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


 
LEGISLATIVE HEARING ON H.R. 2818, H.R. 5554, H.R. 5595, H.R. 5622, H.R. 
                          5729, AND H.R. 5730 

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 15, 2008

                               __________

                           Serial No. 110-82

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

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

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 
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                            C O N T E N T S

                               __________

                             April 15, 2008

                                                                   Page
Legislative Hearing on H.R. 2818, H.R. 5554, H.R. 5595, H.R. 
  5622, H.R. 5729, and H.R. 5730.................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    32
Hon. Jeff Miller, Ranking Republican Member, prepared statement 
  of.............................................................    32
Hon. Phil Hare...................................................     8
Hon. Shelley Berkley.............................................     9
Hon. John T. Salazar, prepared statement of......................    33

                               WITNESSES

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., 
  FAAFP, Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    26
    Prepared statement of Dr. Cross..............................    44

                                 ______

American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission..........................    15
    Prepared statement of Mr. Wilson.............................    36
Brown-Waite, Hon. Ginny, a Representative in Congress from the 
  State of Florida...............................................     6
Carney, Hon. Christopher P., a Representative in Congress from 
  the State of Pennsylvania......................................     4
    Prepared statement of Congressman Carney.....................    34
Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................    16
    Prepared statement of Ms. Ilem...............................    37
Ellsworth, Hon. Brad, a Representative in Congress from the State 
  of Indiana.....................................................     5
Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs, 
  and a Representative in Congress from the State of California..     2
Michaud, Hon. Michael H., Chairman, Subcommittee on Health, 
  Committee on Veterans' Affairs, and a Representative in 
  Congress from the State of Maine...............................    12
    Prepared statement of Congressman Michaud....................    35
Perlmutter, Hon. Ed, a Representative in Congress from the State 
  of Colorado....................................................     3
    Prepared statement of Congressman Perlmutter.................    33
Veterans of Foreign Wars of the United States, Christopher 
  Needham, Senior Legislative Associate, National Legislative 
  Services.......................................................    18
    Prepared statement of Mr. Needham............................    40
Vietnam Veterans of America, Bernard Edelman, Deputy Director for 
  Policy and Government Affairs..................................    19
    Prepared statement of Mr. Edelman............................    43

                       SUBMISSIONS FOR THE RECORD

American Veterans (AMVETS), Raymond C. Kelly, National 
  Legislative Director...........................................    48
National Association of State Alcohol and Drug Abuse Directors, 
  Inc., Lewis E. Gallant, Ph.D., Executive Director..............    50
Paralyzed Veterans of America, statement.........................    54

                   MATERIAL SUBMITTED FOR THE RECORD

Hon. James B. Peake, M.D., Secretary, U.S. Department of Veterans 
  Affairs, to Hon. Bob Filner, Chairman, Committee on Veterans' 
  Affairs, letter dated, August 28, 2008, transmitting 
  Administration views on H.R. 5730..............................    56


LEGISLATIVE HEARING ON H.R. 2818, H.R. 5554, H.R. 5595, H.R. 5622, H.R. 
                          5729, AND H.R. 5730

                              ----------                              


                        TUESDAY, APRIL 15, 2008

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

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Hare, Berkley, Salazar, 
Miller, and Brown of South Carolina.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to thank everyone for coming this 
morning.
    Today's hearing is an opportunity for Members of Congress, 
the Veterans Service Organizations (VSOs), and the U.S. 
Department of Veterans Affairs (VA), and other interested 
stakeholders and parties to provide their views and discuss 
recently introduced legislation within the purview of this 
Subcommittee.
    The six bills before us today will cover a wide range of 
topics that are germane to veterans' healthcare issues. Issues 
addressed in today's hearing are bills that would address spina 
bifida, Epilepsy Research Centers, substance use disorder 
treatment and prevention, expansion of dental care, timely 
access to care, and a bill of rights.
    I do not necessarily agree or disagree with all these 
bills, but I think it is a very important part of the 
legislative process to hear the legislation before us.
    I want to thank our first panelists here today, and I would 
now like to ask Mr. Hare if he has any comments he wants to 
make.
    [The prepared statement of Chairman Michaud appears on
p. 32.]
    Mr. Hare. No, Mr. Chairman.
    Mr. Michaud. Thank you. We will start right off with the 
Honorable Chairman of the full Committee on Veterans' Affairs 
who has a long history of fighting for veterans issues.
    Mr. Filner, I want to thank you for your leadership as it 
relates to Veterans' Affairs. And your tenacity in making sure 
that Congress does whatever we can do to help our veterans.
    And you presented us today H.R. 5730. So without any 
further ado, Mr. Filner.

STATEMENTS OF HON. BOB FILNER, CHAIRMAN, COMMITTEE ON VETERANS' 
  AFFAIRS, AND A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
 CALIFORNIA; HON. ED PERLMUTTER, A REPRESENTATIVE IN CONGRESS 
   FROM THE STATE OF COLORADO; HON. CHRISTOPHER P. CARNEY, A 
REPRESENTATIVE IN CONGRESS FROM THE STATE OF PENNSYLVANIA; HON. 
BRAD ELLSWORTH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
   INDIANA; AND HON. GINNY BROWN-WAITE, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

                  STATEMENT OF HON. BOB FILNER

    Mr. Filner. Thank you, Mr. Chairman and thank you for your 
leadership. We have passed, under your leadership as Chairman, 
a wide variety of bills on veterans' health care. And we will 
continue to do so. I think the veterans across the Nation will 
be better off because of the work of this Subcommittee.
    As you said, I am speaking on H.R. 5730, the ``Injured and 
Amputee Veterans Bill of Rights.'' As we see servicemembers 
returning from Iraq and Afghanistan with amputations and 
musculoskeletal injuries, many will require prosthetic and 
orthotic care and will be entering the VA healthcare system for 
that care.
    In order to mitigate the impact of these potentially 
debilitating injuries, I believe the VA should establish a set 
of standards outlining the expectations and rights that 
returning veterans with musculoskeletal injuries have with 
respect to their prosthetic and orthotic needs.
    H.R. 5730, which I introduced, requires that the Secretary 
of Veterans Affairs prominently display an ``Injured and 
Amputee Bill of Rights'' at every VA prosthetic and orthotic 
clinic.
    This bill of rights outlines standards of care to ensure 
that injured and amputee veterans across the country have the 
same access to the highest quality of orthotics and prosthetics 
care in the most timely manner and using the most effective 
technology and treatments available.
    For the most part, VA has provided quality orthotic and 
prosthetic care to injured veterans. But there are some areas 
where there are inconsistencies that require improvement.
    Adoption of this bill of rights will establish a consistent 
set of standards that will form the basis of expectations of 
all veterans who have incurred an amputation or musculoskeletal 
injury requiring the prosthetic and orthotic care.
    Our injured veterans deserve the assurance that they will 
receive the best care possible. And I believe this bill will 
provide a step in that direction.
    Mr. Chairman, I thank you for taking up all these bills 
today. This bill was inspired by a wide variety of experiences. 
I have talked to both patients and healthcare professionals 
both with staff within and those outside the VA who provide the 
prosthetics that are necessary.
    So I look forward to working with you to get this bill 
done.
    Mr. Michaud. Thank you, Mr. Chairman, and I look forward to 
working with you as well as we move forward with this piece of 
legislation.
    The next bill is H.R. 2818, the Epilepsy Centers for 
Excellence, by Mr. Perlmutter.

                STATEMENT OF HON. ED PERLMUTTER

    Mr. Perlmutter. Thank you Mr. Chairman, and Mr. Miller, and 
Mr. Hare. Good morning. I want to thank you for holding this 
hearing on H.R. 2818, the ``Veterans' Epilepsy Treatment Act of 
2008.''
    The VA Epilepsy Centers of Excellence Act, which I 
introduced on June 21, 2007, will create at least six VA 
Epilepsy Centers within the VA care system. A companion bill 
introduced by Senator Patty Murray passed the Senate VA 
Committee on December 12, 2007.
    The Centers of Excellence will care for all veterans 
experiencing seizures and especially those we predict will 
develop epilepsy as a result of suffering a Traumatic Brain 
Injury (TBI) while serving in Operation Iraqi Freedom and 
Operation Enduring Freedom.
    Epilepsy is defined as two or more seizures. During 
Vietnam, a number of men and women returned home with head 
wounds and head injuries. Of those who came home with these 
types of injuries, some 53 percent developed epilepsy within 15 
years. And 15 percent of those who developed epilepsy did so 5 
or more years after their combat injury.
    Last year, I met with Dr. John Booss, the former Director 
of Neurology for the VA. He advised me that in 1972, the VA 
responded to the rise in veterans returning with seizures by 
creating VA Health Centers around the Nation that specialized 
in the treatment and research of epilepsy. The VA Centers 
partnered with medical schools to assist it in treating 
veterans with seizures and building a body of knowledge 
concerning epilepsy.
    However, sometime in the 1980s or early 1990s, the increase 
in veterans developing epilepsy subsided, funding dissipated, 
and the centers were curtailed. At this time, the VA operates 
seven epilepsy monitoring sites. But these sites lack the 
resources and capacity to care for our current veterans with 
epilepsy.
    Dr. Booss and a number of organizations such as the 
American Academy of Neurology, the Epilepsy Foundation of 
America, the Brain Injury Association, and the Citizens United 
for Research in Epilepsy have highlighted the need to rebuild 
the Epilepsy Centers of Excellence for the many men and women 
returning from the Middle East with head wounds and brain 
injuries.
    Your Committee is only too aware of the injuries suffered 
by our servicemen and women in Iraq and Afghanistan. It is 
estimated that today some 89,000 veterans have epilepsy of 
which 42 percent of that number is service connected. If our 
country's experience in Vietnam is any indication of what to 
expect in the future, the number of veterans with epilepsy is 
surely bound to rise.
    As an example, after I introduced this bill, I was 
contacted by one of my constituents, Naval Reserve Petty 
Officer Brian Johnson. He suffered a TBI while assigned to Navy 
Mobile Construction Battalion 7 just outside of Fallujah, Iraq.
    And on November 7th, 2004, his position came under fire and 
he sustained a brain injury when he was blown against a wall 
when two mortars exploded nearby. After returning home, he 
resumed his small plumbing business but eventually lost it due 
to the incidence of seizures.
    Petty Officer Johnson's story is just one of many emerging 
from the experiences our servicemen and women are having after 
returning home.
    H.R. 2818 establishes a process where VA Medical Centers 
partner with medical schools across the country to compete for 
the designation of a VA Epilepsy Center of Excellence. Six of 
these centers would be selected by the VA and would be 
disbursed across the country.
    The VA's telemedicine capacity would also be expanded to 
track the neurological diagnostic tests of our rural veterans. 
And it is anticipated that each of these centers would cost 
about a million dollars for the first 4 years.
    I want to thank the Disabled American Veterans, the 
Paralyzed Vets, the Blinded Veterans, and the Vietnam Veterans 
of America, and the other organizations I mentioned for their 
support of this bill.
    I want to thank you for your time. And I look forward to 
answering any of your questions.
    [The prepared statement of Congressman Perlmutter appears 
on
p. 33.]
    Mr. Michaud. Thank you very much, Mr. Perlmutter. The next 
piece of legislation is H.R. 5595, the ``Make Our Veterans 
Smile Act of 2008,'' presented by Mr. Carney.

            STATEMENT OF HON. CHRISTOPHER P. CARNEY

    Mr. Carney. Good morning, Mr. Chairman, Mr. Michaud, and 
Ranking Member Miller, and our distinguished colleagues. I 
appreciate having this opportunity to discuss the bill I 
introduced with Congressman Mark Kirk, H.R. 5595, the ``Make 
Our Veterans Smile Act of 2008.''
    The ``Make our Veterans Smile Act'' will expand dental care 
offered by the Department of Veterans Affairs to all service-
connected disabled veterans. The VA has done an excellent job 
of providing dental services to those that are able to receive 
them and the VA should continue to provide these services.
    However, the VA does not provide dental services to 
disabled veterans who are 90 percent or less disabled. The Make 
Our Veterans Smile Act will fix this problem by allowing all 
service-connected veterans to receive dental care through the 
VA. This will add another 2.4 million disabled veterans to the 
VA dental program.
    I believe we have a moral obligation to care for these 
veterans. And I understand that the VA might have problems 
meeting the demand for dental services that will occur because 
of this legislation.
    That is why this legislation allows service-connected 
disabled veterans to use contractor facilities for dental care. 
However, this legislation does not mandate contractor 
facilities be used. Instead it simply gives the VA greater 
authority to use these facilities.
    The cost of this bill is a cost of the war. It is an 
investment in our way of life and our future. As every Member 
of this Subcommittee knows, to ensure a ready fighting force 
for tomorrow, we need to take care of our veterans today.
    I would also like to point out that conditions such as 
missing teeth and cavities can be barriers in seeking 
employment. And I believe every effort must be made to ensure 
that there is a smooth transition for our military members who 
are entering the civilian workforce.
    We must also ensure that disabled veterans from past wars 
are also given every tool to keep meaningful jobs and this 
includes dental care.
    I would like to point out that numerous studies have shown 
that there is a clear correlation between dental health and 
someone's overall health.
    I would like to thank the Enlisted Association of the 
National Guard of the United States, the Navy Reserve 
Association, the Air Force Association, the Military Order of 
the Purple Heart, and AMVETS for support of this bill.
    I would also like to thank you again, Chairman Michaud, and 
Ranking Member Miller, and our distinguished colleagues, for 
holding this hearing and for allowing me to testify. I would be 
happy to answer any questions you might have.
    [The prepared statement of Congressman Carney appears on
p. 34.]
    Mr. Michaud. Thank you very much, Mr. Carney. The next bill 
is H.R. 5729, the ``Spina Bifida Health Care Program Expansion 
Act,'' presented by Mr. Ellsworth.

                STATEMENT OF HON. BRAD ELLSWORTH

    Mr. Ellsworth. Thank you, Chairman Michaud, Ranking Member 
Miller, and Members of this Subcommittee. I would like to thank 
you all for inviting me to testify in support of my bill, H.R. 
5729, the ``Spina Bifida Health Care Program Expansion Act.''
    Last year I testified in front of the Veterans' Affairs 
Subcommittee on Disability Assistance and Memorial Affairs on 
behalf of my constituents, Honey Sue Newby and the Nesler 
family of New Harmony, Indiana. I shared the heart-wrenching 
story of Honey Sue. This is a woman who lives with a 
complicated neurological disorder rooted in spina bifida and 
her parents Susan and Ron Nesler. They provide around-the-
clock, 24-hour attendance and care.
    Honey Sue's biological father served 8 years in the Marine 
Corps and completed three combat tours in Vietnam. The VA 
concedes and testifies that Honey Sue's condition is the direct 
result of her biological father's exposure to Agent Orange, a 
defoliant and herbicide used to protect our armed forces in 
Vietnam.
    I introduced H.R. 5729 in an attempt to clear this 
seemingly insurmountable bureaucratic hurdles that continue to 
frustrate the Neslers. Each time the Neslers seek medical care 
for Honey Sue, they must provide a letter from a doctor from 
the VA stating that her condition is directly related to spina 
bifida. That is a given. It has been testified to and it is 
proven.
    The Neslers must repeat this routine despite the fact that 
Honey Sue is recognized as a Level III child. And as you know, 
Level III children are eligible for the same full healthcare 
coverage as a military veteran with 100 percent service-
connected disability.
    It is my hope that H.R. 5729 will provide people facing the 
same challenges as Suzanne and Ron immediate relief from the 
paperwork and give them the piece of mind that their children 
will have unconditional access to attendant care when they are 
no longer capable of providing it themselves.
    With the passage of this bill, Honey Sue and the estimated 
1,200 children--I would like to emphasize, this is only 1,200 
children with Levels I, II, and III spina bifida as caused by 
parents exposure to Agent Orange that we dropped on that 
country and dropped on our veterans. They will receive the same 
full healthcare coverage as the 100 percent service-connected 
military veterans.
    I look forward to working closely with Dr. Gerald Cross at 
the Veterans Health Administration (VHA) and House VA Committee 
to ensure this legislation provides the Neslers and other 
families caring for children suffering from spina bifida with 
the much needed and long overdue relief from the tremendous 
bureaucratic hurdles that they currently face. I would also 
like to take just a moment to thank Cathy Wimblemo and Mark 
Heyman with the Subcommittee staff for being so helpful in this 
process.
    I look forward to hearing the expert testimony from the 
witnesses on panel two and from Dr. Gerald Cross on panel 
three. Thank you and I yield back.
    Mr. Michaud. Thank you very much, Mr. Ellsworth. The next 
piece of legislation is H.R. 5622, the ``Veterans Timely Access 
to Health Care Act.''

              STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. Thank you, Mr. Chairman and Ranking Member 
Miller, for the opportunity to testify before this Subcommittee 
today.
    I am pleased to have the opportunity to discuss this bill 
known as the ``Veterans Timely Access to Health Care Act.'' 
This bill makes a responsible and reasonable commitment to 
veterans throughout the country by ensuring that veterans 
receive the care that they deserve.
    Under H.R. 5622, if a veteran cannot get an appointment 
with a primary care physician within 30 days of a request, the 
veteran may see a private physician at no additional cost.
    This bill contains provisions similar to those found in 
other bills that I have introduced in the past. However, this 
bill is unique in several ways. First, H.R. 5622 would create 
just a pilot program. It wouldn't go nationwide. It would be a 
pilot program that encompasses the Veteran Integrated Services 
Network (VISN) 8, which includes most of south Georgia, 
Florida, Puerto Rico, and the U.S. Virgin Islands.
    The pilot program would give veterans receiving healthcare 
in VISN 8 the opportunity to seek healthcare from a primary 
care provider outside the VA if they have to wait more than 30 
days for an appointment through the VA.
    Mr. Chairman, it is more than reasonable for a veteran to 
expect to be seen by a primary care physician within 30 days. 
If the VA cannot provide this basic service to our veterans, 
then our veterans should have the option to look elsewhere.
    My bill--and I would like to emphasize this does not force 
any veteran out of the VA healthcare system. It simply provides 
them another option to go outside the VA if they desire.
    Should a veteran seek to see a physician outside the 
system, it is imperative that the VA be able to keep track of 
that veteran's medical records to ensure continuity of care. 
Therefore, this bill directs the Secretary to provide a form to 
veterans that would authorize the VA to obtain the records from 
these out-of-network visits. This provision is critical as the 
goal of H.R. 5622 is to ensure veterans not only receive access 
to timely healthcare, but to quality healthcare as well. This 
makes sure that there is a continuity of care and information 
sharing.
    Mr. Chairman, as a Member of Congress from VISN 8, I would 
like to make this option available to the veterans in and 
around VISN 8 and certainly to expand it nationwide. There is 
no reason why any veteran should have to wait more than 30 days 
to receive basic care.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much, Ms. Brown-Waite. We have 
one more bill, which is actually my bill. So we will not hold 
up the rest. The panel will start taking questions. The first 
bill, H.R. 2818, Mr. Perlmutter's bill on Epilepsy Centers of 
Excellence. I will open it up for any questions or comments. 
Mr. Miller.
    Mr. Miller. The one thing on H.R. 2818, the ``Veterans' 
Epilepsy Treatment Act of 2008,'' I think that I was--and I 
apologize, I was looking at another bill. I am trying to get my 
things together.
    Last year in H.R. 2199, the ``Traumatic Brain Injury Health 
Enhancement and Long-Term Support Act of 2007,'' we talked 
about establishing five TBI centers. We did address the 
epilepsy issue, albeit not to the extent that you have, and 
said that one of those five centers needed to focus on the 
issue, the epilepsy issue.
    Do you think if we just expanded what is currently in place 
with those TBI centers to go from one to all five, that would 
assist in what you are trying to accomplish?
    Mr. Perlmutter. I think--yes. I think the goal is to have 
geographically dispersed centers of excellence to study 
epilepsy, because when you start having seizures, it is 
different in many ways. And I should state, as full disclosure, 
I have a daughter with epilepsy. And so one of the things that 
clearly happens here is when the VA brings its force to bear 
and its knowledge is developed, it is--you know, that--there is 
a great spillover effect to society as a whole from the 
research that they develop.
    But the goal here is to provide the men and women that are 
coming back, and then develop seizures, and develop epilepsy 
with the best lives possible and with the best treatments 
possible. And, you know, cures where, you know, the research 
centers and the VA hospitals can develop them.
    And so under the bill, we couple a medical school with a VA 
hospital. They have to compete for it. If the TBI centers wish 
to do that, that is fine with me. The goal is to be able to 
provide the best service possible to the people having seizures 
that they--and we know that coming back from Iraq and 
Afghanistan, our servicemen and women who have had these head 
injuries are going to--some of them are going to start 
developing epilepsy.
    Mr. Miller. Thank you very much. Ms. Brown-Waite, my 
colleague from Florida, could you talk a little bit about the 
rationale requiring veterans to provide a written notification 
of his or her choice to receive care at a VA facility if 
available following care at a non-VA facility?
    Ms. Brown-Waite. Well, certainly you want to have 
continuity of care. And if their preference and if their 
records--they want their records because of financial reasons 
or any other reasons, that they would want to have the non-VA 
information shared with the VA. I know that many of our 
veterans--and one year I had the highest number and one year 
you had the highest number of any Member of Congress. I know 
that they like having the services and the economy of going to 
the local Community-Based Outpatient Clinic (CBOC) and/or the 
local hospital.
    But if they can't get that appointment within 30 days, it 
is almost like justice delayed is justice denied. Healthcare 
delayed is healthcare denied.
    Mr. Miller. Thank you very much for bringing this forward. 
I have no further questions, Mr. Chairman.
    Mr. Michaud. Mr. Hare, any questions?

