[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 2790, H.R. 3458,
H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146,
H.R. 4204, AND H.R. 4231
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JANUARY 17, 2008
__________
Serial No. 110-63
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
41-363 WASHINGTON DC: 2008
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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
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
January 17, 2008
Page
Legislative Hearing on H.R. 2790, H.R. 3458, H.R. 3819,
H.R. 4053, H.R. 4107, H.R. 4146, H.R. 4204, and H.R. 4231...... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 32
Hon. Jeff Miller, Ranking Republican Member...................... 9
Prepared statement of Congressman Miller..................... 32
Hon. Jerry Moran................................................. 1
Hon. Ginny Brown-Waite........................................... 6
WITNESSES
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 23
Prepared statement of Dr. Cross.............................. 53
______
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Division............................ 14
Prepared statement of Mr. Wilson............................. 35
Boswell, Hon. Leonard L., a Representative in Congress from the
State of Iowa.................................................. 8
Prepared statement of Congressman Boswell.................... 34
Capito, Hon. Shelley Moore, a Representative in Congress from the
State of West Virginia......................................... 7
Prepared statement of Congresswoman Capito................... 33
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 15
Prepared statement of Ms. Ilem............................... 38
Hare, Hon. Phil, a Representative in Congress from the State of
Illinois....................................................... 2
Herseth Sandlin, Hon. Stephanie, a Representative in Congress
from the State of South Dakota................................. 5
Prepared statement of Congresswoman Herseth Sandlin.......... 33
Honda, Hon. Michael M., a Representative in Congress from the
State of California............................................ 12
Kagen, Hon. Steve, a Representative in Congress from the State of
Wisconsin...................................................... 10
Space, Hon. Zack, a Representative in Congress from the State of
Ohio........................................................... 4
Veterans of Foreign Wars of the United States, Christopher
Needham, Senior Legislative Associate, National Legislative
Service........................................................ 17
Prepared statement of Mr. Needham............................ 44
Vietnam Veterans of America, Richard F. Weidman, Executive
Director for Policy and Government Affairs..................... 19
Prepared statement of Mr. Weidman............................ 49
SUBMISSIONS FOR THE RECORD
American Academy of Physician Assistants, statement.............. 64
Berkley, Hon. Shelley, a Representative in Congress from the
State of Nevada, statement..................................... 66
Mental Health America, statement................................. 66
Paralyzed Veterans of America, statement......................... 69
MATERIAL SUBMITTED FOR THE RECORD
Jonathan Archey, Manager, Federal Relations, Ohio Hospital
Association, to Hon. Sherrod Brown, U.S. Senate, and Hon. Zack
Space, U.S. House of Representatives, letter dated October 18,
2007, supporting S. 2142/H.R. 3819............................. 73
Richard M. Dean, CMSgt (Ret.), Chief Executive Officer, Air Force
Sergeants Association, to Hon. Zachary Space, U.S. House of
Representatives, letter dated November 5, 2007, supporting H.R.
3819........................................................... 73
U.S. Department of Veterans Affairs, News Release, entitled ``VA
Vet Centers Coming to 39 Communities, Peake: Provide Counseling
for All Combat Veterans,'' dated July 9, 2008.................. 74
LEGISLATIVE HEARING ON H.R. 2790, H.R. 3458,
H.R. 3819, H.R. 4053, H.R. 4107, H.R. 4146,
H.R. 4204, AND H.R. 4231
----------
THURSDAY, JANUARY 17, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at
10:01 a.m., in Room 340, Cannon House Office Building, Hon.
Michael H. Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Snyder, Hare, Miller,
Moran.
Also Present: Representative Brown-Waite.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. Why don't we get started. It is my
understanding we have votes at 11:30, so we will try to move
this along so we can hear everyone.
I would like to thank everyone for coming here today.
Today's legislative hearing is an opportunity for Members of
Congress, veterans, the U.S. Department of Veterans Affairs
(VA) and other interested parties to discuss recently
introduced legislation that comes under this Subcommittee's
jurisdiction.
I do not necessarily agree or disagree with the bills
before us today, but I believe that it is an important process,
that we encourage a frank discussion of new ideas. We have
eight bills before us today. I look forward to hearing the
testimony on these bills.
And I would turn it over to Mr. Moran if he has an opening
statement.
[The prepared statement of Chairman Michaud appears on p. 32
.]
OPENING STATEMENT OF HON. JERRY MORAN
Mr. Moran. Mr. Chairman, thank you very much. I am happy to
serve as the acting Ranking Member until Mr. Miller arrives,
and I am interested in hearing the testimony from our
colleagues on a variety of issues affecting veterans across the
country.
And I am of the opinion that oftentimes we get some of our
best ideas in this Committee by listening to colleagues who do
not serve with us on the House Veterans' Affairs Committee, and
I welcome the two gentlemen that are with us already this
morning and look forward to hearing what they have to say.
I thank you, Mr. Chairman.
Mr. Michaud. Thank you very much.
I now would like to recognize Mr. Hare who also serves as a
member of this Committee and a very strong advocate for our
veterans.
Mr. Hare.
STATEMENTS OF HON. PHIL HARE, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF ILLINOIS; HON. STEPHANIE HERSETH SANDLIN, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF SOUTH DAKOTA; HON.
ZACK SPACE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
OHIO; AND HON. SHELLEY MOORE CAPITO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF WEST VIRGINIA
STATEMENT OF HON. PHIL HARE
Mr. Hare. Good morning. Thank you, Mr. Chairman. Thank you
for holding this hearing today, and I am pleased to provide
testimony in support of H.R. 2790, the bill I introduced to
elevate the current Physician Assistant (PA) Advisor to the
Veterans Affairs Under Secretary of Health to a full-time
Director of PA Services in the VA's Central Office.
I would like to thank my colleague, Representative Jerry
Moran, for his leadership with me on this bill, as well as
Chairman Filner, and Representatives Berkley, Corrine Brown,
and Doyle for joining us as cosponsors of the bill.
PAs have long been a critical component in providing care
in the Veterans Health Administration (VHA) with nearly 1,600
PAs currently employed, many of whom are Reservists, Guardsmen,
and veterans. While the PA advisor position has been valuable
in establishing guidelines for utilizing PAs, we do see
unnecessary restrictions on PA use, and too many problems still
exist.
I do not believe that Congress' original intent for a
position has been fulfilled. Confusion still exists about the
medical services PAs can provide from facility to facility.
VA facilities are telling PAs that they cannot and will not
hire PAs and, most critically, the PA advisor has been excluded
from critical planning and policy development.
These issues not only hinder the ability of PA advisors and
PAs currently employed by the VA, but they also discourage PAs
from even entering the VA system.
Without the PA advisor being able to fully perform his or
her role in the full-time Director position, the VHA is missing
a clear opportunity to improve the quality of healthcare for
our veterans. Quite simply, this is a position that needs to be
made permanent and be based on the VA's Central Office.
The lack of establishing the Director position ignores a
valuable resource in improving care, prevents improvements in
the recruiting and retention of the PA workforce, and
disregards utilizing a critical aspect of the VHA workforce.
Considering the fact that nearly 40 percent of all VA PAs
are projected to retire in the next 5 years, the VA is in
danger of losing its PA workforce unless some attention is
directed toward the recruitment and retention of this critical
group.
One of the biggest challenges currently facing future PAs
in the VA system is their exclusion from any recruitment and
retention efforts or benefits.
The VA designates physicians, nurses as critical
occupations and so priority and scholarships and loan repayment
programs go to these critical occupations. However, the PAs
have not been designated as a critical occupation, so no monies
are directed their way.
This is despite the fact that the VA has determined PAs and
Nurse Practitioners (NPs) to be functionally interchangeable
and equal in the work that they perform. Many of these problems
could be addressed by a Director of PA Services.
H.R. 2790 would legitimatize and recognize the role PAs
play by creating a permanent Director that would serve as a
clear voice in strategic planning, policy, and staffing
development initiatives, as well as an advocate for the
physician assistants.
The VA's position on my bill is that the status quo is
working just fine and that no change is necessary. I strongly
disagree with that position. The VA prefers a field-based
position and thinks that only 75 percent of the individual's
time is necessary to devote to PA patient-care issues in the
VA.
However, even though the VA opposes this legislation, VHA
Under Secretary for Health, Dr. Kussman, said he intended to
make the PA advisor a full-time position in the VA's Central
Office.
There is no significant cost to elevating and relocating
this individual position. This change is common sense and it
promotes quality medical care for our veterans.
This bill is supported by the American Academy of Physician
Assistants (AAPA), the Veterans of Foreign Wars, the Disabled
American Veterans, Vietnam Veterans of America, the Blinded
Veterans of America, and the Veterans' Affairs Physician
Assistant Association.
I would like to thank all the Veterans Service
Organizations (VSOs) for their support in this legislation and
particularly thank the AAPA for their dedication on this issue.
I thank you, Mr. Chairman, for giving me the opportunity to
be here this morning to testify on this critical piece of
legislation.
Mr. Michaud. Thank you very much, Mr. Hare.
And we have had a request from one of the cosponsors of
this legislation to speak who also sits on the Committee. So if
there is no objection, Mr. Moran.
Mr. Moran. Mr. Chairman, thank you, and I am pleased to
join my colleague, Mr. Hare, as an original cosponsor of H.R.
2790, and am pleased to support the testimony that he provided
this morning.
I suspect that the Department of Veterans Affairs will
testify that this legislation is not necessary, but that is
certainly not what I am hearing from my Kansas physician
assistants, and very much hope that we can see this bill's
passage.
I represent one of the most rural congressional districts
in the country and I know in healthcare that our physician
assistants are some of our most valuable resources in trying to
meet the healthcare needs of Kansans who live in those rural
communities.
And I know that that can be equally as true in the VA, and
I have been an advocate for our Community-Based Outpatient
Clinics (CBOCs) and our physician assistants who are providing
tremendous services to veterans through the outpatient clinics.
I also know that medical institutions like Cleveland
Clinic, Mayo Clinic, M.D. Anderson Cancer Clinic at the
University of Texas, and others have Directors of PA Services
to make sure that they employ the PAs in an integrated way into
their healthcare delivery system. And I believe that the VA can
utilize the same technique to provide a stronger voice for our
PAs in making healthcare policy.
It makes sense to me to give the PAs a stronger voice and
invite their participation among the healthcare professions
that have full-time Directors or consultants within the VA
already at the Central Office, our social work, nursing,
pharmacy, psychology, dentists, and dietitians. This just makes
a lot of sense to allow the physician assistants the same kind
of opportunity.
And I thank Mr. Hare for his leadership on this issue, and
thank the Committee for allowing me to speak.
Mr. Michaud. Thank you very much, Mr. Moran.
I now would like to ask unanimous consent that Ms. Brown-
Waite be invited to sit at the dais for this Subcommittee
hearing.
Ms. Brown-Waite. Thank you, Mr. Chairman.
Mr. Michaud. Hearing no objections. It is so ordered.
I would now like to recognize Zack Space who is also
another strong advocate for our veterans in this Nation. I want
to thank you for presenting your legislation and look forward
to your testimony.
Mr. Space.
STATEMENT OF HON. ZACK SPACE
Mr. Space. Thank you, Chairman Michaud, Ranking Member
Miller, and Members of the Subcommittee, for holding today's
hearing and including H.R. 3819, the ``Veterans Emergency Care
Fairness Act.'' I am grateful for the opportunity to discuss
this bill.
In March, I received a letter from Terry Carson who is
Chief Executive Officer (CEO) of Harrison Community Hospital in
Cadiz, Ohio, a small critical care facility in rural Harrison
County. Mr. Carson wrote to me about a problem he was
experiencing at his small hospital when providing emergency
care for veterans.
In late May, Senator Sherrod Brown of Ohio and I held a
joint field hearing on the issues facing rural veterans, and
Mr. Carson participated as a witness to share his experiences.
Mr. Carson explained that currently the VA reimburses non-
VA hospitals for emergency care provided to veterans up to the
point of stabilization. Once the patient is deemed stable
enough to transfer, he or she is moved to a VA hospital.
Oftentimes that is several hundred miles away from hospitals in
rural areas of our country.
The problem Mr. Carson brought to my attention is that
oftentimes veterans experience a waiting period for a bed in a
VA hospital. During this limbo, the VA is not required to
reimburse the private hospital for care. Meanwhile, people like
Mr. Carson feel morally obligated to continue care despite the
fact that they cannot count on reimbursement.
And it should be emphasized that many of the small
hospitals, not just in southeastern Ohio but throughout the
country, are operating on very, very narrow profit margins. So
it is an economic burden as well.
The ``Veterans Emergency Care Fairness Act'' closes this
loophole by requiring the VA to cover the cost of care while a
transfer to a VA hospital is pending and if the private
hospital can document attempts to transfer the patient.
Senator Brown introduced an identical companion bill on the
Senate side and that has already advanced out of the full
Committee. Senator Brown and I believe this legislation is a
reasonable solution for the VA, private hospitals, and most
importantly our Nation's veterans.
I have received support for this legislation from people
all across the country who have found either themselves or a
loved one caught in this hospital limbo. Additionally, the Ohio
Hospital Association and the Air Force Sergeants Association
have written letters of support which I can submit for the
record today.
This bill is a very good example of how our system of
representational democracy is supposed to work. The constituent
contacts his member of Congress. The member listens, and a
legislative fix is found.
I am proud to have had a chance to advocate for Mr. Carson,
and I hope you will join me in recognizing his efforts and the
efforts of those veterans that his hospital cares for by
supporting H.R. 3819.
And, again, I thank you for the opportunity.
[The letters from the Ohio Hospital Association and the Air
Force Sergeants Association appear on p. 73.]
Mr. Michaud. Thank you very much, Mr. Space.
And now I would like to recognize Mrs. Herseth Sandlin for
her piece of legislation. I want to also thank her for her
long-time support for our veterans' issues and for being a
long-time member of this Committee.
STATEMENT OF HON. STEPHANIE HERSETH SANDLIN
Ms. Herseth Sandlin. Thank you, Mr. Chairman. Good morning
to you and to the Ranking Member and other Members of the
Subcommittee. I want to thank you for having today's hearing
and I appreciate the opportunity to be here to discuss with you
the ``Women Veterans Healthcare Improvement Act.''
This bill, H.R. 4107, which I introduced last fall along
with Congresswoman Brown-Waite of Florida, will expand and
improve Department of Veterans Affairs healthcare services for
women veterans, particularly those who have served in Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).
I would like to thank the Disabled American Veterans (DAV)
for their support in helping craft this important bill. And I
would also like to thank the Veterans of Foreign Wars of the
United States of America (VFW) for their endorsement of the
legislation.
As you know, more women are answering the call to serve and
more women veterans need access to services that they are
entitled to when they return from their deployments or separate
from service and return to civilian life.
With increasing numbers of women now serving in uniform,
the challenge of providing adequate healthcare for women
veterans is more considerable than ever. In the future, these
needs likely will be significantly greater with more women
seeking access to care for a more diverse range of medical
conditions.
In fact, more than 1.7 million women nationally are
military veterans. More than 177,000 brave women have served
our Nation in Iraq and Afghanistan since September of 2001, and
nearly 27,000 are currently deployed in these wars.
By August of 2005, 32.9 percent of women veterans who had
served in OIF or OEF had received VA healthcare. By the end of
the following year, that number had increased to 37 percent.
And as the VA compiles the final data for 2007, the percent is
expected to increase again.
And according to the VA, the prevalence of potential post
traumatic stress disorder (PTSD) among new OEF/OIF women
veterans treated at the VA from fiscal year 2002 to 2006 has
grown dramatically from approximately 1 percent in 2002 to
nearly 19 percent in 2006.
So the trend is clear, but not surprising. More women are
serving in our Armed Forces, including the National Guard and
Reserves. More women are being deployed overseas and more women
veterans need access to healthcare services. So clearly we must
do everything we can from a public policy standpoint to meet
the new challenge that this trend presents.
The ``Women Veterans Healthcare Improvement Act'' calls for
a study of healthcare for women veterans who served in OIF and
OEF, a study of barriers to women veterans seeking healthcare
at the VA, enhancement of VA sexual trauma programs,
enhancement of PTSD treatment for women, expansion of family
counseling programs, establishment of a pilot program for
childcare services, establishment of a pilot program for
counseling services in a retreat setting for women veterans,
and the addition of recently separated women veterans to serve
on advisory committees.
We must ensure that the VA is positioned to provide
adequate attention to women veterans' programs so quality
healthcare and specialized services are available equally for
both women and men.
I believe this bill will help the VA better meet
specialized needs and develop new systems to better provide for
the quality healthcare of women veterans, especially those who
are returning from combat who were sexually assaulted or who
need childcare services, especially in order to better access
the healthcare services provided by the VA.
So, Mr. Chairman, Ranking Member Miller, again, thank you
for inviting me to testify, and I look forward to answering any
questions that you or other Members of the Subcommittee may
have.
[The prepared statement of Congresswoman Herseth Sandlin
appears on p. 33.]
Mr. Michaud. Thank you very much.
I have also had a request of one of the original cosponsors
to speak on this bill, Ms. Brown-Waite.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. Thank you, Mr. Chairman and Mr. Ranking
Member Miller.
When I tour the hospitals in my district, whether it is St.
Petersburg, Tampa, or Gainesville, one question I always ask
when I see women veterans there waiting is, how is the care. Do
you think you are getting the same services.
And particularly in the area of mental health, women have
told me, no, they do not believe they are getting the same
services. And we might ask why.
When a woman comes back from the military, very often she
has family at home, children, and it is the caregiver in her
that she takes care of the children, takes care of the house,
might have a job that she goes to.
And the trauma of having been at war or having been perhaps
sexually assaulted does not really come back until later
because the female physiology is a whole lot different.
This bill, I think, will go a long way toward making sure
that our female veterans are receiving all of the care that
they need and the care that is necessary and tailored to them.
You know, the specific healthcare needs of female
servicemembers and veterans are sometimes overlooked by the
Department of Defense as well as Department of Veterans
Affairs. This bill will go a long way toward making sure that
we have evidence-based treatment that women need to get the
help to help them recover from whether it is sexual assaults or
trauma of the war.
Thank you, Mr. Chairman, and I yield back and certainly
commend Ms. Herseth Sandlin for putting together this bill. And
I am sure you hear the same story from women veterans. And
thank you, Mr. Chairman.
Mr. Michaud. Thank you very much.
And the last bill for the first panel is H.R. 3458,
introduced by Ms. Moore Capito.
Ms. Capito. Thank you.
Mr. Michaud. Thank you for coming this morning. Appreciate
it.
Ms. Capito. Thank you, Mr. Chairman.
Mr. Michaud. Thank you for your interest in veterans'
issues as well.
STATEMENT OF HON. SHELLEY MOORE CAPITO
Ms. Capito. Thank you. Thank you for giving me the honor of
presenting this to the full Committee. I appreciate that. I
want to thank the Ranking Member as well.
May I submit my full statement for the record, and I am
going to speak very briefly because I have to be on the floor.
So if you saw me looking panicked, that was my problem.
My issue is rural veterans. I represent a State, West
Virginia, which I have in my research material shows that over
14 percent of West Virginians are veterans living in my State.
And I am very concerned with the traumatic brain injury
(TBI) issues that many veterans in many rural States and across
the Nation are dealing with and making sure that they are able
to access the kind of care that they need and deserve. And I
think the Chairman shares the same, I know, issue.
My bill basically introduces five pilot projects where the
Secretary would pick five States that do not have the traumatic
brain injury centers in their States and designates a case
manager for the TBI victims in the State that would be able to
follow their cases through their treatment.
And it also opens up the possibilities of using local
providers, whether it is a CBOC or a local provider, to help
that veteran. I mean, you can imagine having an injury such as
this and then to actually see the physician, you might have to
travel 8 or 9 hours by car makes it very difficult to do it on
a regular basis and certainly in some cases almost impossible.
So this is what the bill asks for. It asks for a pilot
study of five States. It asks for a case manager for each State
to specifically deal with this issue. This was brought to light
for me from the Office of Rural Health at West Virginia
University who deals with rural healthcare in the State of West
Virginia quite frequently.
It also asks for a report back to Congress every year to
see how the needs of rural veterans are being met who
unfortunately are suffering from the results of traumatic brain
injury.
I thank the Chairman. I thank all the Members of the
Committee. It is an important issue across the country. And as
I was reading through my background material, I guess I did not
realize that rural States really provide a relatively larger
majority of men and women to our military than some of our
metropolitan areas. And we want to see that they are able to
access the care. Thank you.
[The prepared statement of Congresswoman Moore Capito
appears on p. 33.]
Mr. Michaud. Thank you very much.
Are there questions for any of our first group of
panelists?
[No response.]
Okay. Hearing no questions, we will dismiss the first
panel.
I would like to ask the second panel to come forward. I
would like to thank the second panel. We are looking forward to
hearing your testimony. And we will start off with Mr. Boswell.
STATEMENTS OF HON. LEONARD L. BOSWELL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF IOWA; HON. STEVE KAGEN, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF WISCONSIN; AND
HON. MICHAEL M. HONDA, A REPRESENTATIVE IN CONGRESS FROM THE
STATE OF CALIFORNIA
STATEMENT OF HON. LEONARD L. BOSWELL
Mr. Boswell. Well, thank you, Mr. Chairman, Mr. Miller, and
all of you on the panel. Good to see you and I appreciate the
hard work you are doing for veterans. Thank you so very, very
much.
I would just like to make a couple points here. I know you
are very busy, but some say that suicide is an epidemic, which
is sweeping through our veteran population. And for too long,
suicide among veterans has been ignored. I feel that now is the
time to act.
We can no longer be afraid to look at the facts and the sad
fact is we are missing adequate information on the number of
veterans who commit suicide every year.
Probably all of you, all of us could tell or make reference
to how a person or someone in our own acquaintance had a mental
health problem and it was not dealt with and oftentimes just
kind of swept under the rug and looked at as a sign of
weakness. And that time has to be gone, has to pass.
I was shocked as I am sure many of you were when I saw a
CBS Evening News report focusing on veteran suicide. They found
that in 2005, over 6,200 veterans committed suicide, 120 a
week.
The report also found that veterans were twice as likely to
commit suicide as nonveterans. And these are very devastating
circumstances.
However, the data collected did not come from the
Department of Veterans Affairs, but rather from individual
States. That is why I introduced H.R. 4204, the ``Veterans
Suicide Study Act,'' to direct the Secretary of Veterans
Affairs to conduct a study on the rate of suicide among our
Nation's veterans.
I believe it is imperative we have the facts on this
terrible problem if we are to effectively treat our veterans as
they return home.
While I am pleased that the ``Joshua Omvig Veterans Suicide
Prevention Act'' is now law, we need to continue to get all the
facts on suicide among our veterans in order to better treat
them as they return home.
I implore this Committee and Congress to act swiftly on
H.R. 4204 so we can ensure we have the data we need to treat
our Nation's heroes. This is an issue important to veterans and
their families in Iowa and across our Nation.
And I would like to thank you, Mr. Chairman, for allowing
me this time, and I would be glad to answer any questions you
might have.
But a thought comes to me and I know we have talked to
several of you about the ``Suicide Prevention Act.'' But at
some point, we want to measure, and how are we going to measure
if we do not have some data? You know, is it effective? Maybe
we need to go in and adjust that as we work with it or whatever
we might need to do.
So I feel like we need to have this information and then we
can make comparisons as we see whether we have been effective
or not. We have to take care of our veterans. And I know every
one of you are committed to that as well. Thank you very much.
[The prepared statement of Congressman Boswell appears on
p. 34.]
Mr. Michaud. Thank you.
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. May I make a statement real quick?
Mr. Michaud. Okay. Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman.
Mr. Boswell, I salute you on bringing this bill, H.R. 4204,
the ``Veterans Suicide Study Act,'' forward. I am probably not
going to be able to stay past 10:30 and I just want whoever is
here from VA to hear this from me beforehand.
All I hear on this particular piece of legislation H.R.
4204, is why we cannot do it and why it is not the right piece
of legislation. I would like to see VA get with the sponsor.
Let us see if we can fix the language and come out with a piece
that says ``we can'' instead of ``we cannot.''
Mr. Boswell.
Mr. Boswell. Well, I am not stuck on authorship. I want
something to happen. You can make it a Committee bill for all I
care. I want something to happen.
Mr. Miller. This will be the Boswell bill, I am sure, but I
want VA to let us get this thing moving forward.
Mr. Boswell. Thank you.
[The prepared statement of Congressman Miller appears on p.
32.]
Mr. Michaud. Thank you, Mr. Miller.
Mr. Kagen.
STATEMENT OF HON. STEVE KAGEN
Mr. Kagen. Thank you, Mr. Chairman. I really appreciate the
opportunity to provide these few minutes to present H.R. 4231,
which is entitled the ``Rural Veterans Mental Health
Improvement Act.''
I will review with you some of the facts you are already
aware of. We have all become aware that mental health
conditions affect many of our soldiers. And as a physician, I
can tell you that the brain is still a vital organ in the human
body. We ought to do everything we can to protect it and to
heal it.
There are 9 million veterans who live in rural regions in
America. And only one out of three of these veterans are
receiving the medical benefits that they have already earned.
To say it another way, two-thirds of rural veterans when
they come home do not get their medical benefits for reasons
that are becoming apparent more and more every day.
Fifteen percent of veterans who have served in Iraq and
Afghanistan now suffer from PTSD, post traumatic stress
disorder, but barely of those who have already been diagnosed
receive the care that they require.
When people come home from overseas and combat, they have
higher rates of divorce and this affects not just our families
but our communities because when our soldiers are wounded
mentally, they are unable to perform at work. They lose their
jobs, lose their incomes, and all of our communities lose their
tax base as a result.
It is not a surprise to anyone that an early and accurate
diagnosis of any medical condition saves lives and saves human
tragedy. And that is what we must accomplish by serving all of
our veterans, especially those who live in rural areas.
What H.R. 4231 seeks to do is to make it easier for
affected patients to receive the care they have earned, first
by providing an accurate diagnosis from a qualified mental
health specialist at a VA medical center or clinic. Secondly,
for those patients who are affected and diagnosed as having a
mental condition, they need to receive care as soon as possible
and as close to home as possible.
For those patients who live more than 30 miles away from a
VA medical center, H.R. 4231 seeks to create a voucher system
where each affected veteran would receive a voucher, receive
the care, the expert care they need from qualified specialists
close to home. If it is close to home, they are going to have a
higher probability of receiving the care that they need.
We know from our common experience as Congressmen and women
that if it is close to where we are, we are much more likely to
get there to that event or to that, shall we say, fundraising
opportunity.
The third thing H.R. 4231 seeks to do is to guarantee that
the families who are also affected by the post traumatic stress
disorder, by drug and alcohol addictions that occur in such
affected veterans, that the family gets the counseling and care
that they require to help keep them together.
I am proud to say that my wife, Gayle, who was President of
the Congressional Spouse Association for the class of 2006, has
made a marriage between United Way and the National Military
Family Association to create access to a telephone number that
will help rural veterans and those in the cities to get the
care and the benefits that they have already needed.
But we have to do more. This Congress can do more. And
H.R. 4231 seeks to do just that. It is a pilot program. It is
something that we can measure and monitor to guarantee to push
our affected veterans into the care that they really require.
If we fail to do this, if we turn our back on the needs of
our veterans now, especially those mental impairments, the
wounds that you will never see, we will be failing to do our
complete job.
And I thank you again for the time that you have provided
to me. I will submit my written statement to your official
records, and I am open to any questions that you may have.
Mr. Michaud. Thank you very much, Mr. Kagen.
Are there any questions from the Committee?
Mr. Hare.
Mr. Hare. No questions, Mr. Chairman, except to say to my
two friends, Mr. Boswell and Mr. Kagen, I think both bills have
a tremendous amount of merit. And I know how hard you have
worked on this issue of suicide among veterans.
And, Mr. Boswell, I will tell you that anything I can do to
assist you on this I will, and I am proud to be on the bill
with you.
And, Mr. Kagen, let me just say I come from a very rural
area too, in west central Illinois with all or parts of 23
counties. I do not think we ought to be hung up on who they are
talking to, if it works for them, and they can stay close to
home. Their families can go with them.
I have had veterans that have had to travel 2\1/2\ hours by
van, get out of the van, go in, and literally sit for 2, 2\1/2\
hours waiting to be seen for something. And, quite frankly,
they just give up and leave.
And I think it is incumbent upon us and this Congress to
make sure that any veteran, any place, just because you live in
a rural area, you have problems too. These people have served.
