[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
FINDINGS OF THE PRESIDENT'S COMMISSION
ON CARE FOR AMERICA'S RETURNING
WOUNDED WARRIORS
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 19, 2007
__________
Serial No. 110-43
__________
Printed for the use of the Committee on Veterans' Affairs
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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
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
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C O N T E N T S
__________
September 19, 2007
Page
Findings of the President's Commission on Care for America's
Returning Wounded Warriors..................................... 1
OPENING STATEMENTS
Chairman Bob Filner.............................................. 1
Prepared statement of Chairman Filner........................ 32
Hon. Steve Buyer, Ranking Republican Member...................... 3
Hon. Harry E. Mitchell, prepared statement of.................... 33
Hon. Jerry Moran, prepared statement of.......................... 33
Hon. Ginny Brown-Waite, prepared statement of.................... 34
WITNESSES
President's Commission on Care for America's Returning Wounded
Warriors:
Hon. Donna E. Shalala, Co-Chair (former Secretary of Health
and Human Services)........................................ 4
Prepared statement of Secretary Shalala.................. 34
Hon. Bob Dole, Co-Chair (former United States Senator from
the State of Kansas)....................................... 8
Prepared statement of Senator Dole....................... 36
SUBMISSIONS FOR THE RECORD
Disabled American Veterans, Joseph A. Violante, National
Legislative Director, statement................................ 38
Miller, Hon. Jeff, a Representative in Congress from the State of
Florida, statement............................................. 40
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to
Hon. Donna E. Shalala, Co-Chair, President's Commission on
Care for America's Returning Wounded Warriors, and
President, University of Miami, and Hon. Bob Dole,
President's Commission on Care for America's Returning
Wounded Warriors, letter dated October 18, 2007, also
transmitting additional questions from Hon. Joe Donnelly... 42
Reports:
``Serve, Support, Simplify: Report of the President's
Commission on Care for America's Returning Wounded
Warriors,'' July 2007...................................... 45
``Serve, Support, Simplify: Report of the President's
Commission on Care for America's Returning Wounded
Warriors,'' Subcommittee Report and Survey Findings, July
2007....................................................... 82
FINDINGS OF THE PRESIDENT'S COMMISSION
ON CARE FOR AMERICA'S RETURNING
WOUNDED WARRIORS
----------
WEDNESDAY, SEPTEMBER 19, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m., in
Room 334, Cannon House Office Building, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner, Snyder, Herseth Sandlin,
Mitchell, Hall, Hare, Berkley, Salazar, Rodriguez, Donnelly,
McNerney, Space, Walz, Buyer, Moran, Brown of South Carolina,
Boozman, Brown-Waite, Turner, Bilbray, Lamborn, Bilirakis,
Buchanan.
OPENING STATEMENT OF CHAIRMAN FILNER
The Chairman. This meeting of the House Committee on
Veterans' Affairs is called to order and we have a
distinguished panel to address us this morning.
As we all know, in March the President signed an Executive
Order to establish the President's Commission on Care for
America's Returning Wounded Warriors. That came in the wake of
the Walter Reed scandal and I must say there were a couple of
silver linings in that cloud we call Walter Reed. One was the
Commission that was formed and your report, for which we are
grateful. The other, of course, was, we were able to add in the
various budget bills that went by over $13 billion of resources
for veterans' healthcare for this year over last year, because
all of America understood that we are not caring for the
veterans who came back from Iraq and Afghanistan the way they
thought that we were doing and we should be doing.
The Commission was charged with the task of examining the
effectiveness of returning wounded servicemembers' transition
from deployment in support of the Global War on Terror to
returning to productive military service or civilian society,
and recommend needed improvements.
That report, of course, was recently released and we will
be hearing from the Co-Chairs of that Commission, Secretary
Donna Shalala and Senator Bob Dole. I look forward to a frank
discussion of your recommendations.
Of course, we are all focused on how to serve our troops
when they transition from the Pentagon to the U.S. Department
of Veterans Affairs (VA) for their healthcare. In order for our
troops to experience the seamless transition that they deserve,
the bureaucratic problems that prevent many from getting the
care they need must be fixed. And while both VA and the U.S.
Department of Defense (DoD) have made adjustments and changes
over the last few years in an attempt to address these issues,
many obstacles, as you point out, still remain.
As Chairman of the Committee on Veterans' Affairs, I am
sensitive to the difficulties involved in coordinating the
activities of the Department of Defense and the Department of
Veterans Affairs. They have different missions. But we no
longer have the luxury of time and we, as a country, must act.
Right now, while we prepare to discuss this issue, our
servicemembers are in harm's way. Some of these brave men and
women will be killed or seriously wounded. We have talked about
the necessity of providing a seamless transition for a long,
long time. But now we have a test as a Nation and this is a
test that, with your help, we will pass.
I want to welcome our two distinguished panelists. Donna
Shalala was appointed by President Bill Clinton as Secretary of
the U.S. Department of Health and Human Services (HHS) in 1993
where she served for 8 years, becoming the longest serving
Secretary of HHS in our Nation's history. She directed the
welfare reform process, made health insurance available to an
estimated three and a half million children, raised child
immunization rates to the highest levels in history, led major
reforms of the Food and Drug Administration's drug approval
process and food safety system, revitalized our National
Institutes of Health and directed a major management and policy
reform of Medicare.
You have dealt, Secretary Shalala, with large bureaucracies
like the VA and DoD before this, and so we welcome your
experience in implementing programs that work for people, not
against people.
Senator Dole, your story is well-known. But every time I
read it, I am just amazed by your strength and courage. You
were twice decorated for heroism, receiving two Purple Hearts
for injuries and the Bronze Star Medal with combat ``V'' for
valor. You joined the United States Army's Enlisted Reserve
Corps to fight in World War II and became a second lieutenant
in the 10th Mountain Division. In April 1945, while engaged in
combat in the hills of northern Italy, you were hit by German
machine gun fire in the upper right back and badly injured,
waiting 9 hours on the battlefield before being taken to the
evacuation hospital before you began your recovery at a U.S.
Army hospital in Michigan. And then, of course, a distinguished
career in politics.
So thank you both for your service, not only on this
Commission, but I know your commitment to implementing the
recommendations. You are not letting this just become something
on people's shelves. I asked both of our panelists what they
were going to do and they said we are going to get this done.
And so we welcome your energy, your enthusiasm, and the
expertise that you brought to this adventure and we look
forward to hearing from you.
I would yield to the Ranking Member, Mr. Buyer.
[The prepared statement of Chairman Filner appears on p.
32.]
OPENING STATEMENT OF HON. STEVE BUYER
Mr. Buyer. Thank you, Mr. Filner.
Secretary Shalala and Senator Dole, we thank you for your
work. Your report is before us and we appreciate your service
to our country. Our country continues to call upon you, and you
always step forward willingly to serve others and that is what
separates you from so many. So on behalf of the country, I
extend my appreciation for your contribution.
We are involved in a long war against terrorism. For this,
the Nation's mothers, fathers and spouses trust their sons and
daughters and spouses to the Nation's armed forces. They must
be confident that they will be cared for should harm come their
way. I believe that systems are still dysfunctional. The
question is, are the bureaucracies, organizationally and
culturally, ill-suited to make the bold changes necessary for a
seamless transition?
I have my questions, because the bureaucracy will tell us
that they are on top of it, that they are fixing it. The
bureaucracy has had 6 years of ground combat to fix this
problem. We have developed new combat systems in the last 6
years, perfected new tactics, ushered in new governments. It is
time our servicemembers and veterans have seamless transition.
I personally have been fighting this battle over seamless
transition since I arrived in Washington in 1992. From the year
2004, when I was a Subcommittee Chairman and a full Committee
Chairman, I held 19 hearings on the issue of seamless
transition. Legislation mandating the cooperation between the
Pentagon and VA, Senator Dole, dates back to perhaps your
memory. Nineteen eighty-two is when the mandate came from
Congress and the Senate.
So it is time our servicemembers and veterans have the
seamless transition. It is why I was equally enthused when I
heard that President Bush hailed your work product and directed
that the Administration prepare legislative proposals
reflecting your recommendations. I think I can speak for all of
us here that we look forward to seeing these proposals. We
expect to get those proposals soon so we can act to improve the
care and the seamless transition that our Nation's warriors are
entitled.
We look forward to your testimony and your candor is always
welcomed.
I yield back.
The Chairman. Thank you, Mr. Buyer.
You have as much time as you need and we will start with
Secretary Shalala. Thank you again for your service.
STATEMENTS OF HON. DONNA E. SHALALA, CO-CHAIR, PRESIDENT'S
COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS
(FORMER SECRETARY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES); AND HON. BOB DOLE, CO-CHAIR, PRESIDENT'S COMMISSION
ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS (FORMER U.S.
SENATOR FROM THE STATE OF KANSAS); ACCOMPANIED BY EDWARD A.
ECKENHOFF, MEMBER, PRESIDENT'S COMMISSION ON CARE FOR AMERICA'S
RETURNING WOUNDED WARRIORS, AND FOUNDER, PRESIDENT, AND CHIEF
EXECUTIVE OFFICER, NATIONAL REHABILITATION HOSPITAL, AND
MEMBER, BOARD OF DIRECTORS, DISTRICT OF COLUMBIA HOSPITAL
ASSOCIATION; MARIE E. MICHNICH, DR.PH., EXECUTIVE DIRECTOR,
PRESIDENT'S COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED
WARRIORS, AND DIRECTOR, HEALTH POLICY EDUCATION PROGRAMS AND
FELLOWSHIPS, INSTITUTE OF MEDICINE / THE NATIONAL ACADEMIES;
KAREN GUICE, M.D., MSP, DEPUTY DIRECTOR, PRESIDENT'S COMMISSION
ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS, AND CLINICAL
PROFESSOR OF SURGERY, MEDICAL COLLEGE OF WISCONSIN, MILWAUKEE,
WI; AND SUSAN D. HOSEK, CO-DIRECTOR, RAND CENTER FOR MILITARY
HEALTH POLICY RESEARCH, AND GROUP MANAGER, ECONOMICS AND
STATISTICS, RAND CORPORATION
STATEMENT OF HON. DONNA E. SHALALA
Secretary Shalala. Mr. Chairman, Mr. Buyer and sitting
Members of the Committee, thank you for giving us the
opportunity to testify today, and in particular with Senator
Bob Dole, about the recommendations of our Commission----
The Chairman. Madam Secretary, can you pull the microphone
closer to you--thank you.
Secretary Shalala. Thank you for giving me the opportunity
to testify today. It is truly a privilege to serve, to have
served on the President's Commission on Care for America's
Returning Wounded Warriors, especially with Senator Dole, whose
shrewdness and distinction as a great public servant and whose
knowledge of this subject and dedication was really an
inspiration to all of us.
We worked hard, but we had an awful lot of fun and I
learned a lot from him in the process. We were joined by a
stellar group of Commissioners, each of whom gave their full
energy and attention to the critical mission we faced. One of
them, Ed Eckenhoff, who just arrived, of course, is the head of
the National Rehabilitation Hospital here in Washington and one
of the great experts on rehabilitation in this country and we
are delighted to see Commissioner Eckenhoff here with us.
As you know, we had an extremely short timeframe to
complete our mission, but we were propelled by a sense of
urgency that the issues before us required. Mr. Chairman and
Members of the Committee, we know you share this sense of
urgency and that is why we are pleased to be with you today to
discuss not only our recommendations, but the critical need to
implement them.
We have been truly heartened by the response to our report
that we have received from Congress, from the White House and
throughout the country. This country has rallied behind the
need to help those who have put their lives on the line in
service to our country and we are optimistic that the Congress
and the Administration will move quickly to respond to this
need by enacting all of our recommendations.
We were reminded again in Saturday's Washington Post the
problems facing our injured service men and women have not gone
away. Congress and the Administration have spent a great deal
of time these past few weeks discussing the future of the war
in Iraq. And while this debate is one that our Nation must
have, I implore you not to forget about those who have already
sacrificed so much--our injured men and women. They need to be
front and center in the congressional debate and within the
Administration. The story of Staff Sgt. John Daniel Shannon, as
told in the Washington Post, is a story that we heard
throughout our time with the Commission, a story of numerous
case managers, none of whom held responsibility for
spearheading an integrated care system, a story of lost
paperwork and frustration, a story of a disability system that
was in desperate need of repair.
It is stories like this that sparked the creation of our
Commission and stories like this that should and must drive
immediate congressional and White House action. This past July,
it was the Commission's honor to present to the President, to
Congress and the public, six groundbreaking patient and family
centered recommendations that make sweeping changes in military
and veterans' healthcare and services. The recommendations
include the first major overhaul of the disability system in
more than 50 years.
It includes the creation of recovery plans with recovery
coordinators; a new e-Benefits Web site; and guaranteeing care
for post-traumatic stress disorder (PTSD) from the VA for any
servicemember deployed to Iraq and Afghanistan. Our report,
Serve, Support, Simplify, is a bold blueprint for action that
will enable injured servicemembers to successfully transition,
as quickly as possible, back to their military duties or to
civilian life. Our report calls for, and I quote, ``fundamental
changes in care management and the disability system.'' I
respectfully request that this report be submitted for the
record, Mr. Chairman.
Specifically, our six recommendations will immediately
create comprehensive recovery plans to provide the right care
at the right time and in the right place. We recommend that we
completely restructure the disability determination and
compensation systems, aggressively prevent and treat post-
traumatic stress disorder and traumatic brain injury (TBI),
significantly strengthen support for families, rapidly transfer
patient information between DoD and VA, and strongly support
Walter Reed by recruiting and retaining first rate
professionals through 2011.
Our 6 recommendations do not require massive new programs
or a flurry of new legislation. We have identified 34 specific
action steps that must be taken to implement the 6
recommendations. Only 6 of the 34 items require legislation,
and that is what we will focus on today. A complete list of the
action steps for the 6 recommendations is included on the last
page of my testimony.
Let me summarize the first three actions that require
legislation and then my colleague, Senator Dole, will cover the
remaining three.
The first is to improve access to care for servicemembers
with post-traumatic stress disorder. We call on Congress to
authorize the VA to provide lifetime treatment for PTSD for any
veteran deployed to Iraq or Afghanistan in need of such
services. This presumptive eligibility for the diagnosis and
treatment of PTSD should occur regardless of the length of time
that has transpired since the exposure to combat events.
The current conflicts involve intense urban fighting, often
against civilian combatants, and many servicemembers witness or
experience acts of terrorism. Five hundred thousand
servicemembers have been deployed multiple times. The longer
servicemembers are in the field, they are more likely to
experience events which can lead to symptoms of PTSD. The
consequences of PTSD can be devastating. The VA is a recognized
leader in the treatment of combat-related PTSD, with an
extensive network of specialized inpatient, outpatient, day
hospital, and residential treatment programs. Therefore, we ask
that any veteran of the Iraq or Afghanistan conflicts be able
to obtain prompt access to the VA's extensive resources for
diagnosis and treatment.