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. Not really, Mr. Chairman. Just a couple of 
comments. Let me just say to all of you, first of all, thank 
you for being here. Each of these bills--it seems to me, you 
know, we sit on this Committee and we have talked a lot. We 
really have a moral obligation. I think that was mentioned by 
you Mr. Carney in terms of what we need to be doing here to 
assist our veterans.
    And I was struck, Mr. Ellsworth, when you were talking 
about Agent Orange and the defoliant. My predecessor spent 8 
years trying to get the VA to admit that Agent Orange caused 
more than severe acne in our veterans. And now we find out, 
because of, you know, spina bifida.
    So I would just to all of you every--each one of these 
pieces of legislation is critical to our veterans. And the 
question isn't how can we afford to do this? The question is 
how can we afford not to do this?
    Whether it is--as you said, Ms. Brown-Waite, on a trial 
basis and hopefully to expand this nationwide, because at the 
end of the day what I have--what I have said all the time since 
I have been on this Committee, and as you know I am new here, 
but if we make a promise to our veterans that we are going to 
take care of them and their families, we have to keep the 
promise or we have no business making that promise.
    And, you know, with all due respect to the VA who I know 
might have some problems with some of these pieces of 
legislation, you know, lets fix the problem but lets enact the 
legislation. So at the end of the day those families, those 
veterans, the people that need help, have an opportunity.
    And I just want to let you know that from my end, you have 
a very easy lobby, a lobby on me here today. If I am not on 
these bills, I will tell you I will be on them by the end of 
the day. But I commend you for standing up for our veterans. I 
appreciate the time and the effort that you have, you know, put 
into this. And anything that I can do to help you and, you 
know, I stand ready to do it.
    So, Mr. Chairman, I don't have any questions. I just really 
want to compliment all of you for standing up for the men and 
women and their families. Mr. Ellsworth, particularly with 
these kids with spina bifida who are so profoundly impacted.
    And one last thing. You know, Mr. Carney, yours is on 
dental. And I will tell you, sometimes I think that is the last 
thing people really think about. And I have to tell you, I 
think that is one of the first things we should be looking at 
too. It is just as important in healthcare for our veterans as 
anything we can talk about. So I really appreciate your being 
here.
    And with that, Mr. Chairman, I would yield back.
    Mr. Michaud. Thank you very much, Mr. Hare. Ms. Berkley.

           OPENING STATEMENT OF HON. SHELLEY BERKLEY

    Ms. Berkley. Thank you, Mr. Chairman. And thank all of my 
colleagues for being here. I embrace everything that my 
colleague just said.
    But for me, the cost of taking care of our veterans is the 
cost of going to war. And if you are not prepared to take care 
of our veterans when they come home from serving and 
sacrificing for their fellow citizens and our Nation, then you 
ought not send them in the first place.
    But I am also agonizing over how we intend to pay for this. 
And you know there is a movement to make the President's tax 
cuts permanent. I think as a Nation and as a Congress we are 
going to have to figure out what our priorities are and fund 
them appropriately.
    And as far as the VA is concerned, and as you know I work 
very closely with the VA given the number of veterans in my 
district that you hear about quite often, but if we are going 
to continue to pile more responsibility on the VA and all of 
these pieces of legislation are very laudatory and important, 
but we better provide the VA with the necessary amount of money 
that they are going to need to carry out our will. And so far I 
haven't seen that happening.
    As we all know for those of us who are veterans of this 
Committee, you know the last 7 years we just saw a very 
inattentive VA with an Administration that always underfunded 
the VA. We are playing catch-up now. But the needs are so 
dramatic, from everything from Post Traumatic Stress Disorder 
(PTSD) to making sure that our veterans get the care that they 
need in a timely manner, that I just think unless we have a 
national recognition that this is a major priority to take care 
of our veterans, and adequately fund them, and adequately fund 
the VA, and give them the necessary personnel to carry out the 
tasks that we are giving them, then we better just forget the 
whole thing.
    And I think that is an important--that is important to me. 
And I thank you for listening to my soapbox.
    Oh, and, Mr. Carney, may I call on you?
    Mr. Carney. Yes.
    Ms. Berkley. May I ask the Chair to call on him?
    Mr. Carney. Well, however you guys do it here. That is 
fine. I just wanted to comment that I am a veteran myself. And 
if we don't live up to the promises that we make to our 
veterans, no one is going to enlist anymore. We are an all-
volunteer force. And if we ignore the problems that are created 
by the service that young men and women provide to our country, 
we will not be able to have an all-volunteer force anymore. We 
will have to institute a draft again. And our sons and our 
daughters will feel that pain. And we don't want that.
    Ms. Berkley. Mr. Carney, we are spending $4,000 a second. 
Let me be precise, $3,919 a second in Iraq. And if we are going 
to spend that kind of money, we better make sure that we spend 
a requisite amount of money when these veterans come home.
    And when I hear the President and Administration officials 
talking about supporting the troops, the best way to support 
our troops is to support the veterans when they come home.
    Mr. Carney. Well, Ms. Berkley, I agree 100 percent with 
that. You know, if we could just somehow figure out a way to 
siphon off even 20 or 25 percent of the graft and corruption 
going on in Iraq, we could fund all these programs and many, 
many more.
    Ms. Berkley. And let me mention something else that we are 
working on. And let me give an effort to give full disclosure. 
My husband is a nephrologist. And they have a very, very busy 
practice. It is a kidney doctor. They have a very, very busy 
practice in Las Vegas. They also contract with the VA. They 
have not been paid in over a year. And talk about people not 
enlisting and volunteering to serve this Nation. If these 
doctors don't get paid, I mean I am not talking in a timely 
manner. I am talking about not getting paid. You are not going 
to get any doctors treating these veterans when they get home, 
especially those that are contracting with the VA.
    So we have a ton of problems in the VA right now. And we 
are going to have to work through those. And, again, give the 
VA the necessary resources in order to provide the services 
that our veterans demand and we are obligated to provide.
    Mr. Carney. I couldn't agree more.
    Mr. Michaud. Ms. Berkley, if you didn't talk about Nevada 
and the VA system, I would think something was wrong.
    Ms. Berkley. I would never disappoint you, Mr. Chairman.
    Mr. Michaud. Thank you. Mr. Salazar.
    Mr. Salazar. Thank you, Mr. Chairman. And I would like to 
take this opportunity to give a special welcome to my friend 
and colleague from Colorado, Mr. Perlmutter, who has been a 
champion on veterans' issues.
    People on this Committee and people who work on veterans' 
issues don't do it because it is a glamorous job. They do it 
because they care. I just want to commend each and every one of 
you for the incredible work that you have done on veterans' 
issues.
    I agree with everything that my colleagues have said this 
morning. Ms. Brown-Waite, I do not oppose your bill, I am very 
supportive of what you want to do.
    Have you taken into account or do you have a cost estimate 
as to what your bill would do should we adopt it nationwide? 
The reason I am asking is not because I oppose it. I am very 
supportive. We just need to start getting prepared for budget 
requests, in the future.
    Ms. Brown-Waite. The bill was never heard before the full--
even a Subcommittee before to take it nationwide. That is why I 
decided to truncate it. We did not--all we were told was it was 
too expensive. It would be too costly.
    And, again, I want to reiterate, this doesn't--this gives 
the veteran the opportunity. It doesn't mandate that he has to 
go to a healthcare provider outside of the VA system. It is an 
option that I think we should be giving to our veterans.
    But the answer is no. I do not--I never did--we never did 
get a full Congressional Budget Office scoring on taking it 
nationwide.
    Mr. Salazar. I think what you have is a very important 
bill. In Craig, Colorado, with Secretary Nicholson before he 
left, we were able to establish a CBOC, which had been in 
place. Scott McInnis, my predecessor, had been working on it 
for 12 years.
    An area where veterans had to drive 5 to 6 hours in order 
to get to a primary healthcare physician within the VA center. 
Mountainous areas can be very dangerous especially for veterans 
who are older. It was very difficult for them to get there and 
still in very remote and rural areas. Many of you know it is 
very difficult to get to a primary healthcare physician.
    I had a friend in Colorado who was suffering from chest 
pains. He was a veteran who actually served at the same time I 
did. We couldn't get him an appointment at the VA health center 
in Colorado for almost 6 months. And we were able to get him an 
appointment to go to the VA hospital in Albuquerque. Two days 
after they saw him in Albuquerque, they gave him a quintuple 
bypass on his heart. That shows how critical this is.
    There is a long waiting list of people waiting to get 
healthcare.
    So I applaud each and every one of you, and thank you very 
much for being here today.
    Mr. Michaud. Thank you, Mr. Salazar.
    One question I have actually is for Mr. Carney dealing with 
dental care. As you probably noticed, the VA estimate that the 
cost for your bill is $817 million for fiscal year 2008 alone 
and almost $11.3 billion over the next 10 years, which is 
pretty costly.
    Is your interest primarily in making sure that they get 
dental care? And if so, would you be amenable to working with 
the Armed Services Committee in opening up dental care? A good 
example is the Army National Guard. Even though they might have 
a dentist in the facility--in their State, all that they can do 
is look into your mouth and say you have a problem. They can't 
take care of it.
    Would you be amenable in trying to change the rules and 
regulations so that maybe the U.S. Department of Defense (DoD) 
or Army National Guard might be able to take care of some of 
the dental care?
    The other area you mentioned is contracting out. I know in 
Maine for instance, that some dentists they make their own 
right there on site. Other dentists actually contract out with 
a denturist. However, when they bill for the dentures, it is 
six-seven times higher than what they actually paid for it.
    Would you be amenable to looking at having more denturists 
within the VA system and making them in-house versus 
contracting that out?
    Mr. Carney. Of course. Anything that would help the dental 
health of our veterans I would support. And, of course, we are 
very sensitive to the costs of these things. The $11 billion 
number was much higher than the one that we had.
    But whatever we can do to assure that we are taking care of 
our veterans and covering this 90 percent of the population of 
service disabled that don't have the dental coverage I think we 
should explore.
    It is not about us. It is not about any particular bill. It 
is about doing the right thing by our veterans. And of course I 
will be able to do that.
    Mr. Michaud. Okay. Thank you. Once again I would like to 
thank our four panelists for your testimony this morning. I 
look forward to working with you as we look at each one of 
these individual pieces of legislation. Thank you very much for 
coming here this morning. Thank you. We have one more piece of 
legislation this morning, which I am presenting. So I will turn 
the gavel over to Mr. Miller.
    Mr. Miller. Thank you, Mr. Michaud. Also, I would like to 
ask unanimous consent that my opening statement be placed into 
the record.
    [The prepared statement of Congressman Miller appears on p. 
32.]
    Mr. Michaud. Without objection.
    Mr. Miller [presiding]. Thank you. I also might add there 
was a comment by a colleague earlier in regards to tax cuts and 
spending, and certainly we all understand we need to be prudent 
with our expenditures.
    If we have $50 billion that this Congress can pass for AIDS 
in Africa, certainly we have the ability to spend the necessary 
dollars, and we all agree on veterans. The money is there. It 
is how this Congress decides to allocate that money.
    Mr. Michaud, you are recognized.

STATEMENT OF HON. MICHAEL H. MICHAUD, CHAIRMAN, SUBCOMMITTEE ON 
HEALTH, COMMITTEE ON VETERANS' AFFAIRS, AND A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF MAINE

    Mr. Michaud. Thank you very much. I present H.R. 5554.
    Nearly 300,000 veterans of Operation Enduring Freedom (OEF) 
and Operation Iraqi Freedom (OIF) have been seen by the VA 
healthcare system. And over 40 percent of these individuals 
were diagnosed with mental health conditions.
    Separating from military service can be a very difficult 
transition. Mental and physical wounds make it even more 
difficult for veterans to adjust.
    According to the VA Office of Public Health and 
Environmental Hazard, 48,661 OEF and OIF veterans have met 
criteria for substance use disorder. This number only 
reflects--the veterans who have been seen by the VHA, which 
means that the total number of veterans with substance use 
disorder is likely higher than that number. Also when you look 
at the lower income veterans they too have a higher prevalence 
of substance use disorder.
    To address this issue, Ranking Member Miller and I 
introduced the Veterans Substance Use Disorder Prevention and 
Treatment Act of 2008.
    Our legislation will require the VA to provide the full 
continuum of care for substance use disorder, and it will 
require this full spectrum of care to be available at every VA 
medical center.
    Our legislation will also direct the VA to conduct a pilot 
program for internet-based substance use disorder treatment for 
OEF and OIF veterans. This will enable our newest generation of 
veterans to overcome the stigma associated with seeking 
treatment and receiving the necessary care--in a comfortable 
and secure setting.
    We heard from individuals in the past that Internet-based 
substance abuse disorder treatment can be very beneficial and 
helpful. So I think that is definitely an option.
    This bill is not a finished product. I appreciate the 
comments from the witnesses today.
    Substance abuse can tear apart a family and individual 
lives. We have heard it over and over again from veterans, from 
their spouses, what effect it has on the family. I think it is 
very important that this Committee do whatever we can to 
provide service in this particular area.
    With that, Mr. Miller, I will yield back the balance of my 
time and answer any questions that anyone might have.
    [The prepared statement of Congressman Michaud appears on
p. 35.]
    Mr. Miller. Ms. Berkley. Mr. Hare, excuse me. No, Ms. 
Berkley.
    Ms. Berkley. Thank you very much. And I think this is an 
important piece of legislation. It dovetails nicely with my 
legislation.
    And if I can refresh your memory, I had a constituent by 
the name of Justin Bailey who developed a substance abuse 
problem when he came back from Iraq. And his parents insisted 
that he check himself into a VA facility. It was very poorly 
run, very poorly administered, and even though Mr. Bailey was 
already taking five--was hooked on five medications, the VA 
treated him with yet another medication. And he OD'd in the 
facility. And he died under the care of the VA.
    So we definitely need to get in front of this crisis, 
because it is nothing less than a crisis. But I would like to 
have more information about the Internet component. I mean, if 
you are somebody like Justin Bailey, going on the internet and 
getting information isn't going to do squat for you.
    And I don't--I mean, given the fact that our resources are 
limited, how does that--if you can explain this to me I would 
appreciate it, because I think this is far more serious than 
going on the Internet and getting some practical advice on how 
to get yourself off of--wean yourself off of drugs.
    Mr. Michaud. No. That is a very good question. It is 
something that I was kind of skeptical about at first, but 
having talked to those in the healthcare provider area, that is 
actually one area that has been very beneficial.
    That is why I am recommending that they do a pilot project 
dealing with the internet-based substance use disorder 
treatment to see how it actually works.
    That is not the primary focus of this legislation. It is 
only one component. The area we have heard about over and over 
again from our veterans is, the stigma that is attached to 
substance abuse and drug abuse. No matter what it is, there is 
a stigma attached to it. Quite frankly, some people actually 
feel more comfortable dealing with the Internet.
    If you look at our troops today, they are very Internet 
savvy. This is one option. It is not the primary focus of this 
legislation. But I think it is very important that we provide 
whatever effective tools that we can for our servicemen and 
women.
    That is why I thought it was important to set up a pilot 
project to actually see how it works.
    Ms. Berkley. And thank you for that. And, again, my only 
admonishment is if we are going--I think this is very 
important. But we better make sure the VA has the tools, and 
they have personnel trained, and enough personnel trained to 
take--to address these issues.
    When some kid like Justin Bailey checks himself into a VA 
facility, there should be an expectation by his or her family 
that someone there is going to know what they are doing and 
not--you know, like maybe read his medical records before they 
give him yet another medication.
    And I am not sure that exists right now. So we better make 
sure that the medical personnel that we are paying, actually 
know what they are doing and can treat these kids that we are 
sending to the VA or we are--I mean, we are creating, not 
creating, we are no better than, you know, doing malpractice on 
these people. If we are telling them this is an opportunity and 
a treatment that is available to you, we better make sure it is 
available with expertise and knowledge, because I feel that we 
would be contributing to the death and mental instability of 
these kids if we are sending them there with the expectation 
that they are going to get treatment and they are not.
    Mr. Michaud. Thank you.
    Mr. Miller. Any further questions? Thank you, Mr. Chairman.
    Mr. Michaud. Thank you.
    Mr. Miller. I yield back the gavel also.
    Mr. Michaud [presiding]. Thank you. I would like to call up 
the second panel.
    The second panel will include Joseph Wilson who is the 
Deputy Director of Veterans Affairs and Rehabilitation 
Commission of the American Legion; Joy Ilem, Disabled American 
Veterans (DAV); Christopher Needham who is with the Veterans of 
Foreign Wars (VFW) of the United States and Richard F. Weidman 
who is--it is Bernie Edelman from the Vietnam Veterans of 
America (VVA).
    So I want to thank this panel for coming today. I look 
forward to your testimony. And I would now recognize Mr. Wilson 
for your testimony.

   STATEMENTS OF JOSEPH L. WILSON, DEPUTY DIRECTOR, VETERANS 
AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; JOY J. 
    ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED 
  AMERICAN VETERANS; CHRISTOPHER NEEDHAM, SENIOR LEGISLATIVE 
 ASSOCIATE, NATIONAL LEGISLATIVE SERVICES, VETERANS OF FOREIGN 
WARS OF THE UNITED STATES; AND BERNARD EDELMAN, DEPUTY DIRECTOR 
 FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

                 STATEMENT OF JOSEPH L. WILSON

    Mr. Wilson. Thank you, Mr. Chairman. Mr. Chairman and 
Members of the Subcommittee, thank you for this opportunity to 
present the American Legion's views on these pieces of 
legislation.
    We will begin with H.R. 2818. This bill seeks to amend 
title 38 to provide for the establishment of Epilepsy Centers 
of Excellence within the VHA of the Department of Veterans 
Affairs.
    According to VA research, approximately 53 percent of 
veterans who suffered a penetrating traumatic brain injury or 
TBI in Vietnam developed epilepsy within 15 years. The VA, in 
its effort to treat this condition, became the leader in 
epilepsy research. However, due to lack of funding, research 
resources eventually diminished.
    According to the American Academy of Neurology or AAN, 
returning veterans with TBI injuries will eventually develop 
post traumatic epilepsy. Currently there is an increasing need 
for the presence of epilepsy centers throughout the Nation. 
This is due to the high count of Operation Iraqi Freedom/
Operation Enduring Freedom or OIF/OEF troops returning with 
TBI.
    The American Legion supports the efforts of H.R. 2818, 
which proposes to establish Centers of Excellence within the 
Department of Veterans Affairs for the various injuries related 
to blast trauma.
    This would also ensure the best quality of care and 
treatment is accessible to current and future veterans 
suffering from the effects of blast injuries, to include 
epilepsy.
    Next are H.R. 5554. This bill seeks to amend title 38 to 
expand and improve healthcare services available to veterans 
from the Department of Veterans Affairs for substance abuse 
disorders and for other purposes.
    This bill also proposes that the medical center provides 
ready access to a full continuum of care for substance use 
disorders for veterans in need of such care.
    The American Legion has no official position on this issue. 
However, when substance abuse disorders are secondary to 
service-connected conditions, it is our position that veterans 
should have full access to the quality and adequate healthcare 
in which they are entitled.
    H.R. 5595, this bill seeks to amend title 38 to direct the 
Secretary of Veterans Affairs to provide dental care to 
veterans with service-connected disabilities and for other 
purposes.
    The American Legion has no official position on this issue.
    H.R. 5730, this bill seeks to direct the Secretary of 
Veterans Affairs to display in each prosthetic and orthotic 
clinic of the Department of Veterans Affairs an Injured and 
Amputee Veterans Bill of Rights.
    The American Legion has no official position on this issue.
    H.R. 5729 seeks to direct the Secretary of Veterans Affairs 
to provide comprehensive healthcare to children of Vietnam 
veterans born with spina bifida.
    The American Legion endorses the expansion of the spina 
bifida program provided by H.R. 5729. It will ensure that the 
child of any veteran who suffers from this crippling birth 
defect resulting from their parent's exposure to Agent Orange 
during military service receives complete medical care.
    H.R. 5622 seeks to direct the Secretary of Veterans Affairs 
to carry out a pilot program to establish standards of access 
to care for veterans seeking healthcare from certain Department 
of Veterans Affairs facilities.
    The American Legion agrees with H.R. 5622. However, in the 
event VA is unable to schedule the veteran for an appointment 
within 30 days and VA contracts with non-VA facilities, it must 
be ensured these facilities are in par with VA standards.
    Mr. Chairman and Members of the Committee, the American 
Legion sincerely appreciates the opportunity to submit 
testimony on these pieces of legislation. Thank you.
    [The prepared statement of Mr. Wilson appears on p. 36.]
    Mr. Michaud. Thank you. Ms. Ilem.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Mr. Chairman and Members of the 
Subcommittee.
    We appreciate the opportunity to present the views of the 
Disabled American Veterans on the healthcare measures before 
this Subcommittee today, which cover a range of issues 
important to DAV, veterans and their families.
    The first measure under consideration, H.R. 2818, would 
require the VA Secretary to designate not less than six 
healthcare facilities as centers of excellence in research, 
education, and clinical care in the diagnosis and treatment of 
epilepsy to ensure improved access to state-of-the art 
treatment throughout the VA healthcare system.
    While DAV has no adopted resolution from our membership on 
this matter, we have been concerned about literature emerging 
to suggest the incidence of co-morbid epilepsy in veterans with 
traumatic brain injury.
    Therefore, we believe this legislation addresses a real 
need and DAV would have no objection to its passage.
    H.R. 5554, the ``Substance Use Disorders Prevention and 
Treatment Act of 2008,'' would mandate that VA provide system-
wide access to a full continuum of care for substance use 
disorders with a special emphasis on outreach to veterans who 
served in Operations Enduring and Iraqi Freedom.
    This measure would require an annual report on the 
availability of the substance use disorder treatment throughout 
the system, the number of veterans receiving such care, the 
barriers to accessing these services, and the quality of care 
provided.
    Finally, the bill would require a pilot program 
specifically designated to offer web-based--designed to offer 
web-based options for self-assessment, education, and specified 
treatment of substance use disorders.
    DAV has a growing concern about the reported effects of 
combat deployments in Iraq and Afghanistan on our newest 
generation of war veterans and the converging evidence that 
substance abuse is a significant problem for many of these 
veterans.
    For these reasons, DAV fully supports this comprehensive 
measure aimed at substance use disorder prevention, early 
intervention, outreach, education and training for veterans and 
their families to close the current gaps in VA's existing 
efforts.
    H.R. 5595, the ``Make Our Veterans Smile Act of 2008,'' 
would extend eligibility for outpatient dental services and 
treatment to all veterans with service-connected disabilities.
    DAV recognizes that the oral health is integral to the 
general health and well being of a patient and is part of 
comprehensive healthcare. Consequently, DAV supports the 
passage of this bill.
    H.R. 5622, the ``Veterans Timely Access to Health Care 
Act,'' would establish a 5-year pilot program in VISN 8 to 
ensure a 30-day standard of access to primary care for enrolled 
veterans.
    In the case where VA is unable to meet the 30-day access 
standard, the bill would require VA to contract for private 
healthcare.
    DAV supports contract care options when needed services are 
unavailable in VA facilities and in other circumstances 
authorized by law.
    However, we believe contract care should be used 
judiciously and that VA needs to better coordinate the 
contracted care it currently authorizes to ensure high quality, 
safety, and cost effectiveness.
    While we appreciate the sponsor's intentions to improve 
access to care and acknowledge that enactment of this bill 
would be helpful for some veterans, it potentially could damage 
the VA system by eroding funding needed to sustain VA's 
viability to continue providing specialized services to 
service-disabled veterans.
    For these reasons, we are unable to support this measure.
    H.R. 5729, the ``Spina Bifida Health Care Program Expansion 
Act,'' would amend the existing authority to provide a more 
comprehensive range of healthcare services for Vietnam 
veterans' children afflicted with spina bifida, including 
access to domiciliary care.
    DAV believes the goals of the bill are in the best interest 
of the children involved. Therefore, we have no objection to 
enactment of this measure.
    H.R. 5730 would require VA to establish and prominently 
display in each VA healthcare prosthetic and orthotic clinic a 
bill of rights for veterans who are injured or have 
amputations.
    The bill of rights would include the right to timely, high-
quality prosthetic and orthotic care, qualified parishioners, 
and continuity of these services throughout the VA healthcare 
system.
    We believe this measure is consistent with providing 
comprehensive, high-quality, patient-centered healthcare 
services for our Nation's sick and disabled veterans, 
especially those with specialized needs. Thus, we would have no 
objection to its enactment.
    Mr. Chairman, that concludes my testimony. And I would be 
pleased to answer any questions from you or other Members of 
the Subcommittee. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 37.]
    Mr. Michaud. Thank you. Mr. Needham.

