of training do you think
    additional training they need?
        Ms. Watson. Yes. To address your first concern, it is one
    of our top calls that comes in to my office and I had my
    staffers in here who could supply the actual numbers. But in
    Los Angeles, our homeless population on any given night is
    somewhere between 80,000 and 90,000. Those people who are
    homeless, 33 percent of them, are vets in need of mental health
    services.
        So it is a pervasive problem that we must address. And I
    hope in Markup to put a provision in this bill that would say
    that the training must come from highly trained professionals.
    And the kind of training that it will supplement what is
    already called for in prior legislation is the handling and the
    respect for dealing with mentally ill patients.
        And so we get in to the actual behavior of law enforcement
    and other personnel that deal with the mentally ill.
        Mr. Michaud. Great. Thank you. My next question is for Mr.
    Moran. You had mentioned setting up this separate hotline. Do
    you know if there is currently a national hotline for suicide
    prevention? How many calls go in to that hotline that actually
    deal with veterans? Do you have any idea of that?
        Mr. Moran. I don't have the numbers, Mr. Chairman. The way
    I came up with this idea was that I was talking with some
    people that are involved with a group called Crisis Link that
    provides suicide prevention throughout the Washington
    Metropolitan area. And one gentleman I was asking what is going
    on and he said, ``Well when veterans found out that we had a
    veteran volunteer that they could talk to, that veteran become
    overwhelmed with calls.'' He is spending overtime. It is taking
    up much of his life, because the word spreads. And there is a
    clear indication that most veterans would like to talk to
    another veteran that can empathize with them. That is what is
    distinct.
        And I think that the numbers don't necessarily reflect
    that, but the fastest increasing number of calls with this
    group was because of the presence of that veteran on the other
    end of the line, but I don't have any specific numbers as you
    have asked.
        Mr. Michaud. Great. Thank you. My last question actually
    goes back to Ms. Watson. Is the police force at VA facilities,
    is that a contracted service or are they regular VA employees?
        Ms. Watson. They are employees that have come in under a
    contract and I don't know whether they are paid from the
    contract or from the VA. Would you know that information? They
    are Federal officers.
        Mr. Michaud. Okay. Great. And hopefully the VA officials
    here will be able to let us know of all facilities whether they
    are VA Federal officers or contracted positions.
        Mr. Miller?
        Mr. Miller. Thank you, Mr. Chairman. Mr. Moran, I think we
    agree that the end result of what you are trying to have done
    is what we are trying accomplish, though I do have a question.
    We passed H.R. 327, the Joshua Omvig Veterans Suicide
    Prevention Act, earlier this year that required an in-house 24-
    hour hotline. Can you expand a little bit on why we would need
    this hotline. H.R. 327's hotline is veterans, these are members
    of the VA Office, and they are specially trained, why we would
    need to go outside and do this independently?
        Mr. Moran. That is a very good question. I think the
    difference, and I address this in my testimony, is that the VHA
    line is designed to get people into the VA system, it's doctors
    and psychologists who are not necessarily veterans that are on
    the other end of the line.
        What this is, what I am suggesting is a volunteer
    organization. These organizations exist in many of our
    districts. People who are not necessarily professionals, but
    get specific training. And many people have found that they can
    relate better to the veteran. They are not trying to get them
    in to necessarily a mental health establishment immediately and
    there is some stigma to calling the VA. And while the VA does
    wonderful work, and the professionals associated with the VA do
    a great job, the veteran that may be attempting suicide is not
    necessarily wanting to get in to what they consider to be the
    establishment to talk to necessarily a professional who has an
    objective. We find that in other situations.
        And what we are going to try to do if this is established,
    if it is not then groups will try to do it on their own, is to
    find a great many veterans who are willing to volunteer to get
    the training to be there for other veterans on a volunteer
    basis. So it is a different kind of thing.
        One is professional. It is an official arm of the
    Department of Veterans Affairs. It is designed to get people in
    to the VA system. Another is volunteer hotline for people that
    can perhaps empathize to a greater extent with who will be
    there for them if they are having difficulty coping.
        And so it is different personnel. It is a differently run
    organization. The ultimate purpose, of course, is the same; to
    save people's lives and to be there for people in crisis.
        Mr. Miller. Thank you, I had some other questions, but all
    of you did such a good job. Ms. Watson?
        Ms. Watson. Yes. If I can extend the response. I mention
    that we have 33 percent homeless vets on the streets, and so
    this service nationally will allow them an opportunity. They
    are not necessarily in-house, but wherever they are and I was
    just thinking as Representative Moran was speaking, that we
    might want to locate these services in homeless shelters, on
    skid rows, and places that will be assessable.
        What we find in Los Angeles is that many of our people who
    are homeless are committing suicide through overdoses of drugs.
    And they really need someone to talk to. They don't know how to
    access that. So I think the idea of having them locate it where
    homeless people or homeless vets would go on the streets is
    something that we need to fill in our chain of services.
        Mr. Miller. I think, if I am correct, Mr. Moran's proposed
    legislation is a single provider, a single hotline. That is why
    I was asking the questions in regards to the single hotline
    that is already provided or will be provided under the Omvig
    bill that we passed earlier this year.
        There may be a desire to expand it, but then you are
    talking about other mental health providers. Now we are really
    beginning to go far beyond what I think the original intent and
    scope, which is to provide a single call that that veteran can
    make to somebody when he or she is at their very darkest,
    lowest moment.
        That was what my question was. Again, I think we are all
    trying to get to the same place, and I salute everybody here.
    My other questions you have already answered in your opening
    statements. Thank you.
        Mr. Michaud. Mr. Salazar?
        Mr. Salazar. Thank you, Mr. Chairman. I just have a
    question for, let's see, Ms. Watson, Mr. Moran, and Mr.
    Rodriguez. Most of your issues deal with mental health issues
    of veterans. Is there a way to be able to coordinate your three
    bills into one bill, which might be a little more effective way
    of addressing the issue of veterans and mental health issues?
        Mr. Rodriguez. Let me just indicate that the need for us to
    provide especially in mental health settings to provide
    training for those officers to treat people and to recognize
    them is essential. And that has got to happen. That has to
    occur. Those people that are law enforcement, first responders,
    need to be aware of that whether they are public sector or
    private sector.
        Secondly, the area of mental health we just have one too
    many veterans that are committing suicide. So we need to
    provide that access. And you yourselves and your offices I have
    had veterans come in to my offices that threaten our office and
    they are mentally ill. And they need services. And that is why
    we really need to push forward, and because we are just having
    one too many of them committing suicide.
        The contracting out to the community mental health centers
    throughout this country, those are the ones that provide the
    most access to mental health than anyone else in this country.
    Those were created in the sixties. It is a great opportunity to
    provide that access. Major metropolitan areas have crisis
    intervention centers that have 1-800 numbers.
        But one of the ways to look at it is maybe in some of the
    rural communities, there is one thing to provide the access,
    but the other thing is the referral that are needed and the
    follow up that is required in order to respond to those needs.
    And some how we have to fill those gaps.
        And I think a comprehensive program that allows that to
    occur, and especially in rural America where you don't have as
    much and some of those mental health services are available
    where you don't have VA services. So I think a comprehensive
    program is needed and the sooner we can do that the better.
        Mr. Salazar. Mr. Moran?
        Mr. Moran. Mr. Salazar, everything that we have recommended
    is complimentary and deliberately complimentary of everything
    that the Department of Veterans Affairs is doing. Mine is
    pretty limited in scope. It is simply to have one single
    national hotline number that is available any time that
    veterans can memorize and call and find another veteran at the
    other end of the phone to expand it to include these, which is
    fine. The dollar amount that is being recommended over a 3 year
    period would have to be substantially greater to do it right.
    That is why the amount of resources that I suggested is pretty
    limited.
        So they are all fine things, it is just that as you expand
    them you would have to contribute provide more money to make
    them work properly.
        Ms. Watson. And in response, we gave a name to our bill
    because we want to send a message out there. So we are naming
    the Jose Medina. And if it would fit in to other pieces of
    legislation that is to be considered as well. But we wanted to
    tag this with his name to send the word out there like the
    Miranda Act, and so, it comes out of an event. And we want to
    let the veterans know that these incidents are very important.
    We are sensitive to them so we put his name on it.
        And so I guess we could integrate this in to another piece
    of legislation and we can talk about that.
        Mr. Salazar. Thank you. Ms. Herseth Sandlin, your bill
    talks about housing and the transition from homelessness toward
    someone who can actually live in a home. Does your bill address
    the issue of those who are almost at the transition point of
    becoming homeless? They have a home, but because of their
    income they are almost there or are in danger of becoming
    homeless?
        Ms. Herseth Sandlin. I think the bill is more focused on
    the transition of the veterans subpopulation that has had
    episodes of homelessness, has transitioned to temporary housing
    programs of which we may be familiar with in our districts, but
    then addresses really that next hurdle of moving to more
    permanent housing.
        So your question is a good one. I think that we could
    certainly as the Secretary would have the authority in
    establishing the criteria for the non-profit organizations or
    cooperatives, consumer cooperatives, that would be utilized to
    extend the service that certainly it could address those that
    might be at danger of homelessness, although I think we are
    catching them already to a degree, at least a significant
    percentage of them in the subpopulation that has previously had
    episodes of homelessness.
        So I appreciate the question and it is something that we
    could pursue I think more if we were to get this enacted with
    the Secretaries. We work with them to establish a formula and
    the criteria as it relates to contracting with the non-profits.
        Mr. Salazar. Thank you. I yield back, Mr. Chairman.
        Mr. Michaud. Mr. Brown?
        Mr. Brown of South Carolina. Thank you, Mr. Chairman and I
    thank the witnesses for coming and bringing testimony to solve
    a problem that we have been trying in this Committee for a long
    time to connect to the homeless veteran. We recognize that
    there are many homeless veterans that do have a mental
    condition.
        We have tried to provide resources, and I believe they are
    adequate resources out there if we could just match the
    homeless veteran to the resource. I appreciate the effort that
    you are trying to do that.
        Ms. Watson. If I might respond, Mr. Chairman? One unique
    feature of our bill is that we address police brutality. We
    have received complaints from not only the West Los Angeles
    Medical Center, which is just right next to my district it is
    coterminous, but from Michigan, San Antonio, Texas and so on
    and it is all referring to the police brutality. So we address
    that issue uniquely in our bill.
        Mr. Brown of South Carolina. I know, Mr. Moran, in your
    bill and I appreciate that for the trying to reach out to those
    veterans that need particularly care. And I know in our region
    we have like the 2-1-1 number where they can call and talk to
    some counselor that is online all the time.
        Is part of your bill to require that there be some voice at
    the end of that line all the time?
        Mr. Moran. Thank you, Mr. Brown, for asking that question.
    The answer is yes. Many of these suicide prevention hotlines
    are very good and they have very fine people, but I notice that
    the volunteers tend to be young, single people who have the
    time to provide. They don't necessarily tend to be veterans.
    And what this would do is to put a special emphasis upon
    getting trained veterans on the other end of the line.
        Now, they are not veterans who have the career choice or
    interest, ability, whatever, to become doctors or psychologists
    or specific mental health counselors. They are trained simply
    to be there to listen and to try to get help, get somebody to
    get through a crisis. So we would be going out to veterans
    organizations just trying to get recruits to volunteer to help
    them to be there and have one single line nationally that would
    be toll free that people could call.
        That is why it is fairly limited in scope, but it is
    particularly designed to get a veteran on the other end of the
    phone.
        Mr. Brown of South Carolina. Thank you. Thank you, Mr.
    Chairman.
        Mr. Michaud. Mr. Hare?
        Mr. Hare. Thank you, Mr. Chairman. Thank you for holding
    this hearing this morning, it is very important. Let me thank
    my four colleagues for being here today and for proposing
    various legislation. You know we have seen a lot and heard a
    lot about all wounds that people have aren't necessarily wounds
    that people can see. So I am really delighted that you have
    come together on this and I want to commend you all for that.
        I have a question, if I could, for Mr. Rodriguez as soon as
    I find it. Sir, like you, I have a lot of rural area in my
    district. I know your district is extremely large, probably one
    of the largest in the country. And I wonder if you could tell
    me a little more about how the bill that you have would address
    the problems that your constituents face accessing mental
    healthcare particularly in a geographic area that is so
    incredibly large?
        Mr. Rodriguez. First of all, the one of the few
    organizations that is responsible for that and that provides
    some degree of access to healthcare to in mental health
    throughout this country is the community mental health centers.
        And so to provide services, and this is one of the few
    areas that where we can provide that access and the follow up.
    The purposes of the community mental health centers were
    basically were to try to get the mentally ill out of the
    institutions in the sixties. So they were created to reach out
    to the community throughout America and meet those needs.
        And so these centers are trained to do that. And I really
    believe that we have some figures that we have seen of three
    million veterans committing suicide every year directly are
    tied in to the VA and there is a larger number that are not
    tied to them. And so we really need to you know, provide those
    services as quickly as possible. And I really believe I would
    of preferred it under the VA System, but I really believe that
    they don't have the capability at the present time to meet the
    massive need that is needed out there.
        And so I really believe that this is one of the few ways of
    meeting that need and that is reaching out through the
    community mental health centers that exist throughout the
    country, even in rural communities. And they can reach out and
    get some kind of professional treatment that is required. There
    are some areas where we don't. I got one psychiatrist in one
    community and I think it was a contract that was out there in
    the private sector, but the community health center there is
    actually a little better equipped to handle that.
        Now the urban areas have the crisis centers and have the
    for the homeless and others, but in those other areas you know
    we have got to do more to those individuals that are out there,
    especially the ones who have hit the bottom of the totem pole
    which is the homeless veterans that find themselves without
    anything and find themselves without access. And you have got
    to have those outreach workers that do that.
        And I think that that is one of the better ways. Now we
    still have a problem in that in rural America in terms of how
    do we, you know, in those areas where you have to provide that.
    I have that problem in terms of trying to provide offices. I
    have five offices right now and I don't have the manpower to
    provide the staffing throughout my office. And so there is
    still a need to provide some mobile units to go out in to rural
    America.
        Mr. Hare. Thank you. And I just have a question for my
    colleague Ms. Herseth Sandlin. And I apologize for coming in
    just a bit late, I was on the floor. But you know we see the
    stand downs that we have throughout the country every year to
    help homeless veterans. The problem is that is a weekend,
    excuse me, that is a weekend opportunity. And I was amazed in
    my district that when Congressman Evans was hosting these and
    working on them, that the number of veterans that would use,
    you know, the stand down and be able to come in.
        I am wondering could you just expand a little bit on what
    your bill would do to establish assistance program so that we
    can move homeless veterans into, to give them some decent
    housing that they clearly, ``A,'' need; and ``B,'' deserve?
        Ms. Herseth Sandlin. Well thank you for the question. And
    you are right. With the weekend stand downs one of the
    wonderful things about that is that you have generally this a
    centralized location that offers a whole host of other services
    that are either important to veterans who are interested in
    what they can access to avoid homelessness, if they are very
    low income veterans, but certainly those that have had episodes
    of homelessness that have perhaps been in transitional housing
    but the eligibility is 24 months of transitional housing and
    then what more may be needed in terms of financial counseling,
    access to other benefits to which they are eligible to have a
    more holistic approach, comprehensive approach to what the
    needs of the veterans are on a more consistent basis than the
    weekend stand downs where they look forward to that opportunity
    and word gets around the veteran population of a particular
    community or particular region of a district or a State.
        And so what the bill does is I think it addresses a gap
    that currently exists in what the VA can provide in setting up
    a grant program, establishing a formula and the criteria for
    non-profit organizations and consumer cooperatives to access
    the grant and provide these services, particularly targeted
    toward veterans and their families who are very low income who
    are in that transition period.
        But as Mr. Salazar asked earlier, I think that the
    availability of support services for very low income veterans
    and their families that may already be in housing but at great
    risk for homelessness can also be provided within the terms of
    this bill.
        So I think it addresses a significant gap that exists and I
    think especially at this time in our country's history when we
    have many veterans returning who have very young children, who
    are very young themselves, this is an important grant program
    that needs to be established.
        Mr. Hare. Thank you very much. And once again, Mr. Moran
    and Ms. Watson, thank you very much for your legislation. I
    think they are wonderful pieces of legislation. I yield back.
        Mr. Michaud. Dr. Snyder, you have any questions?
        Once again, I would like to thank our first group of
    panelists for your testimony today and look forward to working
    with you as we look at this legislation later on. Thank you.
        Mr. Moran. Thank you.
        Mr. Rodriguez. Thank you.
        Mr. Michaud. I would now like to welcome our second panel.
        The first individual I will ask to give his statement is
    Mr. Hodes. I want to thank you, Mr. Hodes, for your interest in
    veterans issues. I know you have been a strong advocate for
    veterans issues, we have dealt with your legislation earlier in
    the year as well. So thank you very much for coming here today.
    Mr. Hodes?

    STATEMENTS OF HON. PAUL W. HODES, A REPRESENTATIVE IN CONGRESS
       FROM THE STATE OF NEW HAMPSHIRE; HON. JOHN T. SALAZAR, A
      REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; HON.
     NITA M. LOWEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
     NEW YORK; AND HON. JEFF MILLER, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF FLORIDA

                    STATEMENT OF HON. PAUL W. HODES

        Mr. Hodes. Thank you, Chairman Michaud, and Ranking Member
    Miller for holding this important hearing today. I appreciate
    the opportunity to come before this Subcommittee to testify
    about H.R. 2192, the bipartisan bill I introduced establishing
    an Office of the Ombudsman in the Department of Veterans
    Affairs. I also want to thank Chairman Filner, who is not here,
    for his support of the bill.
        This bill grew out of the visits I made to Walter Reed Army
    Medical Center and the hearings held by the Oversight and
    Government Reform Committee on which I sit. I talked with
    numerous soldiers about the problems they experienced
    transitioning out of active duty and into the VA. I also talked
    with numbers of veterans organizations within my own State, New
    Hampshire, and numbers of veterans.
        Veterans in my district have repeatedly told me their
    compelling stories of the great difficulties and challenges
    they have faced in understanding and receiving all the benefits
    and services to which they are entitled. The ombudsman's
    office, which as proposed in this bill, should serve as the
    outreach master office. A coordinating and coordinated center
    for benefits and health information services available both
    within and outside of the VA.
        I am not interested in creating another meaningless layer
    of bureaucracy. Instead, I would like the Ombudsman Office to
    become a one stop shop for veterans. A CENTCOM for veterans
    benefits information. I applaud the VA for their hard work in
    providing information that veterans need. The VA has numerous
    hotlines and support services available to veterans. I have
    counted ten different 1-800 numbers on the VA's website to help
    with different types of benefits. One for disability pension,
    another for healthcare benefits, another for life insurance,
    etc.
        And while the VA provides veterans benefits and services
    information, the veterans may not know where they put their
    informational pamphlets 6 months or one year down the road when
    they have a question or a problem. Our veterans are falling
    through the cracks and do not know where to turn.
        It was very interesting to me, recently a number of both
    active duty wounded soldiers and veterans came to the floor of
    the House to talk with a number of Members of Congress. There
    were seven or eight members of Congress there and we heard
    compelling stories there on the floor from veterans who
    described what they--described as their ordeal working through
    the bureaucratic maze and the red tape in the Veterans
    Administration. And this office is designed to provide that one
    stop shop that would help them cut through the red tape.
        It would provide a focal point of information within the
    VA. The office should head up the advocacy and information
    campaigns that the VA already has in place and consolidate the
    information services with an 800 number to address all the
    veterans needs and complaints. For a veteran who has just
    returned from active duty an Operation Iraqi Freedom (OIF) or
    Operation Enduring Freedom (OEF) with traumatic brain injury,
    it would be a whole lot simpler and easier to have only one
    office to call to receive the information he or she needs.
        The VA has a patient advocacy program for healthcare but a
    lot of brave men and women need help with loans for their homes
    and schooling too. They shouldn't have to run around asking the
    same ten questions to ten different offices. The Ombudsman's
    Office can help the veteran figure out all the services in the
    benefit system not just the healthcare and not just about
    disability.
        I have reviewed the testimony of the esteemed panelists,
    the VA and VSOs who have presented written testimony before
    this Subcommittee. And just in the six testimonies that
    specifically discuss the Ombudsman's Office, the panelists
    referred to 14 different programs both within and outside of
    the VA that veterans could turn to for help with benefits
    coordination. That is good news and the bad news.
        The good news is the services are available. The bad news
    is there are so many of them which can be confusing. These 14
    programs are extremely important to our veterans in providing
    specialized services. But as a healthy member of Congress and
    not a PTSD patient or an ailing elderly veteran, I am even
    confused to some degree about which programs to use and under
    which circumstances.
        So, Mr. Chairman, I am not trying to make redundant
    services. The VA provides advocacy and resources and many VSOs
    provide advocacy and resources. I look forward to working with
    the Honorable Members of the Committee to mold the Office of
    the Ombudsman in to a viable helpful resource for veterans. I
    believe that this consolidation of various information sources
    in to a coordinated center of information will help make sure
    the veterans receive the care they need and cut through the
    seemingly endless amounts of bureaucratic red tape.
        I would like to point out to the Subcommittee that
    especially with respect to the duties section as it is
    currently set forth in the draft bill, I believe that through
    markup and working with the expertise of the Committee, that
    section probably didn't come back as complete to me from
    legislative counsel as it ought to be and should be expanded so
    that the duties include coordination of services and benefits
    both within the VA and also that may be available through VSOs
    and or the communities in which the veterans are so that it is
    a comprehensive coordination effort.
        Thank you again for giving me the opportunity to testify
    before this Subcommittee and I look forward to working with the
    Committee to help veterans understand and access the benefits
    they deserve.
        [The prepared statement of Congressman Hodes appears on p. 6
    0.]
        Mr. Michaud. Thank you very much, Mr. Hodes. Mr. Salazar?

                   STATEMENT OF HON. JOHN T. SALAZAR

        Mr. Salazar. Thank you Chairman Michaud and Ranking Member
    Miller and Members of the Subcommittee. I want to first of all
    thank you for your interest in rural veterans healthcare and I
    know that you have both been major leaders in this fight.
        Mr. Chairman, today I am happy to bring H.R. 2005 to the
    Subcommittee. I am looking forward to discussion of this
    important legislation. This bill called the Rural Veterans
    healthcare Improvement Act seeks to improve healthcare services
    to veterans in rural areas.
        As many of you have heard over the last several years in
    this Committee that a study of more than 767,000 veterans by
    researchers working for the Department of Veterans Affairs
    shows vets in rural areas are in poorer health than vets living
    in the cities.
        The VA found that the health of rural veterans still
    persist even after researchers adjusted for social economic
    factors such as race, education, and employment status. It was
    identified in this study that access is a care--to care is a
    key factor. The study suggested that in addition to
    establishing more clinics in rural areas VA should consider
    coordinating services of Medicare and other healthcare services
    based in rural areas similar to what Mr. Rodriguez was talking
    about earlier in the earlier panel.
        As a way to begin addressing some of these issues, the
    Veterans Benefits Health Care and Information Technology Act of
    2006, which passed at the end of the 109th Congress created the
    office of Rural Health within the VA. Dr. Kussman's testimony
    will tell you that the VA is opposed to this legislation
    because the Office of Rural Health is charged with these tasks.
        I would like to make the point that even though Congress
    directed VA to establish this office it has not yet been
    implemented. This new office, when the VA decides to set it up,
    needs support, direction, and resources in order to fulfill its
    mission of coordinating care in this vital constituency. The
    Rural Veterans Health Care Improvement Act of 2007 would task
    the director and the Office of Rural Health with developing
    demonstration projects, centers of excellence, and a
    transportation grant program. And the bill would also more
    fairly reimburse veterans in rural areas for traveling expenses
    they incur when driving long distances to VA medical clinics.
        Mr. Chairman, with both an ailing veteran population to
    care for and a new generation of veterans returning from
    service in Iraq and Afghanistan, we immediately need to address
    access to care issues in rural areas. It is estimated that
    nearly 45 percent of all new recruits are coming from rural
    America and with a large percentage of this war burdened on our
    national Guard, the number is only going to increase.
        Many vets must travel hundreds of miles to access medical
    care that we promised and they do so almost entirely at their
    very own expense. Currently we reimburse veterans at the rate
    of 11 cents a mile. The rate has not been increased since 1978.
    In 1978 the average price of a gallon of gasoline was 63 cents
    a gallon. Today in rural America, in rural Colorado, the
    average is right around $3.39 a gallon.
        This legislation would increase the reimbursement rate to
    48 cents a mile the same rate paid by--to Federal employees.
    This legislation also establishes a transportation grant
    program called Vet's Ride. Vet's Ride encourages veteran
    service organizations to develop innovative transportation
    options to vets in rural areas. With a grant up to $50,000, the
    VSO can purchase a van or find other ways to assist veterans to
    travel to VA medical centers.
        This bill also establishes centers for excellence to
    research waste, to improve care for rural veterans. These
    centers would be based at VA medical centers with strong
    academic connections. The outcome of these centers would be the
    development of specific models to be used by VA in providing
    health services to vets in rural areas.
        The Rural Veterans Health Care Improvement Act of 2007 also
    tasks the office of Rural Health with following their studies
    own advice. It develops demonstration projects that would
    examine the feasibility of expanding care to rural areas
    through partnerships. Partnerships between the VA centers for
    Medicare and Medicaid services, the Department of Health and
    Human Services through critical access hospitals and community
    based centers.
        Demonstration projects would also be carried out in
    partnership with Indian Health Services to improve healthcare
    for Native American veterans. In 2003, the VA entered into a
    memorandum of understanding with the departments to encourage
    partnerships like these. However, 4 years have passed without
    accomplishments and our vets have suffered.
        Mr. Chairman, we must explore every option to ensure that
    healthcare services we promised to our veterans were delivered.
    The Rural Veterans Health Care Improvement Act of 2007 aims to
    improve one of the greatest problems that plagues the VA
    system. I am proud of this bipartisan work. We have--we
    currently have over we are close to 40 co-sponsors. Very
    bipartisan legislation.
        And I want to thank the Chairman and the Ranking Member and
    members of this Subcommittee for allowing us to testify in
    front of this Committee.
        [The prepared statement of Congressman Salazar appears on p.
     57.]
        Mr. Michaud. Thank you very much, Mr. Salazar. Ms. Lowey?

                    STATEMENT OF HON. NITA M. LOWEY

        Ms. Lowey. Thank you very much, Mr. Chairman. Mr. Ranking
    Member, members of the Subcommittee. I really do appreciate,
    number one, your holding this hearing and for considering the
    VA Hospital Quality Report Card Act of 2007.
        I introduced this legislation in an effort to provide
    increased disclosure and accountability in the VA hospital
    system, and ultimately increase the quality of care for the men
    and women who have served in the armed forces.
        The treatment provided to our veterans is not a partisan, a
    political issue, and I am pleased that this legislation is
    cosponsored by some of my republican colleagues as well. I do
    believe that we can all agree that quality care initiatives and
    public disclosure should not end when an individual leaves
    active military service. In fact the quality of care for those
    who have bravely served our Nation should be of the highest
    standard possible.
        To achieve that goal, we must have a clear picture of the
    quality of care provided by the Department of Veterans Affairs,
    and this information must be continually assessed and updated.
    As we learned, unfortunately, with Walter Reed Army Medical
    Center, a facility that once defined excellence may not do so
    the next time without constant internal assessments. My
    legislation would require the Department of Veterans Affairs to
    establish a formal Hospital Report Card Initiative and publish
    reports on individual hospitals level, and quality of care.
        The resulting report cards would provide clear outcomes
    data to be used for peer review and quality improvement,
    galvanize hospitals to make changes by creating public
    accountability, and provide our veterans with the information
    they need to make sound healthcare decisions. Several States,
    including Pennsylvania, New York, California, Florida, and
    Illinois have already implemented Hospital Report Card
    Initiatives.
        March 2007 Veterans Administrative report exposed major
    deficiency in the physical condition in many veteran's
    facilities. In this report, the VA Hudson Valley Health Care
    System, which serves over 25,000 veterans throughout my
    district and the surrounding areas, was cited for ceiling
    molds, suicide hazards in the psychiatric ward, and cosmetic
    deficiencies.
        I am going to repeat one part of that because I think it
    underscores the level of neglect seen throughout the VA
    healthcare system. Suicide hazards in a psychiatric ward in
    area in hospitals that most certainly should limit the ability
    of an individual to harm him or herself.
        Dr. Michael Kussman, Under Secretary for Health at the VA
    previously stated, ``VA hospitals are inspected more frequently
    than any other healthcare facilities in the Nation.'' If this
    is true, then the Department should have no problem complying
    with the requirements of this legislation.
        If we are serious about ensuring a seamless transition
    between the U.S. Department of Defense (DoD) provided
    healthcare and VA provided healthcare, we must have an accurate
    assessment of the VA system and the VA Hospital Quality Report
    Card Act of 2007 would provide just that.
        So, I thank you very much. Thank you for your work. And I
    would be delighted, as I know my colleagues are, to respond to
    any questions.
        [The prepared statement of Congresswoman Lowey appears on p.
     61.]
        Mr. Michaud. Okay. The last member of the panel is also the
    Ranking Member of this Subcommittee, Mr. Miller?

                     STATEMENT OF HON. JEFF MILLER

        Mr. Miller. Thank you very much, Mr. Chairman. I have two
    bills for the hearing today. The first one I would like to
    discuss is H.R. 2623. This bill is designed to prohibit the
    collection of copayments for all hospice care furnished by the
    Department of Veterans Affairs.
        Currently VA offers a compliment of hospice and palliative
    care options as part of the comprehensive healthcare benefit
    provided to all enrolled veterans. Hospice and palliative care
    are a continuum of comfort oriented supportive services
    provided across settings including a hospital, extended care
    facilities, outpatient clinics, and private residences.
        Under current law a veteran receiving hospice care in a
    nursing home is exempt from any applicable copayments. However,
    if hospice care is provided in any other setting such as an
    acute care hospital or even in the veteran's home, the veteran
    may be subject to an inpatient or outpatient primary care
    copayment. Essentially, VA's current policy penalizes a veteran
    who chooses to remain at home for their hospice care or out of
    medical necessity receives that hospice care in an acute care
    setting.
        Mr. Chairman, this legislation would correct this inequity
    by exempting all hospice care provided through VA from
    copayment requirements. This bill is important to ensuring that
    every veteran preference for end of life care is provided for
    in an equitable and compassionate manner.
        I thank you for the opportunity to present this bill and I
    would be available to answer questions.
        If I could move to H.R. 1925, a bill to direct the
    Secretary of Veterans Affairs to establish a separate Veterans
    Integrated Service Network (VISN) for the Gulf Coast region of
    the United States. I have a couple of charts. We will go--we
    will flip back and forth. This will give you an idea of the
    work loads at the different VISNs. I apologize for the people
    in the audience not having an available one for you to see as
    well.
        [Chart.]
        Mr. Miller. Twelve years ago most of you know that the VA
    instituted the VISN. The plan was put in motion as a way for
    the large VA network that healthcare that VA provides would be
    more attuned to the needs of its patients.
        You can see where it basically is today and graphically
    it's there are 22 VISN's although there is a number 23 on there
    some time ago, there were two VISN's that were combined into a
    single VISN, but that gives you the idea. The gray is the
    enrollees, the red is the actual patient load.
        The VISN's were implemented as a way to maintain the high
    quality of care while allowing more regional management so that
    the central office in DC was not unnecessarily micro managing
    the day-to-day aspects of the delivery of the healthcare. The
    network has enjoyed its successes in providing better access
    and more patient centered care. However, as always, there is
    room for improvement and I think that the Gulf Coast region of
    this Nation is an area where such improvement is needed.
        Having already seen, as I said earlier, the consolidation
    of two VISN's since it's creation, it is clear that flexibility
    within the healthcare system is necessary. This bill creates a
    VISN specifically targeted to improving the delivery of
    healthcare to a large and ever increasing number of veterans
    living in the Gulf Coast. In other words, a Gulf Coast VISN.
        It would create a better healthcare network that can better
    respond to veterans and the unique needs and problems facing
    veterans in the area. The area involved would, if you would
    flip it over, give you an idea. Everything the gray shaded
    areas are not part of VISN 16, but the teal and the purple and
    the peach color that is VISN. There is also a little green down
    at the very bottom, that is VISN 16. So basically it goes from
    the center of the Florida panhandle all the way to the Oklahoma
    panhandle geographically. It is the largest geographic VISN,
    but that is not necessarily the point. The point is the
    workload that is in there now.
        Obviously, my district, district one is on the southeast
    corner of the panhandle, so that gives you an idea of how large
    the VISN is. If you would, there are some and I don't know if
    staff going to handout, smaller charts for you to look at. VISN
    16 is actually the second largest in patient enrollment and
    patients as well.
        This creates again, as I said, the ability for VA to
    deliver to the unique needs and problems facing veterans in the
    area. It does stretch all the way from the Florida panhandle
    over to the State of Louisiana and up into Alabama. The Capital
    Asset Realignment for Enhanced Services (CARES) Program did
    identify this area as under served, and its unique geographical
    location is no doubt part of the reason that it was so
    designated. Most of the region would be in VISN 8. It would be
    where VISN 16 meets VISN 8. By the way, VISN 8 as Ms. Brown
    knows is also the number one VISN in the country. It happens to
    be the peninsula part of the State of Florida.
        You can see that the veteran population continues to grow
    in those regions. Looking back and looking at the map you can
    see how diverse and how largely rural. As we have talked about
    with other testimony today, regions can be over looked because
    of major metropolitan areas that are being served. We don't
    think, and I am sure that most people would agree that the
    300,000 veterans that are currently being served in that region
    there are many, many more veterans, but these are enrolled
    veterans. They certainly don't want their healthcare overlooked
    either.
        Several reasons why I see this bill as important and
    successful. Again, a new Gulf Coast VISN director could take
    great advantage of the sharing opportunities that are there
    between DoD and VA. The Gulf Coast is home to multiple defense
    installations and while a few DoD/VA facilities exist now,
    there is tremendous opportunity for expanding this relationship
    to deliver a wider range of healthcare service.
        I would say that all of our veterans across the Nation
    deserve more timely access to VA healthcare. The intent of my
    bill, albeit there could be other geographic areas that are as
    under served as ours, is to get a first step toward creating
    that access. Again going all the way back to it's original
    creation, obviously the demographics have shifted and time for
    a re-look is upon us.
        Mr. Chairman, thank you for letting me testify on this
    bill, and I can and am ready to answer questions on this or the
    other bill as well.
        [The prepared statement of Congressman Miller, and the
    charts attached to Congressman Miller's statement, which he
    referred to, appears on p. 58.]
        Mr. Michaud. Thank you very much, Mr. Miller. A few
    questions: The first one for Mr. Hodes. If I understand
    correctly, what you want to do is look at all of these programs
    and work toward having one access point for veterans to be able
    to access these programs.
        Have you given any thought about also trying to streamline
    the process? And for those who can use a computer, to ask just
    a few basic questions on a computer-based system that will tell
    them where to go?
        The reason why I mention that is when we had a couple of
    mills shut down and healthcare was a big issue, drug companies
    offered programs for individuals. There are 329 different
    programs that drug companies offered with applications for each
    one of those programs. And if you are laid off trying to find a
    job and healthcare, you are not going to do it.
        However, what they did was take all of these programs,
    narrowed it down to four basic questions, established an 800
    number and that will show an individual applying for one of
    these programs where to go.
        Is that something that you would envision under your
    legislation as well?
        Mr. Hodes. That would certainly be part of a good way for
    the Ombudsman Office to accomplish it's work, because I guess
    if I had to use a word I see the Ombudsman Office as providing
    the hub to which people go. And it--the Ombudsman Office would
    then help route people through the system. They could then
    return to the Ombudsman Office as they are working their way
    through the system for other questions.
        So your suggestion would certainly be a good part of
    implementing the Office of the Ombudsman. Thank you, Mr.
    Chairman.
        Mr. Michaud. Ms. Lowey, I have read the testimony from the
    Department and they talk about the Joint Commission previously
    known as the Joint Commission Accreditation of Health Care
    Organizations (JCAHO). They have a website that provides a lot
    of the data that you were talking about. Have you looked at
    that website and is it inclusive of what you are including in
    your legislation?
        Ms. Lowey. Well, I thank you for bringing up that question,
    because the Joint Commission does reviews. We have been told it
    is about every two, 3 years and it is not as--it is not as
    comprehensive as the kind of review we propose.
        And again the basic idea here is to do it frequently at
    least twice a year, provide up-to-date information,
    transparency so that VA's veteran's can access this information
    and actually make some decisions based upon the information
    provided.
        Mr. Michaud. Great. And my last question actually deals
    with one of Mr. Miller's bills, the hospice bill. If I read and
    heard your testimony correctly, veterans will not have to pay
    the copayment if they go through VA for services. Now does that
    include contract services? I am just thinking of someone in a
    rural area that needs hospice care, how do you envision that?
        Mr. Miller. It would cover them. Absolutely.
        Mr. Michaud. It would cover them. Okay. Good. Thank you.
    Mr. Miller do you have any questions?
        Mr. Miller. Ms. Lowey, I am interested in and we all can
    appreciate the desire to set some type of standard. Do you
    envision measuring VA hospitals against private facilities in
    some way where or is this just within the VA healthcare system
    where you are saying this one is an ``A,'' ``B,'' ``C.'' Are we
    going to measure them against other facilities?
        Ms. Lowey. That is an important question. And it has been
    suggested to me and I certainly would be flexible about it,
    that we might call it VA Medical Center because it would
    encompass a more extensive group of hospitals that would be
    included in this review.
        I was thinking about the VA system, but I would certainly
    be open if the Committee would suggest it to making it more
    expansive.
        Mr. Miller. The reason I ask the question is the Joint
    Commission on Accreditation of Healthcare Organizations (JCAHO)
    standards that you know all hospitals go through accreditation,
    how would this be more in depth? How would it compare to those
    standards, and if you are not sure right now you can report
    back.
        Ms. Lowey. I am not sure about the JCAHO standards.
        Mr. Miller. No, I would like to know in regards to
    standards that are out there that VA currently has to abide by
    how far we are looking at going forward.
        Ms. Lowey. You know I am very interested in the idea of
    providing facilities that specialize, for example, in traumatic
    brain injury (TBI) to veterans making them inclusive and
    expanding opportunities for veterans getting these services.
        So, although I was talking about the VA system, I am hoping
    that we can bring in hospitals such as the Helen Hays Hospital
    in part of my district in Rockland County which has expertise
    in traumatic brain injuries.
        So it is another issue that I know some people are thinking
    about, because the numbers of people that are coming out of the
    hospital. Just recently I was talking to a group called the
    ``Wounded Warrior Project.'' And they are providing the role of
    the intermediary. I was interested in what my colleague was
    talking about in the ombudsman position, because many of these
    veterans come out so lost and need additional guidance and
    additional help.
        So with this bill, I was talking about an assessment of the
    VA hospital system to provide the transparency and to provide
    the information to the veterans. But I certainly would be happy
    to work with you, Mr. Miller, to see if you believe that it
    should be more expansive and more inclusive.
        Mr. Miller. Thank you very much. The other question, Mr.
    Salazar is in regards to the mileage reimbursement, would you
    envision it paying for service and non-service connected visits
    or just service connected visits?
        Mr. Salazar. Basically just service-connected visits and it
    would just be similar to what we get. I mean, as members of
    Congress we get 40 or we are allowed to get 48 cents a mile.
    The current reimbursement rate of course is only 11 cents.
        And I get the story, I represent a district that is larger
    than half of the State of Colorado. And many of my veterans
    have to drive 5 hours to one center or another and some even
    have to go to Albuquerque. And many of them will tell me that
    their wives cannot go with them because gas is so expensive
    they can't afford the hotel to stay in over night. So for that
    reason I think it is only fair that we look at this. You know
    gas was only 63 cents a gallon in 1978 and that is when the
    last raise was or the last, I guess, increase was made. So
    thank you.
        Mr. Michaud. Mr. Hare?
        Mr. Hare. I don't have any questions, Mr. Chairman.
        Mr. Michaud. Dr. Snyder?
        Mr. Snyder. Thank you. I wanted to ask our Ranking Member,
    Mr. Miller, just a couple questions. I notice that the bill
    regarding the hospice co-pay is not on the list that Dr.
    Kussman discusses. Was that a late add on or do you know what
    the VA position is on that bill?
        Mr. Miller. VA supports it.
        Mr. Snyder. Supports it. Okay. And then the second with
    regard to the VISN lines. Were all the VISN boundaries have
    they been set by statute in the past or were those set
    administratively?
        Mr. Miller. I believe they have been set administratively.
        Mr. Snyder. Administratively. Thank you.
        Mr. Michaud. Ms. Brown.
        Ms. Brown of Florida. I don't have any questions at this
    time.
        Mr. Michaud. Thank you. Once again, I would like to thank
    the panelists for your testimony this morning. I look forward
    to working with you as we move forward with these pieces of
    legislation. Thank you very much.
        Mr. Hodes. Thank you very much.
        Ms. Lowey. Thank you.
        Mr. Michaud. I would like to ask the third panel to come
    up. We have Shannon Middleton, American Legion; Kimo
    Hollingsworth, AMVETS; Adrian Atizado, Disabled American
    Veterans; Carl Blake, Paralyzed Veterans of America; Dennis
    Cullinan, Veterans of Foreign War; and Barry Hagge, Vietnam
    Veterans of American.
        I would like to welcome all the panelists here today and I
    look forward to hearing your testimony.
        We will start with Ms. Middleton and just work down the
    table.

     STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH,
     AMERICAN LEGION; KIMO S. HOLLINGSWORTH, NATIONAL LEGISLATIVE
       DIRECTOR, AMERICAN VETERANS (AMVETS); ADRIAN M. ATIZADO,
      ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN
    VETERANS; CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, PARALYZED
      VETERANS OF AMERICA; DENNIS M. CULLINAN, DIRECTOR, NATIONAL
      LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED
     STATES; AND BARRY HAGGE, NATIONAL SECRETARY, VIETNAM VETERANS
                               OF AMERICA

                     STATEMENT OF SHANNON MIDDLETON

        Ms. Middleton. Mr. Chairman and members of the
    Subcommittee, thank you for this opportunity to present the
    American Legion's views on the several pieces of legislation
    being considered by the Subcommittee today.
        The American Legion commends the Subcommittee for holding
    the hearing to discuss these very important issues. And I will
    limit my comments to just a few of the bills being considered.
        Mr. Michaud. Could you pull the microphone up a little bit
    closer please?
        Ms. Middleton. This better?
        Mr. Michaud. Much better.
        Ms. Middleton. Much better. H.R. 2005, the ``Rural Veterans
    Health Care Improvement Act of 2007,'' addresses many issues
    affecting veterans who reside in rural areas. It seeks to
    increase the beneficiary travel rate to make it equivalent to
    the rate provided to Federal employees; establish centers for
    rural healthcare--rural health research, education, and
    clinical activities; offer transportation grants for service
    organizations to assist rural veterans; and explore
    alternatives to improve transportation to medical facilities
    for rural veterans. The American Legion fully supports this the
    provisions in this bill.
        Beneficiary travel pay has not been increased from its
    current rate since 1978. The price of gasoline has steadily
    increased since the 11 cent per mile rate was established,
    creating a financial hardship for veterans who have to travel
    long distances for care, or those who have limited financial
    resources.
        Since service-connected veterans and other veterans
    authorized beneficiary travel only receive 11 cent per mile and
    are subjected to a six dollar per trip deductible, this amount
    does very little to defer the cost of travel.
        There are no provisions in law that VA must increase the
    per mile travel authorization on a regular basis. The
    beneficiary travel program is discretionary and the Secretary
    of Veterans Affairs has determined that it is necessary to
    maintain the current reimbursement rate in order to allow the
    VA healthcare system to accommodate the increasing patient
    workload.
        The lack of a consistent and reliable mechanism to
    periodically adjust the rate authorized for beneficiary travel
    creates an injustice and an unfair economic burden for many
    veterans. The American Legion believes that mandatory funding
    for VA healthcare would allow the Secretary to provide adequate
    healthcare without inversely affecting programs designed to
    mitigate the cost of accessing that care.
        Establishing centers for rural health research, education,
    and clinical activities would afford VA the opportunity to
    build strategies to improve it's system of care for rural
    veterans, as well as educate and train healthcare professionals
    on health issues prevalent in specific rural veteran
    populations.
        And offering transportation grants for organizations that
    can assist rural veterans and exploring alternatives to improve
    transportation to medical facilities for rural veterans would
    make accessing care easier for those who are not financially
    able to travel to facilities, especially those who, due to
    their financial--sorry--their physical condition are not able
    to make extremely long trips in 1 day. If more transportation
    options became available it may also improve coordination of
    care for those who have to travel distances for special
    services, especially in the unavailability of a family care
    giver.
        H.R. 2173 seeks to amend title 38, U.S. Code, to authorize
    additional funding for the Department of Veterans Affairs to
    increase capacity for provision of mental health services
    through contracts with community mental health centers, and for
    other purposes.
        The American Legion believes that VA should contract with
    community providers only when it is unable to provide needed
    services to the veteran, if travel for the veteran would be a
    danger to his or her health, or the veteran resides in a rural
    area. As long as VA healthcare remains discretionary, VA will
    always struggle to maintain sufficient funding to provide
    access to quality care for eligible veterans seeking care in VA
    facilities. Mandated funding would provide a method to provide
    dependable stability, stable and sustained funding for veterans
    healthcare.
        H.R. 2378, Services to Prevent Veterans Homelessness Act.
    This bill aims to establish a financial assistance program to
    facilitate supportive services for very low income veteran
    families to assist them in ending their chronic homelessness
    state and to prevent chronic homelessness.
        Enactment of this legislation will enable funding to
    provide much needed supportive services to veterans and their
    dependants. It takes into account that the VA Grant and Per
    Diem Program can only provide services to veterans and fill a
    much needed gap of caring for their dependents.
        Veterans require a coordinated effort that provides secure
    housing and nutritious meals; essential physical healthcare,
    substance abuse aftercare, mental health counseling; as well as
    personal development and empowerment. They also need job
    assessment training and placement assistance.
        The American Legion fully supports this bill in it's
    efforts to assist homeless veterans. And we applaud that the
    bill recognizes that families also suffer alongside the
    veterans struggling with homelessness.
        Again, thank you Mr. Chairman for giving the American
    Legion this opportunity to present it's views on such important
    issues and we look forward to working with the Subcommittee to
    address these and other issues affecting veterans.
        [The prepared statement of Ms. Middleton appears on p. 62.]

                   STATEMENT OF KIMO S. HOLLINGSWORTH

        Mr. Hollingsworth. Mr. Chairman, members of the
    Subcommittee, I am pleased to offer testimony on behalf of
    AMVETS regarding the health legislation for this Subcommittee.
        Regarding the Hospital Quality Report Card Initiative,
    AMVETS would like to note that the Government Performance and
    Results Act requires that agencies develop measurable
    performance goals and report these results against these goals.
        In addition, the Department has tracked and monitored the
    quality of care at VA facilities since the early seventies
    through comprehensive quality management programs. In addition,
    there are some Federal laws that require VA Office of Inspector
    General to oversee VA Quality Management (QM) Programs at every
    level. And a large part of the VA Inspector General's Office
    performs the Combined Assessment Program (CAP). These reports
    review focus on quality safety and timeliness of VA healthcare.
        Overall AMVETS supports efforts to improve VA healthcare
    and supports the intent of H.R. 1448. However, we believe the
    bill would mandate a duplicative effort as many of the items to
    be reported in the report card are already reviewed and
    reported through either the VA QM and CAP programs.
        Regarding the training of police officers to interact with
    visitors and patients at medical facilities who are suffering
    from mental illnesses, AMVETS supports this bill.
        Regarding the creation of a new VISN, AMVETS has testified
    previously that CARES was supposed to be system-wide process to
    prepare the VA for meeting the current and future healthcare
    needs of veterans. Overall, AMVETS supported the CARES process,
    and we believe that Congress should consider the CARES
    recommendations in deliberations about VA infrastructure to
    include deliberations about the current VISN model.
        I would like to note that there has been some considerable
    time has elapsed since implementation of the VISN model, and
    there clearly have been some demographic changes within the
    general population that would most likely include changes to
    the veteran population as a whole.
        Regarding the Rural Health Care bill, AMVETS continues to
    support an increase to the mileage reimbursement rate.
    Regarding the overall Centers of Excellence, AMVETS would like
    to note that Congress did set up the Office of Rural Health
    Care and we urge Congress to fully fund and require the VA to
    conduct that assessment.
        With regards to the establishment of the Ombudsman within
    the Department of Veterans Affairs, AMVETS supports this bill.
    H.R. 2219 would direct the Secretary to award a grant to a
    private non-profit entity to establish and publicize a toll
    free suicide prevention.
        Overall, Mr. Chairman, AMVETS would oppose efforts by
    Congress to mandate the Secretary enter in to contracts with a
    private entity for these services. And we believe that the
    Secretary must continue to have the flexibility in how he
    implements these services.
        Lastly, H.R. 2378 regarding a financial assistance program
    to facilitate the provision of supported services for very low
    income veteran families in permanent housings. We support the
    intent. A large part of this bills, many of these services are
    already available to veterans. However, we do have concerns
    with the provision that specifically targets payments to
    veterans. And we would urge Congress instead to consider
    priority assistance at one of the other agencies that deals
    with housing.
        This concludes my testimony. I would be happy to answer any
    questions.
        [The prepared statement of Mr. Hollingsworth appears on p.
    65.]

                     STATEMENT OF ADRIAN M. ATIZADO

        Mr. Atizado. Mr. Chairman, Ranking Member Miller, members
    of the Subcommittee, thank you for inviting the DAV to testify
    at this important legislative hearing. For the sake of brevity,
    I will cover a number of bills or provisions relevant to the
    DAV and would request the Subcommittee refer to my written
    testimony for more details regarding all the measures under
    consideration with exception to the two draft bills that we
    were unable to provide comments due to time constraints.
        While we support sections two and four of H.R. 2005, the
    ``Rural Veterans Health Care Improvement Act of 2007,'' we
    consider these provisions a good first step to ensure sick and
    disabled veterans are able to access the medical care they
    need.
        As funding for both provisions will most likely come from
    VA's medical services account, we urge first and foremost that
    Congress and VA correct inequity in the VA beneficiary travel
    program. This program unlike the Transportation Grant Proposal
    affects access for all veterans residing in rural, urban, and
    medically under served areas.
        Second, for good stewardship of taxpayer dollars and for
    the most effective use of such precious medical care funds, we
    urge that this Transportation Grant Program not be duplicative
    of current services, particularly those provided by the DAV
    Transportation Network or other transportation networks in
    existence.
        Further, the implementation of this proposed program should
    be coordinated through the Office of Rural Health to assure
    that unmet needs of rural veterans are addressed. As you may be
    aware, the DAV knows first hand the benefits of a
    Transportation Program. The DAV, in coordination with VA's
    Voluntary Service Program, began buying and donating vans to
    the VA facilities. To date, we have donated nearly 2,000 vans
    at a cost exceeding $39 million.
        Since inception, these vans, the dedicated VA volunteer
    drivers and volunteer transportation coordinators have
    transported more than 10 million veterans over 397 million
    miles to and from VA medical appointments.
        Having said that, we must not forget one of the reasons our
    transportation program began in 1987. Regulations amended by
    the VA, effective April 13, 1987, severely curtailed and
    restricted the eligibility and method by which beneficiary
    travel was paid. Many veterans in need of VA medical care found
    themselves effectively precluded from receiving such care.
        In addition to our transportation program, DAV has a
    longstanding resolution to repeal the beneficiary travel pay
    deductible to create a line item budget for this program and to
    increase travel reimbursement rate, which remains unchanged
    since 1977 at 11 cents a mile.
        We urge this Subcommittee to approve and enact legislation
    this year to reform the VA beneficiary travel program.
        H.R. 2173 would allow the VA to provide mental health
    services through contracts with community mental health
    centers. The DAV believes that VA-purchased care is an
    essential tool in providing timely access to quality medical
    care.
        However, as VA's contract workloads have grown
    significantly at a cost of about $3 billion this year, we are
    concerned that this bill does not provide any consideration for
    the judicious use of purchased care. Nor does it address our
    concerns regarding the lack of a systematic process to improve
    VA contract care services.
        H.R. 2219, the ``Veterans Suicide Prevention Hotline Act of
    2007,'' would require the VA to award a grant to a private,
    nonprofit entity to establish and operate a national toll-free
    suicide prevention hotline.
        The DAV notes that there is already in existence a
    Federally funded 24-hour, toll-free suicide prevention service
    comprised of over 120 individual crisis centers across the
    country. From the toll-free number, a caller is seamlessly
    routed to a certified provider of mental health and suicide
    prevention services nearest to the call of origination.
        If applied to service veterans, a veteran could be
    transferred similarly, but to a VA mental health provider if
    the individual wants the services and support of the VHA.
        We would like to thank Ranking Member Miller for
    introducing H.R. 2623 and Chairman Michaud for including it in
    today's hearing. This bill seeks to prohibit the collection of
    copayments for all hospice care furnished by the VA.
        The DAV has previously testified before this Subcommittee
    on this important issue, and we support the intent of this
    measure. We would just like to ensure that its scope is broad
    enough to include exemption of veterans from copayments for
    hospice care provided in any treatment setting.
        This concludes my testimony. I'd be happy to answer any
    questions you may have.
        [The prepared statement of Mr. Atizado appears on p. 68.]

                        STATEMENT OF CARL BLAKE

        Mr. Blake. Mr. Chairman, Ranking Member Miller, and members
    of the Subcommittee, on behalf of Paralyzed Veterans of
    America, I would like to thank you for the opportunity to
    testify today.
        Given the broad spectrum of bills on the agenda, I will
    limit my comments to only a few items.
        Although PVA has no objection to the requirements for a
    Hospital Quality Report Card Initiative, as outlined in H.R.
    1448, we remain concerned that this wealth of information will
    go unused.
        Collecting this information and assessing it without acting
    on any findings from that information, would serve no real
    purpose. We would hope that the congressional Committees will
    use this information published in these reports each year to
    affect positive change within the VA.
        PVA generally supports H.R. 2005, the ``Rural Veterans
    Health Veterans Health Care Improvement Act.'' However, we have
    concerns about the demonstration projects that will establish
    partnerships between the VA and the Centers for Medicare and
    Medicaid Services to seek care in critical access hospitals or
    community health centers.
        Principally we believe that this legislation is ``jumping
    the gun'' by getting ahead of the Office of Rural Health, which
    is responsible for determining if solutions, such as this
    proposed demonstration project, are feasible.
        We think that this new office in the VA should be given
    time to do its job before Congress begins legislating solutions
    to the problems that rural veterans face. However, this
    certainly does not say that Congress should not pressure the VA
    into implementing this office expeditiously as we believe they
    have not done so.
        PVA has serious concerns about the provisions of H.R. 2172.
    PVA strongly opposes the provisions of H.R. 2172. PVA strongly
    opposes the provision of section 2 of the bill that would allow
    the VA to contract for service and repair of prosthetic
    devices.
        We interpret this legislation to mean that the VA can
    contract with a single entity to provide these services and
    repairs. This is absolutely a bad idea. By using a single
    entity, the pool of devices and services available will be
    severely limited.
        A one-size-fits-all approach to prosthetics cannot be
    applied. As an example, prosthetics departments that serve PVA
    members needing wheelchairs often, if not always, contract with
    multiple different vendors to provide those wheelchairs.
        Because every PVA member, and every disabled veteran for
    that matter, is different, the equipment they need varies.
    Although an Invacare power chair may be suitable for one spinal
    cord injured veteran, another spinal cord injured veteran might
    be better served by a Jazzy wheelchair.
        Two uniquely different veterans cannot be expected to use
    the same equipment simply because it might streamline processes
    for the VA.
        PVA has no objection to the provision of the legislation
    that would require certification of VA orthotic-prosthetic
    laboratories with the ABC in Orthotics and Prosthetics or the
    Board of Orthotics and Prosthetic Certification.
        However, we believe that the VA already meets these
    requirements, but if this provision will reinforce that action,
    then we have no problem with it.
        The incidence of suicide among veterans, particularly OEF
    and OIF veterans, is a serious concern that needs to be
    addressed. PVA principally supports H.R. 2219. Any measure that
    will reduce the incidence of suicide among veterans is
    certainly a good thing.
        However, we must emphasize a couple of important points.
    First and foremost, there need to be absolute standards
    established that ensure that the individuals staffing this
    hotline are adequately trained to handle the complex issues
    associated with individuals contemplating suicide.
        We certainly support the idea that this service should be
    staffed by veterans, but they must have the proper training to
    deal with these cases. Simply having the shared experience of
    military service is not enough.
        Secondly, clear steps for referral into VA mental health
    clinics and other VA facilities with related services must be
    outlined. The private entities responsible for the operation of
    the suicide prevention hotline must understand how to refer
    veterans dealing with these problems into programs that will
    provide the services that they actually need.
        These services are essential to helping the veteran
    overcome the suicidal feelings he or she may be dealing with.
        Mr. Chairman, Mr. Miller, and members of the Subcommittee,
    we look forward to working with this Subcommittee to develop
    workable solutions that will allow all veterans to get the best
    quality care available.
        I would like to thank you again for allowing us to testify,
    and I would be happy to answer any questions that you might
    have.
        [The prepared statement of Mr. Blake appears on p. 72.]

                    STATEMENT OF DENNIS M. CULLINAN

        Mr. Cullinan. Mr. Chairman, distinguished members of the
    Subcommittee, On behalf of the men and women of the Veterans of
    Foreign Wars, I want to thank you for inviting us to
    participate in today's most important legislative hearing.
        The VFW is pleased to support H.R. 1488, the ``VA Hospital
    Quality Report Card Act.'' Resulting data would allow veterans
    to compare quality of services the VA provides, letting them
    make more important judgments about their healthcare.
        It would allow VA to identify areas of improvement, and it
    would provide essential data for Congress to better use its
    essential oversight.
        We only urge that this action not conflict with the
    reporting requirements that VA is already undergoing and
    attempting to implement.
        The VFW supports H.R. 1853, the ``Jose Medina Veterans
    Affairs Police Training Act.'' Given the large numbers of
    returning veterans who are suffering from mental illnesses of
    various degrees, extra training for VA employees on how to deal
    with these patients is entirely appropriate. This is especially
    true for those patients who are vulnerable and suffering the
    most. The extra training will ensure that wounded warriors are
    treated with dignity and respect.
        The VFW has no objection to H.R. 1925, legislation that
    would establish a new VISN in the Gulf Coast Region.
        The VFW is pleased to support H.R. 2005, the ``Rural
    Veterans Health Care Improvement Act.'' The legislation is
    aimed to solve one of the greatest problems facing the large
    number of veterans who live in remote areas: access to care. It
    aims to improve services including transportation for disabled
    vets, research and partnerships with small communities.
        We are strongly supportive of section 2, which would
    increase the mileage reimbursement rate veterans receive for
    their travel expenses related to VA healthcare to the rate
    provided to all Federal employees.
        The VFW is supportive of H.R. 2172. However, the VFW is not
    sure if changing the rules of VA's prosthetic programs is
    needed, and we have concerns that the certification
    requirements that would affect all service and repair programs
    for prosthetics and orthotics is necessary.
        We are also concerned that some efforts to create a
    certification process could lead toward excessive
    standardization that aims for one-size-fits-all solution.
        The VFW supports H.R. 2173 that would allow the Secretary
    to enter into contracts with service for community mental
    healthcare.
        With the number of returning servicemembers who are
    suffering from mental health conditions, it is clear that VA
    can and must do more.
        However, an over reliance on contract care, especially the
    mental health area, could lead to some extensive continuity of
    care problems.
        Among other things, VA would have to determine some way to
    ensure that no veteran falls through the cracks when going from
    the department to a local provider.
        Further, it would be absolutely critical that patient
    records be transferable among all providers so that all
    information is provided to all involved healthcare givers. With
    respect to H.R. 2192, ``Providing for VA Ombudsman,'' the VFW
    is supportive of the intent of this act. We only question
    whether it's feasible for a single office or entity to gather
    together and properly coordinate so much information.
        Be that as it may, there is definite need for additional
    assistance for veterans in this complex system.
        The VFW supports H.R. 2219, the ``Veterans Suicide
    Prevention Hotline Act.'' We understand, however, that the VA
    is in the process of establishing a similar hotline. So it may
    be necessary to determine how much overlap there is between the
    programs. It is clear, however, that the program would be
    beneficial.
        The VFW supports H.R. 2378, which would establish a program
    of financial assistance to help veterans and their families
    from slipping back into homelessness.
        The VFW offers our strong support for H.R. 2623 that would
    exempt patients seeking hospice care from paying copayments.
    This is a compassionate idea that relieves a burden on the
    veteran and their loved ones at a most critical time.
        Thank you, Mr. Chairman, for my testimony.
        [The prepared statement of Mr. Cullinan appears on p. 76.]

                        STATEMENT OF BARRY HAGGE

        Mr. Hagge. Good morning Mr. Chairman, Ranking Member
    Miller, and Members of this Subcommittee. Thank you for giving
    Vietnam Veterans of America the opportunity to offer our
    comments on several veterans' health-related bills that are up
    for discussion here today.
        All of these bills, with the possible exception of H.R.
    1853, are extremely important. And with a few reservations,
    they are worthy of your consideration and certainly our
    support.
        I note that while we have not adopted an official position
    on H.R. 1925, we do not object to it.
        The topic of accessibility to VA medical services for
    veterans who live in rural areas has been percolating of late.
    We believe that H.R. 2005 offers pragmatic solutions to address
    the problems of access to healthcare experienced by too many
    rural veterans.
        The bill would increase travel reimbursement for veterans
    who travel to VHA facilities to the rates paid to Federal
    employees.
        The current reimbursement rate was established decades ago
    and does not adequately compensate for the costs of gasoline,
    ``wear and tear'' on the vehicle and increased insurance that
    may be necessary in order to travel to distant medical centers.
        In the same vein, the grant program for rural veterans'
    service organizations to develop transportation programs could
    be an innovative way to strengthen community resources that may
    already assist with veterans' travel needs.
        The establishment of centers of excellence for rural health
    research, education, and clinical activities, another component
    of this bill, should fill a gap in VA healthcare and should
    lead to innovation in long-distance medical and telehealthcare.
        These centers have brought the synergies of clinical,
    educational, and research experts to bear in one site. Such
    centers have allowed VA to make significant contributions to
    the field of geriatric medicine and mental illnesses.
        It would require demonstrations of rural treatment models.
    Demonstrations on treating rural veterans' populations would be
    extremely useful in assessing effective ways to offer
    healthcare to individuals who are generally poorer, more likely
    to be chronically ill, and almost, by definition, more likely
    to have challenges in access to regular healthcare.
        And establishing partnerships with the Indian Health
    Service and with the Department of Health and Human Services
    should also add to greater cooperation and collaboration in
    meeting the needs of rural veterans.
        We would caution, however, that we would not like to see
    these demonstration projects exploring more opportunities to do
    widespread contracting out of veterans health services.
    Demonstration models should be assessed according to a number
    of outcomes such as quality of care, cost, and patient
    satisfaction and the results reported back to Congress.
        H.R. 1448, the ``VA Hospital Quality Report Card Act of
    2007,'' is a quality control measure that would help with
    accountability and issues regarding follow-up care and timely
    visits.
        It would require the VA to provide grades for its medical
    centers on measures such as effectiveness, safety, timeliness,
    efficiency, patient``centeredness,'' and equity. Health-care
    quality researchers have long thrived trying to objectively
    define some of these measures.
        As members of this Subcommittee are aware, the VA has a
    number of performance measures it regularly assesses in order
    to reward its medical centers and network directors among
    others. Some of these outcomes, such as immunizations for flu,
    foot care and eye care for diabetics, set the benchmark for
    care in the community.
        In addition to these internal performance measures, VHA
    voluntarily submits to Joint Commission on Accreditation of
    Healthcare Organization, Commission on Accreditation of
    Rehabilitation Facilities, and managed care quality review
    standards.
        VVA understands the importance of quality measurement.
    There is an expression with which we agree, and it's called
    ``What's measured, matters.''
        We also agree that VA officials should be held to the
    highest degree of accountability, and whatever measures are
    available to allow this to better occur, we wholeheartedly
    endorse.
        However, before enacting this clearly well-intended
    legislation, we could require significant retooling of quality
    measurement systems in the VA. The Committee should hold a
    hearing to identify the gaps and deficiencies in current
    performance and quality measurement systems.
        It would also be useful to understand how report cards
    would be used and reported to improve VHA processes and
    performance rewards. Would poor grades be dealt with by changes
    in management? By withholding bonuses to senior executives?
    With more funding? How would good grades be rewarded?
        Such questions should be addressed before requiring a
    significant new quality measurement program to be installed.
        Again, VVA appreciates the opportunity to testify before
    this Subcommittee, and we thank the Chairman for the
    opportunity.
        [The prepared statement of Mr. Hagge appears on p. 77.]
        Mr. Michaud. I would like to thank all the panelists once
    again for your testimony, and we appreciate all the work that
    you are doing and have done as it relates to fighting for
    healthcare services for our veterans. We really appreciate it.
    You represent your organizations very well.
        I only have a couple of questions. The first one to Mr.
    Blake. You were talking about Mr. Salazar's bill. You mentioned
    that we ought to wait and see what happens with the Office of
    Rural Health, which was enacted in the 109th Congress. How long
    should we wait for that office to get up before we start, you
    know, taking steps?
        A lot of bills that we have heard today, a lot of bills
    that we heard earlier, dealt with access issues. If the VA
    would move forward, whether it is the Office of Rural Health,
    whether it is the CARES process, we would not see a lot of
    these bills if they were doing the job that they should be
    doing.
        And quite frankly I have a problem with this Congress,
    because of the funding issues, but hopefully we will be
    addressing that later on today. Mr. Blake?
        Mr. Blake. Mr. Chairman, I would say that I guess on some
    level you kind of answered the question for me. I would say
    that they--it should have been done in January. When the bill
    was enacted in December, they should have gotten it up and
    going right away, and we haven't seen any sign. I mean, maybe
    they have, but we haven't seen any real sign that they have
    done anything with that office yet. And maybe the VA will be
    able to testify to the--what the office is doing now when they
    have the opportunity.
        Short of that, I mean, I couldn't give you a timeframe to
    say, well, let us give them six more months and act. I
    understand all of the members frustration, and given that you
    created an office that doesn't seem to be doing anything, I
    don't necessarily blame you for taking action.
        But we don't want to jump over that hurdle without giving
    an office that is directed with this responsibility the chance
    to come up with something.
        Mr. Michaud. Thank you very much.
        My next question goes to Mr. Atizado, and it relates to,
    once again, Mr. Salazar's bill dealing with the increase in
    mileage reimbursement.
        I know the DAV has vans that help veterans with getting to
    VA services and facilities. My question is where are you on
    your vans? Is there a need for more vans? Do you think that
    this might be a way to help hold down costs by getting more
    veterans to utilize the vans?
        Mr. Atizado. Well, thank you for the question, Chairman
    Michaud. The DAV transportation network obviously cannot
    provide its services to all veterans who need it. Every year we
    have requests from our local chapters requesting additional
    vans for the network, and the way that it is structured, it is
    actually structured for services in--basically in concentric
    circles outside the facility. And when we map that out across
    the Nation, there are some gaps out there.
        What we would like to see is that, as I had mentioned in my
    testimony, the moneys, the funds that are going to go into this
    program, are going to come from the medical care services
    account, which as we have noted earlier, has experienced some
    shortages, and we have always advocated for additional funding
    in those accounts.
        In fact, our resolution speaks to that about the
    beneficiary travel pay. That is these funds are to be used out
    of that--out of that account for which--for either one of these
    programs, that it be done efficiently, effectively, and without
    duplication of services.
        Mr. Michaud. Could you provide for the Subcommittee what
    these are as it relates to the gaps that you have talked about
    as far as getting vans?
        Mr. Atizado. Sure. We would most certainly love to work
    with the Subcommittee on that. We will give you that answer for
    the record.
        Mr. Michaud. Great. Thank you very much. Mr. Salazar?
        Mr. Salazar. Thank you, Mr. Chairman.
        I believe that most of you understand that what we are
    trying to do here is to create a quality--some kind of
    semblance of the fact that 40-some percent of most veterans are
    coming from rural communities, and we need to address the needs
    and the shortfalls.
        You know, the study that I related to, it talked about how
    healthcare or basically veterans health was in poor shape in
    rural communities, and that is basically what our intent is
    with this legislation.
        In reference to the reimbursement rate, this is only
    relative to those traveling 100-mile radius, over 100-mile
    radius. In my district, many veterans have traveled 250 to 300
    miles to get access to healthcare.
        So I understand the situation, but I also hope that you can
    understand that we have to continue fighting for rural
    veterans, because I think they are the ones that lack access.
    Thank you, Mr. Chairman.
        Mr. Michaud. Mr. Hare?
        Mr. Hare. Thank you, Mr. Chairman. Just a comment to you,
    Mr. Blake, and then a couple of questions.
        I do share with you this concern of the contract out of the
    one-size-fits-all for folks, and I would like to say I want to
    get--I want us to be very careful that we do not hurt our
    veterans while we are trying to help. So I share with you that
    concern, and I think that is something that we need to be
    taking a look at.
        I would like to ask you, Mr. Hollingsworth, with regard to
    H.R. 2378. In your testimony you urged Congress to provide
    priority assistance to the Department of Health and Human
    Services, as opposed to creating a new program.
        Now, I was wondering why you think that would address the
    problem better?
        Mr. Hollingsworth. Well, I think it is a good--it is a fair
    question. We struggled with this bill internally, and I think
    our overall concerns are clearly we want to help those at risk.
    Clearly we want to help homeless veterans not become homeless.
        But I think we are dealing with the reality of limited
    financial resources for a lot of things. We want to maintain
    true to the mission of VA with regards to providing priority
    service healthcare to those injured in the line of duty and
    service.
        And I think our overall fear, quite frankly, is what we
    didn't want to see happen is to create a voucher program within
    the Department of Veterans Affairs for low-income veterans.
        Mr. Hare. Thank you. I appreciate that. Just one other
    question for--that I have.
        Mr. Atizado, regarding H.R. 2173, to increase the funding
    for the VA, can you tell me a little bit more about the
    concerns that you have for the bill and how you think it would
    affect the VA and the current VA system?
        Mr. Atizado. I'm sorry, Congressman.
        Mr. Hare. That is okay.
        Mr. Atizado. If you could repeat the question.
        Mr. Hare. Sure.
        Mr. Atizado. Because I had to look up what the bill was.
        Mr. Hare. I was just wondering if you could tell me on H.R.
    2173, the bill to increase the funding for the VA for mental
    health services, could you tell me a little bit more about the
    concerns that you had with the bill and how it would affect the
    current VA system?
        Mr. Atizado. I thank you for that question it actually
    deals with the issue--it is a two-prong issue. Right now VA has
    the authority to contract services.
        Our concern isn't what the quality of care providing
    community mental health clinics. Our concern is how this
    legislation implements services to be provides through
    community mental health clinics.
        The two-prong issue is how it requires VA to contract these
    services, as opposed to using its current statutory authority
    to make discriminate use of limited resources to contract care.
        The second concern we have is how VA actually provides
    contract care. There are some issues such as care--coordination
    of care, getting veterans out to seek care in the private
    sector and then back into the healthcare--the VA healthcare
    system, to ensure that VA's holistic care of a disabled veteran
    is, in fact, intact.
        When a Veteran leaves the VA healthcare system to seek care
    outside, it is subject to issues that VA has addressed and is
    considered high quality such as patient satisfaction, medical
    and medication errors, patient safety issues.
        So we would like to make sure that these veterans who
    receive care outside the VA healthcare system, come back in to
    enjoy what has been called the best healthcare system at least
    in the Nation.
        Mr. Hare. I just want to conclude, Mr. Chairman, by saying
    that--to all the panelists, I have only been here for going on
    6 months now that the great thing is to see that the pieces of
    legislation, the numbers of this legislation coming out for
    veterans, I think that is a wonderful thing.
        And I appreciate all of you and what you do. And I look
    forward to working with you, because I certainly have no quorum
    of wisdom on all these bills. And it is good to hear from the
    people that you represent with what you think is right about
    these bills, what you think is wrong about them. I think it
    helps us to put together a better bill.
        And I just want to compliment all of you for--and thank you
    for taking the time, but also compliment you on what you do
    to--for representing the people that you do each and every day.
        So I was look very much forward to working with you on
    that. Not just these bills, but other bills, the assured
    funding and some other things as we go down the path.
        So with that, Mr. Chairman, I give it back.
        Mr. Michaud. Dr. Snyder?
        Mr. Snyder. I don't have any questions. Thank you all for
    being here.
        Mr. Michaud. Ms. Brown?
        Ms. Brown of Florida. Yes. I just have a couple of
    questions, Mr. Chairman, thank you.
        Mr. Hollingsworth, can you expound a little bit more about
    the report card? You say a lot of the information is available,
    but it seems to be scattered, and difficult to use. Can you
    expound upon that a little bit more?
        Mr. Hollingsworth. As I indicated in my testimony, the VA
    does track and report on quite a few statistics and quality of
    care initiatives.
        I can speak very specifically to the combined assessment
    program, because I have actually had some personal dealings in
    that area. And it is a very thorough review. The assessment
    team will go into the facility. It is generally supposed to be,
    to the best of my knowledge, unannounced, and they do kind of
    the top-to-bottom review. And it looks at everything from
    patient care to patient safety issues.
        And they issue a report, and generally within that report,
    not only are there discrepancies listed, but they recommend
    courses of action to fix those discrepancies. And they provide
    a period of time for the VA to come back and fix those.
        So I guess the only thing I am saying is that we would
    encourage--you know, there are numerous programs in place, and
    we would encourage Congress to continue to hold VA accountable
    for those programs in those reports.
        You know, last but not least, and I forget the exact
    numbers and the statistics, but I would encourage this
    Committee to possibly take a look at formally.
        There are a lot of reports the VA puts together. Okay? And
    it costs a lot of time, money, and resources, and many of these
    reports their time may have come and gone.
        So we are leery about mandating the fact that you are going
    to formally institute something for VA to do something when
    they are going to take manpower, resources to put together
    these things and provide it to Congress when, in fact, it just
    may become another program that is there.
        Ms. Brown of Florida. Thank you.. Mr. Blake, you mentioned
    the hotline. You had some concerns about that. Could you
    expound on that a little bit?
        Mr. Blake. Well, after listening to some of the discussion
    this morning about what the VA is doing with their own internal
    hotline versus this outside entity, I thought the discussion
    was interesting in that Mr. Moran suggested that these are
    different types of people providing, you know, an outside
    service.
        And the VA, as I understand it, is going to staff their
    hotline, and maybe I am incorrect, with clinical professionals
    and individuals who work in the mental health field. And not to
    suggest that those aren't the right people, but this secondary
    hotline maybe provides a different perspective.
        Now, I have to reiterate our point that we made that you
    can't just stick anyone behind--on the other end of the
    receiver and have them answering phone calls, particularly for
    this population of veterans.
        But the shared perspective of a veteran, I think, is
    important. Understanding that they have to have some kind of--I
    don't want to say expertise maybe, but some kind of formal
    training in understanding how to handle these types of
    individuals.
        I mean, most of the hotlines for special needs like that
    are volunteers that don't necessary--aren't necessarily
    clinical professionals as well. And it provides some
    perspective that might provide balance to what the VA is doing
    internally.
        Ms. Brown of Florida. My last question concerns not the
    reimbursement, the cost, but about moving forward and
    permitting another program.
        I am thinking that we need to be considering how we can
    pool resources and other ways to get people to the different
    facilities, as opposed to what is wrong here. Everybody wants
    to drive their own car. I understand that, but that is part of
    our problem.
        With gasoline being $3.00-plus a gallon, we have got to
    come up with some alternative ways to move people. And it seems
    to me it could be scheduling, working together, and more vans,
    more car pools. What are your ideas?
        Mr. Hollingsworth. Well, from AMVETS perspective, we have
    testified in the past and will continue--rural healthcare and
    in under served areas, it is a real issue. And it is a problem.
    I think all of the veteran organizations know that.
        You know, the Secretary of Veterans Affairs does have the
    authority in some cases to contract out. You know, we walk a
    fine line, because, you know, from an AMVETS perspective, we
    want to maintain the integrity of the Veterans' Affair system.
    But at the same time, we want to provide rural veterans in
    underserved areas healthcare.
        So we would encourage the Secretary to continue to contract
    out. However, we, obviously, hope he uses that authority
    judiciously where applicable.
        Ms. Brown of Florida. Mr. Chairman, I have a couple more. I
    want to see if he can answer my question.
        Mr. Blake. I just wanted to kind of reiterate our point
    about the travel reimbursement rate. I think most of the
    organizations here, if not all of them, principally believe
    that if you had a reasonable travel reimbursement rate, you
    might do away with some of the complaining that veterans have
    about access in rural areas. That is not to say it solves the
    problem entirely. That certainly doesn't.
        But a lot of the problem that veterans have that live in
    rural areas is they have to foot a large part of the bill out
    of their own pocket just to get the care from a VA facility.
    Yes, some veterans have to drive 250 miles. Well, that is
    expensive, because it is a tank of gas.
        But in a lot of cases they foot the bill for a hotel,
    because they probably have to stay somewhere overnight if they
    have to travel that far, eating, and all those types of things.
    And 11 cents to the mile just doesn't get it done when
    addressing that concern.
        So we think that some of those concerns would be offset if
    they knew that they weren't going to have to foot the bill out
    of their own pocket. Now again, some rural access issues are
    broader than that. Some of them are just--but an area that are
    clearly under served as a whole.
        That is not just the VA. I mean, there are a lot of areas
    across the country that are under served for healthcare in
    general. So--and I think that is another issue that falls in
    line with that as well.
        Ms. Brown of Florida. Thank you, Mr. Chairman.
        Mr. Michaud. Maybe we could get railroad access to some.
        Ms. Brown of Florida. We will work it out.
        Mr. Michaud. The Chairwoman chairs the Railroad
    Subcommittee on Transportation. Mr. Miller?
        Mr. Miller. No questions.
        Mr. Michaud. Once again, I thank the panel for your
    testimony this morning, and we look forward to continue to work
    with you as we deal with veteran issues. Thank you.
        And the last panel that we have this afternoon is Dr.
    Michael Kussman who is the Under Secretary for Veterans Health
    Administration, who is accompanied by Walter Hall who is the
    Assistant General Counsel for the Department of Veterans
    Affairs.
        I want to thank both of the gentlemen for coming today, and
    I turn it over to you, Dr. Kussman. I want to congratulate you
    for no longer acting as the Under Secretary of Health, and now
    that you are no longer acting, hopefully we will see good,
    strong results, particularly as it relates to the Rural
    Healthcare Office.

      STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., MS, MACP, UNDER
      SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S.
    DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. HALL,
     ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS

        Dr. Kussman. Thank you Mr. Chairman and Mr. Ranking Member,
    and other Members of the Subcommittee.
        When you were talking about no longer being acting, I want
    to assure you that I am now going to pretend to be the Under
    Secretary of Health.
        Thank you for inviting me here today to present the
    Administration's views on the nine bills affecting the
    Department of Veterans Affairs health programs.
        As you mentioned, sir, with me today is Walter A. Hall,
    Assistant General Counsel.
        As you already did, Mr. Chairman, I don't have to request
    that the written statement be submitted for the record, because
    you all did that.
        Mr. Chairman, I am going to focus on my remarks on five of
    the bills, but I would like to state from the beginning, VA
    does not oppose the intent of any of the bills under
    consideration.
        In some cases, the VA's current efforts meet or exceed the
    requirements of the bill and in others, some additional work is
    needed to allow the Congress and the VA to best serve our
    Nation's veterans.
        And our request would be that we could continue to partner
    with you and the staff to get the best bills possible.
        Mr. Chairman, H.R. 1925 would require the Secretary to
    establish a separate ``Veterans Integrated Services Network''
    for the Gulf Coast region.
        While VA certainly desires to serve all our veterans, we
    find at this point, on the basis of information that we have,
    no justification for establishing a separate VISN for a service
    area driven by the workload needed to make such a significant
    organizational change cost-effective.
        Current facilities and referral patterns provide the best
    access for the veterans on the Coast using the combined efforts
    of VISNs 7, 8 and 16 who--which are--work very well together to
    provide the care for veterans living in the area.
        H.R. 2005 is intended to improve the VA's ability to meet
    the healthcare needs of rural veterans. The VA recently
    established the Office of Rural Health, which is charged with
    determining how we can best continue to expand access to care.
        And the Office of Rural Health is developing a strategic
    plan for operations that there is consideration for a proposal
    to create new research centers.
        We would request that the Congress wait until these
    assessments are complete before requiring further action
    Moreover, while we recognize the significant increase in fuel
    prices, beneficiary travel payments are paid to a limited
    category of eligible veterans out of funds appropriated for
    healthcare for all the veterans.
        Our initial estimates project that the bill would cost
    potentially and approximately up to $7 billion over the next
    ten years. At present, that cost would have to come out of
    medical care services.
        H.R. 2173 would amend VA's authority readjustment
    counseling while permitting the Secretary to enter into
    contracts with community mental health centers for the
    provision of mental health services.
        I have to admit that I have been a little bit confused by
    the discussion, because the bill talks about veterans health
    centers, not the VA in general contracting for care. The Vet
    Centers currently have authority to contract with community
    mental health agencies for the provision of readjustment
    counseling services.
        For veterans with more complex mental health needs, the
    veterans--Vet Centers routinely refer them to the VA medical
    facilities.
        This provision, if it really was intended for the Vet
    Centers to contract out for the full services of mental health,
    would blur the distinction between the VA's readjustment
    counseling and more sophisticated mental health services.
        Readjustment counseling is a special, more than medical
    community based counseling service that creates--that treats
    veterans and family members under the bereavement counseling to
    help them make a successful readjustment from combat to
    civilian life.
        VA mental health is a medical care service provided by VA
    mental--medical centers for enrolled veterans. We already have
    the authority to outsource and contract if for care, and it is
    very clear that my guidance is that there are only two ways
    that you can do this. Let me make it three, but one is
    unacceptable.
        One is that you--we have an obligation to provide whatever
    services are necessary for the veterans consistent with out
    benefit package. That we can either do it in-house, and if we
    can't have the resources, you don't have the infrastructure,
    then we are obligated to buy it. In other words, contract with
    it.
        The third thing is not to do it, and that is totally
    unacceptable.
        H.R. 2219 would require the Secretary to establish a
    national toll-free hotline for suicide prevention, staffed by
    peer-to-peer counselors.
        Mr. Chairman, as you already know and has been mentioned
    already, VA's already developing a comprehensive program for
    suicide prevention, including a national 24-hour toll-free
    hotline.
        The VA plans to staff the hotline with VA mental health
    professionals who may access the electronic health record of
    the callers and can work with local facility suicide prevention
    coordinators to provide immediate and provide more
    comprehensive care.
        H.R. 2378 intends to prevent low-income veterans in
    permanent housing from falling back into their former homeless
    condition.
        The VA generally supports H.R. 2378, but we strongly
    recommend the bill be modified to allow VA to establish
    additional criteria to ensure that this program reaches veteran
    families requiring additional support to end their
    homelessness.
        There was one bill, the 2623, the ``Hospice Care Bill''
    that I don't know exactly what happened in the process. I did
    not provide comments on that either in written or verbal, but I
    would be happy to answer any questions about it. But we didn't
    develop a formal response to that bill.
        [Comments for H.R. 2378 and H.R. 2623 were provided by the
    U.S. Department of Veterans Affairs on August 19, 2007, and
    appear on p. 91.]
        I am pleased to answer any questions you or any of the
    other members may have, Mr. Chair.
        [The prepared statement of Hon. Kussman appears on p. 80.]
        Mr. Michaud. I have a few questions. What have you provided
    to the Subcommittee dealing with Ms. Watson's bill as far as
    training. Looking at PVA's testimony, they had mentioned that
    they had talked to one of the VA chiefs and were told that the
    officers received training primarily on how to handle veterans
    aged 60 to 70 years old. I want to know if you could provide to
    the Subcommittee what other requirements for the officers as
    far as training goes.
        [The FY 2007 Basic Police Officer Training Course Syllabus
    and Training Schedule from the U.S. Department of Veterans
    Affairs Law Enforcement Training Center, North Little Rock,
    Arkansas, is being retained in the Committee files.]
        Mr. Michaud. Another issue talked about--a report on the
    reports. I think it is important that we have reports. But, I
    am concerned about the redundancy and how we can streamline
    that process.
        Regarding testimony the VA does a good job on a lot of its
    programs, but I can see the frustration that people might have
    in trying to access the system.
        It is my hope that the VA will look at how it can improve
    access to programs, such as through a computer and telephone
    system. Did you want to comment on that?
        Dr. Kussman. Yes, sir. I would be happy if I could, if I
    could remember all the questions you had.
        But first and foremost, as was mentioned, all our VA police
    are VA employees by statute. They are not contracted. There may
    be some confusion. I think that there is some contracting for
    guards, but not for the police themselves.
        If I may just take a minute. Clearly, the description of
    what happened to Jose Medina is unacceptable, and all I can say
    as the leader of the VHA, that is unacceptable. And we
    apologize for whatever happened or anything veteran who is
    inappropriately treated by any employee in our system, much
    less the police.
        Now, we--in the hiring our VA police, there is an extensive
    training program done even before they get to the ability to
    work. There is an 80-hour basic injury level of training course
    at whatever medical center they are going to be employed on.
    And then a 200-hour residential basic police office training
    course at our law enforcement training center, I think, that is
    in Little Rock, Arkansas. And we have been lauded by much of
    this training.
        Title 38, U.S. Code, section 902, requires VA to create
    regulations with respect to training department police
    officers, with particular emphasis on situations involving
    patients.
        The specific question that you had, it was alluded to that
    the training was only for people over 60. I have to go back and
    look at that, but clearly our job is to take care of the full
    depth and breadth of veterans, with specific emphasis on
    adjustment reactions in mental health and people who may or may
    not be acting in a way that is not normal the way they act
    because they are ill. And that is something that all medical
    employees have to do.
        Whether it is a policeman or anybody else is that people
    don't necessarily act the way they might in the department
    store versus--or a bank versus when they come into mental--for
    medical services, because that is the problem. They are coming
    for medical services.
        Much of the training, there is a 17.5 hour block of
    training in behavioral science, which includes training on
    mental illness----
        Mr. Michaud. Instead of going through that whole thing----
        Dr. Kussman. Okay.
        Mr. Michaud [continuing]. Could you provide that for the
    Subcommittee?
        [The following was subsequently received:]

        By statute, the Secretary is required to provide VA Police Officers
    with training that emphasizes effective management of situations
    involving patients. To carry out that mandate, VA provides specialized
    training to VA Police Officers in dealing with disruptive and other
    unusual behaviors, key portions of which are taught by VA
    psychologists. VA officers must successfully complete:

          An 80-hour basic entry level training course at their
    Medical Center;
          A 200-hour residential basic police officer training
    course at the VA Law Enforcement Training Center in Little Rock,
    Arkansas;
          A 17.5-hour block during their residential basic officer
    training in Behavioral Science (including topics such as mental
    illness, communications/conflict management, verbal judo, crisis
    intervention/conflict resolution, and the dynamics of the suicidal
    individual); and
          A biannual refresher training program.

        Dr. Kussman. Sure.
        Mr. Michaud. I know my time is up.
        Dr. Kussman. Okay. I am sorry. Just--okay.
        Mr. Michaud. But the other issue you could look at that we
    are dealing with today is the budget. It is a very robust
    budget for the VA system, and our problem, when you look at the
    bills that you mentioned earlier, a lot of these issues could
    have been dealt with if the VA had the budget and moved
    forward, whether it is the CARES program or other access
    issues.
        I am also looking at how we can help save costs. A good
    example, is the dental area.
        For example when you go to the VA for dentures or you need
    amalgam fillings, it depends on whether the VA gets it. If you
    go to the dentist, the dentures tend to cost twice as much, as
    much as $600.00 or more if you went--than if you went to a
    denturist. Likewise, if you go to a dentist and they decide to
    fill a filling with a white filling versus an amalgam filling.
    The white tends to be a lot more expensive and it doesn't last
    as long.
        So hopefully the VA is looking at ways where they might be
    able to save money, and it might make the system more
    effective. I will ask other members to ask that question, and
    we will go a second round if we have time.
        Mr. Miller?
        Dr. Kussman. So you--there was one--on the last part of
    your question about the ombudsman?
        Mr. Michaud. Yes
        Dr. Kussman. Yes.
        Mr. Michaud. Excuse me.
        Dr. Kussman. And, obviously, in intent, that is a great
    idea, and it really depends on what type of veteran you are
    talking about. Whether it is the more routine veteran that is
    getting out, using the Benefits Delivery at Discharge (BDD)
    process, the Transition Assistance Program (TAP) process, and
    all those things. That is where a lot of that counseling goes.
        But we realize that people who are injured in service,
    particularly with TBI and more severe injuries, needed a lot
    more care. And as you know, we have had our benefits counselors
    and case managers get deeply involved with these VA facility.
    They wrap themselves around, try to communicate with them, make
    sure everybody knows that their benefits are. Military people
    who are in our four Polytrauma Centers to help on the reverse
    way of making sure that people get help if they are worried
    about the Medical Evacuation Proponency Directorate (MEPD)
    process.
        We also, as you know, just put in place a program of
    transition patient advocates that are going to glom themselves
    on, on a one-on-one basis with people who are in the Walter
    Reeds of Bethesda and Brooks, and help them longitudinally as
    they go through the process but not give up on them. They are
    going to have cell phone contact. They are going to picked by
    where the patient would generally want to go and will keep in
    contact with them over a period of years.
        Mr. Michaud. Thank you. Mr. Miller?
        Mr. Miller. Thank you very much, Mr. Chairman. Doctor, good
    to see you.
        Dr. Kussman. Nice to see you, sir. Thank you.
        Mr. Miller. I look forward to working with you. I did put
    the chart back up so you could refer to the VISN in the Gulf
    Coast Region.
        You stated in your testimony that there was not sufficient
    workload to make an organization change, create a new Gulf
    Coast VISN. Could you give me some type of idea of what you
    consider as sufficient workload?
        Dr. Kussman. The information that I have, and, sir, I would
    have to go back and validate it and discuss with you further,
    but the information that I have is that in 2005, there were
    88,000 enrollees in the area that you are describing, with
    281,000 veterans of which 88,000 were enrolled with us.
        Mr. Miller. So you are saying--my question is not----
        Mr. Snyder. I was not sure of his answer. Is the number he
    is giving in the new area that he wanted----
        Mr. Miller. You can't--I mean, you--I mean----
        Dr. Kussman. Okay.
        Mr. Snyder. Yeah, that is what I figured.
        Mr. Miller. My first question is what do you consider an
    adequate workload, a sufficient workload? Looking at this
    chart, it is very clear that there are two VISNs that are
    absolutely covered up. One is 16; one is eight.
        Obviously, a lot has changed since the inception of the
    VISN, and I think the Gulf Region is the concept works, and,
    obviously, because we took two and we fold them into one, there
    is flexibility in doing what needs to be done.
        Clearly, you can look and see that VISN 16 has three times
    the number of Gulf veterans as VISN two, five, or 19. My
    question is at what time would the enrollment be too high that
    you would look at splitting? Splitting, not combining, but
    splitting this?
        Dr. Kussman. That actually is a very good question, and I
    don't think we have a criteria for that. And we certainly
    should look at it.
        [The following was subsequently received:]

        Question: For the record, ``the opportunity for VA to look closer
    at the numbers'' of VISN 16, particularly how many veterans it has
    relative to other VISNs and whether that should be reconfigured.
        Response: Currently, we have no data to support an additional VISN
    in the Gulf Coast Region. The size of the area proposed for a VISN does
    not have the workload needed to be cost effective, nor to require that
    level of management. This area has only 88,583 enrollees and 281,476
    veteran population in 2005, with the 2025 projections at 94,779
    enrollees (a 7% increase) and 223,598 veteran population (a 21%
    decrease). The smallest VISN currently has at least 200,000 enrollees
    and over 500,000 veteran population.
        This area has one hospital, the Gulf Coast Veterans Healthcare
    System in Biloxi, Mississippi, and no tertiary care facility. The Gulf
    Coast area has four operational Community Based Outpatient Clinics
    (CBOCs) in Panama City, Pensacola, Dothan, and Mobile, and one approved
    to open in the next year in Jackson County, Florida. In addition, there
    are sharing agreements in place at three major military installations
    in Pensacola, Ft. Walton, and Panama City for inpatient and other
    healthcare services as needed.
        Each of the other 22 VISNs has at least four hospitals, with at
    least one providing tertiary care, and at least 15 CBOCs to manage the
    services and healthcare for veterans. With only one facility in the
    Gulf Coast, there is no need for Network Management. In addition,
    balancing the budget, opening new programs, and making large capital
    investments, among others, will be difficult at best. The Gulf Coast
    area does not have a tertiary care facility and as is the current
    practice, patients would still be referred to the closest tertiary care
    facility--Birmingham, Alabama; Jackson, Mississippi; or Gainesville,
    Florida.
        The current facilities and referral practices in this area provide
    access for veterans. VISNs were originally created around referral
    patterns and geographic boundaries. In addition, VISNs work together
    along their borders to ensure access to healthcare for veterans in
    those areas. The Gulf Coasts region is one area where VISNs seven,
    eight, and 16 have worked together to manage care for veterans in the
    area. VA has no plans at this time to add an additional Network for
    this region.
        Mr. Miller. What catches me by surprise with a visual such
    as this, that is it is very, very clear that there are some
    areas I would say are underserved or under worked.
        Now, they won't say that, and I would never impute that or
    imply that, because they are all overworked. However, if the
    folks in VISN two, five, and 19 are overworked, then eight and
    16 are really overworked.
        I would like for the record the opportunity for VA to look
    closer at the numbers, and if it is time to realign the whole
    network, fine. I am looking obviously at the veterans in the
    Gulf Coast Region, but it may be other regions as well.
        Another thing, on a personal note if I may, Public Law 109-
    461 required a report not later than 180 days after enactment
    on the option of construction of a VA medical center in
    Okaloosa County. We are upon that date. In fact, it may even be
    next week. My question is are we going to meet that deadline,
    and when can we see a copy of the report?
        Dr. Kussman. Sir, we working on it, and let me get back to
    you exactly when we will get that report to you.
        [The ``Report to Congress on Options for the Construction
    of Department of Veterans Affairs Medical Center in Okaloosa
    County, Florida,'' dated June 26, 2007, is being retained in
    the Committee files.]
        Mr. Miller. Okay. Thank you.
        Mr. Michaud. Mr. Salazar?
        Mr. Salazar. Thank you, Mr. Chairman. And, Dr. Kussman,
    thank you for being here, and I understand the issues that you
    face with VA funding. And I can assure you that this Congress
    is trying to do everything they can to provide these funds that
    are badly needed for veterans.
        Can you tell me what model you use to estimate the $7
    billion that you talked about that it would cost VA for mileage
    reimbursement?
        Dr. Kussman. I would have to go back to policy and planning
    and resource managers, and I will get you an answer. I don't
    have it at the tip of my tongue about how they develop the
    estimation.
        [The following was subsequently received:]

        Question: What was the methodology used to determine the $7 billion
    cost for beneficiary travel in Section 2 of HR 2005, the Rural Veterans
    Health Care Improvement Act of 2007?
        Response: (16, 10A5, 17) Beneficiary travel is a discretionary
    program with funding coming directly from the annual VA healthcare
    appropriation. Funds expended for beneficiary travel decreases those
    available for direct medical care. The Secretary is required to
    undertake a yearly evaluation of the program in order to determine
    whether VA has sufficient funds to continue to provide veteran
    transportation benefits and whether any rate changes should occur.
    Given the unprecedented rise in veteran patient workload and the
    associated demand for limited VA medical care resources, the current
    reimbursement rates of .11 mile for travel relating to medical care and
    .17 mile when a veteran is recalled to redo a portion of a C&P
    examination that were established in 1979 have been maintained. Note:
    Under current law, when the beneficiary travel rate is adjusted, the
    deductible is adjusted proportionately to the adjustment.
        The proposed legislation requires VA to reimburse veteran mileage
    at the same rate as that of federal employees. It would also pay a
    subsistence amount (e.g. meals, lodging) at the same rate as a federal
    employee for that locality. Cost determination data is presented below.
        Cost Analysis: H.R. 2005, Section 2, changes the method of
    determining the mileage reimbursement rate of the VA Beneficiary Travel
    Program by equating it to that received by Federal employees as well as
    provides for a subsistence rate equal to that of a federal employee.
    The following provides a 5-year and 10-year estimate of the cost that
    would result from enactment of the proposed bill.

    ----------------------------------------------------------------------------------------------------------------
                                                     Estimated Reimburseable                        Increased Cost
                      Fiscal Year                           Mileage*            Payment Rate**        (Millions)
    ----------------------------------------------------------------------------------------------------------------
    2008                                                        675,363,636                .375                $253
    ----------------------------------------------------------------------------------------------------------------
    2009                                                        776,668,181                 .40                $311
    ----------------------------------------------------------------------------------------------------------------
    2010                                                        893,168,408                .425                $380
    ----------------------------------------------------------------------------------------------------------------
    2011                                                      1,027,143,669                 .45                $462
    ----------------------------------------------------------------------------------------------------------------
    2012                                                      1,181,215,219                .475                $561
    ----------------------------------------------------------------------------------------------------------------
    5-Year Total                                                                                             $1,967
    ----------------------------------------------------------------------------------------------------------------
    2013                                                      1,358,397,502                 .50                $679
    ----------------------------------------------------------------------------------------------------------------
    2014                                                      1,562,157,127                .525                $820
    ----------------------------------------------------------------------------------------------------------------
    2015                                                      1,796,480,696                 .55                $988
    ----------------------------------------------------------------------------------------------------------------
    2016                                                      2,065,952,800                .575              $1,188
    ----------------------------------------------------------------------------------------------------------------
    2017                                                      2,375,845,720                 .60              $1,426
    ----------------------------------------------------------------------------------------------------------------
    10-Year Total                                                                                            $7,068
    ----------------------------------------------------------------------------------------------------------------

        May not add up due to rounding

        *Estimated 15% increase in mileage per year
        **Federal Rate minus current .11 mileage rate

        Methodology: Number of miles for FY 2008 is based upon projected
    expenditures for Budget Object Code (BOC) 2120, ``Beneficiary Travel-
    Mileage'' from the first half of FY 2007. Note: While VA does pay 17
    cents per mile for recalls due to the need to redo a portion of a C&P
    exam this is considered to be relatively rare, therefore the 11 cents
    per mile rate is used to determine base miles).
        Projected expenditures for FY 2007 are a 15% increase over FY 2006,
    and based upon continued increase in the number of veterans accessing
    VA healthcare it is estimated that this mileage rate increase will
    continue. Base Federal employee rate of 48.5 cents per mile is current
    rate. For the past 10 years there has been an annual average 2.5 cents
    per mile increase to the Federal employee rate, thus the rate changes
    noted.
        A subsistence rate adjustment has not been included since meals and
    lodging is estimated to have minimal impact due to current operations
    of only paying when hotel or other VA lodging is not available and the
    trip requires an overnight stay. VA usually pays actual charges in this
    event for lodging and meals.

        Mr. Salazar. I would appreciate that very, very much. And
    as far as the office that was established in January, the
    Office of Rural Health Care, could you also provide to this
    Committee an assessment as to what you have done to date in the
    last 6 months?
        Dr. Kussman. Yes, sir. Thank you for the question. As you
    know, we owe you a response in September of 2007, a written
    response about what progress has been made in the Office of
    Rural Health.
        Right now it has been stood up under the auspices of the
    Office of Policy and Planning under the direction of the
    Assistant Deputy Under Secretary for Health, Pat Vandenberg.
    This is a good place for this office, because it is involved
    with the office that does projections on workload, access,
    CARES, and the Milliman Model.
        Right now, Peter Sellick is in charge of that office, and
    they are looking at some strategic recommendations. At the same
    time, they are in the process of hiring a full-time director
    and establishing the necessary staff. So we will have a report
    for you.
        Mr. Salazar. So we still do not have a director, and we
    still are not fully staffed?
        Dr. Kussman. Right. That is correct.
        [The U.S. Department of Veterans Affairs, Veterans Health
    Administration, submitted the following report on January 10,
    2008,``Plan to Increase Access to Quality Long-Term Care and
    Mental Health Care for Enrolled Veterans Residing in Rural
    Areas,'' which appears on p. 96.]
        Mr. Salazar. One other question, Doctor. You talked a
    little bit about the Centers of Excellent and your objection to
    us directing you to establish the Centers of Excellence; is
    that correct?
        Dr. Kussman. I----
        Mr. Salazar. Could you tell us what your objection is to
    this?
        Dr. Kussman. Yes, sir. I will try. By the way, I was
    accused last year when I was here as being ``Dr. No.'' I
    don't--I would like to be ``Dr. Yes.''
        But to answer your specific question, we are not--I am
    not--I don't think anybody is against the Centers. The question
    is is there five, or four, or three that would be needed, and I
    think that is what we would hope that the Office of Rural
    Health, approaching the appropriate experts and everything,
    would recommend of how many or whatever that we need of these
    centers, because I think they are valuable centers.
        Mr. Salazar. But would you also agree that it is really up
    to members of Congress to request from you that these offices
    wouldn't just be established on one coast or the other and
    forget about middle America?
        And, you know, I think that is one of our reasons for
    trying to move this legislation forward so that we can
    basically make these Centers of Excellence, you know, located
    in--so that they address the needs of middle America as well,
    like Colorado, or Montana, or South Dakota.
        Dr. Kussman. Yes, sir. I wouldn't take exception. I don't
    recall that the legislation prescribed where they would be, but
    I don't disagree with you. It ought to be in areas that have
    the most need for the research and development of things
    related to rural health.
        Mr. Salazar. Thank you. I yield back.
        Mr. Michaud. Mr. Hare?
        Mr. Hare. Thank you, Mr. Chairman. Thank you for coming
    today, Dr. Kussman. Just three questions, I guess. One on H.R.
    2623, the--which prohibits the collection of copayments for the
    hospice care.
        I was wondering if the VA has a position on that or----
        Dr. Kussman. Well, as I mentioned earlier, I apologize. For
    some reason we didn't get that bill to put together an official
    policy. But in the past, and as we have done already with
    certain segments, we understand the need for that.
        And I don't want to prejudice the ability to look at the
    legislation, but it is clearly something that we need to look
    at.
        Mr. Hare. Thank you. The other one is on H.R. 2219, the
    ``Veterans Suicide Prevention Hotline.'' I was wondering if you
    could just maybe update me on the status of the--of this
    project that you have.
        Specifically, when you expect it to be up and running, the
    qualifications of the people who are staffing the hotline, and
    does the VA plan on advertising this resource, so that the
    veterans have an understanding that it is there or their
    families have an understanding that it is there to be used? And
    if so, how are you going to do that?
        Dr. Kussman. Well, yes, sir. Obviously, any suicide is one
    too many, and our goal is to be as aggressive as we can. And we
    put together a very aggressive suicide prevention program,
    including having suicide coordinators at every facility, and
    this is another aspect of that, training all our people to know
    about how to look for and treat, even non-mental health people.
        The intent here, this will be established fully by the end
    of September of this year, and that we believe, after much
    discussions and everything--and by the way, the Joshua Omvig
    bill actually drove saying--we were doing this before that, but
    it was consistent with the bill, that said that they would be
    mental health professionals.
        And so our intent is to have the most sophisticated
    responses available to people when they call in, especially
    that they have access to the medical records if they weren't a
    veteran that we had never seen, so that they would be able to
    know about the veteran and assess the patient, because they
    would have the information. And then be able to coordinate
    directly with the suicide coordinators and the clinical people
    who are actually taking care of this person.
        Mr. Moran's point is well taken, and I think that it is
    something that we want to look at in balancing this, because
    there are veterans who don't like to use the system. That is
    what the Vet Centers, the readjustment counseling centers, are
    so valuable for.
        So I think that this is just another thing that we need to
    work together to decide what was the best way to do this. But
    having two hotlines, I am not sure how productive that would
    be.
        Mr. Hare. How do you plan on advertising this so the
    veterans can call in? The other question I had was for those
    who are staffing the hotline, what qualifications they had to
    have in order to be there?
        Dr. Kussman. With all our communication efforts with our
    newspapers and information papers at the facilities, we will do
    everything we can to make sure that people and their families
    know.
        Clearly when people transition out of the military, they
    will know as well as all the other veterans. Our intent is to
    have fully trained psychiatrists or psychologists available to
    provide that service.
        Mr. Hare. Do you have--just one last question. Is there a
    guesstimate, if you will, on how many veterans or families who
    would utilize this hotline during the course of the year? I am
    thinking several thousand.
        Dr. Kussman. Well, I am sorry. I don't know. We can look at
    per capita things that have happened in other hotlines, and
    presume that that would be----
        Mr. Hare. Would you--would you expect the numbers would be
    significant or your thought maybe even?
        Dr. Kussman. I don't know if they would be higher than we
    thought, but I think that we need to do it even if it is small
    numbers.
        Mr. Hare. I agree. All right. Thank you. I yield back, Mr.
    Chairman.
        Mr. Michaud. Dr. Snyder?
        Mr. Snyder. Thank you, Mr. Chairman. Dr. Kussman, I--is it
    Kussman or Kussman?
        Dr. Kussman. I think my father who is deceased would say it
    was Kussman, but everybody says Kussman. So I have been called
    worse.
        Mr. Snyder. There was a San Diego Padre ballplayer named
    Kussman. I don't know if you----
        Dr. Kussman. It is K-O-O-S.
        Mr. Snyder. If I call you Koosman, I will harass you for
    your batting average.
        Dr. Kussman. I don't see well enough.
        Mr. Snyder. Regarding--Mr. Miller had to leave, but in
    regard to this VISN issue, you know, part of VISN 16 includes
    Arkansas. And I have not heard much. You try to reach out a
    little bit on Mr. Miller's bill, and I have heard many
    complaints either way about how the lines have been drawn.
        I do have some concerns though that if we were to start
    drawing these lines by statute, and regarding seeing some
    benefit to doing that, and we changed the lines. And so I would
    hope that you would take into consideration Mr. Miller's
    concerns about those areas and waiting on the veterans. And I
    think it has been growing. And I hope we take a very formal
    look at this.
        And it may well be that in Arkansas we should also be
    concerned. Maybe there is an additional benefit to our veterans
    to have a smaller number of them under that administrative
    umbrella. I don't know what is magic, but I don't think Moses
    had golden tablets that said, what the most efficient number of
    enrollment is, this number versus a smaller number.
        It doesn't follow beyond that because you have a larger
    number. You can be more efficient. I would assume that the
    staffing would reflect the numbers of veterans, and those kinds
    of issues.
        But I hope you will formally look at that, and get that
    evaluation back to us, because----
        Dr. Kussman. Yes, sir.
        Mr. Snyder [continuing]. It has been a while since we took
    a look at it administratively.
        The second question I want to ask, but I share your
    concerns about the dental hotlines. So many years ago was that
    before I ever got into medicine and practiced medicine,
    staffing hotlines, you really do get a lot of kinds of calls
    that come into the different hotlines.
        But there are--every once in a while, there is one that
    really is a major problem and how that call is handled can make
    a huge difference in that person's life for better or worse.
    And I share your concern about who we would have on the
    hotline, and then like the real hotline. I think there could be
    some real confusion.
        I think, ultimately what everyone wants is that there be a
    place that people can go when they really are having a problem.
    If everything else is broken down, hopefully they are calling
    their health professionals or before they reach the hotline,
    but I share your concern.
        The issue of contracting out service in rural areas, about
    half my district is--would be considered rural, if not a little
    bit more. A great expanse of Arkansas are considered rural. We
    are very pleased with our VA system, the healthcare system in
    Arkansas.
        One of the things I like about it is if something goes
    wrong, I can pick up the phone or my staff can pick up the
    phone and go straight to a VA employee and say, ``Fix this.''
    When things are contracted out, that is not so easy to do. You
    have people who have contractual responsibilities, which is
    different than having responsibilities to a member of Congress.
    I remember my office sent you a letter. We faxed it yesterday
    afternoon. If you haven't seen it, we have an issue going on
    now with regard to the seat back business in my district. I
    know we are hearing about veterans.
        But my specific question is, if they can provide the best
    care, more power to them. The problem is, I also noticed
    reports--especially reports out of Eureka, California, that
    they were rejected for a contract out there. We have had some
    indication that one of the VA's out there said they were real
    concerned about the company. That they decided to reject that
    contractor.
        But now we have got them in another VISN. That people may
    have a different set of information. How much information is
    shared when you have these kinds of--when you use this kind of
    contractor? How much information is shared amongst the
    decisionmakers, so that we are sure that the experience is good
    or bad and the contractors in one area that they reach out to
    other areas? How is that information shared so we know that
    they work on the same basis, and don't have to rediscover?
        Dr. Kussman. Thank you for the question. I have not seen
    the facts, so I apologize. But I think that the point is very
    well taken. Obviously is what do we learn from one place to
    another.
        You know, the old adage, you have seen one VA, you have
    seen one VA, is not what I believe. We have to have standards
    and consistency in the deliver.
        I have no idea why that Eureka, California, contractor was
    rejected. There could be a lot of reasons. If it was truly the
    quality of care, then we certainly should be able to track
    that, because what brought in all the other sea box that they
    may be contracted around the country.
        So I think we certainly have to look at that, and see if
    how we transmit information related to good contracts or bad
    contracts.
        Mr. Snyder. The number of contracts contracted is certainly
    going down. Thank you, Mr. Chairman.
        Mr. Michaud. Thank you. Ms. Brown.
        Ms. Brown of Florida. Thank you. Mr. Chairman, I don't have
    all of the details right before me, but in the last couple of
    days there was a news report. It indicated that veterans, over
    the last, I think it said 10 years, were twice as likely to
    commit suicide than people who were non-veterans.
        And I guess in response to that and other issues, the
    Department has indicated that they are going to hire 153
    prevention counselors at all of the veteran centers.
        My question lies--and I am not one for contracting out, but
    perhaps in a situation like this, it would be better, because I
    don't know what the cost is to hire 153. But how would those
    people who can't be available 24 hours help all the veterans.
    This would be the opportunity to work with some organizations
    and other groups to have people available and training in
    coordination.
        I just don't know how it is going to work. Can you expound
    upon that?
        Dr. Kussman. Yes, ma'am. We are constantly looking at our
    mental health processes, suicide, PTSD, whatever it is.
        Ms. Brown of Florida. Are you familiar with the study that
    I am talking about?
        Dr. Kussman. I am aware of it. I haven't read the study
    specifically. The subject matter experts are looking at that to
    determine, because a lot of times the small numbers, and it is
    hard to know for sure what was in the report. I am not
    debunking the report at all.
        I mean, I--but the ones--the counselors we were talking
    about are suicide coordinators to make sure that the facilities
    have all the programs and processes in place. That the staff is
    educated in things of that sort.
        I have put in place a new policy related to mental health.
    That when somebody surfaces, that they need to be evaluated
    within 24 hours of what it is. Now, obviously, if a suicide,
    you can't even wait 24 hours, but we have people on call 24
    hours a day. And we will make that the standard in our
    facilities.
        So if somebody calls, again, and they call the hotline,
    that hotline has the way of getting to wherever the geography
    if the person will tell us. Sometimes they call and won't tell
    you where they are, and you have got to look at the call--
    caller ID and see the area code.
        But if somebody comes to the emergency room or somebody
    knows about it, we have people on call 24/7 to come in and
    assess that person, because you have to take every person who
    says, ``I think I am going to do something bad to myself,''
    seriously.
        Thank God most of them don't do it. But there are enough
    that do that we have an obligation to try to intervene to the
    maximum extend possible.
        Ms. Brown of Florida. One follow up. You indicated in your
    written testimony you generally support most of the bills, but
    under the area of permanent housing for the homeless vets, why
    would clinical indicators be a reason to deny permanent
    housing?
        I felt that if we are looking at veterans, there is going
    to be a big increase in funds to deny a program to staffing
    issues is kind of--is very unacceptable to me. And I would like
    for you to be ``Dr. Yes.''
        Dr. Kussman. Or ``Maybe Could Be.'' I don't know. But in
    truth, I don't think we are against the permanent housing. I
    think what we were saying is that we support the bill. It would
    be a better bill for us if we could add some of these clinical
    services that are there.
        For instance, we would want to know what--if there was a
    history of mental illness, whether there was a history of
    substance abuse, demonstrated significant impediments to
    holding a job, whether there was social dysfunction in the
    family. All those things would make it better for us to be able
    to provide services.
        Ms. Brown of Florida. Well, would you work with us as we
    move forward----
        Dr. Kussman. Yes.
        Ms. Brown of Florida [continuing]. With the bill and my
    staff to make sure that we include those areas that you think
    would make it better?
        Dr. Kussman. Yes, sir. And I think as the Chairman knows, I
    would like to do that in all the different bills, because I
    think we agree in principle as I said. We just want to
    maximally affect what we can do, and not, perhaps, get
    someplace where we are duplicating what we are doing.
        But our effort is to take care of veterans.
        Ms. Brown of Florida. I know you know that there is a lot
    of frustration----
        Dr. Kussman. Right.
        Ms. Brown of Florida [continuing]. With us, because we all
    care about the veterans, and it is just--it seemed to be not
    working for them.
        Dr. Kussman. Right. It----
        Ms. Brown of Florida. And they are very frustrated, and
    they get on us. And then we have to get on you.
        Dr. Kussman. Yes, ma'am, I understand that. I have been
    sworn in since the 30th of May.
        Ms. Brown of Florida. All right, ``Dr. Yes.''
        Mr. Michaud. Just a follow up. I think it was Mr. Hare's
    question and others about hospice. I believe that was actually
    requested from the VA back in the 2006 budget.
        Just one last question, and we'll take questions in
    writing. It gets to questions asked earlier about the Office of
    Rural Health. You had mentioned you had not hired a director or
    anyone in that office.
        Dr. Kussman. I have to go ask Matt about that. I think that
    they have, but I don't want to give you the wrong information.
    Let me get back to you on that, whether they have actually
    hired any specific--they have a lot of detailed work out to
    hire the people. I don't know if anybody has actually been
    brought on.
        As you know, there some challenges sometimes when we want
    to go hire somebody. It has got to go through all the process
    that can take months.
        Mr. Michaud. Again, it would be interesting to know, and
    particularly for the director of Rural Health, who that
    individual might be and what you are looking for in that
    individual. I would hate to have someone from Boston or Los
    Angeles or Chicago. But I would like to have somebody who
    really understands and has a mindset of problems that people
    are facing in rural areas.
        Dr. Kussman. Yes, sir. And there is a job description that
    is established. I would be happy to try to get it to you.
        [The job description for the Program Analysis Officer,
    Office of the Assistant Deputy Under Secretary for Policy and
    Planning, Veterans Health Administration, U.S. Department of
    Veterans Affairs, appears on p. 103.]
        Mr. Michaud. Great. Once again, I want to thank the panel
    for your testimony today and we look forward to continue
    working with the VA as we move forward in this upcoming
    Congress. Thank you very much.
        Dr. Kussman. Thank you, Mr. Chairman.
        The hearing is adjourned.
        [Whereupon, at 12:41 p.m., the Subcommittee was adjourned.]