I think we have an obligation to give them the type of care and
the access to the care that they deserve.
So I commend you both for your pieces of legislation and
hopefully down the road, we will see this become law because to
do anything less, I think, really dishonors the service that
these people have put in for this Nation.
So I want to just thank you, Mr. Chairman.
Mr. Michaud. Thank you very much.
I want to thank this panel as well. And the last member of
the panel, Mr. Honda, who is presenting H.R. 4146, thank you
very much for joining us today and we look forward to your
testimony.
STATEMENT OF HON. MICHAEL M. HONDA
Mr. Honda. Thank you, Mr. Chairman, and thank you for this
opportunity. I would like to thank the leadership of this
Committee for holding this hearing and inviting me to testify
before the Subcommittee. I really do appreciate the opportunity
to share my thoughts on veterans' emergency services and
reimbursement.
In the 109th Congress, I introduced legislation which would
amend the ``Millennium Healthcare Act'' and provides that the
VA should cover an uninsured veteran's emergency healthcare
cost before and after stabilization if no VA hospital bed is
available at a geographically accessible VA facility.
It is a problem that I have been facing with our
constituents in my district since I have been on the Board of
Supervisors.
As the Subcommittee knows, I reintroduced this bill as H.R.
4146 right before Veterans Day last year. And the need for this
legislation was brought to my attention by again a constituent,
Robert Dahlberg, who is a Vietnam-era veteran. I would like to
read a detailed account of what happened to Robert and why he
contacted me. I will be very brief.
``About 2 years ago, after my helicopter crashed while fire
fighting in northern California, I went to register for my
veteran's medical benefits. And as I was signing up at the VA,
I asked a lot of questions to understand what my obligations
were in order to get the care.
At one point, I heard the words, and then you will need to
get yourself once stabilized to a VA hospital, and these words
alarmed me.
And after further investigation, that was it. Even if I had
a heart attack and was stabilized at a non-VA hospital, it was
my responsibility to get myself to a VA hospital. The VA
requirements to get one's self to a VA hospital after
stabilization is at best a joke and could financially devastate
veterans of all ages and family status, leaving them destitute
with a huge bill from the non-VA hospital. And to me, this is
unconscionable.''
The unintended loophole created by the ``Millennium
Healthcare Act'' can leave veterans in a financial disaster.
The problem, if nothing is done, is likely to grow as veteran
ranks swell with servicemen and women returning from the wars
in Iraq and Afghanistan.
Mr. Chairman and Committee Members, we, as legislators,
must fix this loophole. We have a responsibility to our
veterans to do so. We owe them a debt of gratitude for their
service and it is inexcusable for us to allow this loophole to
even exist.
It is an unnecessary burden for our returning veterans, Mr.
Chairman. This important fix will save many veterans a great
deal of grief and we should not stand by idly as more veterans
are served absurd inordinate hospital bills because of this
situation, especially as VA hospitals reduce the number of beds
they have available.
American Veterans (AMVETS) and the American Legion support
this bill, along with some Members of this Committee such as
Ms. Ginny Brown-Waite and Mr. John Hall. I appreciate the
bipartisan support this bill has received and urge the
Committee to fix this problem with the health and financial
stake of our veterans in mind.
Again, I thank you, Mr. Chairman, for this opportunity, and
am willing to answer any questions.
Mr. Michaud. Thank you very much, Mr. Honda.
Are there any questions?
[No response.]
We are letting you off easy today. Thank you very much. We
really appreciate your testimony.
And as staff is preparing the table for panel three, there
is one more piece of legislation that was introduced by Ms.
Berkley. It is H.R. 4053. She is not able to be here, but it is
my understanding that Mr. Hare will present that legislation.
Mr. Hare. Thank you, Mr. Chairman. I will be very brief.
And I thank you and I thank my friend, Mr. Moran, for allowing
me to speak on this bill this morning.
Unfortunately, Ms. Berkley could not be here today to talk
about her bill. As a cosponsor of her legislation, I would just
like to say a few words in support of it.
Nationally, one in five veterans returning from Iraq and
Afghanistan suffers from post traumatic stress disorder.
Twenty-three percent of members of the Armed Forces on active
duty acknowledge a significant problem with alcohol use. It is
vital that our veterans receive the help that they need to deal
with these conditions.
Ms. Berkley has introduced legislation which aims to
improve the treatment and services provided by the Department
of Veterans Affairs to veterans with post traumatic stress
disorder and substance abuse disorders by establishing national
centers of excellence on PTSD and substance abuse disorders and
expanding the assistance of mental health services for families
of veterans, among other initiatives.
As a cosponsor of the ``Mental Health Improvements Act,'' I
feel this bill takes a step in the right direction in providing
our veterans with the care that they have earned.
I thank you very much, Mr. Chairman, for allowing me to
read this into the record on behalf of Ms. Berkley. And it is
my sincere hope that we will get bipartisan support on this
vital piece of legislation from the Committee. Thank you, Mr.
Chairman.
[The prepared statement of Congresswoman Berkley appears on
p. 66.]
Mr. Michaud. Thank you very much, Mr. Hare.
Any questions for Mr. Hare?
[No response.]
Thank you.
So I would invite the third panel to come on up. And as
they are coming up, it will be Joe Wilson who represents the
American Legion, Joy Ilem who represents the Disabled American
Veterans, Christopher Needham, the Veterans of Foreign Wars,
and Richard Weidman who represents the Vietnam Veterans of
America (VVA).
I would like to thank all of you for coming here this
morning to give your testimony on the piece of the legislation
that we just heard. And we will start with Mr. Wilson and move
on down the table.
Mr. Wilson.
STATEMENTS OF JOSEPH L. WILSON, DEPUTY DIRECTOR, VETERANS
AFFAIRS AND REHABILITATION DIVISION, AMERICAN LEGION; JOY J.
ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED
AMERICAN VETERANS; CHRISTOPHER NEEDHAM, SENIOR LEGISLATIVE
ASSOCIATE, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN
WARS OF THE UNITED STATES; AND RICHARD F. WEIDMAN, EXECUTIVE
DIRECTOR FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF
AMERICA
STATEMENT OF JOSEPH L. WILSON
Mr. Wilson. Good morning, Mr. Chairman and Members of the
Subcommittee. Thank you for this opportunity to present the
American Legion's views on legislation being considered by the
Subcommittee today.
The American Legion commends the Subcommittee for holding a
hearing to discuss these important and timely issues.
In regards to H.R. 2790, although the American Legion has
no specific official position on this issue, we believe VA
should do everything in its power to improve access to its
healthcare benefits to include providing adequate funding to
support programs within the VA medical system.
In regards to H.R. 3458, the American Legion favors the
intent of this bill to create a pilot program that would train
and assign specified VA case managers for veterans diagnosed
with TBI, or traumatic brain injury, and residing in rural
areas.
However, we would encourage the implementation of this
program to every venue nationwide thereby ensuring across-the-
board quality and adequate healthcare.
In regards to H.R. 3819 and also H.R. 4146, the American
Legion supports provisions to allow VA to pay for emergency
room care at non-VA facilities. We believe this would prevent
any delays in treating life-threatening injuries or illnesses
for veterans not in close proximity to a VA facility.
We also support H.R. 4146 because H.R. 4146 would alleviate
the hardship or burden of veterans paying out-of-pocket
expenses unfairly incurred, which is also due to unavailable
beds at VA facilities.
In regards to H.R. 4053, according to the Diagnostic and
Statistical Manual of Mental Disorders IV, post traumatic
stress disorder always follows a traumatic event that causes
intense fear and/or helplessness in an individual. Typically
the symptoms develop shortly after the event, but may take
years. Psychological care is considered the most effective
means of treatment for PTSD.
In addition to treatment for PTSD, other mental health
conditions such as acute reaction to stress and abuse of drugs
or alcohol require much attention. Due to the increasing
numbers of veterans seeking care at VA medical facilities to
include those from the Gulf War era and OEF/OIF, the American
Legion supports a bill to further improve treatment and
services provided by the VA to our Nation's veterans.
In regards to H.R. 4107, the American Legion supports this
bill to include sections 101 to 103 and sections 201 to 206. In
addition, we support expansion and improvement of healthcare
services to all veterans.
And regarding H.R. 4204, the American Legion receives
contact from actual veterans who disclose their need for
immediate help due to their thoughts of harming themselves. As
the number of calls to suicide prevention call centers
increase, the need for more suicide prevention counselors
throughout the VA medical centers is warranted.
The American Legion supports continued studies on suicides
among veterans. In a proactive effort, these findings must be
readily communicated to suicide prevention divisions to
increase the prevention of potential tragedies.
In regards to H.R. 4231, according to research conducted by
the Department of Veterans Affairs, one in five veterans
nationwide who enroll to receive VA healthcare reside in rural
areas. The American Legion believes no veteran should be
penalized or forced to travel long distances to access quality
healthcare because of where they choose to live.
Furthermore, all care, to include pilot programs, should
include outreach to every rural venue in which veterans reside.
The American Legion favors the intent of this bill to create a
pilot program that would accommodate veterans residing in rural
areas.
However, we would encourage the inclusion of every Veterans
Integrated Service Network (VISN) across the country as well as
a more condensed pilot program than the above mentioned.
Again, thank you, Mr. Chairman, for giving the American
Legion this opportunity to present its views on such important
issues. We look forward to working with the Committee in
continuing the enhancement of access to quality care for all
veterans.
[The prepared statement of Mr. Wilson appears on p. 35.]
Mr. Michaud. Thank you.
Ms. Ilem.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Mr. Chairman and Members of the
Subcommittee. We appreciate being invited to testify at this
legislative hearing today.
The first measure under consideration, H.R. 2790, would
establish the position of Director of Physician Assistant
Services as a full-time position within the VA Central Office.
We believe PAs are a critical component of VA healthcare and
urge the Subcommittee's approval of this measure.
H.R. 3458 would require VA to establish a rural pilot
program of VA case-managed traumatic brain injury care. The
bill would require the pilot program be conducted in
consultation with the VA Office of Rural Health and includes
protections to ensure rural veterans with TBI receive
sufficient care from competent, trained providers.
This measure is consistent with recommendations of The
Independent Budget related to VA care coordination of fee-basis
and contract care, rural healthcare services, and TBI.
Therefore, we have no objection to its enactment.
H.R. 3819 would require the VA to reimburse for emergency
treatment provided in a non-VA facility until an eligible
veteran is transferred to VA. In accordance with the mandate
from our membership, DAV supports this bill to improve
reimbursement policies for non-VA emergency healthcare
services.
We believe H.R. 4146 is intended to achieve the same
purpose as the bill just mentioned. However, based on our
analysis, we recommend the Subcommittee to proaction on this
measure and instead favorably report H.R. 3819.
DAV supports H.R. 4053, a bill to establish new and
enhanced treatment programs for post traumatic stress disorder
and substance abuse disorder with a special regard for the
treatment of veterans who suffer from these co-morbid
conditions.
It would also provide VA new authority to treat OEF/OIF
veterans and their families for combat readjustment problems.
We appreciate the emphasis in section 201 of the bill which
includes provisions for peer counseling and outreach, requires
VA referral and coordination with the Office of Rural Health,
while ensuring that private providers are properly trained and
compliant with VA standards.
However, we continue to have concerns about contracting
with non-VA providers for specialized PTSD treatment and other
combat readjustment issues.
H.R. 4107 is a comprehensive measure aimed at evaluating
the unique needs of women veterans including those who served
in Operations Iraqi and Enduring Freedom and improving VA's
healthcare and mental health services for women veterans.
This legislation is consistent with recommendations from
the research, experts in women's health, The Independent
Budget. And, therefore, we support this measure and urge the
Subcommittee to recommend its enactment.
H.R. 4204 would require VA to conduct a study on the number
of veterans' suicides since 1997. DAV supports this bill, but
recommends including other relevant measures in the legislation
that could help reduce veterans' suicide as outlined in our
written statement.
H.R. 4231 would establish a 5-year mental health services
pilot program in seven specific VA networks in which veterans
would be issued vouchers for private mental health services at
VA expense for up to 1 year.
We have a number of concerns about this measure,
specifically that it lacks contract care coordination features
that we believe are essential to the protection of veterans'
health and the long-term maintenance of veterans' health
services.
Additionally, under this measure, a veteran who receives
care in the community without connection to VA loses the many
safeguards built into the system for their protection including
VA's electronic medical record, evidence-based medicine,
patient safety programs, and most importantly VA's expertise in
combat-related mental health readjustment services. For these
reasons, we cannot support this measure.
As a community, all of us are concerned about rural
veterans' access to care including mental health and
readjustment services, especially for our newest generation of
war veterans.
However, DAV wants to ensure that veterans receiving
contract care through VA are treated in accordance with VA's
internal standards of care.
VA has developed a national mental health strategic plan to
deploy new mental health programs, ramp up existing specialized
services for PTSD and substance abuse treatment, and hire new
staff.
Additionally, last year, Congress mandated VA, through its
Office of Rural Health, to take specific steps to improve rural
veterans' access to care including assessing fee-basis programs
and developing a plan to improve access and quality, meeting
mental health needs, and conducting an extensive rural outreach
program to OEF/OIF veterans and their families.
Implementation of VA's mental health strategic plan in
conjunction with the mandate to the Office of Rural Health
should create greater access to mental health services for all
rural veterans.
Prior to final consideration of this bill, we urge the
Subcommittee to request the mandated reports from VA's Office
of Rural Health to see what progress has been made thus far. In
our opinion, these reports should provide essential information
on how to best develop a comprehensive solution and meet rural
veterans' mental health and other healthcare needs.
Mr. Chairman, that completes my statement, and we thank you
for the opportunity to testify.
[The prepared statement of Ms. Ilem appears on p. 38.]
STATEMENT OF CHRISTOPHER NEEDHAM
Mr. Needham. Mr. Chairman and Members of the Subcommittee,
the VFW thanks you for the opportunity to testify today.
There is a wide range of healthcare legislation before us
and the common theme through most of them is access. VA
provides first-rate, high-quality healthcare to thousands of
veterans every day, but barriers to care remain, whether that
is for a veteran living in the country far from a VA clinic,
for a woman veteran unsure of her entitlement to healthcare, or
for a wounded warrior suffering from TBI who is finding that VA
is not yet providing the range of treatment he or she needs.
Today's hearing addresses some of those barriers and we are
generally supportive of all of the bills. Because of time
considerations, I will limit my remarks to a few of them. Our
full comments can be found in our written statement.
The first two bills concern a number of our members. H.R.
3819 and 4146 would close the loophole that is costing a number
of our veterans thousands of dollars out of their own pocket
for emergency care. This especially affects veterans who live
in rural areas far away from VA clinics.
Under current law, VA can pay for emergency treatment for a
veteran who goes to a non-VA facility under certain
circumstances and must be an enrolled veteran who uses the
system and who does not have any other form of insurance. It is
a safety net for those who otherwise would have no emergency
care.
The wrinkle occurs in that once the veteran is stabilized,
he or she must be transferred to a VA facility. There have been
cases, though, where VA is unable to accept the veteran. Maybe
VA cannot provide the type of care that the veteran needs or
maybe there are not any beds available.
Whatever the reason, when VA refuses to accept a patient,
they also refuse to pay for the care. This is wrong and defeats
the purpose of that safety net.
We strongly urge the Committee to close this loophole to
ensure that veterans are not penalized for VA's inability to
adequately care for them.
The VFW urges passage of H.R. 4107, the ``Veterans
Emergency Care Fairness Act.'' This comprehensive bill would
authorize a number of important studies on the healthcare needs
of women veterans, especially those returning from Iraq and
Afghanistan.
The current conflict is one of a true front line, exposing
all to the hazards of combat. The study in section 101 would
look at the healthcare needs of returning female servicemembers
not just for the short term but also the long term. With the
new type of conflict they are facing, it is essential that we
stay on top of any potential health problems that may arise.
We also welcome the assessment from section 102 of that
bill, which would require VA to study barriers to care that may
prevent women veterans from receiving healthcare on par with
what men receive. It may be a matter of not enough outreach or
substandard gender-specific care. Regardless, it is important
to find these reasons out so that VA can correct them,
especially as the number of women veterans continues to rise
dramatically.
Another bill we support is H.R. 2790, which would create a
full-time Director of Physician Assistants at VA's Central
Office. VA is the largest employer of PAs in the country with
around 1,600 of them providing essential care to veterans.
Around one-quarter of all primary care patients are seen by PAs
making them a critical component of the healthcare delivery
system.
Because of this, they should have a voice in the process
and a full-time Director would allow PAs to take part in VA's
strategic planning committees.
Finally, I would make a note on the contracting provisions
on a few of the bills, notably H.R. 4231 and H.R. 3458.
It is our goal that VA develops the in-house expertise to
provide the full range of treatment and recovery for all
veterans, especially our wounded warriors. These brave men and
women are likely going to be with the VA for the rest of their
lives and the system must adapt to their needs.
VA has made great strides to improve their services, but
they are not all the way there yet. These men and women cannot
afford to wait for VA to develop these in-house systems. They
need treatment now.
For that reason, we support the proposals of these bills to
contract for care. As always, we would urge strong oversight of
these programs to ensure that they really are meeting the needs
of our veterans and that they are complying with VA's clinical,
safety, and privacy protocols.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions you or the Members may have.
[The prepared statement of Mr. Needham appears on p. 44.]
STATEMENT OF RICHARD F. WEIDMAN
Mr. Weidman. Mr. Chairman, thank you for the opportunity to
appear here today. There are a number of bills, so I will try
to move very quickly.
H.R. 2790 addresses a problem that should have been solved
by VA several years ago. We have great hope that Secretary
Peake and the new General Counsel are going to change the
attitude regarding some laws that they do not like as just cute
ideas advanced by the Congress and actually follow through in
congressional intent on statutes put in place that are passed
by the Congress and enacted by the President's signature.
To make the PA advisor a full-time position in Central
Office and as part of the strategic planning committees only
makes sense.
One of the places where VA is falling down now and even by
their own admission is rural healthcare. We know that a great
number of those serving today come from areas that are not in
proximity to one of the VA hospitals which generally are
located in major population centers.
PAs came about as a profession largely to serve rural areas
and other underserved communities. And this ought to be
exploding as opposed to being diminished.
There are a number of things that we would recommend in
addition to early passage of this legislation. First is to end
what is often a hostile work environment toward PAs not just at
the national level, but at the local level and ensuring that
they are on the VA committees and on par with nurse
practitioners.
Secondly, that their scope of practice be no less than that
which is accorded in the United States Army and the other
military services. In many cases, it is more narrow at the VA.
And the third thing is to create a scholarship program for
returning Navy corpsmen and Army medics to become PAs in the VA
system. It is akin to the nursing scholarships. It needs to be
done. It needs to be done now with a nationwide effort in order
to utilize these extraordinary experiences of these men and
women who have served in combat and served well.
VVA strongly supports the bill as written, but urges that
you take some additional steps here, Mr. Chairman.
H.R. 3458 is the pilot program for the provision of
traumatic brain injury care. Something has to be done in order
to serve these rural vets when it comes to TBI. But I would
join the DAV and my colleagues at the table in making sure that
we do not contract out and then that is it, that these people
are competent, that they know how to deal with veterans and
other problems. It is not uncommon for people who have TBI to
have PTSD at the same time, which may or may not be diagnosed.
In terms of the numbers of people, last May, there was a
survey done out at Fort Carson and they found 19 percent of
OIF/OEF returnees had undiagnosed TBI. These were not people in
med halls or in the hospital. These were just troops in the
Garrison. So it is a huge problem and we do need to follow
through with it.
We would, however, suggest that you make a number of
changes to require frequent substantive input by the veterans
service organizations as part of the legislation, frequent
reporting to this Committee and other accountability mechanisms
to ensure that this does not go awry.
Often good ideas get twisted and we would bring to your
attention Project Hero having to do with the effort to
rationalize the contracting out of care.
H.R. 3819, the ``Veterans Emergent Care,'' just makes great
sense and we are very much in favor of ending what is often an
ugly, protracted, and unsuccessful effort on the part of
veterans who have to use emergency service not in VA in order
to get reimbursed or face financial ruin.
H.R. 4053, the ``Mental Health Improvement Act,'' we are
very much in favor of. A lot of the problems at VA, however, we
would point out have been, in mental health in particular, have
been because they do not have the organizational capacity and
the resources in order to do what is done and, therefore, cause
distortion in the system.
The distortions in the system and the reduction of 10,000
physicians post 1996, during the flat-line period 1996 to 1999,
caused great distortions in the system and nowhere more than in
substance abuse. And in substance abuse, some VISNs, it was
practically wiped out. And whatever resources they had were
shifted into primary care for mental class vets. This needs to
be restored. It is a resource problem in addition to a focus
problem.
And, once again, for any of the legislation that you pass,
we encourage you strongly to build in more accountability
mechanisms, et cetera.
For H.R. 4107, we are very much in favor of this. We have
been talking about the need for VA to gear up for women
veterans since the beginning of the war. We would suggest you
make it clear in that there has to be a full-time women's
coordinator at each one of the VA medical centers across the
country. More cases than not, it is an ancillary duty.
Further, there should be expansion at the major medical
centers who see a good number of women into a free-standing
women's clinic. And that will help solve the problem having to
do with women seeking help for Military Sexual Trauma (MST).
Nobody knows why anybody goes to the women's health clinic at
Washington, D.C., and that should be the model. And I would
encourage the Committee Members to visit it.
The last is H.R. 4146. VVA supports this bill. Excuse me.
It is not the last. And H.R. 4204. There is a suicide study
that VVA has informed staff has been done at VA, but it has not
been released. It is in peer review for publication now, but
there is no reason why the staff cannot get a confidential
briefing and certainly the Members get a confidential briefing
on the results of this study done by VA.
In regard to suicide among all veterans or certainly among
Vietnam veterans, National Vietnam Veterans Longitudinal Study
(NVVLS) is currently still not done even though it was supposed
to be delivered to the Congress 2\1/2\ years ago. And we would
encourage following through on that because one of the things
that will show up is the suicide rate of the last generation,
major generation of combat veterans and, therefore, give us
some sense about what is likely to happen in the future with
OIF/OEF veterans.
Our best defense against suicide is a vet center system
that is more robust than it is today. It is a great system. The
Vet Centers work, but there is just flat not enough staff.
These are our forward aid stations and that is where a veteran
and/or her family, his or her family is more likely to go than
to a VA hospital because it is in the community. We need to
expand the vet center system number of staff.
There was $17 million provided and a supplemental passed,
enacted on March 7th. It did not reach the readjustment
counseling service until mid-August when it was too late to get
anybody onboard much less spend the $17 million, so they spent
it on other services.
This is the kind of decision on the part of VA that is
simply short-sighted and needs to be, if it requires specific
legislation to require them to come up to a certain Full Time
Equivalent (FTE) level and readjustment counseling service,
then we encourage you to do so if, in fact, it will not be
reasonable.
Thank you very much, and I appreciate your indulgence for
going over time on my summary, sir.
[The prepared statement of Mr. Weidman appears on p. 49.]
Mr. Michaud. Thank you very much, each of you, for your
testimony today.
As you know, we have been focusing a lot on mental health
issues, and TBI, and rightfully so. We have several pieces of
legislation before us today.
So I would like to ask each of you what type of legislation
would you like to see come before the Subcommittee that is not
included in what we saw today. Is there anything that we are
missing? I will start with Mr. Wilson.
Mr. Wilson. Nothing I see at this time, Mr. Chairman.
Ms. Ilem. I think the measures that are before the
Committee are some of the most very important things that we
are hearing about today. And I think it is a good start. I
cannot think of anything right offhand that could be added
additionally at this time.
Mr. Needham. I think I would agree with what Mr. Weidman
had to say concerning sort of the Vet Centers. I agree with him
that they do seem to sort of be a really effective tool in
terms of dealing with mental health. Particularly, I know from
reading VA's prepared statements, they were concerned about
some of the family provisions in some of the bills before us
today in discussing how they overlap with what Vet Centers are
doing.
We are particularly concerned about some of the effects of
mental health problems on the families. And so if Vet Centers
are the way to go, then it would definitely be something we
would need to take a little closer look at.
Mr. Weidman. We ask that you specifically require that the
Special Committee on PTSD have VSO access to attend their
meetings and constituent input on some kind of a basis, and
further that you follow through on requiring VA to set here to
sunshine good government standards with the seriously mentally
ill advisory committee and that that also, the entire thing, be
open.
Dr. Kussman, his response when we have requested that is
that they cannot carry on candid discussions with anybody there
from the outside. Our response back to that is that just means
you are saying things that you cannot stand in the light of
day.
And, frankly, he should not be saying those things if they
cannot stand up in the light of day. And so we would request
that you take those two steps.
The other thing is something that we have discussed before,
sir, and that has to do with taking a military history as part
of the computerized patient treatment record. We have empty
promises for years upon years and different Under Secretaries
and different Directors of Clinical Care.
And in point of fact, the new system that they are
designing does not have in there the taking of a military
history, branch of service, when did you serve, where did you
serve, what was your Military Occupational Specialty (MOS), and
what actually happened to you and utilization of that through
clinical reminders in the diagnosis and treatment process.
If they will not do it on their own within the next very
short period of time, then we ask that the Committee pass
legislation, which incidentally was passed by the House in
2000, that requires them to do so. The Senate did not pass it
at that time. We have talked to the Senate and believe they
would be amenable to passing such a provision today. It only
makes good sense.
When you ask any of your constituents, or tell any of your
constituents, that when people go to a VA hospital, they do not
ask completely what did you do in the war, dad, what did you do
in the war, mom, and use that in the diagnosis and treatment
modalities, people look at you blankly and say, but is that not
what we are paying for. And the answer is yes, that is what we
are paying for.
And that is the whole purpose of having a specialized VA
system. But if you do not take the military history, then you
are going to miss things like, for instance, TBI, post
traumatic stress disorder, tropical parasites, and endemic
diseases whether it is southwest Asia or southeast Asia or
Korea, or wherever it might be.
The point is that the primary purpose of having a separate
VA hospital is to have a veterans' healthcare system, not a
general healthcare system that happens to be for veterans. It
is both in the long run cost effective, but it is also cost
efficient in the long run because you will have better
diagnoses and treat people.
Ms. Ilem. Mr. Chairman?
Mr. Michaud. Very good point. Yes.
Ms. Ilem. If I may, I did think of a couple of things as
the discussion continued. One would be touching on the family
issues, the caregiver issues related.
I do not think that that is something that has been
completely fully discussed within the Subcommittee as yet and
those that are really caring for our most seriously wounded and
perhaps some additional services for them and benefits.
Also, on the mental health side, substance abuse disorder
from talking to so many OEF/OIF veterans, we believe that is
really going to be a critical issue. We would like to hear more
from VA about, through its mental health strategic plan, number
one, what is the implementation phase of that plan and how
quickly is it moving in terms of the substance abuse programs
that they have promised that they are putting online and
ramping up.
And one last thing was the mild TBI issue. Although there
is, you know, much care and discussion about the severe TBI and
lots of bills that have been introduced regarding that issue,
the mild TBI issue from mental health providers and
physiatrists within the VA, I believe that that is going to be
such a critical piece of the undiagnosed milder TBI that is
still coming out within mental health problems.
So we would like to see about, you know, what VA is doing
in terms of its treatment plan, its strategic plan for those
veterans and to really be able to catch them. Thank you.
Mr. Wilson. Mr. Chairman, I cannot help but speak on this
critical issue as it is progressing very rapidly. On behalf of
the American Legion, my concern involves the connection between
research and the critical divisions within the VA medical
center.
During the American Legion's 2007 site visits to polytrauma
centers, the staff inquired about research being conducted in
the area of traumatic brain injury. The researcher had no
response to the question. To be more specific, in one of the
main polytrauma centers visited, was a brain research chamber.
The researcher was asked how their research served the clinic
side of the VA medical center, still, no response. In
conclusion, there should be an inquiry to assess whether or not
there is complete communication and interaction between
research and clinical divisions throughout the VA medical
center system.
Mr. Michaud. Thank you very much.
Mr. Hare.
Mr. Hare. Thank you. Nothing, Mr. Chairman.
Mr. Michaud. Okay. Well, once again, I would like to thank
each of you for your testimony today and look forward to
working with you as we move forward with these pieces of
legislation.
Mr. Weidman. Thank you, Mr. Chairman.
Mr. Michaud. The last panel today is Dr. Cross who is the
Principal Deputy Under Secretary for Health, and he is
accompanied by Walter Hall who is the Assistant General
Counsel.
