[Senate Hearing 110-171]
[From the U.S. Government Publishing Office]
S. Hrg. 110-171
HEARING ON PENDING HEALTH CARE LEGISLATION
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MAY 23, 2007
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Larry E. Craig, Idaho, Ranking
Virginia Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Kay Bailey Hutchison, Texas
Jon Tester, Montana John Ensign, Nevada
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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May 23, 2007
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Prepared statement........................................... 2
Obama, Hon. Barack, U.S. Senator from Illinois................... 3
Murray, Hon. Patty, U.S. Senator from Washington................. 4
Burr, Hon. Richard, U.S. Senator from North Carolina............. 6
Tester, Hon. John, U.S. Senator from Montana..................... 6
Craig, Hon. Larry E., Ranking Member, U.S. Senator from Idaho.... 56
Prepared statement........................................... 56
Isakson, Hon. Johnny, U.S. Senator from Georgia.................. 65
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 66
WITNESSES
Cross, Gerald M., M.D., FAAFP, Acting Principal Deputy Under
Secretary for Health, Department of Veterans Affairs;
accompanied by Walter Hall, Assistant General Counsel,
Department of Veterans Affairs................................. 6
Prepared statement........................................... 8
VSO letter opposing S. 815................................. 17
Response to additional information requested by Committee
Members during the hearing................................. 19
Blake, Carl, National Legislative Director, Paralyzed Veterans of
America........................................................ 69
Prepared statement........................................... 71
Cullinan, Dennis M., Director, National Legislative Service,
Veterans of Foreign Wars of the United States.................. 75
Prepared statement........................................... 77
Ilem, Joy J., Assistant National Legislative Director, Disabled
American
Veterans....................................................... 80
Prepared statement........................................... 82
Middleton, Shannon, Deputy Director for Health, Veterans Affairs
and Rehabilitation Commission, The American Legion............. 89
Prepared statement........................................... 90
Edelman, Bernard, Deputy Director, Policy and Government Affairs,
Vietnam Veterans of America.................................... 93
Prepared statement........................................... 95
Vietnam Veterans of America's views on rural veterans health
care....................................................... 98
Beck, Meredith, National Policy Director, Wounded Warrior Project 102
Prepared statement........................................... 104
Booss, John, M.D., Professor Emeritus of Neurology and Laboratory
Medicine, Yale University School of Medicine; on behalf of the
American Academy of Neurology.................................. 106
Prepared statement........................................... 108
Reed, Jerry, Executive Director, Suicide Prevention Action
Network USA.................................................... 109
Prepared statement........................................... 111
APPENDIX
Allard, Hon. Wayne, U.S. Senator from Colorado, prepared
statement...................................................... 115
Huston, Ann, Executive Director and CEO, American Therapeutic
Recreation Association, prepared statement..................... 116
American Academy of Physical Medicine and Rehabilitation,
prepared
statement...................................................... 119
American Congress of Rehabilitation Medicine, prepared statement. 121
Brain Injury Association of America, prepared statement.......... 123
Commission on Accreditation of Rehabilitation Facilities,
prepared statement............................................. 124
Vermont resident e-mail to Senator Sanders received May 17, 2007. 126
Coelho, Tony, Epilepsy Foundation, letter of support for S. 1233. 126
HEARING ON PENDING HEALTH CARE LEGISLATION
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WEDNESDAY, MAY 23, 2007
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:30 a.m., in
Room 562, Dirksen Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Obama, Brown, Tester,
Sanders, Craig, Burr, and Isakson.
OPENING STATEMENT OF DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The U.S. Senate Committee on Veterans'
Affairs will come to order. Aloha and good morning, everyone.
Welcome to the Committee's hearing on pending health
legislation.
The Committee has quite a docket of legislation to review,
so I will make my opening remarks quite brief so that we can
get started. As I said at our last legislative hearing, I am
thankful for Members' interest in the needs of veterans and
their families and the range of attempts to tackle some of the
most pronounced issues. I know that our witnesses had quite an
undertaking to do in order to give us views on the various
bills we have before us. The Committee has done extensive
oversight work and held numerous hearings on these matters. The
legislation before us is a culmination of those activities.
Ranking Member Craig and I heard the testimony of witnesses
at our March 27 hearing on seamless transition and care for
veterans with traumatic brain injuries. We used that testimony
to develop bipartisan legislation on TBI, which takes a
comprehensive approach to providing the best possible care for
veterans with this devastating injury.
I want to mention my legislation to extend the period of
eligibility for VA health care for combat service from two to
five years. It is my view that doing so will help ensure that
returning servicemembers receive the care they need from VA in
the five years immediately following separation or deactivation
without having to meet strict eligibility rules. The changes my
bill would make will contribute to the seamless transition of
military personnel from active duty to veteran status.
While the Administration has opposed this legislation in
the past, I am delighted that the obvious growth in the
diagnosis for mental health conditions has prompted a
reconsideration of their previous position. Two years is often
insufficient time for symptoms related to PTSD and other mental
illnesses to manifest. In many cases, it takes years for such
symptoms to present themselves and many servicemembers do not
immediately seek care. Five years would provide a bigger window
to address these risks. We face a growing group of recently
discharged veterans and this legislation will help smooth their
transition to civilian life.
I thank the witnesses from VA and other organizations for
coming today to share their views. Because the number of
measures before us this morning is unusually large and a number
of them have been added to the agenda only recently, witnesses
may not have had an opportunity to review them and formulate
positions. Therefore, the Committee will hold the record of
this hearing open for two weeks so that witnesses can submit
supplemental views on any legislative item.
It is important that we have your input well in advance of
our markup, which is scheduled for late next month. I look
forward with all of you in the days ahead to move the
Committee's agenda forward.
[The prepared statement of Senator Akaka follows:]
Prepared Statement of Hon. Daniel K. Akaka, Chairman,
U.S. Senator from Hawaii
Aloha and good morning. I welcome everyone to the Committee's
hearing on pending health legislation. The Committee has quite a docket
of legislation to review, so I will make my opening remarks quite brief
so that we can get started.
As I said at our last legislative hearing, I am thankful for
Members' interest in the needs of veterans and their families and the
range of attempts to tackle some of the most pronounced issues. That
said, I know that our witnesses had quite a load to carry in order to
give us views on the various bills.
The Committee has done much oversight work and held various
hearings, and the legislation before us is a culmination of those
activities. Ranking Member Craig and I heard the testimony of witnesses
at our March 27th hearing on seamless transition and care for veterans
with traumatic brain injuries. We used that testimony to develop
bipartisan legislation on TBI, which takes a comprehensive approach to
providing the best possible care for veterans with this devastating
injury.
I want to speak very briefly about some of the items on the agenda.
First, I introduced legislation again this Congress to extend the
period of eligibility for VA health care for combat service from two to
five years. It is my view that doing so will help ensure that returning
servicemembers receive the care they need from VA in the five years
immediately following separation or deactivation, without having to
meet strict eligibility rules. The changes S. 383 would make will
contribute to the ``seamless'' transition of military personnel from
active duty to veteran status.
While the Administration has opposed this legislation in the past,
I am delighted that the obvious growth in the diagnoses for mental
health conditions has prompted a reconsideration of the previous
position. Two years is often insufficient time for symptoms related to
PTSD and other mental illnesses to manifest. In many cases, it takes
years for such symptoms to present themselves, and many servicemembers
do not immediately seek care. Five years would provide a bigger window
to address these risks. We face a growing group of recently discharged
veterans, and this legislation will help smooth their transition to
civilian life.
Second, S. 117, The Lane Evans Veterans Health and Benefits
Improvement Act of 2007, introduced by Senator Obama, is a fitting
tribute to the former Ranking Member of the House Committee on
Veterans' Affairs. The legislation, among other things, would make
combat-theater veterans eligible for a VA mental health evaluation
within 30 days of the veteran's request. Such a request could be made
up to five years after the date of the veteran's discharge or release
from active military service.
S. 479, The Joshua Omvig Veterans Suicide Prevention Act, would
require the Secretary to develop and implement comprehensive programs
to reduce suicide among veterans. The bill is named after Joshua Omvig,
a young veteran who committed suicide after returning from Iraq. On
April 25, 2007, the Committee heard testimony from Joshua Omvig's
parents about his struggle. It became clear that VA must place greater
emphasis on reaching out to returning servicemembers, so as to prevent
these types of tragedies from occurring in the future.
S. 1147, the Honor our Commitment to Veterans Act, would repeal the
ban on enrollment of middle-income veterans, known as Priority 8
veterans, in the VA health care system. In the Majority's Views and
Estimates letter to the Budget Committee, we recommended including
funding in VA's Fiscal Year 2008 budget to enable VA to fully open its
doors to all veterans who desire VA health care. In doing so, I do not
believe that we need to undo what was done in eligibility reform, that
is, to allow the VA Secretary to manage a priority system for care
within the confines of a limited budget. I do believe that this year,
the Congress will appropriate sufficient resources to allow for open
access to VA health care while not severely altering the construct of
eligibility reform or overburdening the system.
As I mentioned a moment ago, I am quite proud of S. 1233, the
Veterans Traumatic Brain Injury Act of 2007. Senator Craig and I worked
to develop a bill to address VA shortcomings in rehabilitation
treatment, research and clinical care programs for veterans. The Brain
Injury Association of America, the American Academy of Neurology, and
the American Academy of Physical Medicine and Rehabilitation all
support the legislation.