                                A P P E N D I X

                                  ----------

            Prepared Statement of the Honorable Michael H. Michaud,
                        Chairman, Subcommittee on Health
        Today's legislative hearing will provide Members of Congress,
    veterans, the VA and other interested parties with the opportunity to
    discuss legislation within the Subcommittee's jurisdiction in a clear
    and orderly process.
        While I may not necessarily agree or disagree with the bills before
    us today, I do believe that this is an important process that will
    encourage frank discussions and new ideas.
        We have ten bills before us that seek to improve healthcare for the
    nation's veterans, and I look forward to hearing the views of our
    witnesses.
        I also look forward to working with everyone here to continue to
    improve the quality of care available to our veterans.
        There are two draft discussions that are not before us today. There
    is a discussion draft on homelessness, and a discussion draft on mental
    health services. Congressman Patrick Murphy of Pennsylvania has also
    introduced H.R. 2699. I ask that the members of the third panel, the
    VSOs, and the fourth panel, VA, provide comments and views on these
    three items for the record once they are made available. We would like
    your written comments submitted to the Committee by June 21st, 2007.

      Prepared Statement of the Honorable Jeff Miller, Ranking Republican
                         Member, Subcommittee on Health
        Thank you, Mr. Chairman.
        I appreciate your holding this legislative hearing and welcome the
    opportunity to discuss the ten different legislative proposals before
    us today. I would like to offer brief introductory remarks, and note
    that I have introduced two of the bills and will expand on these bills,
    H.R. 1925 and H.R. 2623, at the appropriate time.
        As we evaluate this legislation, it is important to consider that
    the demand for veterans' healthcare is increasing and will continue to
    grow. While there may be some areas that will see a decrease in the
    veteran population, other areas, including my own Florida district, are
    experiencing a large increase in the veteran population. In fact, in
    the past 10 years, the number of veterans living in FL CD 1 has grown
    more than 30% and is among the top 10 districts in the United States
    for growth of veterans since 2000.
        I'd like to thank my colleagues, Dr. Kussman and all of the veteran
    service organization representatives for their commitment to join us
    today to discuss these very pertinent issues affecting our Nation's
    veterans.
        Thank you, Mr. Chairman, I yield back.

         Prepared Statement of the Honorable Stephanie Herseth Sandlin,
          a Representative in Congress from the State of South Dakota
        Chairman Michaud and Ranking Member Miller, thank you for allowing
    me to be here to discuss the Services to Prevent Homelessness Act, a
    bill which I introduced on May 17, 2007, to provide supportive services
    for very low-income veterans.
        The U.S. Census Bureau estimates that 1.5 million of our nation's
    veterans live in poverty, including 702,000 veterans with disabilities
    and 404,000 veterans in-households with children. 634,000 of the 1.5
    million poor veterans live in extreme poverty. These poor veterans face
    residential insecurity due to their low-income levels or their past
    episodes of homelessness. They also face health and vocational
    challenges and access barriers to supportive services, which limit
    their ability to sustain housing and maintain independence from more-
    costly public institutional care and support. These poor veterans may
    benefit from flexible and individualized support services provided in
    home-based settings.
        The Services to Prevent Veterans Homelessness Act would authorize
    the Secretary of Veterans Affairs to provide financial assistance to
    nonprofit organizations and consumer cooperatives to provide and
    coordinate the provision of supportive services that addresses the
    needs of very low-income veterans occupying permanent housing. The
    financial assistance shall consist of per diem payments for each
    household provided supportive services.
        Supportive services that may be offered include physical and mental
    health, case management, daily living, personal financial planning,
    transportation, vocational counseling, employment and training,
    education, assistance in obtaining veterans benefits and public
    benefits, child care, and housing counseling.
        Veteran subpopulations expected to benefit from the program include
    veterans transitioning from homelessness to permanent housing, poor
    disabled and older veterans requesting supportive services in home-
    based settings, and poor veterans in rural areas with distance barriers
    to centrally located services.
        While federal programs exist to help create veterans homeownership,
    there is no national housing assistance program targeted to low-income
    veterans. Permanent housing opportunities for veterans ready for
    independent living are limited. In addition, the VA currently is not
    permitted to provide grants to create affordable permanent housing, and
    the resources that are available for providers are inadequate and
    highly sought after by competing housing projects.
        Thank you again for allowing me to be here. I look forward to
    continuing to work with the Chairman and Ranking Member to support
    efforts to meet the housing assistance needs of our Nation's low-income
    veterans through the establishment of a permanent housing assistance
    program for low income veterans.
        I would be happy to answer any questions you may have.

       Statement of the Honorable Ciro D. Rodriguez, a Representative in
                        Congress from the State of Texas
        Chairman Michaud, Ranking Member Miller, and distinguished Members
    of the Subcommittee. Thank you for the opportunity to speak before you
    in support for an issue near and dear to my heart. H.R. 2173, a bill I
    introduced with my friend and colleague Congresswoman Napolitano,
    provides for the increase in capacity for mental health services
    through contracts with qualified community mental health centers.
        Recent surveys show that one in eight returning Iraqi war veterans
    report symptoms of post traumatic stress disorder (PTSD). The same
    studies also report high incidence of major depression and anxiety
    disorders among returning members of Army and Marine combat units. As a
    Member of this Committee, we have long identified mental health
    services as a major issue facing returning soldiers as well as at the
    Veterans Administration (VA).
        Experts note that the manifestation of clinical symptoms of PTSD
    and other mental health disorders often occurs over several years. With
    the increase of active duty, guardsmen and reservists returning from
    combat, the necessary capacity to provide mental health services is
    relatively unknown. It is difficult to know if our large number of
    returning veterans will need mental health services beyond what the VA
    is capable of providing.
        My bill, H.R. 2173, authorizes the VA to contract with community
    mental health centers to increase their capacity. In my opinion the
    need has outpaced the capacity for the VA to provide mental health
    services in outpatient clinics. Contracting out to community mental
    health centers is already been done successfully in some states and
    could serve as a model for VA-wide implementation.
        Mr. Chairman, in my previous career, I worked in the mental health
    field as a social worker. I am fully aware of the great service
    provided by community mental health centers. If there is any doubt of
    the quality of care they provide, I can tell you of the hundreds of
    families whose lives have been changes by the treatments received
    during my professional career in the field. But don't take my word for
    it. Each year, community health centers give nearly 6 million children,
    adults, and families in communities across the country the chance to
    recover and lead productive lives. Our returning soldiers deserve the
    same opportunity.
        As I mentioned before, it is clear that our soldiers are returning
    with an increased need for mental health services, but after this long
    war, it is unclear what the VA's capacity to fulfill this need will be.
    It is my hope that H.R. 2173 can provide the VA with the tools to
    continue to provide top notch mental health services to veterans in
    their own communities.
        Mr. Chairman, I would like to again thank you and the Members of
    this Subcommittee for the opportunity to speak on this bill. I urge the
    Members to support this important legislation. Thank you and I would
    gladly answer any questions you may have.

                   Statement of the Honorable James P. Moran,
            a Representative in Congress from the State of Virginia
        Mr. Chairman, members of this Subcommittee, I want to thank you for
    holding this important hearing today and commend the Subcommittee for
    the work that it has already undertaken on behalf of our Nation's
    veterans.
        The problem of suicide among our veterans is one of the most
    serious issues that we have to address as we care for our older
    veterans and prepare for a new generation of returning soldiers.
        The Centers for Disease Control recently released a troubling
    statistic: Each year, approximately 115,000 veterans attempt suicide.
    This accounts for nearly 20% of all suicide attempts, yet, the veteran
    population only accounts for 11% of the entire population.
        The disproportionate prevalence of suicide among veterans suggests
    that, in addition to our overall national strategy on suicide
    prevention, particular attention must be paid to preventing suicide
    among this special population.
        Unfortunately, I expect this trend to continue as more of our brave
    men and women return from multiple deployments with the symptoms of
    post-traumatic stress disorder, or PTSD. As we have learned, a
    staggering 20% of soldiers returning from Iraq are experiencing
    depression, sleep deprivation, anxiety and other symptoms of PTSD.
        I am proud that this Congress has already acknowledged the growing
    problem of PTSD and dedicated substantial resources to it. Still, I
    believe, as scientific evidence suggests, that as our returning
    soldiers are increasingly susceptible to PTSD, they are at an elevated
    risk for suicide attempts.
        My bill, the ``Veterans Suicide Prevention Hotline Act of 2007'',
    would create a 24-hour national toll-free hotline to assist our
    Nation's veterans in crisis. It would be staffed predominantly by
    veterans, trained to appropriately and responsibly answer calls from
    other veterans. This hotline would follow the models of the National
    Suicide, Sexual Assault and Domestic Violence hotlines, where
    volunteers trained in active listening and crisis de-escalation respond
    to a variety of crisis calls.
        I believe that this cultural competency--the ability to connect to
    another veteran who understands best what the caller may be
    experiencing--can make a real difference in crisis counseling. It is
    difficult to connect on this level with anyone else, even trained
    doctors or other professionals.
        To build this capacity nationwide, my bill calls for a 3-year,
    competitively awarded grant for $2.5 million in the next three fiscal
    years. The funding will be made available to a qualified non-profit
    crisis center to establish, publicize, and operate the hotline,
    including developing curricula to train and certify volunteers.
        We have reached out the Department of Veterans' Affairs and are
    encouraged that the VHA is undertaking new efforts to establish a
    suicide hotline and address mental health needs. Their plan is to
    divert callers from the National Suicide Prevention Hotline to a VA
    facility, staffed by doctors, psychologists and other certified
    counseling professionals.
        On the surface the VHA's effort may appear duplicative of my
    proposal, but there are some very important differences that I feel
    need to be highlighted.
        First, my legislation requires that the people answering the
    phones, those dealing directly with the veterans, are veterans
    themselves. There are times when speaking with someone who has the
    cultural competence and empathy to really understand the experiences of
    veterans in crisis can help make the difference between successful
    integration into mental health treatment and failure to reach a veteran
    in dire need of services.
        Second, The VHA has many responsibilities for providing the highest
    quality of healthcare for our veterans. However, they have experienced
    stretched budgets and staffing shortages in recent years. Because the
    demands placed on any veterans' hotline may be great as our Nation
    redeploys from Iraq in the future, I have concern that the VHA may not
    have the capability and commitment to the hotline that a non-profit
    organization dedicated to suicide prevention as its sole purpose might
    be able to provide.
        Third, there are times when a person in crisis doesn't want to talk
    to a doctor--they want to talk to a volunteer. Mentally ill individuals
    all face societal stigma associated with seeking care. Research from
    the Air Force's suicide prevention efforts suggests that this is
    perceived to be even more profound in the military and veteran
    communities. Fear of ``the system'', of an unfriendly mental health
    establishment, and of potential job-related consequences keep many from
    seeking care.
        One of the motivations behind the National Suicide hotline and this
    bill is to give people in crisis another option--an anonymous hotline
    that can respond to their immediate crisis.
        To conclude, our vets deserve as much support when they return from
    combat as they receive while in battle. Too many of our veterans are
    struggling to make the difficult adjustment back to society and need
    someone they can talk to, someone who's walked a mile in their shoes.
        This legislation will offer a caring voice at the end of the line
    when it feels like there's no where else to turn.

                  Statement of the Honorable Diane E. Watson,
           a Representative in Congress from the State of California
        Thank you Mr. Chairman for holding today's hearing, and letting me
    speak about my bill, H.R. 1853--The Jose Medina Veterans Affairs Police
    Training Act. I believe this legislation is vital to protect our heroes
    who have sacrificed their minds and bodies to protect our freedoms.
        Mr. Chairman, too many veterans are suffering from mental health
    problems after returning from combat, and they are not receiving the
    proper treatment they deserve. Congress has a responsibility to provide
    quality healthcare for our veterans. We must analyze every aspect of
    services associated with the treatment of Post Traumatic Stress
    Disorder, or PTSD, for our vets.
        I have introduced H.R. 1853--The Jose Medina Veterans Affairs
    Police Training Act, a bill that would force the Department of Veterans
    Affairs to better prepare its police force to interact with patients
    and visitors at VA medical facilities who suffer from mental illnesses.
        Jose Medina is a constituent of mine. He is a Vietnam veteran who
    suffers from PTSD. In January 2006, Mr. Medina was assaulted by two
    West Los Angeles VA police officers who kicked him and forced him to
    the ground after he isolated himself and fell asleep in a hallway at a
    VA Medical Center in Los Angeles.
        After a physical altercation ensued, this fifty-six year old
    veteran was forced to lay face down on a hospital floor. The officers
    injured Mr. Medina, and after the altercation they did not allow him to
    use the hospital's emergency room. Instead, the officers handcuffed him
    and detained him for an hour, before sending him home with a loitering
    ticket. This is not the way we should be treating veterans who have
    served and protected this country.
        What bothers me the most is that when you see someone sitting on a
    hospital floor, one would think law enforcement and hospital staff
    would ask the individual if they were all right, or in need of
    assistance. Instead, in this case, Mr. Medina was mistreated. This is
    happening to too many of our brave veterans.
        As we look to the future, thousands of veterans will be entering
    the VA healthcare system. We must ensure that the VA has the ability to
    administer quality healthcare services to veterans that suffer from
    mental illnesses. With over 20% of the one and a half million veterans
    that served in Iraq or Afghanistan showing signs of PTSD, we do not
    want any of them to endure what Mr. Medina had to endure.
        Mr. Chairman, the Veterans Administration believes this legislation
    is unnecessary, but the story of Jose Medina and other veterans from
    around the country who have contacted my office with similar problems
    has proven to me that this training is indeed necessary. As Congress
    debates funding strategies and timelines for our military missions, we
    must not forget that not only do we need our vets to have the resources
    for the battlefield; they must also be treated with dignity and respect
    once they resume their lives after combat. We must ensure that this
    happens!
        Mr. Chairman, I thank you for the opportunity to address your
    committee, and I urge the members of the committee to support H.R.
    1853.

                  Statement of the Honorable John T. Salazar,
            a Representative in Congress from the State of Colorado
        Thank you Mr. Chairman.
        Mr. Chairman, I'm pleased to bring H.R. 2005 to the Subcommittee
    this morning, and I look forward to the discussion on this important
    legislation.
        The Rural Veterans Healthcare Improvement Act seeks to improve
    healthcare services to veterans living in rural areas.
        A study of more than 767,000 veterans by researchers working for
    the Department of Veterans Affairs shows vets in rural areas are in
    poorer health than vets living closer to cities.
        The VA found that the health of rural veterans still persisted,
    even after researchers adjusted for socioeconomic factors such as race,
    education or employment status.
        It was identified in the study, that access to care is a key
    factor.
        The study suggested, that in addition to establishing more clinics
    in rural areas, VA should consider coordinating services with Medicare
    or other healthcare services based in rural areas.
        As a way to begin addressing some of these issues, the Veterans
    Benefits, Health Care, and Information Technology Act of 2006, which
    passed at the end of the 109th Congress, created the Office of Rural
    Health within the VA.
        Dr. Kussman's testimony will tell you that the VA is opposed to
    this legislation because the Office of Rural Health is charged with
    these tasks. . . .
        I would like to make the point that even though Congress directed
    VA to establish this office, it has yet to be implemented.
        This new office, when the VA does decide to set it up, needs
    support, direction, and resources in order to fulfill its mission of
    coordinating care to this vital constituency.
        The Rural Veterans Healthcare Improvement Act of 2007 would task
    the Director of the Office of Rural Health with developing:

          demonstration projects
          centers of excellence
          a transportation grant program

        and the bill would also more fairly reimburse veterans in rural
    areas for the traveling expenses they incur when driving long distances
    to VA medical facilities.
        Mr. Chairman . . . with both an ailing veteran population to care
    for, and a new generation of veterans returning from service in Iraq
    and Afghanistan, we immediately need to address access to care issues
    for our rural vets.
        It is estimated, that nearly 45% of all new recruits are coming
    from Rural America, and with a large percentage of this war burdened by
    our national Guard, that number is only going to increase.
        Many vets must travel hundreds of miles to access the medical care
    we've promised and they do so almost entirely at their own expense.
        Currently, we reimburse veterans at a rate of $0.11 cents per mile,
    a rate that has not increased since 1978.
        In 1978 . . . the average price of gasoline was $0.63 cents. I
    don't have to remind the Committee of the price of gasoline today.
        This legislation would increase the reimbursement rate to $0.48
    cents per mile, the same rate paid to federal employees.
        This legislation also establishes a transportation grant program
    called VetsRide.
        VetsRide encourages Veterans Service Organizations to develop
    innovative transportation options to vets in rural areas.
        With a grant up to $50,000, a VSO could purchase a van, or find
    other ways to assists veterans with travel to VA medical centers.
        This bill also establishes Centers of Excellence to research ways
    to improve care for rural veterans. These centers would be based at VA
    Medical Centers with strong academic connections.
        The outcome of these Centers would be the development of specific
    models to be used by VA in providing health services to vets in rural
    areas.
        The Rural Veterans Healthcare Improvement Act also tasks the Office
    of Rural Health with following their studies own advice.
        It develops demonstration projects that would examine the
    feasibility of expanding care in rural areas through partnerships.
        Partnerships between the VA; Centers for Medicare and Medicaid
    Services; and the Department of Health and Human Services through
    critical access hospitals and community health centers.
        Demonstration projects would also be carried out in partnership
    with the Indian Health Service to improve healthcare for Native
    American veterans.
        In 2003, the VA entered into a Memorandum of Understanding with
    these departments to encourage partnerships just like these, however 4
    years have passed without accomplishment and our vets have suffered.
        Mr. Chairman . . . We must explore every option, to ensure that the
    healthcare services we promised to our veterans are delivered.
        The Rural Veterans Healthcare Improvement Act of 2007 aims to
    improve one of the greatest problems that plague the VA system.
        I am proud of the bipartisan work that has gone into this bill and
    the forty cosponsors that share these goals.
        Thank you Mr. Chairman. I'm happy to answer any questions the
    Committee might have.

                    Statement of the Honorable Jeff Miller,
             a Representative in Congress from the State of Florida
        Mr. Chairman, thank you for considering H.R. 2623. This bill would
    prohibit the collection of co-payments for all hospice care furnished
    by the Department of Veterans Affairs (VA).
        VA offers a complement of hospice and palliative care options as
    part of the comprehensive heath care benefit provided to all enrolled
    veterans. Hospice and palliative care is a continuum of comfort-
    oriented and supportive services provided across settings, including
    hospital, extended care facility, outpatient clinic and private
    residence.
        Under current law, a veteran receiving hospice care in a nursing
    home is exempt from any applicable copayments. However, if the hospice
    care is provided in any another setting, such as in an acute-care
    hospital or at home, the veteran may be subject to an inpatient or
    outpatient primary care copayment.
        Essentially, VA's current policy penalizes a veteran who chooses to
    remain at home for their hospice care or out of medical necessity
    receives hospice care in an acute care setting.
        Mr. Chairman, this legislation would correct this inequity by
    exempting all hospice care provided through VA from copayment
    requirements.
        This bill is important to ensuring that every veteran's preference
    for end-of-life care is provided in an equitable and compassionate
    manner.
        I appreciate the opportunity to testify on H.R. 2623, and will be
    happy to answer any questions on the bill.

                                   H.R. 1925

        Thank you, Mr. Chairman.
        Nearly 12 year ago, the VA's Veterans Integrated Service Network,
    or ``VISN,'' plan was set in motion as a way to make the large VA
    healthcare network more attuned to the needs of its patients. For
    certain, VA provides some of the best care in this nation. The VISNs
    were implemented as a way to maintain the high quality of care while
    allowing more regional management so that the central office in
    Washington did not unnecessarily micromanage the day-to-day aspects of
    healthcare delivery.
        The VISN network has enjoyed its successes in providing better
    access and more patient-centered care. However, there is room for
    improvement, and the Gulf Coast region of our nation is an area where
    such improvement is needed. Having already seen a consolidation of two
    VISNs since their creation, it is clear that flexibility within the VA
    healthcare system is necessary. My bill, H.R. 1925, would create a VISN
    specifically targeted to improving the delivery of healthcare to the
    large and ever-increasing population of veterans living in the Gulf
    Coast--a ``Gulf Coast VISN.''
        A new Gulf Coast VISN would create a healthcare network that could
    better respond to the unique needs and problems facing veterans in the
    area. The area involved covers the coastal counties just west of
    Tallahassee, Florida over to the Louisiana state line, an area home to
    few VA clinics and lacking hospitals providing inpatient care. It is an
    area identified by the CARES report as underserved, and its unique
    geographical location is no doubt part of that reason. Most of the area
    that would make up the Gulf Coast VISA is in the region where VISN
    eight meets VISN 16. VISN eight encompasses the rest of the state of
    Florida. VISN 16, the largest single VISN in the country, reaches all
    the way west past Houston, Texas, and all the way up through Oklahoma.
        Looking at the map, you can see how this largely rural region can
    get overlooked in such a huge VISN with major metropolitan areas. The
    more than 300,000 veterans that would be directly served within this
    VISN do not want their access to care overlooked--and that has happened
    for far too long. With even basic outpatient care being difficult for
    many to obtain, it is time to ensure that the Gulf Coast's veterans are
    provided the full range of services they have earned.
        There are several reasons why I see this bill as being successful.
    With an increased focus on the unique, shared needs for veterans in the
    area, the Gulf Coast VISN director could take great advantage of the
    sharing opportunities with the Department of Defense (DoD) that are
    available in that region. The Gulf Coast is home to multiple DoD
    installations, and while a few joint VA/DoD facilities exist now, there
    is a tremendous opportunity for expanding this relationships to deliver
    a wider range of healthcare services.
        The VISN system was founded on good principles to improve access
    and quality of care by eliminating the inefficiencies of a centralized
    bureaucracy and promoting a local, patient-focused system of healthcare
    delivery. However, it is not perfect, and with the findings of the
    CARES Commission as well as the simple fact that veterans in the Gulf
    Coast area have to drive upward of three hours in many instances to
    receive inpatient care, it is abundantly clear that improvements are
    still needed. I feel the creation of a Gulf Coast VISN can do just
    that. Its implementation would be neither costly nor particularly
    difficult. In addition, the bill would give VA the authority to decide
    on the location of the VISN headquarters.
        The GulfCoast's veteran population clearly deserves more timely
    access to VA healthcare. Creating a Gulf Coast VISN would be a
    significant step toward providing that access.
        Thank you, Mr. Chairman, for considering this important legislation
    and I am pleased to answer any questions on the bill.
    [GRAPHIC] [TIFF OMITTED] 37465A.001

    [GRAPHIC] [TIFF OMITTED] 37465A.002

                   Statement of the Honorable Paul W. Hodes,
          a Representative in Congress from the State of New Hampshire
        Thank you Chairman Michaud and Ranking Member Miller for holding
    this important hearing today. I appreciate the opportunity to testify
    today about H.R. 2192, the bipartisan bill I introduced establishing an
    Office of the Ombudsman in the Department of Veterans' Affairs. I would
    also like to thank Chairman Filner for his support of the bill.
        I recently visited Walter Reed Army Medical Center with the
    Oversight and Government Reform Committee. I talked with soldier after
    soldier about the problems they experienced transitioning out of active
    duty and into the VA. Veterans in my district have repeatedly told me
    their compelling stories of the great difficulties and challenges they
    have faced in understanding and receiving all the benefits and services
    to which they are entitled.
        The Ombudsman's Office should serve as the outreach master office--
    a coordinating and coordinated center for benefits and health
    information services available both within and outside of the VA.
        I am not interested in creating another meaningless layer of
    bureaucracy. Instead, I would like the Ombudsman's Office to become a
    one stop shop for veterans, a CENTCOM for veterans' benefits
    information.
        I applaud the VA for their hard work in providing information that
    veterans need. The VA has numerous hotlines and support services
    available to veterans. I've counted 10 different 1-800 numbers on the
    VA's website to help with different types of benefits--one for
    disability pension, another for healthcare benefits, another for life
    insurance, etc.
        While the VA provides veterans benefits and service information,
    the veterans may not know where they put their informational pamphlets
    6 months or 1 year down the road when they have a question or a
    problem.
        Veterans are falling through the cracks and do not know where to
    turn.
        The Office of the Ombudsman would provide a focal point of
    information within the VA. The Ombudsman's Office should be a one stop
    shop of information and resources. The Office should head up the
    advocacy and information campaigns that the VA already has in place,
    and consolidate the information services with one 1-800 number to
    address all the veterans' needs and complaints.
        For a veteran who has just returned from active duty in OIF
    (Operation Iraqi Freedom) or OEF (Operation for Enduring Freedom) with
    Traumatic Brain Injury, it would be a whole lot simpler and easier to
    have only one office to call to receive the information he or she
    needs. The VA has a patient advocacy program for healthcare, but a lot
    brave men and women need help with loans for their homes and schooling
    too. They should not have to run around asking the same ten questions
    to ten different offices. The Ombudsman's Office can help the veteran
    figure out the all the services in the benefits system, not just
    healthcare, and not just disability ratings.
        I have reviewed the testimony of the esteemed panelists, the VA and
    VSOs. Just in the six testimonies that specifically discussed the
    Ombudsman's Office, the panelists referred to fourteen different
    programs both within and outside of the VA that veterans could turn to
    for help with benefits coordination. These fourteen programs are
    extremely important to our veterans and providing specialized services.
    But, as a healthy Member of Congress and not a PTSD patient or an
    ailing elderly veteran, I am even confused about which programs to use
    and under which circumstances.
        Mr. Chairman, I am not trying to make redundant services. The
    Veterans Administration provides advocacy and resources, VSOs provide
    advocacy and resources.
        I would, however, like to work with the Honorable Members of the
    Committee to mold the Office of the Ombudsman into a viable, helpful
    resource for veterans. I believe that this consolidation of various
    information sources into a coordinated center of information will help
    make sure the veterans receive the care they need and cut through the
    seemingly endless amounts of bureaucratic red tape.
        Thank you again for giving me the opportunity to testify before the
    Subcommittee on Health today. I look forward to working with the
    Committee to help veterans understand and access the benefits they
    deserve.

                   Statement of the Honorable Nita M. Lowey,
            a Representative in Congress from the State of New York
        I want to thank the Committee for holding this hearing today and
    for considering the VA Hospital Quality Report Card Act of 2007. I
    introduced this legislation in an effort to provide increased
    disclosure and accountability in the VA hospital system, and ultimately
    increase the quality of care for the men and women who have served in
    the Armed Forces.
        The treatment provided to our veterans is not a partisan or
    political issue, and I am pleased that this legislation is cosponsored
    by some of my Republican colleagues.
        I believe we can all agree that quality care initiatives and public
    disclosure should not end when an individual leaves active military
    service. In fact, the quality of care for those who have bravely served
    our Nation should be of the highest standard possible.
        To achieve that goal we must have a clear picture of the quality of
    care provided by the Veterans Administration, and this information must
    be continually assessed and updated. As we learned with Walter Reed
    Army Medical Center, a facility that once defined excellence may not do
    so in the future without constant internal assessments.
        My legislation would require the Department of Veterans Affairs to
    establish a formal Hospital Report Card Initiative and publish reports
    on individual hospitals' level and quality of care. The resulting
    report cards would: provide clear outcomes data to be used for peer
    review and quality improvement; galvanize hospitals to make changes by
    creating public accountability; and provide our veterans with the
    information they need to make sound healthcare decisions. Several
    states, including Pennsylvania, New York, California, Florida and
    Illinois, have already implemented Hospital Report Card Initiatives.
        A March 2007 Veterans Administration report exposed major
    deficiencies in the physical conditions in many veterans' facilities.
        In this report, the VA Hudson Valley Health Care System, which
    serves over 25,000 veterans throughout my district and the surrounding
    areas, was cited for ceiling mold, suicide hazards in the psychiatric
    ward and cosmetic deficiencies. I'm going to repeat one part of that
    because I think it underscores the level of neglect seen throughout the
    VA healthcare system--suicide hazards in a psychiatric ward, an area in
    hospitals that most certainly should limit the ability of an individual
    to harm him or her self.
        Dr. Michael Kussman, Under Secretary for Health at the VA,
    previously stated, ``VA facilities are inspected more frequently than
    any other healthcare facilities in the nation.'' If this is true, the
    Department should have no problem complying with the requirements of
    this legislation.
        If we are serious about ensuring a seamless transition between DOD-
    provided healthcare and VA-provided healthcare, we must have an
    accurate assessment of the VA system, and the VA Hospital Quality
    Report Card Act of 2007 would provide just that.
        I thank the Members of the Subcommittee once again for this hearing
    and I look forward to working with each of you to provide our veterans
    with the level of healthcare worthy of their service and dedication to
    our country.

          Statement of Shannon Middleton, Deputy Director for Health,
        Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Subcommittee:

        Thank you for this opportunity to present The American Legion's
    view on the several pieces of legislation being considered by the
    Subcommittee today. The American Legion commends the Subcommittee for
    holding a hearing to discuss these very important and timely issues.
        H.R. 1448, VA Hospital Quality Report Card Act of 2007, seeks to
    establish the Hospital Quality Report Card to ensure quality measures
    data on the Department of Veterans Affairs (VA) hospitals are readily
    available and accessible.
        The state of VA healthcare/medical facilities are an important
    issue for The American Legion. Each year the organization is mandated
    by resolution to conduct a series of site visits to various VA medical
    facilities and submit a report to the President, Congress and VA.
        The bill is similar in scope to our report--A System Worth Saving.
    Periodic assessments would enable VA to get a clearer picture of its
    system-wide needs and assist lawmakers in determining adequate funding
    for the VA healthcare system.
        H.R. 1853, Jose Medina Veterans Affairs Police Training Act of
    2007, seeks to ensure that VA police officers receive training on
    interacting with visitors and patients suffering from mental illness at
    VA medical facilities. The American Legion has no official position on
    this issue, but hopes that VA is training all of its employees to
    interact with veterans and their families in the dignified, respectable
    manner in which they deserve.
        H.R. 1925, A Bill to Direct the Secretary of Veterans Affairs to
    Establish a Seprate Veterans Intergrated Service Network (VISN) for the
    Gulf Coast Region of the United States, would mandate that the
    Secretary create a VISN that would encompass several counties in the
    states of Florida, Alabama and Mississippi. The American Legion has no
    position on this issue.
        H.R. 2005, Rural Veterans Health Care Improvement Act of 2007,
    addresses many issues affecting veterans who reside in rural areas. It
    seeks to increase the beneficiary travel rate to make it equivalent to
    the rate provided to federal employees; establish centers for rural
    health research, education, and clinical activities; offer
    transportation grants for service organizations that assist rural
    veterans; and explore alternatives to improve transportation to medical
    facilities for rural veterans. The American Legion fully supports the
    provisions in this bill.
        Beneficiary travel pay has not been increased from its current rate
    since 1978. The price of gasoline has steadily increased since the
    $0.11 per mile rate was established, creating a financial hardship for
    veterans who have to travel long distances for care, or those who have
    limited financial resources.
        Since service-connected veterans and other veterans authorized
    beneficiary travel only receive $0.11 per mile are subjected to a $6
    per trip deductible not to exceed $18 per month--this amount does very
    little to defray the cost of travel. Eligible veterans are not
    reimbursed at a reasonable level for costs incurred to visit a VA
    medical facility for service-connected or other authorized care and
    treatment.
        There are no provisions in law that VA must increase the per mile
    travel authorization on a regular basis. The beneficiary travel program
    is discretionary and the Secretary of Veterans Affairs is required to
    review the program annually to determine the Department's ability to
    maintain the program and its ability to increase the reimbursement rate
    for eligible veterans. The Secretary has determined that it is
    necessary to maintain the current reimbursement rate in order to allow
    the VA healthcare system to accommodate the increasing patient
    workload.
        The lack of a consistent and reliable mechanism to periodically
    adjust the rate authorized for beneficiary travel creates an injustice
    and an unfair economic burden for many veterans. The American Legion
    believes that mandatory funding for VA healthcare would allow the
    Secretary to provide adequate healthcare without inversely affecting
    programs designed to mitigate the cost of accessing that care.
        Establishing centers for rural health research, education, and
    clinical activities would afford VA the opportunity to build strategies
    to improve its system of care for rural veterans, as well as educate
    and train healthcare professionals on health issues prevalent in
    specific rural veteran populations.
        Offering transportation grants for veterans' service organizations
    that assist rural veterans and exploring alternatives to improve
    transportation to medical facilities for rural veterans would make
    accessing care easier for those who are not financially able to travel
    to facilities, especially those who, due to their physical condition,
    are not able to make extremely long trips in 1 day. If more
    transportation options became available, it may also improve
    coordination of care for those who have to travel distances for special
    services, especially in the unavailability of a family care giver.
        H.R. 2172, Amputee Veteran Assistance Act, would require that VA's
    orthotic-prosthetic laboratories, clinics, and prosthetists are
    certified by either the American Board for Certification in Orthotics
    and Prosthetics or the Board of Orthotics and Prosthetic Certification.
    It is The American Legion's understanding that VA's ortho-prosthetic
    labs/clinics are accredited and each has at least one orthotist that
    has certification which is how the labs were able to gain
    accreditation. The orthotists and prosthetists are being trained on
    latest prosthesis at Walter Reed, so they can be knowledgeable about
    the prosthetics being given to returning soldiers. They also
    participate in focus groups with veterans' service organizations, and
    OIF veterans. Furthermore, VA already contracts with non-Department
    entities when the medical facility is not capable of providing the
    service or the veteran lives too far away and patients are given
    information about their prosthetic choices.
        H.R. 2173, Seeks to Amend Title 38, United States Code, to
    Authorize Additional Funding for the Department of Veterans Affairs to
    Increase Capacity for Provision of Mental Health Services Through
    Contracts with Community Mental Health Centers, and for Other purposes.
    The American Legion believes that VA should contract with community
    providers only when it is unable to provide needed services to the
    veteran, if travel for the veteran would be a danger to his or her
    health, or if the veteran resides in a rural area. As long as VA
    healthcare remains discretionary, VA will always struggle to obtain
    sufficient funding to provide access to quality care for eligible
    veterans seeking care in VA facilities. Assured (mandated) funding
    would provide a method to provide dependable, stable and sustained
    funding for veterans' healthcare. The American Legion believes that
    Congress should designate assured funding for VA medical care; continue
    to provide discretionary funding, as required, to fully operate other
    programs within the Veterans Health Administration's budgetary
    jurisdiction; and provide, if necessary, supplemental appropriations
    for budgetary shortfalls in VHA's mandated and discretionary
    appropriations to meet the healthcare needs of America's veterans.
        H.R. 2192, A Bill to amend Title 38 USC, to establish an Ombudsman
    within the Department of Veterans Affairs, would designate an Ombudsman
    to serve as a liaison for veterans and their families to guarantee the
    receipt of VA healthcare and benefits. The American Legion supports the
    provisions of this bill. Establishing a point of contact to work with
    families to ensure that veterans receive all benefits, to which he or
    she is entitled, based on his or her unique situation, would reduce the
    stress and frustration associated with navigating the complex VA
    healthcare and benefits system.
        H.R. 2219, Veterans Suicide Prevention Hotline Act of 2007. The
    American Legion has no position on this issue.
        H.R. 2378, Services to Prevent Veterans Homelessness Act. This bill
    aims to establish a financial assistance program to facilitate
    supportive services for very-low income veteran families to assist them
    in ending their chronic homeless state and to prevent chronic
    homelessness.
        Enactment of this legislation will enable funding to provide much
    needed supportive services to veterans and their dependents. It takes
    into account that the VA Grant and Per Diem (GPD) program can only
    provide services to veterans and fills a much-needed gap of caring for
    their dependents..
        The American Legion fully supports this bill in its effort to
    assist homeless veterans. We applaud that the bill recognizes that
    families also suffer alongside the veteran struggling with
    homelessness.
        The American Legion supports the efforts of public and private
    sector agencies and organizations with the resources necessary to aid
    homeless veterans and their families. The American Legion supports
    proposals that will provide medical, rehabilitative and employment
    assistance to homeless veterans and their families.
        Currently, the VA has no authority to provide grant funding to
    create affordable permanent housing units for low-income veterans and
    those who have completed their transition programs. Veteran service
    providers must compete with other housing projects for limited HUD
    funding, and constantly search for additional funding sources to
    provide this housing option.
        This legislation will be in addition to the VA Grant and Per Diem
    program, but will enable the mechanism of funding supportive services
    to become more streamlined.
        Homeless veteran programs should be granted full appropriations to
    provide supportive services such as, but not limited to outreach,
    healthcare, habilitation and rehabilitation, case management, daily
    living, personal financial planning, transportation, vocational
    counseling, employment and training, and education.
        Veterans need a coordinated effort that provides secure housing and
    nutritious meals; essential physical healthcare, substance abuse
    aftercare and mental health counseling; as well as personal development
    and empowerment.
        Veterans also need job assessment, training and placement
    assistance. The American Legion believes all programs to assist
    homeless veterans must focus on helping veterans reach their highest
    level of self-management.
        The most effective programs for homeless and at-risk veterans are
    community-based, nonprofit, veteran-staffed groups. It is critical that
    community groups continue to reach out and help to provide the support,
    resources and opportunities most Americans take for granted.
        Homelessness impacts every community in the nation. Approximately
    200 community-based veterans' service organizations across the country
    have successfully reached homeless veterans through specialized
    programs. Veterans who participate in these programs have a higher
    chance of becoming productive citizens again.
        A full continuum of care--housing, employment training and
    placement, healthcare, substance abuse treatment, legal aid, and
    follow-up case management--depends on many organizations working
    together to provide services and adequate funding. The availability of
    homeless veteran services, and continued community and government
    support for them, depends on vigilant advocacy and public education
    efforts on the local, state and federal levels.
        The FY 2006 Department of Veterans Affairs Community Homelessness
    Assessment, Local Education and Networking Groups (CHALENG) report
    estimates that nearly 200,000 veterans are homeless at any point in
    time. Prior reports state that one out of every three homeless men
    sleeping in a doorway, alley or box in our cities and rural communities
    has put on a uniform and served this country. According to the February
    2007 Homeless Assessment Report to Congress (U.S. Department of Housing
    and Urban Development 2007) veterans account for 19% of all homeless
    people in America.
        For FY 2006, The VA Health Care for Homeless Veterans (HCHV)
    reports that 101,182 homeless veterans are enrolled in their programs.
    Community-based organizations are attempting to assist the overwhelming
    remainder of veterans who are homeless.
        In addition to the complex set of factors affecting all
    homelessness (the extreme shortage of affordable housing, livable
    income, and access to healthcare), a large number of displaced and at-
    risk veterans live with lingering effects of Post Traumatic Stress
    Disorder (PTSD), substance abuse, and a lack of family and social
    support networks. Many times these veterans have mental health
    disorders related to their honorable service to their country, are
    unable to compensate for their condition. They unfortunately
    deteriorate to unrecognizable individuals compared to their pre-
    military experience.
        Operation Iraq Freedom and Operation Enduring Freedom (OIF/OEF)
    veterans are at high risk of becoming homeless. Combat veterans of OIF/
    OEF and the Global War on Terror who need help--from mental health
    programs to housing, employment training and job placement assistance--
    are beginning to trickle into the nation's community-based homeless
    veterans' service organizations. Already stressed by an increasing need
    for assistance by post-Vietnam Era veterans and strained budgets,
    homeless services providers are deeply concerned about the inevitable
    rising tide of combat veterans who will soon be requesting their
    support.
        Since 9/11, nearly 800,000 American men and women have served or
    are serving in a war zone. Rotations of troops returning home from Iraq
    are now a common occurrence. Military analysts and government sources
    say the deployments and repatriation of combat veterans is unlike
    anything the nation has experienced since the end of the Vietnam War.
        The signs of an impending crisis are clearly seen in VA's own
    numbers. Under considerable pressure to stretch dollars, VA estimates
    it can provide assistance to about 100,000 homeless veterans each year,
    only 20% of the more than 500,000 who will need supportive services.
    Hundreds of community-based organizations nationwide struggle to
    provide assistance to as many of the other 80% as possible, but the
    need far exceeds available resources.
        VA's HCHV reports 1,049 OIF/OEF era homeless veterans with an
    average age of 33 years young. HCHV further reports that nearly 65% of
    these homeless veterans experienced combat. Now receiving combat
    veterans from Iraq and Afghanistan daily, the VA is reporting that a
    high percentage of those casualties need treatment for mental health
    problems. That is consistent with studies conducted by VA and other
    agencies that conclude anywhere from 15 to more than 35% of combat
    veterans will experience some clinical degree of PTSD, depression or
    other psychosocial problems.
        Homeless veteran service providers' clients have historically been
    almost exclusively male. That is changing as more women veterans and
    women veterans with young children have sought help. Additionally, the
    approximately 200,000 female Iraq veterans are isolated during and
    after deployment making it difficult to find gender-specific peer-based
    support. Access to gender-appropriate care for these veterans is
    essential.
        More women are engaging in combat roles in Iraq where there are no
    traditional frontlines. In the past 10 years, the number of homeless
    women veteran has tripled. In 2002,the VA began a study of women and
    PTSD. The study includes subjects whose PTSD resulted from stressors
    that were both military and non-military in nature. Preliminary
    research shows that women currently serving have much higher exposure
    to traumatic experiences, rape and assault prior to joining the
    military. Other reports show extremely high rates of sexual trauma
    while women are in the service (20-40%). Repeated exposure to traumatic
    stressors increases the likelihood of PTSD. Researchers also suspect
    that many women join the military, at least in part, to get away from
    abusive environments. Like the young veterans, these women may have no
    safe supportive environment to return to, adding yet more risk of
    homeless outcomes.
        ``Homeless providers continue to report increases in the number of
    homeless veterans with families (i.e., dependent children) being served
    at their programs. Ninety-four sites (68 percent of all sites) reported
    a total of 989 homeless veteran families seen with Los Angeles seeing
    the most families (156). This was a 10-percent increase over the
    previous year of 896 reported families. Homeless veterans with
    dependents present a challenge to VA homeless programs. Many VA housing
    programs are veteran-specific. VA homeless workers must often find
    other community housing resources to place the entire family--or the
    dependent children separately. Separating family members can create
    hardship.'' (FY 2006 VA CHALENG report)
        Homeless veteran service providers recognize that they will have to
    accommodate the needs of the changing homeless veteran population,
    including increasing numbers of women and veterans with dependents. In
    conclusion, The American Legion supports the provisions in H.R. 2378
    which will be helpful in addressing the issues of homeless veterans.
        H.R. 2623, Seeks to amend title 38, United States Code, to prohibit
    the collection of copayments for all hospice care furnished by the
    Department of Veterans Affairs. The American Legion is continuing to
    study the bill and will provide an addendum to this testimony to the
    Committee.
        Again, thank you Mr. Chairman for giving The American Legion this
    opportunity to present its views on such important issues. We look
    forward to working with the Subcommittee to address these and other
    issues affecting veterans.