I want to thank you, Dr. Cross, for coming here today. I
look forward to hearing your comments and to you answering the
Committee's questions. So without any further ado, I will turn
it over to you, Dr. Cross.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A.
HALL, ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Dr. Cross. Good morning, Mr. Chairman and Members of the
Subcommittee, and thank you for inviting me here to present the
Administration's views on several bills that would affect the
Department of Veterans Affairs.
And, of course, joining me today is Walt Hall, Assistant
General Counsel.
And I would like to request that my written statement be
submitted for the record.
Mr. Michaud. Without objection.
Dr. Cross. Given the breadth of issues covered in these
bills, I will simply highlight a few key issues. We would
welcome the opportunity to brief the Committee and provide
technical assistance on any of the issues that we discuss today
including our PTSD, suicide, and outreach programs among
others.
Mr. Chairman, VA strongly supports H.R. 3819. Effective
reimbursement or payment of emergency treatment has been an
issue of longstanding concern to the Department. H.R. 3819 more
appropriately resolves important billing issues than does H.R.
4146 and properly places the financial onus on the Department.
VA believes H.R. 4204, H.R. 3458, and sections of H.R. 4107
are unnecessary given VA's current efforts which I would be
delighted to discuss with the staff.
Specifically we do not believe the study required in H.R.
4204 on veterans' suicide rates would generate the information
that would further our understanding of how to effectively
screen and treat veterans who may be at risk of suicide. In
fact, certain requirements mandated by the bill make its
implementation unfeasible.
Similarly, H.R. 3458 is unnecessary as VA has developed and
implemented a number of recent traumatic brain injury
initiatives including programs addressing case management. This
bill would potentially fragment care for veterans in the
greatest need of receiving healthcare in a well-coordinated,
continuous manner.
And since the bill was introduced, each VA facility has
established an OIF/OEF case management program for severely
injured OIF/OEF members.
VA also created the Care Management and Social Work Service
to ensure that each VA facility has an appropriate treatment
team caring for these veterans.
Mr. Chairman, VA believes the studies recommended in
sections 101 through 103 and sections 201 through 203 of H.R.
4107 would prove costly and duplicate current efforts.
Regarding Title 1, VA's strategic healthcare group for women
veterans already studies and uses available data to assess the
needs of women veterans and has developed a variety of
mechanisms already to improve their care.
For example, VA funds Drs. Donna Washington and Elizabeth
Yano who were examining access for women veterans and how
staffing issues impact quality.
In response to Title 2, VA prepares our clinicians through
multiple venues in identifying and treating military sexual
trauma, utilizing evidence-based psychotherapies for mental
health conditions and counseling women veterans in our Vet
Centers.
VA generally opposes H.R. 4053 and H.R. 4231. H.R. 4053 is
the companion bill to Senate bill 2162, which the Department
discussed with your Senate colleagues in October.
While we appreciate the intent of the bill, we cannot
support its approach of mandating forms of treatment, treatment
settings, and composition of treatment teams.
VA does not support the Title 4 of H.R. 4053 because it is
unclear how these readjustment and transition assistance
services are intended to differ from or interact with the
readjustment counseling services and related mental health
services already available to our veterans and their families
through our Vet Centers.
This provision would not effectively enhance current
activities and has serious potential to create confusion and
disruption for both VA and for our beneficiaries.
We strongly oppose H.R. 4231 as presently drafted without
exception. A recommendation for a veteran's receipt of mental
health counseling services by a non-VA provider should be made
only by appropriate departmental mental health professionals.
This ensures a continuum of care for the veteran, reduces the
potential for self-referrals or conflicts of interest by
participating providers, and supports appropriate coordination
and oversight of all medical services furnished to the veteran.
Mr. Chairman, this concludes my prepared statement, and Mr.
Hall and I are prepared to answer your questions.
[The prepared statement of Dr. Cross appears on p. 53.]
Mr. Michaud. Thank you very much.
You heard the testimony of the previous panels and some of
the discussion about how the VA has done their own suicide
study.
Is that something you are willing to share with the
Committee?
Dr. Cross. Yes, sir.
Mr. Michaud. And is that complete now or is it----
Dr. Cross. I understand it is being submitted for
publication.
Mr. Michaud. Okay.
Dr. Cross. But, you know, we can brief you on it.
Mr. Michaud. Okay. Also, Mr. Weidman mentioned the Special
Committee on PTSD and having VSOs be more involved in the
process and he talked about the Deputy Secretary as well.
Why is the VA reluctant to get more involvement and have
open discussions with the VSOs?
Dr. Cross. To tell you the truth, Mr. Chairman, that is a
new issue for me and I need to go check on it and find out what
the background is on that.
But I do want to say this. We meet with our VSO colleagues
frequently in small groups, in large groups. We share
information. We share papers. We have excellent personal
relationships in terms of the mission that we have to carry
out.
And it is my intent and I believe it is all of our intent
to share whatever information, to coordinate with them as
closely as possible and to do so more than perhaps ever done
before.
Mr. Michaud. We also heard, and I agree with the comment,
about Vet Centers. They do an outstanding job in a lot of the
rural areas and they deal with a lot of issues of mental
health.
One of the issues that we have heard from VSOs, and a lot
of the bills that are referred to us are introduced because
veterans in rural areas are still not getting the healthcare
that they need. And I think part of it is underfunding of the
VA which hopefully the last budget will--I know that it
definitely will help out.
What are you doing to make sure that the Vet Centers get
the resources as quickly as they can to take care of the
veterans in the rural areas?
Dr. Cross. Here is what we are doing. We are expanding
them. And I was surprised at the testimony earlier because we
are opening more and more Vet Centers, expanding them into
other areas. We are adding staff to our Vet Centers.
And by the way, I have a representative from the Vet
Centers here with me today. And I would recommend that, you
know, if anyone wants to talk afterwards or at some other time,
we can arrange a definitive briefing on that.
Mr. Michaud. I would like to know where you are beefing up
the Vet Centers with additional staff, what are the vacancies,
or if all the current positions are filled, as well as the new
Vet Centers that you are planning to open. A lot of the bills
we are seeing, directly go back to that particular area.
Dr. Cross. Mr. Chairman, we would be absolutely happy to
provide you with that. And I would like to highlight that we
are adding staff. We are making sure that we have an
environment in our Vet Centers as welcoming to women veterans.
We are adding more female staff specifically to our Vet Centers
to support that.
We are changing the very way we construct our Vet Centers
to make sure that that environment is conducive to both males
and females. We want them to feel like this is their home and
that they are welcome there.
We are expanding. We will get you that list, show you where
they are at, show you what our plans are.
[The list of Vet Centers was included in a News Release
from the Department of Veterans Affairs, dated July 9, 2008,
which appears on p. 74.]
Mr. Michaud. Great. And it was mentioned this morning when
you look at the Office of Rural Health and that, as you well
know, has been a big issue with a lot of us on this Committee,
that office getting up and running.
And have they made any reports or any recommendations on
how we should be moving forward in rural health areas and when
will those be available for the Committee?
Dr. Cross. We are keeping them busy as bees. They are
wonderfully motivated. It is a young staff who are very
engaged, who consider this their passion, their mission. They
are working on papers. They are working on proposals.
What they are doing is very interesting. I wanted to tell
you their strategic direction. It is not so much to create
entirely new programs, but what they wanted to do, and this is
brilliant on their part, is to go look at all the programs that
the VA already has and to reconfigure some of those programs,
to readjust them to better serve veterans in the rural
environment. So not just start from zero, but to take what we
have already gotten built from that and adjust that to make it
more effective for our rural veterans.
Mr. Michaud. And have they come up with any recommendations
so far?
Dr. Cross. Absolutely. They have drafted plans. They have
already been to my office.
Mr. Michaud. And since they have been in your office, have
you acted upon the plans?
Dr. Cross. We are working on acting on the plans, giving
them money to move those initiatives forward in substantial
amounts.
Mr. Michaud. I would like to also see exactly what they are
recommending if it would be possible.
Dr. Cross. Mr. Chairman, we would love to brief you on
that.
Mr. Michaud. Because I think that that is a very important
issue, and a lot of the concerns that we hear as Members of
Congress deal with a lack of service or access to that care in
rural areas. So I think it is very important that we get as
much information as possible and that the VA acts upon it, but
also one of the problems that we see is lack of communication a
lot of times that causes a lot of problems. And it is important
for not only elected officials, but also the VSOs, to be
involved in the process and that they know what is happening
out there so we can move forward.
My last question deals with Mr. Hare's bill. How can this
be effectively accomplished if a Director of Physician
Assistant Services is not located at the VA's Central Office?
Dr. Cross. We have a PA advisor. He works in a very similar
manner to our other advisors, for instance, for infectious
disease, cardiology, podiatry, orthopedic surgery, and so
forth.
We are field based. That was the way it was originally
designed because we thought it added credibility to the
position, that they are still engaged in the practice and
advise us.
We did increase his percentage of time that he works with
the Central Office from half time to three-quarters which is
typical for what we do with others as well, in the ones I just
mentioned.
Having said that, we are flexible. I would rather that you
did not mandate this for the following reason: When the current
advisor who I work with very closely leaves at some point in
the distant future, we will be recruiting for another advisor.
I would like to recruit nationwide and for the best one I can
find.
Quite frankly, sometimes getting people to come and move to
Washington is a challenge for us. And if I restrict it to those
who can only come to Washington, we have had people in the past
for many different positions, not just PAs, say thank you, but
no.
And so I am willing to show flexibility on that, and I
understand the concern. I understand the concern from the PA
group. And I met with them personally and I am willing to show
some accommodation.
Mr. Michaud. Okay. Thank you.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
Thank you, Doctor, for coming this morning. I just have
four questions for you, two regarding H.R. 2790 and then two on
H.R. 4053.
What will the cost estimate be for the Director of PA
Services if you were to include the offset that would come from
eliminating the PA advisor role?
Dr. Cross. It is a relatively small amount. I do not know
the number offhand.
Mr. Hare. So it would not be a significant amount of----
Dr. Cross. The money is not an issue.
Mr. Hare. There are a large number, as you know, of VA-
employed PAs that are veterans, some estimates are as high as
32 percent. And many are active members in the Guard and
Reserve units and with important military medical experience.
I am wondering what is being done about recruitment and
retention of this occupation in terms of getting people to come
in and to do this.
Dr. Cross. Let me say right from the start we tremendously
value our physician assistants. They are part of the team. And
our current advisor has been in so many meetings, it would be
hard to count in terms of our policy and particularly those
policies relevant to what they do and what we all do.
You noted something earlier. I think you listed the number
of PAs at 1,600 plus. When I came in, it was upper 1,400 or
1,500. We have increased the numbers. I heard somebody say that
the number had gone down. It is actually going in the other
direction as I understand it.
So they are part of the team. We are increasing their
numbers as we are increasing the numbers for others as well.
Mr. Hare. Well, maybe if you could just spend a second or
two talking about how you do the recruitment, I mean in terms
of getting people to come in and do these.
Dr. Cross. We go out to events. We advertise. We have a
group in New Orleans, an office there that puts out our
announcements.
Mr. Hare. Just a couple questions on H.R. 4053. A lot of
us, I mean, you have heard I know a lot of discussion about
rural districts and I have a very rural district in west
central Illinois. I have all or part of 23 counties.
Could you explain what the VA does when veterans who live
in rural areas and they have this lack of access to mental
health services through the VA, is there something in place to
try to be able to bring those veterans in and to get the
treatment that they need, because to be honest with you, I hear
that all the time?
I had instances where veterans were telling me that they
have to get into a van, and not just for mental health
services, but in general. Even for a chest x-ray, we have
veterans that are going 2\1/2\ hours in a van to get a chest x-
ray and having to wait when they get there for tremendous
periods of time and they just, quite frankly, Doctor, give up
and say ``I am not doing this again,'' you know, ``I can't do
this.''
So I am wondering if you would maybe be able to tell me,
particularly in the mental health area, but also generally how
we address this in your opinion.
Dr. Cross. I agree with what you said and the premise of
your statement, I think, is correct. It is a challenge in the
rural environment to provide all the medical services that
might be needed in that environment.
So here is what we are doing. We have taken rather dramatic
action and have much more planned. First of all, you have heard
about the Office of Rural Health that is helping to organize
this. But here are some of the things that we have done, and I
want you to be proud of this because it is an aggressive
effort. Lots of time, money, people are devoted to this.
In the past about a year and a half, 2 years, we have added
over 3,700 mental health staff in the VA. I think that is
absolutely phenomenal. That includes 147 addiction therapists,
343 psychiatrists, 720 psychologists, 1,024 social workers. And
we are distributing those across the Nation including where we
can into the rural environments.
We are opening more community-based outpatient clinics, and
I think you are all well aware of those and when we opened them
because it is quite a big deal.
But going beyond that, sometimes our community-based
outpatient clinics can create satellite sites where they can
operate out of and we are doing that more and more, part-time
places where they can get into the smaller communities and
address the needs of our veterans.
But two other things I wanted to tell you about
particularly. We do not want the patient to have to come to the
big medical center unless they really have to. And one of the
things they have to come to us most often for is medicine. And
so we have arranged to send it to their home and we have
arranged through the computer process or the phone process so
that they can call up and get their refills through that
mechanism.
And we are doing one other thing, which is absolutely
wonderfully innovative, secure messaging. We have a pilot
project starting now and this was really directed at the rural
environment, but to others as well, but particularly the rural
environment, how to get a question asked, that information,
that personal touch from your doctor, your PA, nurse
practitioner.
And we were concerned that e-mail was not secure enough.
Secure messaging will allow us to do that. We are starting the
pilot project. They can submit the question and we will help
them get the answer back. Better than a phone system because
when you call up, you have to go through the phone system. The
doc might not be available right at that time. The doc might
call them back later. The patient might not be home at that
time.
This will work much better, I think. And so many more of
our people, our veterans now have some form of computer access,
either in the home or in a library nearby where they might be
able to use this.
There are so many things that we can do for the rural
environment. I think we should be excited about this. We should
see this as an opportunity and grab hold of it. And we have
lots of ideas that we can talk to you about on this.
Mr. Hare. Thank you, Doctor.
Thank you, Mr. Chairman.
Mr. Michaud. Dr. Snyder.
Mr. Snyder. Thank you. I am sorry I was late. The Armed
Services Committee was having a hearing going on at the same
time.
But I just had one general question as I have flipped the
material. It seems like we have several instances here in your
discussion of some of these bills' proposals in which you feel
that the veterans healthcare system is already providing the
services.
Do you think that we have a gap in the awareness that
Committee Members have or are we aware of gaps in our own
particular areas that generally you do not see across the
country or are we not spending enough time just trying to
understand everything that you all have going on in this
dynamic situation? We are treating more and more people coming
back from Iraq and Afghanistan with, you know, the number of
wounded and folks we are treating, counseling.
Where do you think the gap is as you see members, good
faith members, good members coming forward with bills that you
do not think that there is a need for? Where do you all see the
gap?
Dr. Cross. I really appreciate that question because that
is exactly how I feel and many of us because Congress has been
good to us, and the Administration has been good to us, in
terms of getting us more resources and doing more things in the
past several years.
Let me give you an example, and this is why I am so anxious
to volunteer, that we and my staff gathered here today have
times outside the hearing to meet with your staff to explain
some of this in great detail because we are doing many things
that often we do not have time to really express in the hearing
environment.
On the Women's Health Act, for instance, so many of these
things we think are great ideas and really support them except
we are already doing them. I'll give you an example.
The proposal for a long-term study on health. Well, we
started it in 2007. It is a VA initiated, 10-year longitudinal
epidemiological surveillance on the mortality and morbidity of
OIF/OEF veterans, including women veterans. With the interest
of Congress, we are quite willing to also expand the sampling
that we do in regard to women veterans. And they said that we
should go out and look
at some of the gaps or services that we provide to women
veterans. Well, we agree and we are already doing it. The VA
contracted
for a national survey of women veterans in fiscal year 2007, a
structured survey based on a pilot survey originally conducted
in
VISN 21. We will examine the barriers to care and the access to
care and we will include women of all areas of service and
include veterans who never even utilize VA care.
Just two examples. When I read through these proposals, I
thought, well, many of these are good ideas except, and
particularly in the TBI, we are already there. In some cases,
the proposal here was to do things, which is actually less than
we are anticipating doing on our own.
One of the proposals was in regard to a $50 million
expenditure related to PTSD. Our mental health enhancement fund
last year, which was heavily for PTSD and heavily for substance
abuse and similar things, was $307 million.
So I would really appreciate the opportunity to show what
we have done recently because some of these things may not have
caught up with general knowledge as to what we are doing. And I
think that we should be proud of that.
Mr. Snyder. Thank you.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much.
Just a couple of quick questions. I know you are going to
provide the position counts, what have you, for the Vet
Centers. But for the Office of Rural Health, are all those
positions filled in that particular office?
Dr. Cross. I think there is a GS14 coming in 2 weeks that
we are waiting for.
Mr. Michaud. Okay. Now, then they will be completely
filled?
Dr. Cross. Well, we just started the office in, you know,
really September officially, although we were working on it
before. I expect the office will change and expand.
Mr. Michaud. You mentioned a longitudinal study, and I know
we have heard quite a bit from the Vietnam Veterans of America
as far as their longitudinal study that has never been
completed.
Do you know where that is in the process? Does the VA plan
to move forward with that study?
Dr. Cross. Truthfully, Mr. Chairman, I am not an expert on
that. I would rather get my experts together and give you a
detailed briefing rather than try and wing it in this
environment.
Mr. Michaud. I appreciate that because I am sure we will be
hearing more about that study again. So I would like to know
and try to move it forward if at all possible.
So, once again, I would like to thank you very much, Dr.
Cross, for coming in today, Mr. Hall. I look forward to the
followup answers to our questions. Look forward to working with
you as we move forward in making sure that our veterans of this
great Nation of ours are taken care of in a timely and an
appropriate manner. So, once again, thank you for your
testimony.
The hearing is adjourned.
[Whereupon, at 11:32 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members of
Congress, veterans, the VA and other interested parties to discuss
recently introduced legislation within the Subcommittee's jurisdiction
in a clear and orderly process.
I do not necessarily agree or disagree with the bills before us
today, but I believe that this is an important process that will
encourage frank discussions and new ideas.
We have eight bills before us today.
I look forward to hearing the views of our witnesses on these bills
before us.
I also look forward to working with everyone here to improve the
quality of care available to our veterans.
Prepared Statement of Hon. Jeff Miller,
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman.
I appreciate your holding this legislative hearing to start the New
Year.
Currently we have over 265,000 servicemembers deployed overseas in
the Global War on Terror. These men and women and their families expect
and should know that when they return home their service and sacrifice
will be honored and supported with benefits and health care services
tailored to meet their needs.
Today we will look at eight different bills that have been
introduced to improve the way we deliver health care to our Nation's
veterans.
I want to thank my colleagues who have brought forth these
legislative proposals and for joining us to provide testimony on their
respective bills.
The first bill on the agenda, H.R. 2790, would elevate the
Physician Assistant Advisor position Congress established seven years
ago to a full-time Director of Physician Assistant Services. It was
introduced in a bipartisan manner by Phil Hare and Jerry Moran. The
Physician Assistant profession has a strong relationship with the
military, as it originated with medical corpsmen who wanted to
transform their military medical training into the civilian health care
field. And, it is important that we encourage VA to foster the
recruitment and retention of these important health care providers.
Two bills we will consider, H.R. 3819 and H.R. 4146, would amend
current law to clarify VA requirements for the reimbursement and
payment of emergency medical care for veterans in a non-VA medical
facility. A veteran enrolled in VA health care should never be subject
to post-emergency treatment costs for any emergency health related
situation and I strongly support a legislative change to correct any
ambiguities that exist in current law.
We will also consider a number of bills that seek to create new
authorities for new programs, research and studies for veteran patients
with a traumatic brain injury; mental health concerns, including PTSD
and substance use disorder; and to meet the specialized needs of women
veterans. The Fiscal Year 2008 Consolidated Appropriations Act provided
VA with significant new funds targeted to addressing the provision of
care for these emergent needs. As we examine these measures, it is
important that we keep in mind the importance of developing solutions
that are principle centered, patient centered and complement rather
than replicate existing authorities and ongoing efforts.
I look forward to a very productive discussion on legislation that
would ensure our wounded warriors receive the best and most advanced
medical care that is available.
Again, I thank all of our witnesses and those in the audience who
have chosen to participate in today's hearing.
Thank you, Mr. Chairman, I yield back my time.
Prepared Statement of Hon. Stephanie Herseth Sandlin,
a Representative in Congress from the State of South Dakota
Good morning, Chairman Michaud and Ranking Member Miller. Thank you
for holding today's hearing. I appreciate having the opportunity to be
here to discuss the Women Veterans Health Care Improvement Act.
The Women Veterans Health Care Improvement Act (H.R. 4107), which I
introduced on November 7, 2007, along with Rep. Brown-Waite, will
expand and improve Department of Veterans Affairs health care services
for women veterans, particularly those who served in Operation Iraqi
Freedom and Operation Enduring Freedom (OIF/OEF).
I would like to thank the DAV for their support in helping craft
this important legislation. I would also like to thank the VFW for
their endorsement of the bill.
As you know, more women are answering the call to serve, and more
women veterans need access to services that they are entitled to when
they return. With increasing numbers of women now serving in uniform,
the challenge of providing adequate health care services for women
veterans is overwhelming. In the future, these needs will likely be
significantly greater with more women seeking access to care and a more
diverse range of medical conditions.
In fact, more than 1.7 million women nationally are military
veterans. More than 177,000 brave women have served our Nation in Iraq
and Afghanistan since September 2001 and nearly 27,000 are currently
deployed in these wars.
By August of 2005, 32.9% of women veterans who had served in OEF/
OIF had received VA health care. By the end of the following year
(2006) that number had increased to 37%. As the VA compiles the final
data for 2007--the percent is expected to have increased again.
And according to the VA, the prevalence of potential PTSD among new
OEF/OIF women veterans treated at VA from fiscal year 2002-2006 has
grown dramatically from approximately one percent in 2002 to nearly 19
percent in 2006.
So the trend is clear, but not surprising: More women are answering
the call to serve . . . and more women veterans need access to services
that they are entitled to. Clearly, we must do everything we can from a
public policy standpoint to meet this new challenge of women veterans.
The Women Veterans Health Care Improvement Act calls for a study of
health care for women veterans who served in OIF and OEF, a study of
barriers to women veterans seeking health care, enhancement of VA
sexual trauma programs, enhancement of PTSD treatment for women,
expansion of family counseling programs, establishment of a pilot
program for child care services, establishment of a pilot program for
counseling services in a retreat setting for women veterans, and the
addition of recently separated women veterans to serve on advisory
committees.
The VA must ensure adequate attention is given to women veterans'
programs so quality health care and specialized services are available
equally for both women
and men. I believe my bill will help the VA better meet the specialized
needs and develop new systems to better provide for the health care of
women veterans--especially those who return from combat, who were
sexually assaulted, or who need child care services.
Chairman Michaud and Ranking Member Miller, thank you again for
inviting me to testify. I look forward to answering any questions you
may have.
Prepared Statement of Hon. Shelley Moore Capito,
a Representative in Congress from the State of West Virginia
Good day, Chairman Michaud and Ranking Member Miller and the
members of the Subcommittee. I want to first take this opportunity to
thank you sincerely for holding this hearing on this Veteran's TBI
pilot program bill. In doing so you are demonstrating to our brave men
and women in the Armed Services your commitment and concern for their
well-being. You are also demonstrating to the American people, and your
constituents that you are sincere about upholding the promise made to
these young men and women by their country.
As the Subcommittee is already aware Traumatic Brain Injury has
become one of the signature injuries of the Middle Eastern theatre of
the War on Terror. TBI is a multifaceted injury with a wide range of
severity and a wide spectrum of symptoms. Many sufferers require in-
home care and extensive treatment and rehabilitation.
Symptoms of mild cases of TBI include persistent headaches, ringing
in the ears, sleep disturbances, and chronic dizziness. In the more
severe cases symptoms of TBI include loss of consciousness, personality
changes, seizures, slurred speech, debilitating weakness or numbness in
the extremities, loss of coordination, increased confusion,
restlessness, and/or agitation. Many returning veterans also suffer
from PTSD which commonly accompanies TBI. These symptoms can compound
duress, and will also complicate recovery.
You may recall the story of a Sergeant David Emme, of the U.S.
Army. Sergeant Emme's convoy came under an IED attack. Emme suffered a
textbook case of TBI. Although he was conscious on and off for 10 days
after the attack he could not recall what happened until he woke up at
Walter Reed after having been transferred from Iraq. What Emme suffered
could be likened to the recovery of a stroke victim. He had to relearn
names, and redevelop cognitive abilities like talking. Emme noted being
horribly confused and disoriented during the first few days of his
recovery in which he confused nurses and doctors for CIA agents.
According to the Defense and Veterans Brain Injury Center, in just
2003 TBI comprised up to 20% of all surviving casualties. I will remind
you 2003 saw the fewest U.S. military deaths in Iraq (486 deaths) and
saw little over half the deaths of the next most violent year (822
deaths in 2006). We can only conclude that this percentage has
increased with the prominence of IED attacks as the preferred method of
attack of insurgents.
As of January 5th, according to the Department of Defense, 28,870
members of the Armed Services have been wounded in Iraq. Twenty percent
of that number is 5,774, therefore at an absolute minimum almost 6,000
returning veterans suffer from some form of TBI.
Currently the VA only has four treatment centers that specialize in
treatment for battle related TBI: Richmond, VA, Tampa, FL, Minneapolis,
MN, and Palo Alto, CA. In June of 2006 the National Rural Health
Association gave testimony on the need for intensive treatment for
geographically isolated veterans suffering from TBI. The testimony also
emphasized the importance of Community Based Outreach Centers and local
care facilities in providing the intensive treatment needed to overcome
TBI.
What my bill proposes is a five year pilot program run by the
Secretary of the VA with the Office of Rural Health. The program will
be run in five States selected by the Secretary. For the VA hospitals
in these five States case managers will be assigned to any recovering
TBI sufferer receiving treatment at a VA facility. In carrying out the
pilot program, the Secretary is directed to provide training at
Department of Veterans Affairs medical facilities located in the
selected States for the case managers who are assigned to individuals
diagnosed with TBI.
The Secretary will also coordinate with non-Department medical
facilities located in the selected States to provide the appropriate
training necessary to manage the rehabilitation and treatment of TBI
sufferers. Also the Secretary must determine an appropriate ratio of
TBI patients to each case manager to ensure the patients receive proper
and efficient treatment.
For a State in which no Department of Veterans Affairs medical
facility is easily accessible, the Secretary can enter into a contract
with a private health care provider located in that area for which the
provider will be reimbursed. The Secretary is responsible for reporting
to those providers the most recent and up to date information on the
TBI patients they are treating.
Finally, the Secretary of Veterans Affairs shall submit to Congress
an annual report on the pilot program.
In summation I would like to express my gratitude to the committee
for allowing my testimony today, and for the opportunity for H.R. 3458
to be considered before the U.S. Congress. Again, I would like to
acknowledge the committee's observation of the valiance and the
sacrifices of the armed services. I am convinced by your actions that
at heart you do have the best interests of veterans.
Prepared Statement of Hon. Leonard L. Boswell,
a Representative in Congress from the State of Iowa
Chairman Michaud, Ranking Member Miller and Members of the
Committee, I would like to thank you for inviting me to speak before
you today and for holding this hearing over many important pieces of
veteran's health legislation.
Some say suicide is an epidemic which is sweeping through our
veteran population. For too long suicide among veterans has been
ignored; now is the time to act. We can no longer be afraid to look at
the facts and a sad fact is we are missing adequate information on the
number of veterans who commit suicide each year.
I was shocked, as I am sure many of you were, when I saw a CBS
Evening News report focusing on veteran's suicide. They found that in
2005 over 6,200 veterans committed suicide--120 per week! The report
also found that veterans were twice as likely to commit suicide as non-
veterans. These statistics are devastating.
However, the data collected did not come from the Department of
Veterans Affairs, but rather from individual States. That is why I
introduced H.R. 4204, the Veterans Suicide Study Act to direct the
Secretary of Veterans Affairs to conduct a study on the rate of suicide
among our Nation's veterans. It is imperative we have the facts on this
terrible problem if we are to effectively treat our veterans as they
return home.