Next, we ask Congress to strengthen the support for our
military families. In our travels across the country, it has
become abundantly clear that we not only need to help the
severely injured, we need to help their loved ones as well.
These loved ones are often on the frontlines of care and they
are in desperate need of support. Therefore, we call upon
Congress to make servicemembers with combat-related injuries
eligible for respite care and aide and personal attendant
benefits. These benefits are provided in the current Extended
Care Health Option program under TRICARE.
Presently, DoD provides no other benefit for caregiving.
Yet we know that many families are caring for their injured
servicemember at home, and many of these servicemembers have
complex injuries. These families, forced into stressful new
situations, don't need more anxiety and confusion. They need
support. Families are unprepared to provide 24/7 care. Those
that try, wear out quickly. By providing help for the
caregiver, families can better deal with the stress and
problems that arise when caring for a loved one with complex
injuries in their homes.
We also recommended that Congress amend the Family and
Medical Leave Act (FMLA) to extend unpaid leave from 12 weeks
to up to 6 months for a family member of a servicemember who
has a combat-related injury and meets the other FMLA
eligibility requirements. According to initial findings of
research conducted by the Commission, approximately two-thirds
of injured servicemembers reported that their family members or
their close friends stayed with them for an extended time while
they were hospitalized; one in five had to give up their job to
do so. That is simply unacceptable.
Getting family members to the bedside of an injured
servicemember is not a problem. The services have developed
effective procedures to make this happen, and the private
sector has stepped up to provide temporary housing. Because
most injured servicemembers recover quickly and return to duty,
a family member's stay may be short. However, for those whose
loved one has incurred complex injuries, the stay may last much
longer. Extending the Family and Medical Leave Act for these
families will make a tremendous difference in the quality of
their lives. Congress enacted the initial Family and Medical
Leave Act in 1993, when I was Secretary of Health and Human
Services. Since then, its provisions have provided over 60
million workers the opportunity to care for their family
members when they need it most. We have tremendous experience
and evidence with that Act. All of these family members have
been able to care for a family member without losing their
jobs.
We were pleased to see the Senate has already unanimously
passed the Support for Injured Servicemembers Act which
implements this particular recommendation. We hope that the
House will quickly follow suit.
Mr. Chairman, having served in government for about half of
my adult life, I believe that government can work to improve
the lives of its citizens. But sometimes, people of good will
want to solve a problem and their idea is to fix a problem by
adding a program or a new regulation. What we have done in this
report and the reason why it is short and very focused, is
rather than simply coming to you and recommending new
legislation on top of existing legislation, we have rethought
existing programs.
And one of the things we have done that is never done on
commissions is that we have suggested simplifying the program
itself so it is very clear who is responsible for what. And
Senator Dole will be speaking to the disability provision that
we have recommended. So don't think of this as adding another
piece of legislation that adds a program on top of programs. I
spent years, as you well know, trying to sort out Medicare.
Part of the problem with the most complex legislation is that
it is almost impossible for an ordinary competent government
worker to administer the programs, let alone the people that
are supposed to get the services of that legislation to
understand them, not because someone tried to create a complex
bureaucracy, but because they kept trying to fix problems by
adding new legislation which added to the complexity of the
administration.
So read this and the word ``simplify'' as attempting to
make clear who is responsible for what and making it much
easier for the patient and their families, as well as the
people that have to administer the programs, to administer
those programs in a way that is very responsive and very
efficient for the programs.
I believe our recommendations are doable, whether it is
requiring congressional legislation or implementation by DoD or
VA. We made sure what we were recommending could actually be
acted on quickly. The advantage of having Senator Dole and me
up here is that in many ways we are the old warriors. We know--
--
[Laughter.]
Me too. We have a pretty good feel for what the bureaucracy
can administer and what can be implemented, because we have
been through this. And I hope that you, I know that you agree
with us that our seriously injured servicemembers must not be
made to wait. They deserve a healthcare system that serves,
supports and simplifies.
So I would like to thank the Committee again on behalf of
the Commission for the opportunity to discuss our
recommendations. And because those of you who know me know I
don't mince words, I leave the Committee and the Administration
with three simple words. Just do it. Thank you very much.
Senator Dole.
[The prepared statement of Secretary Shalala appears on p.
34, and the Commission reports appear on p. 45 and p. 82.]
Senator Dole. Oh, thank you.
STATEMENT OF HON. BOB DOLE
Senator Dole. Well, first let me thank the Chairman, Steve
and others for being here. I want to thank Congressman Moran,
Congressman Salazar, Congresswoman Berkley and others who have
already introduced a draft of the legislation which may not be
totally accurate, because we drafted it as we were going
through. I know the Administration is working on a draft, and I
know there are others on the Committee who have joined this
bipartisan effort, which leads me to the second point.
I know which political party my Co-Chair is in and she
knows which party I am in. But frankly, I don't know the
political affiliation of any of the other seven members. We
never discussed politics. It was totally nonpartisan. We never
discussed costs. My view was, if we spend billions and billions
and billions of dollars of getting young women and men in
harm's way, we will have to spend what it takes to get them
back in as normal a life as possible, whatever it takes. And I
think that is where we are coming from.
So it is going to cost a little money. And Bob, we may use
some of that which you have authorized. So----
The Chairman. Are you sure you are not a Democrat?
[Laughter.]
Senator Dole. Pardon?
The Chairman. Are you sure you are not a Democrat?
Senator Dole. Yeah. But, you know we----
[Laughter.]
No. We went way back to the Commission headed by Omar
Bradley in 1956. Now, most of you weren't around then, but I
was. And there have been a lot of Commissions. This problem
just didn't happen with Building 18 at Walter Reed Hospital. It
has been out there for years and years and years. We have 25
million, probably 26 million, veterans now. As they get older,
especially the World War II generation, more and more need
hospital care and VA care. One thing we found, and we had
visits all over the country, I don't remember a single
complaint--there may have been one--about the acute care the
soldiers received from the battlefield until the end of their
acute care.
That is not the problem, as my Co-Chair Secretary Shalala
pointed out, it is what happens after that. It is the
bureaucracy, which is true in many civilian hospitals, too. And
that is why we are so honored to have Ed Eckenhoff, Chairman of
the National Rehabilitation Hospital, on our Commission. He
understands the private sector. One thing we also underscored
in our report is that we want the soldier to get the best
possible care. If it is not available in a DoD or a VA
facility, then they are authorized to go to the best private
facility that they can find. We can do no less. And Ed was very
helpful, not only in that area, but many others.
We had a young man named Jose Ramos on the Commission, and
he would have been here today but he has a test. He is back in
school. He lost an arm in Iraq. Another young man from our
Commission, Marc Giammatteo, is attending Harvard, which I
won't hold against him, but--well, my wife attended Harvard.
Marc has a very badly damaged leg. We had a young woman on the
Commission, Tammy Edwards, whose husband had burns on 70
percent of his body. So we had a good representative
Commission. We had people who really understood the problem.
And I must say, I had a Co-Chairman who must have invented
the Energizer Bunny, because all we did was work, work, work
and she would tell us what to do and we would all try to do it.
We learned a lot from each other and we really think we have
some commonsense ideas. Some have said, ``Why didn't you go way
back and overhaul the whole system?'' Well, our charter was
limited to Iraq and Afghanistan and people who may follow. Now,
we hope that war ends quickly. We don't want any more injuries.
One is too many. One death is too many.
But one thing we discovered in trying to get down to the
brass tacks was the group, the seriously injured group, those
were severe TBI or spinal cord injuries or amputees or
whatever. There are about 3,000. Now, if we can't manage the
care of that group in the United States of America, with all
the VA facilities and all the DoD facilities we have, we are in
pretty bad shape. And we can. We just need to work out some of
the wrinkles and that is where we believe our Commission can be
helpful.
We can't dictate anything to this Committee. I spent 35\1/
2\ years in Congress and I know how the system functions. And
we know it takes time. We have been pushing the Executive
Branch. I was at the White House last week and I can say very
honestly, I am really not surprised, but I am very pleased with
the effort they are making on the executive side and they will
have their legislation ready in what, another 10 days?
Secretary Shalala. Ten days.
Senator Dole. So the veteran groups can look at it, and
certainly Members of this Committee. We also had some
outstanding staff, and I would just introduce our Director,
Marie Michnich, who is here and Karen Guice who worked with the
Veterans Service Organizations (VSOs) and Sue Hosek of RAND
Corporation who has had about 30 years experience working with
these same problems. So I think we have some credibility. At my
age, I don't need this job. And you know, I told that to the
President. Well, I guess I didn't see him. I saw him later. But
I told that to the people at the White House and we told it to
Bob Gates. Donna--excuse me, Secretary Shalala, she has a lot
to do. She is busy.
The University of Miami football team, they got off to kind
of a bad start, but they will recover.
[Laughter.]
So, you know, we wanted to do something that might mean
something to somebody. I talked to a young man from Kansas 2
days ago. I was at Fort Sam Houston. He is a triple amputee. I
think there are about 10 or 11 of those. His name is Sergeant
Matt Lammers and I just was in disbelief of his attitude and
his spirit and what an inspiration he is. He said he can get
down with one arm. He has two legs gone above the knee and one
arm above the elbow missing. He has two children, one 6 and a
baby about 1 year old. And how he can get down on the floor and
play with his children and get back in a chair by himself
without any assistance.
Now, if that doesn't inspire us to do what we need to do to
make certain that young man and his family and his children are
taken care of. If you would just write him a blank check, it
would be all right with us. But are those young people going to
be able to go to college? Is he going to be able to earn enough
money? He won't be able to do it with the pension he gets. So
these are some of the things you may want to look at and I know
some of the things have been looked at elsewhere.
I have been interested in veteran affairs--I will confess.
I didn't know much about disabilities until I had one, and then
you suddenly become interested. I served as a service officer
of the American Legion and VFW when I was County Attorney 100
years ago in Russell, Kansas. And I worked with veterans all my
life and all my years in Congress and now I am working with
World War II veterans. They have what they call an Honor Flight
where they bring in World War II veterans from your districts,
without any cost to them. They charter them in. They go out and
visit the memorials--spending most of their time at the World
War II Memorial. They have a box lunch and they go back home
and this makes their whole life. There will be a group in from
Cleveland this afternoon. I will be down to say hello.
But the point I make is that we hope we have credibility.
This is not perfect and there are changes you will want to
make. And Secretary Shalala, I can't think of anybody with more
experience in working with Congress than she has had and
anybody more effective. So I just want to touch on three other
points.
As Secretary Shalala said, there are six areas where we
believe Congress needs to act, and you may think of others. And
what we would like to do, but it may not be possible, is
somehow get some of our suggestions into a conference report
that you may be holding later this year on the Senate passed
bill and your bill because these veterans can't wait much
longer. And when we talk about the wait they have to get their
claim settled and we know that if it doesn't make it in this
year's bill, it will be next year, and that is a long time.
We think Saturday's story in the Washington Post would not
have been there had Secretary Shalala's idea been adopted with
the care coordinator. When you get out of the battlefield, and
you walk or are carried into Walter Reed, you are assigned a
recovery coordinator who stays with you throughout your
treatment. Jose Ramos, who is on our Commission, had so many
caseworkers that he couldn't remember their names. And that is
what happened to this Sergeant Shannon.
So Secretary Shalala had a great idea. It is the first
recommendation. And we are not talking about adding thousands
or another bureaucracy. We are talking about 20, 30, 40, 50
people who have followed the seriously injured from day one
until the time they leave the hospital or go back home or back
to work. Secretary Shalala has already touched on that. She
outlined three major recommendations. Let me just touch on the
others.
We want to get the DoD out of the disability business and
we think they wouldn't mind doing that themselves. Veterans
tell us that they get better ratings from the Veterans
Administration, so we are trying to figure out some way--how do
we work this so it is fair and we don't penalize anybody and
still have the DoD with some. First they would have to get
together with the VA and work out what kind of a physical it
would be. And after the physical, when you are determined to be
unfit for duty, then you go to the VA and they make your
disability rating--not the DoD, but the Veterans
Administration.
We have also added what will be called transition payment.
I know from personal experience, when you first get out of the
service, whether you are in the hospital or not--it doesn't
make any difference--you are sort of at sea for 2 or 3 months.
And so we have these transition payments. It would be your base
pay for 3 months, or whatever Congress decides, while you are
getting home, getting settled, getting your kids in school,
getting a job, whatever.
There is another payment. It will all be in the same
check--but something that has never really been considered
separately and that is called quality of life. I think when you
get your rating, I am certain if you are an amputee or you lost
your sight, it is a consideration. But if you have lost your
sight or if you are Sergeant Lammers who has lost three limbs,
your quality of life has gone from a 10 to what, 1, 2 or 3? We
think that should be compensable and that should be added to
any other payment, whatever your rating may be, because you
have lost that qualify of life forever.
It has never been specifically identified. I guess some who
examine soldiers would probably say, well, they will include
something. But we want to make certain that happens. Then, of
course, there is the earnings loss payment which you would
receive based on your disability, what your earnings loss might
have been in your lifetime.
So we think, and we know there is another commission
working on the disability program. I think it is fair to say
that they have endorsed what we have done with two, is it two
exceptions, Karen or Sue?
Ms. Guice. They are still working on their recommendations.
Senator Dole. In other words, we are pretty much in
agreement and their report is due out, I think, sometime in the
next 30 days or 45 days. But in other words, we don't want to
wait and I know you don't want to wait. I think they would tell
you now what they are going to do. So now there are differences
in ratings depending on which military service or which
regional office determines the rating. In our national survey
of injured servicemembers, fewer than half understood the DoD's
disability evaluation system and only 42 percent of retired or
separated servicemembers who had filed a VA claim understood
the process. That is about one out of two that even understood
what was happening.
So, as I said, we recommend that DoD do one thing. They
retain the authority to determine the fitness to serve. Out of
the 28,000 wounded, 60, 70 percent are back to duty in 30 days
and then there is another 10 or 12 percent that aren't
hospitalized very long. But there is a group, say around 3,000,
3,200 that are very seriously injured and are going to need
very special care for a long time. We believe that there should
be only one physical exam, done by the DoD, and then the VA
should resume all responsibility for establishing the
disability and the rating.
This new structure, I think, makes it reliable and
transparent and accountable. Under this action item, DoD and VA
can focus on what they do best. The DoD determines fitness and
the VA can determine your earnings loss and what your rating
should be and the other things that my colleague has mentioned.
The VA can do what they should do and I think it is a much
simpler system that better supports the needs of those who
transition between active duty and veteran status.