Finally, I also introduced S. 1384, which would make a number of
changes to the funding for homeless programs; expand programs to aid in
the transition to civilian life for both incarcerated veterans and
servicemembers being discharged from the military; and improve
domiciliary care for women veterans. All of these changes are yet
another step in combating the prevalence of homelessness among those
who have served our Nation.
I thank the witnesses from VA and other organizations for coming
today to share their views. Because the number of measures before us
this morning is unusually large and a number of them have been added to
the agenda only recently, witnesses may not have had an opportunity to
review them and formulate positions. Therefore, the Committee will hold
the record of this hearing open for two weeks so that witnesses can
submit supplemental views on any legislative item. It is important that
we have your input well in advance of our markup which is scheduled for
late next month.
I look forward to working with all of you in the days ahead to move
the Committee's agenda forward. Thank you.
I would like to ask for any other remarks. Senator Obama,
and then Senator Murray.
STATEMENT OF HON. BARACK OBAMA,
U.S. SENATOR FROM ILLINOIS
Senator Obama. Thank you, Mr. Chairman, and thank you for
holding this hearing. I also want to thank the panelists and
especially our friends in the VSO community and expert
witnesses for their feedback on legislation under discussion
today.
I would like to briefly discuss two important measures that
I have introduced in this Committee. The Lane Evans Veterans
Health and Benefits Improvement Act, which you mentioned, Mr.
Chairman, very graciously, and I appreciate, would enhance
mental health care and access for our veterans by enabling them
to receive a mental health screening within 30 days of a
request and full access to care required as a result of that
screening, including hospital care, nursing home care, or
family and marital counseling. Veterans would be eligible to
request the screening 5 years after discharge and would be
eligible for any resulting treatment for 2 years. The bill
would also establish one-on-one face-to-face mental health
screening for all returning servicemembers and would require
that they receive individual electronic records upon
discharge.
Now, unfortunately, the VA has expressed opposition to one
provision in the bill, a proposed veterans' information
tracking system that would help anticipate the needs of our
veterans and lead to more robust policy planning by the VA and
Congress. Although VA has regularly struggled--and both you,
Mr. Chairman, as well as Senator Murray have been working on
this for a long, long time--to adequately anticipate its own
budgetary needs and provide information requested by Congress,
it argues that current reporting is sufficient and believes
this provision is too costly and onerous.
I would argue that whatever costs would be incurred in
setting up this tracking system would be more than offset by
the better care that we could provide our Nation's veterans. It
just strikes me that our planning process continues to break
down. In the time that I have been on this Committee, we
constantly have to come back with supplementals because we have
not anticipated needs. I don't understand why the VA is
resistant to instituting the sort of mechanisms that I think
every large business and institution around the country puts
into place to make sure that their budget is adequate to their
needs. So I am going to be interested in finding once again why
the VA is not willing to do that.
I am also pleased to have introduced the VA Hospital
Quality Report Card Act. Our VA hospital system is considered
by many to be the best health care system in the Nation and I
think it is a wonderful success story, the progress that the VA
has made over the last several decades. This bill does not
question the assessment that VA has a high-quality health care
system in place. Rather, it is intended to encourage the
examination of hospital-specific performance to ensure
uniformity and quality across hospitals. The bill would also
require hospitals to measure and report quality information for
sub-populations that have historically received lower quality
care.
The VA's own research studies have identified a number of
racial and ethnic differences in health outcomes and patient
experiences, some positive and some negative, which support
continued data collection and analysis for minority
populations. This likely holds true for other patient
populations, as well, and I believe that all hospitals should
be tasked to conduct this work.
I worked in the Illinois State Senate to pass similar
legislation. It succeeded in making my State's hospitals more
responsive to the needs of their patients.
Mr. Chairman, I want to thank you again for holding this
hearing. I look forward to working with you on passing these
measures and thank the panelists for their invaluable feedback.
I probably will not be able to stay for all the testimony, but
I am hoping to get some of the testimony before I have to go.
Chairman Akaka. Thank you very much, Senator Obama.
And now, Senator Murray.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman. I really
appreciate your holding this important hearing on ways that we
can help improve the health care for our veterans and I think
it is really appropriate that we are holding this hearing so
close to Memorial Day. It is the day that we honor all of those
who have paid the ultimate price for our freedom, and as we
remember their sacrifice, it is an appropriate time to make
sure we are keeping our commitment to all of those who served
us.
Mr. Chairman, as the needs of our veterans change, we have
to update our policies to meet those needs. For example, we
just recently learned that there is a significant association
between exposure to nerve agents in the First Gulf War and
long-term brain damage. That is a great example of how recent
research should guide us to improve our care for veterans and I
am working with Senator Rockefeller and Senator Bond to do
that.
Our veterans do deserve the best care and we are taking
steps to provide it. Last week, we passed a budget that
provides $3.5 billion more than the President asked for for our
veterans' programs, and in fact, Mr. Chairman, working with
you, we provided 98 percent of what the Independent Budget
requested, and importantly, that budget did away with the
Administration's proposed fees and copays for our veterans.
But we do have to do more and it is why we are looking at a
variety of bills here today. I am really pleased that there are
a number of really great proposals. One of them is legislation
that I have introduced that will open the door to VA health
care for veterans who were unfairly shut out by this
Administration more than 4 years ago. The Bush Administration
cut off enrollment of Priority 8 veterans into the VA health
care system. Priority 8s are those veterans without service-
connected disabilities whose incomes are above a means-tested
level that varies throughout the country. But many of those so-
called high-income veterans have incomes as low as $26,902.
My legislation is the Honor Our Commitment to Veterans Act
of 2007. It would rescind the Administration's January 2003
decision to prevent new enrollment of Priority 8 veterans into
the VA health care system and I am very pleased that this
legislation is supported by the American Legion, Veterans of
Foreign Wars, Vietnam Veterans of America, and the Paralyzed
Veterans of America.
Mr. Chairman, according to a recent Congressional Research
Service report, the VA estimates that if an enrollment freeze
was lifted, approximately 273,000 Priority 8 veterans would
have been eligible to receive medical care from the VA in
fiscal year 2006, and 242,000 Priority 8 veterans would have
been eligible in 2007.
Mr. Chairman, we are nearly 5 years into this war and our
veterans are facing lengthy waits just to get to see a primary
care physician. They are having trouble accessing critical
mental health services and some are waiting up to 2 years for
the benefits that they were promised to be processed. These are
real problems facing real people and they deserve solutions.
Instead of cutting off enrollment to veterans of modest
means 4 years ago, the Bush Administration should have asked
Congress for the resources necessary to address its
shortcomings and increase access to the VA. It is absolutely
unacceptable that veterans in need of care are being prohibited
from enrolling in the system that is supposed to serve them.
Veterans who have fought hard to secure our freedoms shouldn't
have to fight for access to health care at home. They deserve
better.
So, Mr. Chairman, I appreciate this opportunity for my bill
and the others on the calendar today and I look forward to
hearing from our witnesses.
Chairman Akaka. Thank you very much, Senator Murray.
Senator Burr for your remarks.
STATEMENT OF HON. RICHARD BURR,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Mr. Chairman, I thank you. I would only say
thank you for holding this hearing. I look forward to the
panels of witnesses that we have today and believe that what we
are going to learn will help this Committee to move forward
with some very important legislation. I thank the Chair.
Chairman Akaka. Thank you. Thank you very much.
Now Senator Tester for any remarks he may have.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman. I, too, want to
thank you for holding the hearing. I think there are some very
good bills here. I look forward to hearing the Department's
opinion on them and the discussion that will revolve around
them. I think there are some important issues out there and I
think some of these bills deal with those issues, so thank you,
Mr. Chairman.
Chairman Akaka. Thank you very much for your remarks.
Now again, I want to welcome our witnesses from VA, Dr.
Gerald M. Cross, the Acting Principal Deputy Under Secretary
for Health, who is accompanied by Walter Hall, Assistant
General Counsel.
I thank both of you for being here this morning and look
forward to your testimony. VA's full statement will appear in
the record of this hearing. Dr. Cross, will you please proceed
with your testimony.
STATEMENT OF GERALD M. CROSS, M.D., ACTING PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, DEPARTMENT
OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER HALL, ASSISTANT
GENERAL COUNSEL, DEPARTMENT OF VETERANS AFFAIRS
Dr. Cross. Thank you, sir, and good morning, Mr. Chairman
and Members of the Committee. Thank you for inviting me here
today to present the Administration's views on several bills
that would affect programs administered by the Department of
Veterans Affairs in the provision of health care to veterans.
With me today is Walter Hall, Assistant General Counsel.
Sir, with your permission, I would also like to introduce a
guest who happens to be accompanying me this morning, a
fighting SeeBee, Michael Christianson--can you stand up,
Michael--who is accompanying the VA team this morning. He is on
a commission working with us and others looking at their needs.
I wanted to thank Michael for his service since he is here with
us today, and he actually comes from Washington State.
Senator Murray. Very good. Welcome.
Chairman Akaka. Welcome to the Committee.