                STATEMENT OF CHRISTOPHER NEEDHAM

    Mr. Needham. Chairman Michaud, Ranking Member Miller, and 
Members of this Subcommittee, on behalf of the 2.3 million 
members of the Veterans of Foreign Wars of the U.S. and our 
Auxiliaries, I would like to thank you for the opportunity to 
testify at today's important legislative hearing.
    There was a wide range of healthcare bills under 
consideration today. So I will limit my remarks. Our full 
comments on all may be found in my written statement.
    The VFW is pleased to support H.R. 2818, which would create 
centers of excellence for the treatment of epilepsy within VA.
    The experience of today's servicemen and women leads us to 
believe that epilepsy will be a growing problem in the coming 
years. One of the main contributing factors for some forms of 
epilepsy is brain injury, an ailment that most consider the 
signature wound of this war.
    While not much study has been done on these issues with 
respect to today's veterans, if the past is our guide, we could 
see a wave of epilepsy and other seizure disorders soon.
    The VA/DoD research into Vietnam veterans with certain 
types of head injuries showed a rate of epilepsy that was 25 
times higher than that of their non-veteran cohorts. Further, a 
large number of these disorders did not occur until at least 5 
years after the initial injury. This means that we will not see 
the impact on today's veterans for a few years.
    These centers would allow VA to better research, diagnose, 
treat, and educate about these conditions. And we urge this 
Subcommittee to take swift action to forestall what will be a 
growing problem.
    The VFW is also happy to support H.R. 5554, the ``Veterans 
Substance Use Disorders Prevention and Treatment Act.'' We are 
especially supportive of section 2 of the bill, which would 
expand the range of services the VA provides to veterans 
suffering from these disorders. It lists ten services that VA 
must provide, including peer to peer counseling, but also 
family and marital counseling. These expanded services are 
critical. Substance abuse often goes hand in hand with other 
mental health issues, such as depression and PTSD. VA's 
services for substance abuse have decreased over the last 
decade, and we need to ramp these services back up given the 
problems OEF/OIF veterans face. The VFW hopes that the 
Subcommittee favorably reports this bill.
    VFW is also happy to support H.R. 5595, the Make Our 
Veterans Smile Act. We have long believed that dental care 
should be part of the standard healthcare benefits package that 
veterans receive. Poor dental healthcare can create bigger 
healthcare problems down the road, and the image of poor dental 
care can be a barrier to employment for some veterans.
    On H.R. 5622 we have some concern. While we support the 
ultimate goal of this legislation, which is providing timely 
access to VA's high quality healthcare, we do have some 
concerns in the way in which this bill would achieve it. This 
bill would mandate VA to provide contract care when they cannot 
see a veteran within 30 days of his or her scheduled 
appointment. Contracted care comes at a rate typically much 
higher than that of VA care, further draining resources from 
the system. If the cost of this contracted care were instead 
applied to VA we believe that VA would be better able to take 
care of more veterans, reducing the waiting times that we are 
seeing. VA needs a sufficient, timely, and predictable 
healthcare budget. With that in place, we believe that the 
problems that this bill aims to solve would likely go away.
    I would note that we do strongly support the reporting 
requirements from the bill. Accurate information about the 
waiting times will better allow us to understand and fix some 
of these problems.
    We also support H.R. 5622, which would require VA to 
display a Prosthetics Bill of Rights. And we support the draft 
bill, which would expand healthcare to those children of 
Vietnam veterans who are suffering from spina bifida. Given 
that these children are suffering from the debilitating and 
lifelong effects of this condition because of their parents' 
exposure during military service, it is only fair that we give 
them proper care and the full range of healthcare services. We 
would note, though, that these benefits should also be extended 
to the children of Korean war veterans, who are also eligible 
for certain types of healthcare.
    Mr. Chairman, this concludes my statement and I would be 
happy to answer any questions you or the Members of the 
Subcommittee may have.
    [The prepared statement of Mr. Needham appears on p. 40.]
    Mr. Michaud. Thank you very much. Mr. Edelman.

                  STATEMENT OF BERNARD EDELMAN

    Mr. Edelman. Good morning, Mr. Chairman, Mr. Miller and Mr. 
Hare. VVA thanks you for holding this hearing this morning. And 
I would like to focus our oral comments, though, on only four 
of the bills under consideration by the Subcommittee.
    H.R. 2818, VVA generally supports this legislation but we 
would like to offer this caveat to you. We believe that the 
location of such centers of excellence must be in close 
proximity and closely associated and partnered with the 
Traumatic Brain Injury Centers of Excellence that are already 
in operation. We believe the reasons for this are clear. Within 
our veteran cohort, epilepsy is most often the result of 
Traumatic Brain Injury, which many consider to be the signature 
wound of the fighting in Iraq and Afghanistan. Epilepsy or 
seizure disorder caused by either a concussive or a contusive 
brain injury is never just an isolated incident. Over time, 
without proper diagnosis, treatment and care, this can impact a 
survivor's cognitive, motor, auditory, olfactory, and visual 
skills. It can also collapse a family. There is also one issue 
that needs to be considered. Although licensed clinical case 
managers number in the tens of thousands, licensed brain injury 
case managers number only in the tens of dozens, according to 
the Case Management Society of America. Of all the medically 
challenging injuries, brain injuries require the most 
involvement and cost over time. VVA believes H.R. 2818 is a 
good beginning for vitally needed legislation.
    H.R. 5554, we believe is laudable. We believe it is doable. 
Too many--far too many--veterans self-medicate to assuage the 
demons inside, demons that often derive from their experiences 
while in uniform. In order for them to lead complete and 
productive lives they need to get the monkey off their backs. 
Of course, VA is going to have to gear up to comply with the 
provisions if H.R. 5554 becomes law, they are going to need to 
find and hire enough experienced substance abuse counselors and 
clerical staff, something we believe the VA is quite adept at 
doing. We hope that they will do this as part of compliance 
with a new law.
    H.R. 5622, VVA cannot endorse, unfortunately. We believe 
that this bill would likely cause more bureaucratic and 
clerical headaches than make the delivery of healthcare more 
efficient. Congress has sought to improve the very services 
this bill seeks to remedy by appropriating several billion 
additional dollars over the past 2 fiscal years for VA 
healthcare. We would advise the Subcommittee to take a very 
hard look at the potential for damaging the very system a bill 
like H.R. 5622 seeks to help. Congress, I believe, must demand 
accountability. If there are waiting lines in Florida or in 
Seattle, there has got to be a reason for it. Is it incompetent 
management? Do they need more funding? Offering veterans simply 
the option to go out of the VA healthcare system will cause, we 
believe, major problems and will undermine the very effective 
healthcare that the VA seeks to give.
    ``The Spina Bifida Health Care Program Expansion Act,'' 
H.R. 5729, we certainly support. We would advocate, however, 
that Congress consider either as part of this bill or in a new 
bill, mandating that the VA conduct research into other 
potential intergenerational effects of exposure to dioxin and 
other toxins while in military services. We are hearing far too 
many stories from far too many children, most of them women, of 
in-country Vietnam veterans who tell of the birth defects they 
have suffered as well as birth defects suffered by their 
offspring. And they wonder, ``Could this be somehow related to 
my father's or my mother's exposure to Agent Orange?'' We have 
no answer for them, unfortunately.
    With this I conclude my oral remarks. And thank you for the 
opportunity to address you.
    [The prepared statement of Mr. Edelman appears on p. 43.]
    Mr. Michaud. Thank you very much, and once again I want to 
thank the panel for your testimony this morning. All of your 
organizations support the Epilepsy Centers for Excellence, 
either in whole or in part. The VA has stated in their 
testimony that the bill is unnecessary. How can it be that 
there is such a disconnect between the stakeholders and the 
users of the system such as yourself, and the VA's view that 
this bill is not necessary? I will start with Mr. Wilson.
    Mr. Wilson. Mr. Chairman, I could only respond by stating 
that the disconnect is lack of information or lack of outreach. 
In my visits to the VA Medical Center, if I am responding 
correctly, I have spoken with veterans who have stated that 
they are driving 70, 80 miles still to receive care. And when I 
informed them that there is either a mobile clinic or a CBOC 
within that area, they basically know nothing about it. So 
there continues to be a disconnect.
    I think I spoke on pilot programs being erected in certain 
parts of the country. Each VA Medical Center is pretty unique, 
to its respective community of course. So to establish 
consistency I think we, when we are talking about programs, we 
really need to think about it geographically because you have 
certain areas where there are large catchment areas and it does 
not reach certain veterans. And I think as far as the 
disconnect, I think in certain VISNs, they are looking at their 
respective VISN as far as contacting every veteran, when you 
are talking about VISNs where in Nevada and Wyoming and such 
places, you would hear more of a disconnect, even within the VA 
Medical Center, or amongst the VA Medical Center Staff.
    Mr. Michaud. Ms. Ilem.
    Ms. Ilem. I would just note, I remember from the Senate 
testimony, we testified on the companion bill and remembering 
what VA, I think their indication was that they felt it was 
unnecessary because, that there should not be a specialized, 
you know, one disease. These Centers of Excellence should cover 
other, other diseases. It should not be so specified. So it 
will be interesting to hear if Dr. Cross has comments today, 
specifically from you, about the suggestions that have been 
made to perhaps combine it with the TBI Center, which, you 
know, could obviously make sense in terms of looking at these 
veterans who have a potential TBI with this rate that we expect 
to increase, and perhaps epilepsy associated with that as a co-
morbid disorder.
    Mr. Needham. Sort of the ultimate goal, the reason that we 
sort of support the Centers of Excellence, is that we need an 
emphasis on this. And as Ms. Ilem was saying, that if it were 
done sort of in concert with the TBI Centers that would 
certainly be an approach we would be happy to look at. The key 
is that this is going to be a growing problem. And VA needs to 
manage it, to get on top of it, but also to research it. And as 
long as it is a high priority that is probably something we can 
support.
    Mr. Edelman. Why the VA opposes this we will find out from 
Dr. Cross, of course. But I think the reality is that very few 
medical facilities, even VA medical facilities, are capable of 
providing even the most minimal level of specialized care for 
brain injured patients. And I think that would extend to 
epilepsy. We see the idea of symbiosis, particularly if these 
are co-located, Epilepsy and Traumatic Brain Injury Centers of 
Excellence. We think that can do a lot in the form of research 
and in actually helping patients who come down with epilepsy. 
So we support it.
    Mr. Michaud. Thank you. My next question is, if you had to 
pick two of the top healthcare issues that would require a 
legislative fix, what would they be? We will start with Mr. 
Wilson again. If you had to pick two top healthcare issues that 
we should focus our attention on that would require a 
legislative fix, what would the top two healthcare issues be?
    Mr. Wilson. I would say the first being traumatic brain 
injury and the second, blind eye injury.
    Ms. Ilem. I think the substance use disorder issue is one 
of the top issues that we have concern over right now. We have 
had a number of calls, veterans and their families that are 
seeking this care and a lot of problems that they have 
encountered with VA in terms of continuity of care, having 
access to a bed, having access to detoxification services. And 
then the continuation of that care and it relates to PTSD or 
some readjustment issues, and having the combination of those 
services continue on without an interruption. So certainly the 
substance use disorder care would be high on the list. And I 
think that of the bills before us today as well I would think 
that, I mean, there is a number of them that I think would be 
certainly doable but they affect a small number of veterans and 
I think they are extremely important. The dental issue also 
would be, I think, critical as we are hearing more and more 
about that and the impact, and obviously for service-connected 
disabled veterans, you know, do not have that availability 
right now unless you are 100 percent service disabled or in 
unique circumstances. Thank you.
    Mr. Needham. I would certainly agree with the substance 
abuse and sort of the mental health/PTSD issues. Sort of hand 
in hand with that, it is not purely a legislative fix although 
it does involve legislation, is funding for Vet Centers 
particularly in the staffing side. We have done a lot to expand 
the number of them but we need full staffing to ensure that 
there are no waiting times for veterans. You know, they are 
sort of a convenient access for care particularly for veterans 
in more rural areas who do not have access to a large, 
inpatient VA hospital or facility.
    From the bills under current consideration we have a 
resolution with respect to the Epilepsy Centers of Excellence. 
So something in that direction would be good. But also, another 
one that is important came up at a hearing, I cannot remember 
when it was, earlier this year I believe, about the emergency 
care. And that would be certainly something we would hope to 
push for, where emergency care is paid for, for veterans who, I 
am trying to remember the particulars of the issue. I remember 
the bill number on that. But the emergency care----
    Mr. Michaud. H.R. 3819?
    Mr. Needham. Yeah, I believe that is it, yes, correct.
    Mr. Edelman. You know, it is really hard to pick two out of 
a dozen, or two out of ten, or whatever it is. A lot of these 
health issues are interwoven--Traumatic Brain Injury, with 
PTSD, with stigma, a whole bunch of issues that all kind of 
come together. We believe one of the greatest problems faced by 
veterans, still from Vietnam as well as OEF/OIF, is stigma 
associated with seeking help. And there is a lot of reasons 
behind the stigma. And in some of the services it is still. You 
are a wuss if you go for mental health help. And I am not sure 
what legislation needs to be done on that but it is something 
that I would gather a bunch of the experts, who are the 
servicemen and servicewomen who are affected, and listen to 
what they have to say.
    Also, I would suggest the issue that I brought up with 
Agent Orange, with dioxin. We are talking about spina bifida, 
which is recognized as being associated with exposure to this 
toxin. But there are a number of other childhood diseases, 
birth defects, that are also, we believe, associated with 
exposure to dioxin and there has been very little research. VA 
does not have any research projects going on now. When we asked 
if they have had any going on we were told, ``Well, there may 
have been one a while ago.'' They do not know. We think 
legislation that would ask them these hard questions may be the 
way to go.
    Mr. Michaud. Thank you. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman. Your questions have 
covered quite a bit of the area that I was looking at. I do 
have one question for Mr. Edelman. How do you reconcile your 
opposition to Ms. Brown-Waite's bill, H.R. 5622, because it 
allows people to go outside of the system? Yet, you have full 
support for Chairman Filner's bill, H.R. 5730, which gives the 
right to the person to select their own practitioner outside of 
the system, so long as, I think it is, they are under contract 
with VA, or they are a private practitioner with specialized 
expertise? In one instance you are saying you do not want 
people going outside of the system, and in another instance you 
are saying that it is okay.
    Mr. Edelman. Well, H.R. 5730, I believe, is the Prosthetic 
and Orthotic Clinic, which would mandate display of an Injured 
and Amputee Veterans Bill of Rights and I am not seeing any, 
any----
    Mr. Miller. Well, number three in that Bill of Rights says, 
``The right to select a practitioner that best meets the 
orthotic or prosthetic needs, whether or not that practitioner 
is an employee of the Department of Veterans Affairs, a private 
practitioner who has entered into a contract with the Secretary 
of the Department of Veterans Affairs to provide prosthetic or 
orthotic services, or a private practitioner with specialized 
expertise.''
    Mr. Edelman. We think that the prosthetics program in the 
VA has come an awful long way under Fred Downs over the past 
couple of decades. There are areas that, if you need repair, 
etcetera, you are not going to be able to travel to a VA 
Medical Center which will have the ability to do this. This can 
be contracted out. Right now the VA contracts out in fee-basis 
care something like one out of every ten healthcare dollars. We 
do not have any objection to this. We do believe, for a variety 
of reasons, you need physical therapy, you are 2\1/2\ hours 
away from the VA Medical Center, it can be done effectively 
locally, that is fine. The VA does have to get a better handle 
on this, and also get electronic health information, which we 
do not believe they may necessarily be getting now.
    When Congress has given the VA as much additional funding 
over the past 2 fiscal years as it has, it seems to us that 
waiting times should be one of the first things that needs to 
be eliminated. And there is really no reason folks cannot be 
seen within a 30-day time period. And we believe if you open 
that up by putting a, ``Well, if you cannot do it in 30 days 
you can go outside of the system,'' I think that is going to 
lead to chaos. And I do not think it is the way to go.
    Mr. Miller. So, you do not mind people going outside of the 
VA system for certain types of care?
    Mr. Edelman. For certain types of care or for the----
    Mr. Miller. Because your testimony, if I recall, was that 
allowing them to go outside, if they could not get an 
appointment within 30 days, would degrade the quality of the 
care, it would degrade the VA system. I am just trying to 
figure out, I think you might need to at least go back and 
revisit your testimony. I understand your testimony, but I 
think they are conflicting. We have heard just this morning an 
enormous amount of projects that are going to require 
additional funding and resources, and this Committee will do 
everything that it can to authorize that. It may be that some 
people would sit here and say that the first thing that you 
need to focus on with additional resources that the Congress 
provided is not shortening the wait time. If that is the case, 
then we should not trap the veteran in the system for whatever 
reason it may happen to be. You did, thank goodness, say that 
it could be for inappropriate management, or it could be for 
lack of dollars. I do not think anybody would want to say that 
the veteran would have to be trapped inside the system, and not 
be able to go outside to get the required care that is 
necessary.
    Mr. Edelman. I would not disagree with that.
    Mr. Miller. That is all, Mr. Chairman. Thank you very much.
    Mr. Michaud. Thank you. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. This question is for the 
entire panel regarding H.R. 5622, the ``Veterans Timely Access 
to Health Care Act.'' You know, I understand the VSO's concerns 
about contracting out VA care to the private sector and lack of 
oversight cost issues, etcetera. But I represent a very rural 
area. And let me give you an example of, I got a call from a 
State senator who had a veteran sitting across her desk and he 
needed a chest x-ray. In order for him to get that he was going 
to have to go 2\1/2\ hours in a van to the nearest facility. He 
would probably end up waiting hours, be at the end of the line, 
for the chest x-ray, something that he could have 5 minutes 
from where he was sitting when he made the phone call to me. 
And it seemed to me, particularly in the rural communities 
where we do not have the CBOCs, we have some. And I am 
certainly trying to get a couple more, and hopefully get a 
chance to talk to Dr. Cross about one after the hearing. But my 
point is that for a lot of veterans who have to travel those 
types of miles, what we are finding, or what I am finding is, 
veterans are saying, ``I am not getting in the van. I am not 
traveling that far. I am not going to sit there and wait for 
hours and hours and hours for something that I am 5 minutes 
away from.'' Is there not a way, or maybe there is, but is 
there not a way under this bill where things of that nature, a 
blood test, a simple blood test, and chest x-ray, blood 
pressure, whatever it is that could be done in a matter of 
minutes for this veteran literally minutes from his or her home 
can be done without having to put that person in the van.
    A lot of, as I said, because what is happening is a lot of 
veterans, you know, they are elderly. The high price of gas, as 
you know, is getting expensive just for them to make the trip. 
Is there not a way that they could get that test and have that 
information transmitted to where it needs to be without having 
to put through that type of a wait? And, you know, it would 
just seem to me, I understand major things. But these type of 
procedures that we could do literally in the matter of minutes, 
we could save hours and tons of frustration and, as I said, I 
do not want to see a veteran say, ``I am not going to go 
through this process again.'' Because to me this was just, it 
took an entire day and into the evening by the time that 
veteran got back.
    So I am wondering if, you know, if you have any thoughts on 
that and how we can make this so that we can, you know, help 
veterans, particularly as I said, I have twenty-three counties 
and literally hundreds of miles in my district. I am just 
interested, you know, in your thoughts on that.
    Mr. Wilson. Well, I think there is an inconsistency, that 
is, when speaking on issues of outreach and information being 
disseminated amongst veterans throughout this Nation; to add, 
there is a way to monitor veterans within the VA system through 
means of telemedicine and telehealth. The American Legion has 
visited various VA Medical Centers. Within these facilities are 
telehealth systems which are used to monitor the veteran's 
blood pressure as well as other vitals. While visiting in the 
State of Idaho, a veteran stated he had to travel 80 miles to 
seek medical care. He waited in the waiting room for 
approximately 2 hours, however, it took only a few minutes to 
treat this veteran. To obtain his medicine, the veteran had to 
go home again and wait. Conclusively, we found that the veteran 
was uninformed of the VA's accommodation of the veteran within 
his or her respective community. I think in this current era of 
technology, one would at least be aware that information could 
be disseminated to those veterans who are enrolled via the VA 
database. Overall, I think it is a matter of inadequate 
outreach, that is, effective outreach from VA to veterans 
throughout our Nation.
    Ms. Ilem. I would just note that I think we are really 
looking forward to the Office of Rural Health to address some 
of these issues. Certainly, you know, Congress established that 
office, you know, it has been almost over a year now and there 
were a number of bandaids to look at these very specific 
issues. And I think these factors need to be taken into 
consideration with regard to travel and geographic barriers 
that veterans face that live in, you know, significantly rural 
areas. And our concern is, is that as far as I am aware there 
is still just one staff member at the Office of Rural Health. I 
think they are in the midst of hiring an additional person. But 
without I think oversight and attention from this Committee, 
you know, I am not sure where they are going to go in terms of 
really trying to address these tough rural issues. And it seems 
to be an important issue to the Subcommittee and the full 
Committee, in fact. A number of these, you know, rural 
healthcare questions have come up and, you know, what is in the 
best interest of the veteran and what is a reasonable 
expectation in terms of travel for these more, you know, 
primary care and more minor, you know, healthcare things that 
really are important to the maintenance of their health and 
preventing, you know, larger problems. So we are hoping that 
the oversight of this Committee will, you know, bring the 
Office of Rural Health in or for these types of questions and 
hold them to the mandate of the law. There is a number of 
reports that I know are due to try to look at these issues.
    Mr. Hare. Yeah, and I would, let me just say and then my 
time is up. Mr. Chairman, I apologize for going over but for a 
veteran to have to spend 6 hours to get a chest x-ray and 
travel, and then the hospital that he lives in, if you live in 
Carlinville, Illinois, the hospital in Carlinville was 6 
minutes from his home. It just seems to me for that veteran, to 
put that person in a van, transport him for a chest x-ray that 
took literally a few minutes and then bring him back after he 
waits with all of the other vets that had to be transported 
over, we can do a whole lot better than that. And I am hopeful 
at the end of the day that we can get to the point where we can 
make it easier. Because these people are starting to get up in 
years. And this is a, this is difficult for them to be able to 
do, particularly in the Midwest, with the winters that we have, 
it makes it very difficult for them. So I am just hoping that 
at some point anything we can do to make it easier for them, 
and then transfer the data to the VA, you know, hospital, I do 
not think is going to hurt anybody. We are not asking them to 
do, we are just talking about basic, small, considered to be 
small, but basic things that do not take a whole lot of time. 
So I apologize for going over, Mr. Chairman.
    Mr. Michaud. No problem. Thank you very much, Mr. Hare. 
Once again I want to thank the panel for your testimony this 
morning. We look forward to working with each of your 
organizations as we move forward to deal with the legislation 
before us today. So, thank you. The last panel that we have 
today is Dr. Cross, who is the Principal Deputy Under Secretary 
for Health. He is accompanied by Walter Hall, who is the 
Assistant General Counsel for the Department of Veterans 
Affairs. I would like to welcome you, Dr. Cross, once again 
before this Subcommittee. I want to thank both of you for your 
service to our country and taking care of our veterans, also, 
in this great Nation of ours. Without any further ado I 
recognize Dr. Cross for your statement.