In our fifth action step, we recommend healthcare coverage
for servicemembers who are found unfit because of conditions
that were acquired in combat, supporting combat or preparing
for combat. That includes about everybody, because once you
sign up you are getting ready for combat the next day. So we
think Congress should authorize comprehensive lifetime
healthcare coverage and pharmacy benefits for those
servicemembers and their families through DoD's TRICARE
program.
Is it fair to say what the White House maybe----
Secretary Shalala. Well----
Senator Dole. We think the White House is going even
further on this.
Secretary Shalala. We think the White House is considering
going even further to recommend that everyone who is declared
unfit for service for health reasons, they will cover the
individual and their family's healthcare forever. The advantage
of that is, obviously, it is easier to get a job if you are
disabled, even if you can work 20 hours a week, if you don't
have to worry about working for benefits for your family
members. I think it will help keep families together and will
allow people to go to work and not have to worry about getting
their healthcare covered. It is a tremendous step forward. We
have limited jurisdiction and the White House may recommend
going further in that regard.
Senator Dole. So we have given a short summary here and we
know there are questions and other members may want to make
statements. We know everybody on this Committee wants to do
what we want to do, and that is to make it work, and
particularly for those who are really going to be jammed up the
rest of their life. We want outcomes. We put in more money, as
the Secretary indicated, for education. To keep people in the
program, we raised the benefit 10 percent a year if they
stayed. There is also a stipend to keep them in school. When
these veterans finally leave the hospital and go to school,
they are going to be better equipped to move into the
mainstream of American life and have a better quality of life
and a life of dignity for themselves and their family.
So you all know the figures. In Vietnam, five out of eight
seriously injured survived. Now it is seven out of eight and we
owe a debt to the people on the battlefield, the medics, the
doctors, the nurses, therapists and all the people that take
care of these men and women who come back. Many who come back
are not injured or wounded. Their illnesses, the things that
happened to them are not their fault. But they are entitled to
the same care. You don't have to be shot to receive benefits
under our program. If it is combat-related which, as I said,
covers about everybody, and if you are on the way to combat or
whatever you are doing and you have an injury that is, that
should be covered.
So I just say, Congressman Filner and Congressman Buyer and
others, we are grateful for this opportunity. We did tell the
other Commissioners that we would continue to try to help get
this done. We are going to be around, Secretary Shalala will be
around, for a long time. I will be around for a while at least
and we are going to keep working on this. Hopefully, we are
going to have your help. So thank you very much.
[The prepared statement of Senator Dole appears on p. 36.]
The Chairman. Thank you so much.
[Applause.]
Your common sense and your sense of urgency come through
and provide a standard through which we have to meet. The
Executive Branch will speak for itself. But we, in Congress
here, have to act and act quickly. And we thank you for giving
us that impetus and that charge and the background that you
have here.
Secretary Shalala, you have had quite an effect on the
Senator. If you had talked to him, or if he had talked like
this----
Secretary Shalala. We assure you, though, he did not become
a Democrat in the process.
The Chairman. If he had learned this 10 years ago, you
might not have had your last 4 years in the Cabinet, so----
Senator Dole. I think the key, Mr. Chairman, is that I
don't think we had any disagreements--I mean we may have--it
doesn't mean everything was just whatever somebody wanted. But
a lot of our Commission members had the ideas. On electronic
transfer of records, we had this outstanding doctor from the
Cleveland Clinic. He was a tremendous help to us because it is
one of the problems out there. The VA has a great system. The
DoD is trying to catch up. When you leave Walter Reed, you
leave with a stack of paper. When you leave a VA hospital, you
don't have anything. They can just punch a button and they can
get your record. And there is a recommendation on information
technology (IT), which we think makes a lot of sense and
doesn't cost a big, big bundle of money.
The Chairman. Again, thank you so much. Your charge was the
current war, but when I read your recommendations and I think
about our Vietnam vets, it seems we could easily substitute
Vietnam for what you said and do the same things. I think we
did not treat our returning Vietnam vets with the honor,
respect and care that they needed and we are paying a heavy
price for it. And we still can correct some of that, but we
also see what we have to do to get it right. Otherwise, we are
going to be left with the kinds of homelessness and suicide
rates that we saw----
Senator Dole. I don't want to--this is the last time I will
interrupt but----
The Chairman. I doubt it.
Senator Dole. We are in the Senate. We never interrupt. But
what we discussed is that it is a new kind of warfare. There
are new kinds of injuries. There is new technology. There are
new opportunities. We tried to update--and I know the Chairman
would have rather gone way back and kind of overhauled the
whole system--but we did what our charter said. We tried to
update and make some recommendations that are forward-looking.
Now, some people may resist change. I assume in the Bradley
Commission report there were some who resisted change. But we
have to bring the benefits and everything else up to date and
we tried to do that in our report.
The Chairman. Did you at all, as we looked at the
disability system and recommended a major transition, we do
have a problem that exists right now, 600,000 or more
backlogged claims. Some of us want to just cut through that
bureaucracy right now, for example, and if a claim has been
well documented and had advice of a veteran service officer,
for example, to accept in the same way the Internal Revenue
Service accepts your tax return and sends you a check for a
refund, subject to audit, and just move out those 600,000, you
know, as rapidly as we can. Did you at all think about that or
take that up at all?
Secretary Shalala. No. We actually didn't look at the
backlog. As you know, this country has had considerable
experience. The backlogs in Social Security were cleaned up.
That requires a systems approach. That was not within our
jurisdiction. We do believe, though, that our recommendations
will actually help to make sure we don't create new backlogs
because it will be much more straightforward as to who is
responsible for what, what you are going to get and the
combination of benefits, including, I should point out, an
annuity even if you haven't spent 20 years in the military. All
those found medically unfit to serve and leave before 20 years,
will get an annuity.
I got an annuity after 14 years in the Federal service. If
you are injured, you ought to be able to take that annuity with
you from the DoD. So that is added to the pieces and that is
pretty straightforward. I think that the combination of
transition and some of these different ways of simplifying the
system will help eliminate the backlog. So we didn't speak to
it directly, but we just need a more modernized,
straightforward system that is easier for everybody to
understand.
Senator Dole. Another thing is, I remember way back when I
was at the retirement board and I had some pretty serious
injuries. I couldn't use my hands and I couldn't walk at the
time. But I got a disability based on the fact that I was a
captain. If I were a colonel, I would have gotten a lot more
money, even with lesser disabilities. That didn't make any
sense to me then, and it doesn't make any sense to me now. So
we think we have devised a system where you get this annuity
payment, but then you also get a rating, whether you are a
colonel or a private first class. We think we ought to make
certain that you are being compensated for the disability.
And your rank--if you have been in the service 10 or 20
years, and many people dedicate their life to the service and
we want to reward that, you will get the payment that the
Secretary just pointed out, this so-called annuity, whether you
have been in the service 6 years or have been in the service 25
years.
The Chairman. You all mentioned, on the basis of a medical
discharge, that TRICARE should be given for life. This
Committee has been concerned about the practice of using a
personality disorder discharge which we think is almost a
purposeful misdiagnosis of a preexisting condition, and
therefore, would not obligate our government from compensating
these servicemembers in the future. We think that is a big
mistake and I don't know if you took that up in your report or
not. But I mean we think we might have to put a temporary stop
to these diagnoses because they are doing great disservice to
these young men and women who are serving so faithfully. Did
you look at that issue at all?
Senator Dole. I think the Secretary is looking for the--we
have the facts on it. I think the number discharged for
personality disorder since 2000 has been about 6,000. I think
there are some misleading figures out there; am I correct, or
did you find that?
Secretary Shalala. Right. I think--that is right. Eighty
percent were never in combat.
Senator Dole. We did check on that because you had raised
the question when you testified.
Secretary Shalala. On page 47 of our supplemental report,
it is 6,000. And if I remember correctly, most of them were not
in combat specifically. That obviously could use some study.
But one of the things that we recommend is that the standard of
care for PTSD, and a lot of the appeals are about that, must be
widely disseminated. We need more research on that subject. But
everyone who comes for care ought to be treated and everybody
ought to be eligible to be treated, no matter when they served
in combat.
And I wish I could say that the private sector had great
centers of excellence. The experts in the world are in our
military and in our VA, in particular. And while there are some
private sector rehab hospitals that have some capabilities,
most of this is in-house. We need to disseminate the standard
of care. There are a number of centers and we need to make that
available to everyone.
The Chairman. And thank you, Senator Dole, for praising the
whole system of care, not only in the VA, but on the
battlefield today. The Secretary, the VA and I and Congressman
Boozman just returned from Iraq and Afghanistan and what we did
was, we followed that trail of the wounded warrior from when
they are wounded, to their medical evacuation, to a forward
base hospital, to a regional hospital, to Landstuhl, Germany,
and we followed that for very specific individuals and the
incredible professionalism, expertise, dedication, morale. I
mean, and these kids, I mean they are 19, 20, 21, who are doing
all of this and we were just amazed at their professionalism
and leading to this, you know, this incredible survival rate
once you, if you survive a battlefield injury. So thank you for
praising them, because they are a tremendous, tremendous asset
to this Nation.
Senator Dole. I think in our report there is a segment that
tracks a veteran from injury through medical treatment.
Secretary Shalala. We did.
Senator Dole. We have a little chart in there.
Secretary Shalala. We did. And the University of Miami
actually trains those trauma teams. The soldiers and military
personnel fly in from different parts of the country. We turn
them into a team before they go off to Iraq and Afghanistan.
And the medicine today is unbelievable. The disability system
is based on a 30-year-old medical system. That is the whole
point here. If you saw the schedules on orthopedics in the
disability system that we have in VA, it is unbelievable. It
doesn't reflect modern medicine. This has to be brought up to
date. It is just unacceptable the way it is currently set. And
in this case, we know what to do.
Senator Dole. The one place we need help, and Steve may
have pointed this out in his hearings, is in the mental health
field. There are not enough professionals available in the
private sector or in VA and military hospitals. I don't know
where they are going to come from, but----
The Chairman. Thank you. Thank you again. And that
teamwork, by the way, was so vital, as we watched it in Iraq
and Afghanistan.
Mr. Buyer, you are recognized for 5 minutes.
Mr. Buyer. Thank you.
You know, it is great to see your enthusiasm. As you know,
that can move mountains. And so not only is it your
credibility, but your enthusiasm that has me excited. And Mr.
Dole, they kind of poked you here a little bit when you talked
about spending as much money as necessary. I think you espoused
exactly how you felt all the years that I have known you on
these issues. When I came here in 1992, we had a VA system that
was depicted in the movie ``Born on the Fourth of July.'' And
as a country we didn't do well.
And Ms. Shalala, Dr. Ken Kaiser, your good friend who was
then the Under Secretary of Health during the Clinton
Administration, had his ideas of moving to outpatient care and
we embraced that. And we have invested well--when you look at
1995 as a benchmark, we have invested probably in excess of
$300 billion.
So I embrace exactly what you said, Senator Dole, and----
Senator Dole. Thank you.
Mr. Buyer [continuing]. A couple of things I wanted to
touch on and I thank you, Secretary Shalala, for your comments.
You made yourself narrow and then you went deep and that is why
you have a good product. We have the Disability Commission that
was out there, so you were respectful of them. Yet you touched
on a few areas. So we are with great anticipation waiting on
their testimony to us.
I have some questions regarding the TRICARE for Life. I
created the TRICARE for Life for the military retirees when I
was Chairman of the Personnel Subcommittee in our Armed
Services Committee. So when you say, Senator Dole, that you
would like to get DoD out of the disability business, there are
a couple of things that I need to ask. In order to get DoD out
of this business, we still have the medical retirees, or as
your recommendation, to even do away with medical retirees.
That is one question.
The other is, if we are going to say that TRICARE for Life
is available to those who are found unfit because of conditions
acquired in combat, supporting combat or preparing for combat,
then DoD pays for the TRICARE for Life. So they are not going
to be totally out of that. We are not going to be able to
stovepipe that. So there are still going to be payors. And so I
will be a good listener when the Disability Commission comes
over and I will embrace your recommendations.
My question to you is about implementation. So if we are
going to take the TRICARE for Life program and we are now going
to implement that, the eligibility, are we going to restrict
that eligibility to a core constituency, meaning those, as you
defined here, and what is the effective date?
Senator Dole. Why don't you go first?
Secretary Shalala. The effective date is going to be
determined by Congress and there will be legislation that will
be coming up. I think----
Mr. Buyer. Do you have a recommendation?
Secretary Shalala [continuing]. We are talking about, that
will be part of, back to 2001. And you will see legislation.
That, obviously, is something that can be discussed with
Congress in terms of setting that, as well as who is to be
covered. We are simply talking about DoD making only the fit/
unfit decision and if one is not fit for health reasons and you
get a medical discharge, then you ought to have the
opportunity--and then you go over and get your disability out
of VA. You ought to have the opportunity to have your
healthcare covered.
The addition here is to cover your family as well, to
encourage you to go on and get education, as well as to get
ready to go to work, if you can. If you can't, obviously, there
are all sorts of services that would be available for you.
Mr. Buyer. All right. With regard to the issue on VA
contract care, if DoD, what you are trying to do is move these
to be patient-centric, thank you very much. I wanted to jump up
and hug you when I heard you talk about patient-centric.
Secretary Shalala. Oh, that would be fun.
[Laughter.]
The Chairman. Trust me, it is not.
[Laughter.]
Mr. Buyer. Well, I am hetero, Mr. Filner.
Senator Dole. Steve, could I ask----
Mr. Buyer. I am not sure.
[Laughter.]
Sure, Senator Dole.
Senator Dole. You raised a point that I don't have an
answer to on medical retirees.
Sue, would you, or Karen, address that? Let's say you have
served 25 years and you----
Secretary Shalala. This is Sue Hosek from the RAND
Corporation.
Senator Dole. RAND Corporation. She has had 30 years
working with these issues.
How do you treat the medical retiree--I should know, but I
don't.
Ms. Hosek. If you are declared unfit, you get your
discharge for medical reasons. And, obviously, if you have
served 20 years, you are still going to get your retirement.
What our proposal does is to provide essentially a partial
retirement benefit in the form of an annuity payment for those
who don't reach the 20 years. Right now they walk away with
nothing. And so we don't want the person who has, you know,
say, 15 years of military service to walk off without that. And
so that is an important change that we----
Senator Dole. But then you get your earnings loss from the
VA.
Ms. Hosek. Yes. Then the VA takes care of the disability
benefits that you would be entitled to, yeah.
Mr. Buyer. Thank you.
Senator Dole. Well, they are a little different, Steve. I
wanted to say just one word about Walter Reed. I think the
initial Washington Post story was kind of a wake up call for
all of us and everybody began to focus on a lot of things that
should have been focused on before. But, again, having been
treated there for a lot of--I had several operations there. It
is a great hospital.
