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




                   LEGISLATIVE HEARING ON H.R. 3051,
                        H.R. 6153, AND H.R. 6629

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 9, 2008

                               __________

                           Serial No. 110-102

                               __________

       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
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio               STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana

                   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
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina
DONALD J. CAZAYOUX, Jr., Louisiana   VERN BUCHANAN, Florida

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


                            C O N T E N T S

                               __________

                           September 9, 2008

                                                                   Page
Legislative Hearing on H.R. 3051, H.R. 6153, and H.R. 6629.......     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    29
Hon. Jeff Miller, Ranking Republican Member, prepared statement..    29
Hon. Phil Hare...................................................     1
    Prepared statement of Congressman Hare.......................    29

                               WITNESSES

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., 
  FAAFP, Principal Deputy Under Secretary for Health, Veterans 
  Health Administration..........................................    18
    Prepared statement of Dr. Cross..............................    40

                                 ______

American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission..........................    11
    Prepared statement of Mr. Wilson.............................    38
Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................     9
    Prepared statement of Ms. Ilem...............................    32
Johnson, Hon. Eddie Bernice, a Representative in Congress from 
  the State of Texas.............................................     3
    Prepared statement of Congresswoman Johnson..................    30
Salazar, Hon. John T., a Representative in Congress from the 
  State of Colorado..............................................     4
    Prepared statement of Congressman Salazar....................    31
Shea-Porter, Hon. Carol, a Representative in Congress from the 
  State of New Hampshire.........................................     6
    Prepared statement of Congresswoman Shea-Porter..............    31
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior 
  Analyst for Veterans' Benefits and Mental Health Issues........    13
    Prepared statement of Dr. Berger.............................    39

                       SUBMISSIONS FOR THE RECORD

American Veterans (AMVETS), Raymond C. Kelly, National 
  Legislative Director, statement................................    49
Brain Injury Association of America, Susan H. Conners, President/
  Chief Executive Officer, statement.............................    50
Hodes, Hon. Paul W., a Representative in Congress from the State 
  of New Hampshire...............................................    51
National Military Family Association, Inc., Barbara Cohoon, 
  Deputy Director, Government Relations, statement...............    51
Paralyzed Veterans of America, statement.........................    54
Schraa, James C., Psy.D., Neuropsychologist, Licensed 
  Psychologist, State of Colorado, Craig Hospital, Englewood, CO.    57
Veterans of Foreign Wars of the United States, Christopher 
  Needham, Senior Legislative Associate, National Legislative 
  Service, statement.............................................    58
Wounded Warrior Project, Anna Frese, Family Outreach Coordinator 
  for Brain Injury, statement....................................    59

 
                   LEGISLATIVE HEARING ON H.R. 3051,
                        H.R. 6153, AND H.R. 6629

                              ----------                              


                       TUESDAY, SEPTEMBER 9, 2008

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

    The Committee 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, Snyder, Hare, Berkley, 
Salazar, Miller, and Brown of South Carolina.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call this hearing to order. 
And I would like to thank everyone for coming today. Today's 
legislative hearing is an opportunity for Members of Congress, 
veterans service organizations (VSOs), the U.S. Department of 
Veterans Affairs (VA), and other interested parties to provide 
their views and discussion on the legislation that has been 
introduced within the Subcommittee's jurisdiction. I do not 
necessarily agree or disagree with these bills before us today, 
but I believe that this is an important part of the legislative 
process that will encourage frank discussion of new ideas.
    We have three bills before us today. Congressman Salazar's 
bill, H.R. 3051, the ``Heroes at Home Act of 2007,'' H.R. 6153, 
Congresswoman Johnson's bill, the ``Veterans' Medical Personnel 
Recruitment and Retention Act of 2008,'' and H.R. 6629, 
Congresswoman Shea-Porter's bill, the ``Veterans Health Equity 
Act of 2008.'' I look forward to hearing the views of our 
witnesses on these bills before us. Due to the late inclusion 
of H.R. 6629 we do not expect to have written testimony today. 
However, I would ask the witnesses if they would submit their 
views in writing on H.R. 6629 within ten legislative days after 
the ending of this hearing.
    [The prepared statement of Chairman Michaud appears on
p. 29.]
    Mr. Michaud. I would like to ask Mr. Hare if he has an 
opening statement.

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. I do. Thank you, Mr. Chairman. First, let me 
thank you and Ranking Member Miller for holding this hearing 
today.

The three bills before us today address important issues, all 
of which have huge impacts on the welfare of our Nation's 
veterans.
    Secondly, I would like to thank the sponsors of these 
bills, the three Members that are testifying before the 
Subcommittee today. Mr. Salazar is a fellow Committee Member 
and I know from sitting next to him over the past 2 years that 
he is a tireless advocate for veterans, especially the many 
rural veterans that live in his large district in the State of 
Colorado. His bill addresses family caregivers of veterans 
suffering from Traumatic Brain Injuries (TBI), and also 
telehealth services. These are crucial matters that are 
directly in line with Mr. Salazar's passion for improving the 
lives of veterans and their families.
    Ms. Johnson is also a big supporter for veterans. For 
fifteen years she worked at the Dallas VA Medical Center (VAMC) 
as a medical and psychiatric nurse. Appropriately, her bill 
aims to help VA recruit and retain more nurses and other 
healthcare professionals.
    Ms. Shea-Porter and I came into Congress at the same time, 
and I know without a doubt that there is nobody more dedicated 
to serving our veterans than she is. It is a paradox then that 
her home State, the great State of New Hampshire, does not have 
a VA Medical Center. Her bill attempts to resolve this 
injustice.
    Third, I would like to thank all of our witnesses for 
testifying today, including Dr. Cross of the VA, and each 
representative of the three VSOs present. I would also like to 
congratulate the Disabled American Veterans (DAV) for recently 
electing Raymond Dempsey, a fellow Illinoisan, as National 
Commander. Speaking on behalf of this great State of Illinois I 
take pride in knowing that such a well respected organization 
is under the leadership of Mr. Dempsey.
    Mr. Chairman, thank you again for holding this important 
hearing. I look forward to our witnesses testifying this 
morning. Thank you.
    [The prepared statement of Congressman Hare appears on p. 
29.]
    Mr. Michaud. Thank you very much, Mr. Hare, for your 
opening statement. Mr. Miller.
    Mr. Miller. Thank you very much, Mr. Chairman. I apologize 
for being late. I would like to just submit my opening 
statement for the record.
    [The prepared statement of Congressman Miller appears on
p. 29.]
    Mr. Michaud. Without objection so ordered.
    Now I would like to thank our first panel for coming here 
this morning. I look forward to your testimony. We will start 
off, in the order that you arrived, with Congresswoman Johnson 
of Texas to introduce her piece of legislation first. Thank 
you.

 STATEMENTS OF HON. EDDIE BERNICE JOHNSON, A REPRESENTATIVE IN 
   CONGRESS FROM THE STATE OF TEXAS; HON. JOHN T. SALAZAR, A 
REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO; AND HON. 
CAROL SHEA-PORTER, A REPRESENTATIVE IN CONGRESS FROM THE STATE 
                        OF NEW HAMPSHIRE

            STATEMENT OF HON. EDDIE BERNICE JOHNSON

    Ms. Johnson. Thank you very much, Mr. Chairman, and other 
distinguished members of the panel. I will submit my written 
statement and try to summarize.
    As has been said, I worked as a professional psychiatric 
nurse at the Veterans Administration Hospital for fifteen years 
before entering public office, and I opened the psychiatric 
unit. And I know how important the psychiatric unit became day 
after day as veterans started coming back from active wars. 
Recently there were four suicides of psychiatric patients at 
the VA hospital that made the front page of the paper. The VA 
hospital is in my district so I went to visit to see what the 
problem was. And they explained that the real problem is they 
are not attracting enough professional nurses to do what they 
need done to observe psychiatric patients. As you know, 
psychiatric patients are supposed to be observed at least every 
fifteen minutes. It is also very important for consistency. It 
is important that they develop a relationship with the nurses. 
And the nurses remain the profession with the most trust of the 
public.
    They are using part-time nurses because the work in the VA 
hospital for nurses is a little more stringent than in other 
facilities. And they identified their problem as not having 
nurses in the Medical Personnel Recruitment and Retention Act. 
And it actually came out because nurses were so tight, there 
was such a shortage, that they thought that this would give 
more even distribution of nurses to other facilities as well. 
But they found that they lost many, many nurses because of the 
work. It is just hard in facilities like the VA.
    It does not take much to observe that. You can go into a 
private facility and if you find a professional nurse they are 
usually seated at the desk. You go into a VA hospital and they 
are usually walking, taking care of patients. So it is really a 
difference, and I can tell you that from experience.
    So I came back to see what I could do. They specifically 
asked for this type of legislation. And I saw where Senator 
Akaka had introduced a bill, it is Senate Bill 2969, that 
address the same problem. And so this simply is a companion 
bill to his. It is an urgent need. Very early I put an 
amendment on one of the bills to see that when patients were 
admitted to psych, admitted, coming directly from war, that 
they got a psychiatric evaluation by professionals right away 
because most of them come back with post traumatic stress 
disorder (PTSD) even if they do not have head injuries, and 
many are coming back with head injuries. The earlier they are 
diagnosed, the earlier the intervention, the better the 
outcome.
    When I worked at the VA hospital, there were long-term 
patients because at the time the modality was not experienced 
enough to

have very early intervention. Consequently, we had a number of 
long-time, chronic patients. The approach has changed now. But 
in order to make it successful, the professionals must be 
available. And this legislation directly addresses that issue 
by placing nurses in the same category of physicians and 
dentists, and other therapists, so that their pay rate pays 
them back into it. So that their pay will be on the scale that 
it had been on the professional level.
    I know that this is asking for additional money, probably 
not right away but in the scale as it comes. But if we want to 
give the appropriate attention to those people that have given 
much of their lives in defending this country, I think it is 
only right to make sure that they have adequate care, and a 
large enough and professionally qualified staff; especially 
nurses, who spend more time with the patient than any other 
professional. They are in their care, they are there 24 hours. 
And especially on a psychiatric ward you cannot depend on 
people coming in part-time, hitting it one time this week and 
another time next month. You have got to have consistency.
    I see that my time is up and I will be available for any 
questions.
    [The prepared statement of Congresswoman Johnson appears on 
p. 30.]
    Mr. Michaud. Thank you very much, Congresswoman. 
Congressman Salazar, thank you for introducing your piece of 
legislation and for your ongoing commitment to our veterans. I 
open it up for your comments.

               STATEMENT OF HON. JOHN T. SALAZAR

    Mr. Salazar. Well, thank you Mr. Chairman, Ranking Member 
Miller, and Members of the Subcommittee. I surely enjoy being a 
Member of this wonderful Committee and all the work that we all 
do for veterans. I appreciate the trip that we took to Iraq. 
That was a very enlightening trip.
    Mr. Chairman and Ranking Member Miller, first I would like 
to thank Dr. Jim Schraa, a neuropsychologist at Craig Hospital, 
and Anna Frese, with the Wounded Warrior Project, who submitted 
testimony for the record on the bill that I introduced, H.R. 
3051, the ``Heroes at Home Act,'' on July 17, 2007.
    The purpose of this bill is to improve the diagnosis and 
treatment of traumatic brain injury in current and former 
members of the Armed Forces. The program will be located in VA 
healthcare centers across the Nation. This is especially 
important in rural districts like mine where making healthcare 
accessible is a constant challenge. H.R. 3051 addresses the 
needs for access to care by expanding the U.S. Department of 
Defense (DoD) and VA telehealth, and telemental health 
programs. Ultimately the bill will ease the burden on our 
veterans suffering from TBI and the families who care for them.
    Our Committee has heard testimony from many veterans, VSOs, 
and the VA on mounting cases of TBI, PTSD, and other invisible 
wounds of war. I think that many of us agree that veterans are 
often worse off with those unseen injuries than those with 
visible, physical injuries. Unlike injuries that can heal, 
brain injuries are often permanently disabling. In addition, 
TBI can sometimes take

years to develop and diagnose. Even when discovered, the road 
to recovery is long and is borne by families of our brave men 
and women in uniform.
    We have also heard of the link between TBI and other mental 
conditions such as epilepsy. A DoD study after Vietnam found 
that 15 percent of soldiers with a penetrating TBI developed 
epilepsy soon after their injury. H.R. 3051 creates a program 
to train family members of the TBI patients to become their 
personal care attendants. Participants going through the 
program would also become certified and receive compensation 
from the VA so that they can focus their energy on caring for 
their loved one.
    By taking place at home with family, the healing process is 
made more comfortable for our veterans. The cost to the VA for 
having someone cared for at home is less than having them at a 
medical facility and allows the VA to allocate the resources 
they have to serve more veterans. We have soldiers in Iraq and 
Afghanistan spending longer periods of time in harm's way and 
away from their families, and with this in mind we need to 
ensure that there are programs in place to care for them when 
they return home.
    A program that provides quality care for our veterans and a 
financial benefit for the family seems appropriate for the 
difficult economic times our country is facing. Most 
importantly, the bill will help us reach our goal of ensuring 
our veterans the best care.
    Mr. Chairman, I still have 2 minutes and I anticipated some 
of the questions that you might have. If you do not mind, I 
would like to address some of those. I know that one of the 
questions is how much is this going to cost? The Congressional 
Budget Office has not scored this bill. However, the cost of 
having someone cared for at home is much less than having them 
at a medical institution. In fiscal year 2006, San Diego VAMC 
spent $825,000 for Personal Care Attendants (PCA) services for 
52 veterans. This year they expect the service's cost to be $1 
million. They are currently providing home care services to 56 
individuals. I believe that it is much less expensive to take 
care of these veterans at home with family members. We must 
keep in mind that a family member rate is less than $16 per 
hour versus a professional at a medical facility that may be 
charging $30 or more.
    The training will actually take place at home. Currently 
the Department operates a similar PCA training and 
certification program for the spinal cord injury (SCI), SCI 
population out of San Diego. Senate Bill 3421, the ``Veterans 
Benefits Healthcare and Information Technology Act of 2006,'' 
includes a provision which, in section 214, requires the 
establishment of a pilot program to improve caregiver 
assistance. I think that the language specifically mentions 
caregiver training and certification as part of the pilot and 
authorizes $10 million over the next 2 years.
    With that, Mr. Chairman, I think my time is up. I do 
appreciate your time.
    [The prepared statement of Congressman Salazar appears on
p. 31.]
    Mr. Michaud. Thank you very much, Mr. Salazar. Ms. Shea-
Porter, I want to thank you for coming this morning and 
presenting your piece of legislation, and thank you for 
fighting for our veterans as well.

              STATEMENT OF HON. CAROL SHEA-PORTER

    Ms. Shea-Porter. Mr. Chairman, thank you for the 
opportunity to speak to your Subcommittee about a critical 
inequity facing New Hampshire veterans, the lack of full 
service in State healthcare. New Hampshire has not had a full-
service veterans hospital since 2001. New Hampshire is the only 
State without a full-service VA hospital or comparable 
facility. Veterans in Alaska and Hawaii receive care at 
military hospitals on base. While New Hampshire may be a small 
State, it has a veteran population of 130,000. Unlike many New 
England States whose populations are declining for veterans, 
New Hampshire's veterans population is projected to grow over 
the next 10 years.
    Because New Hampshire does not have a full-service veterans 
hospital, our veterans are forced to travel out of State for 
some medical care. Veterans traveling from the most northern 
parts of the State can travel for 3 hours to Manchester and 
then be forced to travel another hour to Boston if referred 
there for care. Then they have to wait while everybody on that 
van receives their care. So we are sending our sickest and our 
most vulnerable to Boston to wait all day after traveling 
several hours to get to the central meeting point. This 
routinely happens. In 2007, 704 of our veterans were 
transferred out of State for acute care. Three-hundred forty-
six of those veterans were sent to Boston.
    I have been calling for the VA to either restore the 
Manchester facility to full-service hospital care, or allow New 
Hampshire vets to receive care locally since I came to 
Congress. I have been working with both the VA and my 
colleagues to realize that goal. Chairman Filner visited the 
Manchester facility earlier this year and held a series of 
events, including a round table hearing in which we heard about 
the serious burdens placed on the New Hampshire veterans and 
their families simply because we do not have a full-service 
hospital. And again, I would like to emphasize, the only State 
in the country.
    Despite these efforts, the administration refuses to either 
provide local access to care or restore the full-service 
hospital care to New Hampshire. I met with Secretary Peake at 
the Manchester VA Medical Center in June to express my interest 
in working with him to either restore the facility to a full-
service hospital or provide local access. Unfortunately, after 
our meeting, Secretary Peake told the local press that there 
would be no full-service hospital in Manchester.
    The administration's failure to act is just unacceptable. 
New Hampshire veterans deserve the best care possible and the 
current system is not delivering that. That is why I introduced 
H.R. 6629, the ``Veterans Health Equity Act of 2008.'' This 
legislation will ensure that veterans have access to at least 
one full-service VA hospital, or that they can receive care 
locally. That would mean that the VA would have to do one of 
two things, either restore the facility to a full-service 
hospital or provide more local care providers. The men and 
women in our local VA facility have done a herculean job caring 
for these vets despite the limits placed on them. The 
administration has recently shown some willingness to allow 
radiation therapy to be provided locally, but this is not 
enough. Our veterans, regardless of whether they need radiation 
therapy, men-

tal health services, acute care, or anything else, need and 
deserve the care their counterparts in every other State 
receive. It is unconscionable that we deny them this full-
service care and instead we offer ad hoc services.
    Mr. Chairman, I appreciate your leadership in providing the 
best healthcare for our Nation's veterans. I am sure you and 
other members of your Subcommittee appreciate the challenges 
created by the lack of the full-service hospital. I look 
forward to working with you and the Subcommittee to address 
these challenges. Again, thank you for the opportunity to come 
and speak to you about this important issue and I look forward 
to answering any questions that you might have. Thank you.
    [The prepared statement of Congresswoman Shea-Porter 
appears on p. 31.]
    Mr. Michaud. Thank you very much, Congresswoman. And once 
again I would like to thank our first panel for your 
willingness to come before us this morning. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman. Ms. Shea-Porter, you 
only talk about the 48 contiguous States and you do not talk 
about Alaska. You talk about Hawaii, but what about the 
territories as well? Is there a reason----
    Ms. Shea-Porter. Well my understanding, and again we were 
just looking at the ones coming from our States, but they can 
receive access at military bases. And so when we looked at just 
the 50 States, and because that was the best comparison that we 
could make, we are the only State without it. And the others 
have access to military base hospitals. And so, it has really 
created a tremendous burden on these vets, especially as I 
indicated the oldest and the sickest. Because they are the ones 
who are being sent the farthest. And up until now, the families 
were not properly reimbursed for the travel. And when you look 
at who generally has to travel, it is an extra burden on the 
family and the community. If an 80-year-old man, for example, 
needs to go to the VA and he has got a 5-hour trip, that means 
his wife is probably about 80 years old herself, needs to find 
help to bring him at least to the first part to the Manchester 
VA, where they can then head off to Boston.
    So the burden is awful and is unfair. And New Hampshire 
veterans are aware of this. And here is the other problem. We 
need people to enlist in the service. And we have young men and 
women in New Hampshire looking at that and saying, ``You know, 
that just does not seem fair.'' And so, if we also want to make 
sure we recruit and bring our fine New Hampshire men and women 
into the service, we need to make sure that they know we will 
keep our promise to them and our commitment, and care for them 
when they return.
    Mr. Miller. So, it is your understanding that veterans in 
American Samoa and the Virgin Islands have access to military 
hospitals?
    Ms. Shea-Porter. Well, I do not know what they do. I am 
just looking at the 50 States. And as I said, we are looking 
strictly at our 50 States and saying, ``What do they do in 
every other State?''
    Mr. Miller. Actually, you said the 48 contiguous States.
    Ms. Shea-Porter. Well, that is because the other two have 
comparable care. And what I am asking for is either or. I am 
just asking for comparable care. I am not saying it has to be a 
full-service VA hospital as long as they allow contracts 
locally so that our servicemen and women are not forced to take 
on an undue burden.
    Mr. Miller. Thank you. That is all.
    Mr. Michaud. Mr. Hare. Questions? Mr. Brown. Ms. Berkley. 
Okay. I just have one. Thank you, Mr. Salazar, for answering 
the question I had for you. I appreciate that.
    Ms. Shea-Porter, you had mentioned that Secretary Peake 
said no hospital. Did Secretary Peake at least acknowledge that 
there is a concern with veterans accessing healthcare? Is he 
willing to do some type of comparable care, whether it is 
contracting our services in different regions of New Hampshire?
    Ms. Shea-Porter. Well, actually I could not get an answer 
from him. I finally said to him, ``Mr. Secretary, are you 
saying yes or no?'' and he said, ``Neither.'' And so, you know, 
I could not get an answer. But I do know that shortly 
thereafter they talked about providing radiation care in the 
community. But this really has been a long festering problem. 
And when we looked at the numbers of veterans from other 
States, and we looked at their ability, there cannot be any 
explanation for it. You know, we have looked at the stats and 
there is just no explanation for New Hampshire being without 
some kind of care there.
    And, again, I am not insisting that they build a full-
service VA hospital. I want to do whatever is the most 
economical and practical. But we have to keep our commitments 
to our veterans and that is why I am sitting here today. We owe 
it to these New Hampshire vets.
    Mr. Michaud. Now, you mentioned the time it takes for 
veterans to travel to Boston. My concern is access to 
healthcare and Maine, as you know, is a very rural State and we 
have to travel long distances. Normally, when we say it is 
going to take 4 hours to travel from one end to Togus, that is 
at, the speed limit. When you say it is going to take 4 hours, 
how does that traffic affect your veterans traveling? Is it 4 
hours because of congestions? Or is it 4 hours depending on 
what time they go during the day?
    Ms. Shea-Porter. Right. Well, when they start off, and the 
furthest point from my district could be an hour and a half to 
2 hours from the tip of the district down. And it is not that 
heavy. I mean, it is New Hampshire. It does not look like 
Washington traffic for sure, but the roads are slower, because 
if you get in front of a car. So you add that time. And then 
when they get to Manchester and they have to take a van, and 
that is when the traffic really becomes very difficult. And so 
many of our older vets simply must travel in a van for a number 
of reasons. Their unfamiliarity with the roads and with urban 
districts and driving in cities, they are elderly, and they are 
ill. And it is pretty hard to find people in your neighborhood 
who are happy about driving 4 hours to Boston, you know, and 
going through, and picking their way through that traffic in 
that very heavily congested area in an area that they are not 
familiar with.
    So that means they have to come to Manchester and be loaded 
on the van. And there are other people who are receiving 
services as well. And so they come to an urban VA, which is 
very busy, and they have to wait all day. And so these trips 
are absolutely exhausting them. They can go, you know, for 
hours and hours and hours. From Manchester to the VA can take 
an hour and a half. It does take an hour and a half, it can 
take 2 hours. Add that in addition to the 2 to 3 hours, you 
know, each way, 5 hours, and then the wait. And you get a sense 
of what we are putting them through. And again, they are our 
oldest and our sickest that are being sent down.
    Mr. Michaud. Thank you very much. Once again, I would like 
to thank our first panel for your testimony this morning. I 
look forward to working with you as we work to make sure our 
veterans get the adequate healthcare that they need. Once 
again, thank you very much.
    I would like to welcome the second panel. As they come, it 
is Joy Ilem who works for the Disabled American Veterans (DAV), 
Joseph Wilson from the American Legion, and Dr. Thomas Berger 
from the Vietnam Veterans of America (VVA). I would like to 
thank our second panel for your willingness to come today and 
to give your testimony on the bills that we have heard from our 
first panel.
    I would like to start off with Ms. Ilem.

   STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
DIRECTOR, DISABLED AMERICAN VETERANS; JOSEPH L. WILSON, DEPUTY 
   DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION, 
 AMERICAN LEGION; AND THOMAS J. BERGER, PH.D., SENIOR ANALYST 
   FOR VETERANS' BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM 
                      VETERANS OF AMERICA

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you Mr. Chairman and Members of the 
Subcommittee. Thank you for inviting the Disabled American 
Veterans to testify at this legislative hearing. We appreciate 
the opportunity to provide our views on the bills under 
consideration by the Subcommittee today.
    DAV supports the provisions in H.R. 3051, which would 
establish a program for training and certification of family 
caregivers of servicemembers and veterans with traumatic brain 
injury, and authorize these personal care attendants to receive 
compensation for such services. This program would allow these 
family members to have standardized and consistent training and 
to receive compensation that recognizes their efforts that will 
help to ensure the stability of the family at an extremely 
difficult and vulnerable time. We note, however, this section 
of the bill only addresses veterans with traumatic brain 
injuries but could also benefit other catastrophically injured 
veterans with long-term personal assistance needs, such as 
veterans with spinal cord injuries or severe physical trauma 
without brain injury. If successful, we would like to see this 
provision related to training and support for caregivers 
expanded to other catastrophically disabled veterans requiring 
caregiver assistance.
    DAV also supports provisions in the bill requiring outreach 
to educate and make veterans and the public aware of the 
symptoms of PTSD and TBI, and make available best practices for 
these conditions to non-VA healthcare providers. Often a family 
member is the first to notice cognitive changes in the 
veterans' behavior and mood. Thus informing the general public 
is an important element of this bill. Likewise, we appreciate 
the dissemination of best practices on TBI and PTSD to non-VA 
providers to help ensure that veterans who may seek care 
outside the VA and DoD systems benefit from their expertise.
    Mr. Chairman, DAV also supports but with some concerns 
Section 4 of this bill to assess the feasibility of using 
telehealth technology to assess cognitive functioning of 
military members and veterans who have sustained TBI, with a 
priority in rural areas. We support efforts to assess new web-
based diagnostic tools for the prevalent cognitive conditions 
that are emerging among our returning veterans. However, we ask 
the Subcommittee to ensure that any partnership with the 
private sector to expand telemedicine in rural areas include 
coordination through VA's Office of Rural Health and be 
supplemented by appropriate resources.
    On a final note, we ask the Subcommittee to also consider 
expanding this measure to include a standardized and more 
comprehensive package of support services for caregivers, 
including financial support, health and homemaker services, 
respite, education, training, and other necessary relief 
services. Family members of severely injured veterans often 
shoulder great and lifelong responsibility as home and 
institutional caregivers, giving up or severely restricting 
their own employment and educational advancement, and social 
opportunities. Not surprisingly, family caregivers often suffer 
severe financial and personal hardships as a consequence of 
providing care to a severely disabled veteran. Yet, in their 
absence, an even greater burden of direct care would fall to VA 
and DoD at significantly higher cost to the Government and 
reduced quality of life for these veterans who have sacrificed 
so much.
    H.R. 3051 would provide welcome relief to family caregivers 
of severely disabled veterans and is consistent with DAV 
Resolution 165 and recommendations of the fiscal year 2009 
Independent Budget. Therefore, we support this measure and urge 
the Subcommittee to work toward its enactment.
    The next bill for discussion is H.R. 6153, the ``Veterans 
Medical Personnel Recruitment and Retention Act of 2008.'' 
Along with our partners in The Independent Budget, DAV has 
called for improvements in VA policies and procedures used to 
recruit and retain highly qualified VA clinical staff. VA needs 
new authority to achieve and sustain its goal to be competitive 
with private sector providers and become a preferred employer 
for physicians, nurses, dentists, and other medical personnel 
needed to care for our enrolled veterans.
    This bill aimed at providing meaningful financial and 
professional incentives to encourage VA medical personnel to 
pursue full careers in the VA healthcare system is timely and 
appropriate given all of the challenges VA faces to maintain 
delivery of timely, high quality, comprehensive healthcare 
services to our Nation's veterans. The Independent Budget 
conveys a series of recommendations that are fully consistent 
with the intent of this bill. Therefore, DAV has no objection 
to its enactment.
    Mr. Chairman, on the final bill under consideration, since 
we did not have a chance to really review that thoroughly, we 
will be happy to submit in writing our views on that final 
bill. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 32.]
    Mr. Michaud. Thank you. Mr. Wilson.

                 STATEMENT OF JOSEPH L. WILSON

    Mr. Wilson. Mr. Chairman and Members of the Subcommittee, 
thank you for this opportunity to present the American Legion's 
views on these three important pieces of legislation.
    H.R. 3051, the ``Heroes at Home Act of 2007.'' This bill 
seeks to improve the diagnosis and treatment of traumatic brain 
injury in members and former members of the armed services, to 
review and expand telehealth and telemental health programs of 
the Department of Defense and Department of Veterans Affairs, 
and for other purposes. Section 2 of H.R. 3051 requests the 
Secretary of VA to establish a program on training and 
certification of family caregivers of veterans and members of 
the active-duty armed forces with traumatic brain injury as 
personal care attendants.
    Pursuant to Section 744(a)(2) of Public Law 109-364, the 
Veterans Traumatic Brain Injury Family Caregiver Panel was 
established in 2007. The 15-member panel was created by the DoD 
to operate under the Department of Health as a Subcommittee to 
advise and specifically provide DoD and VA with independent 
advice and recommendations on the development of training 
curricula to be utilized by the above mentioned family members 
on techniques, strategies, and skills for care and assistance 
for such individuals with TBI, or traumatic brain injury. The 
panel was convened on occasions, to include a recent townhall 
meeting to discuss matters related to the development of this 
curriculum and to hear from the public about the issue.
    Now, the American Legion asserts that the advice of this 
subcommittee, incorporated into the provisions of this piece of 
legislation, is vital and that its absence may deprive such a 
bill of an effective stance and approach to treatment and care 
of TBI. The American Legion, in its continuing efforts to 
increase access and quality of care to all eligible and 
potentially eligible veterans, supports this proposal as it 
would help to accomplish this ongoing challenge.
    H.R. 6153, the ``Veterans Medical Personnel Recruitment and 
Retention Act of 2008.'' This bill seeks to amend Title 38 of 
the United States Code to enhance the capacity of VA to recruit 
and retain nurses and other critical healthcare professionals 
in addition to addressing other issues. The American Legion 
applauds this proposal to amend the methods of hiring and 
retain an additional medical personnel of various disciplines 
to adequately equip VA medical facilities to ensure the 
adequacy and quality of treatment and care. The American Legion 
supports the proposal requested in section 2(j), which seeks to 
amend 7451(c)(2) to allow critical fields

such as nurse anesthesiologists to exceed rate limitations on 
authorized competitive pay.
    Although VA has various anecdotal programs in place to 
include recruitment, relocation, and retention incentives for 
these hard to fill positions, there remains a shortage of such 
nurses and specialty medical physicians. The overall response 
to the question of shortage indicated that salaries and delays 
in appointments were key causative factors. The American 
Legion, during its VA Medical Center site visits to 49 
facilities in 2008, encountered various recruitment issues, 
including such delays in the appointment of nursing assistants. 
Management attributed these delays to the 3- to 4-month hiring 
process. By the time management completed the hiring process, 
applicants had accepted a position in the private sector.
    Also in their site visits, the American Legion 
representatives ascertained other areas with difficulty 
recruiting. These included mental health positions, 
specifically psychologists and psychiatrists, dermatology, 
gastroenterology, orthopedics, and anesthesia. A study 
published in the New England Journal of Medicine ascertained 
there were shorter inpatient delays and lower complication 
rates in hospitals with higher staffing levels while there were 
longer inpatient stays and increased urinary infections, 
gastrointestinal bleeding, pneumonia, and shock or cardiac 
arrest in hospitals with lower staffing levels.
    We hereby urge Congress to act on this piece of legislation 
by incorporating it into the VA system to prevent the 
healthcare system from being included in the casualties of the 
projected shortage of medical professionals through the year 
2020.
    And I will briefly comment on H.R. 6629, the ``Veterans 
Health Equity Act of 2008.'' The bill seeks to amend Title 38, 
United States Code, to ensure that veterans in each of the 48 
contiguous States are able to receive services in at least one 
full-service hospital of the Veterans Health Administration 
(VHA) in the State or receive comparable services provided by 
contract in the State. The American Legion wholeheartedly 
concurs with one proposal portion of this bill, which urges the 
Secretary of VA to allow veterans equal access to full-service 
hospitals. However, in Section 2, the terminology, ``certain 
States,'' leaves question of an alternative or adverse motive 
unfavorable to proposals to further enhance access and quality 
of care across the board within the VA healthcare system. In 
addition, under Section 2 the proposal to insert the language, 
``access to full-service hospitals in certain States,'' once 
again does not warrant unanimous support for this piece of 
legislation. The term ``certain'' implies some States as 
opposed to all.
    The purpose of this piece of legislation, which is also the 
leading opening statement of the bill, seems to be contradicted 
by Section 2, which includes such language as stated in the 
above mentioned paragraph. The uncertainty of this legislation 
leads the American Legion to avoid a position on this bill.
    Mr. Chairman and Members of the Subcommittee, the American 
Legion sincerely appreciates the opportunity to submit 
testimony. Thank you.
    [The prepared statement of Mr. Wilson appears on p. 38.]
    Mr. Michaud. Thank you very much. Dr. Berger.

              STATEMENT OF THOMAS J. BERGER, PH.D.

    Mr. Berger. Mr. Chairman, Ranking Member Miller, and 
distinguished Members of this Subcommittee and guests, the 
Vietnam Veterans of American, VVA, thanks you for the 
opportunity to present our views on these important pieces of 
legislation affecting the healthcare of America's troops and 
veterans. With your permission, I shall try and keep my remarks 
brief and to the point.
    In general, Vietnam Veterans of American supports the 
intent of H.R. 3051. But remember, medical experts say that 
traumatic brain injuries are the signature wound of the Iraq 
War in particular and in fact TBIs have become so commonplace 
that we are yet again focused on them today in this hearing. 
Certain TBI symptoms, such as seizures, can be treated with 
medications. But the most devastating effects, such as 
depression, agitation, and social withdrawal are difficult to 
treat with medication, especially when there is loss of brain 
tissue. In troops with documented TBIs, the loss of brain 
function is often compounded by other serious medical 
conditions that affect physical coordination and memory 
functions. These patients need a combination of psychological 
and physical treatment that is difficult to coordinate in a 
traditional medical setting, even when properly diagnosed at an 
early date. And we must remember that both concussive and 
contusive brain injuries are never just isolated injuries. Over 
time, without proper diagnoses, care, and treatment, TBI can 
affect nearly everything about the survivor, including one's 
cognitive, motor, auditory, olfactory, and visual skills, 
perhaps ultimately resulting in behavioral modifications and 
definitely not a mental illness. Families say that they 
struggle with the military and the VA medical systems that were 
unprepared for these wounded. In some cases, new equipment and 
specially trained staff needed for the most catastrophic cases 
are not available, or have not kept pace with the advances in 
battlefield medicine that kept these servicemembers alive. In 
addition, there are issues about intensity and drain of needed 
family support that will be hard to sustain, as well as the 
significant issues regarding the complexity of the medical and 
other specialized needs that need to be addressed with TBIs. Of 
all the War's medically challenging injuries, brain injuries 
require the most personal involvement, dedication, and cost 
over time.
    As you are well aware, one of the recommendations of the 
Dole-Shalala Commission was to significantly strengthen support 
for families. This will not be an easy task, but VVA believes 
that H.R. 3051 can be a key step in achieving this 
recommendation and providing a mechanism for empowering the 
families of brain-injured servicemembers if, and only if, the 
VA can develop effective implementation strategies for 
certification, competency evaluations, and meaningful outcome 
measurements to carry it out. As they say, the devil remains in 
the details. And part of our concern, of course, lies with the 
fact that there is so much variation amongst the States' 
regulations relative to training, certification, outcome 
measurements, et cetera, for brain-injured persons. It will be 
a difficult task. But if the VA can pull it off, it certainly 
holds hope for family members.
    Regarding H.R. 6629, we certainly, we did not submit any 
written testimony but we certainly support equitable pay and 
hiring processes that will permit our professional staff at the 
VA facilities to at least achieve comparable pay and salaries 
with those in the private sector to provide the care that is 
needed by our veterans.
    Regarding the, excuse me, that was not H.R. 6629. That was 
H.R. 6153. On H.R. 6629, we just got that on Friday and we have 
not had an opportunity. Now we have heard some background 
information and we will submit written testimony in 10 days. 
Thank you very much for the opportunity to do this.
    [The prepared statement of Dr. Berger appears on p. 39.]
    Mr. Michaud. Thank you very much, doctor. Once again, I 
would like to thank the panel. A couple of questions. Ms. Ilem, 
you had raised concerns with implementing the caregivers' 
training program in each of the VA Medical Centers due to the 
lack of capacity, and recommend that the program be limited to 
polytrauma centers and other units within the Defense and 
Veterans Brain Injury Network to ensure the training is high 
quality. Do you have any suggestions on how we can address, the 
challenges you highlighted so that the program can be 
implemented in all VA Medical Centers?
    Ms. Ilem. Well, we did note that so that, you know, 
initially because we felt that probably that is where the 
families would be. You know, where those patients would be and 
have the initial opportunity to work with those families. So to 
keep consistency, you know, hopefully to be able to develop 
some best practices to make sure it is consistent, standardized 
training, to do that, and then to, you know, be able to press 
that out, if necessary, you know, depending on, you know, the 
need for that. But since so many of those veterans are either 
going to the Veterans Integrated Services Network (VISN) area, 
one of the polytrauma, you know, level one polytrauma centers, 
or then, you know, to their VISN level polytrauma center we 
felt that would be the most appropriate place to start just to 
maintain that high quality and consistency of training.
    Mr. Michaud. Mr. Wilson, I did not expect you to comment on 
the Congresswoman's legislation, but since you did and did not 
take any position on it, would you, having heard her testimony, 
agree that it is important for veterans, regardless of where 
they live, to have access to healthcare? I can understand the 
concern with building a brand new hospital. I want to make sure 
that veterans get the services they need versus bricks and 
mortar. But it appears that the concern is that there is a 
large number of veterans who have to travel 4 hours to get the 
care that they need. Would you agree that it is important that, 
if there is care that is needed, whether it is fee-for-service 
or otherwise, that that be provided?
    Mr. Wilson. Well, in terms of access, and from my 
experience in traveling throughout various VISNs in this 
Nation, and even to include Puerto Rico, there is an issue with 
access in addition to New Hampshire. The American Legion does 
not exclude any one particular VA Medical entity within the VA 
healthcare system. That's where we have concerns regarding the 
overall piece of legislation itself. However, there were 
portions, in regards to the access of care, level of care, and 
quality of care at New Hampshire. And I am sure someone can 
attest to access as an issue. Let's use Nevada, because with 
Nevada has a large catchment area. There is an issue with 
traveling to various VA medical facilities in Nevada. And I can 
name quite a few, actually, in regards to access. We have ``A 
System Worth Saving'' booklet, our annual publication that we 
disseminate to Congressional Members. You can read it in the 
2008 publication, regarding access issues. So we do support the 
issue of improving access to care. However, regarding that it 
is not a competition here. We would like to take all VA medical 
facilities to that level of quality access and care.
    Mr. Michaud. Thank you. Mr. Miller. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman, I just have a couple of 
quick questions here on, for the VVA on H.R. 3051. You 
highlight the need to ensure that VA develop effective 
implementation strategies for certification, competency, 
evaluation, and meaningful outcome measurements. I wonder if 
you could expand on that point? And then, is there additional 
legislative text that you would recommend adding to the bill to 
ensure that the provisions in the bill are implemented 
effectively?
    Mr. Berger. Thank you, sir. In regard to the first part of 
the question, I refer to my comment that there is a great deal 
of variation amongst the States relative to private and not-
for-profit institutions or agencies that offer these kinds of 
services, particularly in rural areas across the country. And I 
am not hinting that they are bad in this State or they are 
better in this State, I am just saying there is no 
standardization across the country.
    My own personal experience in working both with Easter 
Seals of Illinois and United Cerebral Palsy brings this to the 
forefront. The standards for caregivers for brain-injured 
persons in these organizations in two parts of the country were 
extremely different. I think that if the VA were to develop a 
standardized process, for lack of a better term, not to run 
through everything that I said, this would help greatly. And 
then the family members could take advantage of this.
    We are going to have a problem down the road, particularly 
in rural areas, with family caregivers taking care of folks if 
they do not receive proper, standardized training.
    Mr. Hare. I just wanted, maybe all three of you could 
comment on this, on H.R. 6153, supporting the legislation. Are 
there other health professionals who are not included in H.R. 
6153 who face recruitment and retention challenges and would 
benefit from flexibilities provided in the bill? For example, I 
know the Paralyzed Veterans of America (PVA) in their statement 
for the record identified a shortage of spinal cord injury 
disease nurses and the need to apply the specialty pay 
provisions to the groups. So I guess what I am asking you, are 
there other health professionals that ought to be included in 
the bill, or concerns that you may have with that?
    Mr. Wilson. In regards to specialty medical positions, I do 
not want to, I cannot specify further than what I have recorded 
on paper. However, speaking from our various site visits I can; 
we will soon disseminate the ``System Worth Saving'' 
publication in which you could actually read for yourself from 
the horse's mouth, if I can say in retards to the various 
shortages. The concern, in discussion, comes from management 
within each respective VA medical facility.
    Mr. Berger. Mr. Hare, I would certainly add those 
specialized social workers that deal with brain injury and 
seizure disorders.
    Ms. Ilem. I would agree with PVA's statement and I am not, 
any other ones have not been brought to our attention, that 
have been missed. But if we are made aware of any of those we 
will certainly forward those on.
    Mr. Hare. Thank you very much. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you, Mr. Hare. Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman. Mr. Wilson, I wanted 
to follow up a little bit on this issue that Mr. Michaud asked 
about with regard to Carol Shea-Porter's bill. Because I think 
we are all in agreement, you know, we want access for all 
veterans. It is just, I guess it is the reality of the human 
condition is we tend to nibble off things that we can, you 
know, bite-sized morsels and move on. I mean, we have a bill 
coming out on the floor I think tomorrow, or this week, or 
something, Jerry Moran's bill. It came out through this 
Committee and it, what do we call it, highly rural areas 
because we recognize that distances in rural areas are, can 
make it prohibitive. So I, while I understand we are trying to 
equalize everything, I would also hope we would recognize there 
may well be a peculiar nature of New Hampshire.
    I have traveled in Nevada a fair amount. I have traveled 
some in New Hampshire. It can be hard to get around New 
Hampshire some times of the year. I had trouble walking in New 
Hampshire at certain times of the year. I just want us to 
appreciate that driving 100 miles in certain parts of the 
country is probably a whole lot different than driving 100 
miles in New Hampshire in the wintertime. And so I do not think 
we should be afraid of doing something that helps one State 
that for probably historical reasons never got themselves a VA 
hospital for whatever reasons in years ago in the past. I do 
not think we should not be willing to deal with that problem 
hoping that somehow we are going to correct all of the problems 
of access to healthcare before we deal with New Hampshire. That 
does not seem a very good approach. And I use as a model as 
somebody already did the highly rural area we are trying to, as 
a pilot, that Jerry Moran's bill, which I think you all 
supported. I think the American Legion did support Jerry 
Moran's bill and it does not deal with nationally. So thank 
you, Mr. Chairman.
    Mr. Michaud. Thank you, Dr. Snyder. Ms. Berkley.
    Ms. Berkley. I have no questions of the witnesses but I 
want to thank you for taking time out and coming to testify.
    Mr. Michaud. Mr. Salazar.
    Mr. Salazar. Thank you, Mr. Chairman. Mr. Berger, do you 
believe that H.R. 3051 actually begins to implement the 
provisions of the Dole-Shalala recommendations?
    Mr. Berger. I think that particular recommendation about 
support for the family is contained in the bill, yes, sir.
    Mr. Salazar.. Let me just read you a little bit of the 
statement that was submitted for the record by Anna Frese, who 
is with the Wounded Warrior Project. She talks about her 
brother, Retired Army Sergeant Eric Edmundson, who was 
seriously injured in Iraq in October 2005 and is currently 
living at home receiving 24/7 care from her father, Edgar 
Edmundson. This is what the father experienced. ``Upon learning 
of Eric's lifelong challenges, our father resigned his position 
at work in order to provide Eric the full-time care that he 
needed. This decision did leave him and our mother with one 
less income, and in times of need they had to dissolve their 
personal and retirement savings. Just as importantly, now at 53 
years old, my father is no longer covered by health 
insurance.'' So these are the kinds of issues that families 
face----
    Mr. Berger. Yes, sir.
    Mr. Salazar [continuing]. Eespecially in rural communities 
where they do not have facilities close by. It seems to me that 
soldiers or patients who have gone through some kind of 
traumatic brain disorder can actually recover better and have a 
better quality of life by having family caregivers. Is that 
correct?
    Mr. Berger. That is absolutely correct, sir.
    Mr. Salazar. Thank you. I would ask for Mr. Wilson and Ms. 
Ilem to comment on that as well?
    Mr. Wilson. I have no comment currently. Please refer to 
our book, ``A System Worth Saving.''
    Ms. Ilem. We would agree that the family caregiver issue, 
just as you have noted, in talking with family members you see 
how their lives are impacted and DAV is very supportive of 
doing everything we can to support the caregiver to make sure 
veterans have the best care possible, and in the best 
environment for those veterans.
    Mr. Salazar.. Well as you know, VA does not support H.R. 
3051 because they say there are current provisions and existing 
efforts that accomplish the goals of the caregivers training 
program and outreach for PTSD and TBI patients. Would you 
comment on that?
    Mr. Berger. Again----
    Mr. Salazar. Are the programs that are already in place 
sufficient?
    Mr. Berger. I do not believe that they are, sir.
    Mr. Wilson. I also disagree that they are. The Veterans 
Traumatic Brain Injury Family Caregiver Panel, which is in 
place, has not been fully effective in resolving that issue of 
that disconnect, of that family, or family member, or even an 
associate being a caregiver to that particular patient. As I 
stated in the testimony, maybe the two in a contiguous effort, 
or maybe the two actually in consortium may be able to decrease 
the gap there and allow for more continuous care.
    Mr. Salazar. Ms. Ilem.
    Ms. Ilem. In just briefly looking over VA's testimony, I 
think they indicated that they are providing their 
certification and training for these family caregivers through, 
you know, already an outside third party that is doing that. 
And I think in just, you know, looking at that this morning, 
you know, the concern would be with these very special cases of 
TBI and the very high-care needs of these veterans and the 
family members, you know, if we are really understanding and 
making sure that they can go the distance to provide that care 
as well, to make sure that they are taking care of themselves. 
We would like to have VA, you know, at the forefront because 
these are some very specific, you know, service connected 
injuries that are occurring, for them to be at the forefront of 
providing the training and certification to make sure that they 
have, you know, the really overview and the quality of that 
care that they hold so high in esteem in VA.
    Mr. Salazar.. Would any of you wish to comment on how you 
feel that this would actually save the VA some additional 
monies by being able to take care of these veterans at home?
    Mr. Berger. Certainly, sir, your testimony threw out some 
dollar figures that I think are absolutely right in line. I do 
not think you can put a dollar value on the care that can be 
given by family members who are properly trained to care for 
these brain-injured troops. And so I will leave it at that. I 
do not think you can put a price tag on it.
    Mr. Wilson. In regards to TBI itself, there are other 
issues arising from TBI, to include blind eye injury and PTSD. 
If TBI is left untreated, it becomes difficult to distinguish 
from other disorders. For example, a lay person who does not 
understand the symptoms, or in denial, can attribute to the 
breakdown in his/her family. That is also an added issue. And 
after reading this particular piece of legislation, we were in 
agreement at the American Legion that this was something that 
needed to be implemented.
    Mr. Salazar.. Ms. Ilem.
    Ms. Ilem. I think without question the costs would be 
higher if left to the Government to provide, you know, full-
time in-house care versus at home. But I think that most 
importantly it is the quality of life. And if the family wants 
to provide that care for their loved one, then they should be 
provided the resources they need and the support that they need 
to provide the best care to that veteran. But I think cost 
aside, the quality of care issue is probably the most 
important.
    Mr. Salazar. Thank you all for your testimony. I yield 
back, Mr. Chairman.
    Mr. Michaud. Thank you very much, Mr. Salazar. Once again, 
I would like to thank all three of you for your testimony here 
this morning.
    The last panel is Dr. Cross, who is the Principal Deputy 
Under Secretary of Health, and will be accompanied by Walter 
Hall and Joleen Clark. I want to thank you all, for coming here 
today to give your testimony on the two pieces of legislation 
we have, and the third piece that was added at the last moment. 
Without any further ado, Dr. Cross.

  STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A. 
  HALL, ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL, 
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JOLEEN M. CLARK, CHIEF 
 OFFICER, WORKFORCE MANAGEMENT AND CONSULTING, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Cross. Good morning Mr. Chairman and Members of the 
Subcommittee, and thank you for inviting me here today to 
present the administration's views on two bills under 
consideration, H.R. 3051, the ``Heroes at Home Act of 2007,'' 
and H.R. 6153, the ``Veterans Medical Personnel Recruitment and 
Retention Act of 2008.'' VA recently received H.R. 6629, the 
``Veterans Health Equity Act of 2008,'' and is not prepared to 
address the bill today but we will be happy to submit our views 
and cost estimates on the bill for the record. VA is still 
preparing cost estimates on the other two bills on today's 
agenda. As soon as those become available, we will supply them 
for the record. Also, I want to say I am accompanied today by 
Mr. Walter Hall, Assistant General Counsel, and Mrs. Joleen 
Clark, our Chief Officer for Force Management and Consulting.
    [As of January 12, 2009, the VA failed to provide the 
Administration views on H.R. 3051, H.R. 6153, and H.R. 6629.]
    I will begin with H.R. 3051. section 2 would require VA to 
establish a program to train and certify family members of 
veterans and servicemembers with traumatic brain injury, which 
is also called TBI, as personal care attendants. VA supports 
using family members as caregivers for these veterans, but 
believes VA's current home healthcare program already 
accomplishes this in a more efficient and effective manner than 
would be possible under the bill. Implementing section 2, as 
written, could give rise to potential conflicts concerning the 
veteran's care between the family member, the caregiver, and 
the VA, with the veteran. This would place VA in an untenable 
position. We strongly urge the Congress to allow VA to continue 
to obtain caregiver services under the Home Healthcare Program, 
which uses a third party to provide for the training and 
payment of personal care attendants.
    Subsection 3 of H.R. 3051 would require VA to conduct a 
comprehensive outreach to enhance the awareness of veterans and 
the general public about the symptoms of post traumatic stress 
disorder and TBI and available VA healthcare services. VA 
already has an extensive and expanding outreach program in 
place to inform veterans and the general public about PTSD and 
TBI, as well as the services we provide to veterans with these 
injuries. We, therefore, think this statutory mandate is not 
necessary.
    Section 4 would require DoD and VA to jointly establish a 
demonstration project to assess the feasibility and 
advisability of using telehealth technology to assist cognitive 
functioning of Members and former Members of the Armed Forces 
who have sustained head trauma in order to improve the 
diagnosis and treatment of TBI. VA supports the goals of this 
provision, but cannot support this section as written because 
it is too prescriptive. VA and DoD should be allowed more 
flexibility in executing the demonstration project and would be 
pleased to work with the Subcommittee's staff to develop 
legislative language that would enhance its value.
    I turn now to H.R. 6153, the ``Veterans Medical Personnel 
Recruitment and Retention Act of 2008.'' We support many 
provisions that would contribute to VA's mission, such as the 
expansion of VA's education assistance program outlined in 
section 4. Similarly, we endorse several measures that would 
improve VA's ability to provide comparable pay and benefits to 
nurses, physicians, and executives. Other sections of the bill 
need only minor adjustments, such as the authority to add nurse 
assistants to the list of so-called hybrid occupations. We 
believe this authority should apply to healthcare delivery 
occupations in general.
    However, there are some provisions that would negatively 
impact patient care and VA must oppose. Subsection 2B would 
change the probationary period for full and part-time 
registered nurses from 2 years to the equivalency of 4180 
hours. Part-time Title 38 employees, including RNs, do not 
serve probationary periods. These apply only to full-time 
permanent employees. We see no benefit in creating a 
probationary period for part-time nurses, since it would not 
make them the equivalent of tenured employees for purposes of 
discipline or discharge.
    VA also opposed section 2C, which would limit temporary 
part-time employments of hybrid nurses, specifically licensed 
practical nurses, LPNs, and licensed vocational nurses, LVNs, 
to no more than 4180 hours. Currently, the part-time hybrid 
appointments may be for periods exceeding 1 year. 
Operationally, this change could severely limit VHA by 
preventing us from appointing highly qualified LPNs and LVNs 
who only want to work on a part-time basis.
    Finally, we oppose Subsection 2M since it appears to create 
a windfall by extending premium paid benefits for employees 
performing occasional work. We also note subparagraph 2 would 
not be limited to registered nurses, which we understand is the 
intent of this provision. It would also apply to other 
employees. We are similarly concerned that Subsection 3B, which 
would amend the ``Baylor Plan,'' could provide an unwarranted 
bonus structure.
    Mr. Chairman, this concludes my prepared statement. I am 
happy to answer any questions that you or the Subcommittee may 
have.
    [The prepared statement of Dr. Cross appears on p. 40.]
    Mr. Michaud. Thank you very much, Dr. Cross. You noted that 
VA refers interested family members to home health agencies 
that VA contracts with. How many referrals has VA made and does 
VA pay for the training?
    Dr. Cross. Under our program right now, VA currently 
contracts with more than 4,000 home health agencies that are 
approved by the Centers for Medicare and Medicaid Services and/
or State licensed. And many of these have expertise in training 
and certifying home health aides. Many of them also are found 
in rural settings and we can engage them there. I do not have 
for you the exact number of individuals within that program.
    Mr. Michaud. Could you provide that for the Committee?
    Dr. Cross. Yes, sir.
    Mr. Michaud. Of the referrals, how many, have completed the 
certifications as well.
    Dr. Cross. Yes, sir.

    [The following information from VA was subsequently 
received:]

         In situations where a veteran will require long-term or 
        lifetime care or assistance in the requirements of daily 
        living, VA provides counseling and training to family members 
        and other caregivers who are capable and willing to take on 
        this responsibility. VA is not authorized to pay these 
        individuals and, for practical and legal reasons that were 
        discussed in our testimony and at the hearing, we do not 
        believe VA should be the appropriator or payer.
         When it is clinically necessary and appropriate, VA has 
        arrangements with local contractors who will provide caregiver 
        training to family members and qualify them to be a State 
        certified caregiver. Following State certification, the family 
        member caregiver may become a certified, salaried employee of 
        that contractor or another entity that provides caregiver 
        services. The decision for referral to a contractor is made on 
        a case-by-case basis. VA has no data on the number of 
        individuals who elect to use this process.

    Mr. Michaud. Does the VA provide respite care while the 
family caregiver is in training programs so that the family can 
continue to care for the needs of the veteran?
    Dr. Cross. Yes. Our respite program is more broadly 
construed. It can be for any number of reasons. It would not be 
limited to just that one reason.
    Mr. Michaud. In your testimony you identified language on 
the telehealth demonstration as being too prescriptive and 
detailed. Can you expand on that? What type of flexibility do 
you need?
    Dr. Cross. We are working with DoD and the Center of 
Excellence already, and we want to continue doing that, and 
intend to do so. Some of the language in the bill relating to 
using telehealth for educational purposes is kind of a mixed 
approach, using something that we use for diagnosis and 
treatment for what appeared to be a more broad reaching 
outreach effort. And we use other modalities for that. We did 
not think that was a well constructed component within the 
bill.
    Other portions of the bill relating to the reporting 
requirements would be substantial. We can work with your staff, 
sir, to try and mitigate that. I think clearly on the intent, 
we have the same intent.
    Mr. Michaud. Good. Thank you. On H.R. 6153 you mention that 
it is hard to recruit occupations that this provision would 
help with. Can you give us, some of the top five occupations 
that you are referring to?
    Dr. Cross. I will ask Ms. Clark to comment.
    Ms. Clark. Each year we do a, what we call Successions 
Strategic Plan and we have the networks update their plans. And 
we have what we call our top ten critical occupations. And 
those this year are the traditional ones, nurses, physicians, 
pharmacists, LPNs. We do have an administrative one in there, 
human resources, occupational therapists, physical therapists, 
medical technologists. Of the physicians there is several 
occupations that were mentioned, actually, earlier in some of 
the testimony. Gastroenterologist, anesthesiologist, 
psychiatrist, there are a few others. And then inpatient 
nursing areas, we do have a few that we target and certified 
registered nurse anesthetists are also one of those 
occupations.
    Mr. Michaud. Thank you. You mentioned in your testimony 
that VA is facing worsening pay compensation issues within the 
ranks of senior pharmacy program managers in VHA, and that 
special incentive pay provisions for pharmacist executives 
would not address the retention need for the agency in the long 
run. Could you explain what that need might be, number one? And 
number two, what are you doing to try to address that need? 
That is, I know actually, in VISN 1, they are looking at 
building a brand new community-based outpatient clinic (CBOC) 
in the Bangor area, but also we have a private college that is 
interested in working collaboratively with VA for a pharmacy 
program, which would be a great opportunity to work 
collaboratively with higher ed. If you can, explain what the 
needs are and what are you doing to help address those needs.
    Dr. Cross. Sir, I will comment briefly on it and ask Ms. 
Clark to add. In consultation with my Chief of Pharmacy for 
this testimony today, we are holding our own fairly well in 
most places for pharmacists at the staff level. Certainly it 
remains a concern that we have to watch closely, because it is 
a competitive environment. This provision was related to the 
executive level and we have some challenges there in terms of 
long lag times, absences, and difficulty in recruiting.
    To follow on to your other comment, though, and what we are 
doing, we do a great deal of effort in recruiting and reaching 
out to individuals including schools. And I will ask Ms. Clark 
to comment on some of that.
    Ms. Clark. We are quite competitive with the pharmacists, 
the staff pharmacists, because we can set special salary rates 
depending on the area. So that is not as big a concern. We do 
have to be vigilant so that we stay on top of it and keep those 
salaries competitive. As Dr. Cross mentioned, it is our 
executive rank, because there is not special salary rates for 
those executive rank. And so to try to get people to take those 
positions is really hard when they can get special salary rates 
and make almost as much as a staff pharmacist at those levels. 
So it is an issue and it is a problem to try to get those 
salaries, something, some kind of other compensation for that 
level.
    Mr. Michaud. Is it more of a problem in rural areas than?
    Ms. Clark. Well, the rural areas pretty much are just like, 
with setting salaries, are pretty much the same across the 
country. You can set them based on the local market and what 
the local market dictates. And if that dictates paying 
relocation incentives, retention incentives, because you have a 
hard time keeping people in that area, you can pay those things 
on top of the salaries. So there is mechanisms, you know, in 
place for the staff pharmacists or the staff level employee.
    Mr. Michaud. Mr. Miller.
    Mr. Miller. Thank you, Mr. Chairman. PVA expressed concern 
that the development of programs to address the needs for 
veterans with mild or subclinical TBI have not been fully 
developed or implemented. Could you respond to PVA's concern?
    Dr. Cross. We have done a tremendous amount of work in 
regard to TBI. Let me just highlight a couple of key points. We 
started this program back in the mid-eighties, creating special 
centers for TBI which we have now modified to call polytrauma 
centers. There were four of them. We are getting ready to open 
up, we are getting ready to build a fifth one in San Antonio. 
That was not enough. We have expanded those to create centers 
at our Medical Centers, and reaching out even into our smallest 
parts of our program by providing levels of expertise regarding 
TBI at those sites. We have done something that is unique in 
the United States. We are screening for mild TBI and we have 
developed the screen in such a way as to be more sensitive than 
specific.
    Our intent was to not miss anyone. And so we designed the 
program with some elements from DoD to create that screening 
program. We have screened thousands and thousands at this time. 
And when they screen positive we put them into a special 
program. And what is more, we are reaching out to the ones that 
we have not seen yet because we are concerned that there are 
people who might need these services that we have not even 
addressed. We are calling every single veteran from Operation 
Iraqi Freedom and Operation Enduring Freedom who has not been 
to one of our facilities and contacting them by phone and 
saying, ``Hey, how are you doing? Can we help you?''
    Mr. Miller. I think PVA is still saying the milder 
subclinical issue has not been addressed.
    Dr. Cross. Well, perhaps there is always more to be done. 
And I value my colleagues in PVA's opinion. I take that very 
seriously. I would be happy to have an engagement to go over 
what we are doing currently because we have been pretty fast 
moving on this, and there is a lot that has been done in the 
past year or two.
    Mr. Miller. Thank you, great idea. I think that, just 
sitting down and having a conversation with them may clear up 
some misconception. Also, on H.R. 6153, their concerns were 
expressed that hiring and promotion processes under Title 38 
hybrid is facing extraordinary delays because of boarding the 
process. My question is, are the concerns valid? Are there 
really problems with the boarding process?
    Dr. Cross. Frankly, there are some concerns that I have 
about how long it takes to bring someone on once we identify an 
individual that is interested in the job. I should give you 
just a couple of numbers and I will ask Ms. Clark to comment on 
the process a little bit. But we have had some success. We have 
expanded the number of nurse anesthetists. We added in net 
several thousand additional nurses to the VA last year. I have 
the most recent statistics yesterday. And Ms. Clark, can you 
comment?
    Ms. Clark. Yes, I will just add on to that. This year in 
2008, we are projected in VHA to hire over 40,000 new 
employees, which is approximately a 49 percent increase in 
hiring over last year, over 2007. So it is like 13,000 more 
that are being hired just because of the increase in services 
that we are now adding. So that does add an extra burden. With 
that, we do realize that it takes too long. We have added 
different steps in the process with credentialing because we 
think it is important to have all our staff credentialed and 
make sure they are credentialed properly. So it has added some 
timeframe.
    We went through what we call process redesign to look at 
all the steps and see where things can be cut out, and we are 
working actively. Last year we started it. This year we are 
going full force with it again. We have even included a 
performance metric within all of our network directors 
performance plan that after somebody is identified they have to 
be brought on, or not brought on, but be offered the position 
within 30 days. You know, usually they have to give a notice to 
their employer but they can start effectively then if they 
wanted to, actually, after that 30-day timeframe. And it has 
been very successful in some areas. Some areas are still 
struggling. But they all are improving their timeframes.
    Mr. Michaud. Thank you. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. Dr. Cross, I just wanted 
to, just a couple things on H.R. 3051. You, in your testimony, 
you identified the language of the telehealth demonstration as 
being too prescriptive and detailed. I wonder if you could 
maybe expand on the point and explain what flexibilities that 
you think are needed?
    Dr. Cross. I think if you could just leave it up to us to 
design a demonstration project, working with our colleagues in 
DoD we could come to a very workable, practical approach to 
this. In fact, the truth is we are already doing much of this 
in terms of collaboration. There has never been, in my 
experience, I have been in the military 20, 25 years before 
coming to the VA, I have never seen as much interaction and 
collaboration between these two organizations as exists now. We 
are in meetings with them at some level virtually every single 
day. So we can work this through. And I think sometimes the 
people on the ground can put this together better than anyone 
else.
    Mr. Hare. Well let me just say that, you know, last spring 
we heard of internal VA emails identifying 12,000 annual 
suicide attempts, an estimated suicide rate of 6,570 per year 
across our veterans population. And these statistics to me show 
that current efforts are not enough to help with the hundreds 
of thousands of returning Iraq and Afghanistan veterans. So I 
would really urge the VA to not be complacent with current 
activities and to implement a comprehensive strategy and share 
best practices with non-VA healthcare practitioners. I think 
this bill goes a long way. And I commend my colleague for 
introducing the bill. And I would I would like to see, you 
know, and I agree with what Mr. Miller said earlier, that the 
working together between the VA and the VSOs to come up with 
something that is actually going to work here. And as you know, 
I am very troubled by the numbers of that as I know you are. 
And whatever we can do that will help, whether it is, you know, 
and again, I think this bill goes a long toward doing just 
that. But I would really like to see a collaborative effort 
here on behalf of the VA and the VSOs to come up with something 
that A will work. And when you design this demonstration 
project, I was just wondering if I could go back to that for a 
second. When you say, how long is that going to take, do you 
think, to be able to design that project and before we----
    Dr. Cross. The demonstration on telehealth?
    Mr. Hare. Yes.
    Dr. Cross. And the cognitive assessment? I met with my 
staff on this, the experts. I did not actually get a timeframe. 
I would have to get back to you with an answer to be accurate.
    [The following information from VA was subsequently 
received:]

         Question: What is the projected timeframe for developing the 
        joint DoD and VA demonstration project to assess the 
        feasibility and advisability of using telehealth technology to 
        assess cognitive functioning of Members and former Members of 
        the Armed Forces who have sustained head trauma, in order to 
        improve diagnosis and treatment of traumatic brain injury?
         Response: A timeframe has not yet been established. However, 
        the DoD and VA have made significant progress in the area of 
        interoperability since the National Defense Authorization Act 
        designated DoD as the lead agency and VA as the collaborating 
        agency in this initiative. The two departments have developed 
        an in-depth interoperability plan for the demonstration project 
        that includes verification of an existing evidence-based and 
        validated telehealth application to assess cognitive function. 
        In developing the timeframe, DoD and VA will need to allow 
        sufficient time for both departments to develop the project's 
        clinical scope, arrange technology support, determine location 
        and necessary personnel, and consider legal and regulatory 
        issues before the actual demonstration project is underway.

    Mr. Hare. Thank you, Mr. Chairman.
    Mr. Michaud. Mr. Salazar.
    Mr. Salazar. I do appreciate your having this hearing 
today, first of all. Dr. Cross, you state that whether the 
caregiver compensation is for caregivers as a VA employee 
versus the benefit, that raises significant legal issues 
relating to liability, taxation, the VA relationship and 
responsibilities to the veteran, and the caregiver, can you 
explain that and expand on that a little bit?
    Dr. Cross. Well, I will do my best but I think my counsel, 
Mr. Hall, will probably do a better job than I can so I will 
turn it over to him.
    Mr. Salazar. And before you answer that, can you also 
address the issue of, how this bill adheres to what the Dole-
Shalala recommendations were. And, are you saying that they 
were just spitting in the wind when they made these 
recommendations because you were already doing all of this? Or 
could you expand on that a little bit as well?
    Dr. Cross. Let me, I wanted to have a chance to respond to 
that. Because we support the intent of this. And in fact, that 
bill, you know, those provisions have been out and under 
discussion for some time now. And so, yes, we have already been 
acting on many of these things. Outreach for PTSD and TBI, we 
have, I listed just in the written testimony several paragraphs 
of our measures that we have instituted. The suicide prevention 
hotline, Mr. Hare's comment about suicide, tremendously 
important issue for us. The clinical guidelines, we are 
publishing them, working with DoD every day to refine them and 
develop them further. We call in the Institute of Medicine to 
help us with TBI and PTSD issues. Telehealth, we have got tens 
of thousands of patients now receiving support from telehealth. 
So, yes, we are taking these very seriously. We did not wait 
for today to start on this. And that is why we phrased our 
comments the way we did. But our intent is very much consistent 
with what you have here. And I will ask Mr. Hall to expand on 
the fine points of that distinction.
    Mr. Salazar. Let me just follow-up on it. So in other words 
what you are saying is, we do not need the legislation to 
address the issues. We are already doing everything Dole-
Shalala recommended, is that correct?
    Dr. Cross. Well, the training for family members was not 
one of those. We think that there are significant issues that 
have to be addressed there and the way that the bill was 
phrased to provide the support directly was problematic for us. 
And we wanted to continue using what we have found to be the 
more effective, efficient working well mechanism using these 
healthcare agencies across the United States.
    Mr. Salazar. Well, are you currently providing compensation 
for family members, not only the training part of it, but 
family members when they have to quit their jobs to take care 
of someone who has PTSD or traumatic brain injury?
    Dr. Cross. I will ask Walt to correct me if I am off base 
here but the home health agencies that we contract with can 
hire the family member and do so.
    Mr. Salazar. Okay.
    Mr. Hall. Yes, sir. That is what in fact is going on now, 
is that we contract with the home healthcare provider who then 
hires the family member, provides them the training, then 
supervises the care that they give to the veteran. That puts 
them in the position of being responsible for assuring the 
quality, assuring the liability coverage of the caregiver, the 
family member, in case, and making sure that the quality of the 
care that they are getting meets the standards that are 
required.
    The way the legislation is phrased it says that VA will 
compensate the caregiver. It does not say exactly what the 
status of the employee, or the caregiver, will be. Will they be 
VA employees? Will they be responsible to VA? Will VA be 
responsible for them as far as things like insurance liability, 
liability for care, if the care that they are not giving 
somehow, the care that they give somehow injures the veteran? 
What is the liability? If it is a VA employee then of course 
the VA is responsible for that liability regardless of the 
relationship between the caregiver and the veteran. It is just 
a, it raises a number of issues like that. If it is 
compensation, is it compensation to the veteran? Or is it 
compensation to the caregiver? Do they become a VA beneficiary, 
for example, like somebody receiving compensation and pension 
would be receiving? If, and then that raises the case of VA's 
responsibility for overseeing that care. What is the quality of 
that care? Are they doing the job that the veteran needs? If 
they are not what is VA's recourse? Do we terminate the 
compensation, and what is the mechanism for doing that? It just 
raises a lot of----
    Mr. Salazar. So then what you are saying, you do not really 
have any oversight over the caregivers that you currently have? 
I mean, that is what I heard you say, is it not? Because of the 
liability issue?
    Mr. Hall. No.
    Dr. Cross. First of all, of course, as I pointed out in the 
written testimony I think, we look for those home healthcare 
agencies that are approved by the Centers for Medicare and 
Medicaid Services and State licensed.
    Mr. Salazar. Okay. But they assume the liability in case 
something goes wrong?
    Dr. Cross. Correct.
    Mr. Salazar. And you have oversight over those caregivers?
    Mr. Hall. Yes, sir. They are responsible under the contract 
that we have with them to provide care to a certain standard.
    Mr. Salazar. And what is your recourse if they do not?
    Mr. Hall. Then we are able to, under the, we have recourse 
under the contract, either to demand damages or payment from 
them, or to terminate the contract.
    Mr. Salazar. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much, Mr. Salazar. I just have 
one follow up question, Dr. Cross. Actually, the three of us 
and Ranking Member Miller, had the chance to go to Iraq and 
visit with the troops, and talk to the individuals over there 
about healthcare. One of the issues that, I actually asked 
several of the generals we met with is, what they are doing 
personally to help, destigmatize PTSD, or traumatic brain 
injury. We got, the normal response that we get. But the 
interesting thing is, at one facility after we went out and did 
our photo shoot out front, someone with lesser command came up 
to me and very discreetly said, you know, ``We need more 
help.'' They are not getting the help that they need to, to the 
soldiers.
    You mentioned that you are working with the DoD on a daily 
basis. What are you doing to help with that destigmatization? 
For instance, a couple of days ago when I was in Indiana, we 
had a veteran who called a Congressman, as well as the press, 
and said he was going to kill himself during our meeting at the 
CBOC. We were able to take care of that. But, there is a big 
problem out there. Are you working with other groups? What 
actually came to my attention when you look at a lot of our 
athletes, which are looked at as heroes as well, when you look 
at the concussion that athletes have, which is mild TBI, are 
you working with the other organizations such as, sports, to 
see what they can do to help destignmatize issues such as TBI 
or PTSD?
    Dr. Cross. Thank you for that question, sir. The stigma is 
very real. We recognize that. We do not deny that. And we take 
it very seriously. Let me tell you three or four of the things 
that we are doing in conjunction with your experience in Iraq.
    I do not think many people necessarily who are experiencing 
depression are anxious to go sit in a waiting room that says 
psychiatry or mental healthcare. We recognize that so we 
created a nationwide initiative which we have already executed 
to insert our mental healthcare, a portion of it into primary 
care clinics, where the patients have already been and are 
already usually comfortable. We start the process right there, 
make the diagnosis, make the first contact, break the ice, so 
to speak, right in that setting. Then we are doing education. 
If you go out on the metro here in Washington, or watch some of 
the buses going by, you will see a sign. It says, it is a 1-800 
number, ``Call it for help.'' It is from the VA. If you call 
that number and press 1 as it tells you, it takes you to our 
facility at Canandaigua, New York. And when you, and you can 
call them anonymously you do not have to give them a name, but 
they will encourage you to do that. And that is our suicide 
prevention hotline in which we have had like, I think 50,000 or 
60,000 calls since we have opened it. Now, many of those were 
not veterans. Many of them were people just calling for 
information. But some of them were significantly asking for 
help and we have done many rescues.
    Our Vet Centers are a key tool that we have, where you have 
combat veterans talking to combat veterans. Combat veterans on 
our staff, and they have a totally different record system and 
create a real sense for that individual of privacy and 
confidentiality, and a lack of bureaucracy, perhaps, that would 
be different from a large hospital. So those are several of the 
things that we are doing.
    We recognize that issue. We think it is very important, and 
that is why we are putting these programs, and have already put 
those programs in place.
    Mr. Michaud. I know it is out of your jurisdiction, but 
actually I was reading an article somewhere where they had, I 
think, the Dallas Cowboy Cheerleaders overseas to bring morale 
to the troops. During your discussions, I am just wondering 
whether it might be worthwhile with your discussion with DoD 
whether or not you do have these athletes who will admit that 
they have mental health problems and could really help with 
destigmatization of this issue.
    Dr. Cross. Sir, even while we are speaking right now there 
is a conference going on, I believe, back at my headquarters 
and the tape, it is not an athlete but it is a movie star. They 
are doing a press release with a videotape of Gary Sinise. I 
think that was Lieutenant Dan. And talking about the issues of, 
you know, how we are encouraging folks to come in and get help. 
John Elway was also involved with us on some public releases 
that we have done. He has been very helpful, and others as 
well. And I hesitate because I might leave somebody out, but a 
number of them have been very helpful.
    Mr. Michaud. Okay. Well, thank you very much. Lastly, I 
know you are going to provide written testimony on 
Congresswoman Shea-Porter's, legislation. She already made 
clear--well, the Secretary did--that they are not going to get 
a hospital, but it appears that there is a problem with her 
veterans getting service. If you are opposed to her legislation 
if there is a way that we can look at addressing her concerns, 
you know, as well it would be very helpful.
    [As of January 12, 2009, the VA failed to provide the 
administration views on H.R. 3051, H.R. 6153, and H.R. 6629.]
    Dr. Cross. Of course, sir, and we will do that.
    Mr. Michaud. Okay. Well, once again I want to thank you Dr. 
Cross for your testimony, but also for your ongoing support for 
taking care of our veterans. You have always been a gentleman 
and I really appreciate working with you and your staff as 
well. If there are no other questions, we will adjourn the 
hearing. Thank you very much.
    [Whereupon, at 11:31 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Michael H. Michaud, Chairman,
                         Subcommittee on Health
    I would like to thank everyone for coming today.
    Today's legislative hearing is an opportunity for Members of 
Congress, VSOs, the VA and other interested parties to provide their 
views on and discuss legislation that have been introduced within the 
Subcommittee's jurisdiction in a clear and orderly process.
    I do not necessarily agree or disagree with the bills before us 
today, but I believe that this is an important part of the legislative 
process that will encourage frank discussions and new ideas.
    We have three bills before us today.
    I look forward to hearing the views of our witnesses on these bills 
before us. I also ask that witnesses submit their views for the record 
on H.R. 6629.