  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 
 HALL, ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Cross. Good morning Mr. Chairman and Members of the 
Subcommittee. Thank you for inviting me here today and joining 
me today is Walter Hall, Assistant General Counsel. I would 
like to request that my written statement be submitted for the 
record.
    Mr. Michaud. Without objection, so ordered.
    Dr. Cross. Mr. Chairman, we have received H.R. 5730, which 
calls for a Veterans Bill of Rights for Injured and Amputee 
Veterans. However, we have not had time yet to review the bill 
and we will submit our views for the record.
    [The Department of Veterans Affairs views for H.R. 5730 
appear on p. 56.]
    VA does not oppose H.R. 5729, which would authorize the 
Secretary to provide eligible children of Vietnam veterans or 
certain Korean conflict veterans who suffer from spina bifida 
with any needed healthcare. Providing a total healthcare 
management program to this beneficiary population would provide 
needed relief for families seeking a complete spectrum of fully 
integrated care. We offer one caveat, however. Providing such 
services in a VA domiciliary treatment setting could prove 
problematic since domiciliary care is unique to the VA 
healthcare system and is used mainly for veterans requiring 
intensive, rehabilitative outpatient care in a residential 
setting.
    H.R. 2818 would require the Secretary to designate six 
Epilepsy Centers of Excellence. While we support the concept of 
expanding epilepsy care, we believe our current and planned 
efforts are effective and responsive to clinical needs. In 
fact, VA already has seven sites capable of meeting the full 
range of clinical and affiliation requirements stated in the 
bill. And we will adjust our resources as needed in the future.
    We support the intent of H.R. 5554, the ``Veterans 
Substance Abuse Disorders Prevention and Treatment Act of 
2008,'' and we have implemented many of its provisions already. 
We fully support the goals of enhancing substance abuse 
services for veterans and our comprehensive mental health 
strategic plan is making significant process to that end. We 
note, however, that the bill would institute certain 
requirements that we believe are inconsistent with scientific 
evidence and established best practices. For instance, it would 
be better to pursue targeted approaches to case identification 
rather than mandatory or universal screening for those 
conditions. We are also concerned universal screening, we are 
talking about for drugs, may deter some veterans from seeking 
VA care. Our providers are trained to assess signs of substance 
abuse disorders and pursue appropriate follow up as needed on 
an individual basis. VA is also undertaking significant 
outreach efforts and is increasing the number of sites of care, 
and we have plans for further and greater expansion.
    H.R. 5595 would require VA to furnish outpatient dental 
services and treatment to any veteran who has a service 
connected disability. I believe I have a poster over here with 
our current dental wait time showing the remarkable progress 
that we have made. While we recognize that providing lifelong 
comprehensive dental services to veterans is laudable, 
enactment of this legislation would make an additional one 
million veterans immediately eligible for VA dental care, 
overwhelming VA's capacity to provide these services in-house. 
Expanding VA's contracting authority would result in a 
thirteenfold increase in fee basis expenses, and would cost the 
Department more than $11 billion, that was billion with a B, 
over the next 10 years.
    Finally, H.R. 5622 would establish a 5 year pilot program 
to study the feasibility of setting a 30-day standard for 
scheduling primary care appointments in VISN 8. When unable to 
meet the 30-day standard the VA would be required to contract 
care and services. With the assistance and support of Congress, 
VA has already made remarkable progress in reducing wait times. 
We would ask the Committee to forego further action as we 
anticipate eliminating this list entirely by the end of fiscal 
year 2009 thereby making this legislation unnecessary. We also 
observe that many patients prefer to schedule appointments 
beyond 30 days of the time that they contact us, and the 
requirement in this bill that veterans submit a written request 
to be seen by a VA provider after receiving care from a non-VA 
facility would be burdensome on veterans and potentially 
disruptive to their care. Further, contracted care would not 
necessarily include the comprehensive screenings, case 
management services, documented quality, and expertise in 
veteran specific conditions that is available in the VA 
healthcare system.
    Chairman Michaud and Ranking Member Miller, we sincerely 
appreciate your interest in and support of our veterans as 
reflected in the legislation you put forward. I believe these 
bills address important issues but some have technical issues 
that need to be addressed, and others duplicate existing 
efforts. Indeed, we have listened to Congress and have already 
implemented or begun development on key aspects of these 
legislative proposals. My staff and I would be happy to help 
the Committee in any way we can, including providing details on 
our ongoing efforts and new initiatives. This concludes my 
prepared statement. I would be pleased to answer any questions 
for the Subcommittee at this time.
    [The prepared statement of Dr. Cross appears on p. 44.]
    Mr. Michaud. Thank you very much, Dr. Cross. I appreciate 
your testimony. Looking at your dental waiting list, that is an 
impressive reduction in the waiting list. During that timeframe 
from 2006, or 2008, has the eligibility of who qualifies for 
dental care changed at all? Or is that consistent?
    Dr. Cross. It changed recently and I think it was a very 
good change. It was done with the support of Congress--for the 
combat veterans returning from the conflict, from 90 days to 
180 days. I was very concerned that they would get back and go 
on leave and the 90 day period would basically expire before 
they got around to applying. So we doubled it and I am hoping 
that will, you know, make it easier for some of them. That is 
the main thing that I think has changed.
    Mr. Michaud. Okay. How much dental care, in terms of 
dollars, does the VA purchase now for all veterans? And how 
many veterans is that?
    Dr. Cross. If you can give me just a moment, sir?
    Mr. Michaud. No problem.
    Dr. Cross. Currently VA dental services treat approximately 
360,000 veterans in a fiscal year. And assuming about 40 
percent of the newly eligible veterans take advantage of dental 
care, the percentage of classification IV veterans seeking 
dental care in a given year would increase by 430,000 patients 
per year, or 120 percent.
    Mr. Michaud. So it is, what, 360,000?
    Dr. Cross. Three-hundred sixty thousand, I believe, is the 
current number.
    Mr. Michaud. And that is what you contract out?
    Dr. Cross. That is what we are currently providing for 
dental services. I believe that is in-house and fee basis.
    Mr. Michaud. What I am interested in is how much are your 
fee basis? How much are you contracting out in fee basis and 
how many veterans are attributed to that?
    Dr. Cross. Well, I have my dental consultant in the room. I 
will ask if he can pass me a note if he has that information. 
Otherwise, I will get it to you in writing.
    Mr. Michaud. Okay, thank you. My next question, you 
mentioned H.R. 5554, the Substance Abuse Disorder legislation 
that the VA is currently implementing some provisions of that. 
What provisions are you implementing? How many veterans does 
that include?
    Dr. Cross. In fiscal year 2007, 33,000 OEF and OIF unique 
veterans were treated for substance abuse disorders and in 
fiscal year 2008 so far there have been about 25,488. I do not 
think those are necessarily exclusive numbers. Here are some of 
the things that we are doing, and I really appreciate the 
opportunity to mention a couple of these. Here are a couple of 
things I want to highlight. All VA Medical Centers now have 
specialized substance abuse disorders service. We have a policy 
in place for mandatory screening for alcohol problems at the 
time the patients first contact with us, and annually 
thereafter. We have established 510 new substance abuse 
counselor positions and those have been authorized. We have 
added substance abuse counselors to 132 Homeless Outreach 
Teams. And we are integrating, you know, one of the speakers 
earlier talked about stigma. And the way that we are 
approaching that, because we recognize that that is very real, 
is we are integrating mental healthcare, mental healthcare 
providers, into our primary care clinics to a place where they 
are already comfortable in going, seeing, to make the first 
diagnosis and start the treatment program right there in the 
primary care setting. I think patients find that more 
acceptable than going and sitting for the first time in a 
clinic that says, ``Mental Healthcare.'' Currently there are 19 
substance use inpatient programs, 65 substance use residential 
rehab programs that are designed exclusively for veterans with 
substance abuse problems, and 123 additional residential rehab 
programs that include substance abuse treatment.
    I wanted to talk about one other thing. One of the other 
speakers mentioned outreach. And we recognize this, and we have 
to learn new techniques for doing this. And I want to mention 
two things that we are getting ready to do or have already 
done. We have already been on Music Television Channel (MTV) to 
reach out to a different segment of the population than perhaps 
we have been used to doing in the past. I watched the segment 
just recently. It was very good. Second we are going to be 
announcing very shortly a remarkable outreach effort to 550,000 
returning veterans who have not yet come to us for care. And 
Secretary Peake will be announcing that probably in a couple of 
weeks.
    Mr. Michaud. Thank you very much. That is creative 
thinking. I never would have thought about MTV, primarily 
because I do not watch it, but, Mr. Miller? Do you watch the 
MTV?
    Mr. Miller. I have my MTV.
    Mr. Michaud. Thank you.
    Mr. Miller. That probably goes way back, though. I have 
some questions to ask. Unfortunately, I have a time constraint 
so I would like to submit them for the record and thank the 
witnesses for the testimony.
    [No questions were submitted.]
    Mr. Michaud. Thank you, Mr. Miller. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. Dr. Cross, I just have 
one. In your testimony on H.R. 5554 you said, and I am quoting 
it, ``it fails to correctly target the veterans in need of 
residential care, those with substance abuse disorders who 
cannot be managed effectively in intensive outpatient 
programs.'' How then would you propose that we correctly target 
the veterans that are in need of residential care?
    Dr. Cross. The way the bill was constructed it appeared to 
us that based on severity would choose the residential approach 
or the outpatient approach. My scientists tell me that is not 
the best way to make that decision. You really make the 
decision based more on the social support and the ability of 
the individual to participate in an outpatient program. And for 
those individuals, perhaps some homeless individuals and others 
who cannot routinely arrange to show up in an outpatient 
program, then sometimes an inpatient program, residential 
program, is better. But that is a different distinction from 
the severity of the illness. It is related to their social 
situation.
    Mr. Hare. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you. And I believe I saw that a note was 
handed to you. I assume it was on the dental?
    Dr. Cross. Sir, I am told the answer is $60 million in fee 
basis, about 40,000 veterans.
    Mr. Michaud. Sixty million dollars in fee basis, 40,000 
veterans? Have you looked at cost savings, particularly if some 
of those were in an area where it might be a lot cheaper to 
actually hire another dentist and hygienist? Have you looked at 
that to hold down costs?
    Dr. Cross. We have. And we have actually done as part of 
our expenditure last year in bringing this down, part of that 
was from in-house expansion. I do not know how much our total 
expansion was in dental in terms of patients. But yes, we are 
looking at that as well. Some of the limiting factors are, when 
our facilities were built we did not necessarily have room for 
so many chairs in place. And so you may reach a point where it 
becomes a construction issue. And so that is where we pretty 
much have gone out for contracted care at that point.
    Mr. Michaud. Are you looking at also, I will use Maine as 
an example, I know the lease in the Bangor CBOC is coming due 
and the Veterans State Nursing Home is looking at building to 
suit whatever needs the VA has for a CBOC at cost. Here is a 
situation where you actually could take advantage of additional 
dental chairs and office space for dental. Are you looking at 
opportunities such as that to help move forward? Also, 
opportunities in working with the Department of Defense. One of 
the problems that our military is faced with today regarding 
readiness is actually dental. Are you looking at working 
closely with the Department of Defense, particularly in the 
area of the Guard and Reserves, where you can collaborate in 
those areas?
    Dr. Cross. On the first question in regard to looking for 
opportunities, yes we are doing that. And I will make sure that 
our staff are looking at the one you mentioned as well. In 
regard to working with DoD, I personally have been in probably 
half a dozen meetings specifically related to dental care. And, 
you know, the concerns were what aspect of it was done before 
they left and what aspect of it was done upon their return, 
before they were turned over to us. And I think we made 
progress. And I am not sure, I would not say there was not more 
to be done, but progress has been made in that area. I think we 
are much further along than we were 2 years ago.
    Mr. Michaud. Great. And my last question actually deals 
with spina bifida. In your testimony you stated that 
beneficiaries of the Spina Bifida Health Care Program would 
benefit from services in VA's continuum of extended care 
services, such as home health, home telehealth, adult day 
health, et cetera. Would these services that you mentioned be 
covered under this legislation as it is currently written?
    Dr. Cross. These services would be comprehensive care as I 
understand it. But they would not necessarily, and probably 
not, be coming from the VA. So as a rule they would not be 
using VA capabilities.
    Mr. Michaud. But are they covered under the legislation as 
written? I see Mr. Hall shaking his head yes.
    Mr. Hall. Yes, sir. They would be covered to the extent 
that VA provides those same benefits to veterans.
    Mr. Michaud. Okay. Well, once again I know there will 
definitely be some additional questions for the record. I want 
to thank you, Dr. Cross, for your continuous service for the VA 
and your willingness to be very open with the Subcommittee as 
well. And also you, Mr. Hall, for your testimony today, your 
answering questions. Once again, I thank both of you. If there 
are no further questions we will adjourn the hearing. Thank you 
very much and thanks to the Subcommittee Members.
    [Whereupon, at 11:50 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's legislative hearing is an opportunity for Members of 
Congress, Veteran Service Organizations, the VA, and other interested 
stakeholders and parties to provide their views and discuss recently-
introduced legislation within the purview of this Subcommittee.
    The six bills before us cover a wide range of topics that are 
germane to veterans' health care. Issues addressed in today's bills 
include Spina Bifida, epilepsy research centers, substance use disorder 
treatment and prevention, expansion of dental care, timely access to 
care, and a bill of rights.
    I do not necessarily agree or disagree with these bills, but I 
believe that this is an important part of the legislative process that 
will encourage frank discussions and new ideas.
    I look forward to hearing the views of our witnesses on these 
bills.
    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. Today, we will 
examine six different legislative proposals that seek to improve the 
delivery of health care for our Nation's veterans.
    This year our Subcommittee has placed renewed focus on the mental 
health concerns of veterans by holding a series of hearings aimed at 
better understanding the unique mental health needs of America's 
heroes. One of the bills we will consider today is H.R. 5554, the 
Veterans Substance Use Prevention and Treatment Act of 2008, which 
Chairman Michaud and I introduced in March in a true bipartisan effort.
    H.R. 5554 would require each VA medical facility to provide ready 
access to comprehensive care for substance use disorders. This bill 
would also direct VA to conduct a pilot program for Internet-based 
substance use disorder treatment for veterans of Operation Iraqi 
Freedom and Operation Enduring Freedom (OIF/OEF).
    This new generation of veterans is comfortable with computers and 
this program will allow VA to reach them by utilizing new and 
innovative technology. Hopefully, this will also help overcome the 
stigma that prevents many military personnel in need from seeking 
services.
    It is important to remember that substance use disorders can be 
treated and recovery is possible. That is why it is critically 
important that we understand the nature of substance use disorder among 
our veterans and effectively break the barriers that prevent veterans 
from obtaining treatment services.
    In addition to H.R. 5554, we will also be considering H.R. 5622, 
the Veterans Timely Access to Health Ccare Act. This legislation was 
introduced by my colleague and fellow Representative from Florida, Ms. 
Brown-Waite.
    H.R. 5622 would create a pilot program aimed at making the standard 
access to care for a veteran seeking primary care 30 days from the date 
the veteran contacts the VA. If unable to meet this timeline, VA would 
be required to provide care at a non-VA facility. The veteran would 
then have a choice whether or not he or she would want to continue care 
at a VA facility.
    Ensuring that veterans seeking health care receive the necessary 
services in a timely manner has long been a priority both of mine and 
this Subcommittee. As such, I support Ms. Brown-Waite in her efforts to 
set appropriate standards for access to care to guarantee veterans 
needing help are not forced to wait unreasonable and lengthy periods of 
time before seeing a health care professional.
    Finally, I would like to thank our esteemed Chairman and my other 
colleagues for bringing forward important legislative proposals that we 
will also consider today.
    Additionally, I thank the representatives from the American Legion, 
the Disabled American Veterans, the Veterans of Foreign Wars, and 
Vietnam Veterans of America; and Dr. Cross from the VA for joining us 
this morning to discuss these and other legislative proposals.
    Our Subcommittee has always worked in a bipartisan manner and I 
look forward to continuing to work with Chairman Michaud and the other 
Members of this Committee to ensure that our veterans receive the very 
best care possible.
    Thank you Mr. Chairman, and I yield back.

                                 
              Prepared Statement of Hon. John T. Salazar,
        a Representative in Congress from the State of Colorado
    Good morning, Chairman Michaud, Ranking Member Miller and 
distinguished members of this subcommittee.
    I look forward to hearing the testimony from our colleagues and the 
experts here today.
    Thank you for joining us and sharing your knowledge and 
experiences.
    On behalf of my district, I am very interested to hear how these 
bills would affect our nation's rural veterans.
    In the third district of Colorado, access to services is a major 
issue because we have so many vets spread out over a wide area.
    I would also like to hear how the various services my colleagues 
propose will reach our veterans in rural areas.
    I welcome my friend and fellow Coloradoan, Representative Ed 
Perlmutter.
    I am a proud cosponsor of his bill that would direct the VA 
Secretary to designate, establish and operate at least six VA health-
care facilities as locations for epilepsy centers of excellence.
    I also look forward to discussing the need for improved dental care 
for our veterans, as well as the proposals to help our veterans deal 
with substance abuse.
    Mr. Chairman, I thank you and the members of this sub-committee for 
the chance to sit with our colleagues and discuss legislation that will 
have a positive effect on the health and well-being of veterans across 
the country.