While I'm pleased that the Joshua Omvig Veteran Suicide Prevention
Act is now law, we need to continue to get all the facts on suicide
among our veterans in order to better treat them as they return home. I
implore this Committee and Congress to act swiftly on H.R. 4204 so we
can ensure we have the data we need to treat our Nation's heroes. This
is an issue important to veterans and their families in Iowa and across
our great Nation.
I would again like to thank members of this Committee for allowing
me the time to speak and your diligence on this matter. I would be
happy to answer any questions you might have.
Prepared Statement of Joseph L. Wilson, Deputy Director,
Veterans Affairs and Rehabilitation Division, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on veterans' health care legislation being considered by the
Subcommittee today. The American Legion commends the Subcommittee for
holding a hearing to discuss these important and timely issues.
H.R. 2790, a bill to elevate the Physician Assistant (PA) Advisor to
the VA's Under Secretary for Health to a full-time director,
located in the VA's central office
P.L. 106-419 required the Department of Veterans Affairs (VA) to
establish a PA (Physician Assistant) Advisor to advise on such PA
issues as qualifications, clinical privileges, and scope of practice.
Prior to the enactment of the law in 2000, VA had never had a PA
advisor and the absence of a knowledgeable resource to advise on these
issues resulted in unnecessary restrictions on PA ability to provide
medical care to the veteran population. In the years since the PA
advisor position was put into place, the VA PA population grew from
1,195 PAs to nearly 1,600 PAs--a 34-percent increase.
The VA's choice to implement the PA advisor provision as a part-
time, field position has resulted in inconsistencies across VA medical
facilities in their utilization of PAs. In one instance, the American
Association of Physician Assistants was informed that a local facility
determined that a PA could not write outpatient prescriptions, despite
licensure in the State allowing prescriptive authority. Other PAs
report that VA medical facilities will not hire PAs.
The Senate Appropriations Committee report on the Department of
Veterans Affairs has included language recommending that the position
be strengthened. In the 2002 report, the Senate expressed concern about
the Veterans Health Administration's (VHA's) limitation of the PA
advisor to a part-time position and encouraged the VHA to implement a
full-time PA advisor in or around Washington, DC. Additionally, the
Senate report urged the VHA to provide sufficient funding to support
the PA advisor position.
Although The American Legion has no specific official position on
this issue, we believe VA should do everything in its power to improve
access to its health care benefits, to include providing adequate
funding to support programs within the VHA, as well as establishing and
maintaining an immediate accessible, relative continuum between VA
Central Office (VACO) and VA medical centers and its attachments
throughout the VHA.
H.R. 3458, a bill to direct the Secretary of Veterans Affairs to carry
out a pilot program on the provision of traumatic brain injury
care in rural areas
This bill directs the Secretary of Veterans Affairs to carry out a
five-year pilot program, in five rural States, under which the
Secretary trains and then assigns a specific VA case manager to each
veteran diagnosed with traumatic brain injury (TBI), who is receiving
care in a VA medical facility within that State.
The American Legion favors the intent of this bill to create a
pilot program that would train and assign specified VA case managers
for veterans diagnosed with TBI and residing in rural areas; however,
we would encourage the implementation of this program to every venue
nationwide, thereby ensuring across-the-board quality and adequate
healthcare.
H.R. 3819, Veterans Emergency Care Fairness Act of 2007
This bill would require the Secretary of Veterans Affairs to
reimburse veterans receiving emergency treatment in non-VA medical
facilities for such treatment until such veterans are transferred to VA
medical facilities, and for other purposes.
The American Legion supports provisions to allow VA to pay for
emergency room care at non-VA facilities. We believe this would prevent
any delays in treating life-threatening injuries or illnesses for
veterans not in close proximity to a VA facility.
H.R. 4053, Mental Health Improvements Act of 2007
This bill seeks to improve the treatment and services provided by
the VA to veterans with post-traumatic stress disorder (PTSD) and
substance use disorders, and for other purposes.
Section 102 seeks to require the Secretary of VA to ensure that the
following services be available at each VA medical center and
Community-Based Outpatient Clinic (CBOC): short-term motivational
counseling, intensive outpatient care, detoxification and
stabilization, relapse prevention, ongoing aftercare, opiate
substitution therapy, outpatient counseling, and pharmacological
treatments to reduce the craving for drugs and alcohol. The American
Legion believes this action would heighten assurance of continuous and
consistent treatment to veterans nationwide.
Section 103 would require VA to ensure concurrent treatment for a
veteran's substance use disorder and co-morbid mental health disorder
by professionals proficient in treating substance use and mental health
disorders. The American Legion has always held the position that
veterans who succumb to alcohol or drug abuse caused by their service-
connected disability are entitled to a level of compensation that
reflects all aspects of their disability.
Section 104 seeks to mandate Vet Centers as an avenue to house peer
outreach programs to re-engage veterans of Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) who aren't able to attend
appointments for PTSD or substance use disorder. In this effort, The
American Legion urges the Congress to authorize sufficient funding for
programs, such as the aforementioned to adequately treat veterans
suffering from PTSD and the effects of substance abuse.
Section 105 would require the VA to establish no less than six
national centers of excellence on PTSD and substance use disorders, to
provide comprehensive inpatient treatment and recovery services to
veterans newly diagnosed with these disorders. While The American
Legion applauds results that would be invoked by section 105, we also
request that these centers of excellence be adequately placed to ensure
veterans residing in rural areas of the country have access to
treatment as well.
Section 106 seeks to require the VA to review all of its
residential mental health care facilities, to include domiciliaries.
This section includes an assessment of the aforesaid facilities, along
with supervision and support provided throughout the entire Veterans
Integrated Services Network (VISN); an assessment of the
appropriateness of rules and procedures for the prescription and
administration of medications to patients in such residential mental
health care facilities; the ratio of staff members at each residential
mental health care facility to patients at such facility; a description
of the protocols at each residential mental health care facility for
handling missed appointments; and recommendations by the VA for
improvements as well.
The American Legion supports this section's request to provide up-
to-standard inhabitable facilities, as well as adequate staff to ensure
continuous and quality care for veterans.
Section 107 would provide for Title 1 of this bill to be enacted in
tribute to Justin Bailey, an OIF veteran who died while under VA
treatment for PTSD and a substance use disorder. According to the
Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, PTSD
always follows a traumatic event that causes intense fear and/or
helplessness in an individual. Typically, the symptoms develop shortly
after the event, but may take years. Psychological care is considered
the most effective means of treatment for PTSD. In addition to
treatment for PTSD, other mental health conditions, such as acute
reaction to stress and abuse of drugs or alcohol, require much
attention.
Due to the increasing numbers of veterans seeking care at VA
medical facilities, to include those from the Gulf War era and OIF/OEF,
The American Legion supports a bill such as H.R. 4053 to further
improve treatment and services provided by the VA to our Nation's
veterans. The American Legion also supports quality treatment and
adequate supervision, to include that which would prevent such
tragedies as Justin Bailey's.
H.R. 4107, Women Veterans Health Care Improvement Act
This bill seeks to amend title 38, United States Code, to expand
and improve health care services available to women veterans,
especially those serving in OIF/OEF, from the VA, and for other
purposes. Section 101 discusses long-term study on health of women
serving in OIF/OEF. This section would also require VA to adjoin with
War-Related Injury and Illness Centers (WRIICs) and contract with
outside organizations to conduct an epidemiologic study on the health
effects of women who served in OIF/OEF. The American Legion concurs
with the intent of this section due to the course of action in
ascertaining the results of the study, which include collaborating with
the Department of Defense (DoD) in acquiring relevant health care data,
such as pre-deployment health and health risk assessments in
conjunction with VA access to the cohort while they are serving in the
Armed Forces.
Section 102 discusses study of barriers for women veterans to
health care from the VA. The current Global War on Terror illustrates a
few deficiencies in services provided for women veterans. Participation
in OIF/OEF has obligated them to expand their military roles to ensure
their own survival, as well as the survival of their units. They
sustain the same types of injuries as their male counterparts. The
American Legion supports studies to identify and alleviate barriers
that hinder quality health care for all veterans, including women.
Section 103 discusses comprehensive assessment of VA's women's
health care programs. The American Legion supports assessment of such
programs as disease prevention, primary care, women's gender-specific
health care, acute medical/surgical, and mental health treatment,
domiciliary, rehabilitation and long-term care to ensure ongoing
delivery of quality and adequate care to women veterans.
Section 201 discusses improvement of sexual trauma care programs of
the VA. The American Legion supports improvement of VA's sexual trauma
care programs, to include a comfortable atmosphere, which may encourage
full disclosure of the veteran's traumatic event.
Section 202 discusses dissemination of information on effective
treatment, including evidence-based treatments, for women veterans with
PTSD. The American Legion supports the dissemination of information
disclosing effective means of treatment for women and all veterans.
Section 203 discusses ensuring adequate provision of services for
women veterans at VA Vet Centers. The American Legion supports adequate
provision of services for women and all veterans at VA Vet Centers.
This also includes effective communication with VA medical centers to
adequately provide quality treatment for veterans requiring more
complicated and/or long-term treatment.
Section 204 discusses a pilot program for childcare for certain
women veterans receiving health care from facilities of the Department.
The American Legion supports programs that allow flexibility for women
and all veterans to obtain quality and adequate health care within the
VHA.
Section 205 discusses a pilot program for women veterans newly
separated from service for counseling in retreat settings. It is
essential that appropriate treatment be provided to veterans who
require special needs treatment.
Section 206 discusses the addition of recently separated women
veterans to serve on advisory committees. It is essential that advisory
committees represent the experiences of all veterans.
H.R. 4146, to amend title 38, United States Code, to clarify the
availability of emergency medical care for veterans in non-
Department of Veterans Affairs medical facilities
This bill seeks to amend title 38, United States Code (USC), to
clarify the availability of emergency medical care for veterans in non-
VA medical facilities. Currently, veterans who are diverted to non-VA
medical facilities are unfortunately overwhelmed with hospital bills
incurred from their stay at the respective facilities. Section 1725 of
title 38, USC, requires that non-facilities transfer the veteran to a
VA facility following his or her stabilization.
However, when there are no accommodations available at a VA medical
facility and the veteran has to remain at the non-VA facility, he or
she incurs the cost of the emergency care from that point. Incurring
costs for actions out of the veteran's control is inherently
unconscionable. The American Legion supports provisions to authorize VA
to cover the costs of emergency room care at non-VA medical facilities
for veterans who are required to remain at these facilities due to
unavailable space at VA medical facilities.
H.R. 4204, Veterans Suicide Study Act
This bill seeks to direct the Secretary of VA to conduct a study on
suicides among veterans. The American Legion receives contact from
actual veterans who disclose their need for immediate help due to their
thoughts of harming themselves. As the number of calls to suicide
prevention call centers increase, the need for more suicide prevention
counselors throughout the VHA is warranted.
The American Legion supports continued studies on suicides among
veterans. With a proactive stance in mind, we ask that these findings
be readily communicated to suicide prevention divisions to increase the
prevention of potential tragedies.
H.R. 4231, Rural Veterans Health Care Access Act of 2007
This bill creates a pilot program in seven geographically diverse
VISNs across the country to provide veterans living 30 miles from a VA
medical facility staffed by a licensed mental health professional with
vouchers that can be used as payment in full for mental health services
at a private, VA approved facility.
The aim of this bill is to also help veterans who require regular,
long-term care and who live in areas that don't allow frequent trips to
a VA medical facility. This would be especially intended to make
counseling for PTSD, drug/alcohol abuse and families more accessible.
Because treatment for a variety of mental conditions requires regular
one-on-one sessions with a professional, we determined, with the input
of veterans groups, that 30 miles was a reasonable distance. Many
veterans are disabled or economically disadvantaged, meaning that a
weekly trip for counseling appointments would be prohibitive or
impossible. Thus, many vets who should be in counseling choose to forgo
it.
According to research conducted by the VA, one in five veterans
nationwide who enrolled to receive VA health care reside in rural
areas. The American Legion believes no veteran should be penalized or
forced to travel long distances to access quality health care because
of where they choose to live. Furthermore, all care, to include pilot
programs, should include outreach to every rural venue in which
veterans reside.
The American Legion favors the intent of this bill to create a
pilot program that would accommodate veterans residing in rural areas;
however, we would encourage the inclusion of every VISN across the
country, as well as, a more condensed pilot program than the above
mentioned.
Again, thank you, Mr. Chairman, for giving The American Legion this
opportunity to present its views on such important issues. We look
forward to working with the Subcommittee in continuing the enhancement
of access to quality health care for all veterans.
Prepared Statement of Joy J. Ilem,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and other Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this legislative hearing of the Subcommittee on Health. DAV
is an organization of 1.3 million service-disabled veterans, and
devotes its energies to rebuilding the lives of disabled veterans and
their families.
You have requested testimony today on eight bills primarily focused
on health care services for veterans under the jurisdiction of the
Veterans Health Administration (VHA), Department of Veterans Affairs
(VA). This statement submitted for the record relates our positions on
the proposals before you today. Our comments are expressed in numerical
sequence of the bills.
H.R. 2790--To amend title 38, United States Code, to establish the
position of the Director of Physician Assistant Services within
the Office of the Under Secretary of Veterans Affairs for
Health
The VA is the largest single federal employer of Physician
Assistants (PA), with approximately 1,600 full-time equivalent employee
(FTEE) PA positions. In the VA health care system PAs are essential
primary care providers for millions of veteran outpatient and inpatient
encounters and work in ambulatory care clinics, emergency medicine, and
22 other VA medical and surgical subspecialties.
The passage of the Veterans Benefits and Health Care Improvement
Act of 2000 (P.L. 106-419) directed the VA Under Secretary for Health
to appoint a PA advisor to that office. Since that time VHA has
assigned this duty to a PA as a part-time, field-based collateral
position, in addition to their local clinical care duties. However,
this important clinical representative has not been appointed to VHA's
major health care strategic planning committees or been fully
integrated into VHA policy and planning management and health care
planning activities. Additionally, the PA advisor has not participated
in establishing priorities or policies for the new Office of Rural
Health, or been utilized for emergency management planning, even though
36 percent of all VA PAs are veterans or currently serve in the
military Reserves or Guard forces. These experiences and perspectives
of VA's PA workforce could bring vital information to a number of new
initiatives for improving veterans health care, including services for
our newest generation of war veterans returning from Operations Iraqi
and Enduring Freedom (OIF/OEF).
The Independent Budget veterans service organizations, including
DAV, believe that PAs are a critical component of VA health care
delivery and urge that the Subcommittee report this bill that would
legislatively mandate the Advisor position as a full-time Director of
Physician Assistant Services within the office of the Under Secretary
for Health in Washington, D.C.
H.R. 3458--To direct the Secretary of Veterans Affairs to carry out a
pilot program on the provision of traumatic brain injury care
in rural areas
This bill would require the VA to establish a five-State pilot
program of VA case-managed traumatic brain injury (TBI) care in rural
States, and would provide various protections to ensure rural veterans
with TBI received sufficient care from competent, trained providers,
whether in VA facilities or those with which VA contracted to provide
necessary specialized services. VA would be required to assign a case
manager to each TBI patient with a determination of an appropriate
ratio of patients to each case manager.
The bill would require the pilot program be conducted in
consultation with the VA Office of Rural Health established under
Public Law 109-461. The bill would also require VA to distribute best
practice information on the treatment of TBI to the VA facilities and
private providers that would participate in this pilot program.
DAV has no objection to this bill since it is consistent with
recommendations of The Independent Budget.
H.R. 3819--Veterans Emergency Care Fairness Act of 2007
This bill would amend the two existing authorities, sections 1725
and 1728 of
title 38, United States Code, that determine the circumstances in which
the Secretary may pay for expenses incurred in connection with an
eligible veteran's authorized emergency treatment in a non-VA facility.
Under current law VA is authorized to pay for non-VA emergency
treatment for a veteran's service-connected disability, a nonservice-
connected disability aggravating a service connected condition, any
condition of veteran who is rated permanently and totally disabled, or
a veteran enrolled in VA vocational rehabilitation. However, expenses
incurred after the period of medical emergency ends but before the
veteran can be transferred to a VA or another Federal facility may not
be reimbursed.
If enacted, this measure would require the Secretary of Veterans
Affairs to reimburse a veteran for emergency treatment provided in a
non-VA facility until such veteran is transferred to VA. In addition to
applying the prudent layperson definition of ``emergency treatment''
under both sections, the bill intends to reverse the current VA
practice of denying payment for emergency care provided to a veteran by
a private facility for any period beyond the moment at which VA
determines the veteran can be safely transferred. Specifically, it
would amend the definition of reimbursable emergency treatment to
include the time when VA or another Federal facility does not agree to
accept a stabilized veteran who is ready for transfer from a non-VA
facility, provided the non-VA provider has made reasonable attempts
(with documentation) to effect such a transfer.
The DAV supports the intent of this bill which is in accordance
with the mandate from our membership and consistent with the
recommendations of The Independent Budget to improve reimbursement
policies for non-VA emergency health care services for enrolled
veterans.
H.R. 4053--Mental Health Improvements Act of 2007
This measure would establish new program requirements and new
emphases on existing programs for treatment of post-traumatic stress
disorder (PTSD) and substance use disorder--with special regard for the
treatment of veterans who suffer from co-morbid associations of these
disorders.
Title I--Sections 102-104 of the bill would require VA to offer a
complete package of continuous services for substance use disorders,
including counseling; intensive outpatient care; relapse prevention
services; aftercare; opiate substitution and other pharmaceutical
therapies and treatments; detoxification and stabilization services;
and other services the Secretary deemed necessary, at all VA medical
centers and community-based outpatient clinics (unless specifically
exempted). The measure would require that treatment be provided
concurrently for such disorders by a team of providers with appropriate
expertise. This section guides allocation funding to facilities for
these new programs, as well as how facilities would apply for such
funding. Sections 105 and 106 would require establishment of not less
than six new national Centers of Excellence on Post-Traumatic Stress
Disorder and Substance Use Disorder, that provide comprehensive
inpatient treatment and recovery services for veterans newly diagnosed
with both PTSD and a substance use disorder. The bill would require the
Secretary to establish a process of referral to step-down
rehabilitation programs at other VA locations from a center of
excellence, and to conduct a review and report on all of VA's
residential mental health care facilities, with guidance on required
data elements in the report.
Title II--Section 201 of the measure seeks to make mental health
accessibility enhancements. This provision would require the
establishment of a pilot program of peer outreach, peer support,
readjustment counseling and other mental health services for OIF/OEF
veterans who reside in rural areas and do not have adequate access
through VA. Services would be provided using community mental health
centers (CMHC) (grantee organizations of the Substance Abuse and Mental
Health Services Administration, Department of Health and Human
Services), and facilities of the Indian Health Service, through
cooperative agreements or contracts. This pilot program would be
carried out in a minimum of two Veterans Integrated Service Networks
(VISNs) for a three-year period. Provisions would require the Secretary
to carry out a training program for contracted mental health personnel
and peer counselors charged to provide these services to OIF/OEF
veterans. All contractors would be required to comply with applicable
protocols of the Department and provide, on an annual basis, specified
clinical and demographic information including the number of veterans
served.
Title III--Section 301 of the bill would establish a new, targeted
research program in comorbid PTSD and substance use disorders, and
would authorize $2 million annually to carry out this program, through
VA's National Center for PTSD. Title IV--Sections 401 and 402 of the
measure seek to clarify authority for VA to provide mental health
services to families of veterans coping with readjustment issues. The
bill would establish a ten-site pilot program for providing specialized
transition assistance in Vet Centers to veterans and their families,
and would authorize $3 million to be used for this purpose. Finally,
provisions included in the measure would require a number of reports on
these new authorities.
Current research highlights that OIF/OEF combat veterans are at
higher risk for PTSD and other mental health problems, including
substance use disorder, as a result of their military experiences. Mr.
Chairman, like you, we are concerned that over the past decade VA has
drastically reduced its substance abuse treatment and related
rehabilitation services, and has made little progress in restoring
them--even in the face of increased demand from veterans returning from
these current conflicts. There are multiple indications that PTSD and
readjustment issues, in conjunction with the misuse of substances will
continue to be a significant problem for our newest generation of
combat veterans; therefore, we need to adapt new programs and services
to meet their unique needs. We are especially pleased with the
provisions pertaining to mental health services for family members. The
families of these veterans are suffering too, and are the core support
for veterans struggling to rehabilitate and overcome readjustment
issues related to their military service. We hope at the same time that
previous generations of veterans and their families could also benefit
from these newly proposed programs and services.
Although DAV has no approved resolution from our membership calling
for a joint treatment program for PTSD and substance use disorders, we
believe the overall goals of the bill are in accord with providing high
quality, comprehensive health care services to sick and disabled
veterans. Additionally, the bill is consistent with recommendations in
the forthcoming Independent Budget for fiscal year 2009. Thus, with
only one exception, stated below, we believe these are very timely
provisions, and we fully support them.
Our concern relates to Title II section 201 of the bill. We support
the peer counseling concept it would authorize, but we continue to have
concerns about contracting with non-VA providers to provide specialized
PTSD treatment.
Although DAV believes that VA contract care is an essential tool in
providing timely access to quality medical care, we feel strongly that
VA should use this authority judiciously. Current law limits the use of
VA purchased care to specific instances so as not to endanger the VA's
ability to maintain a full range of specialized services for enrolled
veterans and to promote effective, high quality care for veterans,
especially those disabled in military service and those with highly
complex health problems such as blindness, amputations, spinal cord
injury or chronic mental health conditions. A major concern is that in
most cases where VA authorizes care to veterans by contract providers
VA has not established a systematic approach to monitor that care, or
consider any alternatives to its high cost, has not analyzed patient
care outcomes, or even established patient satisfaction measures. For
several years, The Independent Budget has recommended VA make major
improvements in its contract and fee-basis programs, but VA has yet to
make any improvement.
DAV wants to ensure that all veterans receiving care from VA or
through its fee basis or contract programs are treated in accordance
with VA's standards. In its 2001 report, ``Crossing the Quality Chasm:
A New Health Care System for the 21st Century,'' the Institute of
Medicine (IOM) put forward six aims that now underpin the standard of
care for U.S. providers. The IOM aims are that health care will be safe
(avoiding errors and injury), effective (based on the best scientific
knowledge), patient-centered (respectful of, and responsive to patient
preferences, needs and values), timely (reduced waiting time and
harmful delay), efficient (avoiding waste), and equitable (unvarying,
based on race, ethnicity, gender, geography, or socioeconomic status).
VA embraces the IOM aims and therefore should manage rural veterans'
health care issues in a way that addresses all of the aims
collectively.
VA also lacks an integrated approach to address the unique health
care challenges of rural veterans, including OEF/OIF veterans living in
rural areas. To remedy the gaps, VA should identify an effective and
creative approach to make health care--including mental health care--
available to our newest generation of wartime veterans irrespective of
their locations of residence. VA should develop performance measures
and quality standards to assess the care that is provided through
contract or fee-basis arrangements. DAV believes that reform in rural,
remote and frontier VA care can be achieved with the same overarching
principles that have accompanied the transformation of the Veterans
Health Administration (VHA) over the past decade. Necessary actions to
achieve this reform would include:
Issuance of clear VHA policy that local facilities and
Networks, through their mental health leadership, are responsible for
creating a VHA-sponsored system that provides a stipulated array of
services reasonably accessible to as many rural veterans, including
OEF/OIF veterans as possible who need these services.
Provision of direct services wherever VHA has a large
enough concentration of veterans needing such services, and has an
existing VHA site of care. This would require VA to upgrade access to
marital counseling and develop brief interventions for substance
abuse--services that VHA does not make easily accessible in even some
of its largest facilities.
Contracting for care where there is not a large enough
concentration of veterans needing readjustment counseling services,
after local and Network leadership assess the availability and quality
of alternative service providers (e.g. Vet Centers, State veterans
services), including the availability and quality of services which
could be purchased in the community, and assuring that a full array of
services is made readily available.
Oversight by Congress of this policy, with evidence that
it is coordinated with the VHA Office of Mental Health Services and the
newly established Office of Rural Health.
Mr. Chairman, VA has received significant new funds targeted to
providing better access to mental health services to all enrolled
veterans. VA has developed a national Mental Health Strategic Plan to
deploy several new mental health programs, ramp-up existing specialized
mental health services and hire new staff. VA should rapidly deploy
those plans then determine the degree of unmet need in rural areas. In
that connection, in Public Law 109-461, sections 212 and 213, Congress
mandated VA to take specific steps to develop innovative and successful
programs to improve care and services for veterans who reside in rural
areas; assess its fee-basis health care programs; and, develop a plan
by September 30, 2007 to improve access and quality of care, including
measures for meeting the mental health needs of veterans residing in
rural areas. VA was also required by that Act to report to Congress not
later than March 30, 2007 on the VA community-based outpatient clinics
(CBOC) and other access points identified by the Capital Asset
Realignment for Enhanced Services (CARES) May 2004 decision document,
and to coordinate that report through the Office of Rural Health.
Finally, VA must conduct an extensive outreach program to OIF/OEF
veterans who reside in rural communities in order to enroll those
veterans in VA health care during the existing two-year enrollment
period after their release from active duty. In carrying out the
program the Secretary is required to work with State agencies,
community health centers, and rural health clinics, to increase
awareness of veterans and their families about the availability of
health care services provided by VA.
Again, we recognize and appreciate the emphasis placed on peer
counseling, outreach and ensuring that non-VA providers are properly
trained and compliant with VA standards, and coordination with VA's
Office of Rural Health in this provision. As a community everyone is
very concerned about rural veterans access to health care--including
mental health and readjustment services, especially for our newest
generation of OEF/OIF veterans. We ask the Subcommittee to request the
above noted reports from the Office of Rural Health to see what
progress VA has made in addressing the needs of rural veterans. This
information will provide essential information on how to best develop a
comprehensive solution and meet the health care and mental health needs
of this population.
H.R. 4107--Women Veterans Health Care Improvement Act
Mr. Chairman, women veterans are a small but dramatically growing
segment of the veteran population. The current number of women serving
in active military service and its reserve and Guard components has
never been larger and this phenomenon predicts that the percentage of
future women veterans who will enroll in VA health care and use other
VA benefits will continue to grow proportionately. Also, women are
serving today in military occupational specialties that take them into
combat theaters and expose them to some of the harshest environments
imaginable, including service in the military police, artillery, medic
and corpsman, truckdriver, fixed and rotary wing aircraft pilots and
crew, and other hazardous duty assignments. VA must prepare to receive
a significant new population of women veterans in future years, who
will present needs that VA has likely not seen before in this
population.
Title I, sections 101-103 of the bill would authorize and mandate
longitudinal studies by VA in coordination with the Department of
Defense (DoD) to evaluate the needs of women who are currently serving,
and women veterans who have completed service, in OIF/OEF. Also, VA
would be required to study and report existing barriers that impede or
prevent women from accessing health care and other services from VA.
Thirdly, this title would require VA to make an assessment of its
existing health care programs for women veterans and report those
findings to the Congress.
Title II, sections 201 and 202 would make improvements in VA's
ability to assess and treat women who have experienced military sexual
trauma (MST), and would mandate the use of evidence-based treatment
practices and methods in caring for women veterans who suffer from post
traumatic stress disorder (PTSD) related to MST and/or combat exposure.
The Secretary would be required to ensure appropriate training of
primary care providers in screening and recognizing symptoms of sexual
trauma and procedures for prompt referral and require qualified MST
therapists for counseling. Under this authority the Secretary would
also be required to provide Congress an annual report on the number of
primary care and mental health professionals who received the required
training, the number of full-time employees providing treatment for MST
in each VA facility, and the number of women veterans who had received
counseling, care and services associated with MST.
Section 203 and 204 would require a study on the adequacy of care
and counseling for women veterans in VA's existing Readjustment
Counseling Service, through its Vet Center programs, and would
authorize a pilot program of childcare reimbursement for certain women
veterans to ensure they are able to avail themselves of VA's existing
mental health and other specialized health care programs. Section 205
would establish a pilot program of counseling in retreat settings for
recently discharged women veterans who could benefit from VA
establishing offsite counseling to aid them in their repatriation with
family and community after serving in war zones and other hazardous
military duty deployments.
Mr. Chairman, this comprehensive legislative proposal is fully
consistent with a series of recommendations that have been made in
recent years by VA researchers, experts in women's health, VA's
Advisory Committee on Women Veterans, The Independent Budget, and DAV.
Therefore, we support this measure and urge the Subcommittee to
recommend its enactment.