                                 
   Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
                         Subcommittee on Health
    Thank you, Mr. Chairman, for holding this legislative hearing.
    Today, we will hear testimony on three legislative proposals--
    H.R. 3051, which would require VA to establish a program to train, 
certify and compensate family members of veterans and servicemembers 
with Traumatic Brain Injury (TBI) as personal care attendants;
    H.R. 6153, the Veterans' Medical Personnel Recruitment and 
Retention Act of 2008; and
    H.R. 6629, which would require that veterans in the 48 contiguous 
states have access to full service medical care through at least one VA 
hospital in the state, or through a contract with other health 
providers in the state.
    Providing the highest quality of care for our wounded warriors 
suffering with a TBI, the recruitment and retention of the very best VA 
healthcare providers, and access to care for every veteran regardless 
of where they live are issues that our Subcommittee has been focusing 
on throughout the year.
    VA has recently developed and implemented many new programs and 
policies to address the needs of veterans with TBI, help recruit and 
retain its corps of healthcare professionals and enhance access to 
care. I want to commend the Department for their ongoing efforts. 
However, during this critical time, we must continue to look at where 
gaps in services still exist and what more can be done to ensure that 
our veterans receive the highest quality healthcare services.
    I want to thank all of our witnesses for being here today. I look 
forward to a productive discussion and the opportunity to fully examine 
the legislative proposals before us. I am hopeful that this debate will 
help guide our actions on developing legislation that will best serve 
our Nation's veterans.
    Thank you Mr. Chairman, I yield back.

                                 
                  Prepared Statement of Hon. Phil Hare
    First, I would like to thank Chairman Michaud and Ranking Member 
Miller for holding this hearing. The three bills before us today 
address important issues, all of which have huge impacts on the welfare 
of our Nation's veterans.
    Second, I would like to thank the sponsors of these bills, the 
three members that are testifying before us today.
    Mr. Salazar is a fellow Committee Member and I know from sitting 
next to him over the past 2 years, that he is a tireless advocate for 
veterans, especially the many rural veterans that live in his large 
district in Colorado. His bill addresses family caregivers for veterans 
suffering from TBI, and also telehealth services. These are crucial 
matters and are directly in line with Mr. Salazar's passion for 
improving the lives of veterans and their families.
    Ms. Johnson is also a big supporter of veterans. For 15 years she 
worked at the Dallas VA Medical Center as a medical and psychiatric 
nurse. Appropriately, her bill aims to help VA recruit and retain more 
nurses and other healthcare professionals.
    Ms. Shea-Porter and I came into Congress at the same time, and I 
know without a doubt, that there is nobody more dedicated to serving 
our veterans than she is. It is a paradox then that her home state, the 
great State of New Hampshire, does not have a VA medical center. Her 
bill attempts to resolve this injustice.
    Third, I would like to thank all our witnesses for testifying 
today, including Dr. Cross of the VA and each representative of the 
three VSOs present. I would also like to congratulate the Disabled 
American Veterans for recently electing Raymond E. Dempsey, a fellow 
Illinoisan, as National Commander. Speaking on behalf of the great 
state of Illinois, I take great pride in knowing that such a well-
respected organization is under the leadership of Mr. Dempsey.
    Mr. Chairman, thank you again for holding this important hearing.

                                 
           Prepared Statement of Hon. Eddie Bernice Johnson,
          a Representative in Congress from the State of Texas
    Thank you, Mr. Chairman, and Members of the Subcommittee, for the 
opportunity to testify today on issues related to veterans.
    Millions of veterans nationwide receive treatment in the VA 
healthcare system. A significant number of these veterans have returned 
from war--including the wars in Afghanistan and Iraq--with serious 
injuries, including traumatic brain injury. Quite understandably, a 
large number of troops are also suffering from psychiatric disorders, 
such as post-traumatic stress disorder.
    It is our duty to ensure that our veterans, who have so 
courageously served our country, receive the medical support they 
deserve. The VA system must be able to successfully compete for the 
best healthcare providers in the United States. Today, I speak in 
support of the Veterans' Medical Personnel Recruitment Act of 2008, 
because it gives the VA the tools to recruit and retain the very best 
medical and professional employees.
    This legislation will raise salaries for nurses, physicians, 
dentists, senior executives and pharmacist executives. It will 
streamline pay systems, making them easier to understand and to 
implement. It will provide incentives to retired employees to return to 
the VA system by removing annuity and salary offsets, thereby 
encouraging the qualified workers most familiar with the VA system to 
return to work. The legislation will also increase education benefits 
for new VA hires and current staff.
    I worked as a medical and psychiatric nurse at the Dallas VA 
Medical Center for 15 years, and I can attest to the unparalleled role 
nurses play in all medical facilities. Nurses are often the medical 
professionals with whom patients have the most contact, and they are 
repeatedly cited by patients as the medical professionals they trust 
the most. There is a nursing shortage in our country, and if we want 
the VA to attract the very best nurses, we must provide the proper 
incentives.
    Standardizing the definition of ``emergency'' will facilitate more 
consistent and equitable use of emergency mandatory overtime. By 
clarifying VA regulations regarding work schedules, overtime and 
emergency duty the Veterans' Medical Personnel Recruitment and 
Retention Act will offer nurses more schedule flexibility and provide 
for the VA to become a more employee-friendly place to work. The 
legislation will also make it easier for the VA to hire and retain 
part-time nurses and to allow full-time nurses to transition to part-
time work schedules.
    The Veterans' Medical Personnel Recruitment and Retention Act will 
strengthen the VA system, helping to make the VA the healthcare 
employer of choice. Our veterans, who have so courageously served our 
country, deserve its passage and implementation.
    Mr. Chairman, this concludes my testimony I will be happy to answer 
any questions that you may have.

                                 
              Prepared Statement of Hon. John T. Salazar,
        a Representative in Congress from the State of Colorado
    Thank you Mr. Chairman.
    First I would like to thank Dr. Jim Schraa, a Neuropsychologist at 
Craig Hospital, and Anna Frese, with the Wounded Warrior Project, who 
submitted testimony for the record.
    On July 17, 2007 I introduced H.R. 3051 the Heroes at Home Act.
    The purpose of this bill is to improve the diagnosis and treatment 
of traumatic brain injury in current and former Members of the Armed 
Forces.
    The program will be located in VA healthcare centers across the 
Nation.
    This is especially important to rural districts like mine where 
making healthcare accessible is a constant challenge.
    H.R. 3051 addresses the need for access to care by expanding both 
DoD and VA telehealth and telemental health programs.
    Ultimately this bill will ease the burden on our veterans suffering 
from TBI and the families who care for them.
    Our Committee has heard testimony from many veterans, Veteran 
Serving Organizations and the VA on the mounting cases of TBI, PTSD and 
other invisible wounds of war.
    Many agree that veterans are often worse off with these unseen 
injuries than those with visible physical injuries.
    Unlike other injuries that can heal, brain injuries are often 
permanent and disabling.
    In addition, TBI can sometimes take years to develop and diagnose.
    Even when discovered the road to recovery is long and is borne by 
the families of our brave men and women in uniform.
    We have also heard of the link between TBI and other mental 
conditions such as epilepsy.
    A DoD study after Vietnam found that 15 percent of soldiers with a 
penetrating TBI developed epilepsy soon after their injury.
    H.R. 3051 creates a program to train the family members of TBI 
patients to become their personal care attendants.
    Participants going through the program would become certified and 
receive compensation from the VA so that they can focus their energy on 
caring for their loved ones.
    By taking place at home with family, the healing process is made 
more comfortable for our veterans.
    The cost to the VA for having someone cared for at home is less 
than having them at a medical facility and allows the VA to allocate 
the resources they have to serve more veterans.
    We have soldiers in Iraq and Afghanistan spending longer periods of 
time in harms way and away from their families.
    With that in mind we need to ensure that there are programs in 
place to care for them when they return home.
    A program that provides quality care for our veterans and a 
financial benefit for their families seems appropriate for the 
difficult economic times our country is facing.
    Most importantly, this bill will help us all reach our goal of 
ensuring our veterans the best care possible.
    Mr. Chairman, I thank you and the Members of this Subcommittee for 
the opportunity to introduce legislation that improves the lives of our 
veterans suffering with TBI.

                                 
             Prepared Statement of Hon. Carol Shea-Porter,
      a Representative in Congress from the State of New Hampshire
    Mr. Chairman.
    Thank you for the opportunity to speak to your Subcommittee about a 
critical inequity facing New Hampshire's veterans--the lack of full 
service, in state healthcare.
    New Hampshire has not had a full service veterans' hospital since 
2001. New Hampshire is the only state without a full-service VA 
hospital or comparable facility. Veterans in Alaska and Hawaii receive 
care at military hospitals on base. While New Hampshire may be a small 
state, it has a veteran population of over 130,000. Unlike many New 
England states whose veterans populations are declining, New 
Hampshire's veterans population is projected to grow over the next 10 
years.
    Because New Hampshire does not have a full service veterans' 
hospital, our veterans are forced to travel out of state for medical 
care. Veterans traveling from the most northern parts of the state can 
travel for 3 hours to Manchester and then may be forced to travel 
another hour to Boston, if referred there for care.
    This routinely happens. In 2007, 704 of our veterans were 
transferred out-of-state for Acute Care. Three hundred forty-six of 
those veterans were sent to Boston.
    I have been calling for the VA to either restore the Manchester 
facility to full-service hospital care or allow NH vets to receive care 
locally since I came to Congress. I have been working with both the VA 
and my colleagues to realize that goal. Chairman Filner visited the 
Manchester Veterans facility earlier this year and held a series of 
events including a roundtable during which we heard about the serious 
burdens placed on the New Hampshire veterans and their families because 
we do not have a full-service hospital.
    Despite these efforts, the administration refuses to either provide 
local access to care or restore full service VA hospital care to New 
Hampshire. I met with Secretary Peake at the Manchester Veterans 
Administration Medical Center in June to express my interest in working 
with him to either restore the facility to a full-service hospital or 
provide local access. Unfortunately, after our meeting Secretary Peake 
told the local press that there would be no full-service hospital in 
Manchester.
    The Administration's failure to act is unacceptable. New 
Hampshire's veterans deserve the best possible care and the current 
system is not delivering that. This is why I introduced H.R. 6629, the 
Veterans Health Equity Act of 2008.
    This legislation will ensure that veterans have access to at least 
one full-service hospital, or that they can receive care, the same care 
they would get in a VA hospital, in the state. This would mean that the 
VA would have to do one of two things, either restore the Manchester 
facility to a full-service hospital, or partner with more local health 
providers to make sure our Veterans can receive the care they need, in 
New Hampshire.
    The men and women in our local VA facility have done a herculean 
job of caring for our vets despite the limits to access imposed on New 
Hampshire vets. The Administration has very recently shown some 
willingness to allow radiation therapy to be provided locally. But this 
is not enough.
    Our veterans--regardless of whether they need radiation therapy, 
mental health services, acute care or anything else--need and deserve 
the care their counterparts in every other state receive. It is 
unconscionable that we deny them this full service care and instead 
offer them ad hoc services.
    Mr. Chairman, I appreciate your leadership in providing the best 
possible healthcare for our Nation's veterans. I am sure you and the 
other Members of your Subcommittee appreciate the challenges created by 
the lack of full service hospital care in New Hampshire. I look forward 
to working with you and the Subcommittee to address these challenges.
    Thank you again for giving me the opportunity to testify on this 
important issue. I look forward to answering any questions you may 
have.

                                 
                   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 legislative hearing of the Committee on Veterans' 
Affairs Subcommittee on Health. DAV is an organization of 1.3 million 
service-disabled veterans, and devotes its energies to rebuilding the 
lives of disabled veterans and their families.
    You have requested testimony today on two bills primarily focused 
on healthcare services for injured military servicemembers and 
veterans, and personnel issues affecting healthcare employees of the 
Veterans Health Administration (VHA) of the Department of Veterans 
Affairs (VA). We appreciate the opportunity to provide our views on 
these measures to the Subcommittee.
H.R. 3051--the Heroes at Home Act of 2007
    In general, this bill seeks to improve the diagnosis and treatment 
of traumatic brain injury (TBI) and raise awareness about post-
traumatic stress disorder (PTSD) among current military servicemembers 
and veterans; provide support to families of severely injured veterans; 
and, expand telehealth and telemental health programs of the Department 
of Defense (DoD) and VA.
    Section 2 of the bill would require VA, in collaboration with the 
Secretary of Defense, to develop a program of training and 
certification of family caregivers and other personal care attendants 
of veterans and still-active members of the Armed Forces with TBI, at 
every VA medical center. The curricula developed would incorporate the 
standards and protocols of national brain injury care specialist 
organizations and, to the degree possible, would require use of, and 
would expand the curricula developed under, the John Warner National 
Defense Authorization Act for Fiscal Year 2007 (Public Law 109-364). 
Certification received by family caregivers or others would qualify 
them to be compensated for personal care services rendered to the 
injured veteran or servicemember. Training would be provided at no cost 
to the veteran or caregiver, but would be borne by VA or reimbursed 
through TRICARE.
    Section 3 of the bill would require VA to conduct comprehensive 
outreach to enhance awareness among veterans and the general public 
about the symptoms of PTSD and TBI and the services provided by the VA. 
It would further require VA to make information available to non-VA 
practitioners on best practices in treatment of TBI and PTSD.
    Section 4 of the bill addresses telehealth and telemental health 
services of DoD and VA, and would require the Secretaries to jointly 
establish a demonstration program to assess the feasibility of using 
telehealth technologies to evaluate cognitive functioning among 
servicemembers who have sustained head trauma. In addition, the bill 
would require an assessment of telehealth tools to obtain information 
regarding the nature and symptoms of brain injury, the use of 
technology to rehabilitate those with TBI, and the usefulness of 
applying such technology to dissemination of educational material to 
veterans and servicemembers. The funds for the demonstration would be 
drawn from the DoD-VA healthcare Sharing Incentive Fund and the results 
of the demonstration would be reported in the administration's joint 
report to Congress on sharing initiatives between the two Departments. 
Another study the bill would require is an ongoing review of telehealth 
and telemental health services, to include the number of servicemembers 
and veterans who have used such services and the extent to which the 
National Guard and Reserve components of the armed forces use them, in 
addition to identifying improvements for such programs. The report 
would also require best practices of civilian mental health providers 
assisting veterans and former servicemembers and demonstrate the 
feasibility and advisability of partnering with civilian mental health 
facilities to provide telehealth and telemental health programs.
    While modern protective gear and battlefield medicine have greatly 
improved from previous conflicts, the intensity of polytrauma injuries, 
including TBI, presents great challenges to DoD and VA in meeting 
servicemembers and veterans acute, rehabilitative and long-term care 
health needs. As you well understand, Mr. Chairman, the most severe of 
these injuries may require a lifetime of care. The family members of 
military polytrauma casualties typically appear at the bedside of their 
loved one and remain with them throughout their acute treatment and 
extensive rehabilitative periods. A survey conducted on behalf of the 
President's Commission on Care for America's Returning Wounded Warriors 
(Commission) found that ``. . . 33 percent of active duty, 22 percent 
of reserve component, and 37 percent of retired/separated 
servicemembers [who were injured] report that a family member or close 
friend relocated for extended periods of time to be with them while 
they were in the hospital.'' \[1]\
---------------------------------------------------------------------------
    \[1]\ The President's Commission on Care for America's Returning 
Wounded Warriors. Final Report: Serve, Support, Simplify. July 2007: 9.
---------------------------------------------------------------------------
    Family members of severely injured veterans often shoulder a great 
and lifelong burden as home and institutional caregivers, giving up or 
severely restricting their own employment and educational advancement 
and negatively impacting social interactions that are taken for granted 
in the normal course of life. The Commission's survey also found that 
``21 percent of active duty, 15 percent of reserve component, and 24 
percent of retired/separated servicemembers [who were injured] say 
friends or family gave up a job to be with them or act as their 
caregiver.'' \[2]\ Not surprisingly, family caregivers often suffer 
severe financial and personal hardships as a consequence of providing 
care to a severely disabled veteran. Yet, in their absence, an even 
greater burden of direct care would fall on DoD and VA, at 
significantly higher financial cost to the Government and a reduced 
quality of life for severely wounded war veterans.
---------------------------------------------------------------------------
    \[2]\ Ibid.
---------------------------------------------------------------------------
    DAV testified before the Senate Committee on Veterans' Affairs 
earlier this year in support of S. 2921, a bill that would require VA 
to develop a pilot program to train and certify family caregivers of 
traumatically brain injured veterans. We are very enthusiastic about 
bolstering the financial support for these vulnerable families and 
believe that this is also an idea that will improve the quality of care 
our veterans receive. We agree with the intent of H.R. 3051 that this 
common-sense program could be started without being a pilot--since 
family caregivers of severely injured veterans are already shouldering 
a great deal of the care these veterans receive. This program would 
allow these family members to have up-to-date and consistent training 
and to receive compensation that recognizes their services and will 
better ensure the stability of the family at an extremely difficult and 
vulnerable time. The needs of these veterans and their families are 
urgent. However, we believe that initially, the training and 
certification process may need to be limited to sites that have these 
capabilities in place--most likely in the polytrauma centers and other 
units within the Defense and Veterans Brain Injury Network. We ask the 
Subcommittee to consider this aspect of the bill and modify it 
accordingly to ensure the training provided is of high quality and 
focused on the particular needs of these families.
    Similar to the provision for a training and certification program 
in S. 2921, section 2 of the Heroes at Home Act would address veterans 
with traumatic brain injuries but would also be beneficial for other 
catastrophically injured veterans with long-term personal assistance 
needs, such as veterans with spinal cord injuries or severe physical 
trauma without brain injury. Indeed, an educational proposal to assist 
family caregivers of all veterans with catastrophic injuries who would 
be taking on personal assistance duties was originally recommended by 
the Commission on Care for America's Returning Wounded Warriors. If 
successful, we would like to see this provision related to training 
caregivers expanded to other catastrophically disabled veterans 
requiring caregiver assistance.
    Section 3 of H.R. 3051 would require that VA conduct outreach 
activities targeted at increasing recognition of symptoms and public 
awareness that resources are available within VA to treat traumatic 
brain injury and PTSD. Veterans may not be the first to recognize the 
changes in their own behavior consequent to their exposure to 
concussive and traumatic events. Indeed, even with the high rates of 
prevalence expected for both TBI and PTSD, some veterans will not 
recognize their own symptoms until weeks or months after repatriation, 
if ever. \[3]\ Often, a family member notices changes in a veteran's 
behavior and mood; thus, informing the general public is also an 
important element of this bill. DAV believes that there must be a 
systematic means of educating veterans and their families about these 
problems and how to find support. We acknowledge that some veterans are 
receiving care for war-related disabilities outside of the VA and 
military systems, so we appreciate the requirement in the bill that VA 
would disseminate best practices on both mild-to-moderate TBI and PTSD 
to non-VA providers.
---------------------------------------------------------------------------
    \[3]\ Invisible Wounds of War: Psychological and Cognitive 
Injuries, Their Consequences, and Services to Assist Recovery. Ed's: 
Tanielian, T; Jaycox, L. RAND Center for Military Health Policy 
Research: 2008
---------------------------------------------------------------------------
    Mr. Chairman, DAV also supports, but with some concern, section 4 
of this bill to improve and expand telehealth and telemental health in 
VA and DoD. DAV certainly agrees that it is a challenge for VA and DoD 
to place resources everywhere veterans want and need to receive care. 
Tele-medicine has played a vital role in filling gaps in care in a 
number of communities--particularly in rural and frontier communities 
that lack access to a full continuum of care, and in some cases even 
basic healthcare services. We support efforts to assess new web-based 
diagnostic tools for the prevalent cognitive conditions that are 
emerging among our returning veterans. However, this section also 
contains a provision that would require VA and DoD to study ways that 
civilian providers might be used to enhance telehealth services offered 
to injured veterans and servicemembers. DAV has long held the position 
that contracting for healthcare outside VA should be attempted 
judiciously so as not to undermine VA's high-quality and specialized 
health and rehabilitative programs, and only when community-based care 
is coordinated and of high quality. Thus, we ask the Subcommittee to 
carefully consider the results of the required study in this bill 
before advancing any legislative mandate for VA or DoD to significantly 
expand tele-medicine into the private sector. Any such expansion should 
include coordination through the VA Office of Rural Health and would 
also need to be attended by new resources outside VA's Medical Care 
appropriation to garner full DAV support.
    While we support this bill, we would ask the Subcommittee to also 
consider the needs of veterans with less severe traumatic brain 
injuries. Mild-to-moderate brain injuries are prevalent among the Iraq 
and Afghanistan deployments--possibly as many as 320,000 veterans may 
be affected, yet of those reporting a probable TBI, 57 percent had not 
been evaluated by a clinician for that injury according to the recent 
RAND report. Key findings of the study also noted that about half of 
those who need treatment for PTSD, depression or probable TBI seek care 
for those conditions, and only slightly more than half who receive 
treatment get minimally adequate care. \[4]\ The DoD and VA must be at 
the forefront of efforts to improve the diagnosis, treatment, 
management and surveillance of all brain injuries to ensure high-
quality and consistent care is obtained for all servicemembers and 
veterans who suffer from concussive blasts in Iraq and Afghanistan. 
This bill would acknowledge the enormous debt the Nation owes, not only 
to injured veterans, but to their family caregivers, whose lives may be 
forever altered. However, we ask the Subcommittee to also consider 
expanding this measure to include the broader slate of initiatives DAV 
supports for family caregivers. DAV supports legislation to provide 
comprehensive supportive services, including financial support, health 
and homemaker services, respite, education and training and other 
necessary relief to immediate family member caregivers of veterans 
severely injured, wounded or ill from military service.
---------------------------------------------------------------------------
    \[4]\ Ibid.
---------------------------------------------------------------------------
    With these cautionary notes, DAV believes the ideas in the bill are 
worthy and if implemented carefully, could provide relief and support 
for sick and disabled veterans, particularly those with invisible 
wounds of war, including TBI and PTSD, and would provide welcome relief 
to family caregivers of the severely disabled. With exceptions noted, 
most of the proposals are consistent with recommendations of the Fiscal 
Year 2009 Independent Budget. Thus, DAV supports this bill and urges 
the Subcommittee to work toward its enactment.
H.R. 6153--Veterans' Medical Personnel Recruitment and Retention Act of 
        2008
    Along with our partners in the Independent Budget, DAV has called 
for improvements in VA policies and procedures used to recruit and 
retain highly qualified VA clinical staff. Also for the past several 
years our organizations have expressed concerns that VA needs new 
authority to achieve and sustain this goal, to be competitive with 
private sector providers and become a preferred employer of physicians, 
nurses, dentists and other personnel needed to care for enrolled 
veterans. With increasing numbers of veterans turning to VA for their 
healthcare and--particularly at a time of ongoing military engagements 
in Iraq and Afghanistan--VA needs the best and the brightest to meet 
the increasingly complex medical needs of an aging veteran population, 
veterans severely disabled during wartime service, and enrollees 
suffering from chronic disease. This bill, aimed at providing 
meaningful financial and professional incentives to encourage VA 
clinicians to pursue full careers in the VA healthcare system appears 
to be timely and appropriate given all of the challenges VA faces to 
maintain its effectiveness as a provider of comprehensive healthcare 
services.
    Section 2 of the bill would provide authority to the Secretary of 
Veterans Affairs to establish additional ``hybrid title 38-title 5'' 
occupations (32 such occupations have been established by previous Acts 
of Congress in section 7401, title 38, United States Code, including 
psychologist, physician assistant, licensed vocational or practical 
nurse, social worker, and numerous technical health fields). Under this 
section, the Secretary would be required to report any such 
reclassification of VA occupations to the Office of Management and 
Budget (OMB) and to both House and Senate Committees on Veterans' 
Affairs. This section would also add ``nurse assistant'' as a specific 
new occupational class in this hybrid category. Section 2 would clarify 
probationary periods and appointment policies for full-time and part-
time registered nurses. The section also would authorize VA on a case-
by-case basis to reemploy Federal annuitants with temporary 
appointments in selective healthcare occupational fields under sections 
7401 and 7403, title 38, United State Code, without offsetting their 
retirement annuities for which they would remain eligible under title 
5, United States Code. This section would provide VA additional 
authority to raise compensation of personnel employed in the immediate 
Office of the Under Secretary for Health; provide VA pharmacist 
executives eligibility for special incentive pay; and provide 
clarification on compensation policy for VA physicians, including 
comparability pay adjustments and market pay provisions in chapter 74, 
title 38, United States Code. Finally, it would provide additional 
policy clarifications on nurse compensation caps, special compensation 
for nurse executives; locality salary systems for VA nurses; part-time 
nurse compensation rules; weekend premium rules, as well as clarified 
direction on the use and disclosures of wage surveys in nurse locality 
compensation determinations.
    Section 3 of the bill would add a new section 7459, title 38, 
United States Code, to specify VA policy on VA's use of overtime by VA 
nurses, in effect reversing VA's