                      Statement of Kimo S. Hollingsworth,
           National Legislative Director, American Veterans (AMVETS)
        Mr. Chairman and Members of the Subcommittee:
        I am pleased to offer testimony on behalf of American Veterans
    (AMVETS) regarding pending health legislation before this Subcommittee.
    AMVETS appreciates the Subcommittee's work to ensure the Department of
    Veterans Affairs can fulfill its obligation to provide healthcare and
    other health related services to veterans.
        Mr. Chairman, some of the issues relevant to today's hearing are
    extremely important to returning veterans from Operations Iraqi Freedom
    and Enduring Freedom. Specifically, suicide prevention, mental health
    funding, and access to healthcare in rural or underserved areas. These
    issues were identified and highlighted at the AMVETS sponsored
    ``National Symposium for the Needs of Young Veterans'' in Chicago,
    Illinois last year. More than 500 veterans, active duty and National
    Guard and reserve personnel, family members and others who care for
    veterans examined the growing needs of our returning veterans. With
    regards to today's legislative agenda, AMVETS would like to offer the
    following observations.
        H.R. 1448 would establish a Hospital Quality Report Card Initiative
    in order to report on healthcare quality in the Department of Veterans
    Affairs Hospitals. The Government Performance and Results Act, Public
    Law 103-62, requires that agencies develop measurable performance goals
    and report results against these goals. In the President's Fiscal Year
    2008 budget request, VA focuses on the Secretary of Veterans Affairs
    priority of providing timely and accessible healthcare that sets a
    national standard of excellence for the healthcare industry. VA
    generally tracks the timeliness of care in two broad areas--primary and
    specialty clinic appointments. Over the next year, the percent of
    appointments scheduled within 30 days of the desired date is expected
    to reach 96% for primary care appointments and 95% for specialty care
    appointments.
        In July 2005, the VA Office of Inspector General (OIG) reported
    that VHA's scheduling procedures needed to be improved and issued eight
    recommendations. As of September 2006, five of the eight
    recommendations for improvement remained open and AMVETS encourages the
    Department to implement the remaining recommendations. The Department
    has tracked and monitored the quality of care at VA facilities since
    the early seventies through comprehensive quality management (QM)
    programs. Furthermore, Public Laws 99-166 and 100-322 require the VA
    OIG to oversee VA QM programs at every level and a large part of the VA
    Office of Inspector General Combined Assessment Program (CAP) reviews
    focus on quality, safety and timeliness of VA healthcare. Mr. Chairman,
    AMVETS supports efforts to improve VA healthcare and supports the
    intent of H.R. 1448. However, we believe this legislation would mandate
    a duplicative effort as many of the items to be reported in a report
    card are already reviewed and reported through the VA QM and CAP
    programs.
        H.R. 1853 would direct the Secretary to ensure the Department of
    Veterans Affairs police officers receive training to interact with
    visitors and patients at medical facilities who are suffering from
    mental illness. VA police officers already receive some degree of
    training in interacting with individuals with potential mental
    illnesses and mandating this training will codify an existing practice.
    AMVETS supports the intent of the bill.
        H.R. 1925 would direct the Secretary of Veterans Affairs to
    establish a separate Veterans Integrated Service Network (VISN) for the
    Gulf Coast Region of the United States. Mr. Chairman, Public Law 104-
    204 directed VA to implement a more equitable resource allocation
    system that was to reflect, to the maximum extent possible, the
    Veterans Integrated Services Network developed by the Department to
    account for forecasts in expected workload and to ensure fairness to
    facilities that provide cost-efficient healthcare; and . . . ways to
    improve the allocation of resources so as to promote efficient use of
    resources and provisions of quality healthcare . . . Obviously the
    Veterans Equitable Resource Allocation (VERA) model is designed to
    bring consistency, fairness and stability to the VA funding process.
    This in turn is dependent upon the VISN model.
        The Capital Asset Realignment for Enhanced Services (CARES) was
    supposed to be a system-wide process to prepare the VA for meeting the
    current and future healthcare needs of veterans. CARES addressed the
    appropriate clinical role of small facilities, vacant space, the
    potential for enhanced use leases and the consolidation of services and
    campuses. To date, it is the most comprehensive analysis of VA's
    healthcare infrastructure conducted. The CARES made some very specific
    recommendations with regards to healthcare infrastructure, to include
    areas of the Florida Panhandle and the Gulf Coast.
        Overall, AMVETS supported the CARES process and we believe Congress
    should consider the CARES recommendations in deliberations about VA
    infrastructure to include deliberations about the current VISN model.
    AMVETS would like to note that VA adopted the VISN model in 1995.
    Considerable time has elapsed since implementation of the VISN model
    and there clearly have been demographic changes within the general
    population that would most likely include changes to the veteran
    population.
        H.R. 2005 would seek to improve healthcare for veterans living in
    rural areas, to include providing an increase in the travel
    reimbursement and establishing centers of excellence for rural health
    research, education and clinical activities. AMVETS continues to
    support an increase to the travel reimbursement rate for our veterans.
    The VA beneficiary travel program was intended by Congress to assist
    veterans when trying to access VA healthcare. The mileage reimbursement
    rate is currently fixed at 11 cents per mile; however, current law
    limits the actual reimbursement with a $3.00 per trip deductible capped
    at $18.00 per month. The Secretary of Veterans Affairs has the
    authority to make rate changes to these rates, but changes have not
    been adopted in more than 30 years. Obviously the price of owning and
    operating a vehicle has risen dramatically during this time period.
    AMVETS believes it is now time for Congress to act by mandating a
    realistic reimbursement rate for the VA beneficiary travel program.
        Regarding the delivery of rural healthcare, an important issue
    brought forth at the ``National Symposium for the Needs of Young
    Veterans'', Sections 212 and 213 of Public Law 109-461 are specifically
    targeted at advancing the healthcare needs of veterans in rural areas.
    VA is mandated to establish an Office of Rural Health within the
    Veterans Health Administration (VHA). The office is charged with
    improving VA healthcare for veterans living in rural and remote areas.
    Among other provisions, the law requires an extensive assessment of the
    existing VA fee-basis system of private healthcare, and eventual
    development of a VA plan to improve access and quality of care for
    enrolled veterans who live in rural areas. AMVETS would encourage
    Congress to fully fund the Office of Rural Health and allow VA to
    conduct the mandated assessment.
        H.R. 2172 would require VA orthotic-prosthetic laboratories,
    clinics and prosthesists to be certified by either the American Board
    for Certification in Orthotics and Prosthetics or the Board of
    Orthotics and Prosthetic Certification. Mr. Chairman, the VA already
    receives certification from these agencies and we support the
    certification process. AMVETS does have concern with the section of the
    bill that would require the VA to enter into contracts for service and
    repair of prosthetic devices with non-department entities. This
    provision would create a ``sole-source'' contract, and AMVETS would
    oppose this provision.
        H.R. 2173 would authorize additional funding to allow VA to enter
    into contracts with local or community health centers. Mr. Chairman, as
    we are all aware, there is a large number of National Guard and reserve
    units that have deployed or will be deployed into a theater of combat
    operations. Many of these units and personnel are from areas of the
    country that do not have VA healthcare or VA healthcare services
    readily available. AMVETS continues to support the Secretary of
    Veterans Affairs in his authority to contract out for medical and
    healthcare services when/where applicable and also supports additional
    funding for these services.
        H.R. 2192 would establish an Ombudsman within the Department of
    Veterans Affairs to act as a liaison for veterans and their families
    with respect to the receipt of healthcare and benefits administration.
    The VA has a long history of special efforts to bring information on VA
    benefits and services to active duty military personnel. These efforts
    include counseling about VA benefits through the Transition Assistance
    Program (TAP), a nationally coordinated federal effort to assist
    military men and women to ease the transition to civilian life through
    employment and job training assistance. A second component of the
    program, the Disabled Transition Assistance Program (DTAP), helps
    separating servicemembers with disabilities.
        VA also has launched special efforts to provide a ``seamless
    transition'' for those returning from service in Operations Iraqi
    Freedom and Enduring Freedom. Internal coordination was improved and
    efforts currently focus on reducing red tape and streamlining access to
    all VA benefits. Each VA medical facility and benefits regional office
    has identified a point of contact to coordinate activities locally to
    help meet the needs of these returning combat servicemembers and
    veterans. In addition, VA increased the staffing of benefits counselors
    at key military hospitals where severely wounded servicemembers from
    Iraq and Afghanistan are frequently sent. AMVETS does not oppose
    legislation to establish an Ombudsman within the VA.
        H.R. 2219 would direct the Secretary to award a grant to a private,
    nonprofit entity to establish, publicize and operate a national toll-
    free suicide prevention telephone hotline targeted to and staffed by
    veterans of the Armed Forces. Mr. Chairman, the Department of Veterans
    Affairs Office of Inspector General recently reported that veterans
    returning from Iraq and Afghanistan are at increased risk of suicide
    because Veterans Administration health clinics do not have 24-hour
    mental healthcare available. Many facilities lack 24-hour staff,
    adequate screening for mental problems, or personnel who were properly
    trained.
        The report also concluded that VA clinics and military hospitals
    must improve their sharing of health information, particularly for
    patients who might return to active-duty status and that VA should
    loosen criteria for inpatient PTSD care. Currently only veterans with
    ``sustained sobriety'' get treatment. It is AVMETS' understanding that
    the VA Undersecretary for Health, concurs with findings and
    recommendations, and that VA has recently installed suicide prevention
    coordinators in each medical center to better develop prevention
    strategies. AMVETS supports the Undersecretary in this endeavor;
    however, AMVETS would oppose efforts by Congress to mandate the
    Secretary of VA to enter into contracts with a private entity for these
    services and believes that the Secretary must continue to have
    flexibility in how he implements these services.
        H.R. 2378 would establish a financial assistance program to
    facilitate the provision of supportive services for very low-income
    veteran families in permanent housing. We continue to urge Congress to
    provide resources and oversight on homeless veterans programs and
    veterans who may be at risk. With regards to the establishment of a
    financial assistance program for very low-income veterans, AVMETS would
    urge Congress to provide veterans priority assistance through the
    Department of Health and Human Services as opposed to creating a new
    program within the Department of Veterans Affairs.
        Mr. Chairman, this concludes my testimony.

                        Statement of Adrian M. Atizado,
      Assistant National Legislative Director, Disabled American Veterans
        Mr. Chairman, Ranking Member Miller and other Members of the
    Subcommittee:
        Thank you for inviting the Disabled American Veterans (DAV) to
    testify at this important legislative hearing of the Subcommittee on
    Health of the Committee on Veterans' Affairs. DAV is an organization of
    1.4 million service-disabled veterans, and along with its auxiliary,
    devotes its energies to rebuilding the lives of disabled veterans and
    their families.
        You have requested testimony today on ten bills primarily focused
    on healthcare services for veterans under the jurisdiction of the
    Veterans Health Administration (VHA), Department of Veterans Affairs
    (VA). Your staff indicated two additional draft bills would be
    considered but we did not receive those two bills in time to include
    them in this testimony. With exception to the aforementioned draft
    legislation, this statement outlines our positions on all of the
    proposals before you today. The comments are expressed in numerical
    sequence of the bills, and we offer them for your consideration.
    H.R. 1448--The VA Hospital Quality Report Card Act of 2007
        H.R. 1448 would establish a ``hospital report card'' covering a
    variety of activities of inpatient hospital care occurring in the
    medical centers of the Department. We support this bill, because it is
    consistent with trends occurring in private sector healthcare. We
    believe that veterans under VA care have the same rights as private
    sector patients to review the quality and safety of the care they
    receive while hospitalized. We do note, however, that the purposes of
    this bill do not cover the grand majority of overall patient care
    workload in VA healthcare, namely primary (outpatient) care and
    extended care services provided in VA's nursing home care units and its
    various contracted programs. Nevertheless, this is a good bill and one
    that is supported by DAV. We do note for the Committee's purposes, that
    the term ``VA hospital'' was supplanted by the term ``VA medical
    center'' in prior legislation. You may wish to consider conforming this
    bill accordingly, should the Committee decide to approve and report it.
    H.R. 1853--The Jose Medina Veterans Affairs Police Training Act of 2007
        H.R. 1853 would require the Secretary of Veterans Affairs to ensure
    that officers of the VA police service be trained with respect to
    officers' interactions with veterans possibly suffering from mental
    illnesses. While DAV does not have a resolution dealing with this
    issue, we consulted with the National Alliance for Mental Illness
    (NAMI) and its NAMI Veterans Council, an advocacy group that, like DAV,
    is deeply concerned about VA mental health programs and veterans who
    benefit from them. NAMI fully supports the concept of adequate training
    being provided to VA police, who are sworn federal police officers
    charged with providing physical and personal security at all VA
    healthcare facilities. We concur with NAMI's views on this issue. We
    would suggest that the bill be amended, however, to ensure that
    properly credentialed mental health practitioners (principally those
    whom VA employs within the VHA to care for veterans with mental
    illnesses) be designated as training resources for the purposes of this
    bill.
    H.R. 1925--To direct the Secretary of Veterans Affairs to establish a
            separate Veterans Integrated Service Network for the Gulf Coast
            region of the United States
        H.R. 1925 would establish a 22nd Veterans Integrated Service
    Network (VISN) in the western Panhandle of Florida, far south Alabama,
    and eastern Mississippi, within 1 year of date of enactment.
        DAV does not have a resolution from our membership addressing this
    issue. It should be noted however, that the bill raises valid questions
    on the relevance and effectiveness of current VISN boundary alignments.
    These VA jurisdictional lines have been in place with only one
    adjustment for the past 12 years. These boundaries were generally
    formed based on veteran patient care referral patterns established in
    the eighties, and it should be recalled that VA has revolutionized its
    patient care system over the past dozen years.
        It is unclear if VA has reviewed whether the current alignment is
    optimal or may need adjustment. Also, it should be noted that some
    parts of the geographic area encompassed by the bill's intent is still
    in transition in terms of VA physical assets, with no major affiliated
    VA medical centers and only one significant VA facility in Florida, the
    Pensacola Outpatient Clinic, one in Alabama, the Mobile Outpatient
    Clinic and one Mississippi VA medical center, in Jackson. Distances and
    access to these facilities is challenging for the veterans of the
    region, especially for specialized VA services that had generally been
    provided by the New Orleans, Louisiana VA facility until Hurricane
    Katrina destroyed it in 2005. It is also important to note that the
    Florida Panhandle area is not a part of VISN eight, constituting the
    remainder of the State of Florida excepting a few counties along its
    northern border. With most of this area now embedded within VISN 16,
    the VA system's largest VISN (encompassing parts of eight States), the
    proponent of this bill makes a valid argument that perhaps a new
    alignment is in order.
    H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
        Section 2 of this bill would improve reimbursement rates for
    veterans for their travel expenses related to VA medical care. It would
    reimburse veterans at the same rate paid to federal employees, by
    increasing it from 11 cents per mile to 48.5 cents per mile.
        For several years, we have urged VA to correct the inequity in its
    travel reimbursement program and include a line item in the budget to
    make a fair adjustment in travel pay while retaining sufficient funding
    for direct medical care. Given the cost of transportation in 2007,
    including record-setting gasoline prices, a reimbursement rate
    unchanged since 1977 pales in comparison to the actual cost of travel.
    Adequate travel expense reimbursement is directly tied to access to
    care for many veterans and not a luxury.
        The VA beneficiary travel program is intended by Congress to assist
    veterans in need of VA healthcare to gain access to that care. While
    the mileage reimbursement rate is currently fixed, actual reimbursement
    is limited by law with a $3.00 per trip deductible capped at $18.00 per
    month. The mileage reimbursement rate has not been changed in almost 30
    years, even though the VA Secretary is delegated authority by Congress
    to make rate changes when warranted. The law also requires the
    Secretary to make periodic assessments of the need to authorize changes
    to that rate. Unfortunately, no Secretary has acted to make those
    changes, despite the obvious need to update the rate of reimbursement
    to reflect rises in travel and transportation costs.
         DAV Resolution No. 212 is a longstanding resolution supporting
    repeal of the beneficiary travel pay deductible for service-connected
    veterans and to increase travel reimbursement rates for all veterans
    who are eligible for reimbursement. Additionally, we support
    legislation that has been introduced in Congress to repeal the
    mandatory deductible and increase the rate veterans are reimbursed for
    their authorized travel to and from VA services. We believe the House
    and Senate bills titled the ``Veterans Travel Fairness Act,'' offer a
    fair and equitable resolution to this situation which we have been
    concerned for many years. We urge this Subcommittee to approve and
    enact legislation this year to reform the VA beneficiary travel
    program.
        Section 4 of this measure would establish a grant program to
    provide innovative transportation options to veterans in remote rural
    areas. The bill tasks the Director of VA's Office of Rural Health to
    create a program that would provide grants of up to $50,000 to
    veterans' service organizations and State veterans' service officers to
    assist veterans with travel to VA medical centers and to improve
    healthcare access in remote rural areas. The bill authorizes $3 million
    per year for the grant program through 2010.
        In 1987, the DAV, in coordination with VA's Voluntary Service
    program, began buying and donating vans to VA for the purpose of
    transporting veterans to receive VA medical care. Since that time, the
    DAV National Transportation Network has become a very significant and
    successful partnership between VA and DAV. We have donated 1,959 vans
    to VA facilities at a cost exceeding $39 million. Since its inception,
    these vans, their DAV volunteer drivers and medical center volunteer
    transportation coordinators have transported more than 10 million
    veterans over 397 million miles. We plan to continue and enhance this
    program, not only because the VA beneficiary travel rate is so low, but
    also we have found our transportation network serves as a truly vital
    link between rural veterans and crucial VA healthcare. Its absence
    would equate to the actual denial of care for eligible veterans because
    many of them have no means to substitute. Although as an organization,
    the DAV does not accept federal funds such as the grant program;
    however, knowing first hand the value and effectiveness of such a
    program, we would not oppose this section of the bill.
        Section 3 of this bill would establish at least one and no more
    than five Centers of Excellence to research ways to improve care for
    rural veterans. The centers would be based at VA medical centers with
    strong academic connections. The Office of Rural Health would establish
    between one and five centers across the country with the advice of an
    advisory panel.
        Existing VA research, education clinical centers, and various
    centers of excellence have proven to be a valuable resource to educate
    sick and disabled veterans as well as VA healthcare providers on new
    and effective treatment regimes. We are hopeful the proposed Rural
    Health Research, Education and Clinical Care Centers will strive to
    strike the balance we seek when providing better outreach and high
    quality VA medical care to veterans residing in rural and remote areas.
        To examine alternatives for expanding care for rural veterans,
    section 5 of this measure would require the VA to conduct demonstration
    projects through the recently created VA Office of Rural Health to
    establish partnerships between the VA, Centers for Medicare and
    Medicaid Services, and the Department of Health and Human Services to
    coordinate care in critical access hospitals and community health
    centers. In addition, VA would be required to expand coordination with
    Indian Health Service for Native American veterans, and a report to
    Congress on these test projects would be due in 2 years.
        While these initiatives are laudable, we recommend the VA office of
    Rural Health be given ample opportunity to discharge the
    responsibilities specified by Congress in Public Law 109-461 which
    would include developing, refining, and promulgating policies, best
    practices, lessons learned, and innovative and successful programs to
    improve care and services for veterans who reside in rural areas of the
    United States. In addition, we urge this Subcommittee to provide
    oversight and urge the Department of proceed with expeditious
    implementation by the Department.
    H.R. 2172--The Amputee Veteran Assistance Act
        This measure seeks to improve VA's prosthetics programs by
    requiring all VA orthotic/prosthetic laboratories and clinics to be
    certified by either of the two leading boards in these fields, the
    American Board for Certification in Orthotics and Prosthetics or the
    Board of Orthotics and Prosthetic Certification, within 5 years of the
    enactment of this bill, and allow disabled veterans to obtain new
    devices and seek care for the repair and servicing of their existing
    prosthetic devices from outside the VA system when VA facilities are
    unable to perform the required service or repairs due to a lack of
    technology or capability or when a suitable VA facility is not within a
    55 mile radius.
        The bill would also require a complete review and a report to
    Congress by VA of its prosthetic laboratories and clinics to determine
    the need to modernize such facilities to ensure that the VA is capable
    of servicing and repairing the most technologically advanced prosthetic
    devices. Also, VA would be required to complete a review and a report
    to Congress on VA prosthesists to determine what kinds of training and
    education will be needed to ensure that its prosthesists have the
    required knowledge to service and repair the latest prosthetic devices.
        The DAV agrees that the Department's prosthetics program should be
    able to provide all necessary prosthetic services, devices, and
    supplies for the proper treatment of service-connected disabled
    veterans. We believe much of the bill's requirements are already being
    addressed and implemented by VA. We are concerned however, with the
    bill's requirement for VA to enter into one contract with one non-VA
    entity to repair and service prosthetic devices in certain
    circumstances. In addition to the arbitrary nature of a 55-mile radius
    as a requirement to contract for the service and repair of prosthetic
    devices, VA currently utilizes numerous service and repair contractors
    to allow a more personalized and convenient care to veteran in need of
    prosthetic and orthotic devices.
    H.R. 2173--To amend title 38, United States Code, to authorize
            additional funding for the Department of Veterans Affairs to
            increase the capacity for provision of mental health services
            through contracts with community mental health centers, and for
            other purposes
        This measure would allow the VA to provide mental health services
    through contracts with community mental health centers, and authorizes
    appropriations of $150 million from fiscal years 2008 through 2010 for
    such contracts.
        First and foremost, DAV's position on contracted or fee-based care
    is well known. We believe that VA purchased care is an essential tool
    in providing timely access to quality medical care. Current law limits
    the indiscriminant use of VA purchased care to specific instances so as
    not to endanger VA facilities' ability to maintain a full range of
    specialized inpatient services for all enrolled veterans and 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.
        Second, as VA's contract workloads have grown significantly at a
    cost of about $3 billion each year, it has not been able to monitor
    this care, consider its relative costs, analyze patient care outcomes,
    or even establish patient satisfaction measures for most contract
    providers. This measure does not include provisions to address our
    concerns that VA has no systematic process for contracted care services
    to ensure that:

          care is safely delivered by certified, licensed,
    credentialed providers;
          continuity of care is sufficiently monitored, and that
    patients are properly directed back to the VA health-care system
    following private care;
          veterans' medical records accurately reflect the care
    provided and the associated pharmaceutical, laboratory, radiology and
    other key information relevant to the episode(s) of care; and
          the care received is consistent with a continuum of VA
    care.

        Any bill seeking to contract for care outside VA without addressing
    these concerns would essentially shift medical resources and veterans
    from VA to the private sector to the detriment of the VA healthcare
    system and eventually sick and disabled veterans themselves. VA
    operates under constant pressure to do more with less and we believe
    the expansion of the current form of VA contracted care would benefit
    some veterans at the cost of eroding VHA's patient resource base,
    undermine the Department's ability to maintain its specialized service
    programs, and endanger the well-being of veteran patients under care
    within the system.
        We are concerned that this bill does not provide any consideration
    for judicious use of contract care nor does it address our concerns
    regarding the lack of a systematic process for contract care. Such a
    measure could place at risk VA's well recognized qualities as a
    renowned and comprehensive direct provider of healthcare.
    H.R. 2192--To amend title 38, United States Code, to establish an
            Ombudsman within the Department of Veterans Affairs
        This measure would require VA to assign an Ombudsman to act as a
    liaison for veterans and their family members to navigate the VA
    healthcare and benefits system. We appreciate the intent of this bill;
    however, we believe VA has taken actions to address these issues by
    providing assistance and outreach to newly returning veterans through a
    cadre of case managers, transition patient advocates, patient
    representatives, peer counselors, suicide prevention coordinators, and
    other special purpose assistance to guide veterans through the VA
    healthcare benefit systems.
        VA's actions noted above raise questions concerning the purposes of
    the proposed Office of the Ombudsman, given the fact that some of these
    positions have only recently been filled or that VA is in the midst of
    recruiting or training personnel to fill these positions. We urge the
    Subcommittee to provide oversight on the effectiveness of these new
    programs before authorizing the additional Office as proposed by this
    legislation.
    H.R. 2219--Veterans Suicide Prevention Hotline Act of 2007
        This measure would require the VA to award a grant to a private,
    nonprofit entity to establish and operate a national toll-free suicide
    prevention hotline. It would establish a 3-year authority for this
    program, at a cost of $7.5 million, to be paid from VA's Medial
    Services Appropriation.
        There is already in existence a federally funded 24-hour, toll-free
    suicide prevention service comprised of over 120 individual crisis
    centers across the country. This service is available to all persons in
    need or in suicidal crisis. Individuals seeking help can call the
    National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255).
    From the toll free number, they will be seamlessly routed to the
    certified provider of mental health and suicide prevention services
    nearest to the call of origination.
        We agree with testimony provided by Mr. Jerry Reed, Executive
    Director of Suicide Prevention Action Network USA (SPAN USA), before
    the Senate Committee on Veterans' Affairs on May 23, 2007, that we
    could build upon what Congress has already funded with the NSPL.
        As it was pointed out during that hearing, once a veteran in need
    calls the number, an option could be provided for that veteran to be
    transferred to a VA call center if the individual wants the services
    and support of the VHA. We also agree that the VA should be providing
    up-to-date information to non-VA crisis centers on all VA suicide
    prevention counselors, hospitals, medical centers, outpatient clinics,
    and peer support groups and, where appropriate, this national network
    of crisis centers should reliably transfer cases to the VHA call
    center. It is our understanding that VHA's mental health program office
    is discussing the possibility of joining the existing system rather
    than mounting an independent VA suicide prevention service. We concur
    with that concept and urge VA to move forward in lieu of Congress
    passing this bill.
    H.R. 2378--Services to Prevent Veterans Homelessness Act
        This bill would direct the VA to provide financial assistance for
    supportive services for very low-income veterans' families in permanent
    housing. Under the bill VA would provide grants to certain eligible
    entities such as private nonprofit organizations or consumer
    cooperatives to provide various supportive services.
        The DAV supports the intent of the bill to better address homeless
    veterans' needs, and to help them move toward independent living.
    Furthermore, unlike the companion bill in the Senate, this measure
    authorizes appropriation and does not divert resources from VA's
    medical care account. However, as well-intentioned as this measure may
    be, we are concerned that a grant under which healthcare and counseling
    services would be provided by private providers versus VA providers
    raises questions about cost, quality, continuity and safety similar to
    our views on other proposals with these goals.
    H.R. 2623--To amend title 38, United States Code, to prohibit the
            collection of copayments for all hospice care funished by the
            Department of Veterans Affairs
        VA is the only public healthcare system that charges copayments to
    hospice patients, and the DAV is greatly concerned particularly as the
    number of veteran deaths has been increasing to a current average of
    1,800 per day. Congress initially addressed this issue, but only to a
    limited extent. section 204 of Public Law 108-422, the Veterans Health
    Programs Improvement Act of 2004, exempted veterans who receive hospice
    care from the requirement to pay copayments, but only if the hospice
    care were being provided at a nursing home.
        The DAV recommends the fulfillment of Congress's original intent in
    Public Law 108-422 by exempting veterans from paying copayments when
    they receive VA hospice care in any authorized setting. We thank
    Ranking Member Miller for introducing this measure and Chairman Michaud
    for including it in today's hearing, which seeks to prohibit the
    collection of copayments for all hospice care furnished by the VA.
        Veterans are subject to inpatient copayments if they seek inpatient
    hospice care at facilities without nursing home beds, or if the hospice
    care must be provided in an acute care setting as a result of clinical
    complexity. Moreover, veterans choosing to remain at home for their
    hospice care are subject to outpatient primary care copayments. While
    the DAV supports H.R. 2623, we recommend that its scope be broadened to
    include exempting veterans from copayments for hospice care provided in
    any treatment setting by amending section 1710 of Title 38 United
    States Code.
        Mr. Chairman, again, the members and auxiliary of DAV appreciate
    being represented at this hearing today, and I appreciate being asked
    to testify on these bills. Mr. Chairman, this concludes my testimony. I
    and other members of the DAV Legislative Staff will be pleased to make
    ourselves available to you and your staffs for further discussion of
    our positions on any of these issues, in hopes of working toward
    compromise on measures that we can eventually support. I will be
    pleased to respond to any of your or other Committee Members'
    questions.

                 Statement of Carl Blake, National Legislative
                    Director, Paralyzed Veterans of America
        Mr. Chairman and members of the Subcommittee, on behalf of
    Paralyzed Veterans of America (PVA), I would like to thank you for the
    opportunity to testify today regarding the proposed legislation. We
    appreciate the fact that you continue to address the broadest range of
    healthcare issues possible to best benefit veterans. We particularly
    support any focus placed on meeting the complex needs of the newest
    generation of veterans, even as we continue to improve services for
    those who have served in the past.

             H.R. 1448, THE ``VA HOSPITAL QUALITY REPORT CARD ACT''

        Although PVA has no objection to the requirements for a Hospital
    Quality Report Card Initiative outlined in this legislation, we remain
    concerned that this wealth of information will go unused. Collecting
    this information and assessing it without acting on any findings from
    that information would serve no real purpose. We would hope that the
    congressional committees will use this information published in these
    reports each year to affect positive change within the VA. However, we
    must emphasize that additional resources should be provided to allow
    the VA to properly compile this information as we believe that this
    could be a major undertaking.

      H.R. 1853, THE ``JOSE MEDINA VETERANS AFFAIRS POLICE TRAINING ACT''

        PVA supports H.R. 1853, the ``Jose Medina Veterans Affairs Police
    Training Act of 2007.'' H.R. 1853 will compliment the training that is
    currently in place for VA police officers. Some of the current
    personnel in the VA police force nationwide may have little or no
    specific training to work with emotionally distressed veterans. A
    majority of VA officers must deal with veterans with various degrees of
    emotional problems. In conversations with some of the VA officers at
    the VA Headquarters here in Washington, D.C., they have informed us
    that they have been told to be ready to deal with the large number of
    new veterans returning from the Iraq and Afghanistan war who may have
    significant mental health problems.
        The current style of conduct as a VA officer is considered
    ``situational enforcement''. While regular law enforcement officers
    take action upon a violation of the law, VA police officers evaluate a
    given situation to determine if the situation presents a danger to
    veterans, medical staff, other individuals, or the officer. If the
    situation is or could become harmful to individuals who are present, or
    to government property, the VA officer then takes action.
        All new officers receive initial training at the VA police officers
    training academy. After that training any future training is at the
    discretion of the Chief of Police at each VA location. The Chief will
    decide what training is required and how much training each officer
    receives. One VA Chief we spoke with told us that his officers receive
    training primarily on how to handle veterans age 60 to 70, as that is
    the age group of most veterans that they see at the VA medical center.
        PVA believes that VA police officers across the system should have
    mandatory, standardized, training to help them address the new
    challenge of dealing with the newest generation of veterans, along with
    the older veteran population. This bill would certainly support this
    idea ensuring that specific training to help VA police officers
    understand how to best handle the new Iraq and Afghanistan veterans and
    how to accommodate them as they come to the VA for services.

                 H.R. 1925 (New VISN in the Gulf Coast Region)

        PVA opposes H.R. 1925, a bill that would establish a new Veterans
    Integrated Service Network (VISN) in the Gulf Coast region. This would
    encompass counties in Florida, Alabama, and Mississippi. PVA has
    serious concerns about the precedent that this legislation would set.
    The VA currently uses the VISN structure as a management tool for the
    entire VA healthcare system. It makes no sense for the Congress to
    legislate how the VA should manage its system. Furthermore, this sets a
    dangerous precedent whereby any member could decide that a VISN, or
    some similar network structure, should be redrawn in such a way to
    support his or her own district.
        However, we certainly believe that the current network alignment
    could be reassessed and possibly realigned. There is certainly nothing
    that suggests that 21 service networks is the optimal structure. But
    where does the VA draw the line when establishing its healthcare system
    structure? With the current 21 VISN's, the VA seems to do a good job of
    managing a massive healthcare system.

         H.R. 2005, THE ``RURAL VETERANS HEALTH CARE IMPROVEMENT ACT''

        PVA generally supports H.R. 2005, the ``Rural Veterans Health Care
    Improvement Act.'' This bill would enhance the implementation of the
    rural health requirements of P.L 109-461 enacted last year. However, we
    still have some concerns about how best to address the needs of
    veterans who live in rural areas. PVA recognizes that there is no easy
    solution to meeting the needs of veterans who live in rural areas.
    These veterans were not originally the target population of men and
    women that the VA expected to treat. However, the VA decision to expand
    to an outpatient network through community-based outpatient clinics
    reflected the growing demand on the VA system from veterans outside of
    typical urban or suburban settings.
        PVA fully supports the provisions of this legislation which would
    align the mileage reimbursement rate afforded to eligible veterans with
    the rate that all federal employees get when they are on travel. It is
    wholly unacceptable that veterans have to live with the 11 cents per
    mile reimbursement rate that the VA currently provides when all federal
    employees receive 48 cents per mile. In fact, PVA believes that some of
    the difficulty in providing care to veterans in limited access areas,
    specifically rural areas, might be eliminated with a sensible
    reimbursement rate. We believe that veterans would be less likely to
    complain about access issues as a result of their geographic location
    if they know that they will not have to foot the majority of the travel
    expense out of their own pocket. This is a change that has been long
    overdue, and we urge the Subcommittee and all of Congress to take
    immediate action to correct this inequity.
        We also support the creation of rural health research, education,
    and clinical care centers. These centers would essentially serve as
    centers-of-excellence for rural healthcare. This could allow the VA to
    address the needs of rural veterans through broad application of the
    ``hub-and-spoke'' principle. This is the same structure utilized in the
    spinal cord injury service. A veteran can get his or her basic care at
    a community-based outpatient clinic (spoke). However, if the veteran
    requires more intensive care or a special procedure, he or she can then
    be referred to the larger rural research, education, and clinical care
    center (hub). 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. It will also allow the VA to develop
    excellence within the actual VA healthcare system, instead of farming
    out these services to the private sector. Likewise, PVA supports the
    provisions to allow for transportation grants to veterans service
    organizations to assist veterans access the VA healthcare system. We
    are all familiar with the success of the Disabled American Veterans'
    (DAV) van program that provides transportation to medical facilities
    for disabled veterans who have appointments. This provision would
    further support similar programs and allow other organizations to play
    an equally useful role.
        PVA has concerns about the demonstration projects that will
    establish partnerships between the VA and the Centers for Medicare and
    Medicaid Services to seek care in critical access hospitals or at
    community health centers. Principally, we believe that this legislation
    is ``jumping the gun'' by getting ahead of the Office of Rural Health,
    which is responsible for determining if solutions, such as this
    proposed demonstration project, are feasible. We think that this new
    office in the VA should be given time to do its job before Congress
    begins legislating solutions to the problems with rural healthcare for
    veterans. This is certainly not to say that Congress should not
    pressure the VA to get the office operating expeditiously.
        Although we do not necessarily have a problem with the reporting
    requirements contained in the legislation, they seem to be redundant.
    PVA believes that similar requirements were placed on the VA with the
    creation of the Office of Rural Health in legislation enacted during
    the 109th Congress. We do not see the need for this requirement if the
    new office at VA will be fulfilling this task once it gets up to speed
    anyway.