H.R. 4146--To amend title 38, United States Code, to clarify the
availability of emergency medical care for veterans in non-
Department of Veterans Affairs medical facilities
Although less comprehensive, this bill is intended to achieve the
same purpose as H.R. 3819, discussed above, to provide equity of
reimbursement to veterans who receive emergency health care services
through private providers under VA eligibility. DAV holds similar views
on both bills, and therefore, supports the merit of this bill. While
supporting the intent, we believe this bill may not offer a complete
remedy to the conditions which prompted its introduction. Therefore, we
recommend the Subcommittee defer action on this bill and instead
favorably report H.R. 3819.
H.R. 4204--Veterans Suicide Study Act
This bill would require VA, in coordination with DoD, State public
health offices and veterans agencies, and veterans service
organizations, to conduct a study and report to Congress the number of
veteran suicides that have occurred since 1997. Given DAV's testimony
on this topic at the full Committee's hearing on December 12, 2007, we
support the need for a study of suicide in the veteran population;
however, DAV recommends the language of the bill be amended to include
other relevant measures that could help reduce veterans' suicides,
specifically--information about risk factors--including age and gender,
combat service and co-morbid medical and behavioral health conditions.
VA should also invest in translational research on how to improve
clinical techniques to prevent suicidal behaviors. Another area VA
should address is the impact on families (including parents) after a
veteran or military servicemember commits suicide and what these
families may need in terms of continued mental health counseling and
care, or other VA or DoD services. Currently neither VA nor DoD knows
very much about impact on these families post-suicide, and to our
knowledge no rigorous studies have been undertaken.
Most importantly, suicidal behavior can be controlled and monitored
with readily available access to quality psychiatric care for those who
may be at risk because of a variety of mental health conditions. Mental
health professionals and suicidologists are well informed about
techniques and treatments that can reduce suicidal behavior (most often
a prelude to suicide attempts), including attentive primary health care
and mental health screening, good psychological health care, early
intervention in substance misuse or abuse, addressing of relationship
and interpersonal problems, reduction in risk-taking behavior, crisis
intervention, protective hospitalization, etc.
While DAV supports the need for data on suicide in the veteran
population and appreciates the intent of this measure, we hope the
Subcommittee will consider making amendments to this bill to address
some of these additional needs.
H.R. 4231--Rural Veterans Health Care Access Act of 2007
This bill would establish a five-year mental health services pilot
program in seven specific Veterans Integrated Service Networks (VISNs),
in which veterans in need of mental health services, but who reside at
least 30 miles from a VA medical facility that employs a full-time
mental health professional, would be issued vouchers by VA to receive
private mental health services at VA expense. Vouchers would expire six
months after issuance but could be renewed for an additional six months
on request of a veteran, if deemed appropriate by the Secretary of
Veterans Affairs. VA would be required to maintain a list of
participating private providers, including family counseling providers
and a contractor's participation would hinge on agreement to accept
VA's vouchers as payment in full. While the program would expire five
years after commencing, the Secretary would be required to recommend
whether the program should be extended or expanded at the time.
We have a number of concerns about this bill. The Independent
Budget is clearly on record as opposed to vouchering, privatization and
other initiatives that could endanger VA's capabilities and lack
contract care coordination aspects that we see as essential to the
delivery of high quality care for veterans and the long-term
maintenance of veterans' health services.
Sick and disabled veterans need a strong and vibrant VA system, one
that offers specialized services for the kinds of serious injuries and
chronic illnesses endemic to that population. Congress has historically
agreed with this premise and in consequence authorized VA to build and
sustain its specialized programs in spinal cord injury, blindness,
prosthetics and sensory aids, amputation care and rehabilitation, and,
importantly in this instance, care for the seriously mentally ill and
other disabled war veterans with mental health readjustment issues
including PTSD. We are sympathetic to the plight of veterans residing
in remote and rural regions, but we believe the type of vouchering
program envisioned by this bill lacks the essential component of VA-
managed care coordination. We believe VA's Offices of Mental Health
Services and Rural Health should identify unmet needs in mental health
within the rural veteran population, then fashion programs or solutions
to meet those needs. As stated previously in this testimony, Congress
has provided VA resources to hire thousands of new mental health
providers, and VA has informed us that over 3,500 have in fact been
hired to date. These new employees, and a multiplicity of new VA mental
health programs, and the mandate to the Office of Rural Health should
create greater access to mental health services for rural veterans. We
ask the Subcommittee to provide oversight and to request from VA its
strategic plan to outreach and provide services to OIF/OEF veterans and
other veterans living in rural areas.
We also call to your attention that under the bill, the decision on
whether an eligible veteran would be in need of mental health
counseling would be made by a ``certified mental health professional''
with no requirement that VA make or confirm that determination. We
believe access to care and its quality, quantity and safety, should be
closely controlled and monitored by VA. We are also concerned about the
intent of the provision in section 3, subsection b(4) of the bill, that
states an eligible veteran would need to ``reside[ ] at least 30 miles
from a medical facility of the Department of Veterans Affairs that
employs a full-time mental health professional'' (emphasis added). We
interpret this provision to mean that if a veteran lives within 30
miles of a VA medical facility, and that clinic or medical center only
has a part-time mental health professional, or more than 30 miles from
a VA facility with a full-time mental health professional, the veteran
would be eligible to seek care through the proposed voucher system
without regard to whether that VA facility were able to provide an
appointment in a timely manner. If a qualified VA provider is unable to
provide the service a veteran needs, VA should make a determination
that veteran's need for care dictates the use of a contract provider.
In any case, we believe VA should identify an appropriate contract
provider and make a prompt referral. However, we believe, to ensure a
veteran has access to VA's full range of services, VA should always
remain that veteran's care manager.
Mr. Chairman, DAV appreciates the opportunity to provide this
written statement for the record and present our views on these bills.
I will be pleased to respond to any questions you or other Subcommittee
Members may have.
Prepared Statement of Christopher Needham, Senior Legislative
Associate,
National Legislative Service, Veterans of Foreign Wars of the United
States
Mr. Chairman and Members of the Subcommittee:
On behalf of the 2.4 million men and women of the Veterans of
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I am pleased to be
before you providing the organization's views on an array of health
care legislation.
The majority of the bills before us today revolve around a central
theme: access to care. Whether a rural veteran, a female veteran, or
one of our heroic wounded warriors, there are gaps in the Department of
Veterans Affairs' (VA) ability to provide first-rate care. The bills
under consideration today aim to close those gaps, ensuring that all of
our veterans are adequately cared for, which is a goal that all of us
certainly share.
H.R. 2790
This legislation would create a full-time Director of Physician
Assistant Services to report to the Under Secretary of Health with
respect to the training, role of, and optimal participation of
Physician Assistants (PA). We are pleased to support it.
Congress created a PA advisor role when it passed the Veterans
Benefits and Health Care Improvement Act of 2000 (P.L. 106-419). The
law required the appointment of a PA advisor to work with and advise
the Under Secretary of Health ``on all matters relating to the
utilization and employment of physician assistants in the
Administration.'' Since that time, however, the Veterans Health
Administration (VHA) has not appointed a full-time advisor, instead
appointing a part-time advisor who serves in the role in addition to
his or her regularly scheduled duties while working in the field, far
from where VA makes its decisions.
The current PA advisor role is likely not what Congress envisioned
when it created the role, and the PA advisor has had little voice in
the VA planning process; VA has not appointed the PA advisor to any of
the major health care strategic planning committees.
With the role that PAs play in the VA health care process, it only
makes sense to invite their participation and perspective. VA is the
largest employer of PAs in the country, with approximately 1,600. They
provide health care to around a quarter of all primary care patients,
treating a wide variety of illnesses and disabilities under the
supervision of a VA physician. Since they play such a critical role in
the effective delivery of health care to this Nation's veterans, they
should have a voice in the larger process. We urge passage of this
legislation and the creation of a full-time PA Director position within
the VA Central Office.
H.R. 3458
The VFW is certainly supportive of the intent of this legislation,
which would create a pilot program to care for veterans suffering from
traumatic brain injuries (TBI) in rural areas.
It is clear that VA needs to do a better job caring for our wounded
warriors, especially for those who transition from the polytrauma
rehabilitation centers, but also for those who suffered, but did not
stay at those specialized clinics. As we learn more about TBI, we are
also finding that veterans can suffer from it without having any
apparent physical injuries, meaning there are likely larger number of
veterans suffering from mild or moderate TBI--diagnosis can come later,
but only if VA properly screens the veteran.
We have all seen the television reports and read the heart-
wrenching stories about wounded warriors falling through the cracks. It
is truly shameful that these brave men and women have had to suffer. We
can and must do better.
This legislation acknowledges these problems, and works to correct
some of them. It would create, in five rural States, a pilot program
that would provide trained case managers to veterans suffering from
TBI, and allow VA to contract for care in places where VA is unable to
meet the demand for care. All are worthy goals.
We would ask, however, that the Committee be mindful of any
potential overlap with the Wounded Warrior legislation that has been
making its way through Congress as part of the National Defense
Authorization. It is our understanding that the provisions, which
earlier cleared both chambers of Congress, are noncontroversial and
that they will likely be a part of any upcoming Defense Authorization
bill.
As always, we would hope that VA would be able to develop the in-
house experience to deal with all these problems, and we believe that
this should remain VA's ultimate goal. In the meantime, there are
hundreds of veterans with a demonstrated need who would benefit from
the contracting care this legislation would provide. We cannot afford
to wait; they must receive adequate care as soon as possible.
H.R. 3620
The VFW is pleased to support H.R. 3620, the Homecoming Enhancement
Research and Oversight Act. This legislation calls for a comprehensive
study on the physical and mental health care needs of OEF/OIF veterans,
produced by DoD, VA and the National Academy of Sciences.
The study, which would consist of two major phases, would look at
the key issues and unknowns confronting those who were deployed
overseas as part of OEF/OIF. It would include a study of the effects of
multiple deployments, the scope of traumatic brain injuries and their
effects on the servicemember and his or her family, and the long-term
impact of other war-related illnesses and disabilities such as post-
traumatic stress disorder. Notably, the study would also assess the
physical and mental health care needs of women veterans. We also
appreciate the emphasis this legislation would place on families and
the effects these illnesses and disabilities appear to have on them.
With the large number of citizen soldiers fighting these conflicts, it
is only proper to see how all are affected, because it is clear that it
is not just the man or woman in uniform who suffers.
A study such as this is essential to allow VA and DoD to properly
manage what appears to be a crisis in our returning veterans. This
assessment would give the departments and policy managers a clear idea
of what the problems are, allowing us to develop plans to treat the
disabilities and impairments we are seeing. The studies that we have
seen have hinted at the problem, and have shown us enough to make
initial efforts at improving the care of these brave men and women.
However, we can and must do more.
We must be proactive with our approach, and move forward. Proper
study of the issues will allow VA and DoD to see if their programs are
accurately meeting the needs of this deserving population of veterans,
and will better allow us to prepare for their care into the future.
There is plenty that we do not yet know about the needs of these
veterans, and the more we find out, the better prepared we will be to
fulfill this Nation's sacred obligations to her sick and disabled
veterans.
H.R. 3819 and H.R. 4146
The VFW is pleased to offer our support for these two pieces of
legislation that deal with an issue important to a number of our
members. These two bills would close a loophole in current law that
causes a number of veterans each year to be saddled with expensive
hospital bills for care related to emergency treatment.
Section 1725 of title 38 authorizes VA to reimburse veterans for
medical expenses related to emergency care at non-VA facilities if the
veteran is enrolled and using the VA health care system, and if he has
no other form of medical insurance. This is an important safety net for
many veterans who have no other means to pay for potentially life-
saving care.
Under that same section, the definitions in (f)(1)(C) create that
loophole that harms veterans. Current law requires that the non-VA
facility transfer the veteran to a VA facility when the veteran is
stable. However, in areas, where there is no suitable VA facility or
when the facility is unable to accept the patient, the veteran is
forced to stay at the non-VA facility and VA makes no payment for that
emergency care. In this case, VA's inability to adequately provide the
care the veteran needs ends up costing the veteran thousands of dollars
out of his or her own pocket, something that is unconscionable.
Clearly, this unfair policy punishes veterans unfortunate enough to
live in areas where no VA facilities are available or able to accept a
veteran. The policy punishes them for something that is no fault of
their own.
Both bills amend that section and close the loophole. H.R. 3819
goes a step further. It mandates that the Secretary provide
reimbursement by striking the ``may reimburse'' from section 1725 (a)
and replacing it with ``shall reimburse.'' This would eliminate any
potential for a weakening of the policy. H.R. 3819 also would amend
section 1728 of title 38 to specify emergency care as a medical expense
eligible for reimbursement to certain categories of service-connected
veterans. While we support the concept, we would note that the
Committee should carefully consider any externalities that could pop up
from replacing ``such care or services'' with ``emergency treatment,''
especially when section 1728(a)(1) already specifies that reimbursement
is for ``such care or services [that] were rendered in a medical
emergency.''
With that in mind, we would urge the Committee to swiftly approve
legislation that would close this loophole so that VA can properly
reimburse those veterans who would be unfairly penalized by the current
law.
H.R. 4053
The VFW is happy to support the Mental Health Improvements Act,
comprehensive legislation that aims to improve the level of mental
health services that VA provides, especially with respect to PTSD and
substance abuse disorders. This legislation acknowledges and aims to
improve the treatment of what is sadly a growing problem among
veterans, especially OEF/OIF veterans. As the findings of the bill
note, a 2005 DoD study found a 23% rate of Active Duty personnel who
acknowledge a significant problem with alcohol use.
Title I of the bill focuses on substance use disorders, especially
in conjunction with PTSD and other mental health issues. It would
require VA to provide treatment--including counseling, therapy, and
detoxification services--for substance use disorders at each VA medical
center and community-based outpatient clinic, although it gives the
Secretary the authority to decide if services are not needed at a
particular location.
Additionally, it would provide funding for services to veterans
suffering from PTSD with substance use disorders. Notably, it would
allow VA to conduct these services in concert with peer groups, but
also families. This flexibility would allow VA to develop a program
that best works for individual veterans, adapting it to the veteran's
particular needs for the most effective results.
The legislation would also create six new centers of excellence
within VA to address PTSD and Substance Use disorders. These centers
would provide comprehensive inpatient treatment for those veterans most
in need of help with these sometimes-debilitating diseases. We are
especially appreciative of the proposal to require the creation of a
referral process for when veterans are ready to leave the centers. This
could help to eliminate the possibility of a veteran falling through
the cracks, ensuring that the veteran really does receive the
additional care that they would need to recover and return to normal
life.
The VFW also supports section 201 of the legislation, which would
create a new pilot program of peer outreach and support to help provide
readjustment counseling and other mental health services. With respect
to the peer outreach and support, we believe that these types of
therapies and support are often preferable to certain veterans. They
may appear to be less formal and more casual, a style that may be
conducive to more effective results among some veterans. We would hope
that the results from the pilot program would lead to improvements in
VA's overall mental health and readjustment programs.
Section 201 would also authorize VA to provide mental health care
to veterans in rural areas through contracts awarded by the newly
created Office of Rural Health. While ultimately, the VFW would like to
see VA have the ability and capacity to provide the full continuum of
care to all veterans within its systems, we support this measure as it
fills a critical gap in service to those veterans who truly need it. We
would urge, however, that VA and Congress provide strong oversight of
these programs to ensure that they really are meeting the needs of our
veterans, and that they are complying with all VA privacy and clinical
protocols.
We also support Titles III and IV of the legislation. They would
require an in-depth study of PTSD and substance use disorders and
extend VA's Special Committee on PTSD through the end of 2012. I would
also make a note of the meaningful change in section 401 of the bill,
which would add marriage and family counseling to the list of services
VA should offer. As we have seen with the current conflict, the range
of mental health services veterans suffer from do not just affect the
individual, but also their families. We must do better, if not just to
help those family members who suffer silently outside of VA's normal
range of treatment, but also to improve the home life of those veterans
suffering, giving them stability and comfort in their home life. That
stability is critical to the effective treatment of the veteran, and
anything we can do to improve upon it, is something we must do.
We thank Ms. Berkley and the members of this Subcommittee who have
signed on to this bill for supporting it, and we would urge its
approval. It could really have a meaningful impact upon thousands of
veterans suffering from the invisible wounds of war.
H.R. 4107
The VFW is pleased to offer our strong support for this
legislation, which would expand and improve upon the health care
services provided to women veterans. Female veterans from OEF/OIF are
experiencing many types of conflict that previous generations did not.
They are involved in a conflict with no true frontline and in a high-
stress situation with almost no relent.
The difficulties they face, and the level of reported mental health
issues that all OEF/OIF veterans have is itself a challenge for VA. It
is essential that VA's strategies not be a one-size-fits-all approach,
but one that adapts and provides our men and women with tailored
programs to give them every chance to return to civilian life fully
healthy. This is especially so for our women veterans, many of whom are
facing unprecedented levels of stress and conflict, and who, when they
return, enter a VA that is predominantly used to caring for male
veterans.
VA has made great strides in the care provided to women veterans,
but they can definitely do more. The Veterans Emergency Care Fairness
Act would push VA even further along, and would address some of the
most critical issues our female veterans face.
Title I of the bill would authorize a number of studies and
assessments as to VA's capacity for care, but also for what the future
needs of women veterans will be. Section 101 would create an essential
long-term epidemiological study on the full range of health issues
female OEF/OIF veterans face. This is critical because it is uncharted
territory. With increasing numbers of women veterans in a hostile
combat zone, there are higher rates of exposures and incidents that
must be studied so that we know what health care issues will come up in
the short- and long-term. There is much we do not know, and lots of
essential information that is necessary to study to ensure that VA is
meeting their full needs.
Section 102 would require VA to study any potential barriers to
care faced by women veterans to determine any improvements that VA must
make so that women veterans can access the care to which they are
entitled. This is especially true of those women veterans who choose
not to use VA care. Is it because of a stigma associated with VA, a
previous bad experience or other reasons? To better prepare for the
future, VA must know the answers to these questions and we strongly
support this study. Along those same lines, section 103 would require
VA to develop an internal assessment of the services it provides to
women veterans, as well as plans to improve where it finds gaps. We,
too, welcome this assessment.
We fully support the sections contained in Title II of the
legislation, which deal with the improvement and expansion of health
care programs for women veterans. We especially appreciate the addition
of two recently separated female veterans to the VA Advisory Committees
on Women Veterans and Minority Veterans.
The VFW supports section 204, which would create a pilot program to
provide childcare for women veterans receiving health care through VA.
This is a terrific idea, which has the potential to eliminate a barrier
for care, especially for single mothers. We note, however, that there
are also a number of single fathers who would also benefit from the
pilot program, but would be prevented from using these child care
services under the definition of ``qualified veteran'' in section
204(a)(3).
The VFW thanks Ms. Herseth Sandlin and Ms. Brown-Waite for the
introduction of this important bill, and we would urge the Committee to
approve it because of the difference it could make for our women
veterans today, but also for long into the future.
H.R. 4204
The VFW supports the ``Veterans Suicide Study Act,'' legislation
that would require VA to determine the number of veterans who have
committed suicide over the last decade.
VA has made improvements to its suicide prevention programs,
improving training for VA staff and employees, and raising awareness of
the seriousness and importance of this issue. VA has established a
national suicide prevention hotline, and hired suicide prevention
coordinators at its medical centers.
Nobody knows the true number of veteran suicides, for a variety of
reasons, but even just one loss is a tragedy. VA's Epidemiology Service
is using rates from previous conflicts to estimate the rate of suicide
among OEF/OIF veterans. Although this may provide VA with an acceptable
starting point, hard data is going to be much more valuable with VA's
efforts to provide truly effective mental health coverage and to
improve its suicide prevention efforts.
Recent studies have shown a demonstrable link between exposure to a
combat zone and the risk of suicide, most notably in the November 2007
Institute of Medicine report on ``Physiologic, Psychologic and
Psychosocial Effects of Deployment-Related Stress.''
While this legislation would not lead to the direct treatment and
care of more veterans, the numbers and information collected by this
report could help VA and DoD get an accurate picture as to the scope of
the problem, and uncover cases and examples that might otherwise go
hidden. With the seriousness of this problem and the attention we must
pay to it, more information is certainly better. The more information
available to VA, DoD and Congress, the more prepared we all are to live
up to this Nation's responsibilities to care for her veterans. Suicide
among our veterans, especially those newly returning from combat, is a
tragedy, and we owe it to our heroes to do everything in our power to
prevent it from ever occurring.
H.R. 4231
The VFW supports this legislation, which would create a pilot
program to provide mental health counseling at non-VA facilities for
veterans who live in rural areas. One of the challenges VA has faced
since OEF/OIF began has been on how to best care for those veterans who
live in more remote areas, especially with the intensive levels of care
some of their illnesses and disabilities require.
This is an issue with no true satisfactory answer, especially as we
would prefer that VA be able to provide a high level of care to all
eligible veterans. As we have seen with many veterans who live in rural
areas, this is not always feasible. Veterans living far away from VA
clinics or medical centers simply have a more difficult time receiving
the same level of care that a veteran who lives in a town with a clinic
receives. The Rural Veterans Health Care Access Act recognizes this and
takes steps to improve their access to care.
To achieve this, it creates a 5-year pilot program that allows VA
to provide 6-month vouchers for enrolled OEF/OIF veterans who live at
least 30 miles from a VA facility that provides full-time mental health
services to receive care with private mental health counselors. We are
pleased to see that the counseling services include family counseling,
since they often suffer from the effects of the veteran's mental health
illness, and counseling can increase family stability, which is often a
critical component in the rehabilitation of these complex mental health
illnesses.
While ideal circumstances would have VA providing this level of
care to all eligible veterans, we understand the difficult situation
today's veterans are in. We would hope that VA not rely on contract
care to provide these specialized services and that the Department
continue to make attempts to provide these services, but in the
meantime, we cannot afford to leave these brave men and women waiting.
This is the least we can do to make them whole, and to ease their
transition back into civilian life.
As with our support for H.R. 4053, however, we would urge vigorous
oversight of this contract authority to determine whether veterans are
truly being helped and that the services VA pays for live up to VA's
clinical, safety and privacy standards.
Mr. Chairman, this concludes my testimony. I again thank you for
the opportunity to present the VFW's views and I would be happy to
answer any questions that you or the members of the Subcommittee may
have.
Prepared Statement of Richard F. Weidman,
Executive Director for Policy and Government Affairs,
Vietnam Veterans of America
Good morning, Mr. Chairman, Ranking Member Brown-Waite, and
distinguished members of the Subcommittee on Health. Vietnam Veterans
of America (VVA) appreciates the opportunity to testify before you on
the eight bills under consideration by the Subcommittee. I hope our
comments and insights will prove of value to you.
H.R. 2790, Amends title 38, United States Code, to establish the
position of Director of Physician Assistant Services within the office
of the Under Secretary of Veterans Affairs for Health. Physician
assistants are an extremely valuable resource for veterans who use the
VA health care system. To ensure that they are properly educated and
trained, and that they are appropriately utilized in the programs and
initiatives of the Veterans Health Administration, should be
facilitated with the establishment of such a position. Veterans will be
well served if the directorship is filled with a physician assistant
with uncommon vision and competence.
For too long the Veterans Health Administration (VHA) has
essentially been allowed to thwart the clear intent of the Congress,
and refuse to properly utilize physicians assistants in the mix of
vitally needed health care practitioners at VHA. It is worth noting
that the VA is the largest single federal employer of physician
assistants (PAs) with the exception of the military, with approximately
1,574 full-time PA FTEE positions. The VA has utilized PAs since 1969,
when the profession first started. However, since the Veterans Benefits
and Health Care Improvement Act of 2000 (P.L. 106-419) directed that
the Under Secretary of Health appoint a PA advisor to his office, VHA
has continued to assign this duty as a part-time field FTEE, as
collateral administrative duties to their clinical duties. VVA has
requested for the past six years that this be a full-time FTEE within
VHA for six years. Most other veterans' service organizations have made
similar requests.
All such requests have been ignored, and generally met with what
can frankly only be characterized as condescending disdain if indeed
not outright derision. VVA points out that this is just one of many
instances where the VA ignores the clear will of the Congress, and even
``black letter law'' directing them to do something, such as complete
the National Vietnam Veterans Longitudinal Study (NVVLS).
This is the fourth Under Secretary of Health who has refused to
establish this important FTEE as full time. This is the case despite
numerous requests from members of Congress, the VSOs, and professional
PA associations. The current Under Secretary has maintained this
position as a part-time, field-based position with a very limited
travel budget, and no discernible access to policymaking. During the
time that the current part-time PA advisor was authorized the number of
PAs have grown from 1,195 to approximately 1,600 today. Despite the
growth, a 34% increase, this important clinical representative has not
been appointed to any of the major health care VA strategic planning
committees, has been ignored in the entire planning on seamless
transition, polytrauma centers, traumatic brain injury planning and
staffing, and has not been allowed to participate in rural health care
or been utilized for emergency disaster planning.
This is despite the facts that 36% of all VA employed PAs are
veterans or currently serve in the National Guard or military reserves.
These veterans who are also PAs could bring vital experiences with
highly dangerous situations to new initiatives for improving veterans'
health care access, particularly in disaster response planning and
execution.
PAs in the VA health care system were vital primary care providers
for millions of veteran encounters in each of he past few years, and
PAs work in ambulatory care clinics, emergency medicine, and in 22
other medical and surgical subspecialties. VVA believes that PAs are a
vital part of VA health care delivery. The PA Director must be included
in VA Headquarters Patient Care Services, be full-time FTEE in
Washington, DC. This needs to be just the first step toward the VHA
changing the corporate culture that does not value PAs on a par with
Nurse Practitioners. We urge Congress to enact H.R. 2790 and fund this
FTEE within the VHA budget for FY 2009 and to ensure the position is in
Washington, DC.
Frankly, what VVA believes the Congress and the VA should do in
addition to prompt enactment and implementation of this bill regarding
physician assistants is: (1) Take steps to dramatically change what is
often a hostile work environment for PAs in the VHA; and (2) Ensure
that the scope of practice of PAs in the VA is at least as extensive as
it is in the Armed Services; and (3) Create a scholarship program for
returning Navy corpsmen (and women) and Army Medics to become PAs in
the VA system, with active recruiting of the separating and
demobilizing Medics, and with partnering agreements with affiliated
institutions. The seasoned expertise of these returning corpsmen
(women) and Medics could be vital in the future to assist VA to deliver
more effective and efficient services, especially in rural areas. VVA
strongly supports the bill as written.
H.R. 3458, Directs the Secretary of Veterans Affairs to carry out a
pilot program on the provision of traumatic brain injury care in rural
areas. While the goal of this bill, which calls for a pilot program, is
laudable, we believe that the best treatment for TBI is to be had in
the VA's polytrauma centers of excellence. Additional treatment ``back
home'' ought to be done by clinicians who can communicate with their
counterparts at these polytrauma centers.
Frankly, we need to change the current paradigm of service for TBI
and other profoundly wounded veterans. While there were many problems
with the VA care received by seriously wounded veterans during Vietnam,
when you were in the VA hospital you were literally IN the VA hospital.
That is no longer the case, as most of the health care at VA is
delivered on an outpatient basis, even to those who cannot drive
because of TBI or other wounds. The current model, which came out
during a recent symposium with prosthetics, depends on an intact
nuclear family with a spouse (or parent) who can take the veteran to
the many medical appointments he or she may have in a given week.
However, it is not always the case that there is an intact nuclear
family and a stable home situation near to the needed medical services
needed by that particular veteran to help shoulder this travel expense
and burden with the new veteran. The ``freeze'' and rule at VA nursing
homes and domiciliary facilities leave them unable to adequately
respond to this need. Perhaps there is need for low cost veterans
housing units that are near VA medical centers or even constructed on
their grounds if there is adequate land may be part of the answer. At a
hearing before the House Committee on Financial Services last month
there appeared to be some interest in such cooperative models by the
Honorable Maxine Waters, a former member of this distinguished panel,
in crafting legislation that would create such housing. Perhaps now is
the time to move quickly on the possibility of such a new paradigm that
would assist new veterans with TBI or other problems, but would also
solve similar transport problems of other deserving veterans who are
dependent on the ongoing treatment modalities at a VHA facility.
We would caution about the use of outside providers of care for
this increasingly common wound of war. While it does make sense to
contract with non-VA clinicians in areas where no VA medical center or
outpatient clinic is convenient for a patient, that outside provider
must be certified as able to care for those with this unique wound. We
do not believe that such clinicians are going to be easy to find.