                                 
               Prepared Statement of Hon. Ed Perlmutter,
        a Representative in Congress from the State of Colorado
    Good morning, Chairman Michaud, Ranking Member Miller and Members 
of the Subcommittee. I want to thank you for holding this hearing on 
H.R. 2818, the VA Epilepsy Centers of Excellence Act.
    The VA Epilepsy Centers of Excellence Act, which I introduced on 
June 21, 2007, will create at least six VA Epilepsy Centers of 
Excellence within the VA Health Ccare system. A companion bill carried 
by Senator Patty Murray passed the Senate VA Committee on December 12, 
2007. These Centers of Excellence will care for all veterans' 
experiencing seizures and especially those we predict will develop 
epilepsy as a result of suffering a Traumatic Brain Injury (TBI) while 
serving in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/
OEF).
    Epilepsy is defined as two or more seizures. During Vietnam, a 
number of men and women returned home with head wounds and head 
injuries. Of those who came home with these types of injuries, some 53% 
developed epilepsy within 15 years. Fifteen percent of those who 
developed Epilepsy did so five or more years after their combat injury.
    Last year, I met with Dr. John Booss, the former Director of 
Neurology for the VA. He advised me that in 1972, the VA responded to 
the rise in veterans returning with seizures by creating VA Health 
Centers around the nation that specialized in the treatment and 
research of epilepsy. The VA Centers partnered with medical schools to 
assist it in treating the veterans with seizures and building a body of 
knowledge concerning epilepsy. However, sometime in the 1980s or early 
1990s the increase in veterans developing epilepsy subsided, funding 
dissipated and the Centers were curtailed. At this time the VA operates 
seven Epilepsy Monitoring sites. These sites lack the resources and 
capacity to care for our current veterans with epilepsy.
    Dr. Booss and a number of organizations such as the American 
Academy of Neurology, The Epilepsy Foundation of America, the Brain 
Injury Association, and the Citizens United for Research in Epilepsy 
(CURE) have highlighted the need to rebuild the Epilepsy Centers of 
Excellence for the many men and women returning from the Middle East 
with head wounds and brain injuries. Your committee is only too aware 
of the injuries suffered by our service men and women in Iraq and 
Afghanistan. It is estimated that today some 89,000 veterans have 
epilepsy of which 42% of that number is service connected. If our 
country's experience in Vietnam is any indication of what to expect in 
the future the number of veterans with epilepsy is bound to rise.
    [As an example, after I introduced this Bill, I was contacted by 
one of my constituents, Naval Reserve Petty Officer Brian Johnson. He 
suffered a TBI while assigned to Navy Mobile Construction Battalion 7 
just outside of Fallujah, Iraq. On November 7, 2004, his position came 
under fire and he sustained a brain injury when he was blown against a 
wall when two mortars exploded nearby. After returning home he resumed 
his small plumbing business, but eventually lost it due to the 
incidence of seizures. Petty Officer Johnson's story is just one of 
many emerging from the experiences our service men and women are having 
after returning home.]
    H.R. 2818 establishes a process where VA Medical Centers partner 
with medical schools across the country to compete for the designation 
of a VA Epilepsy Center of Excellence. Six of these Centers would be 
selected by the VA and would be disbursed across the country. The VA's 
telemedicine capacity would also be expanded to track the neurological 
diagnostic tests of our rural veterans. It is anticipated that each of 
these centers would cost about $1 million for the first 4 years.
    These Centers will develop and administer treatments and possibly 
cures for our veterans that will allow them to live the best lives 
possible. Moreover, the body of knowledge developed through the 
research conducted by the VA and the medical schools will help our 
society as a whole. (And as full disclosure I should mention that I 
have a daughter with epilepsy who might benefit by the body of 
knowledge generated through the research and treatment of our veterans 
with epilepsy.)
    I want to thank the Disabled American Veterans, the Paralyzed 
Veterans, the Blinded Veterans, and the Vietnam Veterans of America and 
the other organizations I mentioned earlier for their support of this 
bill. Chairman Michaud, Ranking Member Miller and Members of the 
Subcommittee, thank you again for inviting me to testify. I look 
forward to answering any questions you may have.
Studies referenced:
    Epilepsy after penetrating head injury. I. Clinical correlates: A 
report of the Vietnam Head Injury Study. Andres M. Salazar, Brahman 
Jabbari, Stephen C. Vance, Jordan Grafman, Dina Amin, and J.D. Dillion. 
Neurology 1985; 35; 1406.

                                 
           Prepared Statement of Hon. Christopher P. Carney,
      a Representative in Congress from the State of Pennsylvania
    Good morning, Chairman Michaud and Ranking Member Miller. Thank you 
for holding today's hearing. I appreciate having the opportunity to 
discuss a bill I introduced with Congressman Mark Kirk, H.R. 5595, the 
Make Our Veterans Smile Act.
    The Make Our Veterans Smile Act will expand dental care offered by 
the Department of Veteran Affairs (VA) to all service connected 
disabled veterans. The VA has done an excellent job of providing dental 
services to those that are able to receive them and the VA should 
continue to provide these services. However, it is understandable that 
the VA will have problems meeting the demand for dental services that 
will occur because of this legislation. That is why this legislation 
allows service connected disabled veterans to use contractor facilities 
for dental care. However, this legislation does not mandate that 
contractor facilities be used. Instead it simply gives the VA greater 
authority to use these facilities.
    While I am glad that the VA currently covers dental care for 
approximately 360,000 veterans, there are many disabled veterans who 
are not able to receive even basic dental care through the VA. I 
believe we have a moral obligation to care for these veterans.
    In 2000, the Department of Health and Human Services released a 
report entitled Oral Health in America: A Report by the Surgeon 
General. This report states ``the oral cavity is a portal of entry as 
well as the site of disease for microbial infections that affect 
general health status.\1\ Individuals such as immunocompromised and 
hospitalized patients are at greater risk for general morbidity due to 
oral infections.'' It goes on to say that, ``Oral-facial pain, as a 
symptom of untreated dental and oral problems and as a condition in and 
of itself, is a major source of diminished quality of life. It is 
associated with sleep deprivation, depression, and multiple adverse 
psychosocial outcomes,'' and that ``self-reported impacts of oral 
conditions on social function include limitations in verbal and 
nonverbal communication, social interaction, and intimacy.'' These are 
just a few of the ways poor oral health can affect a disabled veteran's 
life and their overall general health.
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services. Oral Health in 
America: A Report of the Surgeon General--Executive Summary. Rockville, 
MD: U.S. Department of Health and Human Services, National Institute of 
Dental and Craniofacial Research, National Institutes of Health, 2000: 
Part Three.
---------------------------------------------------------------------------
    The cost of this bill is a cost of war; it is an investment in our 
way of life and our future. As every member of this subcommittee knows, 
to ensure a ready fighting force tomorrow we need to take care of our 
veterans today. I would also like to point out that conditions such as 
missing teeth and cavities can be barriers in seeking employment and I 
believe every effort must be made to ensure that there is a smooth 
transition for our military members who are entering the civilian 
workforce. We must also ensure that disabled veterans from wars past 
are also given every tool to keep a meaningful job and this includes 
dental care.
    I would like to thank the Enlisted Association of the National 
Guard of the United States, the Navy Reserve Association, the Air Force 
Association, the Military Order of the Purple Heart and AMVETS for 
their support of this bill.
    I would also like to thank again Chairman Michaud and Ranking 
Member Miller for holding this hearing and for allowing me to testify. 
I would be happy to answer any questions you may have.

                                 
        Prepared Statement of Hon. Michael H. Michaud, Chairman,
                         Subcommittee on Health
    Nearly 300,000 veterans of Operation Enduring Freedom or Operation 
Iraqi Freedom have been seen by the VA Health Care system, and over 40 
percent of these individuals were diagnosed with mental health 
conditions.
    Separating from military service can be a very difficult 
transition. Mental and physical wounds make it even more difficult for 
a veteran to adjust.
    Unfortunately, many veterans turn to drugs or alcohol to self-
medicate their mental and physical wounds.
    According to the VA Health Care Utilization Among U.S. Global War 
on Terrorism (GWOT) Veterans, VA Office of Public Health and 
Environmental Hazards January 2008, 48,661 OEF/OIF veterans have met 
criteria for substance use disorder.
    This number only reflects veterans who have been seen by the 
Veterans Health Administration, which means that the total number of 
veterans with substance use disorder is likely higher.
    According to the November 2007 National Survey on Drug Use and 
Health, over 7 percent of veterans met the criteria for a past year 
substance use disorder, and approximately one-quarter of veterans age 
18 to 25 met the criteria for a past year substance use disorder.
    Lower income veterans also have a higher prevalence of substance 
use disorder.
    To address this issue, Ranking Member Miller and I introduced the 
Veterans Substance Use Disorder Prevention and Treatment Act of 2008.
    Our legislation will require the VA to provide the full continuum 
of care for substance use disorder, and it will require this full 
spectrum of care to be available at every VA medical center.
    Our legislation will also direct the VA to conduct a pilot program 
for internet-based substance use disorder treatment for veterans of 
Operations Enduring Freedom and Iraqi Freedom. This will enable our 
newest generation of veterans to overcome the stigma associated with 
seeking treatment and receive the necessary care in a comfortable and 
secure setting.
    This bill is not a finished product and I appreciate the comments 
from the witnesses today.
    Substance abuse can tear apart families and ruin lives. I look 
forward to working with the VA, my colleagues and interested 
stakeholders to ensure that the appropriate care and treatment is 
available throughout the VA system, and that we explore new ways to 
encourage our newest generation of heroes to seek help.

                                 
        Prepared Statement of Joseph L. Wilson, Deputy Director,
    Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to submit The American Legion's 
views on the issues under consideration by this Subcommittee.

                               H.R. 2818

    This bill seeks to amend title 38, United States Code, to provide 
for the establishment of Epilepsy Centers of Excellence within the 
Veterans Health Administration (VHA) of the Department of Veterans 
Affairs (VA). This bill would also ensure that the proposed Epilepsy 
Centers of Excellence function as such in research, education, and 
clinical care activities in the diagnosis and treatment of epilepsy.
    According to VA research approximately 53 percent of veterans who 
suffered a penetrating Traumatic Brain Injury (TBI) in Vietnam 
developed epilepsy within 15 years. VA, in its effort to treat this 
condition, became the leader in epilepsy research. However, due to lack 
of funding, research resources eventually diminished.
    According to the American Academy of Neurology (AAN), returning 
veterans with TBI injuries will eventually develop Post Traumatic 
Epilepsy (PTE). Currently, there is an increasing need for the presence 
of Epilepsy Centers throughout the nation. This is due to the high 
count of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) 
troops returning with TBI.
    The American Legion supports the establishment of Centers of 
Excellence within VA for the various injuries related to blast trauma. 
This would also ensure the best quality of care and treatment is 
accessible to current and future veterans suffering from the effects of 
blast injuries, to include epilepsy.

                               H.R. 5554

    This bill seeks to amend title 38, United States Code, to expand 
and improve health care services available to veterans from VA for 
substance abuse disorders, and for other purposes. This bill also 
proposes that the medical center provides ready access to a full 
continuum of care for substance use disorders for veterans in need of 
such care. H.R. 5554 also proposes a pilot program for internet-based 
substance use disorder treatment for OIF/OEF veterans.
    If approved, these pilot programs will be located within those 
medical centers of the Department of Veterans Affairs that have 
established Centers of Excellence for Substance Abuse Treatment and 
Education or that have established a Substance Abuse Program Evaluation 
and Research Center.
    The American Legion has no official position on this issue. 
However, when substance abuse disorders are secondary to service-
connected conditions, it is our position that veterans should have full 
access to the quality and adequate health care in which they are 
entitled.

                               H.R. 5595

    This bill seeks to amend title 38, United States Code, to direct 
the Secretary of Veterans Affairs to provide dental care to veterans 
with service-connected disabilities, and for other purposes.
    The American Legion has no official position on this issue.

                               H.R. 5730

    This bill seeks to direct the Secretary of Veterans Affairs to 
display in each prosthetic and orthotic clinic of the Department of 
Veterans Affairs an Injured and Amputee Veterans Bill of Rights.
    The American Legion has no official position on this issue.
    Mr. Chairman and members of the Subcommittee, The American Legion 
sincerely appreciates the opportunity to submit testimony and looks 
forward to working with you and your colleagues to resolve these 
critical issues. Thank you.

                                 
   Prepared Statement of Joy J. Ilem, Assistant National Legislative 
                               Director,
                       Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this hearing, and for the opportunity to present the views 
of our organization on health care legislation before the Subcommittee 
today. 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.
    The measures before the Subcommittee today cover a range of issues 
important to DAV, to veterans and their families. My testimony includes 
a synopsis of each of the bills being considered, along with DAV's 
position or other commentary. Our comments are expressed in numerical 
sequence of the bills.
H.R. 2818--To amend title 38, United States Code, to provide for the 
        establishment of Epilepsy Centers of Excellence in the Veterans 
        Health Administration of the Department of Veterans Affairs
    This measure would require the Secretary to designate not less than 
six Department of Veterans Affairs (VA) health care facilities as 
epilepsy centers of excellence. The bill would intend these sites to 
function as centers of excellence in research, education, and clinical 
care in the diagnosis and treatment of epilepsy, and would include 
training of medical residents and other VA specialized providers to 
ensure improved access to state-of-the art treatment throughout the VA 
health care system.
    The bill would establish a peer review panel, consisting of experts 
on epilepsy and complex multi-trauma associated with combat injuries, 
including post-traumatic epilepsy, to assess the scientific and 
clinical merit of proposals submitted by VA facilities for 
consideration to be designated as Epilepsy Centers of Excellence under 
this bill. The peer review panel would be required to report its 
assessment of such proposals to the Under Secretary for Health, 
presumably to strengthen the Secretary's decision to designate Centers 
on the basis of merit (but the bill does not specify this peer review 
as a precursor to the Secretary's designations). The Subcommittee may 
wish to make that minor modification to the bill to ensure the best 
proposals are considered by the Secretary as determined by the peer 
review panel.
    Finally, the bill would require the Secretary to consider 
appropriate geographic distribution when making site selections, and 
would authorize $6 million for each of fiscal years 2008-2012 to 
establish and operate these Centers.
    While DAV has no adopted resolution from our membership on this 
matter, we have been briefed by professional associations concerned 
about the decline of availability of epilepsy services in the VA, and 
we share their concerns. Also, literature is emerging to suggest the 
incidence of co-morbid epilepsy in veterans with traumatic brain 
injury. Therefore, we believe this timely legislation addresses a real 
need, and DAV would have no objection to its passage.
H.R. 5554--Veterans Substance Use Disorders Prevention and Treatment 
        Act of 2008
    This measure would amend section 1720A of title 38, United States 
Code, to mandate that VA provide eligible veterans system-wide access 
to a full continuum of care for substance use disorders. The bill would 
require substance use screening in all VA settings; detoxification and 
stabilization services; intensive outpatient care services; relapse 
prevention services; outpatient counseling services; residential 
substance abuse services for severe disorders; pharmacological 
treatments to reduce cravings, including opioid substitution therapy 
when needed; coordination with peer counselors; short term, early 
interventions when needed; and, marital and family counseling. 
Additionally, the bill would require the Secretary to provide outreach 
to veterans who served in Operation Enduring Freedom and Operation 
Iraqi Freedom (OEF/OIF), to increase awareness within that population 
about availability of these VA specialized services for substance use 
disorders.
    H.R. 5554 would attempt to ensure more equitable access to VA 
substance use disorder treatment by allocating funding to assure that 
the full continuum of substance use disorder care was provided to all 
veterans in need, irrespective of their residences. Also, to that end 
it would require an annual report on the number of veterans who used 
care within the substance use disorder continuum as a proportion of all 
veterans who used care at the facility, the number of veterans who were 
screened and the number of veterans who were identified as having a 
substance use disorder, the number of veterans who were referred for 
substance use disorder treatment, and the number of veterans who 
received such care. The report would also address the availability of 
substance use disorder care at each VA facility. Under the terms of 
this bill, this report would be reviewed by the Committee on Care of 
Severely Chronically Mentally Ill Veterans. That Committee would 
analyze and further report the availability of care along the 
continuum, the barriers to access such services and the quality of 
services provided.
    Finally, the bill would require a pilot program specifically 
designed to offer worldwide web-based options for self-assessment, 
education and specified treatment of substance use disorders. The 
program would include, on a voluntary basis, any OEF/OIF veteran, and 
would be accessible from remote, particularly rural, areas. In 
designing the pilot program, the Secretary would be required to 
consider similar pilot programs of the Department of Defense for the 
early diagnosis and treatment of post traumatic stress disorder (PTSD) 
and other mental health conditions, and carry out such programs in VA 
medical centers that have established Centers of Excellence for 
Substance Abuse Treatment and Education, or that have established a 
Substance Abuse Program Evaluation and Research Center.
    DAV fully supports the Veterans Substance Use Disorders Prevention 
and Treatment Act of 2008. As noted in prior testimony, DAV has a 
growing concern about the reported effects of combat deployments in 
Iraq and Afghanistan on our newest generation of war veterans, a 
steadily rising proportion of whom are serving multiple deployments and 
long separations from family. There is converging evidence that 
substance abuse is a significant problem for many OEF/OIF veterans--and 
that the incidence of this problem will likely continue to rise. 
Although substance abuse is a complex problem, there is clear evidence 
that treatment can be brought to bear to reduce some of the negative 
consequences of overuse of substances. This comprehensive measure would 
ensure the unique services necessary to address substance use disorders 
are provided consistently throughout the VA health care system. 
Untreated substance abuse can result in severe physical consequences 
for the veteran, additional stress on the veterans' families, and a 
marked increase in preventable health and social costs.
    We owe our nation's disabled veterans access to timely and 
appropriate care, including specialized treatment programs for those 
suffering with post deployment mental health and related substance use 
disorders. We applaud the Chairman and cosponsors for advancing this 
timely bill that would aim effective VA substance use disorder programs 
at prevention, early intervention, outreach, education and training, 
for veterans and their families, to close the current gaps in VA's 
existing efforts. We support its passage and offer no recommendations 
for amendments.
H.R. 5595--Make Our Veterans Smile Act of 2008
    H.R. 5595 would amend section 1712(a)(1)(G) of title 38, United 
States Code to extend eligibility for outpatient dental services and 
treatment, and related dental appliances, to all veterans with service-
connected disabilities. Current law limits such services to veterans 
with a service-connected disability rated permanently and totally 
disabling; former prisoners of war; to a veteran who sustained a dental 
trauma during military service; and in other very limited circumstances 
related to necessary, ongoing or completion of VA treatment or care. It 
would further allow VA to provide these services through contract 
providers.
    DAV recognizes that oral health is integral to the general health 
and well-being of a patient, and is part of comprehensive health care. 
For these reasons, we support this measure to provide dental services 
to all veterans with service-connected disabilities--a reasonable 
corollary to DAV Resolution No. 178, which supports legislation that 
would provide dental services to all veterans enrolled in VA health 
care. Consequently DAV would have no objection to the passage of this 
bill.
H.R. 5622--Veterans Timely Access to Health Care Act
    This bill would establish a five-year pilot program in Veteran 
Integrated Services Network (VISN) 8 (primarily the State of Florida 
minus most of the Panhandle, but including several Georgia and Alabama 
counties) to ensure a standard of access to primary care for enrolled 
veterans in need of primary health care from VA. Under the bill the 
standard for access to care would be 30 days from the date the veteran 
contacted the VA facility seeking an appointment, until the date the 
primary care visit was actually completed. This measure would require 
VA to conduct periodic performance reviews of the access standards in 
all facilities within VISN 8 and provide Congress an annual report to 
outline the Department's performance in meeting the established 
standard of access to care.
    In the case of any enrolled veteran for whom VA facilities were 
unable to meet the 30-day access standard, the bill would require VA to 
contract for private health care using its existing contracting 
authority (Section 1703(a), title 38, United States Code). 
Additionally, payment for contracted services under this procedure 
would not be permitted to exceed the Medicare reimbursement rate for 
similar services, and under the bill the private provider involved 
could not require the veteran to defray any difference between the 
provider's invoiced charge and that paid by VA.
    H.R. 5622 includes additional quarterly reports to identify the 
number of newly enrolled veterans in VISN 8 after enactment, versus the 
numbers of veterans enrolled in that VISN before October 1, 2001, who 
fall within specified waiting time ranges for primary and specialty 
care. The reports would also include the number of veterans who enroll 
in VA, but who had not sought care in a VA facility since enrollment.
    Finally, the bill would require any veteran whose care were 
contracted out under the terms of this bill who wished to return to a 
VA facility's care to submit a written notice of intent to return, but 
only after expiration of a 30-day period receiving non-VA care. Such a 
veteran would then be authorized to return to VA-provided care, if 
capacity within the VA facility were available to accommodate that 
return.
    DAV appreciates the bill's intent to ensure timely access to health 
care services for veterans in VISN 8. However, in our judgment 
contracting for care is not the best option for addressing this 
problem. DAV has maintained this principle in commenting on other 
bills, and we do so here. To guarantee access to care, VA must receive 
sufficient, timely and predicable funding. Over the past several budget 
cycles Congress has provided increased discretionary appropriations for 
veterans' medical care, but at the same time there have been even 
higher increases in demand for services. Additionally, the budget has 
been late arriving every year, and as a consequence, VA's ability to 
effectively plan and properly manage its resources was greatly 
hampered.
    VA currently spends more than $2 billion annually on contract 
health care services. Unfortunately, VA does not routinely monitor this 
care, consider its relative costs, analyze patient care outcomes, or 
even establish patient satisfaction measures for most contract 
providers. VA has no established systematic process for contracted care 
services to ensure that:

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

    Currently, VA is implementing a Congressionally authorized pilot 
project titled ``Project HERO''--Health Care Effectiveness through 
Resource Optimization. The VISN 8 network is one of the demonstration 
sites participating in this project. According to VA, the purpose of 
Project HERO is to better manage private health care services VA 
purchases, and to ensure that community providers meet the quality 
standards of VA care in caring for participating veterans. As noted by 
VA, one expected benefit of Project HERO is improvement in access to 
specialty care services by veterans living in underserved areas. Given 
the early stages of this initiative, it is unclear what benefits 
Project HERO will yield in providing more timely access to VA health 
care services. In a similar vein, we question whether Congress should 
authorize two competing pilot projects in the same VISN purportedly 
aimed at solving the same problem. Thus, aside from our principled 
opposition to contracting as a primary means of solving access 
shortages in VA, we are concerned about the potential confusion 
enactment of this bill would spur in VISN 8 as it implements the 
Project HERO program.
    DAV is a strong supporter of a robust, viable VA health care 
system, sustained to provide highly specialized health care resources--
some of them unique--to wounded and ill war veterans. DAV supports 
contract care options when needed services are unavailable in VA 
facilities, and in other circumstances authorized by law; however, 
contract care should be used judiciously and VA coordination of outside 
care is essential to ensure high quality, safety and cost 
effectiveness. While we appreciate that enactment of this bill would 
seem to be helpful in the short run for some veterans, it potentially 
could damage the VA system by eroding funding needed to sustain VA's 
viability to continue providing specialized resources to service-
disabled veterans. For these reasons we are unable to support this 
measure, but we appreciate the sponsor's intentions to improve access 
to care.
H.R. 5729--The Spina Bifida Health Care Program Expansion Act
    This bill would amend the language of section 1803(a), title 38, 
United States Code. This section provides basic authority for health 
care services for Vietnam veterans' children afflicted with spina 
bifida. The current language states these individuals receive ``such 
health care as the Secretary determines is needed by the child for the 
spina bifida or any disability that is associated with such 
condition.'' Under the bill, this language would be stricken and 
replaced with ``health care under this section.'' Such simplification 
of authority would ease determinations on eligibility to specific 
health care services, eliminate concerns that arise on the definition 
of ``child'', and moot the need for an association of a specific 
condition with spina bifida. Consequently this amended language would 
likely save administrative costs for VA and improve the quality of life 
for these children and their parents. Finally, this measure includes a 
provision to include domiciliary care as part of the health care 
services available to these individuals.
    DAV does not have a resolution in support of the specific changes 
outlined in this bill; however, we believe the goals of the bill are in 
accord with the intent of the law to provide comprehensive health care 
services to Vietnam veterans' children with spina bifida. Thus, we have 
no objection to enactment of this measure.
H.R. 5730--To direct the Secretary of Veterans Affairs to display in 
        each prosthetic and orthotic clinic of the Department an 
        Injured and Amputee Veterans Bill of Rights.
    This bill would require VA to establish and prominently display, in 
each VA health care prosthetic and orthotic clinic, a Bill of Rights 
for veterans who are injured or have amputations.
    The Bill of Rights enumerated in the bill would include the right 
to:

      access the highest quality prosthetic and orthotic care 
including the most appropriate technology and qualified practitioners
      continuity of care in the transition from the Department 
of Defense to the VA health care system, including comparable benefits 
relating to prosthetic and orthotic services
      select a practitioner that best meets their needs
      consistent, portable and comparable health care services 
and technology across the VA system of care
      timely and efficient prosthetic and orthotic care
      patient-centered care with the option to request a second 
opinion regarding prosthetic and orthotic treatment options
      receive a primary and functional secondary prosthetic and 
orthotic devices
      respectful treatment and the ability to readjust to 
civilian life through access to VA vocational rehabilitation, 
employment programs and housing assistance

    DAV does not have a specific resolution from our membership on this 
proposal; however, it is consistent with providing patient-centered, 
comprehensive, high quality health care services for our nation's sick 
and disabled veterans. Thus, DAV would have no objection to its 
enactment.
    Mr. Chairman, thank you for requesting the views and 
recommendations of DAV on these bills. This concludes my testimony and 
I would be pleased to address your questions and those from other 
Members of the Subcommittee.