Our last recommendation is that until the other place is
totally ready, we have to keep Walter Reed in A-1 condition
before they turn off the lights, because we hope this conflict
is going to end soon. For about 26 percent of the patients,
their first stop is Walter Reed Hospital. So we have to keep
that, if we have to, and we suggest providing incentives,
because a lot of people don't want to stay in a place that is
about to sink. You know, you want to get overboard, get in a
life raft or something or find another job.
So we would recommend some incentives for the civilians who
may be contracting there or even the military personnel--some
kind of a bonus for staying on the job at Walter Reed, because
this is where at least one-fourth of our casualties go. So we
don't want anything but first-rate service there until somebody
finally says, okay, we can turn off the lights.
Mr. Buyer. Thank you for your contribution and viewing this
through the eyes of a soldier.
The Chairman. Thank you. Dr. Snyder is next. I just want to
thank him for focusing on an issue that I know may be not as
part of your charge, but, you know, half of our fighting forces
are the Guard and Reserve units who we think have got to have
access to the same benefits. And Dr. Snyder has led the way and
we thank him. You are recognized.
Dr. Snyder. Thank you, Mr. Chairman. Thank you all for
being here today. We held a hearing yesterday on the
Subcommittee on Oversight and Investigations on the Armed
Services Committee on Military----
Senator Dole. I have a little, I have a little trouble----
Dr. Snyder. I am sorry. We held a hearing yesterday on our
Subcommittee on Oversight on the Armed Services Committee on
DoD civilian personnel and their medical care and benefits and
incentives serving in a war zone. And I will tell you what, I
presented a scenario to the Department of Labor guy. If I was a
DoD civilian that worked 18 hours a day at the Baghdad airport
and had 6 hours off and was playing basketball on the court for
my recreation time and a mortar came in and I got injured,
would I be covered by worker's comp?
And we could not get a definitive answer, that for sure,
even though it was a clear-cut combat-related injury, that a
DoD civilian would be covered by worker's comp. My guess is
they will come back and say well, yeah, we thought about it and
we think we can definitely say that. But I will tell you what,
if you were a civilian government worker working in Iraq right
now, that kind of answer would create some uncertainty for you.
The Disability Commission, I am told, report will be
briefed to the Armed Services Committee staff on October 2nd
and that their report will be made public October 3rd, which
should be out in plenty of time, I think, to inform these
decisions as we go forward in conference and hopefully there
will be things that we can react to this year.
I wanted to ask a couple of specific questions. In your
report, you mention--well, I will just read the two sentences.
``To make the system work, recovery coordinators need
considerable authority and to be paid accordingly. Recruitment,
training and oversight by a new unit of the U.S. Public Health
Service serves as commission corps and the Department of Health
and Human Services should be strongly considered.'' That makes
some of us apprehensive when we consider the years that we have
tried to bring the VA system and the DoD system together and we
are going to throw up our hands and say well, the way to get it
is bring in a third huge system that everybody in this room has
had problems with also in other areas.
Is that really something we need to do in terms of bringing
in HHS, or is there not another way to get at that?
Secretary Shalala. There are other ways, obviously. And our
feeling was that the Commission corps ought to be involved
certainly in the training and that is being considered by the
White House in the legislation they are going to send forward.
The most important thing is a degree of independence, that this
recovery coordinator has to be able to cut across whatever
benefits are available and have some authority and be there for
the full period of time when the soldier, from the time they
are injured until they either go back to civilian life or
complete their disability and rehab period.
If a police officer goes down in my community of Miami, an
officer is assigned to that person from the time they are
injured, right through their hospital stay, right through their
rehabilitation. The problem now, as the Senator pointed out, is
that there are so many care coordinators. These soldiers and
their families can't remember all their names. So that for the
most severely injured people, we need a highly trained
professional. And we are not talking about that many people.
But a number of agencies have to participate in the outline in
that training. Where they are located, who pays their salary,
we were, we strongly recommended that it be independent of the
VA and the DoD. But the most important thing to us is the level
of their training, the fact that they are going to stick with
that soldier and their family right through the process and
that they don't change, for particularly these very complex
cases.
Dr. Snyder. I agree with all----
Secretary Shalala. We are not talking about a large number
of people. Does that answer your question well enough?
Dr. Snyder. It does. I think it is the function that is
key.
Senator Dole. I would just add that there has been some
concern with that provision by the veterans groups, another
layer of bureaucracy. Well, we are not trying to do that. We
are talking about a very small number of people. And if it is
not the Public Health Service, the Secretary has had a lot of
experience with them because HHS is sort of the umbrella group.
But she stated it very clearly. We want somebody with
authority to get an appointment.
Dr. Snyder. No. I want to ask one----
Senator Dole. It might speed up the process and----
Dr. Snyder. I want to ask one final question before my time
runs out. And you talked about it, Senator Dole, when you
talked about the combat-related injury related to training
hazardous duty. I think we have always had a pretty strong
feeling in the Congress that we want to treat all our veterans,
military people, in similar situations the same. And so, I can
come up with scenarios, you know, Little Rock Air Force Base is
in my district. A guy is working on a water tower in the
military, falls off the tower or gets blown off by the wind or
crosses the street and gets hit by a car, has a terrible spinal
cord injury, that we would, I would think that would not fit
under the language of Ms. Berkley's bill or the kind of
language that you outline there and we are going to treat that
person differently and their family medical leave qualification
differently than a person who may have landed on a carrier in
the Gulf and had a similar kind of injury.
I understand the importance of focusing on combat-related,
but on the other hand, we are going to have two classes of
people in our military. I am not sure that we want to go down
that road. What do you think?
Senator Dole. Right. We had a lot of discussion. We talked
about line of duty, combat-related, other ways we can define
it. I think what we, in essence, finally concluded was that
unless it is some reprehensible conduct--you are drunk,
disorderly and you are injured or something--but if you are on
a tower and you are in the line of duty and the wind blows you
off, in my view, you are covered.
Dr. Snyder. Well, take the one you are crossing the street
to the PX and you are hit in the parking lot, that would not be
considered hazardous duty, right?
Senator Dole. Yes.
Dr. Snyder. We could have families living next door that
are treated differently with similar injuries.
Senator Dole. I am not sure we would cover everybody
crossing the street, but our intent was to make it broad----
Dr. Snyder. Right, I see.
Senator Dole [continuing]. Not to limit it. You know, you
don't have to be shot to be----
Dr. Snyder. Severely hurt.
Senator Dole [continuing]. To be injured in the line of
duty serving your country, and you ought to have the same
benefit.
Dr. Snyder. Right. Thank you. Thank you for your service.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Mr. Moran.
Mr. Moran. Mr. Chairman, thank you. Thank you to you and
Mr. Buyer for holding this hearing today and it is a real
privilege to be here with Secretary Shalala and Senator Dole
and I want to thank them for their distinguished service to our
country and especially in this latest effort in regard to their
Commission's work.
Senator Dole, of course, needs to make no statements to
prove his credibility on the topic that is before us. Senator
Dole, I was at the Dole Institute of Public Policy on Monday
before returning to Washington, DC, where I welcomed 100 new
U.S. citizens to our country and used you as the role model,
the example of what one can attain in their life. With the
recognition that in many ways, I suppose, you grew up an
ordinary Kansan, but accomplished extraordinary things.
And Kansans hold you in high regard, as do Americans, for
your public service here in our Nation's capital. But I really
do think it is your service to our country in the military, the
injuries that you incurred and your recovery that is the
remarkable part of your life. And I appreciate the effort that
you make on a daily basis to care for those who have been
injured in service to their country.
You tell in your book One Soldier's Story that none of us
who travel the valleys of life ever walk alone. And your
personal story is one that is a reminder to all of us about how
we do rely upon others. Your mother, Bina, and her day-to-day
efforts in your recovery----
Senator Dole. She was my coordinator, my mother, yeah. She
was there every day. She even held my cigarette. She hated
people who smoked, but it was a little habit I picked up
because in World War II they gave you a little pack with four
cigarettes in it for your dessert, so we all started smoking.
But one of them dropped down my cast one day and we had to pour
water down there and all that stuff, but--but again, you go out
to Walter Reed and if you see a single soldier, I will bet you
10 to 1, in nearly every case, the mother is going to be
standing right there, or the father or some family member. And
that is another area that the Secretary and I want to address.
Mr. Moran. Well, your mother and your family, as well as
the folks of Kansas, particularly your hometown of Russell, the
cigar box story is one that is an inspiration, I think, to all
of us. The community of Russell, which is a typical Kansas
community, put the cigar box in the drug store and collected
money for Senator Dole's rehabilitation and today there are
those in Russell who remember their efforts on behalf of the
Senator and how well he is----
Senator Dole. Well, if I could add, it was only $1,800 and
I was wounded late in the war and all the good doctors, of
course, wanted to go home, because the war was--I was wounded
in April and it ended in Europe in May. In fact, I was wounded
a hill apart and a week apart from where Senator Inouye was
wounded and we ended up in the same hospital together and then
later ended up in the Senate.
But that is an indication--and I wish the Committee could
give me some guidance on, there are all these wonderful groups
out there trying to raise money to help veterans. I don't know
whether, Mr. Chairman, have you ever checked to be sure they
are all bona fide? The volunteer groups are doing a great deal.
In those days, in our little town of Russell, $1,800 was a big
amount. In 1947, that was kind of a recession era. I remember
one man, Mr. Wegley, brought a duck. He didn't have any money,
but he brought a duck, which we couldn't put in the bank, but
we ate it.
So just the generosity of the people and it is still out
there and we want to tap into that, too.
Secretary Shalala. And I think that is also the point,
Senator. We met a mother who is from Ohio whose community is
paying her mortgage while she is down in San Antonio at Brooke
coordinating the care. Three decades later, we are still doing
the same thing and there are other ways to do this that are
more supportive of family. Women are working now. They weren't
in an earlier generation and the whole family is working.
Mr. Moran. Well, I think you both have great credibility in
bringing to us this idea of a support system for those who are
leaving the military. I have one question, although I would
like to tell you, Senator Dole, but for you, I have never seen
any place outside Kansas. I grew up in a family where vacations
were a very rare thing. We only went to Iowa on an almost
annual basis on your behalf. Every time you ran for President
we got to see the rest of the country.
Senator Dole. Yeah, well, it still----
Mr. Moran. It didn't work.
Senator Dole. It is still a possibility for 2008, but I
don't think, I don't think so.
[Laughter.]
Mr. Moran. Let me ask you----
The Chairman. We have an exclusive.
Mr. Moran. Let me ask you, Senator Dole, about contract
care. One of the things that I worry a lot about on behalf of
rural America, rural Kansans in particular, is the ability for
us to have a continuum of care that exceeds just the boundaries
of our cities. The VA traditionally has been bricks and mortar
in large communities. I represent a congressional district,
your congressional district. There is no VA hospital and we
continue to push the VA to provide greater contract care where
the veteran can access through his own, his or her own
physician, local hospital, other providers. And I wonder if
your Commission has looked at what we do to expand the
opportunities across America, not just in the traditional
places at the VA or a military hospital which can provide
assistance.
Senator Dole. Right. You know, I wonder if I could just ask
Ed Eckenhoff, a member of the Commission, to respond to that,
because one thing we emphasize in our report, if you live in
Las Vegas, you know, you have a big, wonderful VA hospital
there. But in some of these rural areas, you have got to drive
300 or 400 miles to get access to good medical care if you are
going to go to a DoD or VA facility.
So we urge--well, we want Congress to make it possible to
underscore that you can go to the private sector to get good
care.
And Ed, can we hear you? You have a good voice.
Mr. Eckenhoff. Well, if you can hear me, I will just stay
right here.
Senator Dole. Yeah, Ed Eckenhoff.
Mr. Eckenhoff. We have talked a great deal about that and
came to the conclusion that while you are absolutely right that
170 plus Veterans Administration hospitals, 60 plus DoD
hospitals, we have 5,200 civilian hospitals, many of them
practicing good acute rehabilitation. Now, within that
population of civilian hospitals, we have roughly 1,100 that
have acute rehabilitation units, anywhere from 10 to 50 beds.
We have roughly 250 freestanding civilian rehabilitation
hospitals, all of these very well-staffed, even though we do
have our vacancy problems, understand rehabilitation
extraordinarily well, particularly the traumatic brain injury,
as we have discovered, is our signature injury within these two
wars.
Secretary Shalala. Our first recommendation was for a
recovery plan and with the recovery coordinator. The point of
that plan is that with an interdisciplinary team, you can
figure out and make adjustments to it when someone can go home,
what care is available where, and particularly for these young
men and women that want to go home, getting access to that care
would be part of the recovery plan. So plotting it out so that
someone could go home as soon as possible, get access to care,
even the use of telemedicine. We have had a lot of experiences
in this country now with rural healthcare. My family, part of
it lives in North Dakota and there are a lot of soldiers in
that place. And making sure people can get home and get care,
the quality of care that they need, using local physicians,
local rehab hospitals, traveling when they need to, ought to be
part of that plan and the recovery coordinator ought to be able
to get them to the right place at the right time.
Senator Dole. That is a good question. It is a big issue.
Mr. Moran. Mr. Chairman, thank you. I appreciate the
gentlemen from Colorado, Mr. Salazar. He and I have joined
together and have introduced as legislation the recommendations
of the Commission. We now know that the Administration also has
a plan to do something similar, but we would welcome any of our
colleagues to join us. Thank you, Mr. Chairman.
Senator Dole. That may be, you know, it is subject to
change, obviously. You may want to change it. I know the White
House is working on a draft. They are actually liberalizing
some of the areas. I think it is good to send a message, you
know. We appreciate your introducing what could be modified
later.
The Chairman. Thank you. I now recognize Mr. Michaud, who
chairs our Subcommittee on Health.
Mr. Michaud. Thank you very much, Mr. Chairman, Mr. Ranking
Member, for having this hearing and I really want to thank both
Senator Dole and Secretary Shalala for all your work, not only
on this, but your continued service to our country. Providing
the best possible care for our men and women who risk their
lives for our country should be, and is, one of our highest
priorities.
I believe that in general we do a good job, but there are
also, as you realize, significant gaps in services that our men
and women receive. I not only thank both of you, but also your
staff for all their hard work in putting this report together.
I really appreciate it. I believe that your recommendations as
they relate to PTSD and TBI, as well as those regarding
assisting families, are very good and we will continue to
hopefully move those ideas forward and I look forward to
working with you as we do move this bill forward.
My question is, I appreciate recommendation number two to
simplify the disability and compensation system, but I want to
make sure that we do not create an unintended negative system
at the same time. This would essentially create a rating system
for current veterans and new veterans that will be coming into
the system. My concern is that dual type system, but also, how
does your, how do you envision this disability, how does that
take into account veterans who, as you know, will manifest
service-connected disabilities much later in life in some
cases? How does this new disability system affect that?