Further, as VA has shown with the mishandling of the inaptly named
``Project HERO'' the VHA must be watched like a hawk to keep them from
distorting a good idea that makes sense.
Having noted all of the above, VVA still favors enactment of this
bill to create such a pilot program, but urge that you amend the bill
to require frequent substantive input by the VSOs, frequent reporting
to this Committee, and other accountability mechanisms to keep this
good idea on track toward something that will strengthen the matrix of
services for these deserving veterans.
H.R. 3819, Veterans Emergency Care Fairness Act of 2007, amends
title 38, United States Code, and requires the Secretary of Veterans
Affairs to reimburse veterans receiving emergency treatment in non-
Department of Veterans Affairs facilities for such treatment until such
veterans are transferred to Department facilities, and for other
purposes. VVA strongly believes that veterans who receive emergency
treatment in non-VA facilities until they can be transferred to a VA
facility should be reimbursed for their out-of-pocket expenses. This
should not be the onerous, often ugly, and lengthy process that it
often is today, and which usually results in the veteran being stuck
with the bill for this emergency care. If they are not among the 1.8
million veterans who do not have health insurance, the VA should be
able to--and does--bill their insurance carrier, which is right and
proper.
VVA supports the bill as written.
H.R. 4053, the Mental Health Improvements Act of 2007, to improve
the treatment and services provided by the Department of Veterans
Affairs to veterans with post-traumatic stress disorder and substance
use disorders, and for other purposes is one of the most important
bills for your consideration. As more and more troops, some disturbed,
others shattered by their wartime experiences come home, and it is
patently and painfully obvious that neither the Department of Defense
nor the VA have enough medical professionals on staff to meet their
needs. The British Medical Journal released a study led by DoD
researchers this past Tuesday that says that at least 1 in 9 returnees
have problems with PTSD. Earlier DoD studies fount a higher rate.
VVA has been pointing out the deficiencies in the number of mental
health professionals at the Veterans Health Administration (VHA) for
almost 10 years, and while there has been quite a bit of progress in
the level of staffing in the past two years, they are still not where
they should be, particularly in as to the substance abuse staff.
Further most VAMC need more full-time mental health professionals as
team members on the primary care teams (as distinct from the mental
health clinic or the PTSD teams). We still hear often about veterans
referred to the mental health clinic or the PTSD team at a VA hospital,
only to be referred back to the primary health care team because the
mental health diagnosis is not their primary diagnosis, and the mental
health clinic does not have the resources to properly serve them.
DoD must be taken to task for having discharged some 28,000
servicemembers for ``personality disorders'' which allegedly pre-
existed their entrance into the U.S. military. To send them off to war,
and then to cut them loose because of some phantom ``preexisting
condition,'' is damnable. It violates the covenant made with these men
and women when they pledged life and limb in defense of the
Constitution of the United States. They need the help of health care
professionals, not the disapprobation of their superiors and the
termination of their enlistment and all the mental baggage that goes
along with it. Further, the military has done really very little on
their pledge to change the corporate culture that punishes those who
admit to problems with PTSD symptoms to one that gets those soldiers
(and their families) much needed help.
VVA went to see Assistant Secretary of Defense for Health about
three weeks before the war started to urge they do a better pre-
deployment health assessment, including a mental health workup. We also
urged that they move to be ready for significant PTSD problems, and
that they set up nonpunitive modalities whereby war fighters could get
help without effectively ending the their military career. Dr.
Winkenwerder essentially was dismissive of all we had to say, and
stated that they saw no need to change any of their policies.
Unfortunately, we were prescient of what was to come, and the
deplorable situation that still exists today. As we are all aware,
DoD's mistakes and nonperformance becomes the problem of the VA as soon
as the servicemember is no longer on active duty.
This bill needs to dovetail with mental health initiatives taken by
the VA to ensure that there is no duplication of effort. More
importantly, its provisions must have the funding needed to be
effective. Anything less is unacceptable.
VVA requests that you modify the provision that mandates the
Special Committee on PTSD to require that this Committee meet in
public, at least to the VSOs and other key stakeholders. Our preference
would be to require that they have consumer representatives meet with
the Committee regularly as well. The current Undersecretary refuses to
allow VSOs even to attend the Special Committee on PTSD meeting, and
continues to conduct their business in secrecy. When asked why his
response has been that they need to be able say things they might not
say in public. VVA's response has been and is that then they perhaps
should not be saying something that cannot stand the light of day.
In this same vein, VVA urges the Committee to require that the
Advisory Committee on (Serious) Mental Illness be public in the sense
that the constituent representatives and the VSOs be allowed to attend
the entire meeting, even if they are participants in the discussion for
only a portion of the multi-day meeting. This Committee began to
conduct much of their business in secrecy during the reign of Dr.
Jonathan Perlin after he summarily fired the most senior and respected
members of that body in what is still known in VHA as the ``Friday
Night Massacre.'' We ask that the Congress require this Committee
return to the way of business that is in keeping with an open and
democratic government.
With the modifications noted, VVA favors passage of this bill.
H.R. 4107, the Women Veterans Health Care Improvement Act, amends
title 38, United States Code, to expand and improve health care
services available to women veterans, especially those serving in
Operation Iraqi Freedom and Operation Enduring Freedom, from the
Department of Veterans Affairs, and for other purposes should go a long
way toward enhancing the health care services offered to--and needed
by--women veterans. Women now constitute 16-18 percent of our Armed
Forces. They are being killed and maimed in record numbers. It is vital
for the VA to gear up to meet their needs now and over the coming
decades.
Beginning a long-term study of the health status of women who
served in Afghanistan and Iraq should be an invaluable tool in enabling
the VA to assess current needs and anticipate future health care needs.
And make no mistake: The PTSD that affects women is not a carbon copy
of that which takes over the psyche of their male counterparts. There
are other psychological ramifications that we are only now beginning to
comprehend.
One would hope that VAMC directors, seeing a spike in the numbers
of women veterans seeking health care, would gear up to meet their
needs. They should not have to be prodded by legislation. Several years
ago, Sanford Garfunkel, who then was the director of the VAMC in
Manhattan, saw an influx of veterans with HIV and full-blown AIDS. He
secured the funding, necessary approvals, and established the first
ward for veterans with these then-fatal conditions. We know there are
bright and committed medical center directors today who react to the
needs of their patients; we would hope that passage of this bill would
be of significant assistance to them.
At minimum every VA medical center facility should have a full-time
women veterans coordinator who sits on the policymaking council for the
hospital, and in the larger cities there should be a full free standing
women's clinic, such as is found at Washington, D.C. VAMC.
H.R. 4146, Amends title 38, United States Code, to clarify the
availability of emergency medical care for veterans in non-Department
of Veterans Affairs medical facilities. This just seems to make a lot
of sense. Amending section 1725(f)(1)(C) of title 38 by adding ``. . .
with the determination of whether the veteran can be so transferred to
be based both on the condition of the veteran and on the availability
of a bed in a Department facility that is no geographically
inaccessible to the veteran'' just makes sense. One has only to wonder
why such a provision needs to be added into law.
VVA supports the bill as written.
H.R. 4204, The Veterans Suicide Study Act, directs the Secretary of
Veterans Affairs to conduct a study on suicides among veterans is based
on two unfortunate realities, recognized by Congress: That suicide
among veterans is a serious problem; and that there is a lack of
information on the number of veterans who commit suicide each year.
Anecdotally, suicide by active-duty troops and recently separated
troops seems to be surging. DoD has tended to minimize the numbers,
tracking only those on active duty who take their lives. No one,
however, is tracking veterans who, months or years after they have
reentered the civilian world, are overcome by war-induced demons.
We doubt very much if truly accurate numbers can ever be arrived
at. But the VA--and DoD--really do need to try harder and not sniff
that the suicide of someone six months removed from Iraq can not be
attributed to his/her service over there.
H.R. 4231, The Rural Veterans Health Care Access Act of 2007,
directs the Secretary of Veterans Affairs to carry out a pilot program
to provide mental health services to certain veterans of Operation
Enduring Freedom and Operation Iraqi Freedom. VVA believes that this
bill needs some careful treading. While it is of the utmost importance
that mental health problems be dealt with forcefully and in a timely
manner, handing out vouchers for mental health services to veterans who
reside in rural America is not necessarily the way to go--unless there
is close communication with case managers and primary care clinicians
at VA clinics and medical centers.
Our concern is that outsourcing a lot of this care can only lead to
future difficulties if not carefully and closely monitored. And, to be
quite frank, we can envision scenarios in which VA managers, rather
than hiring the psychologists and psychiatrists they need, rather than
ensuring that the Vet Centers are adequately staffed, outsource mental
health to the detriment of veterans and their families. This must be
guarded against.
VA Vet Center Staffing and Suicide Prevention--VVA is very
concerned that the VA Vet Centers, operated by the Readjustment
Advisory Service, have not received additional staffing that is vitally
needed. The War Supplemental Appropriations bill enacted early last
March contained $17 million to hire an additional 250 full-time mental
health practitioners at the VA Vet Centers. These funds were not
released to the RCS until mid-August, when it was too late to even get
those staff on board before the end of the Fiscal Year, much less fully
spend the money on additional personnel. So they bought a new computer
system.
If the Congress wants to do something about the first line of
defense against suicide, then forcing the VHA to increase the staffing
of the VA Vet Centers is the single most effective action you can take,
as well as the most cost effective and cost efficient step you can
take. The Vet Centers are essentially the forward Aid stations to go
out and get the wounded and get them into the medical services and
treatment matrix. The Vet Centers see veterans of every generation who
initially would not go anywhere near the VA medical center with a
mental health or PTSD problem, for a variety of societal reason.
VVA thanks the Subcommittee for permitting us to present our views
on these vital issues here today. I will be happy to answer any
questions.
Prepared Statement of Gerald M. Cross, M.D., FAAFP,
Principal Deputy Under Secretary for Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here today to present the
Administration's views on eight bills that would affect Department of
Veterans Affairs (VA) programs that provide veteran health care
benefits and services. With me today is Walter Hall, Assistant General
Counsel.
H.R. 3819 Veterans Emergency Care Fairness Act of 2007
Mr. Chairman, the first bill I will discuss is H.R. 3819. VA
strongly supports this measure, which would amend sections 1725 and
1728 of title 38 to make mandatory, standardize, and enhance our
authority to pay expenses incurred when a covered veteran receives
previously unauthorized emergency treatment in a non-VA facility. Those
sections are currently discretionary (the Secretary ``may reimburse''
as opposed to ``shall reimburse''), cover different veteran
populations, and use different definitions of ``medical emergency.''
Currently, the Secretary may reimburse or directly pay the
reasonable value of non-VA emergency treatment of a service-connected
disability, a nonservice-connected disability aggravating a service-
connected disability, any disability of a veteran with a permanent and
total disability, or for a covered vocational rehabilitation purpose.
When such claims are filed, VA medical professionals must determine
whether there existed an actual emergency of such nature that delay in
obtaining treatment would have been hazardous to life or health.
Expenses incurred once the veteran had been stabilized and could have
been transferred safely to VA or another Federal facility may not be
reimbursed or paid.
The Secretary may also reimburse or pay for the reasonable value of
expenses incurred by a covered veteran for non-VA emergency treatment
where the treatment is sought for a non-service connected disability.
The statutory standard for determining whether the treatment was
emergent is whether a prudent-layperson would have thought it
reasonable to seek immediate medical attention. This prudent-layperson
standard means that if it turns out that the veteran's condition was
not an actual medical emergency, VA can still reimburse or pay the
expenses. This happens, for instance, when a veteran goes to the
nearest emergency room believing a heart attack is underway but a
severe case of heartburn is actually diagnosed. As with claims for
service-connected conditions, the Secretary is only authorized to
reimburse or pay for the reasonable value of the emergency treatment,
and the emergency is considered ended at the point the veteran could
have been transferred safely to a VA facility or other Federal
facility.
H.R. 3819 would make it mandatory for the Secretary to reimburse or
pay for the reasonable value of treatment for any veteran who meets
eligibility criteria and would standardize the programs by applying the
prudent-layperson definition of ``emergency treatment'' in both
situations. Most importantly, it would define ``emergency treatment''
as continuing until (1) the veteran could have been transferred safely
to a VA or other Federal facility, or (2) a VA or other Federal
facility agrees to accept such transfer if, at the time the veteran
could have been transferred safely, the non-VA provider makes and
documents reasonable attempts to transfer the veteran to a VA facility
or other Federal facility. While VA facilities work aggressively to
accept the transfers once an emergency is stabilized, there have been
cases where VA has been unable to find a facility that had the
resources needed to furnish the care required. In those rare cases, the
veteran may ultimately be liable for post-emergency costs, imposing a
serious monetary hardship. The bill would appropriately foreclose this
result.
Effective reimbursement or payment of emergency treatment has been
an issue of concern to the Department. H.R. 3819 appropriately resolves
important billing issues, properly placing the financial onus on the
Department to provide appropriate care either in the VA or Federal
system or at a non-VA facility.
VA determined funds were available within the FY2008 President's
Budget level for this expanded benefit.
As a technical matter, I would like to clarify that if a veteran
currently meets the eligibility criteria on which the reimbursement or
direct payment claim is based, VA invariably pays the claim. Thus,
changing the Secretary's authority from ``may'' to ``shall'' for
purposes of both types of claims would have no practical effect.
Nevertheless, we do not object to such a change.
H.R. 4146 Emergency Medical Care for Veterans in Non-VA Facilities
H.R. 4146 would also amend section 1725 of title 38 to make clear
that the determination as to whether a veteran can be transferred
safely to a VA or other Federal facility is to be based both on the
condition of the veteran and on the availability of a bed in a
Department facility that is not geographically inaccessible to the
veteran.
We favor the approach in H.R. 3819, which would make the same
definition of ``emergency treatment'' apply to claims filed pursuant to
both section 1725 and 1728. H.R. 4146 would amend only section 1725. As
a result, a greater benefit (i.e., VA reimbursement or payment of non-
VA emergency treatment up until the point in time a VA bed is available
for the eligible veteran) would be provided to veterans with non-
service connected disabilities than is available to veterans under
section 1728 for service-connected disabilities, a discrepancy that
cannot be justified. We therefore prefer the standardization of terms,
and increased consistency in application, that H.R. 3819 would provide.
H.R. 4053 Mental Health Improvements Act of 2007
Title I. Substance Use Disorders and Mental Health Care
H.R. 4053 is the companion bill to S. 2162, on which the Department
testified before the Senate Committee on Veterans' Affairs this past
October. While we appreciate the attention given to the critical issues
addressed in this bill, we cannot support its prescriptive approach of
mandating forms of treatment, treatment settings, and composition of
treatment teams.
Section 102 would require the Secretary to ensure that, at each VA
medical center and community-based outpatient clinic (CBOC), available
services would include, at minimum: short term motivational counseling,
intensive outpatient care, detoxification and stabilization, relapse
prevention, ongoing aftercare and outpatient counseling, opiate
substitution therapy, and pharmacological treatments aimed at reducing
cravings for drugs and alcohol. The Secretary could, however, exempt an
individual medical center or CBOC from providing any of the otherwise
required services, but the Secretary would have to report annually to
Congress on the facilities receiving an exemption, including reasons
for the exemption.
Section 103 would require the Secretary to ensure concurrent VA
treatment for a veteran's substance use disorder and co-morbid mental
health disorder by a team of clinicians and health professionals with
expertise treating substance use and mental health disorders, in
conjunction with other professionals as considered appropriate by the
Secretary.
Section 104 would mandate that the Secretary carry out a program to
enhance VA's treatment of veterans suffering from substance use
disorders and PTSD through a competitive allocation of funds to VA
facilities. Funding awarded to a facility would be used for purposes
specified in the bill, such as peer outreach programs through VA's Vet
Centers to re-engage veterans of Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) who miss multiple appointments for post-
traumatic stress disorder (PTSD) or a substance use disorder. These
peer outreach programs would need to be done in tandem with efforts of
CBOCs and PTSD and substance use disorder treatment teams in VA's
medical centers. Funds would also be used for collaboration between
VA's urgent care clinicians and substance use disorder and PTSD
professionals to ensure expedited referrals and for other specified
purposes.
Section 104 would further require the Secretary to allocate $50
million from appropriated funds available for medical care for each of
fiscal years 2008, 2009, and 2010 to fund these programs; the Secretary
would be required to submit a report to Congress within the first year
regarding the program and the facilities for which funding had been
allocated. The bill would require the total expenditure for PTSD and
substance use disorder programs to not be less than $50 million in
excess of a specified baseline amount. (The bill would define the
baseline as the amount of the total expenditures on VA's treatment
programs for PTSD and substance use disorders for the most recent
fiscal year for which final expenditure amounts are known, as adjusted
to reflect any subsequent increase in applicable costs to deliver those
programs.)
Section 105 would require the Secretary to establish not less than
six national centers of excellence on PTSD and substance use disorders,
to provide comprehensive inpatient treatment and recovery services to
veterans newly diagnosed with these disorders. Candidate sites would be
restricted to VA medical centers capable of treating concurrent PTSD
and substance abuse disorders and of providing inpatient care, and
located in a geographical area with a high number of veterans diagnosed
with both PTSD and substance use disorders. This provision would also
require the Secretary to establish a process to refer and aid the
transition of veterans from these national centers to programs
providing step down rehabilitation treatment.
Section 106 would require the Secretary, acting through the Office
of the Medical Inspector (OMI), to review all of VA's residential
mental health care facilities, including domiciliary facilities. The
OMI report must include a description of the care available in
residential mental health care facilities in each Veterans Integrated
Service Network; an assessment of the supervision and support provided
in the VHA residential mental health care facilities; the ratio of
staff members at each residential mental health care facility to
patients at such facility; an assessment of the appropriateness of
rules and procedures for the prescription and administration of
medications to patients in such residential mental health care
facilities; a description of the protocols at each residential mental
health care facility for handling missed appointments; and any
recommendations the Secretary considers appropriate for improvements to
residential mental health care facilities. The bill requires OMT to
submit to Congress a detailed report with these specified findings.
Section 107 would provide for Title I of this bill to be enacted in
tribute to Justin Bailey, an OIF veteran who died while under VA
treatment for PTSD and a substance use disorder.
VA does not support enactment of this title. Title I is overly
prescriptive and would attempt to mandate the type of treatments to be
provided to covered veterans, the treatment settings, and the
composition of treatment teams. Treatment decisions should be based on
professional medical judgments in light of an individual patient's
needs, and experienced health care clinicians and managers are in the
best position to decide how best to deliver needed health care services
at the local level. It is more consistent with the principles of
patient-centered medicine, as well as more efficient, to focus on
making these services available to patients who require them, as
opposed to requiring every VA facility to provide these services.
We are also concerned that section 104 would require all the
competitively funded peer outreach services to be furnished through
VA's Vet Centers. This would make Vet Centers reliant on the medical
centers to provide funding needed to meet the peer outreach
requirements of this program. Vet Centers generally receive their
funding apart from the medical centers. And we do not support section
105. VA has previously expressed its difficulties with the concept of
centers of excellence as opposed to the achievement of an overall
standard of delivery of excellent care on a national basis; this
provision is also overly restrictive and prescriptive. I refer you to
the concerns VA has previously expressed regarding disease-specific
treatment centers and models. Finally, section 106 would impose
extremely onerous and time-consuming requirements on the OMI, which
would overwhelm that office's capacity to meet its responsibility to
oversee and investigate the quality of care furnished in all lines of
service throughout the VA system--an absolutely vital function within
the Veterans Health Administration. To meet the mandate, the Department
would have to expand that office significantly. The OMI should be
focused on its general mission, not on the narrowly focused duties set
forth in section 106.
Title II. Mental Health Accessibility Enhancements
Section 201 of H.R. 4053 would require that, within six months
after enactment of the bill, the Secretary establish a 3-year pilot
program to assess the feasibility and advisability of providing
eligible OIF/OEF veterans, particularly those from the National Guard
or Reserve, with services including peer outreach and support,
specified readjustment counseling, and other mental health services.
Eligible veterans would include those who are enrolled in VA's health
care system and who, for purposes of the pilot program, receive a
referral from a VHA health professional to a community mental health
center or to a facility of the Indian Health Service (IHS).
In providing readjustment counseling services and other mental
health services to rural veterans lacking access to comprehensive VA
mental health services, section 201 would require the Secretary, acting
through the Office of Rural Health, to contract for those services with
community mental health centers (as defined in 42 CFR Sec. 410.2) and/
or IHS facilities.
Sites for the pilot must include at least two Veterans Integrated
Service Networks selected by the Secretary (VISNs). At least two of the
sites would have to be located in rural areas that lack access to
comprehensive VA mental health services. A participating community
mental health center or IHS facility would be required, to the extent
practicable, to provide readjustment counseling and other mental health
services through the use of telehealth services. It would also need to
utilize best practices and technologies and to meet any other
requirements established by the Secretary and would have to comply with
applicable VA protocols before incurring any liability on behalf of the
Department. It would further be required to provide clinical
information on each veteran treated, as required by the Secretary.
The Secretary would be required to carry out a national program of
training for (1) veterans to provide peer outreach and peer support
services under the pilot program; and required training for (2)
clinicians at community mental health centers or IHS facilities to
ensure they could furnish covered services in a manner accounting for
factors unique to OEF/OIF veterans' experiences, including combat and
military training experiences. This provision would also establish
detailed annual reporting requirements for participating centers and
facilities.
Mr. Chairman, all of these services are already available to OEF/
OIF veterans, including those who served in the National Guard or the
Reserves. No demonstrated need exists for the pilot program or these
additional authorities, which are duplicative of currently existing
authorities. It is also unclear to us how the peer outreach services to
be provided under section 201 relate to the peer outreach program that
would be established by section 104.
As to the requirement to contract with a community mental health
center or IHS facility, VA has previously expressed a concern that
imposition of such a requirement may inadvertently reduce the
opportunity for a veteran to receive care from the most highly
qualified contractor. Additionally, it is most often the case that when
VA lacks capacity to provide mental health services in a certain rural
area, the same situation exists for the community mental health centers
and IHS facilities. IHS facilities, staff, and other resources should
be focused on American Indians and Alaska Natives. VA and IHS have a
Memorandum of Understanding (MOU) that provides the appropriate
framework for cooperative ventures within the capacities of each of our
two agencies, using that MOU and our current flexibilities to contract
with the most appropriate provider when VA is not able to provide
necessary services is the most effective way of assuring that rural
veterans get the care they need.
Title III. Research
Section 301 of H.R. 4053 would require the Secretary, through the
National Center for PTSD, to carry out a program of research into co-
morbid PTSD and substance use disorder, including coordination of
research and data collection and dissemination. The bill prescribes
that the research address: co-morbid PTSD and substance use disorder;
systematic integration of treatment for the disorders; and development
of protocols to evaluate care of veterans with co-morbid disorders and
to facilitate the cumulative clinical progress of such veterans.
Section 301 would authorize $2 million to be appropriated for each
fiscal year 2008 through 2011 to carry out this program and
specifically require the funds be allocated to the National PTSD Center
in addition to any other amounts made available to it under any other
provision of law.
Section 302 would continue the Special Committee on PTSD (which is
established within VHA) through 2012; otherwise the Committee's mandate
would terminate after 2008. VA strongly supports continuing the Special
Committee.
With the exception of the extension of the Special Committee, VA
does not support the provisions in title III. VA is a world-recognized
leader in the care of PTSD and substance use disorders, particularly
when these conditions co-exist. Please note that the recent scientific
literature review by the Institute of Medicine did not find that VA's
treatments for PTSD other than Cognitive Processing Therapy (CP
Therapy) and Prolonged Exposure Therapy (EP Therapy) were not
efficacious; rather, the IOM concluded that the scientific literature
did not show that the other therapies used by VA met its standard for
unequivocally and conclusively demonstrating their efficacy in the
treatment of PTSD. The activities required by title III are also
redundant of VHA's ongoing efforts, particularly of the research
efforts being carried out by VA's National PTSD Center. We would
welcome the opportunity to brief the Committee on VA's achievements and
efforts in this area, along with the role of the Office of Mental
Health in overseeing the PTSD and substance abuse programs.
Title IV. Assistance for Families of Veterans
In connection with the family support services authorized in
chapter 17 of
title 38, United States Code (i.e., mental health services,
consultation, professional counseling, and training), section 401 would
amend the statutory definition of ``professional counseling'' to
expressly include ``marriage and family counseling.'' This provision
would also ease eligibility requirements for such services by
authorizing their provision when ``appropriate'' (as opposed to
``essential'') for a veteran's effective treatment and rehabilitation.
Section 401 provides for that these services to be available to family
members in VA medical centers, Vet Centers, CBOCs, or in other
facilities the Secretary considers necessary. Currently, these family
support services are restricted to care provided in inpatient care
settings.
Section 402 would require the Secretary to carry out, through a
non-VA entity, a 3-year pilot program to assess the feasibility and
advisability of providing ``readjustment and transition assistance'' to
veterans and their families in cooperation with Vet Centers.
Readjustment and transition assistance would be defined as preemptive,
proactive, and principle-centered, and would include assistance and
training for veterans and their families in coping with the challenges
associated with making the transition from military to civilian life.
This provision would require the pilot program be furnished pursuant to
an agreement between the Secretary and any for-profit or non-profit
organization the Secretary selects as having demonstrated expertise and
experience providing the designated services. The pilot program would
be carried out in cooperation with 10 geographically-distributed Vet
Centers, which would be responsible for promoting awareness of the
assistance available to veterans and their families through the Vet
Centers, the entity selected to conduct the pilot, and other
appropriate mechanisms. Section 402 would establish detailed reporting
requirements and authorize $1 million to be appropriated for each of
fiscal years 2008 through 2010 to carry out the pilot program. Such
amounts would remain available until expended.
VA does not support title IV. It is unclear how these
``readjustment and transition assistance'' services are intended to
differ from, or interact with, the readjustment counseling services and
related mental health services already available to veterans and their
families through our Vet Centers. The provision conflicts in many
respects with VA's existing authorities to provide readjustment
counseling and related mental health services and creates confusion,
especially regarding client outreach, in what is currently a highly
successful program. (Indeed, the 98-percent rate of client satisfaction
with the Vet Centers is the highest of all VA's programs.)
We also do not understand the implied need for use of a non-VA
organization for provision of these services. Vet Centers already
provide marriage and counseling services to family members as necessary
to further the veteran's readjustment. Let me assure you that, when
necessary, our Vet Centers readily contract with appropriate
organizations and providers to ensure veterans and their families
receive covered family support services. In sum, this provision would
not effectively enhance current authorities or Vet Center activities;
rather, we see that it has serious potential to create confusion and
disruption for both VA and our beneficiaries.
If the purpose of section 402 is to authorize readjustment and
transition assistance services for family members that are other than
those required for the veteran's successful readjustment, we would
object. In contrast to the situation with veterans, if during the
provision of readjustment counseling services, Vet Center staff
identify a family member's need for more complex mental health care
services or other medical care that is not in furtherance of the
veteran's recovery or readjustment, VA can neither refer the family
member to a VA facility for such care nor refer that family member to a
non-VA provider. Consequently, both our Vet Center staff and the
affected family member would be placed in an untenable position.
H.R. 4231 Rural Veterans Health Care Access Act of 2007
Mr. Chairman, VA strongly opposes H.R. 4231, which would require
the Secretary to implement a 5-year pilot program using a voucher
system to pay for mental health counseling at non-VA facilities for
eligible OEF/OIF veterans. Those eligible for this benefit are veterans
eligible to receive hospital care and medical services under section
1710 of title 38, United States Code, who also: served on active duty
in support of a contingency operation (as defined in section 101(13) of
title 10, United States Code); are diagnosed with a mental health
condition for which a certified mental health provider recommends
mental health counseling; and reside at least 30 miles from a VA
medical facility employing a full-time mental health professional.
Under the pilot program, the Secretary would compile and maintain a
list of mental health providers, including family counseling providers,
who agree to accept a voucher as payment in full for counseling
services furnished to the veteran bearing the voucher and to accept VA
payment at the rates specified in the bill. Providers would be required
to comply with all applicable VA protocols. H.R. 4231 would also permit
an eligible veteran to use these vouchers as payment in full for visits
to a family counseling provider (on the list) if a certified mental
health provider or the Secretary recommends that the veteran and the
veteran's family receive family counseling.
Once requested by an eligible veteran, the Secretary would be
required to issue a 6-month supply of vouchers within 30 days. An
additional 6-month supply of vouchers could be provided. To receive
payment under a voucher, following provision of mental health or family
counseling services, the provider would submit a voucher bearing the
signatures of the provider and the veteran.