                                 
               Prepared Statement of Christopher Needham,
      Senior Legislative Associate, National Legislative Services,
             Veterans of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THIS SUBCOMMITTEE:
    On behalf of the 2.3 million men and women of the Veterans of 
Foreign Wars of the U.S. and our Auxiliaries, I would like to express 
our appreciation for the opportunity to testify at today's legislative 
hearing. The issues under consideration today are of great importance 
to our members, and the entire veteran population.

                               H.R. 2818

    This legislation would establish Centers of Excellence for the 
study of and treatment of epilepsy within the Department of Veterans 
Affairs (VA). The voting delegates to the 109th VFW National Convention 
approved Resolution 669, which calls for the creation of these centers, 
and we strongly support this legislation.
    One of the contributing factors of epilepsy is brain injury. As 
many as 20 to 25% of individuals who suffer closed-head brain injuries 
eventually suffer from a form of epilepsy known as post-traumatic 
epilepsy (PTE). With the prevalence of Traumatic Brain Injuries (TBI) 
among OEF/OIF veterans, it stands to reason that VA will see an 
increase in the number of veterans suffering from PTE or other seizure 
disorders.
    In May 2007, Dr. John Boos of the American Academy of Neurology 
testified before the Senate Committee on Veterans' Affairs with respect 
to research into these conditions and what we can expect from the 
present conflicts.

          ``Although we do not have data on post-traumatic epilepsy 
        from the current conflicts, the statistics from the Vietnam era 
        are alarming. VA-funded research conducted in collaboration 
        with the Department of Defense found that 53 percent of 
        veterans who suffered a penetrating TBI in Vietnam developed 
        epilepsy within 15 years. For these service-connected veterans, 
        the relative risk for developing epilepsy more than 10 to 15 
        years after their injury was 25 times higher than their age-
        related civilian cohorts. Indeed, 15 percent did not manifest 
        epilepsy until five or more years after their combat injury. As 
        neurologists, we believe that the rate of epilepsy from blast 
        TBI will also be high.''

    Given the lack of research, and the outstanding questions 
concerning the condition, as well as what is likely to be a dramatic 
increase in the patients seeking treatment through VA, we clearly need 
these centers of excellence for epilepsy. Their creation would improve 
research, clinical care, diagnosis and education and outreach efforts 
throughout the entire Department and veteran community.
    We thank Representative Perlmutter for introducing this important 
legislation, and we would urge the Subcommittee to take action to 
ensure this bill's passage.

                               H.R. 5554

    The VFW is pleased to support the ``Veterans Substance Use 
Disorders Prevention and Treatment Act.'' This legislation would create 
a pilot program to expand and improve VA's ability to treat veterans 
suffering from substance use disorders.
    Section 2 of the bill enumerates ten types of care for the 
treatment of these disorders, including inpatient and outpatient 
counseling. We are especially pleased to see peer to peer counseling, 
interventions and marital and family counseling included among the 
types of services this bill would mandate. This bill takes it a step 
further, requiring VA to conduct outreach about the range of services 
the department provides to OEF/OIF veterans, which will help those 
affected by these disorders get the treatment they need to overcome 
these conditions.
    Section 3 of the bill requires VA to allocate funding for these 
programs fairly based upon the number of veterans seeking these types 
of care, not just based upon the demand for all services within an 
area. This is important since substance use disorders are quite common 
in rural areas, places where access to the full range of VA's services 
is not always easy. Improving outreach, but also the types of services 
VA can provide can only help these veterans receive proper care.
    We support section 4 of the legislation, which would expand VA's 
outreach efforts for these conditions, by creating a pilot program for 
Internet-based self-assessments. Since the majority of OEF/OIF veterans 
are computer literate, and a great number of them use the Internet as a 
daily part of their lives, a convenient web-based resource, where they 
can receive information about the range of options for treatment, can 
only help. We feel that this could also be an important resource for 
families of veterans who are concerned about their loved one's 
condition, and who desire more information about the services available 
to the veteran. When younger generations are looking for information, 
they often first turn to the Internet. This can only help get them the 
answers they are seeking.
    This issue is important because substance abuse often comes hand-
in-hand with other mental health issues, all of which are on the rise 
among OEF/OIF veterans. Substance abuse is linked to depression, PTSD, 
and many other mental health conditions. A 2007 study of the Post-
Deployment Health Reassessments from the Maine Army National Guard 
showed that about 12 percent of returning soldiers reported alcohol 
misuse. Despite this, less than half a percent were referred to 
treatment. VA's services for these conditions have gone down over the 
last decade or so, and it is clear that they must be restored to meet 
this growing demand. Treating these conditions early and managing 
problems before they worsen is the right thing to do for these brave 
men and women, giving them a hand up as they make the sometimes 
difficult transition back into civilian life.
    To alleviate the problems, we urge swift action to restore, expand, 
and improve VA's ability to treat substance abuse disorders among 
veterans.

                               H.R. 5595

    The VFW is happy to support the ``Make Our Veterans Smile Act.'' 
This legislation would require VA to provide outpatient dental care to 
all service-connected veterans. Under current law, only certain types 
of veterans are eligible for dental care, including veterans who have a 
service connection of 100%, or veterans who have a

direct service connection for dental-related issues. The majority of 
disabled veterans are not eligible for care.
    We believe that VA should provide dental care as part of the 
uniform benefits package It is an essential part of health care and 
should be provided as part of the full continuum of health care for 
which we have long advocated.
    Poor dental care can create larger health problems down the road, 
and for some veterans, poor dental health can create image problems, 
which make finding a job difficult. VA does provide dental care for 
certain veterans enrolled in the vocational rehabilitation program, but 
not every veteran is, and although we would like more veterans to 
utilize the service if they need it, it should not be a prerequisite 
for dental treatment.

                               H.R. 5622

    The VFW supports the intent of this bill, the ``Veterans Timely 
Access to Health Care Act,'' but we cannot support it. This legislation 
would create a 5-year pilot program to provide contract care for any 
veteran who would have to wait thirty days or more for primary care in 
VISN 8.
    The VFW shares the desire to see all veterans have timely access to 
high-quality VA health care. It has been and continues to be our 
highest legislative priority. We feel, however, that this legislation 
would create more problems with the availability of health care across 
the system than it would fix for those veterans in the pilot program.
    Contract care is at a much higher rate than the cost of care that 
VA provides. The problems with access to care are a function of VA not 
having enough resources. This bill would take away even more 
resources--at an inefficient price compared to VA care--from the 
system, lessening the number of patients VA can treat with limited 
healthcare dollars even further. We must be mindful of these unintended 
consequences of the legislation.
    The fix for this problem this bill aims to solve is to increase the 
resources available to VA so that they do not have to ration care. With 
proper funding, there should not be a problem. It is also important 
that VA receive funding on time, to ensure that it can properly plan 
for and manage these dollars efficiently. Additionally, on-time funding 
would allow VA to recruit, hire and train doctors, nurses and other 
health care providers, ensuring that VA has sufficient staff to keep up 
with demand. Congress has made great strides in improving the amount of 
funding--for which the VFW applauds your efforts--but a greater effort 
in delivering an on-time budget would help VA to plan properly for the 
year.
    We strongly support the reporting requirements of the bill. 
Accurate information about the waiting times across the system has been 
hard to come by, and hard numbers are always more informative than 
anecdote. Better numbers would allow us to understand the problem, if 
any, as well as to see what areas are having difficulties, aiding 
attempts to fix the problems

                               H.R. 5730

    The VFW supports this legislation, which would require the display 
of an injured and amputee veterans bill of rights. The display simply 
reaffirms the rights of these injured service men and women, letting 
them know what is expected of them, and what they can expect from VA.

   Draft Bill, the ``Spina Bifida Health Care Program Expansion Act''

    The VFW supports this legislation, which would mandate health care 
for children suffering from spina bifida of Vietnam Veterans. It would 
fulfill VFW Resolution 640, which the voting delegates to our 109th 
National Convention approved.
    Under current law, the Secretary has a lot of discretion about 
which care and services VA provides to these children. Although the 
direct care of their condition is typically covered, given the range of 
complicated health care problems they face, and its probable link to 
exposures of their veteran parent, it is only fair that the range of 
services provided to them be opened up fully. Were it not for their 
parent's military service, these children of those veterans would 
likely not be suffering from this life-long and debilitating condition. 
Expanding care to them--including the provision of the bill that would 
give VA the authority to provide domiciliary care--is clearly the 
correct thing to do.
    Mr. Chairman, this concludes my testimony. I would be happy to 
answer any questions you or the Subcommittee may have.

                                 
 Prepared Statement of Bernard Edelman, Deputy Director for Policy and 
            Government Affairs, Vietnam Veterans of America
    On behalf of the members of Vietnam Veterans of America (VVA) and 
their families, we appreciate being afforded the opportunity to offer 
testimony on the health-related legislation up for consideration before 
the distinguished members of the Subcommittee on Health.

    H.R. 2818: This bill would provide for the establishment of 
Epilepsy Centers of Excellence in the Veterans Health Administration of 
the Department of Veterans Affairs.
    While VVA generally supports the intent of this legislation, 
particularly section (e)(3) as it calls for the inclusion of veterans 
on the center facilities' advisory boards, we are obligated to voice 
our concerns with other parts of the bill as written.
    VVA considers that the location of such centers must be in close 
proximity to and closely partnered with the Traumatic Brain Injury 
Centers of Excellence which are already in operation. The reasons for 
this are clear: Within our veteran cohort, epilepsy is most often the 
result of traumatic brain injury, what many consider to be the 
``signature wound'' of the fighting in Iraq and Afghanistan. Thanks to 
antiquated legislation and budgetary cutbacks, very few medical 
facilities in the U.S. are capable of providing even the most minimal 
level of specialized care for brain-injured patients, forcing most 
survivors to find treatment hundreds of miles from home, if they can 
find it at all. And keep this in mind: more than 40 percent of our 
military deployed in Afghanistan and Iraq hail from rural America.
    In addition, the most utilized current treatment modality for 
epilepsy/seizure disorder is medication. However, epilepsy/seizure 
disorder caused by either a concussive or contusive brain injury is 
never just an isolated incident. Over time, without proper diagnosis, 
treatment and care, this can impact a survivor's cognitive, motor, 
auditory, olfactory, and visual skills. Treatment and recovery services 
and programs can also collapse a family and its finances.
    Furthermore, establishment of the epilepsy centers in partnership 
with the TBI Centers will necessitate the hiring of additional clinical 
staff to coordinate treatment and recovery plans. It should also be 
noted, however, that brain injuries cannot be managed any more than a 
thunderstorm can be managed. Although licensed clinical case managers 
number in the tens of thousands, licensed brain injury case managers 
number only in the tens of dozens, according to the Case Management 
Society of America. Of all the medically challenging injuries, brain 
injuries require the most involvement and cost over time.
    So, yes, H.R. 2818, as currently drafted, represents a good 
beginning of vitally needed legislation.

    H.R. 5730: This bill directs the Secretary of Veterans Affairs to 
display in each prosthetic and orthotic clinic of the Department of 
Veterans Affairs an Injured and Amputee Veterans Bill of Rights.
    VVA endorses H.R. 5730

    H.R. 5554: The goal of the ``Veterans Substance Use Disorders 
Prevention and Treatment Act of 2008'' is to ``expand and improve'' 
healthcare services available to veterans from the VA for substance use 
disorders. This is laudable and doable. H.R. 5554 ought to be enacted 
and action taken by the VA to immediately adapt to its provisions. And 
we applaud the provision in this bill that ``report(s) an assessment of 
the feasibility and advisability of the pilot program, of any cost 
savings or other benefits associated with the pilot program, and 
recommendations for the continuation or expansion of the pilot 
program.''
    Far too many veterans self-medicate to assuage the demons inside, 
demons that often derive from their experiences while in uniform. In 
order for them to lead complete and productive lives, they need to get 
the monkey off their backs.
    Of course, the VA will have to gear up in order to comply with the 
provisions of the bill if H.R. 5554 becomes law. A key aspect of this 
gearing up will be to find and hire enough experienced substance use 
counselors and clerical staff, something we believe the VA is quite 
adept at doing.
    VVA endorses H.R. 5554.

    H.R. 5595: The sweetly titled ``Make Our Veterans Smile Act of 
2008'' would direct the Secretary of Veterans Affairs to provide dental 
care to veterans with service-connected disabilities.
    VVA endorses this bill, even though it will mean that VAMCs will 
have to pump up their dental departments. This they ought to be able to 
accomplish, considering the boosts to VA coffers in the current fiscal 
year.

    H.R. 5622: The ``Veterans Timely Access to Health Care Act'' would, 
if enacted, set in motion a pilot program ``to establish standards of 
access to care for veterans seeking health care from certain Department 
of Veterans Affairs medical facilities.''
    This bill, however, will likely cause more bureaucratic and 
clerical headaches than make the delivery of health care more 
efficient. Also, this bill, like H.R. 4915, seemingly does not take 
into account the fact that one out of every ten healthcare dollars 
spent by the VA is spent outside the VA system.
    We fear that a bill such as this will only serve to erode the VA 
system, which has been built up since the advent of the Eligibility 
Reform Act in 1996. Congress has sought to improve the very services 
this bill seeks to remedy by appropriating several billion additional 
dollars over the past two fiscal years for VA health care. We would 
advise the subcommittee to take a very hard look at the potential for 
damaging the very system a bill like H.R. 5622 seeks to help.
    With this in mind, VVA cannot endorse H.R. 5622.

    ``Spina Bifida Health Care Program Expansion Act'': This bill is a 
sensible update, taking into account that a child afflicted with spina 
bifida is no longer a child and hence may need a variety of additional 
medical interventions and healthcare services.
    VVA would advocate, however, that Congress consider, either as part 
of this bill or in a new bill, mandating that the VA conduct research 
into other potential intergenerational effects of exposure to Agent 
Orange and other toxins in military services. We are hearing too many 
stories from too many children of in-country Vietnam veterans who tell 
of the birth defects suffered by their offspring and who wonder: Could 
this be somehow related to my father's--or mother's--exposure to Agent 
Orange?
    I thank you for affording VVA the opportunity to present our views, 
and thank you for what you are doing to assist veterans and their 
families. I will be pleased to answer any questions you may have.

                                 
          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 five 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. 5729. ``Spina Bifida Health Care Program Expansion Act''
    H.R. 5729 would authorize the Secretary to provide an eligible 
child of a Vietnam veteran who suffers from spina bifida with any 
needed health care. It would also authorize the Secretary to provide 
these beneficiaries with domiciliary care. As you know, the law 
currently limits the provision of health care services to those needed 
to treat the condition of spina bifida or an associated disability.
    VA has no objection to H.R. 5729. Providing a total health 
management program to this needy beneficiary population would provide 
needed relief for the families seeking a complete spectrum of fully 
integrated care. Spina bifida is a devastating birth defect resulting 
from the failure of the spine to close. Depending on the extent of 
spinal damage, problems resulting from spina bifida may include: 
permanent paralysis, orthopedic deformities, cognitive disabilities, 
breathing problems, or impaired basic bodily functions. Even with 
appropriate medical treatment, these children will have numerous 
secondary health conditions, such as decubitus ulcers (bed sores), lung 
infections, depression, and fractured bones. Due to the wide range of 
neurological damage and mobility impairments that can be caused by 
spina bifida, it can be difficult to identify the secondary 
disabilities that are either directly or indirectly associated with the 
condition.
    We offer one caveat, however. Providing such services in a VA 
domiciliary treatment setting could prove problematic. Services 
provided under the spina bifida program are currently furnished under 
contract. Domiciliary care is unique to the VA health care system and 
is used mainly for veteran-populations needing intensive rehabilitative 
outpatient care in a residential setting, such as veterans receiving 
treatment for substance use disorders, seriously mentally ill veterans, 
and homeless veterans. The domiciliary program is managed by Mental 
Health Services and is intended as a transitional program to return 
veterans to the community, not as a long-term residential care 
arrangement. Given the nature of the distinct clinical needs of the 
spina bifida beneficiary population and the traditional users of 
domiciliary services, we do not believe VA's domiciliaries would be 
suitable residential treatment settings for spina bifida beneficiaries. 
Instead, those beneficiaries would benefit from the services in VA's 
continuum of extended care services, e.g. home telehealth, homemaker/
home health aide, adult day health care, and nursing home care.
    As a technical matter, we note that this bill amends only 38 U.S.C. 
Sec. 1803 [related to children of Vietnam veterans]. However, a 
separate authority (38 U.S.C. Sec. 1821(a)) authorizes VA to furnish 
certain Korean conflict veterans' children born with spina bifida the 
same health care benefits that are available and furnished to Vietnam 
veterans' children born with spina bifida. Thus, by operation of law, 
the amendments included in H.R. 5729 would extend to those other 
beneficiaries as well.
    We estimate that enactment of this bill will result cost $8.4 
million in FY 2010 and $142 million from FY 2010-2019.
H.R. 2818. Epilepsy Centers of Excellence
    H.R. 2818 would require the Secretary, not later than 120 days 
after the date of the bill's enactment, to designate not less than six 
VA facilities as Epilepsy Centers of Excellence (``Centers''). Subject 
to the availability of appropriations for this specific purpose, the 
Secretary would be required to establish and operate these Centers. 
H.R. 2818 includes general procedures to be followed by the Secretary 
when designating a facility as a Center as well as qualification 
criteria for facilities seeking such designation. For instance, one 
criterion would require a facility to have (or develop in the 
foreseeable future) an affiliation with an accredited medical school 
that provides education and training in neurology, plus have an 
arrangement under which medical residents would receive education and 
training in the diagnosis and treatment of epilepsy. Other criteria 
would require a facility to be able to attract the participation of 
scientists who are capable of ingenuity and creativity in health-care 
research efforts and to also possess the capability to evaluate 
effectively the Center's activities in the areas of education, clinical 
care, and research.
    H.R. 2818 would also establish a national coordinator for epilepsy 
programs, who would report to the official responsible for neurology 
within the Veterans Health Administration (VHA). This individual would 
be responsible for supervising the operation of the Centers, 
coordinating and supporting the national consortium of providers with 
interest in treating epilepsy at VA medical facilities without a 
Center, and regularly evaluating the Centers to ensure their compliance 
with the bill's requirements.
    VA does not support H.R. 2818, because it is unnecessary. VA 
already has seven sites that have the following capabilities: 1) an 
epilepsy monitoring unit; 2) capacity to perform invasive monitoring; 
3) ability to implant vagus nerve stimulators; and 4) ability to 
perform resection of epileptic foci. Five additional sites have the 
capacity to perform epilepsy surgery but not all of the other 
components listed above.
    Moreover, it is increasingly VA's goal to have each of its medical 
facilities capable of providing state-of-the-art epilepsy care. Thus, 
the trend is to establish expertise and capacity on a system-wide 
basis, as opposed to creating a few centers of excellence across the 
country.
    We estimate the cost for FY 2008 to be $6.4 million and $64.7 
million over a ten-year period.
H.R. 5554. ``Veterans Substance Use Disorders Prevention and Treatment 
        Act of 2008''
    Currently, VA is required to develop and carry out individual 
treatment plans for veterans receiving treatment for substance use 
disorders. H.R. 5554 would further require that these treatment plans 
ensure VA medical centers provide a ``full continuum of care'' for 
substance use disorders. The bill would define a ``full continuum of 
care'' as all of the following:

      screening for substance use disorders in all settings;
      detoxification and stabilization services;
      intensive outpatient care services;
      relapse prevention services;
      outpatient counseling services;
      residential substance use disorder treatment in the case 
of veterans with severe recurring substance abuse or substance 
dependence;
      pharmacological treatment to reduce cravings and opioid 
substitution therapy;
      coordination with groups providing peer-to-peer 
counseling;
      short-term, early interventions for substance use 
disorders, such as motivation counseling, that are readily available 
and provided in a manner to overcome the stigma associated with the 
provision of such interventions and related care; and
      marital and family counseling.