Dr. Cross. He is recently back from Iraq.
Knowing my time is limited, I will highlight bills
addressing some of our common interest. I would like to submit,
as you said, Mr. Chairman, my written testimony for the record.
First of all, VA supports S. 383, which extends the 2 years
to 5 years, the period of eligibility for priority access to VA
health care services for combat veterans. This bill would give
additional time for separated servicemembers to seek treatment
of symptoms that may develop later than 2 years in cases such
as PTSD or TBI. We feel that the passage of this bill would
eliminate the need for
S. 117, Section 101 that provides for mental health services
for combat theater veterans after the 2-year eligibility
period.
VA understands the intent of S. 479 and acknowledges the
need to address suicide prevention comprehensively. Mr.
Chairman, a veteran's suicide is a devastating event for
family, for friends, and for those who are entrusted with his
or her care. VA recognizes the pain that families like that of
Joshua Omvig are experiencing and we are fully in sympathy with
the aims of the bill that bears Mr. Omvig's name. We feel,
however, that the bill is unnecessary because it duplicates
many of the efforts that are already underway in the
Department.
VA is currently implementing its Mental Health Strategic
Plan based on the goals of the President's New Freedom
Commission on Mental Health and we are proud of the steps we
have already taken and would be happy to brief the Committee on
our initiatives as well as to explore additional measures with
you that could supplement our efforts, efforts that would honor
the memory of Mr. Omvig and pay proper tribute to his family
that have done so much to keep this issue in the public's eye.
S. 692 requires the VA to establish a hospital quality
report card initiative. VA is already complying with the intent
of this bill as it comes into compliance with Executive Order
134-10, requiring Federal agencies to report provider-level
data to their beneficiaries. In addition, the Joint Commission
on Accreditation for Hospitals makes public information on
hospital performance in key areas of care available on their
web site where veterans may compare VA hospitals to other
accredited hospitals in their communities. Moreover, VA uses
over 100 performance measures related to patient care in VA
facilities as ongoing components of quality improvement. This
information is routinely reported to senior leadership and is a
basis for evaluation for facility and network leadership. For
these reasons, we do not support S. 692, but we would be
pleased to work with the Committee staff to explain how we use
performance measures.
On S. 1233, while VA is continuing to review this bill and
will submit formal views following this hearing, I would like
to emphasize VA shares the passion this Committee has for the
impact of TBI on our combat veterans. Mr. Chairman, as you
know, VA and DOD are working collaboratively on this diagnosis
and on many issues surrounding it, from diagnostic screening
tools to rehabilitative transitional care. There is a range for
TBI injuries from mild to severe. VA is refining continuously
the parts of the program that address all aspects of TBI. VA
now has an effective screening tool in place that also has been
presented and taught to our clinicians and is also being shared
with DOD.
Moreover, VA's comprehensive polytrauma network has
individual case managers for veterans with these complex
injuries and we are now hiring transitional patient advocates
who help families work through the more complex aspects of
care. VA continues to be a leader in new approaches for caring
for these patients with using their emerging consciousness
program. In just 3 years, VA has taken tremendous steps in the
TBI polytrauma arena and we plan to continue these advancements
within VA and within our partnership with DOD.
I am very proud of the steps we already have taken and will
be happy to brief the Committee on any of our programs, and I
would be pleased to answer any questions you or any Members of
the Committee have, sir. Thank you.
[The prepared statement of Dr. Cross follows:]
Prepared Statement of Gerald M. Cross, M.D., FAAFP, Acting Principal
Deputy Under Secretary for Health, Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on several bills that would affect Department of
Veterans Affairs (VA) programs that provide veterans benefits and
services. With me today is Walter A. Hall, Assistant General Counsel. I
am pleased to provide the Department's views on 15 of the 20 bills
under consideration by the Committee. I will briefly describe each
bill, provide VA's comments on each measure and estimates of costs (to
the extent cost information is available), and answer any questions you
and the Committee members may have.
Unfortunately, we are unable to comment on the five other bills
(i.e., S. 1233, S. 1326, S. 1384, S. 1396, and S. 1441) because we only
recently received them and learned they would be on today's agenda.
However, we will evaluate those bills and provide our views and
estimates for the record.
Mr. Chairman, I will begin by discussing four bills on today's
agenda that would address the delivery and types of VA health care
services available to veterans of Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) and future combat operations.
S. 117--LANE EVANS VETERANS HEALTH AND BENEFITS
IMPROVEMENT ACT OF 2007
The first of these is S. 117. We testified regarding certain
benefits-related provisions on May 9, 2007. Today I will discuss three
sections of that bill that relate to health care benefits: sections
101, 202, and 203.
Section 101 of the bill would make combat-theater veterans eligible
for a VA mental health evaluation within 30 days of the veteran's
request. The veteran would be able to request and receive such an
examination up to 5 years after the date of the veteran's discharge or
release from active military service. In addition, such veterans would
be eligible for hospital care, medical services, nursing home care, and
family and marital counseling for any mental health condition
identified during that examination, notwithstanding that the medical
evidence is insufficient to conclude that the mental health condition
is attributable to the veteran's combat service. Eligibility for
medical services needed to treat the veteran's identified mental health
condition would continue for 2 years, beginning on the date VA begins
to provide such services. The bill would not, however, cover any mental
health disability found by the Under Secretary for Health to have
resulted from a cause other than the veteran's combat service.
VA supports section 101. However, we note that this bill would be
wholly unnecessary should the Congress pass S. 383, which is discussed
below.
Section 102 would amend the statutory requirements applicable to
the mandated post-deployment examinations conducted by the Department
of Defense (DoD). As to this provision, we defer to the views of DoD.
Section 202 would require VA to establish an information system
designed to provide an elaborate and comprehensive record of the
veterans of the Global War on Terrorism (GWOT) who seek VA benefits and
the benefits they receive. Section 203 would mandate that VA submit a
quarterly report to Congress on the effects of participation in GWOT on
both veterans and the Department. The first of these reports would be
due not later than 90 days after this Act's enactment. Each quarterly
report would include aggregated information on VA health, counseling,
and related benefits to GWOT veterans, including information on the
enrollment status of GWOT veterans; the number of inpatient stays they
experienced and the related cost of that care (by both enrollment
status and condition); the number of outpatient visits they experienced
and the related cost of such services (again by enrollment status and
by condition); and the number of visits to Vet Centers and the related
cost of providing them readjustment counseling and services.
As we testified on May 9, 2007, this bill's requirements to compile
and frequently report to Congress massive amounts of data, much of
which are not currently available, in the detail and manner specified,
would force VA to divert considerable resources from our primary
responsibilities. Health care data on these veterans are currently
collected and tracked through the Veterans Tracking Application, which
is specific to injured servicemembers who transition to VA care.
However, that information is considered only in the aggregate.
Therefore, collection and tracking the individual-specific data
mandated by the bill would require considerably expanded administrative
personnel and resources. But again first and foremost, complying with
these sections would require resources that would otherwise be devoted
to the medical mission of VA. For this reason, we cannot support
sections 202 and 203 of the bill. We remain very mindful of this
Committee's oversight responsibilities and would welcome the
opportunity to work with staff to identify information that is
currently lacking that would be most helpful to the Committee in
meeting its responsibilities.
We are, as yet, unable to reliably estimate the costs of compliance
[in terms of both manpower and potential for detracting from the
primary mission of the Veterans Health Administration], but we believe
that they would be substantial.
S. 383--EXTENSION OF TREATMENT AUTHORITY
FOR COMBAT-THEATER VETERANS
S. 383 would amend existing law to increase to five the number of
years a combat-theater veteran is eligible for free VA health care for
illnesses or conditions that might be associated with combat service.
The five-year window of eligibility would begin on the date of
discharge or separation from active military, naval, or air service.
Currently, the law provides these veterans with two years of such
eligibility.
VA supports S. 383. When these veterans seek care from VA they are
placed in priority Category 6 and make no copayments for covered
conditions. When the special treatment authority for combat-theater
veterans was originally enacted, it was generally assumed that 2 years
was sufficient. However, experience has shown that this is not always
the case. In caring for OEF/OIF veterans we have discovered that the
onset of symptoms, or adverse health effects, related to Post-Traumatic
Stress Disorder (PTSD), and even Traumatic Brain Injury (TBI), are
often delayed, or do not manifest clinically, for more than two years
after a veteran has left active service. As a result, many OEF and OIF
veterans do not seek VA health care benefits until after their two-year
window of eligibility has closed. Without eligibility for enrollment in
priority Category 6, many, i.e., those with higher incomes and non-
service connected conditions, would not be eligible to enroll because
they would be in priority Category 8.
In addition, many OEF/OIF veterans are non-career military members
who are unfamiliar with veterans benefits and the procedures for
obtaining them. For that reason many fail to enroll in a timely
fashion. Providing combat-theater veterans with an additional 3 years
within which to access VA's health care system would help to ensure
that none of them is penalized because of reasons beyond their control
or because they have been unable to navigate through VA's claims system
in time.
VA estimates the costs associated with enactment of S. 383 to be
$14.1 million in fiscal year 2008 and $289 million over a 10-year
period. These estimates include both expenditures and lost copayment
revenue.