Senator Dole. I am going to let you, but I----
Secretary Shalala. Go ahead.
Senator Dole. One thing we do, and we do it in a positive
way. Now, some may not like it. For the veterans with
disabilities, we have a review every 3 years which will take
care of anything that may arise in that 3-year period if there
is a sickness or illness or something they discover. We think
it is a very positive step. Particularly men don't go to
doctors like they should and there are all kinds of studies on
that issue. I think we really tried to simplify the system. And
I think in every case that we tried to look at, the veteran is
better off under our system dollar-wise.
Even more importantly, we had our eye on what we call
outcome. What is the outcome? What condition will this person
be in when they are finally free of all the hospitalization and
education? Where are they going to fit in society? We think in
both cases we did the best we could and I think Secretary
Shalala has an added comment, with some help. Go ahead.
Secretary Shalala. The disability system will establish,
the new system will establish a really good baseline. So if
someone gets something else a little later, it will be easy to
make that adjustment. The most important thing for people that
have already gotten their disability determination is they will
have a choice. They can keep the current determination or they
can look at the new system and then make a choice of what is
better for them. We believe that in the new system, people will
be much better off. All of our recommendations, it will
simplify it. If you combine the annuity, the extended
disability payment that covers quality of life, as well as
modernizes that actual decision, people will just be better
off.
If they were injured in an accident and there was liability
and they were represented by a lawyer, they would get all these
other payments. They would get the earnings stuff. They get the
quality of life payment. Why is it that these young soldiers
don't get that? Because we have a very old fashioned system.
And yet if they got a similar kind of injury in the private
sector, all of those other things would be taken into account
as part of the payment.
Mr. Michaud. Okay. My next question, actually, Senator
Dole, you had mentioned that, I believe it was in action plan,
your fifth action plan, that the White House is coming up with
actually a more liberal proposal and I couldn't really figure
out the distinction between the report versus what the White
House might be coming up with.
Senator Dole. Well, I can't tell you specifically. I do
know in the TRICARE area they are going to extend it to more
people and families. So that is a big, big step. It is probably
a big cost. But that is already in the mix. As I said, I was
there last week. The Secretary was there yesterday. She may
have some later information. I was very pleased because we have
been pushing the people in the White House and, obviously,
haven't been pushing Members of Congress, but we have been
letting Members of Congress know we were available. We wanted
to follow up. We wanted something to happen. I don't know
whether they spell out any other areas. But they like our
report. I think they really think we did a pretty good job in
the time we had.
We were together with the President at the local VA
hospital where he, in effect, endorsed the report. We know
there is another one coming out on benefits, but again, I think
with minor differences.
Did the White House add anything else you learned
yesterday?
Secretary Shalala. No. This Presidential Commission made
six recommendations that require congressional action. The
White House is preparing draft legislation and has indicated
absolute willingness to work with the Congress. From what we
heard, and I was there yesterday, they are considering
broadening both the definition of who is covered, extending the
TRICARE benefit to those that are discharged for medical
reasons and to their families further than we did.
So I think that you will be very pleased with their
proposal. And that, of course, is draft legislation to give you
another touchstone to work from. So because it was a
Presidential Commission, they will do the drafting of those
six. All of the other recommendations are now being implemented
by the Administration and they are marching through each one
with, from what I could tell, because I have talked to the two
secretaries as well as to the White House, pretty firm
commitments. I can usually tell, since I have been there
before, whether they are really doing it. They have pretty firm
commitments from the agencies that need to do the
implementation, with the expected push back and I think you can
hear our enthusiasm because we think this is going to get done.
I actually don't believe in long commissions. I think you
ought to be able to go in, see where you ought to intervene to
make it better, identify pieces of legislation that need to be
passed and just get it done.
Senator Dole. We have already had a report, and I assume
that--if you don't have it, we will send it up. But what is
happening so far with DoD and VA and their joint meetings and
the areas of our recommendations they have focused on is that
they are starting to implement. So there is positive movement,
so----
Mr. Michaud. Good. I thank you both very much.
The Chairman. Thank you. Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman.
I want to thank you all for your work. I think you are a
great example of how you can take individuals that are very
well respected on both sides of the aisle and really accomplish
a great deal. I think that you are a great example for all of
us.
In dealing with the 3,200, that group that is severely
injured, I think the recovery coordinator is an excellent idea.
All of us though, having been around the bureaucracy and
things, and there is nothing inherently wrong. It is just the
system. I would really encourage that hopefully those people,
those recovery coordinators, will have a general officer,
somebody with some clout that when they run into a roadblock,
they have somebody that can cut through the system that says
hey, these 3,200 are individuals that were totally committed
and have unique situations, many times, that can cut through
the red tape. And I hope somehow we can integrate that into the
thing.
Secretary Shalala. I think that is exactly right for
accountability. I think of them as torpedoes which literally
cut through with the authority to order appointments, to get
agencies and services to work together, but more importantly,
to make sure that individuals with very complex problems and
their families get every benefit they are eligible for and get
it on time.
Senator Dole. Our hope is, when they have that meeting when
the patient arrives at Walter Reed and the doctors are hovering
around there, one member of that team will be the recovery
coordinator and he will be there from, or she or he will be
there from whatever point. I really give full credit for that
to Secretary Shalala, and I think it is a great idea and it is
not a big, big layer. We are talking about 40 or 50
specialists, right?
Secretary Shalala. Yeah, not that many, you know, it is
just a handful of people given the number of people that are
involved. And I think the most important thing is they don't
get deployed. What happens now with the care coordinators is
they are there for a year and then they get deployed. And so
they keep changing and you have one for each kind of service.
You just can't do that when you have a complex situation.
Mr. Boozman. Right. Let me ask you another thing, too, or
maybe you can comment. I have run into another situation. I am
an optometrist and was asked to--I have been to Walter Reed
several times. I went over to Walter Reed, was asked by the
ophthalmologist and optometrist there, they have a situation
where, with traumatic brain injury and they don't really
understand why, but many of these people have symptoms of not
being able to read, you know, like they used to, comprehend.
And so we are trying, we introduced a bill to provide them some
money to go forward with that study.
As you all know, it is very difficult and hopefully we can
get that blended into this legislation or some other. But there
ought to be a pool of money that as these things come up, you
know, a small pool of money was something where they don't have
to have an act of Congress to go forward with these little,
very, very important things. Does that make sense? You all are
very familiar with this issue.
Secretary Shalala. You know, DoD has a lot of research
money for health research, as does the National Institutes of
Health (NIH) and there is no reason why a first class
application for research money for a period of time on
something specific like that ought not to be funded.
Mr. Boozman. And, again, I think you can help by cutting
the----
Secretary Shalala. But it is not that the resources aren't
available. We have just got to make sure that when those
applications go in, that they have the priority they deserve.
Mr. Boozman. Exactly.
Secretary Shalala. And there is an increasing interest. I
am happy to talk to the Director of the NIH and to the DoD
health research people. But you have put a lot of money in DoD
research, as well as in NIH research. I come from a place that
has the number one ranked eye hospital, Baskin-Palmer, and I
know that our scientists are very interested in these kinds of
questions.
Mr. Boozman. Well, again, that would be helpful, like I
say, in getting some priority.
Secretary Shalala. I would be happy to have those conversati
ons.
Mr. Boozman. The last thing, you mentioned unfit for
service. And what does that, what does that entail as far as
disability? That doesn't mean 100 percent, does it, or does
that mean the whole gambit or----
Senator Dole. Well, DoD wants to keep as many people as
they can. So you could have some problems, some health
problems, some disabilities, but still be fit for service. And
it doesn't mean you are in perfect health and everything is
fine.
Mr. Boozman. Sure.
Senator Dole. But there are certain, some things you can do
in the service that if you are 100 percent you couldn't do. So
that is why we want to make certain that they make that finding
and the VA does the rest.
Secretary Shalala. You know, the two young soldiers that
were members of our panel, both of them could have stayed in
the military, that is, in desk jobs. They chose not to. So they
took their discharge and got on with their education. But it
was basically their choice. And the military is trying to keep
some people--first of all, they are great role models and there
obviously are stories of people jumping out of airplanes, you
know, who have a prosthetic limb. But I think they know pretty
well who is fit to serve, but their incentive is to try to keep
people.
Mr. Boozman. Thank you all very much. Senator, you
mentioned the program, the vets coming up, you know, the World
War II guys.
Senator Dole. Honored Flight.
Mr. Boozman. We had a group from Arkansas that you met and
that was such a special thing. So we appreciate those little
things that make such a big difference. Thank you very much.
Senator Dole. Yeah. Well, not many World War II veterans
around are all that active. But I am sort of the official
greeter. I try to go out there whenever I can and greet these
World War II veterans. And if they are not doing it in your
district, you ought to check into it, because it is just a
great thing to do. It may change the life of some of these 80-
year-olds, 85. I met one guy who was 92. He wanted to get a
picture. He was in a wheelchair. I said you stay right there.
He said no, no, I am going to stand up and he stood up straight
and strong, but you can see the tears in their eyes and they
probably reflected when they were young and what they were
doing. It is a great program. You just raise the money locally.
It is called Honor Flight. You can get information on their Web
site. Some fellow that is not a big CEO, but some young
businessman in Hendersonville, North Carolina, named Jeff
Miller came up with the idea and it is really great. Every
Saturday you can almost count on--last Saturday there were 600
from all over the country. And I did have a good chance to
meet, I met two Kansans in that group from Arkansas, so----
The Chairman. Thank you. Mr. Walz.
Mr. Walz. Well, thank you, Mr. Chairman and Ranking Member,
and of course, a thank you to our guests, Senator Dole and
Secretary Shalala.
Senator Dole, you were out in Rochester, Minnesota, to our
soldier's field which we are very proud of our memorial out
there and my friend, Wayne Steelman, and many of our veterans
out there recall that day with intimate detail about your
taking time to tour the memorial and it truly does matter.
As a veteran, when I saw that the two of you were appointed
to this, I couldn't have been happier and the report you
produced is one that I was hoping we would get. It is
absolutely what we need. It comes from two distinguished voices
on this and my regret is today that this hearing is not being
covered with the same, the same gusto as was last week's
hearing, because listening to Senator Dole's words, the two are
intertwined.
I see members out here of our veteran service
organizations, veterans themselves, people who have worked on
this issue for decades and we know you can't separate the two
and I think it is very important for this Nation to understand
that this treatment is truly critical. And I think it is
important when we talk about the VA to recognize the amount of
great work that happens there. I have in Minnesota, at the VA
medical center in Minneapolis, the polytrauma center there. The
work that they are doing--when I hear mothers with severely
injured sons and they say the only thing getting them through
the day are those saints that are there on that floor, those
nurses, those doctors, that is heartwarming.
But the Senator made the point that all of us make on this.
This is a zero sum proposition. One Sergeant Shannon is one too
many. And that is what we have to get to. And I think in all of
these areas, we are trying to figure out what are the systemic
issues here and some of us are trying to understand the
cultural inertia that happens in this. One area that I am
interested in, and I am glad to hear it got reported on, is
this issue of exchanging medical records from DoD to VA. I
represent the City of Rochester, which includes the Mayo
Clinic. And this is an area that has been working, an
institution that has been working on this for years. This is a
very complex issue. It doesn't involve just getting a
standardized database. It involves many things that go into
what is on that record.
And when I talk to the people at the Mayo who have been
looking at this, they are convinced that the VA has the best in
the world. They said this is the best system in the world. And
their suggestion was, and this was made not, you know, this was
a little more anecdotally when I was talking to them about it
with their very intimate knowledge of this, that DoD needs to
maybe adjust to that.
Now, I had the opportunity after talking with the Mayo
people in looking at this to mention this to some, a person in
DoD on the Army side that would have the ability to influence
these types of decisions. And they simply wanted to hear
nothing about it. They didn't want to hear about it. It wasn't
the right way to go.
My question to both of you with vast experience in the
bureaucracy, talking about the torpedo, Secretary, of cutting
through, how do we get to this issue? How do we move these
electronic medical records, this record sharing? It is so
important for the care of our soldiers, for the efficiency and
for everything else. And I guess I am asking you maybe to
answer a really, really difficult question here. But it is one
that I think--this has been around for many of these Members'
entire tenure here and we still can't get it fixed and it is a
critical part of that seamless transition, so, please.
Secretary Shalala. Actually, I don't think it is that
complex, not if you look at it from the point of view of the
patient. I was Secretary of HHS while the VA record system was
being put in place. That technology certainly will need
modernization and some investments in the years ahead. It seems
so simple, why doesn't the military just adopt it and be done
with it. It is in part not the answer because the VA and DoD
are doing different things. That is number one.
But what we focused on is the soldiers now, and what can
you do to get the interoperability of the two systems. We
suggested, under the leadership of a member of our Commission
who does this for the Cleveland Clinic and is an international
expert on the subject, that there are a series of steps that
will get us more rapidly to interoperability, which are now
taking place. They have to do it as fast as they can to make
sure that you have access to information necessary for both
care and services.
That is more important at this point in time than for us to
suggest that you spend billions trying to get one new system
built from the bottom up. And you can tell our pragmatism here,
that first of all, those of us that have experienced the bottom
up systems are a little nervous about starting that while the
technology is changing. It is not that we would ever say we are
opposed to it, but at the moment, what you want to do is serve
these soldiers now and also the ones that come behind them.
There are ways to do that.
We have suggested a series of steps. You don't have to pass
any legislation on it. The government can do it. The two
agencies can do it. They are in the process of doing it. And we
have suggested action steps that can be measured and what the
goals are of those steps so that we can actually hold the DoD
and the VA accountable for making sure those systems work
together. And they are in the process of doing that. That is
the good news here.
The bad news is that we actually did not take a vote or
look at, you know, adopting one system versus another, because
they actually do have different purposes and need different
kinds of interactions, nor did we make a recommendation on a
bottoms up, multi-billion dollar review. We looked at the
practical ways to get the system to work for these soldiers now
so it is not necessary to carry paper records across the
street.
The Chairman. Madam Secretary, we are going to have to
adjourn very soon. But we have time for--I apologize to the
Members. But if Mr. McNerney, Mr. Hare and Ms. Herseth each
have one question before we adjourn----
Secretary Shalala. Okay. We will try to answer it quickly
then.
The Chairman. Do you have a question before we adjourn?
Mr. McNerney. Thank you, Mr. Chairman. I really wanted to
compliment you all on your can-do attitude, which is inspiring,
and on the simplicity of the approach. Sitting here on the
Veterans' Affairs Committee, we see problems that seem
overwhelming and you have taken them by the horns and you have
produced a report that makes it look like we can actually make
significant progress. So I applaud you on that.