    H.R. 5554 would also require the Secretary to provide outreach to 
veterans who served in Operation Enduring Freedom (OEF) or Operation 
Iraqi Freedom (OIF) to increase awareness of the availability of VA 
care, treatment, and services for substance use disorders.
    This measure would further compel the Secretary to ensure that 
amounts available for care, treatment, and services for substance use 
disorders are allocated in such a manner that a full continuum of care 
is available to every veteran seeking such services without regard to 
the location of the veteran's residence. The Secretary would also have 
to submit a detailed report on the services furnished under this 
authority as part of the budget documents submitted annually to the 
Congress, and each such report would need to be reviewed and addressed 
by VA's own Committee on Care of Severely Chronically Mentally Ill 
Veterans. The amendments concerning the allocation of funding would be 
effective October 1, 2009.
    H.R. 5554 would also require, not later than one year after the 
date of the bill's enactment, that the Secretary carry out a two-year 
pilot program to test the feasibility and advisability of providing 
veterans who seek treatment for substance use disorders with access to 
a computer-based self-assessment, education, and specified treatment 
program through a secure Internet website operated by the Secretary. 
Participation in the pilot would be voluntary and limited to veterans 
who served in OEF/OIF. The bill specifies a number of requirements to 
be followed by the Secretary in establishing the pilot program. For 
example, the Secretary would be required to ensure that access to the 
Internet website and the online treatment program does not 
involuntarily generate an identifiable medical record of that access in 
any medical database maintained by VA. The Internet website would also 
need to be accessible from remote locations, including rural areas, as 
well as include a self-assessment tool for substance use disorders, 
self-guided treatment, and educational materials. Plus, appropriate 
information for the veteran's family members would need to be available 
on the website. H.R. 5554 would limit pilot program sites to VA medical 
centers that have a Center for Excellence for Substance Abuse Treatment 
and Education or a Substance Abuse Program Evaluation and Research 
Center.
    We support the goals of enhancing substance use services for 
veterans as described in H.R. 5554, but we cannot support the bill as 
written. First, many of the bill's provisions are unnecessary because 
those enhancements have been included in VHA's Comprehensive Mental 
Health Strategic Plan, which is being funded under the Mental Health 
Enhancement Initiative.
    Second, the bill would provide for residential substance use 
disorder treatment only ``in the case of veterans with severe recurring 
substance abuse or substance dependence.'' This implies that the choice 
between an outpatient and a residential treatment program should be 
based upon the severity and persistence of a substance use disorder. 
There is no evidence that treatment-outcomes for persons with severe 
substance use disorder vary as a function of the setting in which the 
services are delivered. Rather, the important factor is that patients 
be able to consistently attend treatment services. Thus, availability 
of residential treatment is important for patients who could not 
reliably attend outpatient treatment programs because of their distance 
to care, unstable housing arrangements, or health or psychosocial 
factors that prevent consistent treatment attendance. Simply put, the 
bill fails to correctly target the veterans in need of residential 
care: those with substance use disorders who cannot be managed 
effectively in intensive outpatient programs.
    For these reasons, we recommend the Committee forbear in its 
consideration of this bill, and we would welcome the opportunity to 
work with the Committee and to brief the Committee on the Department's 
on-going efforts in this area.
    We estimate the total cost of H.R. 5554 to be $72 million in FY 
2009 and $725 million over a ten-year period.
H.R. 5595. ``Make Our Veterans Smile Act of 2008''
    Mr. Chairman, H.R. 5595 would make two significant changes to VA's 
current authority to furnish outpatient dental services. First, the 
bill would require VA to furnish needed outpatient dental services and 
treatment to any veteran who has a service-connected disability. 
Second, it would authorize the Secretary to invoke our fee-basis 
authority to contract with a private provider for outpatient dental 
treatment and services for any veteran eligible to receive dental 
treatment and services through Department facilities. Both of the 
amendments would be effective on or after January 1, 2009.
    VA does not support H.R. 5595. Although the concept of providing 
life-long comprehensive dental services to veterans with a service-
connected disability is laudable and in concert with our general 
mission of improving the oral health of all veterans, it is not 
feasible. Enactment of this legislation would make an additional 
1,075,000 veterans eligible for VA dental care. This increased workload 
would overwhelm VA's capacity to provide these services in-house (both 
in terms of staffing and the number of physical dental clinics and 
labs). In fact, VA is already operating at full capacity and must now 
purchase dental services for those veterans we cannot treat.
    Of chief concern to us is the estimated cost of this bill. 
Expanding VA's contracting authority would result in a thirteenfold 
increase in the amount VA expends for fee-basis dental care, i.e., over 
$817 million in FY 2008 alone. The total cost for the next ten years 
would be almost $11.3 billion.
H.R. 5622 ``Veterans Timely Access to Health Care Act''
    Mr. Chairman, the last bill on the agenda is H.R. 5622, which would 
establish a five-year pilot program under which the Secretary would be 
required to ensure that a veteran seeking primary care from a VA 
medical facility in Veteran Integrated Services Network 8 is given 
access to care in 30 days. The standard would be measured from the date 
on which the veteran contacts VA seeking an appointment until the date 
on which a visit with a primary-care provider is completed. H.R. 5622 
would also require the Secretary to periodically review the performance 
of covered medical facilities in meeting the 30-day standard. When 
unable to meet the 30-day standard, the bill would require VA to 
contract for the needed care and services.
    When purchasing those services, H.R. 5622 would prohibit the 
Secretary from paying the non-VA provider more than the rate that would 
be applicable under part B of the Medicare Program. It would also 
prohibit the non-VA provider from billing the veteran for any 
difference between the billed charges and the amount paid by VA. The 
Secretary would also be required to develop a form to be used by 
veterans to authorize VA to obtain any records created in connection 
with the veterans' receipt of care from a non-VA facility.
    Once a veteran has received care for 30 days from a non-VA provider 
under this section, the veteran could choose to receive his or her 
primary care at a VA facility, if available. The veteran would need to 
notify VA in writing of this choice.
    VA does not support H.R. 5622, because it is overly prescriptive 
and to a large degree unnecessary. Although we agree with the 
imposition of a 30-day standard for the scheduling of patients, such a 
standard should only apply to new patients. New patients need to be 
tracked to determine if there are difficulties accessing the VA system 
of care.
    VA already complies with and exceeds the 30-day standard. Almost 
all VA facilities currently comply with the 30-day standard 90 percent 
or more of the time and improvement continues. In FY 2007, the percent 
of primary care appointments provided within 30 days of the patient's 
desired date for new patients was 83 percent and 98 percent for 
established patients (established patients are those already being 
seen; the majority of their appointments are for follow-up care in the 
future and they do not need to be seen within 30 days).
    VA is making significant strides to eliminate the waiting list for 
primary care and believes based upon our recent progress and planned 
future efforts that we will reduce the list of primary care patients 
waiting more than 30 days of the desired appointment date to zero by 
the end of FY 2009.
    In those situations where VA would be required by H.R. 5622 to 
contract for care, restricting payment to no more than the Medicare 
rate could make it difficult for VA to obtain that care in the private 
sector. The bill would not require contractors, even if they are 
Medicare providers, to agree to accept the Medicare rate from VA. The 
result could be that VA may not be able to purchase needed services in 
the community, and VA would have to limit the contract services 
available to veterans participating in the pilot program.
    Another fundamental problem with H.R. 5622 is its requirement to 
contract for care for certain veterans. This essentially sends these 
veterans outside the VA system for a 30-day period before they can 
choose to resume care at a VA facility. This would result in their care 
being interrupted and fragmented, lessening the quality of care they 
receive. Also, requiring the veterans to request in writing their 
desire to return to care in a VA facility places an undue 
responsibility on the patients. Lastly, this contracting-requirement 
assumes that all private care providers in the community can meet the 
30-day standard, but there are no measures available to support this 
assumption.
    Finally, contracted care would not necessarily include the 
comprehensive screenings, case management services, documented quality, 
and expertise in veteran-specific conditions that are available in the 
VA health care system.
    We estimate that H.R. 5622, if enacted, would cost $26.2 million 
for the remainder of FY 2008. We are still developing out-year 
projections based on anticipated changes in the demographics of VISN 8, 
but we will supply those for the record as soon as they are available.
H.R. 5730. Injured and Amputee Veterans Bill of Rights
    Mr. Chairman, H.R. 5730, which would direct the Secretary to 
display in each VA prosthetic and orthotic clinic an Injured and 
Amputee Veterans Bill of Rights, was only recently added to today's 
agenda. We are still in the process of developing views on the bill. 
Once completed, we will forward it to the Committee.
    This concludes my prepared statement. I would be pleased to answer 
any questions you or any of the members of the Subcommittee may have.

[A second handout from the Department of Veterans Affairs entitled, 
``Risk Adjustment Mortality as an Indicator of Outcomes: Comparison of 
the Medicare Advantage Program with the Veterans Health 
Administration,'' will be retained in the Committee files.]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

     Statement of Raymond C. Kelly, National Legislative Director,
                       American Veterans (AMVETS)
Chairman Michaud, Ranking Member Miller and members of the 
        Subcommittee:
    On behalf of AMVETS (American Veterans) I want to thank you for 
providing me the opportunity to testify before this Subcommittee 
concerning pending legislation.
    AMVETS supports H.R. 2818 which will amend Chapter 73, title 38, 
U.S.C., to provide for the establishment of Epilepsy Centers of 
Excellence. AMVETS believes that with the number of servicemembers who 
have been exposed to Improvised Explosive Devices (IEDs), VA must take 
every action possible to develop Epilepsy Centers of Excellence to 
conduct research, education, and the highest quality clinical care for 
our veterans who will undoubtedly become epileptic. Research has shown 
that more than 50% of service related TBI from the Vietnam War became 
epilepsy within 1-15 years from the date of the trauma. More recent 
studies have shown that mild to moderate TBI victims, even those who 
did not lose consciousness, are at risk of having cognitive deficits. 
When the brain is working to repair the damage caused by TBI, excessive 
neuroexcitation occurs. When these neuroexcitations misfire it can 
cause, among other symptoms, seizures. Data from a 2003 report found 
that 61% of returning servicemembers were exposed to IED blasts. It is 
unrealistic to predict the number of veterans from current conflicts 
who will become epileptic from TBI, but it is very realistic to predict 
from past evidence and the IED exposure rate that thousands of veterans 
are susceptible to epileptic seizures. It would be irresponsible for 
Congress to wait until there is an epileptic crisis to provide VA with 
the means to research and treat this condition.
    Although AMVETS understands the benefits of being able to be near 
one's home when recovering, we historically oppose contract for care 
when there is timely access to a VA facility. Therefore, AMVETS opposes 
H.R. 4915, the ``Veterans' Access to Local Options for Recovery Act of 
2007'' (VALOR Act).
    H.R. 5554, the ``Veterans Substance Use Disorders Prevention and 
Treatment Act'' expands and improves health care services available to 
veterans from the Department of Veterans Affairs for substance use 
disorders. According to the Substance Abuse and Mental Health Services 
Administration (SAMHSA), one fifth of veterans of wars in Iraq and 
Afghanistan who received care from the Department of Veterans Affairs 
between 2001 and 2005 were diagnosed with substance use disorder (SUD). 
In November of 2007 SAMHSA published the National Survey on Drug Use 
and Health (NSDUH) which stated that an annual average of 7.1 percent 
of veterans (an estimated 1.8 million persons) met the criteria for 
SUD. From 2004 to 2006 approximately 1.5 percent of veterans aged 18 or 
older (an estimated 395,000 persons) had co-occurring serious 
psychological stress (SPD) and SUD. AMVETS recognizes the importance of 
ensuring veterans have access to a full continuum of care and for this 
reason support the expansion of veterans substance use disorder 
programs.
    AMVETS is concerned, however, with section 4 of this bill which 
provides $1.5 million dollars in 2009 and 2010 for a pilot program for 
Internet-based substance use disorder treatment for veterans of 
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 
AMVETS does not believe the Internet is an appropriate medium for 
substance use disorder treatment. It is impossible to provide the 
continuum of care outlined in section 2 of the bill without inpatient 
or intensive outpatient treatment. AMVETS would support appropriating 
those funds to ensure veterans access to more traditional and proven 
treatment options.
    AMVETS wholly supports H.R. 5595 the ``Make Our Veterans Smile Act 
of 2008.'' This will ensure dental service for those who have 
sacrificed so much. Currently, section 1712, Title 38 U.S.C., provides 
dental care for certain eligible veterans. This legislation will 
provide dental services to all disabled veterans. It is well documented 
that poor oral health can attribute to poor physical health. Therefore, 
VA should view dental care as an important aspect of overall health of 
veterans. This legislation would be most beneficial to veterans who are 
rated 100% disabled and have begun dental care through VA, and due to 
reevaluation the disability rating is reduced, leaving the veteran with 
partially completed dental care with no means to complete the care. 
This was the case for one veteran, who has requested to stay anonymous, 
who was rated 100% disabled with PTSD and upon reevaluation his rating 
was reduced to 90%, leaving him with partially completed bridge work 
that was initiated by VA, but because of the rating reduction was no 
longer eligible for dental care. If Congress truly wants to provide a 
full continuum of care for our veterans, then dental health should be a 
part of that care.
    AMVETS views section 2, Subsection (b) of H.R. 5595 as an 
administrative amendment of contract for care and not new authority for 
the Secretary to enter into contracts. Additionally, AMVETS would 
prefer H.R. 5595 be enacted as written, but would consider supporting 
an amendment, based on cost estimates, that would reduce coverage to 
those already receiving care under section 1712, title 38 U.S.C., and 
Priority Group 1 veterans who are not currently covered by that same 
section.
    H.R. 5622 the ``Veterans Timely Access to Health Care Act,'' 
provides a five-year pilot program to evaluate the standard for access 
to care for veterans. AMVETS opposes this legislation. VBA currently 
tracks primary care standard for access; therefore, AMVETS believes 
this program would build unnecessary redundancy in tracking. Current 
tracking should be used to trend VA's need for primary care FTE. Also, 
AMVETS is opposed to contracting primary care. Even though VA can be 
billed by non-department care providers at no cost to the veteran, 
under current VA regulation VA is not allowed to honor non-department 
prescriptions, so the veteran would be obligated to pay for any 
medications the non-department physician would write. Again, AMVETS 
supports tracking of standard of access to care, but only for the 
purpose of evaluating hiring needs.
    Mr. Chairman, this concludes my testimony. I thank you again for 
the privilege to present our views, and I would be pleased to answer 
any questions you might have.

                                 
       Statement of Lewis E. Gallant, Ph.D., Executive Director,
  National Association of State Alcohol and Drug Abuse Directors, Inc.
    Chairman Michaud, Ranking Member Miller, and members of the 
Subcommittee, on behalf of the National Association of State Alcohol 
and Drug Abuse Directors (NASADAD), and our component organizations, 
the National Prevention Network (NPN) and the National Treatment 
Network (NTN), thank you for your leadership on issues related to 
veterans suffering from substance use disorders. We are pleased to 
offer comments on H.R. 5554, the Veterans Substance Use Disorder 
Prevention and Treatment Act of 2008.
    Who We Are: NASADAD members include the State Substance Abuse 
Directors from the 50 States and five U.S. territories. These State 
Directors, also known as Single State Authorities (SSAs), have the 
frontline responsibility for managing the nation's publicly funded 
substance abuse prevention, treatment and recovery systems. SSAs have a 
long history of providing effective and efficient services--with the 
Substance Abuse Prevention and Treatment (SAPT) Block Grant being the 
backbone of the system. SSAs also provide leadership to continually 
improve quality of care, expand access to services, improve client 
outcomes, increase accountability and nurture new and effective service 
initiatives.
    Scope of the Problem: According to the Substance Abuse and Mental 
Health Services Administration's (SAMHSA) National Survey on Drug Use 
and Health (NSDUH), approximately 23.6 million Americans aged 12 or 
older needed treatment for an alcohol or illicit drug problem in 2006. 
During the same year, approximately 4 million received some kind of 
treatment for an alcohol or illicit drug problem. As a result, 
approximately 19.6 million people needed but did not receive services 
in 2006.
    Scope of the Problem Among Veterans: According to the NSDUH, in 
2003, there were an estimated 25 million veterans in the United States. 
One quarter of veterans aged 18 to 25 met the criteria for a substance 
use disorder in the past year compared to 11.3 percent of veterans aged 
26 to 54 and 4.4 percent of veterans aged 55 or older. Heavy use of 
alcohol was most prevalent among veterans compared to nonveterans: an 
annual average of 7.1 percent of veterans aged 18 or older or an 
estimated 1.8 million veterans met the criteria for a substance use 
disorder in 2006.
    Addiction is a Brain Disease: According to research by the National 
Institute on Drug Abuse (NIDA), substance use disorders or addictive 
disorders are defined as chronic, relapsing brain diseases that are 
characterized by compulsive drug seeking and use, despite harmful 
consequences. Substance use disorders literally change the brain's 
structure and how it works. These brain changes can be long lasting, 
and can lead to the harmful behaviors seen in people who abuse drugs. 
Not only do genetics play a large role in one's vulnerability to suffer 
from substance use disorders, but environmental factors, such as 
trauma, also play a role in one's vulnerability to suffer from 
substance use disorders.
    Trauma and Stress are Risk Factors for Substance Use Problems: 
Research shows that a very stressful event or trauma such as military 
combat may lead to the development of Post Traumatic Stress Disorder 
(PTSD) or another form of psychological distress. A NIDA Special Report 
on Stress and Substance Abuse found ``. . . studies have reported that 
individuals exposed to stress are more likely to abuse alcohol and 
other drugs or undergo relapse.'' The NIDA Special Report also found 
that ``. . . high rates of co-occurring substance use disorders and 
PTSD are reported in studies of combat veterans, with as many as 75% of 
combat veterans with PTSD meeting the criteria for alcohol abuse or 
dependence (NIDA: 2005).''
    Services for Substance Use Disorders are Effective: Research shows 
that substance use disorder prevention and treatment services are 
effective. Discoveries in the science of addiction have led to advances 
in treatment that help people stop using alcohol and other drugs and 
resume their productive lives. Research and experience also have found 
that successful treatment approaches are those that are tailored to 
address each person's individual circumstances.
    Publicly-funded State System Yields Results: The Substance Abuse 
Prevention and Treatment (SAPT) Block Grant, which is managed by SSAs, 
represents approximately 40 percent of State substance abuse agency 
expenditures. The SAPT Block Grant is an effective and efficient 
program that provides vital prevention and treatment services for the 
nation's most vulnerable populations. According to SAMHSA, the SAPT 
Block Grant has been successful in expanding capacity to treatment and 
achieving positive results. In particular, outcomes data from the SAPT 
Block Grant found, at discharge, 68.3 percent of clients were abstinent 
from illegal drugs and 73.7 percent of clients were abstinent from 
alcohol. SAPT Block Grant funded programs help people find or regain 
employment; stay away from criminal activity; reunite with families; 
and find stable housing. Some State-specific examples of outcomes made 
possible by the SAPT Block Grant are included below:

      Maine's Office of Substance Abuse (OSA) reported 12,976 
admissions to treatment and provided prevention services to 18,551 in 
State Fiscal Year 2007. In State Fiscal Year 2007, the following client 
outcomes were reported at discharge: 77 percent of clients were 
abstinent from alcohol or other drugs; employment increased by 20 
percent at discharge; and homelessness decreased at discharge.
      Florida's Department of Children and Families reported 
89,716 new treatment admissions and provided prevention services to 
133,024 adults and children received in State Fiscal Year 2006. In SFY 
2006, the Department reported the following client outcomes: 81 percent 
of adult clients were abstinent one year after discharge; 67 percent of 
child clients were abstinent one year after discharge; a 28 percent 
decrease in homelessness for clients receiving treatment; and 
employment rates increased by 20 percent for clients receiving 
treatment.
      South Carolina's Department of Alcohol and Other Drug 
Abuse Services (DAODAS) reported 48,299 admissions to treatment and 
provided prevention services to approximately 208,000 people in State 
Fiscal Year 2006. In SFY 2006, the Department reported the following 
client outcomes from a sample survey comparing admission to 90 days 
after discharge: 80.1 percent of clients reported no alcohol use; 71.6 
percent of clients reported that they were employed; and 98 percent of 
students reported a reduction in suspensions, expulsions or detention.