practice of requiring ``mandatory overtime,'' and extending specific 
protections to VA registered nurses, licensed practical or vocational 
nurses, nursing assistants (and other nursing positions designated by 
the Secretary for purposes of these protections), under the Civil 
Rights Act 1964, from discrimination or any adverse action based on 
their refusal to work required overtime. Under this section, the VA 
Secretary would be provided an emergency exigency power in certain 
circumstances to require a nurse to work overtime, but the section 
defines the term ``emergency'' within narrow grounds. Section 3 also 
clarifies language on weekend duty and other alternative work schedules 
for VA nurses, and would provide a number of associated technical and 
conforming amendments.
    Section 4 of the bill would reinstate the former Health 
Professionals Educational Assistance Scholarship Program, an authority 
that expired in 1998, and would extend its coverage to employees 
appointed under paragraphs (1) and (3) of section 7401, title 38, 
United States Code. It would add ``retention'' as an additional purpose 
of VA's Education Debt Reduction Program, and would increase the 
amounts of assistance to eligible VA employees. The section also would 
establish a loan repayment program targeted to VA clinical research 
personnel who come from disadvantaged backgrounds.
    Mr. Chairman, while DAV has no national resolution adopted by our 
membership that addresses these specific matters, The Independent 
Budget for Fiscal Year 2009, sponsored by DAV, Veterans of Foreign Wars 
of the United States (VFW), American Veterans (AMVETS) and Paralyzed 
Veterans of America (PVA), conveys a series of recommendations that are 
fully consistent with this bill. Therefore, DAV would have no objection 
to its enactment.
    Mr. Chairman and Members of the Subcommittee, as you may know, our 
DAV advocacy campaign, Stand Up For Veterans, is well underway. Its 
purpose is to generate greater public awareness and support for 
strengthening Federal policies to provide greater healthcare assistance 
to veterans disabled in the ongoing wars in Iraq and Afghanistan, as 
well as to sick and disabled veterans from prior eras and conflicts. In 
this effort, our campaign has focused on TBI, post-deployment mental 
health challenges (including PTSD), women veterans' health, family 
caregiver support, and reforms in budgeting that will bring sufficient, 
timely and predictable funding to VA healthcare. DAV has been pleased 
by Congressional responsiveness to many of the proposals emanating from 
our campaign that we have shared and discussed with Members of this 
Subcommittee and others in Congress. We appreciate that responsiveness 
and encourage the Congress to complete a significant package of 
veterans' health legislation before adjournment.
    Mr. Chairman, this concludes my statement on these two bills, and I 
would be happy to answer questions on these issues from you or other 
Members of the Subcommittee.
                         SUPPLEMENTAL STATEMENT
H.R. 6629, the Veterans Health Equity Act of 2008
    This measure would seek to ensure availability of at least one 
full-service hospital of the Department of Veterans Affairs (VA) 
Veterans Health Administration (VHA), or comparable services through 
contract, in each of the 48 contiguous States.
    Congresswoman Shea-Porter provided an opening statement for the 
Subcommittee at the September 9th hearing explaining the 
reasons for the introduction of this measure (H.R. 6629). Ms. Shea-
Porter noted that New Hampshire was the only State that did not have 
access to a VA full-service medical center and that the most ill 
veterans in her state routinely had to drive or be transported to 
Boston for more comprehensive healthcare services. She stated that she 
was particularly concerned that the sickest and generally very elderly 
veterans with complex and chronic health problems were subjected to 
having to first report to the VA's Manchester facility--which could be 
up to a 3 hour drive--and then having to continue on for another hour 
to get to the Boston VA Medical Center (VAMC) or other VA provider 
sites. Finally, the Congresswoman noted that it may not be fiscally 
responsible, given the veterans' population in her state, to have VA 
provide a full continuum of hospital services and that contracting for 
such services may be the best option. Her main concern was that sick 
and disabled veterans in New Hampshire are having to make unnecessarily 
long trips to Boston area VAMCs to get the care they need for complex 
health conditions.
    Convenient access to comprehensive VA healthcare services remains a 
problem for many of our Nation's sick and disabled veterans. While VA 
must contract or use fee basis to provide care to some veterans, it 
maintains high quality care and cost

effectiveness by providing health services within the system. According 
to VA, the Manchester VAMC of New Hampshire provides urgent care, 
mental health and primary care services, ambulatory surgery, a variety 
of specialized clinical services, hospital based home care and 
inpatient long-term care. In addition, community-based outpatient 
clinics (CBOCs) are located in Somersworth, Tilton, Portsmouth and 
Conway.
    In light of the escalating costs of healthcare in the private 
sector, to its credit, VA has done a remarkable job of providing high 
quality care and holding down costs by effectively managing in-house 
health programs and services for veterans. However, outside care 
coordination is poorly managed by VA. When it must send veterans 
outside the system for care, those veterans lose the many safeguards 
built into the VA system through its patient safety program, evidence-
based medicine, electronic health records, and bar code medication 
administration program (BCMA). The proposal in H.R. 6629 to use broad-
based contracting for necessary hospital services in the New Hampshire 
area concerns us because these unique internal VA features noted above 
culminate in the highest quality care available, public or private. 
Loss of these safeguards, which are generally not available in private 
sector systems, equate to diminished oversight and coordination of 
care, and, ultimately, may result in lower quality of care for those 
who deserve it most. However, we agree that VA must ensure that the 
distance veterans travel, as well as other hardships they face, be 
considered in VA's policies in determining the appropriate locations 
and settings for providing VA healthcare services.
    In general, current law places limits on VA's ability to contract 
for private healthcare services in instances in which VA facilities are 
incapable of providing necessary care to a veteran; when VA facilities 
are geographically inaccessible to a veteran for necessary care; when 
medical emergency prevents a veteran from receiving care in a VA 
facility; to complete an episode of VA care; and for certain specialty 
examinations to assist VA in adjudicating disability claims. VA also 
has authority to contract to obtain the services of scarce medical 
specialists in VA facilities. Beyond these limits, there is no general 
authority in the law to support broad-based contracting for the care of 
populations of veterans, whether rural or urban.
    DAV believes that VA contract care for eligible veterans should be 
used judiciously and only in these authorized circumstances so as not 
to endanger VA facilities' ability to maintain a full range of 
specialized inpatient and outpatient services for all enrolled 
veterans. VA must maintain a ``critical mass'' of capital, human, and 
technical resources to promote effective, high-quality care for 
veterans, especially those with complex health problems, such as 
blindness, amputations, spinal cord injury, or chronic mental health 
problems. Putting additional budget pressures on this specialized 
system of services without making specific appropriations available for 
new VA healthcare programs only exacerbates the problems currently 
encountered.
    Nevertheless, after considerable deliberation, and in good faith to 
be responsive to those who have come forward with legislative proposals 
such as H.R. 6629, to offer alternatives to VA healthcare, we have 
asked VA to consider developing a series of tailored demonstration 
projects and pilot programs to provide VA-coordinated care (or VA-
coordinated care through local, state, or other Federal agencies) in a 
selected group of communities that are experiencing access challenges, 
and to provide to the Committees on Veterans' Affairs reports of the 
results of those programs, including relative costs, quality, 
satisfaction, degree of access improvements, and other appropriate 
variables, compared to similar measurements of a like group of veterans 
in VA healthcare. To the greatest extent practicable, VA should 
coordinate these demonstration pilots with interested health 
professions' academic affiliates. We suggest the principles of our 
recommendations from the ``Contract Care Coordination'' section of the 
FY 2009 Independent Budget be used to guide VA's approaches in this 
effort. Also, any such demonstration pilot projects should be funded 
outside the Veterans Equitable Resource Allocation (VERA) system, and 
their expenditures should be monitored in comparison with VA's historic 
costs for care.
    Veterans service organization representatives from the local areas 
involved, and other experts need a seat at the table to help VA 
consider important program and policy decisions, such as those 
described here, that would have positive effects on veterans who live 
in these areas. VA must work to improve access for veterans that are 
challenged by long commutes and other obstacles in getting reasonable 
access to a full continuum of healthcare services at VA facilities and 
explore practical solutions when developing policies in determining the 
appropriate location and setting for providing VA healthcare services.
    As a final note, we believe VA must fully support the right of all 
enrolled veterans to have reasonable access to healthcare and we insist 
that funding for alternative care approaches and outreach be 
specifically appropriated for this purpose, and not be the cause of 
reductions in highly specialized VA medical programs within the 
healthcare system.

                                 
   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 present The American Legion's 
views on these two important pieces of legislation.
H.R. 3051, Heroes at Home Act of 2007
    This bill seeks to improve the diagnosis and treatment of traumatic 
brain injury in members and former members of the Armed Forces; to 
review and expand telehealth and telemental health programs of the 
Department of Defense (DoD) and the Department of Veterans Affairs 
(VA), and for other purposes.
    Section 2 of HR 3051 requests the Secretary of VA establish a 
program on training and certification of family caregivers of veterans 
and members of the active duty Armed Forces with Traumatic Brain Injury 
(TBI), as personal care attendant. Pursuant to section 744(a)(2) of 
Public Law 109-364, a Veterans' Traumatic Brain Injury Family Caregiver 
Panel was established in 2007.
    The 15 member panel was created by the DoD to operate under the 
Department of Health as a Subcommittee to advise and specifically 
provide DoD and VA with independent advice and recommendations on the 
development of training curricula to be utilized by the above mentioned 
family members on techniques, strategies, and skills for care and 
assistance for such individuals with TBI. The panel has convened on 
occasions, to include a recent townhall meeting, to discuss matters 
related to the development of a this curriculum and to hear from the 
public about the issue.
    The American Legion asserts that the advice of this Subcommittee 
into the provisions of this piece of legislation is vital, and that its 
absence may deprive such a bill of an effective stance and approach to 
treatment and care of TBI. The American Legion, in its continued 
efforts to increase access and quality of care to all eligible and 
potentially eligible veterans, supports this proposal, as it would help 
to accomplish this ongoing challenge.
H.R. 6153, Veterans' Medical Personnel Recruitment and Retention Act of 
        2008
    This bill seeks to amend Title 38 of the United States Code to 
enhance the capacity of VA to recruit and retain nurses and other 
critical health-care professionals, in addition to addressing other 
issues. The American Legion applauds this proposal to amend the methods 
of hiring and retaining additional medical personnel of various 
disciplines to adequately equip VA Medical facilities to ensure the 
adequacy and quality of treatment and care.
    The American Legion supports the proposal request in section 2(j), 
which seeks to amend 7451(c)(2), to allow critical fields such as nurse 
anesthesiologists, to exceed rate limitations on authorized competitive 
pay. Although VA has various antidotal programs in place, to include 
recruitment, relocation, and retention incentives for these hard-to-
fill positions, there remains a shortage of such nurses and specialty 
medical physicians.
    The overall response to the question of shortage indicated that 
salaries and delays in appointments were key causative factors. The 
American Legion, during its VA Medical Center site visits to 49 
facilities in 2008 encountered various recruitment issues, including 
such delays in the appointment of nursing assistants. Management 
attributed these delays to a three to 4 month hiring process. By the 
time management completed the hiring process, applicants have accepted 
a position in the private sector.
    In their site visits the American Legion representatives 
ascertained other areas with difficulty recruiting; these included 
mental health positions, specifically psychologists and psychiatrists; 
Dermatology; Gastroenterology; Orthopedics; and, Anesthesia. A study 
published in the New England Journal of Medicine ascertained there were 
shorter inpatient stays and lower complication rates in hospitals with 
higher staffing levels, while there were longer inpatient stays and 
increased urinary infections, gastrointestinal bleeding, pneumonia and 
shock or cardiac arrest in hospitals with lower staffing levels. Thus 
planning and adequate staffing up front can

help curtail long term care costs and unnecessary complications to the 
veteran patients down the road.
    We hereby urge Congress to act on this piece of legislation by 
incorporating it into the VA system to prevent the Healthcare system 
from being included in the casualties of the projected shortage of 
medical professionals through the year 2020.
    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 on the abovementioned 
matters and issues of similarity. Thank you.

                                 
   Prepared Statement of Thomas J. Berger, Ph.D., Senior Analyst for 
   Veterans' Benefits and Mental Health Issues, Vietnam Veterans of 
                                America
    Mr. Chairman, Ranking Member Miller, Distinguished Members of this 
Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you 
for the opportunity to present our views on H.R. 3051, the ``Heroes at 
Home Act of 2007,'' that is designed to improve the diagnosis and 
treatment of TBI (traumatic brain injury) for servicemembers and 
veterans, and to review and expand the telehealth and telemental health 
programs DoD and VA. With your permission, I shall keep my remarks 
brief and to the point.
    First, VVA thanks you, Mr. Chairman and Mr. Miller as well as 
distinguished Members of this Subcommittee for your active concern in 
regard to Traumatic Brain Injury (TBI) and related mental health 
problems of our troops and veterans, and for your leadership in holding 
this hearing today.
    In general, Vietnam Veterans of America supports the intent of H.R. 
3051. However, medical experts say that traumatic brain injuries are 
the ``signature wound'' of the Iraq war in particular, a by-product of 
the explosions caused by I.E.D. roadside blasts and suicide bombers. 
TBIs have become so commonplace that they, in fact, form the basis for 
today's hearing.
    Although TBI may share some symptoms with post traumatic stress 
disorder, it is markedly different than PTSD, which is triggered by 
extreme anxiety, and permanently resets the brain's fight-or-flight 
mechanism. Battlefield medics and corpsmen can often miss traumatic 
brain injuries, and many troops don't know the symptoms or won't 
discuss their problems for fear of being sent home stigmatized with 
mental illness. The same is true for those who return to the U.S. for 
garrison duty or exit their term of military service and become 
veterans.
    Certain TBI symptoms, such as seizures, can be treated with 
medications, but the most devastating effects--depression, agitation 
and social withdrawal--are difficult to treat with medication, 
especially when there is loss of brain tissue. In troops with 
documented TBI, the loss of brain functions is often compounded by 
other serious medical conditions that affect physical coordination and 
memory functions. These patients need a combination of psychological 
and physical treatment that is difficult to coordinate in a traditional 
medical setting, even when properly diagnosed at an early date. And we 
must remember that both concussive and contusive brain injuries are 
never just isolated injures. Over time without proper diagnoses, care 
and treatment, TBI can affect nearly everything about the survivor 
including one's cognitive, motor, auditory, olfactory and visual 
skills, perhaps ultimately resulting in behavioral modifications, not a 
mental illness.
    As more and more troops return home damaged from the war, their 
families must contend with not only the physical desolation of their 
loved ones, but come to grips with the new emotional reality of their 
lives which have changed drastically and not necessarily for the 
better. Take for example, a 35-year old soldier or Marine who returns 
home with what is diagnosed with traumatic brain injury (TBI). His/her 
impairment affects the future of the entire family. His or her spouse 
and children have to deal with his/her ability to concentrate, the mood 
swings, the depression, the anxiety, even the loss of employment. As 
you can well imagine, the economic and emotional instability of a 
family can be as terrifying and as real as focusing or simply waking in 
the middle of the night and crying because of nightmares. In cases of 
severely brain-damaged casualties, spouses, parents and siblings may be 
forced to give up careers, forsake wages, and reconstruct homes to care 
for their wounded relatives, rather than to consign them to the 
anonymous care of a nursing home or assisted living facility.
    Families say that they also struggle with military and VA medical 
systems that were unprepared for these wounded. In some cases new 
equipment and specially trained staff needed for the most catastrophic 
cases are not available or have not kept pace with the advances in 
battlefield medicine that kept these servicemembers

live and brought them home safely. In addition, there are issues about 
the intensity and drain of needed family support that will be hard to 
sustain, as well as significant issues regarding the complexity of the 
medical and other specialized needs that need to be addressed. Of all 
the war's medically challenging injuries, brain injuries require the 
most personal involvement and cost over time.
    TBI also presents a most puzzling challenge, especially in mild to 
moderate cases. Symptoms can be hidden or delayed, diagnosis is 
difficult, and evidence-based treatments are as of yet largely 
undetermined. Very few medical facilities are capable of providing even 
the most basic level of care for brain-injured patients, forcing most 
to seek treatment miles from home, if they can find it at all, and we 
must remember that over forty percent of our troops deployed in Iraq 
and Afghanistan come from rural America.
    As you are well aware, one of the recommendations of the Dole-
Shalala Commission was to ``significantly strengthen support for 
families.'' This will not be an easy task, but VVA believes H.R. 3051 
to be a key step in achieving this recommendation and providing a 
mechanism for empowering the families of brain-injured servicemembers 
IF the VA can develop effective implementation strategies for 
certification, competency evaluations, and meaningful outcome 
measurements to carry it out. As they say, ``the devil remains in the 
details''.
    I thank you again for the opportunity to offer VVA's views on this 
proposed legislation, and I shall be glad to answer any questions you 
might 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 
two bills, H.R. 3051, the ``Heroes at Home Act of 2007,'' and H.R. 
6153, the ``Veterans' Medical Personnel Recruitment and Retention Act 
of 2008.'' I am accompanied by Mr. Walter A. Hall, Assistant General 
Counsel, and Ms. Joleen Clark, Chief Officer, Workforce Management and 
Consulting, Veterans Health Administration.
               H.R. 3051. ``Heroes at Home Act of 2007''
    H.R. 3051 includes several provisions intended to enhance care and 
services to veterans and particularly new OEF/OIF veterans suffering 
from traumatic brain injury. section 2 of H.R. 3051 would require VA to 
establish a program to train and certify family members of veterans and 
servicemembers with traumatic brain injury (TBI) as personal care 
attendants. VA would be responsible for developing curricula for 
training family caregiver personal care attendants and for determining 
the eligibility of family members to participate in the program. A 
family caregiver who is certified as a personal care attendant would be 
eligible for compensation from VA for care provided to a veteran or 
servicemember.
    Mr. Chairman, VA does not support section 2 because VA already has 
a program in place that accomplishes the goals of that section in a far 
more efficient and effective manner. To keep VA from being in the 
position of having to directly oversee the quality of care provided by 
individual caregivers, including family members, VA uses a third-party 
to obtain needed caregiver services. Implementing the bill, as written, 
would not only be impractical but also inadvisable. The resulting 
arrangement could well give rise to potential conflicts concerning the 
veteran's care between the family member-caregiver and the veteran, 
placing VA in an untenable position. We strongly urge the Congress to 
let us continue to obtain caregiver services as we currently do under 
our Home healthcare Program.
    This bill provides that certified family caregivers shall be 
eligible for compensation but it does not state the nature of such 
compensation - is it payment for services provided so that the 
caregivers are VA employees or is it a benefit and, if so, is it to the 
veteran/servicemember or to the caregiver? Whether the compensation is 
for employment or is a benefit raises significant legal issues relating 
to liability, taxation and VA's relationship and responsibilities to 
both the patient and the caregiver. We also note the bill would make VA 
responsible for compensating caregivers of both veterans and active 
duty members of the Armed Forces. That responsibility to pay 
compensation may be that only relationship VA has with active duty 
members.
    Under our program, VA currently contracts with more than 4,000 home 
health agencies that are approved by the Centers for Medicare and 
Medicaid Services (CMS) and/or are state licensed. Many of these 
agencies have expertise in training and certifying home health aides, 
including family members. Many operate in rural communities. VA refers 
interested family members to these agencies and, after their training, 
these family caregivers become paid employees of the agencies. VA 
provides remuneration pursuant to agreements with the home health 
agencies, thus compensating family caregivers indirectly. Importantly, 
VA also ensures that these home health agencies meet and maintain 
training and certification requirements specific to caregivers of TBI 
patients. For the reasons we have discussed, this model is preferable 
to that which would be required by section 2.
    Subsection 3(a) of H. R. 3051 would require VA to conduct 
comprehensive outreach to enhance the awareness of veterans and the 
general public about the symptoms of post traumatic stress disorder 
(PTSD) and TBI and available VA health and other services. Mr. Chairman 
given the extensive and expanding outreach program that we already have 
in place to inform veterans and the general public about PTSD and TBI 
and the services we provide to veterans with these symptoms and 
injuries, this statutory mandate is not necessary. Let me take a moment 
to describe just some of the exciting new efforts underway to reach out 
to returning veterans.
    VA is making intensive outreach efforts to veterans as they leave 
active duty. Upon return from deployment, every eligible veteran 
receives a letter from the Secretary of Veterans Affairs informing him 
or her of the availability of VA services near his or her home. VA is 
currently sending out follow-up letters to all of those returning 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans 
who have not come to VA for care, to reinforce the point that care is 
available through the Department. As of January 2008, more than 796,000 
letters had been mailed. On April 24 of this year, the Secretary 
announced the creation of a ``Combat Veteran Call Center'' to begin 
contacting the nearly 570,000 recent combat veterans who have not used 
VA healthcare services to ensure they know about VA's medical services 
and other benefits.
    In addition, the Vet Center program reaches out to returning 
veterans in their communities. Informing combat veterans and family 
members about the availability of readjustment counseling services is 
one of the primary missions of the Vet Center program. In response to 
the growing numbers of veterans returning from combat in OEF/OIF, the 
Vet Centers initiated an aggressive outreach campaign to welcome home 
and educate returning servicemembers at military demobilization and 
National Guard and Reserve sites. The Vet Center program also provides 
access to other VHA and Veterans Benefits Administration (VBA) 
programs. To augment this effort, the Vet Center program recruited and 
hired 100 OEF/OIF veterans to provide the bulk of this outreach to 
their fellow veterans. Outreach provided by fellow combat veterans 
promotes a peer relationship that helps veterans with PTSD and other 
readjustment problems overcome any perceived stigma that may be 
associated with asking for professional assistance. Vet Center staff 
also participate with VAMC representatives in all onsite and call 
center Post-Deployment Health Reassessment events across the country, 
and provide outreach throughout the local community at events that 
feature veterans and family members. This is essential for making 
effective contact with veterans who have already returned to their home 
communities and are resuming normal family and work life.
    VA is preparing a series of public service announcements to inform 
veterans about various VA services. As a first action, VA has released 
a series of posters and other public service announcements on VA's 
Suicide Prevention Hotline. Additionally, VA is using non-traditional 
approaches to disseminate outreach information, including presentations 
about mental health issues that are played on the Music Television 
Channel (MTV) and targeted at young OEF/OIF veterans and their 
families. VA is also developing a comprehensive nation-wide TBI 
awareness educational campaign that targets active duty servicemembers 
and veterans, media and the general public, Congress, Veterans Service 
Organizations, State VA Offices, and a variety of other key stakeholder 
groups. Some primary messages included in this campaign are 
identification of the symptoms of mild/moderate TBI, how to access VA 
screenings and treatment, and the benefits and advantages of receiving 
care from VA versus that of the private sector. Lastly, VA's National 
Center for PTSD website, www.ncptsd.va.gov, posts regularly updated 
Fact Sheets and other information on PTSD available for the general 
public.
    Mr. Chairman, VA also believes that Subsection 3(b), which would 
require VA to share best practices developed for the treatment of PTSD 
and TBI with non-VA health practitioners, is redundant of activities 
already in place and therefore unnecessary. VA's reports and other 
documentation on best practices are generally a matter of public 
record. Moreover, VA participates in healthcare conferences where best 
practices are exchanged and works continually with national 
organizations to share medical information. The following are a few 
examples of VA's sharing of best practices:

          VA's Clinical Practice Guidelines, including topics 
        such as PTSD, depression, and substance use disorder treatment 
        are publically available on the Internet.
          Local VA medical centers and Mental Illness Research 
        Education and Care Centers (MIRECCs) are collaborating with the 
        States in educating practitioners on issues of military culture 
        and best practices for treatment of returning veterans.