One thing that was interesting was the proposal to ask for
reevaluation on a continuing basis. And my concern is, wouldn't
that seem like it would make the backlog even more for
evaluation of veterans?
Senator Dole. Well, that is one of the practical questions
that we looked at and I don't--it would seem to me, after maybe
a couple evaluations it would stop. You don't do this for the
rest of your life because you are going to know, unless
somebody has a deteriorating condition that you want to
continue to check on. But we are just going to have to find the
people. It is pretty much like the passport problem when we had
this big backlog. Maybe we are going to have to bring in some
of these people who have left and bring them back on a
temporary basis and let them help us get rid of these backlogs.
That could be a problem.
The Chairman. Mr. McNerney, thank you. I----
Secretary Shalala. But we do want to give the opportunity
to upgrade someone's benefits, so there is a positive and a
negative here. But people ought to be able to look at someone's
file and make a pretty quick decision on whether you need to
move forward on that evaluation, because in the vast majority
of the cases it makes no sense. But we want to make sure that
we can upgrade benefits if that is necessary.
The Chairman. Thank you. Mr. Hare.
Mr. Hare. Mine is just real quick. Thank you very much for
what you both have done. The other day, the Secretary was here
just yesterday talking about 177 days for a person as an
average on a claim. And it seems to me, why, and I wanted to
get your thoughts. Why can't we err on the side of the veteran?
In other words, start the process of the claim immediately the
same way you do when somebody files their taxes and the claim
begins.
If we want to audit this claim and we think that there is a
problem with it, fine. But it would seem to me, and the
Secretary said he supported a pilot program, but their goal is
to get it down from 177 to 145 days and for that veteran, I
don't think that is, I don't think that is acceptable. So I
wonder what your thoughts are on being able to err on the side
of the veteran and at the VA here on disability claims.
Secretary Shalala. You know, I think we are always in favor
of erring on the side of the patient, that this has to be
patient-centered. We did not look at how to eliminate the
backlog. I have had some experience in looking at that kind of
thing, but our Commission did not actually review that specific
issue. So I am reluctant to even comment on it, because there
are different ways to approach it. But our point is that you
get a patient-centered system that doesn't delay people's
ability to get the help they need and doesn't delay their
ability to get educational benefits and get those investments
on the front end as quickly as possible.
The Chairman. Thank----
Senator Dole. And some people have a right to appeal and,
of course, the appeal takes a long time and I think, yeah, what
is it, 12 months or something----
Secretary Shalala. Yeah.
Senator Dole [continuing]. Can delay it. So there are other
things that maybe we need to look at. We think with our new
system we are going to streamline the process so you won't have
that big backlog. And you also, obviously, you get paid even
though you will have to wait for a time, but you will get paid
when it is finally adjudicated.
The Chairman. Thank you. Ms. Herseth.
Ms. Herseth Sandlin. Thank you, Mr. Chairman, and thanks to
both of you. I commend you for your great work and the
recommendations. I, too, like many others here, appreciate and
would support the creation of someone who would coordinate
recovery for servicemembers. I have had a number of
constituents who I feel have been kind of caught between DoD
and VA, one in particular who suffered a devastating traumatic
brain injury. His family did not feel that he was getting the
quality of care at a polytrauma center and, after some
intervention, had him transferred to a private rehabilitative
facility in California.
And so I guess just two very quick questions. One, do you
envi-
sion the recovery coordinator serving as the advocate for the pa
tient?
Secretary Shalala. Yes.
Ms. Herseth Sandlin. Okay. And then the other, in all of
the interviews and surveys that you did over the past 4 months,
did you find anything that would suggest that we prematurely
moved traumatically brain injured soldiers to long-term care
who did not receive aggressive ongoing therapy and rehab and,
if they did, would be much better off today than if they were
prematurely transferred to a long-term care facility?
Secretary Shalala. Our survey did not provide answers at
that level of detail, nor did we have a health services
research capacity to be able to answer that question. But it
certainly is a question that ought to be looked at.
Ms. Herseth Sandlin. And one final thought----
Senator Dole. I would just add that Mr. Eckenhoff, who is a
member of our Commission and the National Rehab Hospital
Director--they have a number of, or have had a number of active
duty people where they couldn't get the best care. They can get
the best care at his facility and we encourage that.
Ms. Herseth Sandlin. Okay. Thank you. That answered the----
The Chairman. Thank you, Madam Secretary and Senator Dole.
This has been one of the most productive and helpful sessions
we have ever had here. It reflects your personalities, your
enthusiasm, your commitment and we thank you so much and we
intend to meet your challenge of speed and urgency and being
patient-centered. And we thank you so much. We are going to
have the--next week the Disability Commission will be in to
testify and--I am sorry, the 10th of October. And we look
forward to working with you on behalf of our combat veterans.
Thank you so much.
This meeting is adjourned.
[Whereupon, at 11:44 a.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Bob Filner,
Chairman, Full Committee on Veterans' Affairs
On March 6, 2007, the President signed an Executive Order to
establish the President's Commission on Care for America's Returning
Wounded Warriors.
The Commission was charged with the task of examining the
effectiveness of returning wounded servicemembers' transition from
deployment in support of the Global War on Terror to returning to
productive military service or civilian society, and recommend needed
improvements.
The Report of the Commission was recently released and today the
Committee will be hearing from the Co-Chairs of that Commission--
Secretary Donna Shalala and Senator Bob Dole. I look forward to a frank
and open discussion of the recommendations made by the Commission.
According to the report, there have been 1.5 million servicemembers
deployed to Iraq and Afghanistan. Twenty-eight thousand have been
wounded in action, with 3,082 of those seriously injured. The nature of
the injuries sustained on today's battlefield is very complex and
resource-intensive. Because of the advancements in battlefield
medicine, protective gear and technology, the rate of survival is much
greater than that of past wars.
My concerns are focused on how we serve our troops when they turn
from the Pentagon to the VA for their healthcare. In order for our
troops to experience the seamless transition they deserve, the
bureaucratic problems that prevent many from getting the care they need
must be fixed.
While VA and DoD have made adjustments and changes over the last
few years in an attempt to address the issues surrounding the treatment
of these injuries, as well as the transitioning of severely wounded
servicemembers, many obstacles remain.
As Chairman of the Committee on Veterans' Affairs, I am sensitive
to the difficulties involved in coordinating the activities of the
Department of Defense and the Department of Veterans Affairs. These
Departments do indeed have different missions.
That being said, we no longer have the luxury of time, and we, as a
country, must act.
Right now, while we prepare to discuss this issue, our
servicemembers are in harm's way. Some of these brave men and women
will be killed or wounded. We have talked about the necessity of
providing a seamless transition for many years. This is our test as a
Nation. And this is a test we simply must pass.
I would like to welcome our two distinguished panelists this
morning.
In 1993, President Bill Clinton appointed Donna Shalala as the
Secretary of Health and Human Services (HHS) where she served for eight
years, becoming the longest serving HHS Secretary in our history. As
HHS Secretary, she directed the welfare reform process, made health
insurance available to an estimated 3.3 million children, raised child
immunization rates to the highest levels in history, led major reforms
of the FDA's drug approval process and food safety system, revitalized
the National Institutes of Health, and directed a major management and
policy reform of Medicare.
Secretary Shalala has dealt with large bureaucracies like the VA
and DoD before and she is experienced in implementing programs that
work for the people . . . not against the people.
Senator Dole knows all too well the problems that our brave men and
women face as they deal with the painful injuries of war. Senator Dole
was twice decorated for heroism, receiving two Purple Hearts for his
injuries, and the Bronze Star Medal with combat ``V'' for valor. In
1942, he joined the United States Army's Enlisted Reserve Corps to
fight in World War II and became a second lieutenant in the Army's 10th
Mountain Division. In April 1945, while engaged in combat in the hills
of northern Italy, he was hit by German machine gun fire in his upper
right back and badly injured. He had to wait nine hours on the
battlefield before being taken to the 15th Evacuation Hospital before
he began his recovery at a U.S. Army hospital in Michigan.
I want to take this opportunity to thank you both for your service
to our country and your dedication to our Nation's veterans. We are all
grateful for the work that you do.
Prepared Statement of Hon. Harry E. Mitchell,
a Representative in Congress from the State of Arizona
Thank you, Mr. Chairman.
First and foremost I want to thank Senator Dole and Secretary
Shalala for their efforts.
These distinguished Co-Chairs have not only provided us critical
information . . . they have provided us a model of bipartisanship on an
issue of great importance.
They know that the best way for us to help our Nation's veterans is
for all of us to work together.
And as their report has demonstrated, we have our work cut out for
us.
We need to improve information-sharing between the Department of
Defense and the Veterans Administration. This is not only inefficient,
it poses a risk to the quality of care our veterans receive.
We need to reduce the long wait times veterans are enduring at the
VA, and ensure that the VA has the resources it needs to serve veterans
in a timely manner.
We need to do more to help the families of veterans who, in many
cases, are forced to shoulder the burden of advocating for healthcare
services.
The President's Commission outlined six specific changes to the
current veteran care organization that can be made through Congress,
which would improve the services that our Nation's veterans receive.
Some of these recommendations will be easy fixes requiring little
negotiation or further investigation.
Others, like the restructuring of disability and compensation
systems, will require us to put our partisan differences aside and work
creatively to arrive at the best outcome.
The wars in Afghanistan and Iraq pose different challenges for our
VA than previous conflicts. Many of our returning heroes are bringing
back new and different kinds of injuries which need new and different
kinds of treatments.
Our challenges are great, but working together, I know we can meet
them.
Our veterans have served us, and they have a right to expect us to
serve them. And that is exactly what we are going to do.
I look forward to today's discussion, and I yield back.
Prepared Statement of Hon. Jerry Moran,
a Representative in Congress from the State of Kansas
I want to first welcome our distinguished guests with us today.
Senator Dole and Secretary Shalala have both experienced long and
successful careers in public service. Today, we appreciate their
willingness to use their time and talents for a most worthy goal: to
ensure our country is providing the best care and services to our
military men and women and veterans, especially for those wounded in
service to our country.
A couple years back, Senator Dole published a moving memoir titled
``One Soldier's Story.'' In this book he chronicles his powerful story
of growing up in Russell, Kansas, going off to war, being wounded on a
battlefield in Italy, and his struggle to overcome the odds to recover
and rebuild his life. What I found remarkable about the Senator's
recovery period was not only his personal courage, but also the help
that he received from those around him. Senator Dole wrote, ``None of
us who travels the valleys of life ever walks alone.'' From his mother
who was by his bedside night and day, to the gifted Army doctors, to
the Russell community who collected donations in a cigar box to pay for
his surgeries, the system of support for wounded servicemembers
matters.
Our military members and veterans today deserve a strong support
system, one that matches the times. The Wounded Warrior Commission--
after several months of visits to DoD and VA facilities, public
meetings, and patient surveys and interviews--recommends that
improvements can and should be made. Change is needed to modernize the
current system to adjust to the realities of today's wars and improve
the quality of life of soldiers and their families. The Commission has
put forth a set of action items to do this.
It is now Congress's turn to take a serious look at these
recommendations. To move things along, Congressman Salazar and I have
introduced the Wounded Warriors Commission Implementation Act, H.R.
3502, to enact the recommendations of the Commission requiring
congressional action. Before the Commission's report was released, both
the House and Senate acted to pass legislation addressing some of the
concerns later identified by the Commission. This was a good first step
to improving care and services, but clearly more comprehensive action
is needed. I encourage my colleagues to move quickly to make the
changes necessary to support those who have sacrificed so much for our
country.
Prepared Statement of Hon. Ginny Brown-Waite,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
Senator Dole and Secretary Shalala, I want to thank you for
testifying before this Committee today. I would like to commend you for
your work on the President's Commission on Care for America's Returning
Wounded Warriors. When we send the brave men and women of our armed
forces into battle, we better make sure they have everything they need
when they come home.
Your recommendations suggest the need in some instances to make
sweeping changes to the way the Department of Veterans Affairs conducts
its business. I will be interested in hearing exactly how you think
these recommendations can be implemented
I was pleased to see the recognition you gave to the importance of
addressing post-traumatic stress disorder and traumatic brain injuries
in our returning soldiers. This along with strengthening the support
for their families, will go a long way to help soldiers transition back
to life as a civilian.
Once again, I welcome you to the hearing and look forward to
hearing your thoughts on the issue before us today.
Prepared Statement of Hon. Donna E. Shalala, Co-Chair,
President's Commission on Care for America's Returning Wounded Warriors
(Former Secretary of the U.S. Department of Health and Human Services)
Good morning, Chairman Filner, Congressman Buyer, and distinguished
Members of the Committee. Thank you for giving me the opportunity to
testify today, along with my fellow Co-Chair, Senator Bob Dole, about
the recommendations our Commission presented to the President in late
July.
It was a true privilege to serve on the President's Commission on
Care for America's Returning Wounded Warriors, especially with Senator
Dole, whose knowledge and dedication was an inspiration to us all. We
were joined by a stellar group of Commissioners, each of whom gave
their full energy and attention to the critical mission we faced.
As you know, we had an extremely short timeframe to complete our
mission--but we were propelled by a sense of urgency that the issues
before us required. Mr. Chairman and Members of the Committee, we know
you share this sense of urgency and that's why we are so pleased to be
with you today to discuss not only our recommendations, but the
critical need to implement them.
We have been truly heartened by the response our report has
received in the White House, the halls of Congress and throughout the
country. The Nation has rallied behind the need to help those who have
put their lives on the line in service to our country--and we are
optimistic that Congress and the Administration will move quickly to
respond to this need by enacting our recommendations.
As we were reminded again by the article in Saturday's Washington
Post, the problems facing our injured service men and women have not
gone away. Congress and the Administration have spent a great deal of
time the past few weeks discussing the future of the war in Iraq. And
while this is a debate that our Nation must have, I implore you not to
forget about those who have already sacrificed so much--our injured men
and women. They need to be front and center in congressional debate and
within the Administration.
The story of Staff Sgt. John Daniel Shannon, as told in the
Washington Post, is a story that we heard throughout our time with the
Commission--a story of numerous case managers, none of whom held sole
responsibility for spearheading an integrated care system--a story of
lost paperwork and frustration--and a story of a disability system that
was in desperate need of repair.
It's stories like this that sparked the creation of our
Commission--and stories like this that should and must drive immediate
congressional and White House action.
This past July, it was the Commission's honor to present to the
President, Congress and the public, six groundbreaking patient and
family centered recommendations that make sweeping changes in military
and veterans' healthcare and services. The recommendations include the
first major overhaul of the disability system in more than 50 years;
creation of recovery plans with recovery coordinators; a new e-Benefits
Web site; and guaranteeing care for post-traumatic stress disorder from
the VA for any servicemember deployed to Iraq and Afghanistan. Our
report--Serve, Support, Simplify--is a bold blueprint for action that
will enable injured servicemembers to successfully transition, as
quickly as possible, back to their military duties or civilian life.