               H.R. 2172, THE ``AMPUTEE VETERAN ASSISTANCE ACT''

        PVA has serious concerns about the provisions of this proposed
    legislation. PVA strongly opposes the provision of Section 2 of H.R.
    2172 that would allow the VA to contract for service and repair of
    prosthetic devices. We interpret this legislation to mean that the VA
    can contract with a single entity to provide these services and
    repairs. This is absolutely a bad idea. By using a single entity, the
    pool of devices and services available will be severely limited.
        A one-size-fits-all approach to prosthetics cannot be applied. As
    an example, prosthetics departments that serve PVA members needing
    wheelchairs often, if not always, contract with several different
    vendors to provide those wheelchairs. Because every PVA member, and
    every disabled veteran for that matter, is different, the equipment
    they need varies. Although an Invacare power chair may be suitable for
    one spinal cord injured veteran, a different spinal cord injured
    veteran might be better served by a Jazzy chair. Two uniquely different
    veterans cannot be expected to use the same equipment simply because it
    might streamline processes for the VA. We believe that giving the VA
    the authority outlined in this provision would have a significant
    negative impact on the severely disabled veterans who are the highest
    users of VA prosthetics services.
        PVA has no objection to the provision of the legislation that would
    require certification of VA orthotic-prosthetic laboratories with the
    American Board for Certification in Orthotics and Prosthetics or the
    Board of Orthotics and Prosthetic Certification. However, we believe
    that the VA already meets these requirements, but if this provision
    will reinforce this action, then we have no problem with it.

                       H.R. 2173 (Mental Health Services)

        PVA opposes H.R. 2173 which would authorize VA to contract with
    community mental health centers to meet the needs of veterans dealing
    with mental illnesses. As we testified earlier this year, we oppose any
    effort to allow the VA to contract out care when it can do a better and
    more cost effective job in its own system. Furthermore, by allowing the
    VA to send these veterans out of the system to receive their care, it
    effectively relieves itself of the obligation it has to these men and
    women. The VA must be appropriated adequate funding (steps that are
    finally beginning to take place) and it must be provided in a timely
    manner if it is going to have any chance of meeting these veterans
    needs.
        Moreover, Congress must continue to conduct aggressive oversight to
    ensure that funding specifically allocated for mental health
    initiatives is properly spent. As explained in the Government
    Accountability Office (GAO) report of November 2006, the VA did not
    allocate all of the funding it planned to commit in FY 2005 for new
    mental health initiatives, nor did it spend all of the funds planned
    for FY 2006. VA must be held accountable to ensure that it lives up to
    the goals established in its National Mental Health Strategic Plan.
    Until such time as the VA meets these goals, the burden for mental
    healthcare should not be shifted to the community.

                            H.R. 2192 (VA Ombudsman)

        PVA supports H.R. 2192, a bill that would establish an Office of
    the Ombudsman in the VA. We believe that this office could certainly
    improve the transition of service members and their families from the
    Department of Defense to the VA. The office can be an important
    information tool for the VA. We do find it unfortunate, however, that
    such an office would be necessary as the VA as whole should be
    responsible for fulfilling this role through outreach.

           H.R. 2219, THE ``VETERANS SUICIDE PREVENTION HOTLINE ACT''

        The incidence of suicide among veterans, particularly Operation
    Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a
    serious concern that needs to be addressed. PVA principally supports
    this legislation. Any measure that will reduce the incidence of suicide
    among veterans is certainly a good thing.
        However, we must emphasize a couple of important points. First and
    foremost, there need to be absolute standards established that ensure
    that the individuals staffing this hotline are adequately trained to
    handle the complex issues associated with individuals contemplating
    suicide. We certainly support the idea that this service should be
    staffed by veterans, but they must have the proper training to deal
    with these cases. Simply having the shared experience of military
    service is not enough. This legislation seems to address this concern,
    but the VA cannot be let off the hook for ensuring that this is handled
    properly.
        Secondly, clear steps for referral into VA mental health clinics
    and other VA facilities with related services must be outlined. The
    private entities responsible for the operation of the suicide
    prevention hotline must understand how to refer veterans dealing with
    these problems into programs that will provide the services they need.
    These services are essential to helping the veteran overcome the
    suicidal feelings he or she may be dealing with.

        H.R. 2378, THE ``SERVICES TO PREVENT VETERANS HOMELESSNESS ACT''

        PVA has no objection to the provisions contained in the proposed
    legislation. Clearly, the most important factor in combating the
    problem of homelessness among veterans is preventing homelessness in
    the first place. This legislation would seem to accomplish that task by
    offering financial assistance to organizations or entities that provide
    permanent housing and support services to very low income veteran
    families. In the mean time, we believe that additional resources should
    be invested in programs that actually target veterans and their
    families who are experiencing homelessness as well. With more than
    200,000 veterans on the street on any given night, it is time to make
    real, meaningful efforts to end this problem.

                                   H.R. 2623

        PVA fully supports H.R. 2623, a bill which would prohibit the VA
    from collecting copayments from veterans receiving hospice care whether
    in an inpatient or outpatient setting. As we recall, the VA actually
    supported similar legislation during the 109th Congress. This
    legislation only makes sense as it will align with current statute that
    prevents VA from collecting copayments from veterans receiving hospice
    care in a nursing home setting.
        We look forward to working with the Subcommittee to develop
    workable solutions that will allow veterans to get the best quality
    care available. I would like to thank you again for allowing us to
    testify on these important measures. I would be happy to answer any
    questions that you might have.

                   Statement of Dennis M. Cullinan, Director,
     National Legislative Service, Veterans of Foreign Wars of the United
                                     States
    MR. CHAIRMAN AND MEMBERS OF THIS COMMITTEE:
        On behalf of the 2.4 million men and women of the Veterans of
    Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to
    thank you for the opportunity to testify before you today on a wide
    range of important veterans healthcare bills.

               H.R. 1488, the VA Hospital Quality Report Card Act

        The VFW is pleased to support the VA Hospital Quality Report Card
    Act, legislation that would require VA to develop and implement a
    system to measure data about its healthcare facilities.
        This data would be of great service. It would allow veterans to
    compare the quality of service VA provides, letting them make informed
    judgments about their healthcare. It would allow VA to identify areas
    of improvement, and it would provide essential data for Congress to
    better use its essential oversight authority.

        H.R. 1853, the Jose Medina Veterans Affairs Police Training Act

        The VFW supports this legislation which would require VA police
    officers to undergo training on how to deal with patients and visitors
    who are suffering from mental illnesses.
        Given the large numbers of returning veterans who are suffering
    from mental illnesses of various degrees, extra training for VA
    employees on how to deal with these patients is entirely appropriate.
    This is especially true for those patients who are vulnerable and
    suffering the most. The extra training will ensure that wounded
    warriors are treated with dignity and respect.

                                   H.R. 1925

        The VFW has no objection to H.R. 1925, legislation that would
    establish a new Veterans Integrated Service Network (VISN) in the Gulf
    Coast Region. The regions in this area share many similar geographic
    things in common and, perhaps, aligning them all in one vision will
    allow them to better serve the veterans' population.

             H.R. 2005, Rural Veterans Health Care Improvement Act

        The VFW is pleased to support the Rural Veterans Health Care
    Improvement Act, legislation that aims to solve one of the greatest
    problems facing the large number of veterans who live in remote
    locations: access to care. It aims to improve services including
    transportation for disabled vets, research and partnerships with small
    communities.
        It would require VA to create centers of excellence for rural
    healthcare veterans and to establish a grant program for groups that
    help transport veterans from rural areas. It also includes a provision
    that would create demonstration projects for potential partnerships
    with local hospitals and community health centers, as well as for
    Native American veterans.
        We are strongly supportive of section 2, which would increase the
    mileage reimbursement rate veterans receive for their travel expenses
    related to VA healthcare to the rate provided to all federal employees.
    The current deductible for travel expenses is so limiting that most
    veterans receive little, if any, compensation for their travels. With
    so many veterans facing drives of hundreds of miles for even basic
    care, this is clearly the right thing to do.

                   H.R. 2172, Amputee Veteran Assistance Act

        The VFW is supportive of H.R. 2172, a bill to require that all
    Department of Veterans Affairs orthotic-prosthetic laboratories,
    clinics, and prosthesists are certified by either the American Board
    for Certification in Orthotics and Prosthetics or the Board of
    Orthotics and Prosthetic Certification. However, the VFW is not sure if
    changing the rules of VA's prosthetic program is needed, and we have
    concerns that the certification requirements that would affect all
    service and repair programs for prosthetics and orthotics is necessary.
        VA continues to be on the forefront of advancement in this most
    important area, allowing hundreds of our wounded warriors the ability
    to regain their mobility or to become whole.
        We are also concerned that some efforts to create a certification
    process could lead toward a standardization process that aims for one-
    size-fits-all solutions, instead of a personalized approach necessary
    to deal with each veteran's particular disability. Medical decisions
    must be made on the individualized needs of a veteran and what works
    best.

                                   H.R. 2173

        We support the intent of this legislation, which would allow the VA
    secretary to enter into contracts for service with community mental
    healthcare centers, but we do have some concerns.
        With the number of returning service members who are suffering from
    mental health conditions, it is clear that VA can and must do more. VA
    has made great strides from where they were a few years ago in
    providing care, but the system is far from perfect. This legislation
    aims to fill in the gaps, by allowing VA to utilize local resources,
    presumably in places where there are gaps in the availability of care--
    whether through a high demand or a dearth of providers.
        We remain concerned, however, with an over-reliance on contract
    care. Especially in the mental health area contract care could lead to
    some extensive continuity of care problems. Among other things, VA
    would have to determine some way to ensure that no veteran falls
    through the cracks when going from the department to a local provider.
    Further, it would be absolutely critical that patient records be
    transferable among all providers so that all information is provided to
    all involved healthcare givers. We have concerns, given VA's state-of-
    the-art medical records, that this is feasible in dealing with the
    private sector.
        We need to do more for these wounded warriors, but we need to make
    sure that what we're doing really is in their best interest.

               H.R. 2219, Veterans Suicide Prevention Hotline Act

        The VFW supports this legislation which would establish a grant
    program to an organization to staff and run a suicide prevention
    hotline targeted and staffed by veterans and armed forces personnel.
        We understand that VA is in the process of establishing a similar
    hotline, so it may be necessary to determine how much overlap is
    between the programs. It is clear, however, that the program would be
    beneficial.
        This is a critical issue, especially with the difficulties so many
    of our men and women who have worn the uniform are facing. Anything we
    can do to extend a helping hand, especially when they are suffering and
    in a time of such need, is essential.

                                   H.R. 2623

        The VFW offers our support for this legislation, which would exempt
    patients seeking hospice care from paying copayments. This is a
    compassionate idea that relieves a burden on the veteran and their
    loved ones at a critical time.
        This concludes my testimony and I will be happy to respond to any
    questions you may have.

                 Statement of Barry Hagge, National Secretary,
                          Vietnam Veterans of America
        Good morning, Chairman Michaud, Ranking Member Miller, and members
    of this Subcommittee. Thank you for giving Vietnam Veterans of America
    (VVA) the opportunity to offer our comments on several veterans'
    health-related bills up for discussion here today.
        All of these bills, with the possible exception of H.R. 1853, are
    extremely important. With a few reservations, they are worthy of your
    consideration and our support.
        The topic of accessibility to VA medical services for veterans who
    live in rural areas has been percolating of late. We believe that H.R.
    2005, the ``Rural Veterans Health Care Improvement Act of 2007,''
    offers pragmatic solutions to address the problems of access to
    healthcare experienced by too many rural veterans. The bill would
    increase travel reimbursement for veterans who travel to VHA facilities
    to the rates paid to federal employees. The current reimbursement rate
    was established decades ago and does not adequately compensate for the
    costs of gasoline, ``wear and tear'' on the vehicle or increased
    insurance that might be necessary in order to travel to distant medical
    centers. In the same vein, the grant program for rural veterans'
    service organizations to develop transportation programs could be an
    innovative way to strengthen community resources that may already
    assist with veterans' travel needs.
        The establishment of centers of excellence for rural health
    research, education, and clinical activities, another component of this
    bill, should fill a gap in VA healthcare and should lead to innovation
    in long-distance medical and telehealthcare. These centers have brought
    the synergies of clinical, educational and research experts to bear in
    one site. Such centers have allowed VA to make significant
    contributions to the fields of geriatric medicine and mental illness.
    It would require demonstrations of rural treatment models.
    Demonstrations on treating rural veteran populations would be extremely
    useful in assessing effective ways to offer healthcare to individuals
    who are generally poorer, more likely to be chronically ill, and
    almost, by definition, more likely to have challenges in access to
    regular healthcare.
        And establishing partnerships--with the Indian Health Service and
    with the Department of Health and Human Services--also should add to
    greater cooperation and collaboration in meeting the needs of rural
    veterans.
        We would caution, however, that we would not like to see these
    demonstration projects exploring more opportunities to do widespread
    contracting out of veterans' healthcare services. Demonstration models
    should be assessed according to a number of outcomes such as quality of
    care, cost, and patient satisfaction and the results reported to
    Congress.
        H.R. 1448, the ``VA Hospital Quality Report Card Act of 2007,'' is
    a quality control measure that would help with accountability and
    issues regarding follow-up care and timely visits. It would require the
    VA to provide grades for its medical centers on measures such as
    effectiveness, safety, timeliness, efficiency, patient-
    ``centeredness,'' and equity. Health-care quality researchers have long
    thrived trying to objectively define some of these measures.
        As members of this Subcommittee are aware, the VA has a number of
    performance measures it regularly assesses in order to reward its
    medical center and network directors, among others. Some of these
    outcomes, such as immunizations for flu, foot care and eye care for
    diabetics, set the ``benchmark'' for care in the community. In addition
    to these internal performance measures, VHA voluntarily submits to
    Joint Commission on Accreditation of Healthcare Organization,
    Commission on Accreditation of Rehabilitation Facilities, and managed
    care quality review standards.
        VVA understands the importance of quality measurement; there is an
    expression with which we agree: ``What's measured, matters.'' We also
    agree that VA officials should be held to the highest degree of
    accountability, and whatever measures are available to allow this to
    better occur we wholeheartedly endorse. However, before enacting this
    clearly well-intended legislation, which could require significant
    retooling of quality measurement systems in the VA, the Committee
    should hold a hearing to identify gaps and deficiencies in current
    performance and quality measurement systems. It would also be useful to
    understand how report cards would be used and reported to improve VHA
    processes and performance rewards. Would poor grades be dealt with by
    changes in management? By withholding bonuses to senior executives?
    With more funding? How would good grades be rewarded? Such questions
    should be addressed before requiring a significant new quality
    measurement program to be installed.
        H.R. 1853, the ``Jose Medina Veterans Affairs Police Training
    Act,'' would require VA police to receive training in interacting with
    patients and visitors with severe mental illness. Most VA police are in
    daily contact with veterans with mental illness, often dealing with
    stressful situations that are liable to exacerbate symptoms.
    Sensitivity training in confronting any individuals in crisis could
    potentially assist officers in peacefully de-escalating or defusing
    volatile situations, thus avoiding the use of force.
        VVA does not have a position on H.R. 1925, which would establish a
    Gulf Coast Veterans Integrated Service Network.
        H.R. 2172, the ``Amputee Veterans Assistance Act,'' would require
    that all VA orthotic-prosthetic laboratories, clinics, and prosthesists
    are certified by either the American Board for Certification in
    Orthotics and Prosthetics or the Board of Orthotics and Prosthetic
    Certification. We endorse this bill because, very simply, as more and
    more catastrophically wounded veterans are returning home minus arms
    and legs, it is incumbent on us to ensure that they are receiving
    quality prosthetics and orthotics.
        The VA already has the authority to contract with community mental
    health providers; however, under the strain of thousands of returning
    troops in need of mental health services, the VA is struggling to
    implement provisions of its mental health strategic plan, including
    providing ``round-the-clock'' access to care. The funding authorized in
    H.R. 2173 for the provision of mental healthcare from community
    providers--$50 million--would greatly assist the VA in filling the
    programmatic gaps it recognized in both its strategic plan and in its
    budget submission for FY 2008.
        Community mental health providers should be selected based on
    quality of care indicators such as compliance with standards for either
    the facility or its clinical personnel (what credentials/training are
    required for the clinical personnel?) Standards for community providers
    should be no less rigorous than those required for similar VA
    facilities. And the VA must provide vigorous oversight of the care
    these community facilities provide veterans.
        We should also note that mental health providers across the country
    are eager to assist returning veterans in dealing with their demons.
    Passage of 2173 should help give them the opportunity.
        VVA endorses H.R. 2192, which would establish an Office of the
    Ombudsman within the Department of Veterans Affairs. Although most of
    the duties of an ombudsman are the responsibility of program managers
    and assistant secretaries, veterans and their families who are
    sometimes frustrated by bureaucratic runarounds or non-answers often
    encountered at VA medical centers or regional offices will have a
    champion--if H.R. 2192 is enacted and sufficiently funded.
        VVA very much supports H.R. 2219, the ``Veterans Suicide Prevention
    Hotline Act of 2007,'' which would authorize and fund the establishment
    of a national toll-free suicide prevention hotline. As many of those in
    this room are aware, up to one-third of the thousands of veterans of
    the fighting in Iraq and Afghanistan have screened positive for mental
    illness. As more of these veterans return home from ongoing deployments
    in Southwest Asia, the acute symptoms of these illnesses, including
    post-traumatic stress disorder, depression and anxiety, are likely to
    manifest resulting in more preventable losses of life.
        In a report published last month (May 10, 2007), the VA's Office of
    Inspector General recommended that VA provide such a hotline (VA OIG
    Report No. 06-03706-126). The VA's response indicated that the Veterans
    Health Administration's Office of Mental Health Services was developing
    a hotline that would be rolled out November 30, 2007 and fully
    implemented by January 30, 2008. Enacting this legislation will better
    ensure that the VA meets these goals.
        The provision should assure that contracted services for the
    hotline call for a minimum percent of vets hired--including veterans
    who have recently returned from deployments abroad--over and above the
    3% required for government contracts.
        VVA supports, too, H.R. 2378, the ``Services to Prevent Veterans
    Homelessness Act.'' If veterans at risk of becoming homeless can be
    identified and assisted before they are turned out of their apartment,
    if they can be given the modest assistance they need to maintain their
    independence, if they have access to the supportive services they need
    to maintain their dignity, it is entirely possible that hundreds will
    be saved from having to live with no permanent address, and no roof
    over their head.
        That some 200,000 military veterans, including growing numbers of
    men and women who served in Iraq and on the ``Global War of Terror''
    are homeless is a national scandal. It should shock you into action.
    And indeed, Congress has responded, but often with too little in the
    way of resources that can make a real difference.
        VVA supports the provisions in H.R. 2623 that would prohibit the
    collection of copayments for all hospice care furnished by the VA.
    Hospice care is a service that allows individuals with terminal illness
    to reject extraordinary measures for prolonging life and, instead,
    accept ``comfort care.'' The last year of life is known to be far more
    expensive than those that precede it. It is unfortunate, then, to
    penalize veterans and their families by charging co-payments for
    hospice care when those same veterans might have elected to receive,
    free-of-charge, acute, in-patient care that was far more expensive and
    ultimately fruitless. The VA should be encouraging its patients to
    prepare living wills and advanced directives that specify their choices
    for end-of-life care and educate veterans with terminal illness about
    hospice. Relieving veterans of copayments for hospice care seems one
    means to better ensure that they are able to choose hospice for their
    end-of-life care.
        Members of this Subcommittee, VVA welcomes your comments and your
    questions.

          Statement of the Honorable Michael Kussman, M.D., MS, MACP,
          Under Secretary for Health, Veterans Health Administration,
                      U.S. Department of Veterans Affairs
        Good Morning Mr. Chairman and Members of the Subcommittee:
        Thank you for inviting me here today to present the
    Administration's views on nine bills that would affect Department of
    Veterans Affairs (VA) programs that provide veteran healthcare benefits
    and services. With me today is Walter A. Hall, Assistant General
    Counsel. Mr. Chairman, with the exception of section 2 of H.R. 2005, VA
    has not had sufficient time to prepare cost estimates for the bills on
    today's agenda. As soon as these become available, we will supply them
    for the record. In addition, with the short time available to prepare
    for this hearing, we were not able to provide views on all of the bills
    reflected on the agenda. We can provide those views for the record.
    H.R. 1448--VA Hospital Quality Report Card Act of 2007
        Mr. Chairman, I will begin by addressing H.R. 1448. This bill would
    require VA to establish a Hospital Quality Report Card Initiative
    (``Initiative'') to, among other things, help inform patients and
    consumers about the quality of care in VA hospitals. Under the
    Initiative, the Secretary would be required to publish, at least bi-
    annually, reports on the quality of VA's hospitals that include
    quality-measures data that allow for an assessment of healthcare
    effectiveness, safety, timeliness, efficiency, patient-centeredness;
    and equity.
        In collecting and reporting this data, the Secretary would have to
    include very extensive and detailed information (i.e., staffing levels
    of nurses and other healthcare professionals; rates of nosocomial
    infections; volume of various procedures performed, hospital sanctions
    and other violations; quality of care for specified patient
    populations; the availability of emergency rooms, intensive care units,
    maternity care, and specialty services; the quality of care in various
    hospital settings, including inpatient, outpatient, emergency,
    maternity, and intensive care unit settings; ongoing patient safety
    initiatives; and, other measures determined appropriate by the
    Secretary). VA would be allowed to make statistical adjustments to the
    data to account for differences relating to characteristics of the
    reporting hospital (e.g., size, geography, and teaching status) and
    patient characteristics (e.g., health status, severity of illness, and
    socioeconomic status). In the event VA makes such adjustments, there
    would be a concomitant obligation to establish procedures for making
    that data available to the public.
        The bill would require the Secretary to disclose the entire
    methodology (for the reporting of the data) to all organizations and VA
    hospitals that are the subject of any information prior to making such
    information available to the public. Each report submitted under the
    Initiative would have to be available in electronic format, presented
    in an understandable manner to specified populations, and presented in
    a manner that allows for a comparison of VA's hospital quality with
    local hospitals or regional hospitals. The Department would also need
    to establish procedures to make these reports available to the public,
    upon request, in a non-electronic format (such as through a toll-free
    telephone number).
        In addition, H.R. 1448 would require the Secretary to identify and
    acknowledge the analytic methodologies and limitations on the data
    sources used to develop and disseminate the comparative data and to
    identify the appropriate and inappropriate uses of such data. The bill
    would further mandate the Secretary, on at least an annual basis,
    compare quality measures data submitted by each VA hospital with data
    submitted in the prior year or years by the same hospital to identify
    and report actions that would lead to false or artificial improvements
    in the hospital's quality measurements.
        This measure would further require the Secretary to develop and
    implement effective safeguards to: protect against the unauthorized use
    or disclosure of VA hospital data reported under this measure; protect
    against the dissemination of inconsistent, incomplete, invalid,
    inaccurate, or subjective VA hospital data; and ensure that
    identifiable patient data is not released to the public. In addition,
    the Secretary would need to evaluate and periodically report to
    Congress on the effectiveness of this initiative and its effectiveness
    in meeting the purposes of this Act. And such reports would have to be
    made available to the public. Finally, this legislation would direct
    the Secretary to use the results of the evaluations to increase the
    usefulness of this initiative.
        H.R. 1448 would authorize to be appropriated to carry out this
    section such sums as may be necessary for each of Fiscal Years (FY)
    2008 through 2017. The effective date for this bill and its
    requirements would be 18 months after the date of the bill's enactment.
        Mr. Chairman, VA supports the intent of this bill but opposes the
    bill as written. H.R. 1448 is too prescriptive in its requirements, and
    much of the information that would be required by H.R. 1448 is already
    available through other avenues, such as The Joint Commission's
    (previously known as the Joint Commission on Accreditation for
    Healthcare Organizations) website that provides standardized
    comparative data in a form that has been tested for consumer
    understandability and usefulness. Moreover, VA is in the process of
    compliance with Executive Order 13410, which requires transparency of
    quality measures in Federal healthcare programs. We would welcome the
    opportunity to meet with the Committee members to help them understand
    what is available already, how the members might better access the
    information, and how we can help veterans and the public better access
    that information.
    H.R. 1853--Jose Medina Veterans Affairs Police Training Act of 2007
        H.R. 1853 would require the Secretary to ensure, not later than 8
    months after the date of enactment, all VA police officers receive
    training on how to interact with visitors and patients at VA medical
    facilities who have, or who exhibit symptoms of, mental illness. The
    purpose for this mandate is the bill's express finding that there has
    been, and will continue to be, an increase in the incidence of post-
    traumatic stress disorder (PTSD) among veterans who served in past and
    present combat theaters and thus in their concomitant need for VA
    mental health treatment and services.
        We do not support H.R. 1853 because it is unnecessary. By statute,
    the Secretary is already required to provide VA Police Officers with
    training that emphasizes effective management of situations involving
    patients. To carry out that mandate, VA provides specialized training
    to VA Police Officers in dealing with disruptive and other unusual
    behaviors. VA officers also must successfully complete an 80 hour basic
    entry level training course at their medical centers as well as a 200
    hour residential basic police officer training course at the VA Law
    Enforcement Training Center. Included in the residential course is a
    17.5 hour block of training in Behavioral Science that includes such
    topics as introduction to mental illness, communications/conflict
    management, verbal judo, crisis intervention/conflict resolution and
    the dynamics of the suicidal individual. Much of this training is
    taught by VA psychologists. Moreover, VA officers must also complete a
    biannual refresher training program.
    H.R. 1925--VISN for Gulf Coast Region
        H.R. 1925 would require the Secretary to establish, not later than
    1 year after enactment, a separate ``Veterans Integrated Services
    Network (``VISN'') for the Gulf Coast region of the United States. This
    new VISN would be comprised of specified counties located in Florida,
    Alabama, and Mississippi.
        VA does not support H.R. 1925. We find no justification for
    establishing a separate VISN for a service area that does not have the
    workload needed to make that organizational change cost-effective or to
    require that level of management. The current facilities and referral
    patterns in this area provide the best access for the veterans. VISNs
    were originally created around referral patterns and geographic
    boundaries. In addition, VISNs work together along their borders to
    ensure access to healthcare for veterans in those areas. The Gulf Coast
    region is one area where VISNs seven, eight and 16 have worked very
    well together in managing care for veterans in the area. Therefore, VA
    sees no reason to add an additional Network for this region.
    H.R. 2005--Rural Veterans Health Care Improvement Act of 2007
        H.R. 2005 is intended to improve VA's ability to meet the
    healthcare needs of rural veterans. section 2 of this bill would amend
    VA's beneficiary travel program by requiring VA to pay or reimburse
    eligible veterans at the same per diem rates and mileage rates that
    apply to Federal employees using privately owned vehicles for official
    travel.
        Section 3 would require the Secretary, through the Director of the
    Office of Rural Health, to establish up to five Rural Health Research,
    Education, and Clinical Centers of Excellence (``Centers''). The bill
    sets forth detailed requirements that would govern the Secretary's
    designation and placement of such Centers. It also would limit
    designation of Centers to those facilities found by a peer review panel
    to meet the highest competitive standards of scientific and clinical
    merit and also found by the Secretary to have met the requirements
    specified in the legislation.
        Section 4 would require the Secretary to establish a grant program
    for State Veterans' Service Agencies and Veterans' Service
    Organizations for purposes of providing veterans living in remote rural
    areas with innovative means of travel to VA medical centers (and to
    assist them with their other medical care needs). A grant awarded under
    this section could not exceed $50,000. Grant recipients would not be
    required to provide matching funds as a condition for receiving a
    grant. This section would require the Secretary to prescribe
    regulations to implement this program and also authorize to be
    appropriated $3 million for each of FYs 2008 through 2012 to carry out
    this program.
        Section 5 would require the Secretary, through the Director of the
    Office of Rural Health, to carry out demonstration projects to examine
    alternatives for expanding care to veterans in rural areas. In so
    doing, the Secretary would be required to establish partnerships with
    the Department of Health and Human Services (HHS) to coordinate care
    for veterans in rural areas at both critical access hospitals and
    community health centers. VA would also be obliged to coordinate with
    HHS' Indian Health Service to expand care for Native American veterans.
        The bill would institute annual reporting requirements, the first
    of which would have to include the results of the statutorily mandated
    assessment of VA's fee-basis program on the delivery of care to
    veterans residing in rural areas, along with the results of VA's
    extensive outreach program to OEF/OIF veterans living in rural
    veterans.
        Mr. Chairman, while we appreciate the impetus for H.R. 2005, we do
    not support the bill. In accordance with Congress' mandate in the
    ``Veterans Benefits, Health Care, and Information Technology Act of
    2006,'' VA recently established the Office of Rural Health (ORH) within
    the Veterans Health Administration. Part of that office's charge is to
    determine how we can best continue to expand access to care for rural
    veterans. Presently, ORH is developing a strategic plan for operations
    and is considering a proposal to create new research centers. We would
    request the Congress wait until these assessments are complete before
    requiring action in this area. We will keep the Committee abreast of
    ORH's activities and findings as available.
        VA is working closely with other organizations in a variety of
    areas, including outreach, clinical care, education, expanded services,
    care coordination, and telemedicine, to improve the quality of
    healthcare available to those living in rural areas. The Department of
    Health and Human Services (HHS) and the Department of Veterans Affairs
    (VA) signed a Memorandum of Understanding (MOU) in February 2003 to
    encourage cooperation and resource sharing between the Indian Health
    Service (IHS) and the Veterans Health Administration (VHA) to deliver
    quality healthcare services and enhance the health status of American
    Indian and Alaska Native (AI/AN) veterans. VHA's Office of Rural Health
    (ORH) has also established a working relationship with and sought
    consultation from HHS's Office of Rural Health. As the office matures,
    VHA's plan is to work closely with HHS to maximize the opportunities in
    a range of areas including education, training, research, and access.
    Therefore, a Congressional mandate to encourage cooperation with HHS
    and IHS is not necessary.
        Moreover, while we acknowledge there has been a significant
    increase in fuel prices, beneficiary travel payments are paid out of
    funds appropriated for healthcare treatment and services. In our view,
    VA should use medical care funds for furnishing direct patient care in
    the manner that best serves the most veterans. It is also important to
    note that increasing the beneficiary travel payment and reimbursement
    rates would benefit only the limited categories of veterans who are
    eligible for those benefits e.g., veterans whose travel is in
    connection with treatment for a service-connected disability. For that
    reason, the amendments to the beneficiary travel program that are set
    forth in H.R. 2005 may not advance the Congress' general objective of
    improving access to care for rural veterans.
        We further note that the travel benefits program for Federal
    employees is distinct and on the whole inapposite to VA's beneficiary
    travel benefits program. It is unclear, based upon the text of the
    bill, if the limitations and conditions on Federal employee eligibility
    for travel pay would be applied to veterans. Federal employees do not
    automatically qualify for reimbursement of expenses they incur while on
    official travel. They must meet certain criteria to be eligible for
    such reimbursement, particularly in connection with the use of a
    privately owned vehicle. The criteria and conditions for reimbursement
    that apply to Federal employees (e.g., travel order) would not be
    appropriate to patients traveling to VA facilities for care and
    treatment, and transposing such a system would prove to be very complex
    and difficult to manage. VA estimates the cost of section 2 of H.R.
    2005 to be $253 million for FY 2008 and $7 billion over a 10-year
    period.
    H.R. 2172--Amputee Veteran Assistance Act
        Mr. Chairman, the next bill on today's agenda is H.R. 2172. This
    bill would require the Secretary to ensure, not later than 5 years
    after enactment, that all VA orthotic-prosthetic laboratories and
    clinics are certified by either the American Board for Certification in
    Orthotics and Prosthetics or the Board of Orthotics and Prosthetic
    Certification.
        This bill would also require the Secretary to seek to enter into a
    contract with a non-VA entity for the service and repair of a
    prosthetic device for a veteran in the following situations:

          If the Secretary determines that VA facilities are unable
    to perform the necessary service or repair due to a lack of technology
    or for any other reason that the Secretary determines prevents such
    service or repair in a timely manner; or
          The veteran in need of such service or repair resides at
    a distance greater than 55 miles from the nearest suitable VA facility
    capable of furnishing the service or repair.

        The bill would further require the Secretary to develop and carry
    out a plan to inform disabled veterans at least twice a year of the
    technological advances made in the field of prosthetics. The above-
    discussed contracting and information related requirements would both
    have to be implemented not later than 6 months after the date of the
    bill's enactment.
        Additionally, H.R. 2172 would require the Secretary to conduct and
    complete a review of all VA orthotic-prosthetic laboratories and
    clinics to ensure that the Department is capable of serving and
    repairing the most technologically advanced prosthetic devices. Such
    review would need to be conducted and completed not later than one year
    after the bill's enactment. No later than 6 months after completion of
    that review, the Secretary would need to submit a report to Congress on
    the Secretary's findings and any recommendations to address
    deficiencies in capability that were identified during the mandated
    review.
        Finally, no later than 1 year after the bill's enactment, this bill
    would require the Secretary to conduct and complete a review of VA's
    prosthetists and orthotists to determine what level and kinds of
    training and education will be needed to ensure they are qualified to
    service and repair the most technologically advanced prosthetic
    devices. No later than 6 months after that review is completed, the
    Secretary would be required to submit a report to Congress on the
    Department's findings and any recommendations to address identified
    deficiencies in education, training, or qualification.
        VA does not support H.R. 2172 because it is unnecessary. VA's
    policies already meet or exceed the requirements in the bill. In 2003
    VA mandated all prosthetic and orthotic laboratories be accredited by
    the American Board for Certification in Orthotics and Prosthetics or
    the Board of Orthotics and Prosthetic Certification. Today, all 58 of
    our laboratories are accredited and we require all contractors be
    accredited by these organizations as well. As a prerequisite of
    attaining accreditation, each facility had to employ at least one
    certified Prosthetist/Orthotist to oversee all work. Today, 131 out of
    our 186 prosthetists/orthotists are certified and we are actively
    encouraging all staff to attain this certification. Both ABC and BOC
    require all certified practitioners maintain certification through 5-
    year cycles of continuing education units, including education in new
    and emerging technology. VA will continue to conduct site visits to all
    prosthetic and orthotic laboratories to ensure they meet quality
    standards and maintain their accreditation.
        VA uses over 600 non-department entities for fabrication, service
    and repair of prosthetic devices. Veterans will continue to have their
    choice of contracted providers, including the VA. VA is informing
    veterans of new developments with Open Forums, routine newsletters and
    press releases, and a dedicated web link devoted to the care and
    treatment of amputees.
        As a technical matter we point out that H.R. 2172 would amend
    chapter 31 of title 38, United States Code, which governs vocational
    rehabilitation benefits administered by the Veterans Benefits
    Administration, not chapter 17 of the same title, which governs the
    provision of healthcare benefits, including prosthetic care and
    services.
    H.R. 2173--Authorization for Vet Centers to contract for Mental Health
            Services
        will now discuss H.R. 2173. This bill would amend VA's readjustment
    counseling authority in 38 U.S.C. Sec. 1712A to permit the Secretary to
    enter into contracts with community mental health centers (deemed
    qualified by the Secretary) for the provision of mental health services
    as part of VA's readjustment counseling program.
        VA does not support H.R. 2173. Currently, VA's authority to provide
    mental health services to veterans receiving readjustment counseling
    services under section 1712A of title 38, United States Code, is
    limited to mental health services that are necessary to facilitate the
    successful readjustment of a veteran to civilian life and limited to
    the provision of counseling, training and mental health services
    described in 38 U.S.C. Sec. Sec. 1782 and 1783 (bereavement counseling)
    for the veteran's immediate family members. It is not clear if the
    bill, in creating a new subsection wholly unrelated to the existing
    provisions governing VA's contracting authority under section 1712A,
    means to encompass mental health services beyond those currently
    authorized and those which have traditionally been provided under VA's
    readjustment counseling mission (in contrast to VA's clinical mission).
        As already alluded to, Vet Centers currently have authority to
    contract with private sector community mental health agencies for the
    provision of readjustment counseling services and related mental health
    services. For more complex mental health needs, Vet Centers readily
    refer patients to VA medical facilities. Furthermore, H.R. 2173 would
    obfuscate and blur the special service mission of the Vet Centers as
    defined by law. These services are deliberatively set apart from
    medical facilities to promote more than medical readjustment services
    for combat veterans in an easy to access, community-based setting.
    H.R. 2192--Establishement of Office of Ombudsman within the Department
        H.R. 2192 would establish an Office of the Ombudsman (herein
    referred to as the ``Office'') within the Department and require the
    Secretary to designate an Ombudsman to carry out the duties of the
    Office. The Ombudsman would act as a liaison for veterans and their
    family members with respect to the receipt of healthcare and benefits
    administered by VA.
        This measure would also require the Secretary to ensure the
    services of the Office are available to all veterans and their family
    members and would further direct the Secretary to make available to
    each veteran, and to the family members of all veterans, information on
    contacting and using the services of the Office. Lastly, H.R. 2192
    would authorize the disclosure of information provided by veterans or
    their family members only to the extent necessary to carry out the
    duties of the Office.
        VA does not support H.R. 2192. Of particular concern is the
    provision that would authorize the Ombudsman to act as a liaison for
    veterans and their family members with respect to the receipt of
    healthcare. VHA has instituted a variety of measures to support our
    patients and their families, including appointing patient advocates in
    our Medical Centers, benefits counselors, OEF/OIF Coordinators, and
    Transition Patient Advocates for those seriously injured in combat. Vet
    Center counselors also contribute to resolving situations on behalf of
    veterans. VSO representatives, likewise, serve ably as counselors and
    mentors and many State Departments of Veterans Affairs contribute in
    this area. VBA has also has extensive initiatives and programs aimed at
    assisting claimants with respect to receipt of benefits, including the
    Transition Assistance Program (TAP), the Benefits Delivery at Discharge
    (BDD) Program, and expanded outreach to veterans, dependents, and
    survivors. Adding another layer of oversight and involvement could
    create a confusing situation for patients and families, who might
    become unsure whom to consult. A new Office of the Ombudsman could also
    produce confusion within VA in terms of assignments and
    responsibilities, since the bill, as written, does not delineate
    between the role the new Office would fill vis-a-vis other offices
    within VA.
    H.R. 2219--Veterans Suicide Prevention otline Act of 2007
        Mr. Chairman, H.R. 2219 would require the Secretary to award one
    grant for a period of not more than 3 years to an eligible entity to
    establish, publicize, and operate a national toll-free telephone number
    to serve as a suicide prevention hotline targeted to, and staffed
    predominately by, veterans of the Armed Forces.
        Under H.R. 2219, the grantee would be required to perform the
    following functions:

          enter into a contract with a telecommunication carrier
    for the use of such a national toll-free number;
          select; train; and supervise personnel to answer incoming
    calls and to provide counseling and referral services to callers;
          ensure that sufficient staffing is provided so that the
    hotline services are available to callers at all times;
          assemble and maintain a current database of information
    to be used to refer callers to local service providers and of
    information about the availability of shelters for homeless callers;
          publicize the hotline to potential callers; and
          certify the capacity of, and provide supplemental
    training for, any local crisis center operating as a subcontractor of
    the grantee.