Prior to the pilot program's expiration, the Secretary would be
required to conduct a study of its effectiveness and, based on that
study, recommend whether the program should be extended or expanded. If
the Secretary determines it should be extended or expanded, H.R. 4231
would authorize the Secretary to take such action.
VA strongly objects that as now drafted the bill would permit a
veteran with a diagnosed mental health condition to be eligible for
individual and family counseling services under the program based on a
non-VA provider's recommendation. Without exception, a recommendation
for a veteran's receipt of mental health counseling services by a non-
VA provider should be made only by the appropriate Department mental
health professional. This is necessary to ensure a continuum of care
for the veteran as well as appropriate coordination and oversight of
all the medical services furnished to the veteran. This would also
lessen any potential for self-referrals and conflicts of interest by
participating providers.
Second, this bill would result in fragmentation of care. Vouchers
would be available only for some types of care (mental health
counseling) but the bill does not address their possible need for
biomedically based mental health services and evidence-based
psychotherapy. H.R. 4231 could also lead to further barriers in
integrating mental health services with other components of care and to
the delivery of evidence-based interventions for mental health
conditions.
The Office of Rural Health (ORH) is currently collaborating across
VHA to develop policies and practices that expand and adapt current
initiatives, and to develop new models of care delivery that may be
most appropriate for rural veterans.
More importantly, ORH will leverage the VHA's capabilities to
develop partnerships with governmental and nongovernmental entities to
provide the best solutions to the challenges that rural veterans face
and enhance the delivery of care by creating greater access, engaging
in research, promulgating best practices and developing sound and
effective policies to support the unique needs of enrolled veterans
residing in geographically rural areas.
Lastly, we note the bill does not provide any criteria for
determining the need or scope for family counseling services, whereas,
it limits a veteran's eligibility to counseling services needed to
treat the diagnosed mental health condition.
We further note the distance requirement would not limit this
benefit to veterans residing in rural areas because those in many urban
settings would likewise meet this requirement.
H.R. 2790 Director of Physician Assistant Services
H.R. 2790 would re-title the position of VHA's ``Advisor on
Physician Assistants'' to ``Director of Physician Assistant Services.''
This change in position title would appear to raise the incumbent and
this discipline to the same level as VHA's other directors and lines of
service. The bill would also expand the statutory duties of the
position to require the incumbent to report to the Under Secretary for
Health on all matters relating to the education and training,
employment, appropriate utilization, and optimal participation of
physician assistants within VA programs and initiatives. Finally, it
would also require the incumbent to serve full-time and be located with
the VA Central Office.
The current field-based Advisor position was established in 2000
and is successfully meeting the bill's objectives. Nonetheless, we do
not object to the change in position title, although we note that
physician assistant services do not constitute an actual service line.
We do object to the provision in the bill that would restrict the locus
of the position to VA Central Office. VA derives significant benefits
from having the flexibility to use field-based clinicians in this and
similar positions. Often the best candidates for such positions do not
wish to give up their clinical duties entirely and relocate to
Washington. It is also valuable for us to keep this position as a dual,
as opposed to a full-time, role to enhance the incumbent's
effectiveness by maintaining a ``hands-on'' approach and frontline
perspective. We estimate the cost of converting this position to one
that is full-time would be $34,252 for fiscal year 2008 and $413,151
over a ten-year period.
H.R. 4204 Veterans Suicide Study Act
H.R. 4204 would require the Secretary to conduct a study to
determine the number of veterans who have committed suicide between
January 1, 1997, and the date of the bill's enactment. The study would
have to be carried out in coordination with the Secretary of Defense,
Veterans Service Organizations, and State public health offices and
veterans agencies. The bill would require the Secretary to submit a
report to Congress on his findings within 180 days of the bill's
enactment.
We do not believe the study required by this bill would generate
information that would further our understanding of how to effectively
screen and treat veterans who may be at risk of suicide. It would
merely provide us with the rates for this cohort of veterans. VA has
studied suicide rates for multiple cohorts of veterans and, through
such efforts, has already identified the major clinical risk factors
for suicide. (In fact, we recently completed such a study for OEF/OIF
veterans that we discussed at a recent hearing before the full House
Committee on Veterans' Affairs.) Using the data generated from those
studies, we have developed protocols and processes to mitigate those
risk factors. For these reasons, we do not support
section 103.
Further, certain requirements mandated by the bill make its
implementation not feasible. As now drafted, it would not afford VA the
flexibility needed to develop a thorough and useful study. To design
and carry out a study that is best designed to provide usable
information to address the issue of veteran suicide rates, we believe
the Secretary (not Congress) should determine the organization(s) with
which the Department should coordinate the study. For instance, CDC
currently studies suicide rates among the general population, while
VA's role has been to validate the information compiled by CDC.
Additionally the 180-day timeframe is not realistic, as there is
currently a 2-year time lag in the information released by CDC on
suicide rates. We would be glad to brief the Committee on study designs
we believe would be more feasible and would better serve its ends. We
estimate the cost of this bill to be $1,580,006 in fiscal year 2008 and
$2,078,667 over a 10-year period.
H.R. 3458 Pilot Program on Traumatic Brain Injury Care in Rural Areas
Mr. Chairman, H.R. 3458 would require VA to carry out a 5-year
pilot program to enhance care to veterans with traumatic brain injury
(TBI) in five rural States (selected by the Secretary) in consultation
with VA's Office of Rural Health. VA would be required to assign a VA
case manager to each VA patient diagnosed with TBI. The bill would
further direct the Secretary to take specific actions in the pilot
program States, including:
Providing training to the assigned case managers,
including coordinating with non-Department medical facilities, as
appropriate, for such training;
Determining an appropriate ratio of patients with TBI per
case manager to ensure proper and efficient treatment;
Seeking contracts with private health care providers in
any area where no VA medical facility is easily accessible to TBI-
diagnosed residents, with the independent contractors to be reimbursed
by VA; and
Providing updated information on the treatment of TBI to
such private health care providers as have contracted with VA under the
bill.
We do not support H.R. 3458 because it is not necessary. A number
of TBI initiatives have been developed and implemented by VA under
current authorities, including programs that address the issue of case
management. In determining to provide care directly or by contract, VA
considers not only local capacity and staffing issues but also the
needs of the individual veteran and his or her family.
In our view, the bill would also establish a troubling precedent by
establishing contract authority separate from our fee-basis contracting
authority in chapter 17 of title 38, United States Code, for the
treatment of a single condition/type of injury. These typically are
very complex medical cases involving co-morbidities. Treatment of TBI
and TBI related conditions cannot easily be singled out from other
conditions requiring simultaneous medical attention. That is, TBI
cannot be treated in a vacuum. For that reason the bill has potential
to fragment care for the veteran population that most needs to receive
its VA health care in a well-coordinated manner with continuous
monitoring and oversight. We also note the number of eligible veterans
covered by the bill is potentially great, because this bill is not
limited to TBI due to injuries sustained during service in combat
operations.
Since the time this bill was introduced on August 4, 2007, each VA
facility has put into place an OEF/OIF case management program for
severely injured OEF/OIF members. In October of 2007, VA established
the Care Management and Social Work Service to ensure that each VA
facility has an appropriate treatment team caring for these veterans
(to include a program manager, clinical case manager(s), transition
patient advocate, and a VBA OIF/OEF liaison). All enrolled severely
injured servicemembers receive screening for TBI, and any OEF/OIF
veteran who requests case management services may receive them.
H.R. 4107 Women Veterans Health Care Improvement Act
Title I. Studies and Assessments of Department of Veterans Affairs
Health Services for Women Veterans
In general, Title I of H.R. 4107 would require VA to conduct a
number of studies related to health care benefits for women veterans.
More specifically, section 101 would require VA, in collaboration with
VHA's War-Related Injury and Illness Study Centers, to contract with
one or more qualified entities or organizations to conduct an
epidemiologic cohort (longitudinal) study on the health consequences of
combat service of women veterans who served in OEF/OIF. The study would
need to include information on their general, mental, and reproductive
health and mortality. The bill would require VA to use a sufficiently
large cohort of women veterans and require a minimum follow-up period
of ten years. The bill also would require VA to enter into arrangements
with the Department of Defense (DoD) for purposes of carrying out this
study. For its part, DoD would be required to provide VA with relevant
health care data, including pre-deployment health and health risk
assessments, and to provide VA access to the cohort while they are
serving in the Armed Forces.
Section 102 of the bill would require VA to contract with a
qualified independent entity or organization to carry out a
comprehensive assessment of barriers encountered by women veterans
seeking comprehensive VA health care, especially for those who served
in OEF/OIF. In carrying out this study, the bill recommends VA survey
women veterans who seek or receive VA health care services as well as
those who do not. Section 102 would also set forth specific elements to
be researched as part of the study. They include the following:
Perceived stigma with respect to seeking mental health
care services.
Driving distance or availability of alternate
transportation to the nearest appropriate VA facility on access to
care.
Availability of childcare.
Acceptability of integrated primary care, or with women's
health clinics, or both.
Comprehension of eligibility requirements for, and the
scope of services available under, such health care.
The quality and nature of the reception by providers of
such health care and their staff of the veteran.
The perception of personal safety and comfort of women
veterans in inpatient, outpatient, and behavioral health facilities of
the Department.
Cultural sensitivity of health care providers and staff
to issues that particularly affect women.
Effectiveness of outreach for health care services
available to women veterans.
Other significant barriers identified by the VA
Secretary.
Once the assessment is completed, the Secretary would be required
to ensure the head of the Center for Women Veterans and the Advisory
Committee on Women Veterans (as well as any other pertinent VA program
offices) review the results of the study and submit their own findings
with respect to it. The Secretary would need to include these findings
in the Congressional report required under this section.
Section 103 would require VA to conduct a comprehensive assessment
of all VA health care services and programs for women veterans. In
particular, the assessment would need to address specialized programs
for women with PTSD, homeless women, women requiring care for substance
abuse or mental illnesses, and those requiring pregnancy care. In
conducting this study, VA would be required to determine whether
effective health care services, including evidenced-based health care
services, are readily available to and easily accessed by women
veterans in areas of health promotion, disease prevention and health
care. The determination would need to be based on the following
factors: frequency with which such services are available and provided;
demographics of the women veterans population; sites where such
services are available and provided; and whether, and to what extent,
waiting lists, geographic distance, and other factors obstruct the
receipt of any of such services at any such site.
In response to the comprehensive assessment, section 103 would
further require VA to develop a program to improve the provision of
health care services to women veterans and to project their future
health care needs (including mental health care) and, particularly,
those of women serving in the OEF/OIF combat theaters. In so doing, VA
would have to identify the services available under each program at
each VA medical center and the projected resource and staffing
requirements needed to meet the projected workload demands.
Section 103 would also require VA to submit, not later than one
year after the bill's enactment, a report to the Congress on the
conduct of this assessment. The Comptroller General of the United
States would then be required to review VA's report and to submit to
Congress its own report on the Department's findings, together with any
recommendations for administrative or legislative action.
Mr. Chairman, we do not believe section 101 is needed because a
longitudinal study is already underway. Therefore, VA does not support
this provision. For several years veterans, VA, and Congress have been
concerned with identifying possible war-related illnesses among
returning women veterans, including adverse effects on reproductive
health. To that end, in 2007, VA initiated its own 10-year study, the
``Longitudinal Epidemiologic Surveillance on the Mortality and
Morbidity of OIF/OEF Veterans Including Women Veterans.'' Several
portions of the study mandated by section 101 are already incorporated
into this project; however, to comply fully, we will need to increase
the number of women veterans in the original longitudinal study. We
already have a proposal before the Under Secretary for Health to adjust
the number of study participants accordingly.
Mr. Chairman, section 101(c) of H.R. 4107 would be objectionable
because it requires the DoD to provide health data on active-duty
women, as well as ``access to the cohort of such women while serving in
the Armed Forces.'' This provision could require active-duty women to
participate in a VA survey while still in the military. It also could
require the DoD to provide private medical information before
separation.
Similarly we do not believe section 102 is necessary because a
similar comprehensive study is already underway. VA contracted for a
``National Survey of Women Veterans in FY 2007-2008,'' which is a
structured survey based on a pilot survey conducted in VISN 21. This
study is examining barriers to care (including access) and includes
women veterans of all eras of service. Additionally, it includes women
veterans who never used VA for their care and those who no longer
continue to use VA for their health care needs.
Section 103 would require a very complex and costly study. While we
maintain data on veteran populations receiving VA health care services
that account for the types of clinical services offered by gender, we
lack current resources to carry out such a comprehensive study within a
one-year timeframe. We would therefore have to contract for such a
study with an entity having, among other things, significant expertise
in evaluating large health care systems. This is not to say that such a
comprehensive assessment is not needed and we recognize there may well
be gaps in services for women veterans, especially given that VA
designed its clinics and services based on data when women comprised a
much smaller percentage of those serving in the Armed Forces. (Since
the fifties, the number of women veterans using VA services has
averaged between 3-5% of all veterans. With women now representing 5%
of all veterans using VA, and 38.9% of OEF/OIF returning women veterans
using VA for their health care needs, it is incumbent on us to identify
gaps in services and in availability of gender-related services.) VA's
Strategic Health Care Group for Women Veterans already studies and uses
available data and analyses to assess and project the needs of women
veterans for the Under Secretary for Health. The study required by
section 103 would unacceptably divert significant funding from direct
medical care.
We estimate the costs of section 101 to be $2,327,503 in fiscal
year 2008 and $10,857,000 over a ten-year period. We estimate no costs
for section 102 because VA's own comparable study is underway, with
$975,000 in funding committed for fiscal years 2007 and 2008. Section
103 would have a cost of $4,354,000 in fiscal year 2008.
Title II. Improvement and Expansion of VA Health Care Programs for
Women Veterans
Section 201, titled ``Improvement of Sexual Trauma Care Programs of
the Department of Veterans Affairs,'' would require VA to train all
mental health professionals who provide services to veterans under that
program and to ensure such training is done in a consistent manner that
includes principles of evidenced-based treatment. Section 201 would
also require VA to train primary care providers in screening and
recognizing the symptoms of Military Sexual Trauma (MST) and to ensure
procedures exist for prompt referral of these veterans to appropriate
mental health professionals. The provision recommends that VA's care
and services for MST include the services of therapists who are
qualified to provide counseling and who demonstrate an understanding of
the burden experienced by former service members who experience both
combat and MST.
Section 201 would also require VA to establish staffing standards
used at VA health care facilities for full-time equivalent employees
trained to provide treatment for conditions related to MST. These
standards would need to ensure availability of services, and access to
MST treatment, for all veterans seeking this care. This provision would
also establish detailed reporting requirements for the Department.
We do not support the training-related requirements of section 201
because they are not necessary. In Fiscal Year 2007, VA funded a
Military Sexual Trauma Support Team, whose mission is, in part, to
enhance and expand MST-related training and education opportunities
nationwide. VA also hosts an annual four-day long training session for
30 clinicians in conjunction with the National Center for PTSD, which
focuses on treatment of the after-effects of MST. VA also conducts
training through monthly teleconferences that attract 130 to 170
attendees each month. Recent topics included overviews of several
commonly used evidence-based treatment protocols (e.g., protocols for
CP Therapy, PE Therapy, and Acceptance and Commitment Therapy). VA has
also recently unveiled the MST Resource Homepage, a Web page that
services as a clearinghouse for MST-related resources such as patient
education materials, sample power point trainings, provider educational
opportunities, reports of MST screening rates by facility, and
descriptions of VA policies and benefits related to MST. It also hosts
discussion forums for providers. In addition, VA primary care providers
screen their veteran-patients, particularly recently returning
veterans, for MST, using a screening tool developed by the Department.
We are currently revising our training program to further underscore
the importance of effective screening by primary care providers who
provide clinical care for MST within primary care settings.
We object strongly to the provision in section 201 that would
require VA to establish staffing standards for this program. Staffing-
related determinations must be made at the local level based on the
identified needs of the facility's patient population for MST treatment
and services, workload, staffing, and other capacity issues. Imposition
of national staffing standards would be an utterly inefficient and
ineffective way to manage a health care system that is dynamic and
experiences continual changes in workload, utilization rates, etc.
Section 202 would require VA, through its National Center for PTSD,
to develop and implement a plan for developing and disseminating
information regarding effective treatments, including evidence-based
treatments, for women veterans with PTSD and other co-morbid
conditions. The plan would need to include a proposed timetable for the
dissemination to all VA facilities, but in no case could dissemination
occur later than one year after the bill's enactment. Section 202 would
also require the plan to include any proposed additional resources
needed to provide MST training and MST counseling and treatment. The
measure would establish detailed reporting requirements, as well.
VA does not support section 202 because it is duplicative of
activities already underway by the Department. VA is strongly committed
to making state-of-the-art, evidence-based psychological treatments
widely available to veterans and this is a key component of VA's Mental
Health Strategic Plan. We are currently working to disseminate
evidence-based psychotherapies for a variety of mental health
conditions throughout our health care system. There are also two
programs underway to provide clinical training to VA mental health
staff in the delivery of certain therapies shown to be effective for
PTSD, which are also recommended in the VA/DoD Clinical Practice
Guidelines for PTSD. Each training program includes a component to
train the professional who will train others in this area, to promote
wider dissemination and sustainability over time.
Section 203 would require VA to conduct a study of the Vet Centers'
capacity to provide services for women veterans and to determine their
capacity to provide a sufficient scope and intensity of services. Once
completed, the Secretary would have to develop a plan to ensure that
adequate counseling and mental health services for women veterans are
available at each Vet Center, taking into account their specialized
needs.
We do not support section 203 because it is not necessary and is
duplicative of VA's ongoing activities in this area. VA's Vet Center
program is one of VA's best-received programs as it currently exists,
and it already provides the services sought by this subsection. We
would be glad to brief the Committee on all of our activities,
particularly our extensive outreach efforts and the significant
expansion now underway to increase capacity (both in terms of staff and
new facilities).
Section 204 would require VA, not later than six months after the
bill's enactment, to carry out a two-year pilot program to furnish
childcare services (directly or indirectly) to eligible women veterans
receiving certain services through the Department. Sites for the pilot
program must include at least three VISNs. Child care could only be
provided for the period of time that the eligible veteran receives
covered services at a Department facility and is required to travel to
and from the facility for those services. Eligible veterans would
include women veterans who are the primary caretaker of a child (or
children) and who are receiving one or more of the following health
care services: regular or intensive mental health care services, or
such other types of intensive health care services for which the
Secretary determines the provision of child care would improve access
to those services. Moreover, under section 204, VA could provide the
covered child care services through a variety of means, i.e., stipends
offered by child care centers (directly or by voucher system), the
development of partnerships with private agencies, collaboration with
other Federal facilities or program, or the arrangement of after school
care. Section 204 would authorize $1.5 million to be appropriated for
each year of the pilot and establish Congressional reporting
requirements.
VA does not support section 204. Although we understand that the
lack of available child care services can pose a barrier to access to
care for some of our veterans, providing child care services--either
in-house or through other arrangements--would divert funds and
resources from our primary mission of providing direct patient care. We
note that private health care facilities do not generally provide these
services. Section 204 also unjustifiably discriminates against male
veterans who, but for their sex, would otherwise meet the eligibility
criteria. We estimate the cost of section 204 to be $500,000 in fiscal
year 2008 and $2,500,000 in fiscal year 2009.
Section 205 would require VA to establish a two-year pilot program
to evaluate the feasibility and advisability of providing counseling
and transition adjustment assistance for newly separated women veterans
that is conducted in a group retreat setting for as long as the
Secretary deems is needed to be effective. Participation in the program
would be voluntary and would not require a referral from any provider.
Section 205 provides that the counseling services would be individually
tailored to the participants' specific needs, and they could include
some or all of the following types of counseling: mental health, family
and marital, role and relationship, substance use disorder, or other
counseling services determined to be necessary to assist the veteran
before final repatriation with her family. Section 205 would also
authorizes $2 million for each year of the pilot, and require VA to
submit a detailed report to Congress within six months of the pilot's
completion.
VA does not support section 205. We find the intent of the
legislation confusing in that it would require that counseling be at
the same time provided in a group setting but specifically tailored to
the individual needs of each participating veteran. We know that
counseling services provided in group therapy sessions are not
appropriate or effective for all veterans and/or certain mental health
conditions. Determination of the appropriate treatment milieu for each
veteran should be based on the clinical judgment of a trained VA
professional and should not be mandated--even as a pilot program.
Likewise, we object to the precedent of permitting patients to self-
refer for medical care. The need for these services should be made by
the appropriate VA professional who can ensure they are medically
appropriate and necessary. Moreover, the veterans participating in the
pilot may assume in error that their medical and counseling problems
can be completely resolved through this program with no need for future
VA services. We note that VA has a number of counseling and transition
adjustment programs underway to meet the needs of newly discharged/
separated women veterans.
Finally, section 206 would require the Department's Advisory
Committee on Women Veterans, created by statute, to include women
veterans who are recently separated veterans. It would also require the
Department's Advisory Committee on Minority Veterans to include
recently separated veterans who are minority group members. (It is
noted that section 206 contains a typographical error, as the Advisory
Committee on Minority Veterans was established by section 544 of title
38, United States Code, not section 542.) These requirements would
apply to committee appointments made on or after the bill's enactment.
We support section 206. Given the expanded role of women and
minority veterans serving in the Armed Forces, the Committees should
address the needs of these cohorts in carrying out their reviews and
making their recommendations to the Secretary. Having the perspective
of those who have recently separated would enable the Committees to,
among other things, project the future needs of these veteran groups.
This concludes my prepared statement. I would be pleased to answer
any questions you or any of the members of the Subcommittee may have.
Statement of American Academy of Physician Assistants
On behalf of the nearly 65,000 clinically practicing physician
assistants (PAs) in the United States, the American Academy of
Physician Assistants (AAPA) is pleased to submit comments in support of
H.R. 2790, a bill to amend title 38, United States Code, to establish
the position of Director of Physician Assistant Services within the
office of the Under Secretary of Veterans Affairs for Health. The AAPA
is very appreciative of Representatives Phil Hare and Jerry Moran for
their leadership in introducing this important legislation. The Academy
also wishes to thank Chairman Filner and Representative Berkley for
cosponsoring H.R. 2790.
AAPA believes that enactment of H.R. 2790 is essential to improving
patient care for our Nation's veterans, ensuring that the 1,600 PAs
employed by the VA are fully utilized and removing unnecessary
restrictions on the ability of PAs to provide medical care in VA
facilities. Additionally, the Academy believes that enactment of H.R.
2790 is necessary to advance recruitment and retention of PAs within
the Department of Veterans Affairs.
Physician assistants are licensed health professionals, or in the
case of those employed by the federal government, credentialed health
professionals, who:
Practice medicine as a team with their supervising
physicians.
Exercise autonomy in medical decisionmaking.
Provide a comprehensive range of diagnostic and
therapeutic services, including performing physical exams, taking
patient histories, ordering and interpreting laboratory tests,
diagnosing and treating illnesses, suturing lacerations, assisting in
surgery, writing prescriptions, and providing patient education and
counseling.
May also work in educational, research, and
administrative settings.
Physician assistants' educational preparation is based on the
medical model. PAs practice medicine as delegated by and with the
supervision of a physician. Physicians may delegate to PAs those
medical duties that are within the physician's scope of practice and
the PA's training and experience, and are allowed by law. A physician
assistant provides health care services that were traditionally only
performed by a physician. All States, the District of Columbia, and
Guam authorize physicians to delegate prescriptive privileges to the
PAs they supervise. AAPA estimates that in 2007, approximately 245
million patient visits were made to PAs and approximately 303 million
medications were prescribed or recommended by PAs.
The PA profession has a unique relationship with veterans. The
first physician assistants to graduate from PA educational programs
were veterans, former medical corpsmen who had served in Vietnam and
wanted to use their medical knowledge and experience in civilian life.
Dr. Eugene Stead of the Duke University Medical Center in North
Carolina put together the first class of PAs in 1965, selecting Navy
corpsmen who had considerable medical training during their military
experience as his students. Dr. Stead based the curriculum of the PA
program in part on his knowledge of the fast-track training of doctors
during World War II. Today, there are 139 accredited PA educational
programs across the United States. Approximately 1,600 PAs are employed
by the Department of Veterans Affairs, making the VA the largest single
employer of physician assistants. These PAs work in a wide variety of
medical centers and outpatient clinics, providing medical care to
thousands of veterans each year. Many are veterans themselves.
Physician assistants (PAs) are fully integrated into the health
care systems of the Armed Services and virtually all other public and
private health care systems. PAs are on the frontline in Iraq and
Afghanistan, providing immediate medical care for wounded men and women
of the Armed Forces. PAs are covered providers in TRICARE. In the
civilian world, PAs work in virtually every area of medicine and
surgery and are covered providers within the overwhelming majority of
public and private health insurance plans. PAs play a key role in
providing medical care in medically underserved communities. In some
rural communities, a PA is the only health care professional available.
Why are PAs so fully integrated into most public and private health
care systems? We believe it's because they foster the use and inclusion
of their PA workforce. Each branch of the Armed Services designates a
PA Consultant to the Surgeon General. And, many major medical
institutions credit their integration of PAs in the workforce to a
Director of PA Services. To name just a few, the Cleveland Clinic, the
Mayo Clinic, the University of Texas MD Anderson Cancer Center, and New
Orleans' Ochsner Clinic Foundation all have Directors of PA Services.
We believe that what works for the Armed Services and the private
sector will also work for the VA.
How does the lack of a Director of PA Services at the VA relate to
recruitment and retention of the VA workforce? As far as the AAPA can
tell, there are no recruitment and retention efforts aimed towards
employment of physician assistants in the VA. The VA designates
physicians and nurses as critical occupations, and so priority in
scholarships and loan repayment programs goes to nurses, nurse
practitioners, physicians, and other professions designated as critical
occupations. The PA profession has not been determined to be a critical
occupation at the VA, so moneys are not targeted for their recruitment
and retention. PAs are not included in any of the VA special locality
pay bands, so PA salaries are not regularly tracked and reported by the
VA. We've been told that this has resulted in lower pay for PAs
employed by the VA than for health care professionals who perform
similar medical care. Why are PAs not considered a critical occupation
at the VA? Is it possible they were overlooked, because there was no
one to raise the issue?
The outlook for PA employment at the VA does not differ from that
for nurse practitioners and physicians. Approximately 40 percent of PAs
currently employed by the VA are eligible for retirement in the next
five years, and the VA is simply not competitive with the private
sector for new PA graduates. The U.S. Bureau of Labor Statistics, U.S.
News and World Report, and Money magazine all speak to the growth,
demand, and value of the PA profession. The challenge for the VA is
that the growth and demand for PAs is in the private sector, not the
VA.
According to the AAPA's 2007 Census Report, PA employment in the
federal government, including the VA, continues to decline. AAPA's
Annual Census Reports of the PA Profession from 1991 to 2007 document
an overall decline in the number of PAs who report federal government
employment. In 1991, nearly 22% of the total profession was employed by
the federal government. This percentage dropped to 9% in 2007. New
graduate census respondents were even less likely to be employed by the
government (17% in 1991 down to 5% in 2007).
Unless some attention is directed toward recruitment and retention
for PAs, the AAPA believes that the VA is in danger of losing its PA
workforce. The elevation of the PA advisor to a full-time Director of
PA Services in the VA Central Office is the first step in focusing the
VA's efforts on recruitment and retention of PAs.
The current position of Physician Assistant (PA) Advisor to the
Under Secretary for Health was authorized through section 206 of P.L.
106-419 and has been filled as a part-time, field position. Prior to
that time, the VA had never had a representative within the Veterans
Health Administration with sufficient knowledge of the PA profession to
advise the Administration on the optimal utilization of PAs. This lack
of knowledge resulted in an inconsistent approach toward PA practice,
unnecessary restrictions on the ability of VA physicians to effectively
utilize PAs, and an under-utilization of PA skills and abilities. The
PA profession's scope of practice was not uniformly understood in all
VA medical facilities and clinics, and unnecessary confusion existed
regarding such issues as privileging, supervision, and physician
countersignature.
Although the PAs who have served as the VA's part-time, field-based
PA advisor have made progress on the utilization of PAs within the
agency, there continues to be inconsistency in the way that local
medical facilities use PAs. In one case, a local facility decided that
a PA could not write outpatient prescriptions, despite licensure in the
State allowing prescriptive authority. In other facilities, PAs are
told that the VA facility can not use PAs and will not hire PAs. These
restrictions hinder PA employment within the VA, as well as deprive
veterans of the skills and medical care PAs have to offer.