S. 479--JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT
S. 479 would require the Secretary to develop and implement a
comprehensive program (comprised of 10 specific elements) for reducing
the incidence of suicide among veterans. First, the program would
include a national mental health campaign to increase awareness in the
veteran community that mental health is essential to overall health and
that effective modern treatment can promote recovery from mental
illness. Second, it would call for mandatory training on suicide
prevention for appropriate employees and contract personnel (including
all medical personnel) who interact with veterans. This training would
require the provision of information on the recognition of risk factors
for suicide, protocols for responding to crisis situations involving
veterans who may be at high risk for suicide, and best practices for
suicide prevention. Third, the comprehensive program would include
outreach programs and educational programs for veterans and their
families, in particular OEF/OIF veterans and their families. The
educational programs would serve to help: eliminate or overcome stigmas
associated with mental illness; further understanding of veterans'
readjustment issues; identify signs and symptoms of mental health
problems; and encourage veterans to seek assistance for these types of
problems.
Fourth, the program would include a peer counseling program in
which veterans are trained as peer-counselors to assist other veterans
suffering from mental health issues. (Training of these veterans would
have to include specific education on suicide prevention.) The peer-
counselors would also be responsible for conducting outreach on mental
health matters to veterans and their families. The legislation would
require the Secretary to make this peer-program available in addition
to other mental health services already offered by VA (including those
that would be established by this Act).
Fifth, the Secretary would be directed, as part of the
comprehensive program, to encourage all veterans applying for VA
benefits to undergo a mental health assessment at a VA medical facility
or Vet Center.
Sixth, the program would include the provision of referrals, as
appropriate, to veterans who show signs or symptoms of mental health
problems.
Seventh, the Secretary would need to designate a suicide prevention
counselor at each VA medical facility (other than a Vet Center). These
counselors would work with a variety of local non-VA entities to engage
in outreach to veterans about available VA mental health services. They
would also be responsible for improving the coordination of mental
health care furnished to veterans at the local level.
Eighth, VA's program would have to include research on best
practices for suicide prevention among veterans. Moreover, the
Secretary would need to establish a steering committee to advise on
such research. Such committee would be comprised of representatives
from the National Institute of Mental Health (NIMH), Substance Abuse
and Mental Health Services Administration (SAMHSA), and the Centers for
Disease Control and Prevention (CDC).
Ninth, the Secretary would have to ensure the availability of VA
mental health services on a 24-hour basis.
Finally, the Secretary would be authorized to establish a
continuously operational, toll-free telephone number that veterans
could call for information on, and referrals to, appropriate mental
health services.
This legislation would permit the Secretary to include any other
activities in the comprehensive program that the Secretary deems
appropriate. It would also require the Secretary to submit, not later
than 90 days after the date of enactment, a detailed report to Congress
on all of the Department's suicide prevention programs and activities.
(Any suicide prevention programs VA establishes afterwards would have
to be developed in consultation with NIMH, SAMHSA, and CDC.)
We appreciate the purpose of this legislation; however, we do not
support this bill. It is unnecessary because it duplicates many efforts
already underway by the Department. Indeed, many of the bill's
requirements are already being addressed and implemented through VA's
current Mental Health Strategic Plan. (As you will recall, this
Strategic Plan was designed to both ensure that our Department
continues as a leader in the area of mental health and to implement the
goals of the President's New Freedom Commission on Mental Health.) We
therefore ask that the Committee forbear in its consideration of S.
479. In the meantime, we will be happy to brief the Committee on the
myriad initiatives we have right now and explore with you additional
measures that could supplement these efforts.
Should the Committee proceed to act on this measure, we note our
objection to the bill's requirement to train and use veterans as peer
counselors for other veterans with mental health issues. The use of
adult veterans as peer-counselors in caring for other veterans who
suffer from mental health issues is simply not advisable. Data on the
efficacy of these types of programs do not reflect favorable results.
Although well-intended, we believe such an approach to clinical care
lacks scientific support. We strongly believe that VA mental health
care services, including counseling, should continue to be provided by
our capable, experienced, and appropriately trained cadre of mental
health care professionals.
In addition, we do not think the bill's requirement that we
encourage every veteran seeking any type of VA benefit to obtain a
mental health assessment is justified, and it may cause veterans to
believe they have been stigmatized.
S. 882--VETERAN NAVIGATORS TRANSITION ASSISTANCE PROGRAM
Mr. Chairman, the fourth bill on today's agenda that would have
particular significance for those returning from deployment in OEF/OIF
is S. 882, although it would, in fact, apply to all servicemembers of
the Armed Forces who are transitioning from DoD's health care system to
VA's.
S. 882 would require the Secretary, in consultation with the
Secretary of Defense, to establish and carry out a 5-year pilot grant
program to assess the feasibility and advisability of using eligible
entities to assist members of the Armed Forces in applying for, and
receiving, VA health care benefits and services after completion of
military service.
The mandated pilot grant program would focus on eligible entities
that provide assistance to members with serious wounds or injuries;
members with mental disorders; female members; and members of the
National Guard and the Reserves. Eligible entities would include non-
VA, non-DoD entities or organizations that possess, or which can
acquire, the capacity to provide the described transitional assistance.
The entities would provide the assistance through ``Veteran
Navigators,'' qualified individuals who would provide assistance to
members on an individual basis. The legislation would establish very
specific qualifications for, and responsibilities of, Veteran
Navigators.
S. 882 would require the Secretary to establish at least one pilot
site in the vicinity of a military treatment facility that treats
members of the Armed Forces who are seriously wounded or injured in
Afghanistan or Iraq, another in the vicinity of a rural VA medical
center, and one in the vicinity of an urban VA medical center. To add
additional sites, the Secretary would need to consult with the grant
application evaluation panel, which would be established by this
legislation.
Grants awarded under this pilot program could not exceed 3 years,
although a grant could be renewed for 1 year. Eligible entities seeking
grants would be required to submit a detailed application to the
Secretary, which addresses all of the specified information set forth
in the bill. A grant could not be awarded, however, to an eligible
entity that is receiving Federal funds for the same activities on the
date on which the eligible entity submits an application to VA, unless
the Secretary determines that the entity will use the grant authorized
under this bill to expand services or provide new services. The bill
would permit these grants to be used to recruit, assign, train, and
employ Veteran Navigators.
The grant application panel would be comprised of VA employees, DoD
employees, and representatives from both Veterans Service Organizations
and organizations that provide services to members of the Armed Forces.
It would evaluate all grant applications and make recommendations to
the Secretary. Finally, S. 882 would create reporting requirements for
both the grant recipients and the Department.
The measure would authorize $2 million to be appropriated to carry
out the program for fiscal year 2008; $5 million for fiscal year 2009;
$8 million for fiscal year 2010, $6.5 million for fiscal year 2011; and
$3.5 million for fiscal year 2012. Any amount authorized to be
appropriated would remain available for obligation through the end of
fiscal year 2012.
Mr. Chairman, VA does not support S. 882 because it is unnecessary
and duplicative of ongoing outreach services and seamless transition
efforts currently underway by VA and DoD. It would also duplicate
responsibilities of Veterans Service Organizations and State veterans'
offices and agencies.
S. 815--VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007
Mr. Chairman, we next address S. 815, a bill that would
significantly change the nature of the VA health care system. S. 815
would authorize veterans with a service-connected disability to obtain
their health care at VA-expense from any provider eligible to receive
payment under Medicare or TRICARE. This authority would cease after
September 30, 2009.
VA strongly opposes enactment of S. 815. We fully concur in the
views of several of the major VSOs, who recently wrote to the Chairman
of the Senate Committee on Veterans Affairs in opposition to S. 815.
(We will provide this letter to the Committee for the record.) At
bottom, S. 815 could lead to the undoing of the VA health-care system--
a world-class health care system--as we know it today. For this
fundamental reason, we must oppose this bill.
We also have other concerns. The proposal would fragment the care
of our veterans. VA would no longer have a complete record of all the
care a covered veteran has received. This could lead to VA duplicating
care already provided in the private sector or providing care that
conflicts with what the veteran is receiving in the private sector. As
you are aware, some in the private sector rely on paper records while
the VA uses a comprehensive electronic health record. Electronic
records promote patient safety. We are concerned that the bill, if
enacted, could jeopardize continuity of care for our patients. Last,
unlike the private sector, VA screens all returning combat-theater
veterans for TBI, PTSD, depression, and substance abuse.
S. 1146--RURAL VETERANS HEALTH CARE IMPROVEMENT ACT OF 2007
We now turn to S. 1146, which is intended to improve VA's ability
to meet the health care needs of rural veterans. Section 2 of this bill
would amend VA's beneficiary travel program by making VA pay or
reimburse eligible veterans at the same per diem rates and mileage
rates that apply to Federal employees using privately owned vehicles
for official travel. This section would also repeal existing deductible
requirements that apply to the receipt of VA beneficiary travel
benefits.
Section 3 would require the Secretary, through the Director of the
Office of Rural Health, to establish up to five Rural Health Research,
Education, and Clinical Centers of Excellence (``Centers''). The bill
sets forth detailed requirements that would govern the Secretary's
designation and placement of such Centers. It also would limit
designation of Centers to those facilities found by a peer review panel
to meet the highest competitive standards of scientific and clinical
merit and also found by the Secretary to have met the requirements
specified in the legislation.