        H.R. 2219 would further provide that to be eligible to receive the
    grant under this section, a private, nonprofit entity would have to
    prepare and submit a detailed application to the Secretary addressing a
    number of specified areas. The selected grant recipient would, in turn,
    be required to submit an annual report to the Secretary, in the form
    and with such information as the Secretary may require. The grantee
    would have to include in that report the volume of calls to the
    hotline, the demand for specific types of referrals, and the number of
    trained volunteers answering the hotline. Finally, payments awarded to
    the grantee would be subject to annual approval by the Secretary and to
    the availability of appropriations for each FY.
        For purposes of the grant award, H.R. 2219 would authorize to be
    appropriated $2,500,000 each year for FYs 2008, 2009, and 2010.
        VA does not support H.R. 2219. VA is already developing a
    comprehensive program for suicide prevention including a national 24
    hour toll-free hotline. The services under development in VA are more
    comprehensive that those proposed in H.R. 2219. VA is proposing to
    administer the services with VA mental health professional staff, not
    outside contractors, to provide mechanisms for accessing the electronic
    health records of veteran-callers as part of the response to crisis
    calls, and to establish strong interactions between the national
    hotline and the suicide prevention coordinators in each medical center
    to provide for continuity of care. While we respect the idea of peer-
    to-peer counseling, which is employed with great effectiveness in our
    Vet Centers, VA believes it is more appropriate from a clinical
    standpoint to staff VA's national hotline with trained healthcare
    professionals.
    H.R. 2378--Services to Prevent veterans Homelessness Act
        H.R. 2378 is a measure intended to prevent low income veterans
    transitioning to, or residing in, permanent housing from falling back
    into their former homeless condition. Subject to the availability of
    appropriations provided for the bill's purpose, H.R. 2378 would require
    the Secretary to provide financial assistance to eligible entities to
    provide and coordinate the provision of supportive services for very
    low-income veteran-families occupying permanent housing or
    transitioning from homelessness to permanent housing. The bill would
    further require the Secretary to establish a formula for determining
    the rate of payments to be made to eligible entities providing
    supportive services under this section. The rate would have to be
    adjusted at least annually to reflect changes in the cost of living. In
    calculating the rate payment formula, the Secretary would be authorized
    to consider geographic cost of living variances, family size, and the
    cost of services provided.
        To be eligible to receive funding, H.R. 2378 would require eligible
    entities to submit a detailed application to the Secretary. This bill
    would also authorize the Secretary to give preference to an entity
    providing or coordinating the provision of supportive services for very
    low-income veteran families who are transitioning from homelessness to
    permanent housing.
        This measure would require the Secretary to provide training and
    technical assistance to entities receiving payments under this program
    on the planning, development, and provision of supportive services to
    the targeted families. Such assistance could be provided either
    directly, or through grants or contracts with appropriate public or
    nonprofit private entities.
        As to funding, H.R. 2378 would make available out of the amounts
    appropriated for medical care $25 million for each of FYs 2008, 2009,
    and 2010, of which not more than $750,000 could be used to provide
    technical assistance.
        VA generally supports H.R. 2378 but we strongly recommend that the
    bill be modified to allow VA to establish additional criteria,
    specifically clinical indicators, to ensure this program reaches
    veteran families requiring additional support to end their
    homelessness. H.R. 2378 would require additional staffing resources for
    VHA's Homeless Program Office in the Office of Mental Health Services.
        This concludes my prepared statement. I would be pleased to answer
    any questions you or any of the members of the Subcommittee may have.

          Statement of Andy Behrman, Chair, Rural Health Policy Board,
                       National Rural Health Association
        It is my distinct pleasure to submit my comments for the record in
    regard to H.R. 2005, the Rural Veterans Health Care Improvement Act of
    2007. As the Rural Health Policy Board Chair for the National Rural
    Health Association (NRHA), and as a veteran, I have long been an
    advocate for appropriate change and improvement to our VA healthcare
    delivery system. It is a priority for me and a priority for the NRHA.
        The NRHA is a national nonprofit, non partisan, membership
    organization whose mission is to improve the health of rural Americans
    and to provide leadership on rural health issues. The members of the
    NRHA have long maintained concern for the health and mental healthcare
    needs of rural veterans.
        The members of the National Rural Health Association (NRHA) have
    maintained a special concern for the health and mental healthcare needs
    of rural veterans for many years. NRHA was one of the first non-veteran
    service organizations to develop a policy statement on rural veterans
    and this policy work is evidence of our memberships' concern for rural
    veterans.
        Since our Nation's founding, rural Americans have always responded
    when our Nation has gone to war. Whether motivated by their values,
    patriotism, or economic concerns, the picture has not changed much in
    230 years. Simply put, rural Americans serve at rates higher than their
    proportion of the population. Though only 19% of the nation lives in
    rural areas, 44% of U.S. Military recruits are from rural America. And
    nearly one-third of those who died in Iraq are from small towns and
    communities across the nation.
        There is a national misconception that all veterans have access to
    comprehensive care. Unfortunately, this is simply not true. Access to
    the most basic primary care is often difficult in rural America. Combat
    veterans returning to their rural homes in need of specialized care due
    to war injuries (both physical and mental) likely will find access to
    that care extremely limited. What this means, is that because there is
    a disproportionate number of rural Americans serving in the military,
    there is a disproportionate need for veteran's care in rural areas.
        Additionally, we must all be mindful of long-term needs. While the
    NRHA is pleased that both the House and Senate FY 2008 budgets call for
    greater increases in VA medical care spending than in past years, long-
    term healthcare planning is critical. The wounded veterans who return
    today won't need care for just the next few fiscal years, they will
    need care for the next half century.
        In my testimony to the Committee on April 18, 2007, I presented
    recommendations that NRHA believes to be prudent in terms of developing
    a new approach to serving our rural veterans. These recommendations
    include:
    1. Increasing Access by Building on Current Successes
        Community Based Outreach Centers (CBOCs) open the door for many
    veterans to obtain primary care services within their home community.
    Additionally, Outreach Health Centers meet the needs of many rural
    veterans. NRHA applauds the success of these programs and supports
    their expansion.
    2. Increasing Access By Collaborating with Non-VHA Facilities
        Many rural veterans cannot access VHA care simply because VHA
    facilities are too far away. Linking the quality of VA services with
    rural civilian services can vastly improve access to healthcare for
    rural veterans. As long as quality standards of care and evidence-based
    medicine guide treatment for rural veterans, the NRHA supports
    collaboration with:

          Federally Qualified Community Health Centers. These
    centers serve millions of rural Americans and provide community-
    oriented, primary and preventive healthcare. And, most importantly, are
    located where rural veterans live. A limited number of collaborations
    between the VHA and Community Health Clinics already exist and have
    proven to be prudent and cost-effective solutions to serving eligible
    veterans in remote areas. These successful models should be expanded to
    reach all of rural America.
          Critical Access Hospitals. These facilities provide
    comprehensive and essential services to rural communities and are
    specific to rural states. If these facilities are linked with VA
    services and models of quality, access to care would be greatly
    enhanced for thousands of rural veterans.
          Rural Health Clinics. These clinics serve populations in
    rural, medically underserved areas. In many rural and frontier
    communities, these clinics are the only source of primary care
    available.

    3. Increasing Traumatic Brain Injury Care
        Currently, it appears that Traumatic Brain Injury (TBI) will most
    likely become the signature wound of the Afghanistan and Iraqi wars.
    Such wounds require highly specialized care. The current VHA TBI Case
    Managers Network is vital, but access to it is extremely limited for
    rural veterans--expansion is needed.
    4. Targeting Care to Rural Veterans
      A.  Needs of the Rural Family. Rural veterans have an especially
    strong bond with their families. Returning veterans adjusting to
    disabilities and the stresses of combat need the security and support
    of their families in making their transitions back into civilian life.
    The Vet Centers do a tremendous job in assisting veterans, but their
    resources are limited. The NRHA supports increases in funding for
    counseling services for veterans' and their families.
      B.  Needs of Rural Women Veterans. More women serve in active duty
    than at any other time in our Nation's history. And more women are
    wounded or are war casualties than ever before in our nation's history.

        Targeted and culturally competent care for today's women veterans
    is needed. Rural providers should also be trained to meet the unique
    needs of rural, minority, and female veterans.
    5. Improving Office of Rural Veterans
        The NRHA calls on Congress and the Veterans Administration to fully
    implement the functions of the newly created Office of Rural Veterans
    to develop and support an on-going mechanism to study and articulate
    the needs of rural veterans their families.
        We are grateful to Mr. Salazar for introducing HR 2005 and are
    grateful for the Committee's consideration of the bill. This
    legislation provides important relief for rural veterans and clearly
    addresses our second and fifth recommendations. We hope the Committee
    will consider this as a strong and positive step toward addressing the
    many challenges--especially access challenges--faced by rural veterans.
        To that end, we hope that this Committee will also address other
    ways to improve access to healthcare for our rural veterans. While the
    VA has provided outstanding service to our veterans over the years (and
    I have been one of those recipients), the need to increase access to
    services has become a major concern to the VA, and a critical concern
    to veterans living in rural communities throughout the United States.
        Efforts to increase service points for rural veterans have, in
    large part, been hindered by the VA Administration itself. The VA has
    thwarted attempts to collaborate with organizations that are located
    where rural veterans reside (such as community health centers, critical
    access hospitals, and rural health clinics) because of a false
    assumption that quality of care standards in rural communities are
    inferior. To the contrary, the standards of healthcare in rural America
    are high. In fact, community health centers, for example, have been
    rated as the number one most efficient and effective program in all of
    HHS. CHS must meet the highest standards of care, and in many cases,
    they musts also be Joint Commission accredited. All facilitates must
    meet federal standards of care.
        We must never forget that many veterans forgo care entirely because
    of access difficulties to VA facilities. Often, however, local quality
    care is available within a veteran's own community. In many cases,
    these rural centers, as well as critical access hospitals and rural
    health clinics, are the only providers in a large geographic area. Our
    goal is not to mandate care to our veterans, but to provide them a
    choice, a local choice. We applaud Congressman Salazar and this
    Committee for taking steps toward providing our honored veterans with
    such a choice.
        Thank you again for this opportunity. The NRHA looks forward to
    working with you and this Committee to improve rural healthcare access
    for the millions of veterans who live in rural America.

                  Statement of the Honorable Silvestre Reyes,
              a Representative in Congress from the State of Texas
        Chairman Michaud, Ranking Member Miller, and distinguished members
    of the Subcommittee, I would like to thank you for the opportunity to
    testify before you in support of my bill HR 2172 the Amputee Veteran
    Assistance Act. As a veteran and former member of this Committee, many
    of you know me well and are aware of my commitment to Veteran issues.
    Today as Chairman of the Intelligence Committee and a member of the
    Armed Services Committee much of my time is devoted to ensuring that
    our troops have the necessary equipment and timely intelligence they
    need to fight the wars in Iraq and Afghanistan and to return home
    safely. However, I believe it is also critically important that our
    troops have confidence that if they are wounded in battle that they
    will be cared for in a manner that reflects the great sacrifices they
    have made for our country.
        The wars in Iraq and Afghanistan are placing great strain not only
    on our armed forces but on the Veterans Administration (VA) as well.
    The VA has not experienced this level of casualties since the Vietnam
    War. Despite the committed work of many healthcare professionals within
    the VA, the system is having a tough time dealing with this new influx
    of wounded veterans, while addressing the needs of our others veterans
    who honorably served in previous conflicts.
        As you know, since the beginning of the wars in Iraq and
    Afghanistan, more than 500 of our brave men and women in the armed
    forces have suffered major amputations resulting from wounds and
    injuries received in combat. Many of them have suffered multiple
    amputations. Our wounded servicemen and woman are now receiving world-
    renowned care and access to some of the most modern prosthetic
    technology available under the Department of Defense (DOD) healthcare
    system. Some of our amputee soldiers have even been able to return to
    duty. However, others, because of their own unique situations, are
    transitioning to the VA, a system they will be part of for the rest of
    their lives. I want to assure that the VA is well prepared to provide
    service and care for their advanced prosthetic devices. Some recent
    amputee veterans and veteran support groups have expressed reservations
    that the VA is currently too focused on convalescent care and does not
    have the resources and training to help these wounded men and women
    return to the active lives they led before their wounds.
        During her testimony before the Senate Committee on Veteran Affairs
    last March, Major Tammy Duckworth, an Iraq war amputee and Director of
    the Illinois Department of Veteran Affairs, spoke about her
    difficulties transferring from the DOD healthcare system to the VA. She
    noted that the care she received as an inpatient at Walter Read Army
    Medical Center was exceptional, but her experiences with her local VA
    prosthetic facility were less positive. She pointed out that the VA
    prosthetics departments were ``many decades behind'' in technology and
    that VA staff, while eager to be helpful, lacked the knowledge and
    training to treat amputees at high tech levels set at Walter Reed and
    other major DOD healthcare facilities.
        The Amputee Veteran Assistance Act is an important step toward
    addressing some of these shortcomings in the VA system. I would like to
    emphasize that this bill is not an indictment of the VA. The VA has
    played an important role in research and development in the field of
    prosthetics for many decades and should be commended for its efforts.
    Instead, it is a step toward giving VA personnel the training and
    resources they need to do their jobs better, while addressing the
    immediate concerns of our amputee veterans. It is my hope that this
    bill will help create a more personalized approach for our veterans.
    The field of prosthetics is as much of an art as it is a science. Each
    amputee veteran is a unique case with his or her own specific needs. My
    bill is not an attempt to create a ``one size fits all'' solution but
    to better prepare the VA to address a wide range of demands and give
    our amputee veterans greater options in the mean time.
        This legislation will require that all VA prosthetic facilities and
    prosthesists be certified within 5 years by either the American Board
    for Certification in Orthotics and Prosthetics or the Board of
    Orthotics and Prosthetic Certification. Many of the VA facilities and
    prosthesists are already board certified but some are still lagging
    behind. It also allows amputee veterans to seek care for the repair and
    servicing of prosthetic devices from outside the VA system when VA
    facilities are unable to perform the required service or repairs or
    when a suitable VA facility is not available within a 55 mile radius.
    The VA will also be required to conduct a study to provide
    recommendations on modernizing its facilities and training its
    prosthesists so that it will be able to address the high tech needs of
    these amputee veterans. This report will allow us to get a better
    handle on what kind of resources the VA will need to address these
    problems. It also requires the VA to implement a plan to inform amputee
    veterans twice a year about the latest innovations in the field of
    prosthetics. Advances in the field of prosthetics continue rapidly and
    many amputee veterans may not be aware of some of the new options out
    there for them.
        I know you will all agree that providing for our brave men and
    women in uniform who have sacrificed so much for our great nation is
    imperative. Today we have an opportunity to demonstrate to our disabled
    veterans our firm commitment to providing them with all possible means
    for living a full and rewarding life. Thank you for giving me the
    opportunity to testify before the committee. I will be pleased to
    answer any questions you might have.

                                    United States Ombudsman Association
                                                Des Moines, Iowa, 50325
                                                          June 13, 2007
    Hon. Michael H. Michaud
    Chairman, Subcommittee on Health
    U.S. House of Representatives
    Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, DC 20515

    Dear Representative Michaud:

        On behalf of the United States Ombudsman Association (USOA), thank
    you for your invitation to comment on H.R. 2192, proposed legislation
    to establish an ombudsman within the Department of Veterans' Affairs.
        I have served as President of the USOA for 2 years and am the
    Deputy Ombudsman in the State of Iowa--Office of Citizens' Aide/
    Ombudsman. My short curriculum vitae is appended.
        The USOA, a non-profit association, does not receive any federal
    funds and does not participate in any federal contract or grant, nor
    has it done so for the previous two fiscal years.
        Founded in 1977, the USOA is our Nation's oldest and largest
    organization of ombudsmen working in government to address citizen
    complaints. The membership of the USOA includes practicing ombudsmen at
    all levels of government, some of whom have general jurisdiction over
    multiple agencies and subject matters, and others who have jurisdiction
    over a specified subject matter or agency. (Detailed information
    regarding the USOA can be found at the Association's website: http://
    www.usombudsman.org/.)
        As a matter of good public policy, the USOA supports the
    establishment of independent ombudsman offices for the investigation
    and resolution of complaints involving administrative agencies in
    government at all levels. An ombudsman can serve as an independent
    office not only to address individual concerns, but also to identify
    systemic problems and recommend improvements in policies, practices,
    and procedures. An ombudsman can also help in the important effort to
    provide public and, indeed, legislative oversight of administrative
    agencies in government.
        From this perspective we have reviewed the proposed legislation and
    offer these comments.
        Key to the ability of an ombudsman to function effectively is
    independence. An ombudsman whose position, budget, staff, and
    investigations can be controlled or supervised by persons who (or whose
    actions or decisions) may be the subject of an investigation is not
    independent and will not be perceived as being independent. To the
    extent possible, an ombudsman should be structurally separated from the
    entities that are subject to the ombudsman's review or investigations.
    An ombudsman should be free to hire and fire staff, within the larger
    employment structure, manage the budget, select and prioritize the
    issues to be investigated and determine how they should be
    investigated. This independence allows the ombudsman to act and to be
    viewed by the public as acting as an impartial official who reports
    findings and recommendations based on objective review of the facts and
    the applicable law.
    Structural Location
        H.R. 2192 establishes the ombudsman within the Department of
    Veterans' Affairs. The USOA believes that the best way to make an
    ombudsman independent is by situating the ombudsman's office in the
    legislative branch of government. If that arrangement is not feasible,
    then we believe that everything reasonably possible should be done to
    maximize an ombudsman's independence within the branch of government or
    agency where the office is situated.
    Appointment, Supervision, Term, and Removal
        H.R. 2192 provides for the Secretary of the Department to designate
    the ombudsman. It does not specifically state to whom the Ombudsman
    reports for supervision or direction on job duties. Assuming that the
    ombudsman reports to the Secretary, the USOA believes that can
    compromise the independence of the ombudsman because the Secretary sets
    policies and makes decision relevant to the Department's programs and
    is the person ultimately accountable for decisions made by departmental
    staff. The ombudsman needs to be able to function without fear or
    concern that shat he/she says in regards to supervisory officials might
    affect his/her job.
        For this reason, the USOA believes it would be best for the
    ombudsman to be appointed by Congressional action. If that is not
    feasible, an alternative is for the ombudsman to be appointed by the
    President, with the advice and consent of the Senate (like an Inspector
    General) or a Congressional Committee.
        Furthermore, the term of the office should be set in such a manner
    that it does not coincide with administrative terms of office. In
    addition, removal or dismissal from office within the term should be
    limited to ``just cause,'' with relevant definitions specified in the
    legislation.
        We urge inclusion of these provisions under subsection (a) to
    reinforce the independence of the ombudsman.
    Ombudsman's Staff
        Based on the experience of USOA members, we recommend a provision
    for the ombudsman to appoint at least a deputy or assistant ombudsman,
    to maintain consistent functioning of the office, in the event the
    ombudsman is absent or the position is vacant.
    Authority to Investigate
        Subsection (b), pertaining to duties of the office, states only
    that the ombudsman ``shall act as a liaison for veterans and their
    family members.'' One of the hallmarks of an ombudsman function is the
    authority to investigate the agency which it oversees. The proposed
    legislation is silent in this regard. The USOA recommends that specific
    language be included in the legislation granting the ombudsman the
    authority to investigate complaints related to the healthcare program
    and benefits administered by the Department.
    Authority to Access Information
        H.R. 2192 is also silent regarding the ombudsman's ability to
    gather relevant information, including information which may be
    confidential by law. The duty to investigate ought to include the
    authority to have access to information and to issue subpoenas when
    necessary. While usually an ombudsman will be able to obtain
    information from an agency on an informal basis, there may be instances
    when the agency may resist or deny information. Therefore, we recommend
    adding such a provision regarding this authority. In addition, the
    provision may require the ombudsman to keep confidential any
    information which is confidential by law.
    Authority to Issue Public Reports
        Another important function that is also missing from H.R. 2192 is
    the authority to report the investigative findings and recommendations
    for improvements. Since ombudsmen do not have enforcement authority
    they rely on the ability to persuade an agency to take corrective
    action. The option to publicly criticize an agency enhances that
    ability. In addition, public reports can educate and inform those
    interested in or affected by the issues involved. An ombudsman cannot
    be effective without the duty to investigate and report. In addition,
    the ombudsman should submit an annual report to Congressional members
    and other officials with policy and operational oversight over the
    Department of Veterans' Affairs.
        We recommend adding these duties to subsection (b) of the proposed
    legislation.
    Confidentiality and Immunity
        Subsection (d) provides for information provided to the ombudsman
    by veterans or their family members to be disclosed only as necessary
    to carry out the duties of the office. We recommend expanding this
    provision to grant the ombudsman immunity from being compelled to
    testify or produce complaint and investigative records in any legal
    proceedings, except as necessary to enforce or defend the authority of
    the office.
    Closing
        Thank you for allowing the USOA this opportunity to comment on the
    proposed legislation. We applaud your consideration of creating the
    ombudsman function, in the interest of improving the delivery of
    necessary services to our veterans and their families.
                Sincerely,
                                                       Ruth Cooperrider
                                                              President
                               United States Ombudsman Association, and
                                                       Deputy Ombudsman
                      State of Iowa--Office of Citizens' Aide/Ombudsman

                                    U.S. Department of Veterans Affairs
                                                        Washington, DC.
                                                        August 19, 2007
    The Hon. Bob Filner
    Chairman
    Committee on Veterans' Affairs
    U.S. House of Representatives
    Washington, DC 20515

    Dear Mr. Chairman:

        This letter is in response to your invitation to submit for the
    record the Department's views on two discussion drafts and H.R. 2623
    and H.R. 2699. We received these legislative items too late to address
    them in the statement we submitted to the Subcommittee in connection
    with the June 14, 2007, legislative hearing.
    Discussion Draft on Readjustment Counseling Services and Mental Health
        Section 1 of this discussion draft would require the Secretary to
    establish a program to provide readjustment counseling and mental
    health services to eligible veterans through contracts with community
    mental health centers. Eligible veterans would include combat-theater
    veterans who seek VA care within the 2-year period after their
    discharge or release from service, who served in Operational Enduring
    Freedom or Operation Iraqi Freedom, and who reside in an area where the
    Secretary has determined the Department is incapable of providing
    readjustment and mental health services.
        This provision would cover community mental health centers which:
    (1) meet qualification standards determined by the Secretary; (2)
    require appropriate staff to complete a VA clinical and cultural
    training program; and (3) employ a qualified veteran for the duration
    of the contract. These centers would also be required to submit
    information relating to the program's workload to the Secretary on an
    annual basis.
        Section 1 would further require the Secretary to establish a
    program to provide support and assistance to the immediate family
    members of eligible veterans. Such assistance would include the
    provision of education materials and classes on mental health issues
    (including signs and symptoms of post traumatic stress disorder). This
    provision would also require the Secretary to provide individual
    counseling and mental health services (up to 2 years) to immediate
    family members, if requested.
        Section 1 would also require the Secretary to establish a 5-year
    pilot program in at least four Veterans Integrated Service Networks
    (VISNs) to provide confidential readjustment counseling and mental
    health services to combat theater veterans at non-VA facilities. Under
    the pilot program, veterans would receive a voucher, coupon, or card
    that could be used to receive five visits with any provider on a
    Department-approved list.
        For the reasons discussed below, the Department opposes section 1.
    First, it would blur the distinction between VA's readjustment
    counseling services and mental health services and work at cross-
    purposes with the existing programs. Additionally, these services are
    authorized by separate authorities and employ different eligibility
    criteria. These benefits should not be coupled because they are
    conceptually and operationally very distinct areas of treatment.
        VA's authority to furnish readjustment counseling services includes
    authority to furnish limited mental health services necessary for
    effective treatment of the veteran's readjustment problems. Vet Centers
    provide professional treatment for combat-related Post Traumatic Stress
    Disorder (PTSD), depression, and substance abuse and, if necessary,
    refer the veteran to VA facilities for treatment of additional or more
    complex mental health needs. VA's readjustment counseling services
    encompass many other unique social and psychological readjustment
    services separate from mental health services. Readjustment counseling
    is considered to be a special, ``more-than-medical,'' community-based
    counseling service providing an array of services to combat theater
    veterans to facilitate a successful readjustment from combat to
    civilian life. Vet Centers also have authority to furnish limited
    counseling, education, and training services to the veteran's immediate
    family members when such services are needed for the effective
    treatment and readjustment of the veteran. Family readjustment services
    include outreach, early intervention educational services, and family
    counseling. Family counseling is provided through the Vet Centers to
    treat any psychological, social or other military-related readjustment
    problems of the veteran whether those problems are service connected or
    not. We note that family services currently provided through Vet
    Centers are available throughout the life of the veteran. section 1
    would provide individualized counseling and mental health services for
    immediate family members for no more than 2 years, a significant
    reduction of the current benefit.
        Comprehensive mental health services are furnished as medically
    needed to all enrolled veterans, regardless of combat-status, as part
    of VA's standard medical benefits package. VA already has authority to
    furnish certain family members with counseling, training, and education
    services. However that authority is extremely limited by statute and
    extends only to those family members of veterans receiving treatment
    for a service-connected condition. That authority also requires a nexus
    between the services furnished to the family members and the effective
    treatment of the veteran.
        While we certainly appreciate that a veteran's family member may
    have his or her own mental health needs apart from the veteran's, we
    believe it is beyond the Department's statutory mission to furnish
    treatment or services to family members whose individual mental health
    needs are unrelated to the Department's ability to effectively treat
    the veteran.
        Second, VA already has authority to contract for both readjustment
    counseling services and mental health services. Currently, VA contracts
    for readjustment counseling and related readjustment services with
    private sector community mental health agencies and other professional
    entities. We see no justification for limiting the entities with which
    VA may contract for these services, as the bill would do. Of note, most
    of our contract providers are located in rural areas. In providing
    mental health services, VA collaborates with publicly supported clinics
    in furtherance of VA's Mental Health Strategic Plan. Several existing
    contracting related authorities can be used to ensure a veteran
    receives needed mental health services if VA cannot timely provide the
    needed services in a timely manner. In this regard, section 1 is
    duplicative of VA's existing contract authorities and on-going
    activities.
        Third, section 1 is not necessary because Vet Centers already
    provide veteran-peer outreach and counseling. In 2004, VA began an
    aggressive outreach effort, which included the hiring of combat-theater
    veterans of Operation Enduring Freedom (OEF) and Operation Iraqi
    Freedom (OIF) to provide outreach services and peer-counseling to their
    fellow veterans. To date, the Vet Center program has hired 100 OEF and
    OIF outreach workers.
        The Vet Center program is also undergoing the largest expansion in
    its history. The planned expansion complements the efforts of the Vet
    Center outreach initiative, discussed above, by ensuring sufficient
    staff resources are available to provide the professional readjustment
    services needed by the new veterans as they return home. In fiscal year
    (FY) 2006, VA announced plans for establishing two new Vet Centers in
    Atlanta, Georgia, and Phoenix, Arizona, and augmenting staff at 11
    existing Vet Centers, bringing the current number of Vet Centers to
    209. In February 2007, VA announced plans to increase the number of Vet
    Centers to 232 and augment the staff at 61 existing Vet Centers. The
    following communities will be receiving new Vet Centers: Montgomery,
    Alabama; Fayetteville, Arkansas; Modesto, California; Grand Junction,
    Colorado; Orlando, Fort Meyers, and Gainesville, Florida; Macon,
    Georgia; Manhattan, Kansas; Baton Rouge, Louisiana; Cape Cod,
    Massachusetts; Saginaw and Iron Mountain, Michigan; Berlin, New
    Hampshire; Las Cruces, New Mexico; Binghamton, Middletown, Nassau
    County and Watertown, New York; Toledo, Ohio; Du Bois, Pennsylvania;
    Killeen, Texas; and Everett, Washington.
        In May 2007, VA announced a plan to add 100 new staff positions to
    the Vet Center program in FY 2008. Together with the 100 OEF and OIF
    outreach specialists hired in FY 2004 and 2005, these program
    expansions represent an increase in Vet Center staffing by 369
    positions since 2004, a 39% increase.
        Fourth, while well-intended, the pilot program required by section
    1 could result in harm to a participating veteran. In most cases, five
    sessions is too few to ensure an adequate course of evidence-based
    treatment is delivered safely and effectively. A participating veteran
    may believe, in error, that upon completing the fifth visit that he or
    she has received a full course of treatment and no longer requires
    further assistance from the Department. The draft bill's arbitrary
    limit of five visits could create an unreasonable expectation on the
    part of the patient that he or she should be able to resolve their
    readjustment or mental health problems in that timeframe.
        Moreover, the pilot program would fragment care and impede VA's
    ability to ensure veterans in the program receive the benefits of
    continuity of care. In sharp contrast, VA-furnished readjustment
    services and mental health services are delivered in a manner promoting
    the veteran's continuity of care. Under the readjustment counseling
    program, VA conducts site-visits to contract providers to verify the
    quality of readjustment counseling services being rendered to veterans.
    With respect to mental health services currently provided through
    Department medical facilities, these services are fully integrated. Of
    utmost importance, the patient's medical data are maintained in the
    VA's electronic health record system, which further helps prevent
    fragmentation and ensure continuous high-quality care.
        Finally, the Vet Center program reports the highest level of
    veteran satisfaction recorded for any VA program. For the last several
    years, over 99% of veterans consistently using the Vet Centers reported
    satisfaction with services received and indicated they would recommend
    the Vet Center program to other veterans. In view of the Vet Center's
    authorities and accomplishments, we oppose section 1 because it would
    amend the Vet Center program in a way that adds no value and results in
    substantial confusion between these benefits and those separately
    furnished under VA's mental health programs.
        Section 2 of this discussion draft would authorize the Secretary to
    make a grant to a qualified entity to conduct workshop programs in the
    performing arts, public speaking, writing, and culinary arts to further
    the readjustment of veterans. Qualified entities would include a
    nonprofit private entity with expertise in conducting workshop programs
    or one that the Secretary determines has a program that is likely to
    improve the readjustment of veterans. A grant under this section could
    not exceed $100,000 for any calendar year and would need to be used
    exclusively for the benefit of veterans. section 2 would also authorize
    $2 million to be appropriated to carry out this section each fiscal
    year.
        VA does not support section 2. It is not clear what appropriation
    it is intended that VA use for this authority. We would oppose using
    medical care funds for services that would not constitute medical care.
    Second Discussion Draft on Programs for Homeless Veterans
    Homeless Providers Grant and Per Diem Program
        Section 1 would amend the Department's Homeless Providers Grant and
    Per Diem Program (the ``Program'') by requiring the Secretary to
    furnish funding assistance to grantees on an annual basis; currently
    the grantees receive per diem payments based on the provider's daily
    cost of care. It would also require the Secretary to annually increase
    the annual rate of payment to reflect anticipated changes in the
    grantee's cost of furnishing services and to take into account the cost
    of providing services in a particular geographic area. section 1 would
    further authorize the Secretary to establish a maximum annual amount
    that could be paid to a provider under the Program. Currently, the
    statutory cap on the per diem amount is the same that applies to per
    diem payments made to State homes.
        Section 1 would also eliminate the current requirement that VA
    adjust the per diem rate to exclude other sources of income a provider
    receives for the purpose of furnishing services to homeless veterans.
    However, section 1 would permit the Secretary to continue collecting
    such information as needed to determine the provider's cost of care.
    section 1 would also allow grantees to use VA payments to match, or in
    combination with, other payments or grants for which the grantee is
    eligible.
        The Department does not support section 1 in its entirety. Although
    payment on an annual basis would appear to ease the administrative
    burden of calculating daily per diem rates, it would not offer any
    incentive to providers for maintaining the census and level of services
    throughout the year for which the funding amount is awarded. Providing
    the grantee with an annual lump-sum payment would lessen a provider's
    accountability concerning the use of VA grant funds. This concerns us
    greatly. Also, this measure is unnecessary because the Department
    recently modified its system for determining per diem rates under the
    Program. This should make it much easier to determine the per diem
    rates and alleviate the administrative workload for both VA and the
    grantee.
        However, VA supports the provision in section 1 that would
    establish a maximum rate that could be paid to grantees, VA's grant
    program for State homes and the grant program for homeless providers
    are too dissimilar to justify linking the maximum payment level as is
    currently done by statute. And VA has no objection to eliminating the
    requirement to adjust a grantee's per diem payment by excluding other
    sources of income from the provider's estimated daily cost of care. We
    note, however, that this provision would not prohibit a provider from
    receiving payments from VA and other sources that together exceed the
    grantee's actual cost of providing care or services to homeless
    veterans. We would therefore recommend that section 1 be modified to
    prevent a grantee from being able to receive more than 100 per cent of
    its actual daily cost of care.
        The Department estimates the total cost of section 1 to be
    $88,388,137 for fiscal year 2008 and $1,479,329,118 over a 10-year
    period.
    Dental Benefit for Homeless Veterans
        Section 2 would eliminate the current requirement that in order to
    receive one course of dental services an eligible veteran must also be
    receiving care or services for a period of 60 consecutive days in one
    of the specified treatment settings (domiciliary care, care in a
    therapeutic residence, community residential care, care from a grantee
    under the Program).
        VA strongly opposes section 2. Without the 60-day treatment
    requirement, there is no means to ensure the homeless veteran gets his
    or her other medical needs addressed. The availability of the dental
    benefit often provides the only opportunity to connect a homeless
    veteran to other VA programs that can provide the veteran with more
    vital care. Also, a single course of dental care in the absence of
    other medical services does little to help homeless veterans lift
    themselves from their plight. Most homeless veterans suffer from
    substance or alcohol abuse problems and/or serious mental health
    conditions. These conditions make it difficult, if not impossible, for
    them to find and keep permanent housing and to secure gainful
    employment. If these veterans receive not only the one-course of dental
    care services but also medical services to help them rise above their
    homelessness, everyone's interests are served. VA data support this
    position: homeless veterans have a better rate of treatment success and
    experience longer stays in permanent housing if they complete their
    residential treatment programs. We therefore find no justification for
    changing the current program eligibility criteria,
        The Department estimates the cost of section 2 to be $8.1 million
    for fiscal year 2008 and $98.1 million over a 1 a-year period.
    VISN Staffing
        Section 3 would require the Secretary to ensure that each VISN
    office assigns at least one full-time employee of the Veterans Health
    Administration (VHA) to oversee and coordinate VA's programs for
    homeless veterans. VA regards section 3 as unnecessary. VHA has already
    assigned a full-time employee to coordinate homeless veterans programs
    in every VISN and has fully funded those positions.
    Grants to Repair and Replace Homeless Providers' Facilities
        Section 4 would authorize the Secretary to make emergency grants,
    pursuant to criteria and requirements prescribed by the Secretary, to
    entities receiving grants under the Homeless Providers Grant and Per
    Diem Program for the purpose of repairing or replacing a grantee's
    facility that is damaged or destroyed by a major disaster.
        VA supports section 4. Grantees receiving VA grants and per diem
    for furnishing care to homeless veterans under the Program lost their
    capacity to continue providing care and services (including
    transitional beds) in the aftermath of Hurricane Katrina. Desperately
    trying to find beds for their displaced veterans, the grantees whose
    facilities were damaged turned to VA for additional assistance. To
    assist them, VA had to rely on other departments which administer
    Federal laws and regulations managing the Federal response to disasters
    and national emergencies. This situation resulted in delays, which in
    turn lengthened the time displaced homeless veterans had to survive
    without services previously furnished by the grantee. All-but foremost
    the displaced homeless veterans previously served by the grantee--would
    benefit if VA were able to provide financial assistance to grantees in
    these types of catastrophic situations more quickly. However, we note
    that if a grantee's facility cannot be replaced or repaired, VA would
    still not have authority to award grants out-of-cycle to maintain
    capacity in the area(s) affected. We note that the costs for emergency
    activities of this nature are not typically available within existing
    funding levels.
    Pilot Program for Permanent Housing
        Section 5 would require the Secretary to conduct a 5-year pilot
    program to award grants to public or nonprofit entities with
    established single-room occupancy facilities for the purpose of (1)
    acquiring and operating single-room occupancy housing solely for the
    benefit of homeless veterans and (2) providing rental assistance on
    behalf of homeless veterans. Section 5 would also establish detailed
    reporting requirements and authorize $10 million for fiscal year 2008
    and each subsequent fiscal year to carry out this pilot program.
        VA does not support section 5. As a general matter, VA's statutory
    mission appropriately does not encompass permanent housing for homeless
    veterans. In our view, section 5 is a measure far better suited to the
    expertise, capacity, and mission of the Department of Housing and Urban
    Development. If enacted, VA estimates the cost of section 5 to be $5
    million in fiscal year 2008 and $93 million over a 10-year period.
    H.R.2623 Elimination of Co-payments for Hospice Care
        H.R. 2623, as ordered reported, would exempt a veteran who is
    receiving inpatient or outpatient hospice care from all copayment
    requirements that would otherwise apply.
        We support this measure.
    H.R. 2699 amendments to VA's Homeless Providers Grant and Per Diem
            Program
    Elimination of Adjustments to Per Diem Rate
        Section 1 would repeal the requirement that the Secretary adjust
    the amount of per diem payable to a grantee under the Homeless
    Providers Grant and Per Diem Program by excluding income the grantee
    receives from other sources to provide services to homeless veterans.
    We refer the Committee to our comments on the discussion draft bill
    that included a similar provision and our concern that a grantee could
    receive more than 100% of its cost of care.
    Demonstration Program for Members of the Armed Forces
        Section 2 would require the Secretary to conduct, through September
    3D, 2011, a demonstration program (at a minimum of three sites) for the
    purpose of identifying active duty members who are at risk of becoming
    homeless after they are discharged or released from service. The
    Secretary would also be required to provide (directly or by contract)
    referral, counseling, and supportive services to service members
    participating in the demonstration program. section 2 would also
    require the Secretary of Veterans Affairs to consult with the Secretary
    of Defense (and other appropriate officials) in developing the criteria
    for inclusion in the demonstration program. Finally, section 2 would
    authorize $2 million to be appropriated to carry out this demonstration
    project.
        VA does not support section 2. There exist no reliable criteria for
    identifying which active duty members are at risk of becoming homeless
    once they leave the military, nor is there any reliable means for
    developing such criteria. VA could not carry out such a program.
    Referral and Counseling Demonstration Program
        Section 3 would expand. from 6 to 12, the number of sites
    participating in the Department of Labor's on-going demonstration
    program of furnishing referral and counseling services to veterans at
    risk of becoming homeless upon their release from certain institutions
    (e.g., penal institutions and long-term mental health facilities).
    section 3 would also eliminate this program's demonstration status and
    authorize it through September 30, 2011.
        We defer to the views of the Secretary of Labor, who administers
    this program. We are aware, however, that this demonstration program
    has been very successful at reducing recidivism rates among the
    participating veterans and we therefore applaud Labor's success with
    this program.
        Grants for Staffing Service Centers
        Section 4 would permit service centers receiving grants under the
    Homeless Providers Grant and Per Diem Program to use those funds to
    meet mandated staffing levels. VA has no objection to section 4.
    Domiciliary Care
        Section 5 would require the Secretary to take appropriate actions
    to ensure that the domiciliary care programs of the Department are
    adequate to meet the capacity and safety needs of women veterans. VA
    does not support section 5 because it is unnecessary. The Department
    has on-going efforts to ensure the domiciliaries are able to meet the
    unique needs of women veterans and to ensure their privacy and safety
    while in that setting. Finally we note that the measure would also
    eliminate the authorization for appropriations for fiscal years 2003
    and 2004 currently found in law. That authorization does not expire as
    may be suggested by the caption for section 5.
        The Office of Management and Budget advises that there is no
    objection to the transmittal of this letter in regard to the program of
    the President.
                Sincerely yours,
                                                     R. James Nicholson
                                                              Secretary

                                    U.S. Department of Veterans Affairs
                                                        Washington, DC.
                                                       January 10, 2008
    The Hon. Michael H. Michaud
    Chairman
    Subcommittee on Health
    Committee on Veterans' Affairs
    U.S. House of Representatives
    Washington, DC 20515

    Dear Mr. Chairman:

        In accordance with the requirements of section 212(c) of Public Law
    109461, enclosed is the Department of Veterans Affairs' (VA) plan to
    improve access to quality long term care and mental health services for
    veterans residing in rural areas.
        Similar letters have been sent to other leaders on the House and
    Senate Committees on Veterans' Affairs.
                Sincerely yours,
                                                   James B. Peake, M.D.
                                                              Enclosure

                                  ----------

                         Department of Veterans Affairs
                         Veterans Health Administration
             Plan to Increase Access to Quality Long-Term Care and
        Mental Healthcare for Enrolled Veterans Residing in Rural Areas
                                  January 2008

    Table of Contents

    I.