The Academy also believes that the elevation of the PA advisor to a
full-time Director of Physician Assistant Services, located in the VA
central office, is necessary to increase veterans' access to quality
medical care by ensuring efficient utilization of the VA's PA workforce
in the Veterans Health Administration's patient care programs and
initiatives. PAs are key members of the Armed Services' medical teams
but are an underutilized resource in the transition from active duty to
veterans' health care. As health care professionals with a longstanding
history of providing care in medically underserved communities, PAs may
also provide an invaluable link in enabling veterans who live in
underserved communities to receive timely access to quality medical
care.
Thank you for the opportunity to submit a statement for the hearing
record in support of H.R. 2790. AAPA is eager to work with the House
Committee on Veterans Affairs Subcommittee on Health to improve the
availability and quality of medical care to our Nation's veteran
population.
Statement of Hon. Shelley Berkley,
a Representative in Congress from the State of Nevada
Mr. Chairman,
Thank you for holding this hearing on the important issue of mental
health legislation.
Nationally, one in five veterans returning from Iraq and
Afghanistan suffers from PTSD. Twenty-three percent of members of the
Armed Forces on active duty acknowledge a significant problem with
alcohol use. It is vital that our veterans receive the help they need
to deal with these conditions.
The effects of substance abuse are wide ranging, including
significantly increased risk of suicide, exacerbation of mental and
physical health disorders, breakdown of family support, and increased
risk of unemployment and homelessness. Veterans suffering from a mental
health issue are at an increased risk for developing a substance abuse
disorder.
A constituent of mine, Lance Corporal Justin Bailey, returned from
Iraq with PTSD. He developed a substance abuse disorder and checked
himself into a VA facility in West Los Angeles. After being given five
medications on a self-medication policy, Justin overdosed and died.
I have introduced the Mental Health Improvements Act, which aims to
improve the treatment and services provided by the Department of
Veterans Affairs to veterans with PTSD and substance use disorders by:
Expanding substance use disorder treatment services at
the VA medical centers.
Creating a program for enhanced treatment of substance
use disorders and PTSD in veterans.
Requiring a report on residential mental health care
facilities of the Veterans Health Administration (VHA).
Creating a research program on co-morbid PTSD and
substance use disorders.
Expanding assistance of mental health services for
families of veterans.
It is imperative that we provide adequate mental health services
for those who have sacrificed for this great Nation and those who
continue to serve. This bill takes a step in the right direction in
providing our veterans with the care they have earned. I urge my
colleagues to cosponsor this important piece of legislation, and I look
forward to further action in this Committee.
Statement of Mental Health America
Mr. Chairman, Mental Health America commends you for scheduling
this hearing, and for your and this Committee's ongoing concern about
the mental health of our veterans.
Mental Health America (MHA) is the country's oldest and largest
nonprofit organization addressing all aspects of mental health and
mental illness. In partnership with our network of 320 State and local
Mental Health Association affiliates nationwide, MHA works to improve
policies, understanding, and services for individuals with mental
illness and substance abuse disorders, as well as for all Americans.
Established in 1909, the organization changed its name in 2006 from the
National Mental Health Association to Mental Health America in order to
communicate how fundamental mental health is to overall health and
well-being. MHA is a founding member of the Campaign for Mental Health
Reform, a partnership of 17 organizations which seek to improve mental
health care in America, for veterans and non-veterans alike.
Unique Aspects of Operations Iraqi Freedom and Enduring Freedom (OIF/
OEF)
Importantly, a number of the bills before the Subcommittee address
mental health issues. While service-members have experienced mental
health problems in every war, our operations in Iraq and Afghanistan
differ markedly from prior combat engagements, with critically
important implications for veterans' readjustment and recovery. It is
critical therefore that the Committee target legislation to most
effectively address the unique circumstances of these operations.
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
are unique in their heavy reliance on the National Guard and Reserves
who make up a large percentage of our fighting forces. Reserve forces
alone have made up as much as 40 percent of U.S. forces in Iraq and
Afghanistan, and at one point, more than half of all U.S. casualties in
Iraq were sustained by members of the Guard or Reserves. These
operations are also unique in their reliance on repetitive deployments.
Deploying to a combat zone is necessarily enormously stressful to a
soldier and to his or her family; that stress increases markedly with
each subsequent deployment. The impact of those deployments on service-
members has been profound.
Veterans' Mental Health Needs
A recently published DoD-conducted longitudinal assessment of
mental health problems among soldiers returning from Iraq (published in
the Journal of the American Medical Association, Nov. 2007) found that
42.4 percent of National Guard and Reserve-component soldiers screened
by the Department of Defense required mental health treatment. The high
percentages of Guard and Reservists among OIF/OEF veterans creates
unique challenges that VA has not previously faced. First, these
``citizen-soldiers'' often live in communities remote from VA medical
facilities. Yet they are as likely to have readjustment issues or to
experience anxiety, depression or PTSD as veterans who have good access
to VA health care. Long-distance travel is a very formidable barrier to
a veteran's seeking (and continuing) needed treatment. That barrier is
likely to be even higher for veterans with mental health needs, given
the lingering stigma surrounding mental health treatment and the well
documented reluctance of some veterans to seek VA help because of fears
of disclosures that might compromise their military status.
The high incidence of mental health problems among returning
service-members and particularly among Guard and Reservists should be
cause for alarm, especially in rural and frontier areas, and the many
places in the country where VA lacks any (or sufficient) specialized
mental health service capacity. To be clear, VA is both a facility-
based system, and a largely passive system that generally puts the
burden on the veteran to seek care. While VA reports that significant
numbers of OIF/OEF veterans have been treated at its facilities for
behavioral health problems, there are compelling reasons to question
how many veterans are not seeking and, therefore, not getting needed
mental health treatment.
We should also be mindful of the expert advice of the Department's
own Special Committee on Post-Traumatic Stress Disorder, which in a
report in February 2006 advised that ``VA needs to proceed with a broad
understanding of post deployment mental health issues. These include
Major Depression, Alcohol Abuse (often beginning as an effort to
sleep), Narcotic Addiction (often beginning with pain medication for
combat injuries), Generalized Anxiety Disorder, job loss, family
dissolution, homelessness, violence toward self and others, and
incarceration.'' The Special Committee advised that ``rather than set
up an endless maze of specialty programs, each geared to a separate
diagnosis and facility, VA needs to create a progressive system of
engagement and care that meets veterans and their families where they
live. . . . The emphasis should be on wellness rather than pathology;
on training rather than treatment. The bottom line is prevention and,
when necessary, recovery.'' Importantly, the Special Committee also
advised that ``[b]ecause virtually all returning veterans and their
families face readjustment problems, it makes sense to provide
universal interventions that include education and support for veterans
and their families coupled with screening and triage for the minority
of veterans and families who will need further intervention.''
Early treatment can help resolve post-traumatic stress disorder,
depression, and other problems common in combat veterans. But those who
do not get needed help too often self-medicate (using alcohol or
drugs), develop chronic health problems, and experience interpersonal
difficulties and even family breakup. As the Committee well knows,
alarming numbers of returning veterans have even taken their lives.
H.R. 2874: Needed Legislation
In light of the issues outlined above, we believe this Committee,
to its great credit, has taken a profoundly important step in
developing and adopting H.R. 2874, the Veterans' Health Improvements
Act of 2007, which the House passed last July. We regret that the
Senate has not yet taken action on that measure. In our view, section 6
of that legislation provides critical solutions for the many OIF/OEF
veterans with mental health needs who are not now getting the help they
need from the VA. As you know, the key elements of the bill would
require VA to mount a national program to train a cohort of OIF/OEF
veterans to work as peer-outreach and peer-support specialists. In
areas of the country where veterans cannot reasonably reach VA
facilities, the bill calls on VA to partner with community mental
health centers and similar entities to provide peer outreach and
support services, readjustment counseling and needed mental health
services. As a condition of such arrangements, those community
providers would be required to hire a trained peer specialist. That
individual's role would be to help identify veterans in need of
counseling or services, help overcome any reluctance to treatment, and
navigate and support the veteran through the treatment process. We
believe these provisions merit Senate adoption.
Among the bills before the Subcommittee is H.R. 4053, a measure
that seeks to improve VA's behavioral health service-delivery. While a
key focus of that bill is on improving such services at VA health care
facilities, sections 201 and 402--which require VA to conduct modest
pilot programs on peer outreach services and use of community mental
health centers, in the case of section 201, and readjustment and
transition assistance, in section 402--propose an approach very close
to that in section 6 of H.R. 2847. Our concern is not with the program
design proposed by the bill, but with its very limited scope. Enactment
of sections 201 and 402 would, in our view, inadvertently shut a
critical door to needed services for OIF/OEF veterans in rural,
frontier and many areas of the country that are distant from VA
facilities. Given the alarmingly high rate of mental health problems
being experienced by returning veterans, we urge that the Committee not
retreat from H.R. 2847 nor, in the absence of effective mechanisms to
reach veterans who live at considerable distances from VA facilities,
substitute limited pilot programs in lieu of a robust effort that
offers the promise of helping all OIF/OEF veterans who are experiencing
readjustment or behavioral health problems. We welcome the Committee's
consideration of other sections of H.R. 4053, given the importance of
ensuring that VA behavioral
health service delivery does effectively serve veterans who are able to
access VA care.
Family Services
In that regard, it is noteworthy that H.R. 2874, as introduced,
included a provision that would have directed VA to establish a program
to provide support and assistance to immediate family members of OIF/
OEF veterans. (That provision, which would have authorized VA to
provide immediate family members of OIF/OEF veterans with counseling
and needed mental health services for a period of up to
3 years was not adopted in the Committee's markup of H.R. 2874.)
Importantly,
H.R. 4053 includes a section 401, which is apparently intended to
clarify VA's authority to provide mental health services to families of
veterans. It is not clear, however, that the proposed amendments in
that provision in fact accomplish its admirable goal.
Current law and practice do in fact limit VA assistance to family
members, and warrant change. VA is an integrated health care system
which offers a relatively full continuum of care and services for
eligible veterans. Among those services is ``readjustment counseling.''
These services are provided principally at so-called ``Vet Centers,''
many of which are located in population centers and are operated
independently of VA medical centers and clinics. Typically provided by
psychologists and clinical social workers, Vet Centers' services
routinely include family therapy as a core component. But veterans and
family members who do not have reasonable access to a Vet Center and
rely instead on a VA medical center or clinic would not typically have
access to family services. Most VA medical centers and clinics focus
exclusively on the veteran patient (rather than on the veteran as part
of a family unit). (Indeed those facilities employ measures of
``workload'' data that provide no workload credit for family services.)
This focus and workload system effectively discourage clinicians from
providing family therapy and support services. We see no sound
programmatic rationale for encouraging family support at one set of VA
facilities (the Vet Centers) and discouraging it at others. VA's
Special Committee on PTSD reported in 2006 that ``the strength of a war
fighter's perceived social support system is one of the strongest
predictors of whether he/she will or will not develop PTSD.'' VA health
care, and particularly mental health care, would often be more
effective if barriers to family involvement were eliminated.
Current law does provide VA some limited authority for counseling
family members (but not for any other mental health services). But even
that limited authority is circumscribed. Under section 1782(b) of title
38, family counseling is expressly limited to circumstances where such
counseling had been initiated during a period of hospitalization, and
continuation is essential to hospital discharge (unless the veteran is
receiving treatment for a service-connected condition).
While H.R. 4053 suggests in the heading of section 401 that it
would establish clarifying authority to provide ``mental health
services,'' its substantive provisions are limited to ``marriage and
family counseling.'' For a spouse who has experienced deep clinical
depression or anxiety associated with a service-member's multiple tours
of combat duty and with the profound fears associated with a war that
has claimed thousands of casualties, marriage or family ``counseling''
will not necessarily meet that spouse's clinical needs. Moreover, as a
technical matter, we believe any effort to provide clarifying authority
must address the limitations in section 1782(c) as well as the very
practical ``workload'' disincentives.
Mental Health America would be pleased to work with the Committee
to craft language to provide VA needed authority to assist family
members consistent with its mission of serving veterans.
Statement of Paralyzed Veterans of America
Mr. Chairman and members of the Subcommittee, Paralyzed Veterans of
America (PVA) would like to thank you for the opportunity to submit a
statement for the record regarding the proposed legislation. We
appreciate the continued emphasis on providing the best quality health
care for veterans who experience mental illness as well as veterans who
live in rural areas--two segments of the veteran population that
present some of the most difficult challenges.
H.R. 2790, Director of Physician Assistant Services
PVA fully supports H.R. 2790, a bill that would establish the
position of Director of Physician Assistant Services within the
Veterans Health Administration (VHA) at the Department of Veterans
Affairs (VA). This legislation mirrors the recommendation included in
The Independent Budget for FY 2008 and that will be included in the FY
2009 edition as well.
As explained in The Independent Budget, Physician Assistants (PA)
in the VA health care system are the providers for millions of health
care visits every year in primary care clinics, ambulatory care
clinics, emergency medicine, and in 22 other medical and surgical
specialties. Since the PA advisor position was authorized by P.L. 106-
419, the ``Veterans' Benefits and Health Care Improvement Act of
2000,'' the number of PA's in the VHA have grown significantly. And
yet, four Under Secretaries for Health have all refused to make this
position a full-time equivalent employee position. We appreciate the
fact that this legislation will finally correct this senseless
decision.
H.R. 3458, Pilot Program on TBI Care for Rural Veterans
PVA has no objection to the provisions outlined in H.R. 3458. The
proposed legislation would authorize the VA to conduct a pilot program
in five rural States. The program would be coordinated with the VA's
Office of Rural Health. The goal of the pilot program would be to
provide the best available services for veterans who have experienced
traumatic brain injury (TBI). We appreciate the fact that the
legislation provides some protections to ensure that properly trained
professionals are caring for the needs of this critical segment of the
veteran population.
While we have expressed some concerns in the past with the idea of
contract care for different groups of veterans, we understand that the
VA must tap into the resources and expertise that private providers can
offer. To that end, we have no objection to the provisions of the
legislation that authorize contract care when necessary and
appropriate. It is important that services for veterans who have
incurred a TBI be coordinated between the VA and private providers.
H.R. 3819, the ``Veterans Emergency Care Fairness Act''
PVA generally supports the provisions of H.R. 3819, the ``Veterans'
Emergency Care Fairness Act,'' as the legislation is in accordance with
the recommendations of The Independent Budget for FY 2008. However, we
remain concerned about some of the eligibility criteria that determine
what veterans are eligible for this reimbursement. In accordance with
The Independent Budget for FY 2008, we believe that the requirement
that a veteran must have received care within the past 24 months should
be eliminated. Furthermore, we believe that the VA should establish a
policy allowing all veterans enrolled in the health care system to be
eligible for emergency services at any medical facility, whether at a
VA or private facility, when they exhibit symptoms that a reasonable
person would consider a medical emergency.
H.R. 4053, the ``Mental Health Improvements Act''
First, I would like to say that PVA generally supports this
proposed legislation which improves services provided by the VA to
veterans with Post-Traumatic Stress Disorder (PTSD) and substance use
problems. Current research highlights that Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF) combat veterans are at
higher risk for PTSD and other mental health problems as a result of
their military experiences. In fact, the most recent research indicates
that 25 percent of OIF/OEF veterans seen at a VA facility have received
mental health diagnoses.
We are pleased with the provisions of section 102 and 103 of the
legislation. In fact, The Independent Budget is set to recommend that
VA provide a full continuum of care for substance use disorders
including additional screening in all its health care facilities and
programs--especially primary care. We also believe outpatient
counseling and pharmacotherapy should be available at all larger VA
community-based outpatient clinics. Furthermore, short-term outpatient
counseling including motivational interventions, intensive outpatient
treatment, residential care for those most severely disabled,
detoxification services, ongoing aftercare and relapse prevention, self
help groups, opiate substitution therapies and newer drugs to reduce
craving, should be included in VA's overall program for substance abuse
and prevention.
Although we support the creation of PTSD centers of excellence
outlined in section 105 of the legislation, we wonder whether this step
is necessary. The VA already maintains a broad network of PTSD
treatment centers. Furthermore, in 1989, the VA established the
National Center for Post-Traumatic Stress Disorder as a focal point to
promote research into the causes and diagnosis of this disorder, to
train health care and related personnel in diagnosis and treatment, and
to serve as an information clearinghouse for professionals. The Center
offers guidance on the effects of PTSD on family and work, and notes
treatment modalities and common therapies used to treat the condition.
This Center already functions as a center of excellence. At the very
least, it should be incorporated into this new network of centers of
excellence.
PVA has some concerns with the pilot program outlined in Title II
of the bill. While we certainly support the emphasis placed on peer
counseling and outreach, we maintain our concerns about contract
services with community health centers. The VA should be able to
provide the services described in the legislation through judicious
application of its already existing fee basis authority. We do,
however, appreciate the emphasis on ensuring that the non-VA facilities
are compliant with VA standards, particularly through additional
training managed specifically by the VA.
While we also support Title III of the legislation regarding
research into co-morbid PTSD and substance use disorder, we wonder if
this is duplicative with activities already taking place at the
National Center for PTSD. However, PVA has long supported research
initiatives into various types of conditions and the treatments
associated with them.
Finally, we recognize the unique challenge associated with
providing mental health services to families of veterans. This is an
area that the VA has had little experience with in the past. Likewise,
we see no problem with the VA examining the feasibility of providing
readjustment and transition assistance to veterans and their families.
It is certainly an issue that has become more apparent as more men and
women return from conflicts abroad broken and scarred. The impact that
this has on the veteran and his or her family cannot be overstated.
H.R. 4107, the ``Women Veterans Health Care Improvement Act''
PVA supports H.R. 4107, the ``Women Veterans Health Care
Improvement Act.'' This legislation is meant to expand and improve
health care services available in the Department of Veterans Affairs
(VA) to women veterans, particularly those who have served in Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). More women are
currently serving in combat theaters than at any other time in history.
As such, it is important that the VA be properly prepared to address
the needs of what is otherwise a unique segment of the veterans
population.
Title I of the bill would authorize a number of studies and
assessments that would evaluate the health care needs of women
veterans. Furthermore, these studies would also identify barriers and
challenges that women veterans face when seeking health care from the
VA. Finally, the VA would be required to assess the programs that
currently exist for women veterans and report this status to Congress.
We believe each of these studies and assessments can only lead to
higher quality care for women veterans in the VA. They will allow the
VA to dedicate resources in areas that it must improve upon.
Title II of the bill would target special care needs that women
veterans might have. Specifically, it would ensure that VA health care
professionals are adequately trained to deal with the complex needs of
women veterans who have experienced sexual trauma. Furthermore, it
would require the VA to disseminate information on effective treatment,
including evidence-based treatment, for women veterans dealing with
Post-Traumatic Stress Disorder (PTSD). While many veterans returning
from OEF/OIF are experiencing symptoms consistent with PTSD, women
veterans are experiencing unique symptoms also consistent with PTSD. It
is important that the VA understand these potential differences and be
prepared to provide care.
PVA views this proposed legislation as necessary and critical. The
degree to which women are now involved in combat theaters must be
matched by the increased commitment of the VA, as well as the
Department of Defense, to provide for their needs when they leave the
service. We cannot allow women veterans to fall through the cracks
simply because programs in the VA are not tailored to the specific
needs that they might have.
H.R. 4146, Emergency Medical Care in Non-VA Facilities
While we support the intent of this proposed legislation, we
believe that this issue is handled in a more comprehensive manner by
H.R. 3819. Therefore, we recommend that the Subcommittee table this
bill in favor of approving H.R. 3819.
H.R. 4204, the ``Veterans Suicide Study Act''
The incidence of suicide among veterans, particularly Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans, is a
serious concern that needs to be addressed. Any measure that may help
reduce the incidence of suicide among veterans is certainly a good
thing. As such, PVA supports this legislation. This bill would require
the VA to conduct a study to determine the number of veterans who have
committed suicide since January 1, 1997.
It is important to note that VA has made suicide prevention a major
priority. VA has developed a broad program based on increasing
awareness, prevention, and training of health care staff to recognize
suicide risk. A national suicide prevention hotline has been
established and suicide prevention coordinators have been hired in each
VA medical center. Research into the risk factors associated with
suicide in veterans and prevention strategies is underway.
However, it is equally important to point out that suicide
prevention is something that can be addressed early on in the mental
health process. With access to quality psychiatric care and other
mental health professionals, many of the symptoms experienced early on
can be addressed in order to reduce the risk of suicide down the road.
This extends to proper screening and treatment for veterans who deal
with substance abuse problems as well.
H.R. 4231, the ``Rural Veterans Health Care Access Act''
PVA opposes this proposed legislation. H.R. 4231 would establish a
pilot program that would require the VA to provide vouchers to veterans
who served in OEF/OIF who need mental health services, and who reside
at least 30 miles from a VA facility that employs a full-time mental
health professional. These vouchers could then be used to purchase
mental health services with private providers. PVA finds it difficult
to comprehend the rationale for establishing a precedent for veterans
to seek services outside of the VA health care system, as this proposed
legislation would do.
First, let me say that we are absolutely opposed to any suggestion
that veterans be given a voucher to seek health care services outside
of the VA. This step amounts to nothing more than privatization of the
VA, turning the VA health care system into an insurer of care instead
of a provider of care. Likewise, The Independent Budget has also taken
a position against vouchering in the past. Veterans who would seek care
in the private sector would lose the many safeguards built into the VA
system through its patient safety program, evidence-based medicine,
electronic medical records and medication verification program. These
unique VA features culminate in the highest quality care available,
public or private. Loss of these safeguards, that are generally not
available in private sector systems, would equate to diminished
oversight and coordination of care.
We are also very concerned about the seemingly arbitrary nature
with which a veteran's eligibility for this voucher is established. The
legislation states that if a veteran resides 30 miles or more from a VA
medical facility that does not employ a full-time mental health
professional, then that veteran is eligible for a voucher. Given the
fact that the definition of rural is very subjective, I would suggest
that 30 miles from a facility does not qualify as rural.
Furthermore, we believe that it is patently unfair to suggest that
the VA cannot meet the need if the mental health professional in that
local facility is not a full-time employee. If a VA facility is able to
provide a mental health appointment in a timely manner, regardless of
the employment status of the mental health professional, then it is
unnecessary to allow a veteran to go into the private sector with a
voucher. Otherwise, this represents mandating private care for the sake
of convenience and not for the sake of demonstrated need.
Ultimately, we cannot support vouchering of any health care
services in the VA because we believe it will only diminish the quality
of care in the VA health care system. Furthermore, we believe that this
pilot program would set a dangerous precedent, encouraging those who
would like to see the VA privatized. Privatization is ultimately a
means for the federal government to shift its responsibility of caring
for the men and women who served.
We look forward to working with the Subcommittee to develop
workable solutions that will allow veterans to get the best quality
care available. We would like to thank you again for allowing us to
submit a statement for record on these important measures. We would be
happy to answer any questions that you might have.
MATERIAL SUBMITTED FOR THE RECORD
Ohio Hospital Association
Columbus, Ohio
October 18, 2007
The Honorable Sherrod Brown
United States Senate
455 Russell Senate Office Building
Washington, DC 20510
The Honorable Zack Space
United States House of Representatives
315 Cannon House Office Building
Washington, DC 20511
Dear Senator Brown and Congressman Space:
On behalf of the Ohio Hospital Association (OHA) and our more than
170 hospitals and health systems, we appreciate your recent
introduction of the Veterans Emergency Care Fairness Act of 2007 (S.
2142/H.R. 3819). The legislation will address a significant concern
regarding the reimbursement of medical care provided to America's
veterans.
Currently, veterans who present at a community hospital for
emergency treatment are stabilized and then transferred to a regional
Veterans' Affairs (VA) hospital. The Chief of the Health Administration
Service authorizes reimbursement be made from the U.S. Department of
Veterans' Affairs to the community hospital and the patient for
necessary stabilization services and transfer costs.
Unfortunately, especially in rural areas, the VA hospital is unable
or unwilling to admit the patient for a period of time until
transportation arrangements can be made or until an inpatient bed is
available at the VA. In these circumstances, a community hospital must
care for the patient for an extended period prior to transfer. Current
law is unclear on whether the patient, the community hospital, or the
Department of Veterans' Affairs is responsible for the cost of this
care. Title 38 USC 1725 states that the Department may reimburse for
such treatment.
Your legislation clarifies this issue by requiring the Department
to provide reimbursement to the veteran patient or directly to the
hospital for care provided during the post-stabilization ``waiting''
period, provided the hospital documents reasonable attempts to transfer
the patient to a VA. Hospitals already must document such transfer
attempts, so we do not believe this provision would add an
administrative burden to the community hospital.
Again, thank you for championing this important clarification in
veterans' health policy. We look forward to working with you during the
110th Congress to ensure enactment of the bill.
Sincerely,
Jonathan Archey
Manager, Federal Relations
Air Force Sergeants Association
Temple Hills, MD
November 5, 2007
The Honorable Zachary Space
315 Cannon House Office Building
Washington, D.C. 20515
Dear Congressman Space,
On behalf of the members of the Air Force Sergeants Association, we
offer our support for H.R. 3819, the ``Veterans Emergency Care Fairness
Act of 2007.'' Your bill would provide reimbursement for emergency care
when veterans obtain immediate care at nearby medical facilities.
AFSA's 130,000 members represent the quality-of-life interests of
current and past enlisted members of all components of the Air Force
and their family members. Your bill is important to many of our
members.
Many veterans do not live near a VA medical facility. Accordingly,
one of the great challenges is how to obtain emergency care until the
veteran can be transported to the nearest VA facility and how to pay
for it. Under current law this presents a financial hardship to many.
Your legislation would help rectify such unfortunate situations.
Mr. Space, we support your effort in this regard and I offer AFSA's
assistance in
advancing this important legislation. Please let me know if we can
assist you on this and other matters of mutual concern.
Respectfully,
Richard M. Dean, CMSgt (Ret.)
Chief Executive Officer
DEPARTMENT OF VETERANS AFFAIRS
News Release
FOR IMMEDIATE RELEASE
July 9, 2008
VA Vet Centers Coming to 39 Communities
Peake: Provide Counseling for All Combat Veterans
WASHINGTON--Combat veterans will receive readjustment counseling and
other assistance in 39 additional communities across the country where
the Department of Veterans Affairs (VA) will develop Vet Centers by
fall 2009.
``Community-based Vet Centers--already in all 50 States--are a key
component of VA's mental health program,'' said Dr. James B. Peake,
Secretary of Veterans Affairs. ``I'm pleased we can expand access to
bring services closer to even more veterans, including screening and
counseling for post-traumatic stress disorder.''
The existing 232 centers conduct community outreach to offer
counseling on employment, family issues and education to combat
veterans and family members, as well as bereavement counseling for
families of service members killed on active duty and counseling for
veterans who were sexually harassed on active duty.
Vet Center services are available at no cost to veterans who
experienced combat during any war era. They are staffed by small teams
of counselors, outreach workers and other specialists, many of whom are
combat veterans. The Vet Center program was established in 1979 by
Congress, recognizing that many Vietnam veterans were still having
readjustment problems.
The centers have hired 100 combat veterans who served in Iraq and
Afghanistan as outreach specialists, often placing them near military
processing stations, to brief servicemen and women leaving the military
about VA benefits.
VA's 2009 budget proposal seeks $20 million more than this year's
budget for Vet Centers, to include operating and leasing space for the
new centers. Eighteen of the counties that will have new centers
already have one or more; the other 21 do not.
A list of the new Vet Center locations is attached.
__________
Vet Centers 2/2/2
Communities Receiving New VA Vet Centers
Alabama--Madison
Arizona--Maricopa
California--Kern, Los Angeles, Orange, Riverside, Sacramento, San
Bernardino,
San Diego
Connecticut--Fairfield
Florida--Broward, Palm Beach, Pasco, Pinellas, Polk, Volusia
Georgia--Cobb
Illinois--Cook, DuPage
Maryland--Anne Arundel, Baltimore, Prince George's
Michigan--Macomb, Oakland
Minnesota--Hennepin
Missouri--Greene
North Carolina--Onslow
New Jersey--Ocean
Nevada--Clark
Oklahoma--Comanche
Pennsylvania--Bucks, Montgomery
Texas--Bexar, Dallas, Harris, Tarrant
Virginia--Virginia Beach
Washington--King
Wisconsin--Brown