    Current State Initiatives: A number of States are implementing 
various programs and initiatives to help veterans/military personnel 
and their families. NASADAD would like to call attention to a report 
issued on July 30, 2007 by the National Governors' Association (NGA), 
with the support of the Office of the Deputy Under Secretary of 
Defense, titled State and Territorial Support for Members of the 
National Guard, the Reserves and their Families (see http://
www.nga.org/Files/pdf/07GUARDREPORT.PDF). The report notes that 
Governors are moving above and beyond federal requirements related to 
support for the National Guard and Reserves as many return from 
overseas assignments. The NGA report places the benefits States are 
offering into six categories, including State Employee Benefits and 
Family Support benefits.
    NASADAD is also aware of current activities that include the 
involvement of the State substance abuse agency to address the needs of 
military personnel returning from countries impacted by war. A sample 
of these activities is included below:

      Vermont's Division of Alcohol and Drug Abuse Programs 
reports the development of a State interagency team; training for 
providers on veterans issues; and training for professionals working 
with children and families.
      California's Department of Alcohol and Drug Programs 
(ADP) is working to infuse veterans issues into the statewide needs 
assessment and planning effort. ADP participated in a veterans 
conference in January 2008 to discuss and prepare for the needs of OIF/
OEF veterans.
      Washington State's Division of Alcohol and Substance 
Abuse (DASA) reports working with the U.S. Army at Ft. Lewis, the 
Washington State National Guard, and the State Office of Veterans 
Affairs to engage returning veterans.
      Indiana's Division of Mental Health and Addiction (DMHA), 
in cooperation with the DMHA Advisory Council, convened a forum that 
included the VA Veteran Integrated Services Network (VISN) 11, Indiana 
Department of Veterans Affairs, VA Roudebush Medical Center, VA 
Northern Indiana Medical Center, and the Indiana National Guard to 
discuss the needs of returning veterans and to explore opportunities 
for collaboration. DMHA's Advisory Council, State Planning Council, and 
Transformation Working Group include VA representatives. The Division 
has also designated a liaison to VISN 11.
      Since 2005, ODADAS has participated in a multi-agency 
collaborative, spearheaded by Ohio's Adjutant General, to develop a 
network of specially trained community-based alcohol and other drug and 
mental health providers to address the unique behavioral health needs 
of soldiers returning from Iraq and Afghanistan and their families. 
This initiative, referred to as OHIOCARES, has trained over 400 
community-based providers including Veterans Administration and state 
mental health institution personnel. The OHIOCARES collaborative has 
convened two statewide conferences, published a brochure for military 
personnel and their families on how to access services, a resource 
guide to assist returning service members during their transition from 
active duty and a 1-800 number (1-800-761-0868) and website 
(www.ohiocares.ohio.gov). A marketing/branding Committee was formed in 
2007 and is currently finalizing materials for a statewide public 
awareness campaign. Included in this effort are the development of a 
radio and television PSA, posters, Info Cards, refrigerator magnets and 
web banners. These materials will be finalized and made available in 
May 2008.
      Iowa's Division of Behavioral Health reports working with 
Traumatic Brain Injury advocates and service providers. The Division is 
also working to link with VA systems and participating in training 
through a suicide prevention grant.
      Oklahoma's Department of Mental Health is providing 
briefings to families impacted by deployment.
      Pennsylvania's Bureau of Drug and Alcohol Programs (BDAP) 
participates on the Returning Pennsylvania Military Task Force, along 
with the Pennsylvania National Guard, Social Security Administration, 
State Civil Service Commission, U.S. Department of Veterans Affairs, 
Pennsylvania Department of Education, Pennsylvania Department of Labor 
and Industry, and others. BDAP also sponsored a regional training event 
in September 2007--Serving Those Who Serve: Veterans and their 
Families. The event attracted 170 individuals and provided five 
specific courses designed for counselors and therapists.
      New Hampshire's Office of Alcohol and Drug Abuse Policy 
reports work with the New Hampshire National Guard to augment alcohol 
and other drug intervention service and treatment services with current 
services for those returning home from war.
      New York's Office on Alcoholism and Substance Abuse 
Services (OASAS) reports funding Samaritan Village since 1996 which 
offers a 48 bed treatment facility for veterans in Manhattan; a new 50-
bed residential facility will be placed in Queens; $280,000 was 
allocated for prevention counseling in the Fort Drum impacted schools; 
and a program model is being developed to bring 100 new residential 
beds for veterans into the system that will be responsive to the needs 
and characteristics of veterans, including Traumatic Brain Injury, PTSD 
and other issues.
      New Jersey's Division of Addiction Services (DAS) reports 
participation on the Veterans Subcommittee of the Governor's Council on 
Alcoholism and Drug Abuse, which is developing a directory of resources 
to be distributed to veterans affiliated government and private 
agencies. DAS is working with military officials at Fort Dix, New 
Jersey, in an effort to provide them with training opportunities for 
evidence-based Strengthening Families prevention program which could 
then be implemented on base.
      Kentucky's Division of Mental Health and Substance Abuse 
is working with the State provider network to determine the impact of 
returning veterans and others seeking services in the public sector. 
The State reports that a number of providers have reported increases in 
the number of veterans in the publicly funded system and report an 
increased need for family and children's services.

    Barriers to Service Delivery at the VA: The Department of Veterans 
Affairs (VA) has identified substance use disorders as a significant 
problem among veterans. In 2004, Dr. Richard Suchinsky, Department of 
Veterans Affairs Associate Chief for Addictive Disorders, ranked 
substance use disorders among the three most common diagnoses made by 
the Veterans Health Administration (VHA). The January 2008 VA 
Healthcare Utilization Among U.S. Global War on Terrorism (GWOT) 
Veterans, VA Office of Public Health and Environmental Hazards, found 
that of the approximately 300,000 veterans from Operations Enduring and 
Iraqi Freedom who have accessed VA healthcare, nearly 50,000 have been 
diagnosed with a substance use disorder. Furthermore, data from the 
NSDUH found that an estimated 0.8 percent of veterans received 
specialty treatment for a substance use disorder in the past year, yet 
an estimated 7.1 percent of veterans met the criteria for a substance 
use disorder in the past year, leaving close to 6.3 percent of veterans 
going without treatment. NASADAD recognizes the capacity problems 
across the whole system and applauds the VA for recognizing that 
substance use disorders are a problem among veterans and for making 
efforts to expand capacity to treatment for returning veterans. The 
stigma associated with substance use disorders also presents a barrier 
to veterans seeking treatment for substance use disorders.
    Recommendations: As the Subcommittee engages in discussions about 
substance use disorder services in general, and H.R. 5554 in 
particular, NASADAD offers the following recommendations for 
consideration:
    Coordination with State Substance Abuse Directors: NASADAD 
recommends provisions that foster and enhance coordination and 
communication between SSAs and the VA. As previously mentioned, SSAs 
plan, implement, oversee and evaluate comprehensive statewide systems 
of clinically appropriate care. SSAs already work with a variety of 
public and private stakeholders given the impact substance use 
disorders have on issues such as housing, education, employment, family 
and much more. As mentioned earlier, a number of SSAs are already 
engaged in initiatives regarding services for veterans. The inclusion 
of provisions in H.R. 5554 that foster or enhance coordination with the 
State substance abuse agency would ensure a thoughtful planning process 
and promote a more effective and effective approach to service 
delivery, as well ensure a referral network of competent providers.
    Federal Agency Collaboration: NASADAD recommends continued work to 
encourage coordination among federal agencies that have a role in 
helping veterans receive appropriate services. We recommend continued 
and consistent collaboration between the VA and the Substance Abuse and 
Mental Health Services Administration (SAMHSA) on issues related to 
substance abuse and mental health. This collaboration ensures that 
efforts are made to maximize and leverage the financial resources and 
expertise available on these important issues. One specific example 
relates to the benefit of coordinating the efforts of SAMHSA's regional 
Addiction Technology Transfer Centers (ATTCs) and Centers for the 
Application for Prevention Technologies (CAPTs) with proposals to 
establish within the VA system centers of excellence that would include 
substance abuse as a specific component. The ATTCs and CAPTs serve as 
centers that help take the latest research and infuse the knowledge 
into the publicly funded system through practice improvement 
initiatives, training, workforce development and other mechanisms. 
Federal agency coordination specific to substance use disorders would 
also include work with the National Institute on Drug Abuse (NIDA), 
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Finally, 
NASADAD supports additional federal agency coordination with other 
agencies as well, including Department of Housing and Urban Development 
(HUD), Department of Labor (DoL), Department of Education (Ed), and 
others.
    Adequate Resources: NASADAD wishes to applaud the VA for its work 
and commitment to veterans in States across the country. There is no 
doubt that excellent work is moving forward. We also know that many 
challenges remain. For example, the core funding stream that represents 
the backbone of the State publicly funded system--SAMHSA's Substance 
Abuse Prevention and Treatment (SAPT) Block Grant--has been reduced by 
$20 million since FY 2004. In addition, resources within SAMHSA's 
Center for Substance Abuse Prevention (CSAP) and Center for Substance 
Abuse Treatment (CSAT) remain stagnant. In addition, decreases in 
capacity across the whole system make it difficult to address the needs 
of returning military personnel, such as the returning National Guard 
members.
    NASADAD strongly agrees with the Veterans Affairs Policy Position 
of the NGA (HHS-05) that notes ``Governors recommend that more 
resources be provided to address the impact of completed suicides, 
PTSD, TBI, and substance/alcohol abuse through the VA.'' Additional 
resources are needed for the VA in order to enable the agency to attain 
our common goal of improving access to, and quality of, services for 
substance use disorders. NASADAD would like to recognize recent 
investments made by Congress in support of substance use disorder 
services within the VA and Department of Defense (DoD) over the past 
few years.
    Workforce: As previously noted, treatment for substance use 
disorders is effective and efficient. NASADAD supports the delivery of 
substance use disorder services by practitioners that adhere to 
standards of care set by the State. We believe this approach ensures 
that healthcare professionals have the clinical expertise needed to 
provide the best care possible to returning veterans suffering from 
substance use disorders. NASADAD applauds the VA for efforts to expand 
their addiction-specific workforce in the last couple years. NASADAD is 
committed to partnering with the VA and others to continue this 
expansion given the acute problem of recruiting and retaining a 
qualified health workforce.
    Flexibility: NASADAD encourages initiatives to include the benefits 
of flexibility. As previously mentioned, States across the country are 
implementing a number of initiatives to assist veterans and their 
families. The Association encourages federal initiatives to include 
flexible approaches to policy decisions in order to maximize State 
participation. In addition, NASADAD recognizes that individuals present 
with many circumstances that in turn determine an individual's 
treatment plan. As a result, the Association believes that legislation 
should encourage clinically appropriate care that is based on accepted 
standards set within the State.
    Data Reporting and Management: One of NASADAD's top policy priories 
is the implementation of an outcome and performance measurement data 
system. With this goal in mind, NASADAD and the members have 
successfully partnered with SAMHSA to implement the National Outcome 
Measures (NOMs) initiative. The goal of NOMs is to improve service 
delivery within publicly funded systems using a common set of 
indicators of accountability and performance. States across the country 
are reporting data on the impact treatment services have on abstinence 
from alcohol and other drugs; employment; criminal justice involvement; 
housing; social connectedness and more. States are also reporting data 
on the impact prevention services have on the youth alcohol and other 
drug use; age of initiation; perceived risk/harm of use; drug related 
crime and other measures.
    NASADAD recommends widespread awareness of the NOMs initiative 
across all agencies. The Association also recommends cross-agency 
discussions regarding the benefits of this performance and outcome 
system that is being utilized in every State in the country. 
Synchronized data collection efforts will improve the accuracy of the 
information we have on the number of Americans impacted by alcohol and 
other drugs and enhance our understanding of service delivery.
    Thank You: We applaud you for introducing legislation that seeks to 
expand access to high quality substance use disorder services for our 
nation's veterans. We stand ready to partner with you on this 
initiative and others to ensure that our nation's veterans receive the 
care they need and deserve.

                                 
               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 on H.R. 2818; H.R. 4915, the ``Veterans Access 
to Local Options for Recovery Act;'' H.R. 5554, the ``Veterans 
Substance Use Disorders Prevention and Treatment Act;'' H.R. 5595, the 
``Make Our Veterans Smile Act;'' H.R. 5622, the ``Veterans Timely 
Access to Health Care Act;'' and the ``Spina Bifida Health Care Program 
Expansion Act.'' PVA appreciates the emphasis this Subcommittee has 
placed on critical issues facing all generations of veterans, such as 
substance abuse disorders. We hope that addressing the issues outlined 
in this legislation will better benefit today's veterans and the 
veterans of tomorrow.

               H.R. 2818, Epilepsy Centers of Excellence

    PVA principally supports H.R. 2818, a bill that would create six 
Epilepsy Centers of Excellence within the VA health care system. Much 
like the Multiple Sclerosis (MS) and Parkinson's disease Centers of 
Excellence permanently authorized during the 109th Congress, this 
proposal recognizes the successful strategy of the Veterans Health 
Administration (VHA) to focus its system-wide service and research 
expertise on a critical care segment of the veteran population. The 
designation of these six Centers of Excellence will provide open access 
to centers engaged in marshaling VA expertise in diagnosis, service 
delivery, research and education. Furthermore, these programs will be 
available across the country through the ``hub and spokes'' approach.
    We also hope that this legislation will sow the seeds for broader 
based research and development into Traumatic Brain Injury (TBI), as we 
believe the same concept could be crucial for better treatment for 
veterans in the future. This is particularly important in light of the 
number of veterans returning from service in Iraq and Afghanistan who 
have incurred a Traumatic Brain Injury.

  H.R. 4915, the ``Veterans Access to Local Options for Recovery Act''

    PVA strongly opposes the proposed legislation which would 
essentially allow the VA to expand contract health care opportunities. 
This legislation would give the VA additional leverage to contract out 
any type of medical services. If you review the early stages of VA's 
Project HERO, it is apparent that this is a direction that some VA 
senior leadership would like to go. We believe that this legislation 
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.
    As we have stated in the past, we believe legislation such as this 
is wholly unnecessary. In fact, we would like to point out that current 
law allows VA to contract for care with private health care providers 
in instances where VA facilities are incapable of providing necessary 
care to a veteran; when VA facilities are geographically inaccessible 
to a veteran for necessary care; when medical emergency prevents a 
veteran from receiving care in a VA facility; to complete an episode of 
VA care; and, for certain specialty examinations to assist VA in 
adjudicating disability claims. With this in mind, this legislation 
serves no real purpose other than to encourage contract health care.

   H.R. 5554, the ``Veterans Substance Use Disorders Prevention and 
                            Treatment Act''

    PVA fully supports H.R. 5554, a bill that would expand health care 
services to veterans dealing with substance use disorders. The stress 
and pressure associated with military service, and by extension combat 
service, place veterans at much greater risk for alcohol abuse and 
dependence. In fact, surveys have demonstrated that veterans report 
higher rates of alcohol abuse and dependence.
    We are pleased that the Subcommittee has chosen to address this 
critical need among the veteran population. In fact, the legislation 
would mandate that the VA provide services as recommended in The 
Independent Budget for FY 2009:

          We urge VA to provide a full continuum of care for substance-
        use disorders, including more consistent and universal periodic 
        screening of OEF/OIF combat veterans in all its health 
        facilities and programs--especially primary care. Outpatient 
        counseling and pharmacotherapy should be available at all 
        larger VA community-based outpatient clinics, and 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.

    PVA also particularly appreciates the Subcommittee considering 
innovative new techniques to address the needs of today's newest 
generation of veterans by instituting an Internet-based pilot program. 
These new veterans are very technology savvy and drawn to non-
traditional methods for treatment. We believe that this pilot program 
could be a positive first step in better addressing the needs of these 
veterans who are battling substance use problems.

             H.R. 5595, the ``Make Our Veterans Smile Act''

    PVA supports H.R. 5595, a bill that would allow veterans with a 
service-connected disability to receive dental care through the VA. 
Current law limits this service to veterans whose dental issues are 
either service-connected or aggravated by another service-connected 
condition. The VA is also authorized to provide dental care to veterans 
who are rated as totally disabled. We have no problem with providing 
dental care to any service-connected veteran as it will enhance the 
full continuum of care available to these individuals.

      H.R. 5622, the ``Veterans Timely Access to Health Care Act''

    H.R. 5622, the ``Veterans Timely Access to Health Care Act,'' would 
require the VA to carry out a pilot program to establish standards of 
access to care within the VA health system. Under the requirements of 
the pilot program, the VA will be required to provide a primary care 
appointment to veterans seeking health care within 30 days of a request 
for an appointment. If a VA facility is unable to meet the 30-day 
standard for a veteran, then the VA must make an appointment for that 
veteran with a non-VA provider, thereby contracting out the health care 
service. The legislation also requires the Secretary of the VA to 
report to Congress each quarter of a fiscal year on the efforts of the 
VA health system to meet this 30-day access standard. The concepts of 
this legislation are not unlike similar legislation--H.R. 92--that was 
considered by this Subcommittee last year.
    Access is indeed a critical concern of PVA. The number of veterans 
enrolled in the VA is approaching 8 million and the number of unique 
users is nearly 6 million. Despite the ongoing policy to deny 
enrollment to Category 8 veterans, the numbers of enrolled veterans 
continues to increase, particularly as more and more veterans of the 
Global War on Terror take advantage of the services in VA.
    PVA is concerned that contracting health care services to private 
facilities when access standards are not met is not an appropriate 
enforcement mechanism for ensuring access to care. In fact, it may 
actually serve as a disincentive to achieve timely access for veterans 
seeking care. Contracting out to private providers will leave the VA 
with the difficult task of ensuring that veterans seeking treatment at 
non-VA facilities are receiving quality health care. We do think that 
access standards are important. We believe that the answer to providing 
timely access to quality care in the VA is sufficient, predictable, and 
timely funding coordinated with sufficient staff and capacity. For 
these reasons, PVA cannot support H.R. 5622.

   H.R. 5729, the ``Spina Bifida Health Care Program Expansion Act''

    PVA supports the proposed legislation that would allow for more 
comprehensive health care services to the children of Vietnam veterans 
who suffer from spina bifida and related conditions. We have heard 
anecdotally that some of these individuals have experienced 
difficulties in receiving proper care due to the burden of trying to 
prove that the health issue that they are dealing with is in fact 
related to the spina bifida. This legislation would eliminate that 
concern by ensuring that they can get a full continuum of health care 
services, regardless if a connection to spinal bifida can be proved. As 
an aside, we would like to know if the VA has a record of how many 
individuals it is providing for under the current spina bifida statute 
and if it would be willing to share that information.

         H.R. 5730, Injured and Amputee Veterans Bill of Rights

    PVA generally supports the intent of the proposed legislation. This 
bill would ensure that VA prosthetics clinics around the country 
prominently display the ``Injured and Amputee Veterans Bill of 
Rights.'' This reaffirms the idea that a veteran in need of an 
assistive device or prosthetic gets the highest quality item available 
and in a timely manner. The only concern that we have about this 
legislation is that the language seems to ignore veterans who may be in 
need of special equipment who suffer from a specific disease and not a 
physical injury.
    Mr. Chairman and members of the Subcommittee, PVA would once again 
like to thank you for the opportunity to provide our views on this 
important legislation. We look forward to working with you to continue 
to improve the health care services available to veterans.
    Thank you again. We would be happy to answer any questions that you 
might have.

                                 

                                U.S. Department of Veterans Affairs
                                                    Washington, DC.
                                                    August 28, 2008

The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
    This letter transmits the views of the Department of Veterans 
Affairs (VA) on H.R. 5730. The bill would require the Secretary to 
establish a ``Bill of Rights'' for injured and amputee veterans that 
would be displayed prominently in each VA prosthetic and orthotic 
clinic. Although we appreciate the intent of H.R. 5730, the Department 
cannot support the bill as drafted.
    As a general matter, H.R. 5730 would seek to give unique rights to 
a limited group of veterans. Patient care should not, however, vary 
based either on the condition or injury experienced by a veteran or the 
type of medical services a veteran receives. Giving special benefits to 
amputee patients that are not available to other enrolled veterans 
would result in inconsistent and inequitable treatment among our 
veteran-patients. Patient treatment should be applied uniformly to 
every veteran-patient. VA regulations already require that a 
comprehensive list of patients' rights be posted prominently in all VA 
facilities.
    If tailored for all the different patient-populations, the 
Department would support the majority of ``rights'' that are included 
in this ``Bill of Rights,'' e.g., the right to receive appropriate 
treatment, the right to participate meaningfully in treatment 
decisions, etc. However, a few of the ``rights'' raise serious 
concerns. Specifically, the veteran's ``right'' to select the 
practitioner that best meets his or her orthotic and prosthetic needs, 
including a private practitioner with specialized expertise, is not 
sound from a medical perspective. VA's practitioners are highly 
qualified, and VA is able to continually monitor their performance 
through its rigorous quality management programs. As part of those 
programs, VA has an extensive credentialing and privileging program, 
which surpasses those found in the private sector. VA, generally, does 
not have ready and efficient access to veterans' non-NA medical 
records, as few private providers, if any, employ an electronic medical 
record. Were these veterans permitted to choose their own private 
providers, VA could not oversee the quality of their care, ensure their 
private provider possesses adequate qualifications, and ensure they 
receive a continuum of services. One must also bear in mind that VA's 
legal privacy and confidentiality requirements exceed those applicable 
to the private sector.
    In short, VA has the needed expertise in managing veterans' unique 
issues, including unparalleled expertise in managing and caring for 
amputee patients, particularly those wounded in combat. What we cannot 
provide through our own clinics and labs, we readily purchase through 
contractual arrangements with vendors and providers who are approved by 
the Department. Although our Prosthetics and Orthotics Service labs are 
top-notch and very successful in timely meeting veterans' needs, we 
actively evaluate our programs to identify any areas in need of 
improvement. With respect to our contractor-prosthetists, we conduct 
quality management programs to oversee their performance, thereby 
protecting our veterans and assuring they receive good services. These 
efforts would be significantly hindered were veterans permitted to 
self-refer to private prosthetists and practitioners. Veterans could 
become a vulnerable marketing target by those holding themselves out as 
having special expertise in this field.
    Moreover, including that ``right'' in a ``bill of rights'' would be 
misleading. Congress has very carefully limited our authority to pay 
for non-VA care and services. Stating that a veteran has the ``right'' 
to choose one's own provider would still not make the veteran eligible 
for private care at VA expense if he or she does not otherwise meet the 
eligibility terms of 38 U.S.C. Sec. 1703. This ``right'' could mislead 
veterans into believing they are entitled to seek prosthetic or 
orthotic care or services from a non-VA provider at VA expense. As a 
result, some could incur private medical expenses for which they would 
be personally liable,
    Another concern is raised by the ``right'' to receive comparable 
services and technology at any VA medical facility. Veterans may 
believe this means they can receive the same services and prosthetic 
equipment anywhere they go in the system. However, our facilities must 
meet the demands of their local veteran population and establish lines 
of service that meet those demands. Not all facilities serve 
significant amputee populations. A cookie-cutter approach to VA 
services is not appropriate. It is also more consistent with the 
principles of patient-centered medicine, as well as more efficient, to 
focus on making these services and technologies available to patients 
who require them, as opposed to requiring every VA facility to provide 
them.
    There would be no additional costs associated with enactment of 
H.R. 5730. The Office of Management and Budget advises there is no 
objection to the transmission of this letter from the standpoint of the 
President's program.

            Sincerely yours,
                                               James B. Peake, M.D.
                                                          Secretary

                                 
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