    INTRODUCTION

    II.

    BACKGROUND

    A.

    The Office of Rural Health

    B.

    Definition of Urban/Rural/Highly Rural

    C.

    Demographics

    D.

    Current Services

    III.

    PLAN

    A.

    Goal

    B.

    Long-Term Care Initiatives

    C.

    Mental Health Initiatives

    IV.

    BARRIERS TO RURAL HEALTH CARE

    A.

    Long-Term Care

    B.

    Mental Health

    V.

    CONTINUOUS IMPROVEMENT

    ATTACHMENTS

    Attachment A

    Veteran Enrollee and Patients by Urban/Rural/Highly Rural Designations

    Attachment B

    Veteran Enrollee Drive Time Access Standards

    Attachment C

    Acronyms

    I.

    INTRODUCTION

        On December 22, 2006, the Information Technology Act of 2006,
    Public Law 109-461, was signed into law. Section 212 of this law
    established the Office of Rural Health (ORH) and, among other things,
    requires the Director of the Office of Rural Health to develop a plan
    to improve the access and quality of care for enrolled veterans in
    rural areas.
        Specifically, section 212(c) states the plan shall include:

    (l)

    Measures for meeting the long-term care needs of rural veterans; and

    (2)

    Measures for meeting the mental health needs of veterans residing in rural
    areas

        This plan addresses the specific actions underway in regards to
    mental health (MH) and long-term care (LTC). The plan includes a
    systematic evaluation of the current state of MH and LTC service
    provided by the Veterans Health Administration (VHA) and presents a
    strategy to increase access, either by enhancing existing services or
    developing new initiatives, to further advance access to quality MH and
    LTC services for veterans residing in rural areas.

    II.

    BACKGROUND

    A.

    The Office of Rural Health (ORH)

        VA's Office of Rural Health was established in March 2006, in
    compliance with P.L 109-461 section 212 Sec. 7308(c) under the VHA
    Office of the Assistant Deputy Under Secretary for Health (ADUSH) for
    Policy and Planning.
        The mission of the office is to promulgate policies, best practices
    and innovations to improve services to veterans who reside in rural
    areas of the United States. The office is accomplishing this by
    assessing the delivery of services with a range of VHA program offices
    to ensure the needs of rural veterans are being considered as program
    development and implementation takes place. As a program office, the
    role of the ORH is to provide policy, guidance, and oversight within
    VHA to enhance the delivery of care by creating greater access,
    engaging in research, promulgating best practices and developing sound
    and effective policies to support the unique needs of enrolled veterans
    residing in geographically rural areas.
        As specified in the Public Law, one of the key responsibilities of
    ORH is to conduct, coordinate, promote, and disseminate research into
    issues affecting veterans who reside in rural areas. With a strong
    collaboration between ORH and internal VHA program offices, ORH is also
    responsible to develop, refine, and promulgate policies, best practices
    and innovations to improve services. ORH will translate lessons learned
    into policy and facilitate broader execution through Patient Care
    Services (PCS).

    B.

    Definition of Urban/Rural/Highly Rural

        There is no single, universally preferred definition of rural that
    is used across either government or private sector agencies.\1\
    Currently, more than 15 definitions of rural are used by Federal
    programs. The two most commonly used classification systems are from
    the U.S. Census Bureau and the Office of Management and Budget. In
    order to be consistent with most commonly used definitions, VHA adopted
    a census bureau based classification system, where our definitions are:
    ---------------------------------------------------------------------------
        \1\ Choosing Rural Definitions. March 2007. Rural Policy Research
    Institute Issue Brief. Mueller, et. al.

            Urban: A veteran (or clinic) located in a Census defined
    ---------------------------------------------------------------------------
            urbanized area.

            Rural: A veteran (or clinics) not designated as urban.

            Highly Rural: A veteran (or clinic) that is defined as rural
            and located in counties with less than 7 civilians per square
            mile.

        For this plan, the term rural will refer to both rural and highly
    rural populations.

    C.

    Demographics

        The Census Bureau estimates approximately eight percent of the
    general population are veterans. In FY 2006, the Veterans Health
    Administration (VHA) had almost 7.9 million enrollees and served about
    4.8 million unique patients. In fiscal year 2006, VHA identified
    approximately 39% (1,878,624) of the veteran patients served resided in
    rural areas and another one and six tenths percent (79,464) resided in
    highly rural areas. Of our enrollee population, approximately 36%
    (2,850,173) resided in rural areas and 1.5 percent (118,685) resided in
    highly rural areas (Attachment A).

    D.

    Current Services

    Long-Term Care (LTC)
        Health care services, both within and outside VA, exist along a
    continuum consisting of: (1) ambulatory care, which is predominantly
    offered as primary care (through Geriatric Primary Care or Geriatric
    Evaluation and Management programs when available) with use of urgent
    care and referrals for specialty services; (2) acute care which
    encompasses hospital-based acute and intensive/critical care; and (3)
    long-term care. Long-term care is a spectrum of medical and non-medical
    services provided for a prolonged period of time, to eligible persons
    with chronic, disabling conditions, delivered in institutional and non-
    institutional settings and can be either provided, purchased, or
    coordinated by VA. VHA provides long-term care through programs managed
    by the Office of Geriatric and Extended Care (GEC) and the Office of
    Care Coordination (GCC).
        The GEC provides oversight for the majority of VHA's LTC programs.
    While LTC services are provided to veterans of all ages, the elderly
    comprise a major proportion of those needing LTC (two-thirds of the
    population using VHA LTC are over the age of 75). These LTC programs
    provide a continuum of increasingly resource-intensive services ranging
    from outpatient Geriatric Primary Care to institutionalized nursing
    home care. Veterans can receive services in one or more of VHA's LTC
    care programs concurrently based on need.
        Veterans whose care needs exceed the resources for continued
    support in the home may require placement in settings where
    professional staff on site can support necessary self-care and health
    needs: VA operated nursing home care units, VA contracted community
    nursing homes, and the State Veterans Homes provide this form of long-
    term care. A final form of long-term care is offered to those whose
    disease process is anticipated to result in death. Palliative care
    focuses on the comfort-physical, mental, and spiritual-of-patients. The
    most well known form of palliative care is hospice, which is palliative
    care provided when death is expected in 6 months or sooner. VA provides
    hospice and palliative care in a continuum of environments, both
    institutionally and in-home care, as well as linking with community
    services through participation in Hospice-Veteran Partnerships to
    improve veterans' access to community hospice care in rural areas.
        VHA's strategic direction since the enactment of the Veterans
    Millennium Health Care and Benefits Act, P.L. 106-117 (Nov. 30, 1999),
    has been to develop and offer community and home-based alternatives to
    nursing home care. When veterans are unable or limited in their ability
    to come to a VA facility for care, this strategic direction is to bring
    care closer to the veterans and to enhance the veteran's ability to
    remain in his or her customary place of residence. To meet this need,
    VA has several non-institutional programs, including Home Based Primary
    Care (HBPC), which provides comprehensive longitudinal care by an
    interdisciplinary team in the homes of veterans with complex chronic
    disabling disease. Additional initiatives to increase rural veterans'
    access to care include establishing satellite HBPC programs at remote
    sites such as Community Based Outpatient Clinics (CBOC) and an
    expansion of the Office of Care Coordination's Care Coordination Home
    Telehealth (CCHT) program into 155 VA facilities and clinics
    nationwide. CCHT uses home telehealth technologies to enhance and
    extend care and case management in the home for veteran patients with
    chronic diseases. These veterans are monitored at home using telehealth
    technology that transmits vital sign measurements and symptoms to a VA
    care coordinator. CCHT reduces clinical complications, increases access
    to care when it is needed, and prevents or delays elderly veterans from
    being admitted into long-term institutional care.
        Other non-institutional LTC services that are available include,
    but are not limited to, Community Residential Care (including Medical
    Foster Home), Adult Day Health Care, Homemaker/Home Health Aide,
    outpatient respite services, and purchased skilled home care. To
    develop future opportunities for greater access to care for veterans,
    collaborations with other Federal entities such as the Administration
    on Aging, Indian Health Service, and the Health Resource Services
    Administration have been established.
    Mental Health
        Comprehensive and effective mental healthcare is a top priority for
    VA. VA is making changes to address veterans' needs and is investing
    significantly to improve access to mental health services for veterans
    residing in rural areas and throughout the country. Mental health
    services are available at all VHA outpatient clinics either from
    primary care staff, who are trained to manage many common mental health
    problems, or from mental health specialists, who can manage a full
    range of mental healthcare needs. VA also provides readjustment
    services through the Vet Center program, which is designed to provide
    quality readjustment counseling and some related mental health
    services, for combat veterans and family members (to the extent
    necessary for successful readjustment for the veteran).
        The advancement of technology has increased the range of specialty
    mental health services that can be provided in rural areas, creating
    greater access for these veterans. VA's Office of Care Coordination
    (OCC), in collaboration with the Office of Mental Health Services
    (OMHS), has developed telemental health programs, which involve the use
    of health information and telecommunications systems to enable delivery
    of care when veteran patients and clinicians are separated by
    geographical distance. Telemedicine equipment has been deployed to VA
    facilities and their corresponding CBOCs, thus building an
    infrastructure to provide expert telemental healthcare where direct
    access to mental health specialists is unavailable. The advantages of
    telemental health are that it improves access to mental health
    services, reduces the need for travel by patients and is associated
    with preliminary evidence that it reduces the ``no show'' rate in
    clinics.
        Additionally, VHA has implemented care coordination home telehealth
    (CCHT) to support the care of veteran patients with chronic mental
    health conditions in their homes and local communities. Another example
    of VA telemental health programs is the collaboration with the Indian
    Health Service where VA provides services on several reservations.
        VA OMHS is also meeting the needs of rural veterans through the
    pilot implementation of the Mental Heath Intensive Case Management--
    Rural Access Network for Grouth Enhancement (MHICM-RANGE) program,
    where VA provides community based support for veterans with severe
    mental illness. Other programs include the use of referrals for fee-
    based mental health services in Community Mental Health Centers and a
    program that sends VA mental health providers to Community Mental
    Health Centers where they can use laptop computers for Computerized
    Patient Record System (CPRS) access. Still other efforts include
    integrating psychologists into the Home Based Primary Care program and
    adding mental health professionals to the staffs of CBOCs.

    III.

    PLAN

        The Office of Rural Health (ORH) has collaborated with an array of
    subject matter experts within VHA program offices to develop a plan to
    improve access to quality mental health and long-term care for veterans
    residing in rural areas. This plan takes the results from an internal
    programmatic assessment and either expands current services to increase
    focus on rural veterans or identifies new initiatives to meet the long-
    term care and mental health needs of rural veterans. The performance
    period is FY 2008.

    A.

    Goal: To increase access to quality mental health and long-term care
    services for veterans residing in rural areas.

    B.

    Long-Term Care Initiatives

    1.

    Expand access to VA's innovative non-institutional LTC services for
    veterans residing in rural areas by supporting the Office of Geriatrics and
    Extended Care (GEC) and the Office of Care Coordination (OCC) in
    implementing additional programs that serve rural veterans. Programs
    include:

    a.

    Home Based Primary Care (HBPC)

    b.

    Care Coordination Home Telehealth (CCHT)

    c.

    Medical Foster Home program

    Milestone: During FY 2008 establish CCHT programs in all 21 Networks and at
    most facilities

    2.

    Conduct a baseline assessment of the average daily census (ADC) in non-
    institutionalized settings for veterans residing in rural areas for the
    following programs:

    a.

    Home Based Primary Care (HBPC)

    b.

    Care Coordination Home Telehealth (CCHT)

    c.

    Medical Foster Home program

    Milestone: Completion of baseline by 4th Quarter, FY 08 and completion of
    plan by 1st Quarter FY 09

    3.

    Fund at least two studies or demonstration projects that address issues of
    long-term care, institutional or non-institutional, access or quality for
    veterans residing in rural areas.

    Milestone: Develop a Request for Proposals (RFP) and select projects by 4th
    Quarter, FY 08

    4.

    Create an Office of Rural Health Web site to give veterans greater access
    to information and research.

    Milestone: 4th Quarter, FY 08

    5.

    Establish a Rural Health National Advisory Committee (RHNAC) to examine
    ways to improve and enhance VA services for enrolled veterans residing in
    rural areas through evaluation of current program investment, policy, and
    barriers to providing services as well as the development of strategies to
    improve services. The RHNAC will be comprised of experts within the
    federal, non-federal, academic, and veteran community.

    Milestone: Charter developed by 3rd Quarter, FY 08

    6.

    Develop strategies and incentives to support recruitment and retention of
    staff to provide geriatric care in rural settings, including those
    stationed on a full-time basis within rural settings, those who rotate
    between facilities, and those utilizing telehealth services for care
    delivery.

     Milestone: Ongoing activity in FY 08

    C.

    Mental Health Initiatives

    1.

    Expand the Mental Health Intensive Case Management-Rural Access Network
    Growth Enhancement (MHICM-RANGE) pilot program into additional rural areas
    where need is identified.

    Milestone: 3rd Quarter, FY 09

    2.

    Increase the capacity to provide telemental health services from VA
    facilities over the FY 07 baseline.

    Milestone: Ongoing initiative, FY 08

    3.

    Evaluate strategies and the feasibility of implementing VA collaborations
    with non-VA entities to expand telemental health linkages between VA
    providers and patients in community settings.

    Milestone: Assessment by 4th Quarter, FY 08

    4.

    Through VHA's Strategic Planning process, assess rural geographic areas
    identified as underserved markets based on VHA's drive time access
    standards to primary care (which includes access to mental health services)
    and develop plans for addressing gaps in care.

    Milestone: 4th Quarter, FY 08

    5.

    Require each VA medical center or clinic to develop plans for the delivery
    of VA mental health services by using on-site providers, telemental health,
    referral to other facilities, or referral to community providers as
    appropriate.

    Milestone: Implementation of plans by 4th Quarter FY 08

    6.

    Assess the degree to which CBOCs defined as rural or small (<1500 unique
    veterans) provide timely delivery of mental health services completing an
    initial evaluation within 24 hours of veteran referral and for a full
    diagnostic and treatment planning evaluation for non-urgent cases within 14
    days.

    Milestone: 4th Quarter FY 08

    7.

    Develop metrics to serve as quality monitors for the delivery of mental
    health services in rural areas, in collaboration with mental health
    services.

    Milestone: Development of metrics by 4th Quarter FY 2008

    8.

    Fund at least two studies or demonstration projects that address issues of
    mental healthcare, access or quality for veterans residing in rural areas.

    Milestone: Develop a Request for Proposals (RFP) by 4th Quarter, FY 08.
    Select and begin initiatives by 4th Quarter, FY 08

    9.

    Create an Office of Rural Health Web site to give veterans greater access
    to information and research.

    Milestone: 4th Quarter, FY 08

    10.

    Develop strategies and incentives to support recruitment and retention of
    staff to provide mental healthcare in rural settings, including those
    stationed on a full-time basis within rural settings, those who rotate
    between facilities, and those utilizing telemental health services for care
    delivery.

    Milestone: Ongoing activity in FY 08

    11.

    Develop a Rural Health National Advisory Committee (RHNAC) to examine ways
    to improve and enhance VA services (including mental health services) for
    enrolled veterans residing in rural areas through evaluation of current
    program investment, regulatory policy, and barriers to providing services
    as well as the development of strategies to improve services. The RHNAC
    will be comprised of experts within the federal, non-federal, academic, and
    veteran community.

    Milestone: Charter developed by 3rd Quarter, FY 08

    IV.

    BARRIERS TO RURAL HEALTH CARE

        The ORH has systematically identified barriers to delivery of
    accessible high quality care in rural America. Initial findings
    include:

    A.

    Long-Term Care

        Meeting access and quality standards in rural areas is a challenge
    for both VA and non-VA healthcare systems. This is because rural
    veterans live farther from Veterans Administration Medical Center-
    based, tertiary care options (which are largely in urban areas in order
    to meet the needs of the larger concentrations of veterans), greater
    delay and disease exacerbation before care is accessed, less local
    availability to specialty and geriatrics expertise, and greater
    likelihood referrals to tertiary care centers will be unfulfilled. The
    intrinsic challenges of providing LTC in less populous areas and over
    wider geographic distances are exacerbated by the worsening undersupply
    of trained professionals that characterizes rural settings.
        Additional challenges to rural, elderly veterans include: limited
    transportation services; frail, elderly primary care givers with few
    resources; preferential relocation to urban areas of younger family
    members who might otherwise provide non-professional support services
    and care giving; higher poverty rate; a lower level of awareness of
    those services that may be available, and more constricted financial
    resources.

    B.

    Mental Health

        The provision of mental healthcare in rural settings has
    historically been a challenge for all health systems and providers,
    including VA. While Community Based Outpatient Clinics (CBOCs) have
    been the anchor for VHA's efforts to expand access to veterans in rural
    areas, there are notable challenges in providing mental health services
    in rural communities, such as:

          Availability of qualified mental health professionals in
    small rural communities is often limited.
          Very small rural CBOCs may require mental health
    specialists too infrequently to justify even part-time on-site mental
    health staff. However, telemental health at remote clinics, where
    feasible, has proven to be convenient and is generally well accepted by
    veterans.
          VA salaries at times are not competitive in specific
    locations, both rural and urban.
          Transportation to and from CBOCs is problematic for many
    veterans living in sparse population areas. However, telemental health
    at remote clinics, where feasible, has proven to be convenient and is
    generally well accepted by veterans.
          VHA's CBOCs are complemented by contracts in the
    community for specialty services. The range of specialty care services
    is highly dependent on the services available in the local community.
          Constraints on the expansion of telehealth in VHA, as in
    all organizations, include clinical (e.g. clinician buy-in and training
    of clinicians), technical (e.g. interoperability of technologies,
    telecommunications bandwidth availability, a national video-
    telecommunications, and adequate scheduling systems) and business
    processes (e.g. clinical coding and reimbursement systems).

        While these barriers exist, the ORH will leverage VA's capabilities
    and develop partnerships with governmental and non-governmental
    entities to provide the best solutions to the challenges that rural
    veterans face. Areas of focus include: technology expansion,
    transportation, research and evaluation, workforce recruitment and
    retention, and education and training. By using a data-driven
    decisionmaking and collaborative approach to develop policies and
    practices that expand and adapt current initiatives, as well as
    developing new models of care delivery, the ORH will improve access to
    high quality healthcare care for rural veterans.

    V.

    CONTINUOUS IMPROVEMENT

        VA's plan to increase access and quality mental health and long-
    term care services to veterans residing in rural areas will be
    implemented, evaluated, and undergo continuous improvement. Prior to
    implementation of initiatives outlined in the plan, the Office of Rural
    Health will consult with the Office of Geriatric and Extended Care, the
    Office of Care Coordination, and the Office of Mental Health Services
    within the Office of Patient Care Services, and other VA offices as
    appropriate, to assess feasibility and identify barriers that could
    affect the successful implementation of the initiatives.

                                  ----------

                                  Attachment A
        Veteran Enrollee and Patients by Urban/Rural/Highly Rural
    Designations

    ----------------------------------------------------------------------------------------------------------------
                                                                                                           Rural &
                         Total Enrollees                          Urban         Rural     Highly Rural  Highly Rural
                                                                Enrollers     Enrollees     Enrollees     Enrollees
    ----------------------------------------------------------------------------------------------------------------
    7,848,282                                                   4,879,424     2,850,173       118,685     2,968,858
    ----------------------------------------------------------------------------------------------------------------
    100.0%                                                          62.2%         36.3%          1.5%         37.8%
    ----------------------------------------------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
                                                                                                           Rural &
                         Total Patients                           Urban         Rural     Highly Rural  Highly Rural
                                                                Patients      Patients      Patients      Patients
    ----------------------------------------------------------------------------------------------------------------
    4,877,733                                                   2,919,645     1,878,624        79,464     1,958,088
    ----------------------------------------------------------------------------------------------------------------
    100.0%                                                          59.9%         38.5%          1.6%         40.1%
    ----------------------------------------------------------------------------------------------------------------

                                  ----------

                                  Attachment B
                  Veteran Enrollee Drive Time Access Standards
            Access standard for Primary Care (includes mental health).
            Seventy percent of enrollees within a market meet the following
            drive time standards:
            30 Min.--Urban
            30 Min.--Rural
            60 Min.--Highly Rural

                                  ----------

                                  Attachment C
                                    Acronyms

        ADC--Average Daily Census
        CBOC--Community Based Outpatient Clinics
        CCHT--Care Coordination Home Telehealth
        CPRS--Computerized Patient Record System
        GEC--Office of Geriatric and Extended Care
        HBPC--Horne Based Primary Care
        LTC--Long-Term Care
        MH--Mental Health
        MHICM-RANGE--Mental Health Intensive Case Management--Rural Access
    Network Growth Enhancement
        NHC--VA Nursing Home Care
        OCC--Office of Care Coordination
        OMHS--Office of Mental Health Services
        ORH--Office of Rural Health
        PCS--Patient Care Services
        RFP--Request for Proposals
        RHNAC--Rural Health National Advisory Committee
        VA--Department of Veterans Affairs
        VHA--Veterans Health Administration

                            Program Analysis Officer
                                   GS-340-15
     Office of the Assistant Deputy Under Secretary for Health for Policy
                                  and Planning
                         Veterans Health Administration
                         Department of Veterans Affairs

        Under the general guidance of the Assistant Deputy Under Secretary
    for Health (ADUSH) for Policy and Planning, incumbent provides
    leadership, advice and subject-matter expertise in tasks, projects and
    assignments related to rural health policy development, analysis,
    decision making, and implementation activities affecting the entire VA
    healthcare system. Incumbent serves as Director, Office of Rural
    Health.
        Incumbent functions in a supervisory capacity in contributing to
    attainment of Department of Veterans Affairs (VA) and Veterans Health
    Administration (VHA) goals and objectives with regard to rural health.
    In this capacity, the incumbent works very closely with other key
    Departmental Officials on cross-cutting programs and issues and is
    responsible for the for the planning, direction, coordination,
    development, and implementation of rural health programs and projects.
    DUTIES AND RESPONSIBILITIES
        Directs and leads the development and implementation of the
    Veterans Health Administration Office of Rural Health to address
    healthcare needs of veterans in the rural and highly rural areas.
        Researches, plans, develops, implements, and evaluates policy and
    programs to improve the access and delivery of healthcare services in
    rural and highly rural areas for the planning and implementation of
    appropriate healthcare to improve access and improve the quality of
    healthcare services and enhance the access and delivery of healthcare
    in rural and highly rural areas for veterans.

        Addresses key issues, such as,

          improves communication and coordination among key VA
    health providers and medical administrators within and across the VHA
    and other government healthcare providers, such as, the DHHS in the
    rural and highly rural areas;
          enhances access to select services, (e.g., prescription
    drugs, non-emergency medical transportation, chronic disease management
    programs, mental health and long term healthcare);
          improves travel times and evaluates transportation needs;
          provides quality health assessment data to promote
    information-based health policy and planning; and
          Investigates and improves the capacity of VA rural and
    highly rural healthcare from infrastructure to staffing needs.

        As the focal point within VHA and the Department for monitoring
    rural health issues and coordinating Department-wide efforts to
    strengthen and improve the delivery of veterans health services to
    populations in rural areas, the Director

          coordinates rural health activities within the
    Department;
          oversees the collection and analysis of information
    regarding the special problems and needs of rural healthcare providers;
          maintains a clearinghouse for the collection and
    dissemination of information and research related to veterans rural
    health services;
          manages rural health services outreach projects and
    network development, and support;
          conducts or provides contracts for the conduct of
    specific rural health studies and activities directed toward specific
    rural issues; and
          responds to inquiries on rural health matters from the
    Congress and the public and private sectors.

        Directs the conduct of complex qualitative and/or quantitative
    analysis to assess patient care trends and anomalies in rural and
    highly rural settings.
        Leads and coordinates technical, professional and administrative ad
    hoc teams established to conduct comprehensive studies on patient care
    in rural and highly rural settings; the conclusions of which are
    recommended to management for decisions, relative to the design and
    development of new, or the curtailment or modification of existing
    patient care delivery.
        Serves as the primary link between the Assistant Deputy Under
    Secretary for Health (ADUSH) for Policy and Planning and other
    executive staff and key offices within the Veterans Health
    Administration (VHA), the Office of the Under Secretary for Health and
    other appropriate offices, congressional offices and Committees, and
    other Federal agencies, and a wide variety of external groups and
    organizations with regard to rural and highly rural health issues.
        Counsels the ADUSH for Policy and Planning and key management in
    the development and implementation of policies, plans, guidelines, and
    proposals for patient care in rural and highly rural settings. He/she
    develops written documents for a wide range of matters, including the
    development or the implementation of policies, practices, or other
    operational and management activities. Conclusions, findings,
    recommendations and reports are in many instances used by top VA
    management to make management decisions and to develop policy.
        Acts as a representative of the ADUSH for Policy and Planning on
    interpretation of policy, in public relations issues, and in
    reconciling conflicting interpretations and differences among the Rural
    and Highly Rural staff nation-wide.
        Serves as a member of various Committees as designated by the ADUSH
    for Policy and Planning with Administrative and other key officials,
    other government agencies, and organizations outside the Federal
    Government and represents the ADUSH for Policy and Planning.
        The incumbent plans, organizes, and carries through to completion
    program plans, program/policy analyses, data collection, legislative
    interpretation, and analytical studies involving Federal and VA
    programs and policies on patient care in rural and highly rural
    settings.
        Coordinates special studies and projects with other agencies within
    the Department to ensure involvement of the appropriate Departmental
    officials, as well as involvement by outside groups. Provides technical
    and policy advice on healthcare financing and rural healthcare
    proposals reflecting the Administration's objectives and priorities.
        Promotes effective communication and coordination of departmental
    activities with other Federal agencies and outside organizations.
    Communicates the policies and positions of the Department to
    governmental and private organizations concerned with the provision of
    veterans' healthcare in rural areas.
        Explains a variety of policies and/or procedures to VA officials
    and resolves problems of a highly complex nature. May resolve issues
    independently or make recommendations for resolution. Coordinates
    critical and sensitive office correspondence with top management of the
    Department.
        Directs comprehensive studies from which to analyze and evaluate
    the needs, strategic plans, and goals of the Office of Rural Health,
    and makes recommendations for new directions, initiatives, policies and
    procedures. S/he participates in senior management decisions regarding
    strategic planning and priority-setting for these activities.
        Ensures coordination of reports, evaluations and follow up actions.
    Identifies deficiencies or problems and consults with the ADUSH for
    Policy and Planning for problem resolution
        Supervises the staff of the Office of Rural Health. Plans and
    assigns work to be accomplished. Evaluates performance; gives
    instructions on work and administrative matters; interviews and selects
    candidates for subordinate positions; hears and resolves employee
    problems; and takes disciplinary measures and recognizes noteworthy
    contributions as warranted.
        Identifies and makes provisions for the training of staff as
    needed. Assures that staff in the Office of Rural Health maintain state
    of the art knowledge in this program area. Assures and oversees that
    staff are remaining current with the availability of relevant
    literature, and also with applicable regulations, manual, and other
    related policies. Maintains competency of self and existing staff and
    encourages use of resources and continuing education courses.
        Performs other duties, as assigned.
    SCOPE
        The incumbent is a national level resource, responsible for
    directing and supervising the conduct of complex analysis, design,
    development, technical support work; providing assistance to VA Central
    Office and Field units throughout the VHA system; and utilizes existing
    tools and/or recommends the development of new processes and
    applications to troubleshoot problems and meet specified business
    needs, having a cross organizational affect on Department-wide
    administrative policies and programs, as they relate to providing
    medical services in an effective environment to veterans nationwide.
        The incumbent will have expert knowledge of analytical and
    evaluative methods plus a thorough understanding of how regulatory or
    enforcement programs are administered to select and apply appropriate
    program evaluation and measurement techniques in determining the extent
    of compliance with rules and regulations issued by the agency, or in
    measuring and evaluating program accomplishments. This may include
    evaluating the content of new or modified legislation for projected
    impact upon the Agency's programs and resources.
    EFFECT
        The incumbent directs the completion of significantly complex
    administrative, technical and analytical projects such as qualitative
    and quantitative studies of patient care delivery in rural and highly
    rural settings; data analysis to determine customer satisfaction with
    care provided in rural and highly rural settings; development of tools
    and metrics to monitor the outcomes of newly established or implemented
    policies and procedures to enhance patient care in rural and highly
    rural settings. The work significantly affects Department-wide VHA
    business requirements, veterans using VHA medical facilities,
    stakeholders and end user customer satisfaction.
        This incumbent will be skilled in planning, organizing, and
    directing team study work and in negotiating effectively with
    management to accept and implement recommendations, where the proposals
    involve substantial agency resources or may require change in
    procedures.
        The incumbent will have a mastery of advanced management and
    organizational principles and practices along with a comprehensive
    knowledge of planning, program and budget regulations, guidelines and
    process, and thorough knowledge of the Agency's planning, acquisition,
    and management process to prepare long-range and short-range planning
    guidance in accordance with broad agency program policies and
    objectives.
    ORGANIZATIONAL SETTING
        The incumbent reports directly to the Director of Policy Analysis
    and Forecasting, an SES position and is accountable to the VHA
    Assistant Deputy Under Secretary for Health for Policy and Planning,
    who encumbers a SES Position.
    SUPERVISORY & MANAGERIAL AUTHORITY EXERCISED
        The incumbent directs and supervises a staff of highly analytical
    and technically skilled specialist, and professionals, which may
    include contract staff. Decides methodologies to use in achieving
    program objectives or to determine which goals and objectives to
    emphasize. In addition, he/she serves as an active team member for
    projects encompassing the development, maintenance and improvement of
    patient care in rural and highly rural settings.
        The incumbent plans work to be accomplished by subordinates, sets
    and adjusts short-term priorities, and prepares schedules for
    completion of work; assigns work to subordinates based on priorities,
    selective consideration of the difficulty and requirements of
    assignments, and the capabilities of employees; gives advice, counselor
    instruction to employees on both work and administrative matters;
    evaluates subordinate performance and identifies developmental and
    training needs for employees, providing or arranging for needed
    development and training; finds ways to improve production or increase
    the quality of the work of subordinates and develops performance
    standards for supervised staff'; hears and resolves minor complaints
    from employees, referring group grievances and more serious unresolved
    complaints to a higher-level management; Prepares and updates position
    descriptions and performance plans for subordinate employees;
    interviews applicants, develops criteria for selection of best
    candidate and recommends or makes selection; and approves/disapproves
    leave, makes work assignments, resolves work conflicts and implements
    established or management approved policies, as it relates to customer
    service and support.
    PERSONAL CONTACTS
        Nature of contacts: Contacts include VA program officials
    representing VACO VHA, Staff Offices, OI&T, VHA field offices, VA
    Medical Centers, VISN Offices, Congressional Offices, etc. Contacts
    also include communication media, consultants, affiliated universities,
    professional organizations and associations. Contacts take place in
    planned or unscheduled meetings, including presentations, conferences,
    hearings, etc. As requested, the incumbent prepares reports or
    responses for Congress, executive branch agencies such as the Office of
    Management and Budget, Agency for Health Care Policy and Research and
    foundations such as Academy Health, or media audiences, working through
    appropriate VA offices. Meets and addresses constituency, advocacy and
    national and local veterans groups, as well as Congressional staff and
    professional associations
        Purpose of Contacts: Contacts are designed to meet several
    objectives, including: developing appropriate collaborative
    relationships for sharing information among colleagues and agencies
    with similar interests; communicating information about the Office of
    Rural Health's programs, plans, and strategies; obtaining information
    from well-known rural health experts; to influence managers or other
    officials to accept and implement findings and recommendations on
    organizational improvement or program effectiveness; and to effectively
    provide advice and counsel to management on the resolution of patient
    care in rural and highly rural settings problem issues. The incumbent
    may encounter resistance due to such issues as organizational conflict,
    competing objectives, or resource problems. He/she must be familiar
    with congressional and legislative activities bearing upon VHA Rural
    Health Care program activities.
    DIFFICULTY OF TYPICAL WORK DIRECTED
        The highest graded non-supervisor work directed, which requires at
    least 25% of this position's duty time, is GS-14 or higher, or
    equivalent.
        The incumbent directs and supervises the work of approximately two
    subordinate employee's performing highly analytical, specialized,
    technical and administrative work.
        This position manages through subordinate supervisors and/or
    contractors who each direct workloads comparable to GS-12 or higher.
        Identifying the nature of issues or problems in planning,
    organizing, and determining the scope and depth of rural health
    studies, and discerning the intent of legislation and policy statement
    and how to translate the intent into program actions is extremely
    complex.
        The incumbent provides high-level operational and program
    management leadership. The work is highly varied, visible, and subject
    to an exceptional level of scrutiny by stakeholders and advocacy groups
    within and outside the system.
    TRAVEL
        Position requires 25% overnight travel.
    OTHER CONDITIONS
        The attention paid to the Office of Rural Health is very
    significant. The incumbent must carefully coordinate the myriad efforts
    of the Office's diverse portfolio, ensuring attention to all these
    politically sensitive issues. All this must be accomplished in an
    environment of extraordinary oversight of activities by advocates
    within and outside the Department. The incumbent must deal with
    demands, expectations, and oversight at a very high level.
        This work requires familiarity with a broad range of topics and
    current issues related to the provision and outcomes of rural
    healthcare, and to the conduct of research on those issues. This
    includes general knowledge of concepts and methods drawn from
    healthcare administration, scientific review and evaluation, public
    health, and other health organizations. The incumbent must be a
    critical thinker with excellent writing and organizational skills.
        Requires expert level knowledge of the principles and practices of
    the following disciplines as they relate to rural health: healthcare
    management, resource management, and policy development, in order to
    provide consultation/advice to the ADUSH for Policy and Planning in
    healthcare administration and organizational management matters.
        The incumbent is responsible for extensive coordination and
    integration of work efforts related to rural health policy development
    associated with a national healthcare delivery system. The incumbent
    makes major recommendations that have a direct and substantial impact
    on current and future rural healthcare initiatives. The incumbent must
    be thoroughly familiar with the Department's programs, objectives,
    operations, and the interrelationships among these as well as those of
    other federal agencies, Congress, etc.
        Mastery of program and organizational analysis principles, methods,
    practices and techniques; analytical methods; and interpersonal
    relations practices. Skill to apply this mastery in developing new
    methods and approaches in planning, integrating and evaluating rural
    health programs for the agency. Knowledge and skill to advise other
    specialists in and outside the agency, as well as top managers and
    decisionmakers, on issues of developing, communicating, or enhancing
    program matters involving interaction with all of the agency's publics,
    both nationally and internationally.
        Because of the sensitivity inherent in analyses and recommendations
    made by the VHA Office of Rural Health, the incumbent is expected to
    elicit a high and sustained level of collaboration and trust with VA
    program managers. The incumbent must also demonstrate marked qualities
    of diplomacy, patience, and persistence, professional deportment, and
    discretion suited to all levels of VA management. The incumbent
    develops and implements systems and processes to gather and analyze the
    information needed to make strategic and tactical decisions.
    OTHER SIGNIFICANT FACTS
        Customer Service: Incumbent meets the needs of customers while
    supporting VA missions. Consistently communicates and treats customers
    (veterans, their representatives, visitors, and all VA staff) in a
    courteous, tactful, and respectful manner. Employee provides the
    customer with consistent information according to established policies
    and procedures. Handles conflict and problems in dealing with the
    customer constructively and appropriately.
        ADP Security: Incumbent protects printed and electronic files
    containing sensitive data in accordance with the provisions of the
    Privacy Act 1974 and other applicable laws, federal regulations, VA
    statutes and policy, and VHA policy. Employee protects the data from
    unauthorized release or from loss, alteration, or unauthorized
    deletion. Follows applicable regulations and instructions regarding
    access to computerized files, release of access codes, etc., as set out
    in the computer access agreement that the employee signs.