Section 4 would require the Secretary to establish a grant program
for State Veterans' Service Agencies and Veterans Service Organizations
for purposes of providing veterans living in remote rural areas with
innovative means of travel to VA medical centers (and to assist them
with their other medical care needs). A grant awarded under this
section could not exceed $50,000. Grant recipients would not be
required to provide matching funds as a condition for receiving a
grant. This section would require the Secretary to prescribe
regulations to implement this program and also authorize to be
appropriated $3 million for each of FYs 2008 through 2012 to carry out
this program.
Section 5 would require the Secretary, through the Director of the
Office of Rural Health, to carry out demonstration projects to examine
alternatives for expanding care to veterans in rural areas. In so
doing, the Secretary would be required to establish partnerships with
the Department of Health and Human Services (HHS) to coordinate care
for veterans in rural areas at both critical access hospitals and
community health centers. VA would also be obliged to coordinate with
HHS' Indian Health Service to expand care for Native American veterans.
The bill would institute annual reporting requirements, the first
of which would have to include the results of the statutorily mandated
assessment of VA's fee-basis program on the delivery of care to
veterans residing in rural areas, along with the results of VA's
extensive outreach program to OEF/OIF veterans living in rural
veterans.
Mr. Chairman, in accordance with Congress' mandate in the
``Veterans Benefits, Health Care, and Information Technology Act of
2006,'' VA recently established the Office of Rural Health (ORH) within
the Veterans Health Administration. Part of that office's charge is to
determine how we can best continue to expand access to care for rural
veterans.
Indeed, VA has already done much to remove barriers to access to
care for enrolled veterans residing in rural areas and is continuing a
robust rural health program. Currently, over 92 percent of enrolled
veterans reside within one hour of a VA facility, and 98.5 percent of
all enrollees are within 90 minutes. Still, we continue our efforts to
try to ensure that all enrolled veterans living in rural areas have
adequate and timely access to VA care. We expect the data for this year
to be even better.
Community-Based Outpatient Clinics (CBOCs) have been the anchor for
VA's efforts to expand access to veterans in rural areas. CBOCs are
complemented by contracts in the community for physician specialty
services or referrals to local VA medical centers, depending on the
location of the CBOC and the availability of specialists in the area.
In addition, there are a number of rural outreach clinics that are
operated by a parent CBOC to meet the needs of rural veterans, and
several additional outpatient clinics are positioned to provide care
for veterans in surrounding rural communities. VA's authority to
contract for care under 38 U.S.C. Sec. 1703 provides a local VA Medical
Center director with another avenue through which to meet the needs of
many rural veterans.
These efforts have borne fruit. Rural veterans tell us that they
are satisfied with the services and high-quality care we are providing
to them. This is substantiated by their reporting even higher
satisfaction with VA services than their urban counterparts. Moreover,
performance measure data indicate that as a result of our intensive
efforts to expand services for rural veterans, veterans have access to
services much nearer to home. In 1996, VA users of mental health
services lived an average of 24 miles from the nearest VA clinic; as of
2006, they now live only 13.8 miles away. In addition, quality of care
in the rural environment matches that of urban care on 40 standard
measures.
Mr. Chairman, VA shares the Committee's concern for ensuring that
rural veterans have adequate access to needed health care and services.
However, for the aforementioned reasons, we do not support S. 1146 and
we recommend that no legislative action be taken in this area until VA
has had sufficient time to complete and review the internal assessments
currently underway by ORH and other Department components. We will of
course share ORH's findings and recommendations with the Committee. On
the changes proposed for beneficiary travel, we note that similar
provisions are found in S. 994. We therefore address these changes in
our comments on S. 994, below.
S. 1147--TERMINATION OF THE ADMINISTRATIVE FREEZE ON ENROLLMENT
OF VETERANS IN CATEGORY 8
Mr. Chairman, S. 1147 would require VA to enroll all eligible
veterans in Category 8. As you and the Subcommittee are well aware, VA
suspended the enrollment of new veterans in the lowest statutory
enrollment priority (priority category 8--veterans with higher incomes
and no compensable service-connected disabilities) in January of 2003.
This action was taken to protect the quality and improve the timeliness
of care provided to veterans in higher enrollment-priority categories.
VA strongly opposes enactment of S. 1147. In 1996, Congress enacted
Eligibility Reform legislation that allowed VA to provide comprehensive
care to veterans in the most appropriate treatment setting.
Additionally, in order to protect the traditional mission of VA (to
cover the health care needs of service-disabled and lower-income
veterans), that law originally defined seven priority levels (PL) of
veterans--PL 7 veterans (higher income and not service-disabled) were
the lowest priority. The law mandated that beginning in fiscal year
1999, VA use its enrollment decision to ensure that care to higher-
priority veterans was not jeopardized by the infusion of lower priority
veterans into the system for the first time. In FYs 1999 through 2002,
the VA Secretary determined in each year that all veterans were able to
enroll. Prior to 1999, PL 7 veterans' care was not funded in budgets,
but they could use the system on a space available basis. Consequently,
they were only about 2 percent of the annual users. In fiscal year
2001, 25 percent of enrollees and 21 percent of users were PL 7
veterans (using 9 percent of the resources). In 2001 PL 7 veterans were
split into two parts--those making above the geographic-specific HUD
threshold for means-tested benefits were moved to a new PL 8 category.
More than half of the 830,000 new enrollees in fiscal year 2002 were in
Priority Group 8 and VA was not able to provide service-connected and
lower income enrolled veterans with timely access to health care
services because of the unprecedented growth in the numbers of the
newly eligible category of users. When the appropriation was finally
enacted for fiscal year 2003, VA's Secretary made the decision that the
Department would not enroll any new PL 8 veterans--but those currently
in the system would retain their right to care. Every appropriation
since 2003 has supported this enrollment decision.
S. 1147 would essentially render meaningless the prioritized
enrollment system, leaving VA unable to manage enrollment in a manner
that ensures quality and access to veterans in higher priorities. VA
would have to add capacity and funding to absorb the additional
workload that this bill would entail, and so the quality and timeliness
of VA health care to all veterans, including service disabled and lower
income veterans, would unavoidably suffer until this capacity is added.
We note VA has authority to enroll combat-theater veterans
returning from OEF/OIF in VA's health care system and so they are
eligible to receive any needed medical care or services.
S. 994--DISABLED VETERANS FAIRNESS ACT
Like S. 1146, S. 994 would amend VA's beneficiary travel benefits
program by repealing the statutory deductible-requirements and
requiring the Secretary to reimburse all beneficiary travel benefits
and allowances at the same rates that apply to Federal employees.
Beneficiary travel benefits would be paid out of amounts appropriated
or otherwise made available to VA specifically for this purpose. S. 994
would provide that these changes apply to travel expenses incurred
after the 90-day period beginning on the date of enactment.
Although S. 994 would appear to prevent payment of beneficiary
travel allowances and payments from funds appropriated to VA for direct
patient care, we believe the cost of S. 994 would be utterly
prohibitive. The cost of this bill would be significantly increased
without the buffering effect of deductibles. As you know, deductibles
play an important cost-sharing function and help contain costs by
discouraging needless travel. Increased funding in the amount this bill
would require could be put to better use on the provision of direct
patient care to our veterans, particularly on our aging veterans and
new cohorts of OEF/OIF veterans. We are unique among health care
providers in that we already provide beneficiary travel benefits to
eligible veterans.
S. 692--VA HOSPITAL QUALITY REPORT CARD ACT OF 2007
Mr. Chairman, S. 692 would require VA to establish a Hospital
Quality Report Card Initiative to, among other things, help inform
patients and consumers about the quality of care in VA hospitals. Not
later than 18 months after the date of enactment, the Department would
be mandated to establish a hospital Quality Report Card Initiative.
Under the Initiative, the Secretary would be required to publish, at
least bi-annually, reports on the quality of VA's hospitals that
include quality-measures data that allow for an assessment of health
care effectiveness, safety, timeliness, efficiency, patient-
centeredness; and equity.
In collecting and reporting this data, the Secretary would have to
include very extensive and detailed information (i.e., staffing levels
of nurses and other health care professionals; rates of nosocomial
infections; volume of various procedures performed, hospital sanctions
and other violations; quality of care for specified patient
populations; the availability of emergency rooms, intensive care units,
maternity care, and specialty services; the quality of care in various
hospital settings, including inpatient, outpatient, emergency,
maternity, and intensive care unit settings; ongoing patient safety
initiatives; and, other measures determined appropriate by the
Secretary). However, VA would be allowed to make statistical
adjustments to the data to account for differences relating to
characteristics of the reporting hospital (e.g., size, geography, and
teaching status) and patient characteristics (e.g., health status,
severity of illness, and socioeconomic status). In the event VA makes
such adjustments, there would be a concomitant obligation to establish
procedures for making that data available to the public.
The bill would permit the Secretary to verify reported data to
ensure accuracy and validity. It would also require the Secretary to
disclose the entire methodology (for the reporting of the data) to all
relevant organizations and VA hospitals that are the subject of any
information prior to making such information available to the public.