          VA is involved in national meetings, such as the 
        August 2008 ``Conference and Policy Academy on Returning 
        Veterans and their Families'', which was a collaboration among 
        the Substance Abuse and Mental Health Services Administration 
        (SAMHSA), the Department of Defense, and VA. The meeting was 
        designed to help the states and communities develop effective 
        plans and best practices for helping returning veterans and 
        their families. VA staff made presentations on VA care during 
        the Conference phase and provided consultative support to State 
        teams during the Policy Academy.

          VA's National Center for PTSD has a web based 
        curriculum ``PTSD 101'' providing education on best practices 
        in PTSD assessment and treatment available to non-VA 
        practitioners on VA's National Center for PTSD website 
        (www.ncpted.va.gov.)

          The clinical experience and advances in 
        rehabilitation methodologies at the Polytrauma Rehabilitation 
        Centers (PRC) have been shared with the DoD/VA Senior Oversight 
        Committee (SOC), which functions as the main conduit by which 
        lessons learned are distributed within DoD and VA.

          VA and the Defense Center of Excellence for 
        Psychological Health and TBI are collaboratively developing 
        Clinical Practice Guidelines for mild TBI, which will be 
        published and available to the public in late 2008.

          In June of this year, VA's Office of Rehabilitation 
        Research and Development, in collaboration with DoD, sponsored 
        a State-of-the-Art Conference on Approaches to TBI: Screening, 
        Treatment, Management, and Rehabilitation.

    Section 4 would require DoD and VA to jointly establish a 
demonstration project to assess the feasibility and advisability of 
using telehealth technology to assess cognitive functioning of members 
and former members of the Armed Forces who have sustained head trauma, 
in order to improve the diagnosis and treatment of TBI. In selecting 
sites, priority would be given to locations providing services in rural 
areas. This section would require, among other things, that the 
demonstration project address the use of telehealth technology to 
assess the feasibility of obtaining information regarding the nature of 
any brain injury incurred by a servicemember or veteran and any symptom 
of TBI in such individuals. Mr. Chairman, VA supports the goals of this 
provision but cannot support the section as written.
    Section 4, as written, is too prescriptive and detailed. VA and DoD 
should be allowed more flexibility in executing the demonstration 
project. The technology is evolving and new ideas for utilizing the 
telehealth networks are emerging. DoD and VA should be given every 
opportunity to discover the possibilities of maximizing the technology 
rather than focusing on the enumerated requirements currently specified 
in section 4. We would be pleased to work with Subcommittee staff to 
develop legislative language that would make the project more tenable 
and productive.
    VA is continuing to develop cost estimates for H.R. 3051 and will 
have the results for the Subcommittee as soon as possible.
H.R. 6153. ``Veterans' Medical Personnel Recruitment and Retention Act 
                               of 2008''
    H.R. 6153 contains several provisions intended to enhance VA's 
ability to recruit and retain nurses and other health-care 
professionals. Many of these provisions would be helpful, and we can 
support them. However, several of the provisions would not be helpful 
or are otherwise flawed.
Authority to Extend Hybrid Status to Additional Occupations
    Subsection 2(a) of the bill would amend section 7401(3) to add 
``nurse assistants'' to the list of so called hybrid occupations for 
which the Secretary is authorized to appoint and to determine 
qualifications and rates of pay under title 38. In addition, it would 
authorize the Secretary to extend hybrid status to ``such other classes 
of healthcare occupations as the Secretary considers necessary for the 
recruitment and retention needs of the Department'' subject to a 
requirement to provide 45 days' advance notice to the Veterans' Affairs 
Committees and OMB. Before providing such notice, VA would be required 
to solicit comments from labor organizations representing employees in 
such occupations.
    VA favors such a provision. Nursing Assistants are critical to the 
Veterans Health Administration's (VHA) ability to provide care for a 
growing population of older veterans, who are high-acuity patients and/
or frail elderly requiring 24-hour nursing care.
    Turnover data, 10.5 percent for 2006 and 11.1 percent for 2007, 
illustrate the great difficulty VA experiences in retaining this 
occupation. It is increasingly critical for VHA to be able to quickly 
and easily employ these nurse extenders. The same holds true for other 
hard-to-recruit healthcare occupations. This bill would give the 
Secretary the ability to react quickly when it is determined that these 
authorities would be useful in helping in recruiting and retaining a 
critical occupation without seeking additional legislative authority. 
However, the bill language should be modified to specifically apply to 
occupations that clearly involve the delivery of healthcare. In 
addition, because this authority involves the conversion of title 5 
occupations to title 38 hybrid, the 45-day notice requirement should be 
modified to add OPM. Thus, we recommend modifying subsection 2(a) of 
the bill to read:

          (a) SECRETARIAL AUTHORITY TO EXTEND TITLE 38 STATUS TO 
        ADDITIONAL POSITIONS.

          (1) IN GENERAL.-Paragraph (3) of section 7401 of title 38, 
        United States Code, is amended by striking ``and blind 
        rehabilitation outpatient specialists.'' and inserting in its 
        place the following: ``blind rehabilitation outpatient 
        specialists, and such other classes of healthcare occupations 
        as the Secretary considers necessary for the recruitment and 
        retention needs of the Department who:

          (A) are employed in the administration (other than 
        administrative, clerical, and physical plant maintenance and 
        protective services employees);

          (B) are paid under the General Schedule pursuant to section 
        5332 of title 5;

          (C) are determined by the Secretary to be providing either 
        direct patient care services or services incident to direct 
        patient care services; and

          (D) would not otherwise be available to provide medical care 
        and treatment for veterans.

          (2) The Secretary's authority provided in paragraph (1) is 
        subject to the following requirements:

          ``(A) Not later than 45 days before the Secretary appoints 
        any personnel for a class of healthcare occupations that is not 
        specifically listed in this paragraph, the Secretary shall 
        submit to the Committee on Veterans' Affairs of the Senate, the 
        Committee on Veterans' Affairs of the House of Representatives, 
        the Office of Management and Budget and the Office of Personnel 
        Management notice of such appointment.

          ``(B) Before submitting notice under subparagraph (A), the 
        Secretary shall solicit comments from any labor organization 
        representing employees in such class and include such comments 
        in such notice.''
Probationary Periods for Part-Time Nurses
    Subsection 2(b) provides for probationary periods for part-time 
(PT) Registered Nurses (RN) and revises the probationary period for 
RNs, both fulltime (FT) and PT, from 2 years to its equivalency in 
hours, 4180. It also provides that a PT appointment of a person who 
previously served on a FT basis in a ``pure'' title 38 position 
(7401(1)), and completed a probationary period in the FT position would 
not have to serve a probationary period in the PT ``pure'' title 38 
position. VA opposes this provision because it is technically flawed 
and would not be helpful.
    Part-time title 38 employees, including RNs, do not serve 
probationary periods. Probationary periods apply to full-time, 
permanent employees. We see no benefit to creating a probationary 
period for part-time nurses. Moreover, a probationary period for PT RNs 
would not make them the equivalent of tenured employees, for example 
for purposes of discipline or discharge.
Prohibition on Temporary Part-Time Nurse Appointments In Excess of 
        4,180 Hours
    Subsection 2(c) would amend section 7405(f)(2) to limit temporary 
part-time appointments of hybrid (Licensed Practical Nurse (LPN) and 
Licensed Vocational Nurse (LVN)) nurses to no more than 4180 hours. VA 
opposes this provision. Currently, all part-time hybrid appointments 
may be for periods exceeding 1 year. The purpose of this restriction on 
LPNs and LVNs is not apparent. Operationally, it could hamstring VHA 
when it determines using that part-time LPNs and LVNs best serve 
patient care needs. The result could be to deprive VA of highly 
qualified LPNs and LVNs wishing to work only on a part-time basis, for 
example, for personal and family reasons.
Reemployed Annuitant Offset Waiver
    Subsection 2(d) generally provides that annuitants may be 
temporarily reemployed in a title 38 position without being subject to 
having their salary offset by the amount of their annuity.
    VA instead favors a Government-wide policy on waivers of this 
offset. Under current law, VA must obtain a waiver for individuals on a 
case-by-case basis, or obtain delegated waiver authority from the 
Office of Personnel Management (OPM). VA has done this for some 
critical occupations. The Administration has submitted a bill, which VA 
favors, to provide agencies with the authority to grant offset waivers 
to facilitate the temporary part-time reemployment of annuitants, which 
has been introduced as H.R. 3579/S. 2003. With many VA employees at or 
near retirement eligibility the potential for significant losses of 
mission-critical leaders and technical experts is a significant threat 
to VA's capability to deliver high quality healthcare to our Nation's 
veterans. VA access to retired title 38 healthcare providers, without 
financial penalty, would enhance our ability to meet these challenges 
and maintain the continuity of quality patient care, including support 
in times of disaster. As explained by OPM, 3579/S. 2003 ``would allow 
Federal agencies to rehire recently retired employees to assist with 
short-term projects, fill critical skill gaps and train the next 
generation of Federal employees.''
Minimum Rate of Basic Pay for section 7306 Appointees Set to Lowest 
        Rate of Basic Pay for SES
    Subsection 2(e) would amend section 7404(a) to add a provision 
setting the basic pay of non-physician/dentist section 7306 employees 
at not less than the lowest rate of basic pay for the Senior Executive 
Service (SES). This amendment would be effective the first pay period 
that is 180 days after enactment.
    VA supports the principle of pay equity with SES rates for its 
section 7306 non-physician/dentist executives as a tool needed to meet 
the challenge of recruitment and retention. However, we recommend some 
modifications in the bill's language.
    Equity in pay for executive level managers and consultants is 
essential to attracting and retaining candidates for key positions. The 
pay schedule for 38 USC Sec. 7306 appointees is now capped at the pay 
rate for Level V of the Executive Schedule (currently $139,600). 
Locality pay is paid up to the rate for Level III (currently $158,500). 
Individuals appointed under 38 USC Sec. 7306 serve in executive level 
positions that are equivalent in scope and responsibility to positions 
in the SES. By comparison, employees in the SES receive a significantly 
higher rate of basic pay. The maximum SES pay limitation is the rate 
for Level II (currently $172,200) when OPM has certified that an agency 
meets all regulatory criteria for certified performance appraisal 
systems, including the employing agency makes meaningful distinctions 
based on performance.
    We estimate the costs of this provision to be $225,290 in FY 2009 
and $2,466,862 over a 10-year period.
    We recommend modifying this proposal to state that the basic pay of 
non-physician/dentist section 7306 employees be set at the rates of pay 
for SES employees under section 5382 of title 5. This modification 
would allow VA executive pay to track the full range of SES pay. The 
SES pay system conditions pay up to EL II on OPM certification that an 
agency's SES rating system meets all regulatory criteria for certified 
performance appraisal systems. In this regard we note that VHA

uses the same rating system for its section 7306 executives as it uses 
for its SES members. OPM has certified VA's SES performance appraisal 
system in the past, and it is currently certified by OPM through 
calendar year 2009. For consistency, we also recommend that the bill be 
modified to require that the Secretary make the same certification for 
the rating system covering section 7306 employees. Thus, we suggest 
that subsection 2(e)(3) be modified to read as follows:

          ``(3) Positions to which an Executive order applies under 
        paragraph

          (1) and are not described by paragraph (2) shall be paid 
        basic rates of pay in accordance with section 5382 of title 5 
        for Senior Executive Service positions and not greater than the 
        rate of basic pay payable for level III of the Executive 
        Schedule; or if the Secretary certifies that the employees are 
        covered by a performance appraisal system meeting the 
        certification criteria established by regulation under section 
        5307(d), level II of the Executive Schedule.''
Comparability Pay Program for section 7306 Appointees
    Subsection 2(f) would amend section 7410 to add a new subsection to 
establish ``comparability pay'' for non-physician/dentist section 7306 
employees of not more than $100,000 per employee in order to achieve 
annual pay levels comparable to the private sector. Similar to 
provisions for RN Executive Pay in section 7452(g), it would provide 
that ``comparability pay'' would be in addition to other pay, awards 
and bonuses; would be considered base pay for retirement purposes; 
would not be base pay for adverse action purposes; and could not result 
in aggregate pay exceeding the annual pay of the President.
    VA supports the concept of comparability pay for its non-physician/
dentist executives. However, at this time we cannot support this 
proposal because it is a potentially precedent-setting departure from 
the unitary approach to government-wide SES pay. The Department is 
evaluating alternative proposals that may be more appropriate in 
addressing the comparability pay issues of these executives.
    We estimate the cost of this provision to be $1,165,500 for FY 2009 
and $12,761,900 over a 10-year period.
Special Incentive Pay for Department Pharmacist Executives
    Subsection 2(g) would further amend section 7410 to authorize 
recruitment and retention special incentive pay for pharmacist 
executives of up to $40,000. VA's determination of whether to provide 
and the amount of such incentive pay would be based on: grade and step, 
scope and complexity of the position, personal qualifications, 
characteristics of the labor market concerned, and such other factors 
as the Secretary considers appropriate. As with RN Executive Pay and 
comparability pay added by subsection (l), it would provide that 
``comparability pay'' would be in addition to other pay, awards and 
bonuses; would be considered base pay for retirement purposes; would 
not be base pay for adverse action purposes; and could not result in 
aggregate pay exceeding the annual pay of the President.
    This provision would provide a retention incentive to about 40 
positions: pharmacy benefit managers (PBM), consolidated mail 
outpatient pharmacy (CMOP) directors and VISN formulary leaders (VFL). 
Although VA is facing worsening pay compression issues within the ranks 
of senior pharmacy program managers in the VHA, we cannot support this 
provision because it will not address the Department's retention needs 
in the long-term. The Department is evaluating alternative proposals 
that will be more appropriate in addressing the recruitment and 
retention needs of our pharmacy executives.
    We estimate the cost of this provision to be $1,391,500 for FY 2009 
and $16,324,220 over a 10-year period.
Physician/Dentist Pay
    Section 2(h) concerns physician/dentist pay. VA supports this 
provision.
    Paragraph (1) would provide that the title 5 non-foreign cost of 
living adjustment allowance for physicians and dentists would be 
determined as a percentage of base pay only. This would clarify the 
application of the title 5 non-foreign cost of living adjustment 
allowance to VHA physicians and dentists. The VA physician/dentist pay 
statute, 38 U.S.C. Sec. 7431, does not address how the allowance is 
determined for physicians and dentists. We recommend that this 
provision be amended to clarify that it is applicable only to these 
physicians and dentists employed at Department facilities in Alaska, 
Hawaii, and Puerto Rico. These are the only Department facilities to 
which the title 5 non-foreign cost of living adjustment allowance is 
applicable.
    Paragraph (2) would amend section 7431 (c)(4)(B)(i) to exempt 
physicians and dentists in executive leadership provisions from the 
panel process in determining the amount of market pay and tiers for 
such physicians and dentists. In situations where physicians or 
dentists occupy executive leadership positions such as chief officers, 
network directors, and medical center directors, the consultation of a 
panel has some limitations. The small number of physicians and dentists 
who would qualify as peers for the executive leaders results in their 
serving on each other's compensation panels and, in some cases, on 
their supervisor's panel. Providing the Secretary with discretion to 
identify executive physician/dentists positions that do not require 
that panel process would resolve these issues.
    Paragraph (3) would provide an exception to the prohibition on the 
reduction of market pay for changes in board certification or reduction 
of privileges, correcting an oversight in the recent revision of the 
physician/dentist pay statute. This modification would allow VA to 
address situations where there is a loss of board certification or an 
adverse reduction in clinical privileges. No costs are associated with 
this provision.
RN and CRNA Pay
    Subsections 2(i) and 2(j), relate to RN and Certified Registered 
Nurse Anesthetist (CRNA) Pay.
    Section 2(i) would amend the cap for registered nurse to maximum 
rate of EL V or GS-15, whichever is greater. The current cap is the 
rate for EL V. Subsection (j) would amend section 7451 (c)(2) to exempt 
CRNAs from the current cap of EL V.
    It is important for pay caps to be both fiscally responsible and 
sufficient to promote employee recruitment and retention. These 
proposals are not consistent with these principles. We note the 
alternative GS-15 cap would be meaningless inasmuch as it already is 
lower than the existing cap that is set at EL V, with a difference of 
about $15,000. Moreover, it is unclear whether this alternative cap 
would be at the GS-15 rate before locality pay or after locality pay. 
The CRNA cap would leave CRNA pay rates completely uncapped, which 
would allow rates to potentially exceed those of physicians and 
dentists, the title Executive Schedule (Levels I-V), or the VA 7306 
Schedule.
    We would support this provision if the bill were amended to modify 
section 7451(c)(2) to read: ``The maximum rate of basic pay for any 
grade for a covered position may not exceed the rate of basic pay 
established for positions in level IV of the Executive Schedule under 
section 5315 of title 5.'' This would increase the cap from level V to 
level IV for both RNs and CRNAs, consistent with the pay cap that 
applies to the GS locality pay system. We estimate the cost of this 
provision to be $4,803,964 for FY 2009 and $56,357,188 over a 10-year 
period.
    Subsection 2(k) would make amendments to the RN locality pay system 
(LPS). These provisions are not helpful and unnecessary. No costs are 
associated with this provision.
    Paragraph (1) would require the Under Secretary for Health to 
provide education, training, and support to VAMC directors in the 
``conduct and use'' of LPS surveys. We are concerned that this 
provision's focus on facility-conducted surveys is at odds with Public 
Law Number 106-419, which enabled VAMCs to use third-party salary 
surveys whenever possible rather than VA-conducted surveys. The use of 
third-party surveys is in fact the preference of the Department. We 
recommend modifying this provision to read: ``The Under Secretary for 
Health shall ensure appropriate education and training are available 
with regard to the conduct and use of surveys, including third party 
surveys, under this paragraph''. This would cover both types of 
surveys. Paragraph (2) would require the annual report VAMCs must 
provide to VA Central Office to include the methodology for every 
schedule adjustment. These reports form the basis for the annual VA 
report to Congress. We are concerned that this provision, especially in 
conjunction with proposed paragraph 3, could result in the 
inappropriate disclosure of confidential salary survey data, contrary 
to current section 7451 (d)(5). It also would impose an onerous burden 
inasmuch as VHA has nearly 800 nurse locality pay schedules. We do note 
that VA policy does provide for how these surveys are to be obtained or 
conducted.
    Paragraph (3) would require the most recent VAMC report on nurse 
staffing to be provided to any covered employee or employee's union 
representative upon request. This provision should be modified to 
specify at what point the report must be provided. It would not be 
appropriate to provide an individual a copy of the VAMC report before 
Congress receives the VA report.
    Subsection 2(I) would increase the maximum payable for nurse 
executive special pay to $100,000. This provision would make the amount 
of nurse executive pay con-

sistent with the Executive Comparability Pay in subsection 2(f). For 
the same reason we oppose subsection 2(f), we do not support this 
proposal. We estimate the cost of this provision to be $316,250 for FY 
2009 and $3,710,053 over a 10-year period.
    The caption for subsection 2(m) suggests it provides for 
eligibility of part-time nurses for certain nurse premium pay. However, 
many of the substantive amendments are not limited to part-time nurses, 
or to all registered nurses.
    VA opposes subsection 2(m) as seriously flawed, unnecessary, and 
costly.
    Subparagraph (1)(A) would amend section 7453 (a) to make part-time 
nurses eligible for premium pay under that section. However, part-time 
nurses already are eligible for section 7453 premium pay where they 
meet the criteria for such pay.
    Subparagraphs (1)(B) and (1)(C) would require evening tour 
differential to be paid to all nurses performing any service between 6 
pm and 6 am, and any service on a weekend, instead of just those 
performing service on a tour of duty established for those times to 
meet on-going patient care needs. Under current law, these 
differentials are limited to the RN's normal tour of duty and any 
additional time worked on an established tour.
    The ``tour of duty'' in the current law reflects the requirement of 
ensuring adequate professional care and treatment to patients during 
off and undesirable tours. The limitation of tour differential and 
weekend pay only for service on a ``tour of duty'' rewards those 
employees who are subject to regular and recurring night and weekend 
work requirements. If that is changed to ``period of service'', any 
employees performing night or weekend work on an occasional or ad-hoc 
basis would also be entitled to this premium pay in addition to 
overtime pay, providing an inappropriate windfall for performing 
occasional work.
    Subparagraph (2) would authorize title 5 VHA employees to receive 
25 percent premium pay for performing weekend work on Saturday and 
Sunday. We understand the purpose of this provision is to limit the 
expansion of weekend premium pay to non-tour hours to registered 
nurses. However, it does not fully achieve that purpose. Pursuant to 
section 7454(a) and (b)(2), physician assistants, expanded-function 
dental auxiliaries, and hybrids are also entitled to weekend pay under 
section 7453. The expansion of weekend pay would apply to them as well. 
In addition, because physician assistants and expanded-function dental 
auxiliaries are entitled to all forms of registered nurse premium pay 
under section 7453, the expansion of the night differential premium pay 
would also apply to them. Furthermore, where VA has authorized section 
7453 night differential for hybrids, the expansion of the night 
differential premium pay would apply to them as well.
    Subsection 2(n) would add additional occupations to those exempt 
from the 28th step cap on title 38 special salary rates: LPNs, LVNs, 
and unspecified ``other nursing positions otherwise covered by title 
5''. Notwithstanding the exemption, under current statute, title 38 
special salary rates cannot exceed the rate for EL V. The language 
``nursing positions otherwise covered by title 5'' is unclear as to 
what positions it would include. RNs are appointed under title 38, 
LPNs/LVNs are hybrids, and section 2(a)(2) of the bill would convert 
nursing assistants to hybrid. Moreover, it is not apparent why only 
these positions and not all positions authorized title 38 special rates 
would be exempted. Using the same formula for the cap on title 5 
special rates would afford VA the most flexibility in establishing 
maximum rates for title 38 special rates. Adopting the title 5 fixed 
percentage formula would render the section 7455(c)(2) report for 
exceeding 94 percent of the grade maximum unnecessary, so we propose 
deleting it. Thus we recommend amending section 7455 to read as 
follows:

          (a)(1) Subject to subsections (b), (c), and (d), when the 
        Secretary determines it to be necessary in order to obtain or 
        retain the services of persons described in paragraph (2), the 
        Secretary may increase the minimum rates of basic pay 
        authorized under applicable statutes and regulations, and may 
        make corresponding increases in all rates of the pay range for 
        each grade. Any increase in such rates of basic pay--
                                * * * *
          (c) An increased minimum rate established under subsection 
        (a) may not exceed the maximum rate of basic pay (excluding any 
        locality-based comparability payment under section 5304 of 
        title 5 or similar provision of law) for the grade or level by 
        more than 30 percent, and no rate may be established under this 
        section in excess of the rate of basic pay payable for level IV 
        of the Executive Schedule.
    Subsection 3(a)(1) would add new section 7459, imposing 
restrictions on nurse overtime. section 7459 generally would prohibit 
mandatory overtime for nurses (RNs, LPNs, LVNs, nursing assistants, and 
any other nurse position designated by the Secretary). It would permit 
mandatory overtime by nurses under certain conditions: an emergency 
that could not have been reasonably anticipated; the emergency is non-
recurring and not due to inattention or lack of reasonable contingency 
planning; VA exhausted all good faith, reasonable attempts to obtain 
voluntary workers; the affected nurses have critical skills and 
expertise; and the patient work requires continuity of care through 
completion of a case, treatment, or procedure. VA could not penalize 
nurses for refusing to work prohibited mandatory overtime. Section 7459 
provides that nurses may work overtime hours on a voluntary basis.
    VA favors this mandatory overtime restriction with the caveat that 
first and foremost, VA needs to be able to mandate overtime where 
issues of patient safety are identified by facility leadership. We note 
VAMCs currently have policies preventing RNs from working more than 12 
consecutive hours and 60 hours in a 7 day period pursuant to section 
4(b) of PL 108-445.
    Subsection 3(b) would amend 38 U.S.C. 7456 (the ``Baylor Plan''), 
which authorizes VA to allow nurses who perform two 12-hour regularly 
scheduled tours of duty on a weekend to be paid for 40 hours. This 
work-scheduling practice typically would be used when facilities 
encounter significant staffing difficulties caused by similar work 
scheduling practices in the local community. Currently, VA has no 
nurses working on the Baylor Plan. The proposed revision would 
substitute scheduled ``periods of service'' for ``regularly scheduled 
12-hour tour of duty.'' The purpose and effect of this amendment are 
unclear. VA would oppose a revision of this authority if it were to 
mandate that all work on 12 hour regular weekend tours of duty 
automatically be considered Baylor Plan tours such that it would 
mandate that any nurse who works two 12-hour shifts on a weekend in 
addition to their regular tour of duty to get paid for 40 hours, in 
addition to premium pay for the extra work, such as overtime; and to 
mandate that nurses are not on the Baylor Plan but who routinely work 
12-hour shifts under compressed work schedules that fall on weekends 
are entitled to 40 hours of pay for the 24 hours worked on the weekend 
in addition to pay for the remaining 16 hours.
    Subsection 3(b)(2)(A), in eliminating the requirement that service 
be on a ``tour of duty'' appears to make the Baylor 1,248 hourly rate 
divisor apply to all service on the weekend instead of just non-
overtime hours. It is not appropriate for non-Baylor weekend work 
hours, and VA opposes this provision.
    Subsection 3(b)(3) would delete section 7456(c), the current Baylor 
Plan requirement, which provides for a 5-hour leave charge for each 3 
hours of absence that reflects the relative value of the truncated 
Baylor tour, in effect increasing the value of leave for affected 
employees. VA opposes this provision as providing an unwarranted 
windfall.
    Subsection 3(c) would amend section 7456A to change the 36/40 
alternate work schedule to a 72/80 alternate work schedule, so that 
under the schedule six 12-hour ``periods of service'' anytime in a pay 
period would substitute for three ``12-hour tours of duty'' in each 
week of the pay period. Similar changes would be made to section 
7456A's overtime, premium pay and leave provisions.
    VA is experiencing planning problems with the use of the current 
36/40 schedule. That problem stems from the 36/40 language requiring 
three 12-hour tours in a work week and because VA defines ``work week'' 
as Sunday-Saturday. Changing ''work week'' to ``pay period'' only makes 
the problem occur every 2 weeks instead of every week, so we do not 
view that as helpful. We do support changing the 36/40 alternate work 
schedule to a 72/80 alternate work schedule, so that the six 12-hour 
tours can occur anytime in a pay period, providing more work 
scheduling/planning flexibility. VA will soon undertake a pilot in 
which all hours worked on tours of duty that begin in a work week (even 
if they end in the following work week) will be considered part of the 
work week for the purpose of the 36/40 alternate work schedule. We 
think this may help resolve the problem.
    Section 4 would make amendments to VA's Education Assistance 
Programs. VA supports these proposals.
    Subsection 4(a) would amend section 7618 to reinstate the Health 
Professionals Educational Assistance Scholarship Program through the 
end of 2013. This program expired in 1998. The Health Professional 
Scholarship Program would help reduce the nursing shortage in VA by 
obligating scholarship recipients to work for 2 years at a VA 
healthcare facility after graduation and licensure.
    This proposal would also expand eligibility for the scholarship 
program to all hybrid occupations. This would be helpful in recruiting 
and retaining employees in the several hard-to-fill hybrid occupations. 
We estimate the cost of this provision to be $725,000 in FY 2010 with a 
5-year total of $21,380,000.
    Subsection 4(b) would make certain amendments to the Education Debt 
Reduction Program. It would amend section 7681(a)(2) to add retention 
as a purpose of the program and amend section 7682(a)(1) to make it 
available to ``an'' employee, in lieu of ``recently appointed.'' It 
would also increase the authorized statutory amounts in section 7683 to 
$60,000 and $12,000, respectively.
    The ``recently appointed'' requirement limits eligibility to 
employees who have been appointed within 6 months. VA's experience has 
been that this is not a sufficient period. In several instances, 
employees applying just missed the 6 month deadline. In many cases it 
takes more than 6 months for employees to become aware of this very 
helpful recruitment and retention program. VA also supports the 
increased amounts in light of increased education costs since the 
program was enacted. We estimate the cost of this provision to be 
$5,400,000 for FY 2010 and $77,352,000 over a 10-year period.
    Subsection 4(c) would authorize VA researchers from ``disadvantaged 
backgrounds'' to use authorities in the Public Health Service Loan 
Repayment Program. This program presently is not available to Federal 
employees other than those working for the National Institutes of 
Health (NIH). Clinicians with medical specialization and research 
interests who might otherwise consider career clinical care or clinical 
research opportunities with VHA are therefore less likely to do so 
because VA employees are not eligible for the LRP program. These same 
research-focused, entry-level professionals have historically been the 
highest caliber and most sought-after candidates. VA researchers should 
be able to participate in this much sought-after program. VHA's 
Education Debt Reduction Program (EDRP) is only available for employees 
hired for permanent title 38 positions. Those in time-limited clinical 
research training positions such as the Research Career Development 
Awards (which historically have served as entryways to VA careers in 
clinical care and research) are not eligible. There are no costs 
associated with this proposal; it would not increase the funding of 
this program, but simply authorize VA researchers to participate in it.
    Mr. Chairman, this concludes my prepared statement. I will be happy 
to answer any questions that you and the Members of the Subcommittee 
might have.

                                 
Statement of Raymond C. Kelly, National Legislative Director, American 
                           Veterans (AMVETS)
    Chairman Michaud, Ranking Member Miller, thank you for holding this 
important hearing today. AMVETS is pleased to provide our views on H.R. 
3051, the Heroes at Home Act of 2007, and H.R. 6153, the Veterans 
Medical Personnel Recruitment and Retention Act of 2008.
    H.R. 3051 will establish two separate programs. First it will 
provide training and certification of family caregivers for veterans 
and members of the Armed Forces with Traumatic Brain Injury (TBI). Once 
a family member has been deemed eligible for the certification they 
also become eligible for compensation for the care they provide. H.R. 
3051 will also establish a DoD-VA demonstration project to test the 
feasibility of using telehealthcare to care for servicemembers and 
veterans who have or could have TBI.
    TBI is the signature wound of the current conflicts in Iraq and 
Afghanistan. Identifying, treating, and caring for servicemembers who 
have TBI ranks at the top of AMVETS' priorities; therefore, AMVETS 
fully supports H.R. 3051, which will provide training and certification 
for family members of servicemembers who are affected by the unique 
nature of TBI. Family members are a natural choice for caring for 
patients who need daily in-home care. Because of the desire to help, 
family members will become caregivers. Providing them with the proper 
training and certification will give them the confidence they need to 
fully care for their loved one and reduce VA's need to provide 
additional home healthcare.
    H.R. 3051 will also broaden the use of telehealth and telemental 
health services. VA is a national leader in the development and use of 
telehealth programs. Nearly 200,000 veterans have been seen this year 
by specialists from the convenience of their local CBOC. Evaluating, 
diagnosing and treating mental health conditions related to TBI through 
telehealth will improve the lives of our servicemembers who have 
sustained head injuries. AMVETS supports the provision that will 
establish the telehealth and telemental health demonstration project. 
It is critical that VA and DoD make every effort to make receiving 
treatment for our servicemembers and veterans as convenient and as 
effective as possible, and the use of telehealth will ensure that 
veterans in remote locations or veterans who may have trouble traveling 
any distance will receive the attention and care they need and deserve.
    H.R. 6153, the ``Veterans' Medical Personnel Recruitment and 
Retention Act of 2008'' would give the Department of Veterans Affairs 
an enhanced ability to recruit and retain nurses and other critical 
healthcare professionals at VA facilities. The Veterans Health 
Administration (VHA) is the largest direct provider of healthcare 
services in the Nation and adequate staffing is necessary to provide 
the care our veterans deserve. It is for this reason that AMVETS wholly 
supports H.R. 6153.
    Critical shortages of healthcare professionals, such as registered 
nurses (RN), registered nurse anesthetists, physical and occupational 
therapists, speech pathologists, pharmacists, and physicians make it 
difficult to fill positions in the best of circumstances. Add to this 
the difference between VA compensation and private sector salaries and 
it becomes evident why the VA is understaffed.
    One recruitment and retention tool in H.R. 6153 would be to 
increase pay for critical jobs. Currently VA medical professionals' 
salaries are not in line with what other facilities can pay. This has 
resulted in understaffed hospitals. By increasing the limitation on 
special pay for nurse executives from $25,000 to $100,000, for example, 
the VA has a tool to recruit new professionals as well as provide 
retention incentives for those already employed by VA facilities.
    Another recruitment tool provided for in H.R. 6153 is limits on 
mandatory overtime and more flexible work schedules. It also improved 
education assistance programs and loan repayment plans. Combined with 
increased pay for certain positions, these tools would expand VA's 
ability to recruit and retain employees which would translate into 
improved care for our Nations' veterans. AMVETS wholly supports H.R. 
6153.
    Mr. Chairman, this concludes my testimony. I will be happy to 
answer any questions regarding our opinion on these matters.

                                 
   Statement of Susan H. Conners, President/Chief Executive Officer,
                  Brain Injury Association of America
    The Brain Injury Association of America (BIAA) and its nationwide 
network of state affiliates representing survivors of traumatic brain 
injury (TBI), their families, researchers, clinicians and other 
professionals, strongly supports The Heroes at Home Act of 2007 (H.R. 
3051) and urges the United States House Committee on Veterans' Affairs 
to approve this important legislation in a timely manner.
    The Heroes at Home Act of 2007 (H.R. 3051) would significantly 
improve support for family caregivers of returning servicemembers with 
traumatic brain injury (TBI). This important bill proactively 
acknowledges the reality that a brain injury impacts the entire family, 
not just the individual.
    Importantly, this legislation acknowledges the critical role played 
by family caregivers in facilitating recovery from brain injury and 
addresses the pressing need to increase support for these caregivers 
through programs providing access to training, certification and 
financial compensation for their work as personal care attendants.
    Family care is the most important source of assistance for people 
with chronic or disabling conditions, including people with brain 
injury. Yet, research has found that all too often, the traumatic brain 
injury of a spouse or close relative places extreme stress on family 
caregivers, frequently resulting in adverse physical and emotional 
outcomes for the caregivers themselves. Unfortunately, despite these 
documented physical hardships and psychological stress, family 
caregivers receive little support.
    Specifically, stress reaction is known to occur in situations where 
the demands of the environment exceed an individual's resources. One 
critical component that has been found to be related to caregiver 
burden is whether or not the caregiver perceives the effects of the 
injury to exceed the caregiver's resources to manage the situation. In 
other words, perceived stress has consistently predicted negative 
outcomes for the caregiver.\i\ A lack of financial resources and social 
supports are some of the common perceived stresses impacting family 
caregivers of loved ones with TBI.
---------------------------------------------------------------------------
    \i\ Chwalisz, Kathleen. ``Perceived Stress and Caregiver Burden 
after Brain Injury: A Theoretical Integration.'' Rehabilitation 
Psychology, Vol. 37, No. 3, 1992. pp 189-203.
---------------------------------------------------------------------------
    One longitudinal study found that 47 percent of family caregivers 
of individuals with TBI had altered or given up their jobs at 1 year 
postinjury, and 33 percent at 2 years postinjury, decreases in both 
employment and financial status were reported over a 2-year time period 
postinjury \ii\. Particularly in light of the fact that

caregivers often report severe financial strain and frequently must 
give up their jobs in order to take care of their loved one with TBI, 
increased financial support and access to respite care for family 
caregivers of returning servicemembers with TBI is vital and long 
overdue.
---------------------------------------------------------------------------
    \ii\ Hall KM, Karzmark P, Stevens M, Englander J, O'Hare P, Wright 
J. Arch Phys Med Rehabil. 1994 Aug;75 (8): 876-84.
---------------------------------------------------------------------------
    Again, the Brain Injury Association of America enthusiastically 
endorses The Heroes at Home Act of 2007 (H.R. 3051) and strongly 
encourages the Committee to approve this legislation.

            Sincerely,
                                                   Susan H. Connors
                                  President/Chief Executive Officer

                                 
                    Statement of Hon. Paul W. Hodes,
      a Representative in Congress from the State of New Hampshire
    I strongly support my colleague Carol Shea-Porter's bill, H.R. 
6629, the Veterans Health Equity Act. Her bill would ensure that New 
Hampshire's veterans have access to the healthcare they have earned. I 
thank Chairman Michaud for holding this important hearing that 
highlights the lack of adequate access to healthcare for New 
Hampshire's veterans.
    New Hampshire is the only state in the continental United States 
that does not have a full service Veterans Affairs Medical Center 
(VAMC). In my district alone, there are over 66,000 veterans, making up 
13 percent of the population. New Hampshire's many veterans deserve the 
same access to healthcare services as veterans in other states across 
the country.
    Seven years ago, the Manchester VAMC suspended various inpatient 
and outpatient services and was downgraded from a full-service VAMC. 
Now, veterans in New Hampshire must travel to surrounding states like 
Maine, Vermont or Massachusetts to receive VA healthcare services.
    This travel causes both physical and financial hardships for our 
wounded veterans. Without a full service VAMC in state, New Hampshire's 
veterans are forced to drive across state lines, traveling farther and 
paying more at the pump with record gas prices to access the healthcare 
they earned.
    Recently, the Secretary of Veterans Affairs James Peake visited New 
Hampshire and announced that the VAMC in Manchester will not return to 
a full service VAMC. I was extremely disappointed in Secretary Peake's 
shortsighted remarks. More wounded warriors are returning home from the 
Wars in Iraq and Afghanistan as veterans with physical and mental 
wounds, with Post Traumatic Stress Disorder and Traumatic Brain Injury, 
stretching our veteran's healthcare system.
    With so many soldiers fighting abroad, we should not be turning our 
backs on veterans at home when they need it most. New Hampshire is the 
only state in the continental U.S. without a full service VA. With 
record high gas prices, we shouldn't ask Granite State veterans to 
drive long distances just to get the care they have earned. I strongly 
support H.R. 6629, the Veterans Health Equity Act, which would ensure 
that veterans across the country will receive the same access to 
healthcare that they deserve, no matter which state they live in.

                                 
  Statement of Barbara Cohoon, Deputy Director, Government Relations, 
               National Military Family Association, Inc.
    Chairman Michaud and Distinguished Members of this Subcommittee, 
the National Military Family Association (NMFA) would like to thank you 
for the opportunity to present written testimony for the record on 
`Heroes at Home Act of 2007.' We thank you for your focus on the many 
elements necessary to ensure quality healthcare and mental healthcare 
for our wounded/ill/injured servicemembers, veterans, and the families 
who care for them; and, recognizing the important role caregivers play 
in the care of their loved one.
    NMFA will discuss several issues of importance to wounded/ill/
injured servicemembers, veterans, and their families in the following 
subject areas:

I.

Wounded Servicemembers Have Wounded Families

II.

Who Are the Families of Wounded Servicemembers?

III.

Caregivers

IV.

Mental Health

Wounded Servicemembers Have Wounded Families
    NMFA asserts that behind every wounded servicemember and veteran is 
a wounded family. Spouses, children, parents, and siblings of 
servicemembers injured defending our country experience many 
uncertainties. Fear of the unknown and what lies ahead in future weeks, 
months, and even years, weighs heavily on their minds.
    Transitions can be especially problematic for wounded/ill/injured 
servicemembers, veterans, and their families. The Department of Defense 
(DoD) and the Department of Veterans Affairs (VA) healthcare systems, 
along with State agency involvement, should alleviate, not heighten 
these concerns. It is NMFA's belief the government must take a more 
inclusive view of military and veterans' families. Those who have the 
responsibility to care for the wounded servicemember must also consider 
the needs of the spouse, children, parents of single servicemembers, 
siblings, and especially the caregivers. According to the VA, 
`informal' caregivers are people such as a spouse or significant other 
or partner, family member, neighbor or friend who generously gives 
their time and energy to provide whatever assistance is needed to the 
veteran.''
Who are the families of Wounded Servicemembers
    In the past, the VA and the DoD have generally focused their 
benefit packages for a servicemember's family on his/her spouse and 
children. Now, however, it is not unusual to see the parents and 
siblings of a single servicemember presented as part of the 
servicemember's family unit. In the active duty, National Guard, and 
Reserves almost 50 percent are single. Having a wounded servicemember 
is new territory for family units. Whether the servicemember is married 
or single, their families will be affected in some way by the injury. 
As more single servicemembers are wounded, more parents and siblings 
must take on the role of helping their son, daughter, sibling through 
the recovery process. Family members are an integral part of the 
healthcare team. Their presence has been shown to improve their quality 
of life and aid in a speedy recovery.
    NMFA recently gathered information about issues affecting our 
wounded servicemembers, veterans, and their families through our 
Healing Adventure Operation Purple Camp in August and a focus group 
held this March at Camp Lejeune. They said following the injury, 
families find themselves having to redefine their roles. They must 
learn how to parent and become a spouse/lover with an injury. Spouses 
talked about the stress their new role as caregiver has placed on them 
and their families. Often overwhelmed and feeling as if they have no 
place to turn to for help.
Caregivers
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality of life of 
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to DoD and VA healthcare providers 
because they tend to the needs of the servicemembers and the veterans 
on a regular basis. And, their daily involvement saves DoD, VA, and 
State agency healthcare dollars in the long run.
    Caregivers of the severely wounded, ill, and injured servicemembers 
who are now veterans have a long road ahead of them. In order to 
perform their job well, they must be given the skills to be successful. 
This will require the VA to train them through a standardized, 
certified program, and appropriately compensate them for the care they 
provide. NMFA is pleased with the `Heroes at Home Act of 2007' 
legislation that will provide for the training, certification, and 
compensation for injured servicemembers or veterans with TBI. TBI has 
become the signature wound of this current conflict; however, the 
legislation should be flexible and allow for the expansion of training, 
certification, and compensation to encompass other injuries. Often, our 
wounded servicemembers and veterans present with more than one type of 
injury. This legislation places VA in an active role in recognizing 
caregivers' important contributions and enabling them to become better 
caregivers to their loved ones. It is a win-win for everyone involved.
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve healthcare education and provide needed training and 
resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important, but there is a strong 
need for 24-hour in-home respite care, 24-hour supervision, emotional 
support for caregivers living in rural areas, and coping skills to 
manage both the veteran's and caregiver's stress. These pilot programs, 
if found

successful, should be implemented by the VA as soon as possible and 
fully funded by Congress. However, one program missing is the need for 
adequate child care. Veterans can be single parents or the caregiver 
may have non-school aged children of their own. Each needs the 
availability of child care in order to attend their medical 
appointments, especially mental health appointments. NMFA encourages 
the VA to create a drop-in child care for medical appointments on their 
premises or partner with other organizations to provide this valuable 
service.
Mental Health
    Families' needs for a full spectrum of mental health services--from 
preventative care and stress reduction techniques, to individual or 
family counseling, to medical mental health services--will continue to 
grow. It is important to note if DoD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the VA healthcare system. The need for mental health 
services will remain high for some time even after military operations 
scale down and servicemembers and their families transition to veteran 
status. The VA must be ready. They must partner with DoD and State 
agencies in order to address mental health issues early on in the 
process and provide transitional mental health programs. They must 
maintain robust rehabilitation and reintegration programs for veterans 
and their families that will require VA's attention over the long-term.
    NMFA is especially concerned with the scarcity of services 
available to the families as they leave the military following the end 
of their activation or enlistment. They may be eligible for a variety 
of health insurance programs, such as TRICARE Reserve Select, TRICARE, 
or VA. Many will choose to locate in rural areas where there may be no 
mental health providers available. We ask you to address the distance 
issues families face in linking with mental health resources and 
obtaining appropriate care. Isolated veterans and their families do not 
have the benefit of the safety net of services and programs provided by 
MTFs, VA facilities, CBOCs, and Vet Centers. NMFA recommends the use of 
alternative treatment methods, such as telemental health. The `Heroes 
at Home Act of 2007' provision for telemental health will provide an 
additional benefit to this population. Another solution is modifying 
licensing requirements in order to remove geographical practice 
barriers that prevent mental health providers from participating in 
telemental health services outside of a VA facility.
    NMFA appreciates the `Heroes at Home Act of 2007' inclusion of an 
outreach and public awareness provision. The VA must educate their 
healthcare and mental health professionals, along with veterans' 
families of the effects of mild Traumatic Brain Injury (TBI) in order 
to help accurately diagnose and treat the veteran's condition. 
Veterans' families are on the ``sharp end of the spear'' and are more 
likely to pick up on changes contributed to either condition and relay 
this information to VA providers. VA mental and healthcare providers 
must be able to deal with polytrauma--Post-Traumatic Stress Disorder 
(PTSD) in combination with multiple physical injuries. NMFA appreciates 
Congress establishing the National Center of Excellence and the Defense 
Center of Excellence. Now, it is very important for DoD and VA to 
partner in researching TBI and PTSD. We believe the VA needs to educate 
their civilian healthcare providers on how to identify signs and 
symptoms of mild TBI and PTSD. And, as the VA incorporates Project 
Hero, they must educate civilian network mental health providers about 
our military culture.

    NMFA strongly suggests standardized training, certification, and 
compensation for caregivers of injured servicemembers or veterans with 
TBI.
    NMFA recommends the use of alternative treatment methods, such as 
telemental health; and, the modification of licensing requirements to 
remove geographical practice barriers that prevent mental health 
providers from participating in telemental health services outside of a 
VA facility.
    The VA must educate their healthcare and mental health 
professionals, along with veterans' families of the effects of mild 
Traumatic Brain Injury (TBI) and Post-traumatic Stress Disorder (PTSD) 
to help accurately diagnose and treat the servicemember's condition. 
The VA needs to encourage more education for civilian healthcare 
providers on how to identify signs and symptoms of mild TBI and PTSD. 
NMFA recommends spouses and parents of returning servicemembers and 
veterans need programs providing education on identifying mental 
health, substance abuse, suicide, and traumatic brain injury.
    NMFA recommends Congress require Vet Centers and the VA to develop 
a holistic approach to veteran care by including their families in 
providing mental health counseling and programs.
    NMFA would like to thank you again for the opportunity to present 
testimony for the record on the `Heroes at Home Act of 2007' for 
servicemembers, veterans, and their families. Military families support 
the Nation's military missions. The least their country can do is make 
sure servicemembers, veterans, and their families have consistent 
access to high quality mental healthcare in the DoD, VA, and within 
network civilian healthcare systems utilizing alternative treatment 
methods, such as telemental health. Wounded servicemembers and veterans 
have wounded families. The caregiver must be supported by the VA by 
providing training, certification, and compensation for the care of 
their loved one. The system should provide coordination of care DoD, 
VA, and State agencies working together to create a seamless 
transition. We ask Congress to assist in meeting that responsibility.