Our report calls for (and I quote) ``fundamental changes in care
management and the disability system.'' I respectfully request that
this report be submitted for the record.
Specifically, our six recommendations will:
Immediately Create Comprehensive Recovery Plans to
Provide the Right Care and Support at the Right Time in the Right Place
Completely Restructure the Disability Determination and
Compensation Systems
Aggressively Prevent and Treat Post-Traumatic Stress
Disorder and Traumatic Brain Injury
Significantly Strengthen Support for Families
Rapidly Transfer Patient Information Between DoD and VA
Strongly Support Walter Reed By Recruiting and Retaining
First Rate Professionals Through 2011
Our six recommendations do not require massive new programs or a
flurry of new legislation. We identify 34 specific action steps that
must be taken to implement the six recommendations. Only six of these
34 items require legislation, and that's what we will focus on today. A
complete list of the action steps for the six recommendations is
included on the last page of my testimony.
I will summarize the first three actions that require legislation,
and, then, Senator Dole will cover the remaining three.
The first is to improve access to care for servicemembers with
Post-Traumatic Stress Disorder.
We call on Congress to authorize the VA to provide lifetime
treatment for PTSD for any veteran deployed to Iraq or Afghanistan in
need of such services. This ``presumptive eligibility'' for the
diagnosis and treatment of PTSD should occur regardless of the length
of time that has transpired since the exposure to combat events.
The current conflicts involve intense urban fighting, often against
civilian combatants, and many servicemembers witness or experience acts
of terrorism. Five hundred thousand servicemembers have been deployed
multiple times. The longer servicemembers are in the field, the more
likely they are to experience events which can lead to symptoms of
PTSD. The consequences of PTSD can be devastating. The VA is a
recognized leader in the treatment of combat-related PTSD, with an
extensive network of specialized inpatient, outpatient, day hospital,
and residential treatment programs. Therefore, we ask that any veteran
of the Iraq or Afghanistan conflicts be able to obtain prompt access to
the VA's extensive resources for diagnosis and treatment.
Next, we ask Congress to strengthen support for our military
families.
In our travels across the country, it became abundantly clear that
we not only needed to help the severely injured, we needed to help
their loved ones too. These loved ones are often on the frontlines of
care and they are in desperate need of support. Therefore, we call upon
Congress to make servicemembers with combat-related injuries eligible
for respite care and aide and personal attendant benefits. These
benefits are provided in the current Extended Care Health Option
program under TRICARE. Presently, DoD provides no other benefit for
caregiving. Yet we know that many families are caring for their injured
servicemember at home--and many of these servicemembers have complex
injuries. These families, forced into stressful new situations, don't
need more anxiety and confusion, they need support. Families are
unprepared to provide 24/7 care. Those that try, wear out quickly. By
providing help for the caregiver, families can better deal with the
stress and problems that arise when caring for a loved one with complex
injuries at home.
We also recommend that Congress amend the Family and Medical Leave
Act (FMLA) to extend unpaid leave from 12 weeks to up to six months for
a family member of a servicemember who has a combat-related injury and
meets other FMLA eligibility requirements. According to initial
findings of research conducted by the Commission, approximately two-
thirds of injured servicemembers reported that their family members or
close friends stayed with them for an extended time while they were
hospitalized; one in five gave up a job to do so.
Getting family members to the bedside of an injured servicemember
is not the problem. The services have developed effective procedures to
make this happen, and the private sector has stepped up to provide
temporary housing. Because most injured servicemembers recover quickly
and return to duty, the family member's stay may be short. However, for
those whose loved one has incurred complex injuries, the stay may last
much longer. Extending the Family and Medical Leave Act for these
families will make a tremendous difference in the quality of their
lives. Congress enacted the initial Family and Medical Leave Act in
1993, when I was Secretary of Health and Human Services. Since then,
its provisions have provided over 60 million workers the opportunity to
care for their family members when they need it most--without putting
their jobs on the line.
We were pleased to see that the Senate has already unanimously
passed the Support for Injured Servicemembers Act which implements this
recommendation. We hope the House of Representatives will quickly
follow suit.
Mr. Chairman, having served in government a good deal of my life, I
believe that government can work to improve the lives of its citizens.
But sometimes, people of good will want to solve a problem and their
idea of a fix is to add a program or a new regulation. What we've done
is strip some of that away to simplify the system, to go back to basic
principles and to make necessary programs more patient and family
centered.
Above all, our recommendations are doable. Whether requiring
congressional legislation or implementation by DoD or VA, we made sure
that what we were recommending could be acted upon quickly. Our
seriously injured servicemembers must not be made to wait. They deserve
a healthcare system that truly serves, supports and simplifies.
On behalf of the Commission, I want to thank the Committee again
for the opportunity to discuss our recommendations. And because those
of you who know me know I don't mince words, I leave the Committee--and
the Administration--with these three simple words--Just do it! And, Mr.
Chairman and Members of this distinguished Committee, I know that
through your leadership, our recommendations WILL become a reality for
our servicemembers and their families.
Thank you and I look forward to joining Senator Dole in answering
your questions.
Prepared Statement of Hon. Bob Dole, Co-Chair,
President's Commission on Care for America's Returning Wounded Warriors
(Former United States Senator from the State of Kansas)
Good morning, Mr. Chairman and Members of the Committee.
It is a pleasure to appear before you today, along with my fellow Co-
Chair Donna Shalala.
We look forward to working with you to support this
Nation's goal of assuring that our service men and women receive the
benefits and services they deserve.
It has been an honor to serve on this Commission,
especially with Secretary Shalala. I have said it before and I will say
it here today, she's been a ``Triple A'' Co-Chair. She has boundless
energy and kept us going as we tackled this important challenge. It has
been a great experience to work with her and our fellow Commissioners.
Our recommendations were guided by the Commission chaired
by General Omar Bradley in 1956, which said: ``Our philosophy of
veterans' benefits must be modernized and the whole structure of
traditional veterans' programs brought up to date.''
Problems accompany change--wars change, people change,
techniques change, injuries change, and we need to keep our military
and veterans healthcare system up to date. I find it remarkable that 50
years later we are finding so much of what General Bradley had
recommended is still relevant today.
Secretary Shalala has outlined our recommendations and
some of the action steps to be taken by Congress. I will now review the
remaining three action steps that require legislation and are part of
our call for a complete restructuring of the disability and
compensation systems.
In our next action step, we call on Congress to revise
the DoD and VA disability systems. Right now each of these Departments
assesses each injured servicemember's disability level, based on
different objectives. Each assessment leads to a rating of the amount
of disability. The two systems often disagree, they take way too long,
and the process is way too confusing.
There are differences in ratings depending on which
military service determines the DoD rating and which VA regional office
determines the VA rating. In our national survey of injured
servicemembers, less than half understood the DoD's disability
evaluation process. And, only 42 percent of retired or separated
servicemembers who had filed a VA claim understood the VA process.
We recommend that DoD retain authority to determine
fitness to serve. Servicemembers whose health makes them unfit for duty
would be separated from the military. DoD would provide them a lifetime
annuity payment based on their rank and years of military service.
We believe that only one physical exam should be
performed, rather than the two required now--one by each Department--
and it should be performed by the DoD. The VA should assume all
responsibility for establishing the disability rating based on that
physical and for providing all disability compensation.
This
new structure makes timely, reliable, transparent, and accountable chang
es in both systems.
Under this action item, DoD and VA can focus on what they
do best--determining fitness standards and the health and readiness of
the military workforce. The VA can focus on providing care and support
for injured veterans, including providing education and training early
in the rehabilitation process. It is a much simpler system that better
supports the needs of those transitioning between active duty and
veteran status.
In our fifth action step, we recommend healthcare
coverage for servicemembers who are found unfit because of conditions
that were acquired in combat, supporting combat, or preparing for
combat. Congress should authorize comprehensive lifetime healthcare
coverage and pharmacy benefits for those servicemembers and their
families through DoD's TRICARE program.
We believe this action item would help these individuals
find employment that fits their needs without worrying whether the job
provides adequate family healthcare coverage.
And, in our final action step, we would like Congress to
clarify the objectives for the VA disability payment system by revising
the three types of payments currently provided to many veterans. The
primary objective should be to re-
turn disabled veterans to normal activities, insofar as possible, and
as quickly as possible, by focusing on education, training, and
employment. We recommend changing the existing disability compensation
payments for injured servicemembers to include three components:
transition support, earnings loss, and quality of life.
``Transition Payments'' are temporary payments to help
with expenses as disabled veterans integrate into civilian life.
Veterans should receive either three months of base pay, if they are
returning to their community and not participating in further
rehabilitation; or an amount to cover living expenses for up to four
years while they are participating in education or work training
programs.
``Earnings Loss Payments'' make up for any lower earning
capacity remaining after transition and after training. Initial
evaluation of the remaining work-related disability should occur when
training ends. Earnings loss payments should be credited as Social
Security earnings and would end when the veteran retires and claims
Social Security benefits.
And ``Quality of Life Payments,'' which should be based
on a more modern concept of disability that takes into account an
injury's impact on an individual's total quality of life--independent
of the ability to work.
The disability status of veterans should be reevaluated
every three years and compensation adjusted, as necessary.
By overhauling the DoD and VA disability systems,
Congress will make the systems less confusing, eliminate payment
inequalities, and provide a solid base and incentives for injured
veterans to return to productive life.
I really believe, and I can say this having voted on a
lot of military and veterans bills, having met on other commissions,
having been a service officer in my younger years, and having worked
hard to help veterans in the Legion and the VFW, that these are really
bold action steps. They will do justice for our brave servicemembers
fighting in Iraq and Afghanistan. I also believe these actions, which
support our six recommendations, will benefit past and future
generations of American servicemembers.
You know, in Vietnam \5/8\ seriously injured
servicemembers survived; today
\7/8\ survive--many with injuries that in World War II would have been
fatal. Over 1.5 million servicemembers have been deployed in the Global
War on Terror. At the time of our report, 37,851 had been evacuated
from Iraq or Afghanistan for illness or injury--23,270 of these
individuals were treated and returned to duty within 72 hours. We
believe that the number of seriously injured is small--on the order of
3,000, based on the number who have received Traumatic Servicemembers'
Group Life Insurance (TSGLI).
Both of us are grateful that Congress is determined to
improve the system of care for America's injured servicemembers and
their families. We call upon you to move quickly and implement the
actions we have discussed today. To make the significant improvements
we recommend requires a sense of urgency and strong leadership.
Congress plays a critical role in helping to change the
way our military and veterans healthcare systems work. Together, we are
truly creating a system that serves our bravest men and women who have
made the ultimate sacrifice for our Nation.
In closing, Mr. Chairman, let me emphasize again that our
report is doable and necessary. We ask that you draft legislation to
implement the six action items that Secretary Shalala and I have just
discussed.
Thank you.
Statement of Joseph A. Violante,
National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Committee:
The Disabled American Veterans (DAV), a national veterans service
organization, was founded in 1920 and chartered by Congress in 1932 to
represent this Nation's war-disabled veterans. DAV is dedicated to a
single purpose: building better lives for our Nation's disabled
veterans and their families. While representing the interests of all
service-disabled veterans, DAV counts among its membership 1.3 million
war veterans who were injured in service to the Nation. On behalf of
DAV, I appreciate the opportunity to submit testimony to the Committee
on the matter before you today.
The President's Commission on Care for America's Returning Wounded
Warriors (hereinafter, ``Dole-Shalala'') was ordered by President Bush
following the public outcry earlier this year on discovery of
substandard living conditions and confusing bureaucracy affecting
hundreds of wounded soldiers at Walter Reed Army Medical Center. All of
us were justifiably outraged that our Nation's newest wounded and
disabled military servicemembers were being forced to live in
deplorable conditions and experienced frustrating delays to get their
disabilities adjudicated by the military service departments. But even
today, Mr. Chairman, injured and ill veterans continue to be denied
benefits to which they are rightfully entitled, and I will explain our
stance on this issue further in this testimony.
In general the report issued July 25, 2007 by Dole-Shalala strikes
a positive chord in advocating improved support to the immediate
families of the wounded; calling for better coordination between the
Department of Veterans Affairs (VA) and the Department of Defense (DoD)
across a number of separate, but overlapping responsibilities; and,
establishing within both VA and DoD better guidance and more informed
assistance for wounded servicemembers, veterans and their families.
These are very good ideas and should be implemented rapidly. We support
them and commend the Commission for making these recommendations. In
fact DAV, in our Stand Up For Veterans initiative
(www.standup4vets.org), is developing our own legislative
recommendations, for consideration by Congress, covering areas very
similar to the Dole-Shalala recommendations of better supporting family
caregivers and improving coordination of care. We hope to have our
recommendations from that initiative, formulated by consultants now
working with DAV after completing significant careers in the VA
healthcare system, in legislative form to you by the end of this
session of Congress, and for further consideration by the Committee
early next year.
Over the years DAV and other veterans service organizations have
testified before this Committee and others on numerous occasions to
identify many existing gaps in health and benefits systems, and to urge
they be filled by actions within either VA or DoD, or both, or by
Congress. Congress has responded to many of these initiatives, and we
appreciate that assistance. Nevertheless, we believe a few of the Dole-
Shalala recommendations that seek the same goals are in fact misguided
or fail to recognize a degree of effectiveness that we at DAV
understand and appreciate from decades of direct experience working in
this very field, helping veterans obtain their rightful government
benefits.
Recalling the explosion of media reports earlier this year to
document the Walter Reed Army Medical Center scandal, it is ironic that
the recommendations from a well-conceived, 2-year study by the
President's Task Force to Improve Healthcare Delivery for Our Nation's
Veterans issued in 2003, with broad support from the entire veterans
community, have gone nowhere. Yet the Dole-Shalala recommendations--
some of which could do harm to the very system now in place and
intended to help veterans--are apparently being put on a fast track to
implementation. DAV was invited with others to a White House briefing
only a few days ago to be informed that the Administration is in the
final stages of developing proposed legislation to carry out the Dole-
Shalala recommendations, less than two months following the report of
the Commission. We at DAV hope this Committee--one that will have the
major responsibility to consider the Administration's proposal--will
very carefully evaluate the potential consequences of this bill. Its
untoward affects in some areas that seem to help one group of disabled
veterans may well damage the best interests of another group. DAV's
policy is to protect the interests of all service-disabled veterans,
not one group to the detriment of another.