Each report submitted under the Initiative would have to be
available in electronic format, presented in an understandable manner
to various populations, and presented in a manner that allows, as
appropriate, for a comparison of VA's hospital quality with local
hospitals or regional hospitals. The Department would also need to
establish procedures to make these reports available to the public,
upon request, in a non-electronic format (such as through a toll-free
telephone number).
In addition, S. 692 would require the Secretary to identify and
acknowledge the analytic methodologies and limitations on the data
sources used to develop and disseminate the comparative data and to
identify the appropriate and inappropriate uses of such data. The bill
would further mandate that, at least an annual basis, the Secretary
compare quality measures data submitted by each VA hospital with data
submitted in the prior year or years by the same hospital to identify
and report actions that would lead to false or artificial improvements
in the hospital's quality measurements.
This measure would further require the Secretary to develop and
implement effective safeguards to: protect against the unauthorized use
or disclosure of VA hospital data reported under this measure; protect
against the dissemination of inconsistent, incomplete, invalid,
inaccurate, or subjective VA hospital data; and ensure that
identifiable patient data is not released to the public. In addition,
the Secretary would need to evaluate and periodically report to
Congress on the effectiveness of this Initiative and its effectiveness
in meeting the purposes of this Act. And such reports would have to be
made available to the public. Finally, this legislation would direct
the Secretary to use the results of the evaluations to increase the
usefulness of this Initiative.
S. 692 would authorize to be appropriated to carry out this section
such sums as may be necessary for each of FYs 2008 through 2016.
Mr. Chairman, we do not support S. 692 because it is overly
prescriptive and largely duplicative of existing activities. As such,
we believe this legislation is unnecessary. Relevant information on VA
hospital quality is already available to the public through several
mechanisms, including our compliance with Executive Order 13410 that
requires transparency of quality measures in Federal health care
programs. (Because of our efforts in meeting the Executive Order, we
are way ahead of the private sector in making our health care system
and outcomes data transparent; there exist no bases for comparison with
the private sector.)
Information on the quality of VA hospital care is also available
from the Joint Commission on Accreditation for Healthcare Organizations
(JCAHO). JCAHO provides standardized comparative data in a form that
has been tested for consumer understandability and usefulness.
We believe the design of such a program, such as this, is best left
to industry experts, including VA. We further believe that highly
technical health care matters such as this are not well-suited to
detailed statutory mandates. For example, the proposed measures set
forth in the bill are less reliable, robust, and helpful than those
currently used by VA. Further, they are indicators of process, not of
patient outcomes. We would be pleased to meet with the Committee to
discuss how we comply with Executive Order 13410, identify the sources
of information currently available on the quality of VA hospitals, and
demonstrate how such information may be accessed.
S. 610--CLARIFICATION OF EFFECTIVE DATE OF SECTION 132 OF THE
DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PROGRAMS ENHANCEMENT ACT
(RELATING TO COMPUTATION OF RETIREMENT ANNUITY FOR CERTAIN HEALTH-CARE
PERSONNEL)
Mr. Chairman, another bill under consideration by the Committee is
S. 610, which would retroactively change retirement benefits to certain
VA health-care personnel. VA defers to the Office of Personnel
Management on this issue and notes that it is contrary to
Administration policy to make such changes retroactively.
s. 874--services to prevent veterans homelessness act of 2007
Mr. Chairman, I will next discuss S. 874, which is a measure
intended to prevent low income veterans transitioning to, or residing
in, permanent housing from falling back into their former homeless
condition. Subject to the availability of appropriations provided for
the bill's purpose, S. 874 would require the Secretary to provide
financial assistance in the form of per diem payments to eligible
entities to provide and coordinate the provision of supportive services
for very low-income veteran-families occupying permanent housing or
transitioning from homelessness to permanent housing.
S. 874 would establish the amount of per diem payment as the amount
of the daily cost of care estimated by the eligible entity. Yet, in no
case could that amount exceed the per diem rate that VA pays to State
homes for domiciliary care. The bill would permit the Secretary to
adjust the per diem rate by excluding from the entity's cost-estimate
any costs it incurs in furnishing services to homeless veterans for
which the entity already receives funding from another source (both
public and private). It would further require that such financial
assistance be equitably distributed across geographic regions,
including rural communities and tribal lands.
To receive such financial assistance, eligible entities would have
to submit an application including all of the detailed information
specified in the bill. It would also require the Secretary to consult
with the Secretaries of Housing and Urban Development and Health and
Human Services when selecting the recipients. S. 874 would also require
the Secretary to provide training and technical assistance to
participating entities on the planning, development, and provision of
supportive services. Such assistance could be provided either directly,
or through grants or contracts with appropriate public or nonprofit
private entities.
S. 874 would define ``supportive services'' to include, among other
things, outreach services, health care services, transportation,
educational services, assistance in obtaining income support, legal
assistance, fiduciary and representative services, and child care
services.
As to funding, the proposed law would make available out of the
amounts appropriated for medical care $15 million for fiscal year 2008,
$20 million for fiscal year 2009, and $25 million for fiscal year 2010.
Of these amounts, not more than $750,000 in any fiscal year could be
used to provide technical assistance.
Finally, this bill would require the Secretary to conduct a study
of the effectiveness of this program in meeting the needs of very low-
income veteran-families. As part of the study, the Secretary would have
to compare the results of this program with other VA programs dedicated
to the delivery of housing and services to veterans.
VA opposes S. 874 as currently configured. We understand there is a
high demand for supportive services for these vulnerable low-income
veterans and their families who are at risk of becoming homeless.
However, it is inappropriate to provide such assistance in the form of
per diem payments. We recommend that the bill be modified so that
financial assistance is furnished in the form of grants, similar to all
other Federal programs that provide financial assistance to entities
providing supportive services to homeless persons.
We also note other concerns with this legislation. First, the list
of supportive services should not include health care services because
this would be duplicative of those already furnished to homeless
veterans through VA and/or Medicaid. Second, the term ``habilitation
and rehabilitation services'' is not defined, and supportive services
provided under VA and other Federal programs for homeless persons
typically include referrals to legal services, not actual legal
services. Third, the application requirements are inadequate as they
fail to require the applicants to demonstrate the need for the services
they propose to provide. Fourth, because of the administrative costs
involved, it would be more efficient to disburse the very small amount
of funding available for technical assistance directly and apart from
the grant program. Fifth, the definition of ``private nonprofit
organization'' should not include for-profit partnerships, as it
presently does. Finally, the definition of veteran-family differs from
that used in the McKinney-Vento Homeless Assistance Act (42 U.S.C.
Sec. 11302).
S. 472--MAJOR MEDICAL FACILITY PROJECT FOR DENVER, COLORADO
Mr. Chairman, the last four bills on today's agenda relate to
construction and real property matters. The first of these is S. 472,
which would authorize the Secretary to carry out a major medical
facility project for a replacement facility for the Denver Veterans
Affairs Medical Center in an amount not to exceed $523,000,000. It
would also authorize the Secretary to obligate and expend any
unobligated amount in the ``Construction, Major Projects'' account to
purchase a site for, and for the construction of, that replacement
facility.
VA supports S. 472. Authorization in the amount of $98,000,000 was
provided for this project in P.L.109-461; however, additional
authorization in the amount of $548,000,000 is required to complete the
project, bringing it to the total of $646,000,000, which is consistent
with the President's budget submission request.
S. 1026--RENAMING OF VA MEDICAL CENTER IN AUGUSTA, GEORGIA
The second of these bills is S. 1026, which would designate the
Department of Veterans Affairs Medical Center in Augusta, Georgia as
the ``Charlie Norwood Department of Veterans Affairs Medical Center.''
Captain Norwood helped develop the military's Dental Corps while
serving in Vietnam. After his military service, he continued to provide
needed dental care to military personnel and dependents through his
private practice. Later, as a distinguished Congressman, he was key in
advancing the military's health and dental programs.
The Department defers to Congress in the naming of Federal
property.
S. 1043--USE OF LANDS AT VA WEST LOS ANGELES MEDICAL CENTER
S. 1043 would require the Secretary to submit a report on the
master plan relating to the use of Department lands at West Los Angeles
mandated by Public Law 105-369. Such report would have to include the
master plan, if it exists; a current assessment of the master plan; any
Departmental proposal for a veterans' park on such lands; any VA
proposal to use a portion of these lands as dedicated green space; and,
an assessment of any such proposal. In addition to establishing new
reporting requirements for the master plan, S. 1043 would require that
the master plan be completed before the adoption of the plan under the
Capital Asset Realignment for Enhanced Services (CARES) initiative.
VA shares the Committee's desire to have a short term and long term
strategy to address how we are to manage our capital assets and
operational needs for the care of more than 78,000 enrolled veterans in
the Los Angeles area. However, VA opposes S. 1043. As you are aware,
since the enactment of Public Law 105-368, VA has embarked upon the
CARES Business Plan Studies generally, and specifically the CARES
Business Plan Study (Study) of the West Los Angeles campus. In the
Study, options will be identified for use of any underutilized capital
assets, as well as modernizing the campus to provide care to veterans
now and in the future at the safest state-of-the-art facilities
possible. VA's contractor has completed the initial steps in preparing
planning options for public input through Local Advisory Panel (LAP)
public meeting sessions. The third LAP session is presently expected to
be held this summer and will be well advertised. The LAP sessions allow
for input from those on the reviewing panel, veterans, as well as the
community at large. All LAP and community input will be considered when
formulating final recommendations for the Secretary, as well as during
the Secretary's decisionmaking process. The development of the master
plan for the West Los Angeles campus must be done in conjunction with
this CARES study to ensure that operational needs are met into the
future. Indeed, the CARES study, with some refinement, is designed to
meet the requirement for a master plan as set forth in the Public Law.