                                 
               Statement of Paralyzed Veterans of America
    Chairman Michaud, Ranking Member Miller, and Members of the 
Subcommittee, Paralyzed Veterans of America (PVA) is pleased to present 
our views concerning H.R. 6153, the ``Veterans Medical Personnel 
Recruitment and Retention Act of 2008,'' and H.R. 3051, the ``Heroes at 
Home Act of 2007,'' which will improve the diagnosis and treatment of 
Traumatic Brain Injury (TBI) for members and former members of the 
Armed Forces.
 H.R. 6153, THE ``VETERANS MEDICAL PERSONNEL RECRUITMENT AND RETENTION 
                             ACT OF 2008''
    PVA's primary concern, and the basic reason for our existence, is 
the health and welfare of our members and our fellow veterans. The 
thousands of Department of Veterans Affairs (VA) healthcare 
professionals and all of those individuals necessary to support their 
efforts are at the core of VA's primary mission. These individuals 
serve on the frontline every day, caring for America's wounded veterans 
from Iraq and Afghanistan and seeing to the complex medical needs of 
our countries older veterans from previous wars. PVA believes that VA's 
most important asset is the people it employs to care for those who 
have served our Nation.
    Mr. Chairman, when PVA testified on May 22, 2008 concerning the 
human resources challenges facing the Department of Veterans Affairs', 
we applauded the Subcommittee for its timely and well placed interest 
in the issues concerning VA healthcare personnel. PVA continues to 
believe that Congress must assist VA efforts to recruit and retain its 
corps of healthcare professionals as the demand for healthcare 
increases both because of the ongoing Global War on Terrorism and the 
aging of the veteran population from previous wars. The current serious 
national short fall in the supply of physicians, nurses, pharmacists, 
therapists and psychologists threatens VA staffing as competition for 
experienced medical personnel and newly licensed professionals 
continues to increase. H.R. 6153 is a step in the right direction.
    The United States is currently in the tenth year of a critical 
nursing shortage which is expected to continue through 2020. The 
shortage of registered bed-side nurses and registered nurse specialists 
is having an impact on all aspects of acute and long-term care. 
America's nursing shortage has created nurse recruitment and retention 
challenges for medical-care employers nationwide and is making access 
to quality care difficult for consumers.
    The gap between the supply of and the demand for nurses may 
adversely affect the VA's ability to meet the healthcare needs of those 
who have served our Nation. According to VA, it employs more than 
64,000 nursing professionals, and has one of the largest nursing staffs 
of any healthcare system in the world. Of that 64,000, VA has 43,000 
registered nurses, 12,000 licensed practical nurses, and 9,000 nursing 
assistants. VA also says that approximately 4,300 nurses retire or 
leave each year. VA must be able to recruit the best nurses, and retain 
a cadre of experienced, competent nurses. Providing high quality 
nursing care to the Nation's veterans is integral to the healthcare 
mission of VA.
    During PVA's previous testimony, we asked for the Subcommittee's 
consideration of specially pay for nurses providing care in VA's 
specialized service programs such as: spinal cord injury/disease (SCI/
D), blind rehabilitation, mental health and brain injury. PVA is 
disappointed that the Subcommittee chose not to include such specific 
language in H.R. 6153.
    Mr. Chairman, veterans who suffer spinal cord injury and disease 
require a cadre of specialty trained registered nurses to meet their 
complex initial rehabilitation and life-long sustaining medical care 
needs. PVA's data reveals a critical shortage of registered nurses who 
are providing care in VA's SCI/D center system of care. The complex 
medical and acuity needs of these veterans, makes care for them ex-

tremely difficult and demanding. These difficult care conditions become 
barriers to quality registered nurse recruitment and retention. Many of 
VA's SCI/D nurses are often placed on light duty status because of 
injuries they sustain in their daily tasks. When this happens it 
becomes a significant problem because it places additional patient care 
responsibility on those SCI/D nurses not on light duty. PVA believes 
SCI/D specialty pay is absolutely necessary if nurse shortages are to 
be overcome in this VA critical care area. We strongly encourage your 
committee to include a Title 38 specialty pay provision that will 
assist VA's efforts to recruit and retain nurses in these specialized 
areas.
    PVA is concerned about the VA's current ability to maintain 
appropriate and adequate levels of physician staffing at a time when 
the Nation faces a pending shortage of physicians. Recent analysis by 
the Association of American Medical Colleges (AAMC) indicates the 
United States will face a serious doctor shortage in the next few 
decades. The AAMC goes on to say that currently, ``744,000 doctors 
practice medicine in the United States, but 250,000--one in three--are 
over the age of 55 and are likely to retire during the next 20 years.'' 
The subsequent increasing demand for doctors, as many enter retirement, 
will increase challenges to VA's recruitment and retention efforts. PVA 
believes H.R. 6153 will allow VA to be more competitive in recruiting 
doctors for the VA system.
    Mr. Chairman, the Veterans Health Administration has made great 
strides over the last decade to improve the quality of care it provides 
to our Nation's veterans. Despite these gains, VA now finds itself in a 
precarious situation if it expects to retain its position as a vastly 
improved healthcare system. As stated earlier, H.R. 6153 is only a 
first step in meeting the challenges associated with maintaining a 
highly qualified medical care workforce for VA. Competition to hire 
medical care professionals, during a national period of low supply, is 
making it more-and-more difficult for VA to successfully recruit and 
retain qualified personnel. This Subcommittee and VA must be vigilant 
in developing programs that will provide professional healthcare 
workers to care for our veterans.
             H.R. 3051, ``THE HEROES AT HOME ACT OF 2007''
    Traumatic Brain Injuries (TBI) have become an important topic as a 
result of the wars in Afghanistan and Iraq. In fact, The Independent 
Budget, co-authored by PVA, AMVETS, Disabled American Veterans (DAV) 
and the Veterans of Foreign Wars (VFW), identified treatment for 
veterans with TBI as a critical issue for 2008 and beyond. PVA welcomes 
the Subcommittee's action on H.R. 3051.
    TBI, Spinal Cord Injury, and other serious injuries account for 
almost 20 percent of the combat casualties sustained by U.S. soldiers, 
airman and Marines in OEF/OIF. Explosive blast pressure waves from 
improvised explosive devices (IEDs) violently shake or compress the 
brain within the closed skull and cause devastating and often permanent 
damage to brain tissues. There has been universal recognition that 
veterans with severe TBI will need a lifetime of intensive services to 
care for their injuries. However, PVA is concerned that, at all levels, 
development of programs to address the needs of veterans with mild, 
subclinical TBI have not been fully developed or implemented.
    DoD and VA experts note that TBI can also be caused without any 
apparent physical injuries if a person is in the vicinity of these IED 
detonations. Veterans suffering from this milder form of TBI may not be 
readily detected; however, symptoms can include chronic headaches, 
irritability, disinhibition, sleep disorders, confusion, executive 
functioning and memory problems, and depression, among other symptoms. 
With tens of thousands of IED detonations now recorded in Iraq alone, 
it is believed that many OEF/OIF servicemembers have suffered mild, but 
pathologically significant, brain injuries (including multiple 
concussions) that have gone undiagnosed and largely untreated thus far. 
TBI and its associated symptoms may be detected later only if proper 
screening is conducted.
    PVA is concerned about emerging literature that strongly suggests 
that even mildly injured TBI patients may have long-term mental and 
physical health consequences. According to DoD and VA mental health 
experts, mild TBI can produce behavioral manifestations that mimic Post 
Traumatic Stress Disorder (PTSD) or other conditions. And TBI and PTSD 
can be coexisting conditions. Much is still unknown about the long-term 
impact of these injuries and the best treatment models to address mild-
to-moderate TBI. We believe VA should conduct more research into the 
long-term consequences of brain injury and development of best 
practices in its treatment; however, we suggest that any studies 
undertaken include older veterans of past military conflicts who may 
have suffered similar injuries that thus far have gone undetected, 
undiagnosed or misdiagnosed, and untreated. Their medical and social 
histories could be of enormous value to VA researchers interested in 
the likely

long-term progression of these new injuries. Likewise, such knowledge 
of historic experience could help both the DoD and VA better understand 
the policies needed to improve screening, diagnosis, and treatment of 
mild TBI in combat veterans of the future. This is where PVA sees great 
potential for the demonstration project of Telehealth and Telemental 
programs proposed in H.R. 3051. We would caution the Subcommittee, 
however, to ensure that this program is a supplement to regular VA 
programs and not used as one more way for VA to move veterans' 
healthcare further away from VA facilities.
    Individuals suffering from mild brain injury often present complex, 
difficult-to-assess complaints and conditions that can masquerade as 
other diagnoses. This complexity requires an integrated, personalized 
recovery plan coordinated by a cadre of specialists with expertise in 
TBI to diagnose and manage their medical, psychological, and 
psychosocial needs.
    Although VA has initiated new programs and services to address the 
needs of severe TBI patients, gaps in services still exist. The VA's 
Office of the Inspector General (OIG) issued a report in July of 2006, 
titled ``Health Status of and Services for Operation Enduring Freedom/ 
Operation Iraqi Freedom Veterans after Traumatic Brain Injury 
Rehabilitation.'' The report assessed healthcare and other services 
provided for veterans and active duty patients with TBI, and then 
examined their status approximately 1 year following completion of 
rehabilitation.
    The report found that better coordination of care between DoD and 
VA health-care services was needed to enable veterans to make a smooth 
transition. According to the report, the goal of achieving optimal 
function of each individual requires further interagency agreements and 
coordination between the DoD and VA. PVA believes the true measure of 
success will be the extent to which those most severely injured 
veterans are eventually able to recover, reenter their communities, or 
at minimum, achieve stability of function at home or in the least 
restrictive, age-appropriate continuing care facilities provided by VA 
to meet their needs and preferences.
    PVA strongly supports the provisions of H.R. 3051 which provide 
training and certification for family caregiver personal attendants at 
no cost to the family. Providing the ability for family members to care 
for their loved ones injured in conflict will assist in keeping the 
families strong while properly caring for the veteran. Though PVA 
remains concerned about whether VA has addressed the long-term 
emotional and behavioral problems that are often associated with TBI, 
and the devastating impact on both the veteran and his or her family, 
we believe this program may help address these concerns. As noted in 
the July 2006 OIG report, ``these problems exact a huge toll on 
patients, family members, and healthcare providers.'' The following 
excerpt from the report is especially telling:

        In the case of mild TBI, the [veteran's] denial of problems 
        which can accompany damage to certain areas of the brain often 
        leads to difficulties receiving services. With more severe 
        injuries, the extreme family burden can lead to family 
        disintegration and loss of this major resource for patients.

    The OIG recommendations included improving case management for TBI 
patients to ensure lifelong coordination of care; improving 
collaborative policies between the DoD and VA; starting new initiatives 
to support families caring for TBI patients, including providing access 
to VA or contract caregivers; and recommending that rehabilitation for 
TBI patients be initiated by the DoD when clinically indicated. We 
fully concur with the OIG's recommendations and recognize that 
supporting these patients for a lifetime of care and service will be a 
continuing challenge for VA.
    VA now requires a case manager be assigned to each OEF/OIF veteran 
enrolled in VA healthcare. The case manager's duty is to communicate 
and coordinate all VA benefits and services. Also, VA has created 
liaison and social work positions in DoD facilities to assist injured 
servicemembers with their transitions to veteran status and to provide 
advice and assistance to them and their families in accessing VA 
services. PVA commends VA for its efforts to improve the knowledge and 
skills of VA clinicians through educational initiatives defining the 
unique experience and needs of this newest generation of combat 
veterans. We also acknowledge VA's dedication and commitment to meeting 
the needs of veterans with TBI through high quality services at its 
polytrauma-TBI lead centers, for ongoing research into this 
debilitating injury, and for establishing effective services with 
academic and military affiliates to fill gaps in service when and where 
they are found. However, we are concerned about media reports from 
veteran patients with TBI and their family members who claim that VA 
TBI care is not up to par in certain locations, prompting them to seek 
rehabilitation services from private facilities. VA must ensure that 
its TBI network provides excellent care to all veterans irrespective of 
their degree of impairment. VHA's current continuing education programs 
should be enhanced to ensure that all VA providers are knowledgeable 
about the spectrum of clinical presentation and treatment of veterans 
with combat-related TBI.
    We encourage VA and Congress to ensure that severely wounded TBI 
veterans are receiving the best treatment and rehabilitation care 
available and that the needs of their family caregivers be met with 
innovative and effective programs.
    Mr. Chairman, this concludes our remarks. PVA will be happy to 
respond to any questions you or Members of the Subcommittee may have.

                                 
   Statement of James C. Schraa, Psy.D., Neuropsychologist, Licensed 
     Psychologist, State of Colorado, Craig Hospital, Englewood, CO
    Severe traumatic brain injury is a family injury in the sense that 
it converts the loved ones of the brain injured servicemembers into 
caregivers and personal care attendants. After acute rehabilitation, 
the family members must substitute their judgment, planning and memory 
functions for the cognitive abilities and emotional control that their 
loved one has lost. Positive outcomes following severe traumatic brain 
injury are strongly associated with ongoing family support and 
involvement. Unfortunately, providing care giving and a safe structure 
for the severely brain injured is associated with the experience of 
high levels of stress and very high divorce rates. The civilian 
literature also establishes that brain injury substantially increases 
the frequency of bankruptcy.
    The vast majority of Americans would agree that supporting our 
troops includes helping families to successfully cope with the 
behavioral and adjustment challenges that persist following severe 
traumatic brain injury. Americans want their military servicemembers 
with severe brain injuries to have as much quality of life as possible. 
This is clearly associated with keeping them with their families and in 
their own communities. The Medicare cost literature amply documents 
that maintaining patients in the community is also cost effective. The 
most expensive cases in terms of long-term medical costs are the 
chronically institutionalized disabled. Thus, Representative Salazar's 
Bill, H.R. 3051 not only reflects the loyalty we feel to our fellow 
citizen soldiers, but also represents a cost-effective approach to 
reduce healthcare costs (references available on request). It should 
also be noted that divorce involving patients with severe brain 
injuries results in increased long-term costs to government agencies 
for establishing and managing guardianships and conservatorships.
    The literature on urban versus rural health-related quality of life 
establishes that the rural veteran population experiences lower 
physical and mental quality of life. Numerous studies have established 
that members of the National Guard and Reserve experience higher rates 
of emotionally based symptoms and problems related to alcoholism. Fewer 
supports in rural communities contribute to poorer coping in all at-
risk groups including soldiers with traumatic brain injury. Rural VA 
clinics and Veteran Centers in rural communities constitute tremendous 
improvements for veterans but they usually do not include specialty 
care. Therefore, in all states with dispersed rural populations, 
initiatives to improve telemedicine are needed. Rural veterans with 
moderate to severe traumatic brain injuries will clearly be in need of 
ongoing consultation for the foreseeable future. Given the difficulties 
that this group of brain injured veterans has with driving and 
transportation, telemedicine outreach projects to increase their access 
to services should be supported.
    I have had the experience of working with patients with severe 
traumatic brain injuries and spinal cord injuries for 26 years at Craig 
Hospital. Our experience is that supporting and maintaining families in 
the community is the most cost effective approach to long-term care, 
and the approach that affords the highest quality of life. There is 
literature from the Workers' Compensation Reinsurance industry which 
establishes that maintaining brain injured patients with their families 
in the community is the most cost effective treatment approach. 
Therefore, I strongly recommend that you consider passing H.R. 3051. 
H.R. 3051 is superior to S. 2921 because it will help keep more 
families with a brain injured servicemember intact, and prevent the 
institutionalization of more soldiers with severe brain injury than the 
provisions of S. 2921
            Respectfully submitted,
                                            James C. Schraa, Psy.D.
                                                  Neuropsychologist
                           Licensed Psychologist, State of Colorado
                                      Craig Hospital, Englewood, CO

                                 
    Statement of Christopher Needham, Senior Legislative Associate, 
 National Legislative Service, Veterans of Foreign Wars of the United 
                                 States
    Mr. Chairman and Members of the Subcommittee:
    Thank you for the opportunity to provide testimony for this 
legislative hearing. The 2.3 million men and women of the Veterans of 
Foreign Wars of the U.S. appreciate the voice you give them at these 
important hearings.
                   H.R. 3051, the Heroes at Home Act
    The VFW strongly supports the Heroes at Home Act. This legislation 
would dramatically improve the delivery of healthcare for those 
veterans suffering from traumatic brain injury. We thank Representative 
Salazar and the original cosponsors of this legislation for its 
introduction, and we urge its passage.
    We especially appreciate section 2 of the legislation. It would 
create a family caregiver program to train families or friends of 
veterans suffering from the effects of severe traumatic brain injuries.
    The newest generation of war veterans is presenting VA with many 
new healthcare challenges. Advances in technology and battlefield 
medicine are allowing many hundreds of men and women to survive 
injuries that previously would have been fatal. This, however, is 
coming at a price; many of them are grievously wounded and suffering 
from complex and intertwined ailments that are stretching VA's ability 
to adapt. Once the worst of their ailments are addressed, a great 
number of these men and women are returning home to their immediate 
families. In some cases, this is a spouse and in other cases--
especially given the relatively young age of many of these men and 
women--to their parents.
    The impact on these families is daunting. Their loved ones have 
complex physical and emotional difficulties and they must battle the 
bureaucracy of VA and DoD to ensure that everything the veteran is due 
comes to him or her. These families often have to put their lives on 
hold, delaying work, their education, relationships and other aspects 
of their life because of their veteran's illnesses and conditions, and 
the demands their intensive care require. With the complexity of the 
overlapping bureaucracies, some veterans fall through the cracks and do 
not receive the pays or compensation they need to cover their care. 
Further, in cases where parents--as opposed to spouses--are providing 
care, they may not be eligible for the full range of services and 
benefits the two departments provide.
    Section 2 would go a long way toward fixing these problems, 
training and certifying family and friends to serve as caregivers, 
which would make them eligible for compensation for their time and 
service.
    Section 3 would require the Secretary to conduct outreach to 
educate veterans and the public about PTSD and TBI, as well as to 
provide information about the range of services VA can provide for 
their treatment. Additionally, it would require VA to release 
information about the best practices it develops so that healthcare 
practitioners can learn from VA's experiences when dealing with these 
conditions for all Americans in the civilian world. Both are worthy 
provisions.
    Section 4 of the bill would expand telehealth and telemental health 
options through a pilot program that primarily focuses on rural areas. 
It would determine the feasibility of using these technologies to 
assess the cognitive function of service men and women and veterans, as 
well as to help with rehabilitation. This is a good goal and a creative 
approach to solving the difficulties some veterans experience when 
trying to access their care. Should the program work, it would be of 
great benefit to many thousands of veterans suffering from these 
conditions.
 H.R. 6153, the Veterans' Medical Personnel Recruitment and Retention 
                                  Act
    The VFW is happy to offer our support to this legislation, which 
would improve VA's ability to recruit and retain nurses and other 
healthcare practitioners. This is a continuing challenge for VA and one 
that is shared by all healthcare facilities. With the nursing shortage 
around the country, it is critical that VA have the tools and 
flexibilities it needs to adapt and be competitive in the marketplace 
as the workplace of choice for high quality healthcare providers.
    This bill would improve pays for various healthcare specialties, 
including specific targeting for nurse executives and part-time nurses. 
It also revises rules relating to overtime and weekend duty and work 
schedules, which could help ease the burden many nurses face. 
Additionally, it reinstates the health professional educational

assistance scholarship program, which is an excellent recruitment 
benefit that would make VA more attractive to various healthcare 
providers.
    We believe that its passage would improve VA's abilities to recruit 
and retain high-quality healthcare providers. This can only serve to 
better the care VA provides to this Nation's veterans. For this reason, 
we support this bill.
                               H.R. 6629
    We understand that this bill was introduced to address a specific 
problem in New Hampshire. New Hampshire is the only one of the 
contiguous 48 states that lacks a full-service veterans hospital. As a 
result, veterans seeking certain types of basic care are forced to 
travel to hospitals in other states, whether in White River Junction, 
Vermont or near Boston, Mass.
    This bill would require VA to either run a full-service hospital in 
each of the 48 contiguous states or it would require VA to fully 
contract out for all healthcare services. It is the latter part that 
causes us to have some qualms with the bill.
    First, we believe that New Hampshire veterans deserve better. Many 
face long drives for basic care. In 2007, for example, over 700 
veterans were transferred out-of-state for acute care. If they live in 
the northern part of the state, this could mean a travel time of 4 
hours one-way just for basic services that the Manchester VA should 
otherwise be able to provide. Only recently has the Secretary announced 
that Manchester will begin offering radiation therapy, meaning that 
veterans who needed this for the treatment of cancer had to travel 
hours for care. Clearly, this is unacceptable.
    We believe, however, that the mechanism of this bill could create 
some further inequities. Should the contracting provisions be in force, 
a veteran living across the border from the White River Junction VA 
Medical Center in Lebanon, NH would be entitled to contract care for 
any service they would need. Presumably, they could call up their 
private physician and have an appointment in a matter of hours or days. 
The same veteran, should they live five miles to the west in Vermont, 
would be required to wait in line for their turn at the White River 
Junction Medical Center. That is not fair.
    We have supported contracted care in limited cases, namely where VA 
is otherwise unable to provide care--particularly in the case of 
specialized services. This legislation, though, could lead to wide-
spread contracting, which we oppose.
    VA already has the authority to provide fee-basis care, and it uses 
it with great success in many areas, especially in some remote parts of 
the west. We would urge the Committee to use its oversight authority to 
ensure that VA is doing the right thing for New Hampshire's veterans. 
If VA does not believe that the Manchester Medical Center requires full 
services, then we need the Committee to ensure that veterans who need 
these specific services receive contracted care when they would 
otherwise have to travel these long distances. We need to adapt the 
lessons VA has learned from other areas to New Hampshire, even if most 
people have not previously considered New Hampshire to be a large state 
or one that would require significant travel.
    This concludes my statement. I would be happy to answer any 
questions you may have.

                                 
Statement of Anna Frese, Family Outreach Coordinator for Brain Injury, 
                        Wounded Warrior Project
    The men and women of the Armed Forces have been providing an 
example of service, to their country, for over 200 years. Many families 
have watched and supported their loved one as they head off to fulfill 
the missions assigned to them. Unfortunately, in the process of 
fulfilling those missions, not all loved ones return home as they left. 
The need has presented itself, to assist in supporting the service of 
the family member, whose chosen mission is to care for and provide a 
quality of life to their loved one that has been seriously injured 
while in service to their country.
    I thank the Committee for allowing me the opportunity to 
respectfully submit this testimony for the record and I strongly 
support this direly needed legislation. My name is Anna Frese and I 
currently am working with the Wounded Warrior Project (WWP) as a Family 
Outreach Coordinator for Brain Injury. My understanding for the urgent 
need of H.R. 3051 does not just come from working with the Wounded 
Warrior Project, but also what I witness daily as sister of Retired 
Army Sergeant Eric Edmundson, who was seriously injured in Iraq in 
October of 2005, and is currently living at home receiving 24/7 total 
care from our father, Edgar Edmundson.
    Our family made the decision to bring Eric home and care for him. 
This decision was made knowing that it was what Eric would want. As our 
father says, ``My son went to war, he honored himself, he honored his 
family, and he honored his Nation. He went to war, did his duty and got 
injured. As a parent, Eric, in my eyes is not a handicapped person, he 
is not a 100 percent disabled Veteran; Eric in my eyes is a 28 year old 
husband, a father and a young man with a whole life ahead of him. I as 
a parent need to honor him, and see to it that his needs are met.''
    It is important for Eric's young family that Eric be home, and be 
an active part in daily life. Eric is not only dealing with medical or 
rehab issues, he needs to be home to help deal with everyday issues so 
that he is meeting his responsibilities and being included, involved 
and helping to keep his small family intact. Anyone can be trained to 
take care of medical needs, but when you are 28 years old, a husband 
and father with responsibilities and a desire to get your life back--it 
goes a lot deeper than pills and therapy. You need to be around people 
that know you, understand you, and are willing and able to be there for 
you.
    Our father sees it as his duty to ensure not only that Eric's short 
term goals are met but that a focus remains on his long term goals as 
well. He focuses on helping Eric in maintaining a high morale and self-
esteem which is paramount in the achievement of reaching his goals. 
Some long term goals to getting his life back include his hobbies of 
hunting and fishing--and our family sees that there is no reason that 
he can't have those as a regular part of his life.
    The decision to bring Eric home came with sacrifice and changes on 
many levels. Ours is just one of many families that have adapted to the 
``new normal'' with changes in family infrastructure, in relationships 
with friends and extended family, in finances, in hopes, plans and 
goals for the future. Upon learning of Eric's lifelong challenges, our 
father resigned his position at work, in order to provide Eric the 
full-time care that was needed. This decision did leave him and our 
mother with one less income, and in times of need they had to dissolve 
their personal and retirement savings. Just as importantly, now at 53 
years old my father is no longer is covered by health insurance.
    The financial and emotional stress of not having the ability to 
maintain ones physical health is not only reflected in our family, but 
again in many of the families caring for their severely injured 
Veteran. By the Committee supporting H.R. 3051, family caregivers will 
have the option of receiving training by the VA, certifying them to 
receive compensation for the care they are providing their Veteran. 
This compensation will possibly allow some to better manage their own 
lives and health, so that they will be there for their loved one in the 
future.
    One constant statement that I hear not only from my father, but 
other family caregivers who have made the same decision as ours, is 
that they are grateful. They are grateful to have the opportunity to 
spend time and enjoy the life of their loved one. So many Servicemember 
and Veterans have persevered through immeasurable odds, and families 
see it as their time to persevere and provide as much joy and quality 
of life as possible.
    The family caregivers of these returning wounded warriors 
appreciate the concern, and acknowledge the recommendations that are 
trying to provide for the many others caring for their loved one. These 
warriors need someone at their side who knows them, understands them, 
and someone who is willing to be there for them and speak for them, in 
order for him to fully recover--or recover as much as possible. 
Families just wish it to be known they are committed to being by their 
Veterans side no matter what; the need is just too urgent. This 
legislation will allow family caregivers to follow through on that 
commitment.

                                  
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