In respect to protecting the interests of all disabled veterans, a
major strategic goal of DAV, we appreciate the Committee's interest in
scheduling a hearing next month on the need for reform of funding of
VA's healthcare system--a key issue ignored by the Dole-Shalala
Commission's report. The Senate Committee on Veterans' Affairs held
such a hearing on July 25, 2007, the same date that the Dole-Shalala
Commission issued its report. The President's earlier Task Force in
2003 specifically pointed out the obvious mismatch between funding made
available through the discretionary appropriations process now in use,
versus meeting the true financial needs of VA healthcare. This
President's Task Force hypothesis was validated in 2005 and 2006 by
very public and embarrassing developments in VA healthcare when, during
both periods, the VA Secretary reluctantly admitted to Congress that VA
needed major emergency supplemental funding to keep the system
financially solvent. Congress eventually provided that needed extra
funding, but we continue to believe that significant reform is
necessary. DAV strongly supports conversion of VA healthcare funding to
a mandatory status as our top legislative goal, and we look forward to
further discussions of this issue at your upcoming hearing.
Mr. Chairman, most of the six Dole-Shalala recommendations are
already being addressed in the Department of Veterans Affairs. For
example, early on in these wars VA established polytrauma
rehabilitation centers to treat traumatic brain injuries and other
polytrauma cases from the wars in Iraq and Afghanistan, and VA has been
the pioneering force and recognized expert in the treatment and
research on post-traumatic stress disorder (PTSD). So, in many ways, VA
is far and away ahead of the Dole-Shalala recommendations.
The VA has an established nationwide healthcare system that is a
recognized leader in specialized treatment (including long-term medical
and vocational rehabilitation) of the kinds of injuries and
psychological wounds occurring in the wars in Iraq and Afghanistan.
Yet, initially Dole-Shalala has recommended that DoD take the lead role
in coordinating long-term care for men and women with traumatic brain
injury and post-traumatic stress disorder after they've been released
from the military medical system. The report recommends these
individuals, as veterans, retain lifetime access to DoD healthcare
through its TRICARE program, rather than make a smooth transition to VA
care as the primary locus of their long-term rehabilitation. While we
do not object on its face to continued TRICARE eligibility for this
newest generation of veterans, no former injured veteran group has ever
been given this government benefit (even following the Persian Gulf
War, when casualties were light). This proposal, if approved by
Congress, would set a precedent to continue for veterans of any future
U.S. conflict. After several decades of growing reliance on DoD, rather
than VA, by service-disabled veterans, we question whether the VA
healthcare system we know today would be able to retain its viability
if wounded war veterans were still attached on a long-term basis
primarily to military medicine. The military's top mission in
healthcare is the maintenance of readiness. Giving the military a new
mission to provide lifelong care to severely disabled veterans will sap
resources and challenge the military services' ability to sustain a
strong readiness posture.
Mr. Chairman, we are most troubled by an ill-advised Dole-Shalala
recommendation for a seemingly wholesale and radical overhaul of the
disability evaluation and compensation systems in use today in DoD and
VA. Dole-Shalala would establish a complicated and different system of
compensation payments for our newest injured military members while
failing to address the accuracy and timeliness problems that have
plagued both the VA and DoD for many years. Dole-Shalala would have the
government adjudicate disability for new and future injuries based on
two primary factors--loss of earnings and diminished quality of life--
instead of retaining and fixing the highly structured disability
compensation system now in use that collectively considers both
factors. Even more troubling is the Dole-Shalala recommendation to
drastically reduce the level of government disability compensation when
a veteran stops working or gains eligibility for receipt of Social
Security benefits.
Based on DAV's eight decades of contact with, and work in, the VA
and DoD disability adjudication systems, DAV testified before the Dole-
Shalala Commission and called for adequate staffing, structured
training programs, and strict accountability for claims processing in
VA. Unfortunately, the Commission ignored our recommendations. Our
testimony to the Commission is attached to this testimony to provide
the Committee an opportunity to fully consider our views as provided
previously to the Dole-Shalala Commission. Dole-Shalala had the
opportunity to push the VA to take the first genuine steps toward
effectively reducing to a minimum the present massive claims backlog.
Sadly, it chose not to do so by failing to address the staffing,
accuracy and timeliness problems that have plagued both VA and DoD and
instead proposed a program exclusively attuned to new combat-wounded
veterans. Without that important and vital mandate as suggested by DAV,
the VA may never be fully responsive to the needs of disabled veterans
already in its claims adjudication queue. We question where this leaves
the 600,000 veterans of earlier military service now awaiting
resolution of their VA claims. Implementing this Dole-Shalala
recommendation would set a dual standard for disabled veterans--one
that DAV could not support.
Mr. Chairman, it may be good to remind the Committee that this is
not our first, nor probably our last, war. Currently, like many other
veterans organizations, members of DAV are largely drawn from the
Vietnam War generation. We at DAV are wartime veterans and have
suffered many of the same kinds of injuries that are being suffered now
in Baghdad or Kabul in our latest wars. Had it not been for the
existence of a caring, attentive VA system almost 40 years ago,
including its health and compensation programs that sustained us and
our families through the long-term rehabilitation process, and the VA's
Vocational Rehabilitation Program (under title 38, United States Code,
Chapter 31), that enabled us to embark on many rewarding careers, as
disabled veterans we simply could not know where our lives might have
taken us. The VA healthcare system has been an intimate part of our
lives for decades since those traumatic ``Alive Day'' events in the
early lives of DAV members. The quality of care and dedication to
purpose and commitment of VA employees would be difficult to match
elsewhere, in public or private systems.
We believe VA has a system that has worked well for years, is time
tested and proven, but is now under fire because of the process, as
opposed to the fundamentals. We believe the fundamentals are sound at
VA and should be preserved. To provide VA what it needs in financial
resources to employ and train sufficient staff, and to hold them
accountable for the work they are supposed to do, would go a long way
to keeping the system solvent well into the future to meet the needs of
older veterans, the newest generation of wounded combat veterans, and
future generations to come. Said another way, we at DAV do not see the
need for wholesale changes and the development of an entirely new
compensation and benefit system at VA to replace, for new veterans what
has worked successfully to assist veterans over many decades.
In 2004, in section 1501 of Public Law 108-136, the National
Defense Authorization Act for FY 2004, Congress authorized a Veterans
Disability Benefits Commission to examine VA's disability compensation
system, and to make a report with recommendations for any needed
reforms. The report of that Commission is due for release next month.
We hope this Committee will examine that report at least as closely as
you examine this one from Dole-Shalala, to determine a proper and
equitable disability compensation policy for war-wounded veterans,
whether new or old.
Mr. Chairman, in summary DAV is concerned about the Dole-Shalala
Commission report, especially in the areas indicated. When the
Administration's legislative proposal is released to implement the
intent of the Commission's recommendations, we are hopeful DAV will
have an opportunity to review it and provide the Committee further
commentary before you act on that proposal.
Mr. Chairman, this concludes DAV's statement. Again, on behalf of
DAV, thank you for the opportunity to provide this testimony.
Statement of Hon. Jeff Miller,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
Providing top-notch medical care and a seamless transition for
separating servicemembers between the Department of Veterans Affairs
(VA) and the Department of Defense (DoD) is a priority. This is
especially important when we address care provided by VA to the
severely wounded warriors from the Global War on Terror.
Serving on both the Committee on Veterans' Affairs and the
Committee on Armed Services, I take great interest in the medical care
and services available to our Nation's veterans, and the men and women
serving in uniform.
Today we will review the recommendations to improve the care and
services for our wounded warriors and veterans from the President's
Commission on Care for America's Returning Wounded Warriors, co-chaired
by Senator Bob Dole and Secretary Donna Shalala.
The Dole-Shalala Commission based its recommendations on three
goals to prioritize patients and families, so that we simplify the
complicated systems that are in place while serving and supporting our
wounded warriors from the Global War on Terror. These are important
goals as we address the needs of our veterans and wounded warriors. The
Commission framed its recommendations by these goals.
Among the specific recommendations reported by the Dole-Shalala
Commission we find the immediate creation of comprehensive recovery
plans to provide the right care and support at the right time and place
to help establish a continuity of care. Providing a plan would fulfill
the goals to serve, simplify, and support. These concepts will be
valuable to review as the Committee moves forward this Congress.
Continued support for the severely wounded is imperative. We must
ensure that we are able to provide care and services for our wounded,
and I look forward to the discussion today.
Senator Dole and Secretary Shalala, I appreciate your service to
America and its veterans. Your contribution is appreciated.
Thank you, Mr. Chairman. I yield back the balance of my time.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Washington, DC
October 18, 2007
The Honorable Donna E. Shalala
President
University of Miami
P.O. Box 248006
Coral Gables, FL 33124-4600
The Honorable Bob Dole
Alston & Bird, LLP
950 F Street, NW
Washington, DC 20004
Dear Ms. Shalala and Senator Dole:
In reference to our Full Committee hearing ``Findings of the
President's Commission on Care for America's Returning Wounded
Warriors'' on September 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
November 16, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Debbie Smith by fax at 202-225-2034. If you have any questions, please
call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
__________
Response to Questions from the Honorable Bob Filner, Chairman,
Committee on Veterans' Affairs, to Hon. Donna E. Shalala, Co-Chair,
President's Commission on Care for America's Returning Wounded
Warriors, and President, University of Miami, and Hon. Bob Dole,
President's Commission on Care for America's Returning
Wounded Warriors
Recommendation #2
Completely Restructure the Disability and Compensation System
The report recommends that the VA update its current disability
rating system to reflect current injuries and modern concepts of the
impact of disabilities on quality of life.
Q. What kinds of problems did you see with the current disability
rating schedule?
Response: The current system is not contemporary and reflects
neither quality of life nor earnings loss adequately. For example,
results from the Center for Naval Analysis study provided to the
Veteran's Disability Benefits Commission identify the inadequate
treatment of Post-Traumatic Stress Disorder in the rating schedule. We
heard from several of the Nation's leading disability experts that the
system is in need of fundamental change, a finding that has been
confirmed by two recent reports from the Institute of Medicine, and by
the Veteran's Disability Benefits Commission.
Q. What would you like to see modified or added to the current
system?
Response: We have called for the addition of Quality of Life
payments and a top to bottom revision of the disability system. We have
also recommended routine and regular evaluation and updating of the
system going forward.
The report recommends that all disability-related payments and
benefits for veterans would be obtained through VA. There are listed
three types of payments: transition payments, the earnings-loss
payments and the quality-of-life payments. It is not clear in the
report how these payments affect other government payments. The
earnings-loss payments, similar to compensation payments of today, are
to make up for any reduced earning capacity. Right now, a disability
compensation payment is not taxed.
Q. Under the proposed changes, would this payment be taxed?
Response: The Commission did not take a position on taxation of
disability-related payments.
Q. What happens to this payment once a veteran is eligible to
receive Social Security? Does the payment stop?
Response: Under the proposed new system for payments to disabled
veterans, the annuity payment and quality-of-life payments would
continue throughout retirement while earnings loss would convert to
Social Security payments after retirement.
The streamlined disability compensation system calls for periodic
reassessments of veterans' disability ratings.
Q. Where did the Commission get the 3-year timeframe from?
Response: The Commission considered the frequency of recommended
health evaluations for many stable medical evaluations, ranging from
annual exams for breast cancer screening to every five years for colon
cancer screening. We selected every three years as an average. We
believe that annual evaluations would present a burden to the system
and to the veteran. However, given the nature of some problems, like
Post-Traumatic Stress Disorder, we believed that 5 years would be too
long.
Q. Is that the average length of time under the current system that
veterans generally apply for an increase in a service-connected
disability?
Response: Not that we are aware of.
Q. Will this reassessment take the place of the veteran's current
ability to apply for increases in service connection disability ratings
if and when the disability becomes more debilitating?
Response: No.
Q. Is it the Commission's intention to limit those types of claims
so VBA can cut down on their workload?
Response: No. Resources should be provided to be sure that veterans
are taken care of in a timely manner.
Q. Is it the Commission's intention for the streamlined system in
the report to apply to all veterans or just those that are severely
injured?
Response: All veterans.
Recommendation #5
Rapidly Transfer Patient Information Between DoD and VA
Recommendation 5, Rapidly Transfer Patient Information Between DoD
and VA, lists three caveats with it. One of the caveats is: underlying
organizational problems must be fixed first, or information technology
merely perpetuates them. VA and DoD have struggled for years to find a
fix.
Q. Could you elaborate on what some of the organizational problems
are?
Response: None of the services have systems that easily ``talk to
each other.'' We provide a number of specific examples in the
Commission's Subcommittee Report on Information Systems (page 115 in
the Subcommittee report). Each service has a separate personnel system
that feeds only some information to a central DoD data archive. The
Army computer systems and the Air Force computer systems are not fully
compatible, and we found that electronic medical records for Air Force
servicemembers may not be available to the Army physicians who may
treat them. Most information systems have been developed to support
specific functions and were not originally designed to be integrated.
This information exchange is further compounded by the need to share
information between the VA and the DoD. Even the VA's path-breaking
Vista medical record system today consists of 128 different systems at
individual medical facilities and it does not achieve full
interoperability. Thus inter- and intra-departmental issues abound.
Q. What does the Commission recommend as a ``fix'' to the
underlying organizational problems?
Response: It is necessary to focus on the outcome--information
availability--not the computer systems themselves. The first step is to
assure that all information that supports the development and
implementation of the patient's recovery plan and is needed to provide
healthcare and benefits is viewable by relevant DoD and VA staff within
the next year. That means that clinicians, administrators, and benefit
administrators must be able to see the relevant information in
electronic form so that appropriate decisions may be made and patient
progress may be monitored. We have supplied in our Subcommittee report
on page 131 a template for a Scorecard for Information Exchanges that
can be used as an aid to track the progress for sharing specified
categories of essential data.
Response to Questions from the Honorable Joe Donnelly, Member,
Committee on Veterans' Affairs, to Hon. Donna E. Shalala, Co-Chair,
President's Commission on Care for America's Returning Wounded
Warriors, and President, University of Miami, and Hon. Bob Dole,
President's Commission on Care for America's Returning
Wounded Warriors
Q.(1). Would you support a shift away from the current claims
process to approving veterans' disability claims based on a presumption
of service connectedness?
Response: The scope of the Commission's recommendations did not
include the topic of presumption of service connectedness for the
purpose of VA claims filing. We did, however, look at the Benefits
Delivery at Discharge system, which has been successful in expediting
VA disability evaluation for servicemembers before they leave military
service with a medical separation or retirement. That program would
presumably mitigate the need for presumption at the time of
hospitalization with a known outcome of military discharge.
Q.(2). To what extent would such a change be applied? Would you
only apply the presumption process to new claims of recent veterans, or
for new claims by all veterans?
Response: Again, we did not explore the presumption concept and,
therefore, cannot comment.
As questions 3-5 also pertain to presumption and were not a focus
of the Commission, we are unable to provide comment.
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