We will continue to keep the Committees informed as the process
continues.
S. 1392--MAJOR MEDICAL FACILITY PROJECT PITTSBURGH, PENNSYLVANIA
S. 1392 would authorize an increased amount, $248,000,000 instead
of $189,205,000, for the consolidation of the Department's medical
facilities in Pittsburgh, Pennsylvania (at University Drive and H. John
Heinz III divisions). VA supports S. 1392, as the bill's increased
amount is consistent with the President's budget submission request.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to answer any questions you or any of the Members of the
Committee may have.
______
[Note: The following is a copy of the letter sent by major VSOs to
Senator Larry Craig regarding their views on S. 815.]
March 22, 2007.
Hon. Larry Craig,
Ranking Member, Comminee of Veterans' Affairs,
U.S. Senate, Hart Senate Office Building,
Washington, DC.
Dear Senator Craig: While we appreciate your concern about the need
for veterans' improved access to care in the Department of Veterans
Affairs (VA), your bill, S. 815, to provide health care benefits to
veterans with service-connected disabilities at virtually any private
medical facility, raises a number of concerns among our organizations.
We want to bring these concerns to your attention in hope that you
might reconsider the merits of your proposal.
As a general principle, we believe service-disabled veterans should
have the highest priority access to VA health care services, and that
those services should be of the highest quality. Service-connected
veterans generally have that level of access and quality in VA today,
but no doubt you will recall that early in the current Administration
then-Secretary Principi directed all VA field facilities to ensure that
service-connected veterans not be placed on waiting lists or refused
cure. In fact VA's current policy statement on this issue clearly
affirms this priority, as follows:
``VA is committed to providing priority care for non-emergent
outpatient medical services and inpatient hospital care for any
veteran seeking treatment of his or her service connected
disability. It is VA's policy to provide priority access to
outpatient medical care and elective inpatient hospital care
for any veteran who requires non-emergent care for a service
connected disability . . . For veterans who are 50 percent
service connected or higher, VA's policy is to provide priority
access to medical services and inpatient care, regardless if
treatment is needed for their service connected disability.''
With this policy in mind, it is difficult to comprehend your
rationale for establishing a precedent for the highest priority
veterans in the VA health care system to leave that system and seek
services elsewhere. Over the past year we have read as you did all the
accolades given to VA health care by independent observers,
newsweeklies and other publications. While we believe VA represents the
best available care, oversight is needed to provide an additional
guarantee that VA-provided services are of the highest quality for all
veterans who use VA, but especially for those with service-incurred
disabilities.
While your bill may be well intentioned, it raises a series of
potential unintended consequences, including a rekindled debate on so-
called ``Medicare subvention,'' a policy proposal that Congress and the
Administration have been unable to resolve in ten years, and diminution
of established quality, safety and continuity of VA care. It is
important to note that VA's specialized health care programs,
authorized by Congress and designed expressly to meet the needs of
combat wounded and ill veterans, such as the blind rehabilitation
centers, prosthetic and sensory aid programs, readjustment counseling,
poly-trauma and spinal cord injury centers, the centers for war-related
illnesses, and the national center for post-traumatic stress disorder,
as well as several others, would be irreparably affected by the loss of
service-connected veterans from those programs. The VA's medical and
prosthetic research program, designed to study and hopefully cure the
ills of disease and injury consequent to military service, would lose
focus and purpose were service-connected veterans no longer present in
VA health care. Additionally, Title 38, United States Code, section
1706(b)1 requires VA to maintain the capacity of these specialized
medical programs, and not let their capacity fall below that which
existed at the time when Public Law 104-262 was enacted.
We are also concerned about the financial implications of S. 815.
Previously you have expressed your concern over the increasing costs
for veterans' health care. Yet, your proposal would seem to move VA in
this very direction--toward higher costs. The escalating costs of
health care in the private sector are well documented. To its credit VA
has done an excellent job of holding down costs by effectively managing
its in-house health programs and services for veterans. While as a
consequence of enactment of your bill some service-connected veterans
might seek care in the private sector as a matter of personal
convenience, they would lose the many safeguards built into the VA
system through its patient safety program, evidence-based medicine,
electronic medical records and medication verification program. These
unique VA features culminate in the highest quality care available,
public or private. Loss of these safeguards, that are generally not
available in the private sector systems, would equate to diminished
oversight and coordination of care, and ultimately may result in lower
quality of care for those who deserve it most.
An additional possible consequence of your bill, if enacted, would
be to most likely shift care for service-connected veterans from
discretionary to mandatory spending. While we are devoted to proposals
that Congress move VA health accounts into the mandatory funding arena,
we question whether this would be your intent as well. The undersigned
organizations could not support a bill that would move VA from a
primary provider of health care to an insurer, even if funding for that
function were made mandatory.
We believe that mixing complex chronically-ill service-disabled
veterans with other veterans in VA care creates a needed critical mass
and properly balanced case mix. A diverse case mix with the variety of
acute and chronic clinical patients that motivates excellence in the
academic health center environments cements solid relations beteeen
those tertiary VA facilities and their health professions schools--
another guarantor of quality of care.
We know, as the former Chairman, you would not want to bear witness
to deterioration in quality of care or in availability of services in
the VA for service-disabled veterans as a result of your bill.
Therefore, we question the wisdom of S. 815 and ask that you consider
withdrawing this ill-advised legislation.
Sincerely,
Kimo Hollingsworth,
National Legistative Director,
AMVETS (American Veterans).
Dennis Cullinan,
Legistative Director,
Veterans of Foreign Wars
of the United States.
Joseph A. Violante,
National Legistative Director,
Disabled American Veterans.
Thomas Zampieri,
Director of Governmental Relations,
Blinded Veterans Association.
Herb Rosenbleeth,
National Executive Director,
Jewish War Veterans of the USA.
Hershel Gober,
National Executive Director,
Military Order of the Purple Heart
of the USA, Inc.
Carl Blake,
Legistative Director,
Paralyzed Veterans of America.
Richard F. Weidman,
Director of Government Relations,
Vietnam Veterans of America, Inc.
cc: Chairman Daniel Akaka, Commitee on Veterans' Affairs.
______
Response to Additional Information Requested
by Committee Members During the Hearing
Question 1. Regarding the President's New Freedom Commission on
Mental Health, please provide a list of recommendations and the status
for each one on whether or not it has been implemented.
Response: Please see the attached document providing a list,
description, and status of the requirements of the President's New
Freedom Commission on Mental Health and VHA's Mental Health Strategic
Plan.
Here is a glossary for acronyms used.
AASC = Action Agenda Steering Committee
ADA = Americans with Disabilities Act
CARES = Capital Asset Realignment for Enhanced Services
CBOC = Community Based Outpatient Clinic
CME = Continuing Medical Education
CMO = Chief Medical Officer
CPG = Clinical Practice Guidelines
CPRS = Computerized Patient Record System
CWT = Compensated Work Therapy
CWT/TR = Compensated Work Therapy/Transitional Residence
DOD = Department of Defense
DOL = Department of Labor
DOM = Domiciliary Unit
ECF = Executive Career Field
EES = Employee Education System
ELDA = Enrollment-Level Decision Analysis
EPRP = External Peer Review Program
FE = Family Education
FPE = Family Psycho-Education
FPE/FE = Family Psycho-Education/Family Education
G&PD = Grant and Per Diem
GEC = Geriatrics and Extended Care
HACU = Hispanic Association of Colleges and Universities
HBCU = Historically Black Colleges and Universities
HCS = Health Care System
HEDIS = Health Plan Employer Data and Information Set
HHS = Department of Health and Human Services
HPDM = High Performance Development Model
HR = Human Resources
HRSA = Health Resources and Services Administration
HSR&D = Health Services Research and Development
HUD = Department of Housing and Urban Development
IDMC = Informatics and Data Management Committee
IHS = Indian Health Service
IOM = Institute of Medicine
IT = Information Technology
LT = Long Term
MAP = Medical Advisory Panel
MD = Medical Doctor
MEB = Mental Evaluation Board
MHICM = Mental Health Intensive Case Management Program
MHSHG = Mental Health Strategic Healthcare Group
MHSP = Mental Health Strategic Plan
MHSPWG = Mental Health Strategic Planning Workgroup
MICA = Mental Illness and Chemical Abuse
MIRECC = Mental Illness Research, Education, and Clinical
Center
MOU = Memorandum of Understanding
MST = Military Sexual Trauma
MTF = Military Treatment Facility
NAMI = National Alliance on Mental Illness
NCPTSD = National Center for Post Traumatic Stress Disorder
NEPEC = Northeast Program Evaluation Center
NIMH = National Institute of Mental Health
OAA = Office of Academic Affiliations
OAT = Opiate Agonist Treatment
OCC = Office of Care Coordination
OEF = Operation Enduring Freedom (Afghanistan)
OIF = Operation Iraqi Freedom
OQP = Office of Quality and Performance
ORD = Office of Research and Development
PCS = Patient Care Services
PDHRA = Post-Deployment Health Reassessment
PEB = Physical Evaluation Board
PRRTP = Psycho-social Residential Rehabilitation Treatment
Program
PSR = Psycho-social Rehabilitation
PTSD = Post Traumatic Stress Disorder
QMO = Quality Management Officer
QUERI = Quality Enhancement Research Initiative
RCS = Readjustment Counseling Service (Vet Centers)
RFP = Request for Proposals
SA = Substance Abuse
SAMHSA = Substance Abuse and Mental Health Services
Administration
SARRTP = Substance Abuse Residential Rehabilitation
Treatment Program
SHG = Strategic Healthcare Group
SMI = Serious Mental Illness
SMITREC = Serious Mental Illness Treatment, Research, and
Evaluation Center
STRAF = Special Therapeutics Rehabilitation Activities Fund
TIDES = Translating Initiative for Depression into Effective
Solutions
USB = Under Secretary for Benefits
USH = Under Secretary for Health
VACO = Veterans Affairs Central Office
VAMC = VA Medical Center
VAPAHCS = VA Palo Alto Health Care System
VARO = VA Regional Office
VASH = VA Supported Housing
VBA = Veterans Benefits Administration
VCT = Veterans Construction Team
VHA = Veterans Health Administration
VISN = Veterans Integrated Service Network
WMHC = Women's Mental Health Coordinator
WRAMC = Walter Reed Army Medical Center
[The Comprehensive VHA Mental Health Strategic Plan follows:]
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Question 2. Please provide a listing of Community Based Outpatient
Clinics (CBOCs) and outreach clinics that will be opening. What is the
status of the Secretary's decision on the proposed list?
Response: The only approved Outreach Clinic not yet activated is in
Craig, CO. The following locations were approved by the Secretary for a
Community Based Outpatient Clinic (CBOC) in FY 2007:
------------------------------------------------------------------------
------------------------------------------------------------------------
Morgantown (Monongalia County), WV Dover, DE
Norfolk, VA Childersburg, AL
Stockbridge, GA Bessemer, AL
Morristown (Hamblen County), TN Hamilton, OH
Daviess County, KY Conroe, TX
NW Tucson, AZ Metro East, OR
Canyon County, ID Central Washington, WA
American Samoa, HI Fallon, NV
South Orange County, CA Bellevue, NE
Carroll, IA Cedar Rapids, IA
Marshalltown, IA Shenandoah, IA
Wagner, SD Watertown, SD
Bemidji, MN Holdrege, NE
Spirit Lake, IA Western Wisconsin, WI
------------------------------------------------------------------------
The following three locations were opened in FY 2007: Conroe, TX;
NE Bexar County, TX; and Williston (Outreach Clinic), ND.
The following locations have been approved for a CBOC in FY 2008:
------------------------------------------------------------------------
------------------------------------------------------------------------
Southern Prince George County (Andrews Charlottesville, VA
AFB), MD
Hickory, NC Lynchburg, VA
Franklin, NC Hamlet, NC
Aiken, SC Spartanburg, SC
Eastern Puerto Rico (Fajardo), PR Putnam County, FL
Camden County, GA Jackson County, FL
Hawkins/Sullivan County/Bristol, TN Berea, KY
Madison County, TN Grayson County, KY
Morehead City, KY Perry County/Hazard, KY
Parma, OH Clare County, MI
Elkhart County, IN Alpena County, MI
Knox County, IN Hutchinson, KS
Jefferson City, MO Eglin AFB, FL
Pine Bluff, AR Branson, MO
SE Tucson, AZ Globe/Miami, AZ
Thunderbird (North Central Maricopa West Salt Lake Valley City,
County), AZ UT
Cut Bank, MT Lewiston, MT
North Idaho, ID Metro West, OR
Bellingham Area (Whatcom County/
NW Washington (Skagit County), WA
------------------------------------------------------------------------
RESUMPTION OF PRIORITY 8 ENROLLMENT
Message. Reopening Priority 8 enrollment would require a
significant increase in budgetary requirements. In addition, VA has
serious concerns that this additional demand will strain VA's capacity
to provide timely, quality care for all enrolled veterans and lead to
longer waits for care.
Key points
The Veterans' Health Care Eligibility Reform Act of 1996
opened VA's health care system to all veterans and provided a uniform
medical benefits package of health care services to all enrollees.
The legislation also established a priority-based
enrollment system, and each year, the VA Secretary is required to
assess veteran demand and determine if resources are available to
provide timely, quality care to all enrollees.
Since Eligibility Reform, veteran demand for VA health
care has escalated and the actuarial model predicts continued growth in
demand. In FY 2002, this escalating demand led to waiting lists for
care.
As a result, VA suspended enrollment in Priority 8 on
January 17, 2003, to focus on those veterans who need VA most--those
with service-connected disabilities, those with low income, and
veterans with special health care needs.
Question 3. How much additional funding would VA need to resume
Priority 8 enrollment?
Response. Reopening Priority 8 enrollment in FY 2008 is estimated
to increase enrollment in Priority 8 by approximately 1.6 million and
require an increase in budgetary requirements of $1.7 billion. VA has
serious concerns that this additional demand will strain VA's capacity
to provide timely, quality care for all enrolled veterans and lead to
longer waits for care. VA must also consider the impact of this policy
in future years. In 2017, this policy would increase Priority 8
enrollment by an estimated 2.4 million and would require $4.8 billion
in budgetary requirements. Over the next 10 years, resumption of
Priority 8 enrollment would require $33.3 billion in budgetary
requirements.
Question 4. VA estimated that $1.7 billion is needed to resume
Priority 8 enrollment. How did VA calculate this estimate?
Response. The VA Enrollee Health Care Projection Model (Model) is
extremely robust. Data used in developing the Model includes VHA's
survey of 42,000 enrolled veterans, utilization and cost information
from VA data systems, Medicare utilization information for enrolled
veterans, a detailed analysis of enrollee reliance on VA health care,
and information from the Census 2000 long form which enables VA to
assign veterans into the income-based priorities (Priorities 5, 7 and
8). The Model is built from the bottom up which determines the expected
veteran demand for health care and is used to lay the foundation for
developing resource requirements.
One of the Model's features is its capability to project future VHA
enrollment under a variety of policy scenarios, including the
resumption of enrollment. The rates at which veterans are expected to
enroll are calculated at a very detailed level. The Model has over
13,000 enrollment rate factors which consider veterans priority level,
age and geographic location.
The Model tracks Priority 8 veterans who have applied for
enrollment but were denied. The Model presumes that those veterans who
have been denied eligibility to enroll will be very likely to enroll in
the future if their eligibility status changes and VA resumes
enrollment of Priority 8 veterans.
Reopening Priority 8 enrollment in FY 2008 is estimated to increase
enrollment in Priority 8 by approximately 1.6 million enrollees and
require an increase in budgetary requirements of $1.7 billion.
Priority 8 Veterans--Talking Points
The Veterans' Health Care Eligibility Reform Act of 1996
opened VA's health care system to all veterans and provided a uniform
medical benefits package of health care services to all enrollees.
The legislation also established a priority-based
enrollment system, and each year, the VA Secretary is required to
assess veteran demand and determine if resources are available to
provide timely, quality care to all enrollees.
Priority 8 veterans and eligibility--Veterans who agree to
pay specified copay with income and/or net worth above VA Means Test
threshold and the Geographic Means Test Threshold.
Since Eligibility Reform, veteran demand for VA health
care has escalated and the actuarial model predicts continued growth in
demand. In FY 2002, this escalating demand led to waiting lists for
care.
As a result, VA suspended enrollment in Priority 8 on
January 17, 2003, to focus on those veterans who need VA most--those
with service-connected disabilities, those with low income, and
veterans with special health care needs.
Reopening Priority 8 enrollment in FY 2008 is estimated to
increase enrollment in Priority 8 by approximately 1.6 million and
require an increase in budgetary requirements of $1.7 billion.
VA has serious concerns that this additional demand will
strain VA's capacity to provide timely, quality care for all enrolled
veterans and lead to longer waits for care.
VA must also consider the impact of this policy in future
years.
In 2017, this policy would increase Priority 8 enrollment
by an estimated 2.4 million and would require $4.8 billion in budgetary
requirements.
Over the next 10 years, resumption of Priority 8
enrollment would require $33.3 billion in budgetary requirements.
Question 5. Please provide written clarification on eligibility for
National Guard members and Reservists.
Response: Reservists and National Guard members activated for
Federal service who completed the period for which they were called to
active duty qualify for VA health care, but generally must be enrolled
to receive services, just like any other veteran.
Reservists and National Guard members who served on active duty in
a theater of combat operations during a period of war after the Gulf
War or in combat against a hostile force after November 11, 1998, are
eligible for enrollment in Priority Group 6 unless otherwise eligible
for enrollment in a higher priority group. All Reservists and National
Guard members are eligible for free health care services for conditions
potentially connected to combat service for 2 years following
separation from active duty.
Veterans who enroll with VA under this authority will retain
enrollment eligibility even after their 2-year post discharge period
ends under current enrollment policies. At the end of that 2-year
period, VA reassesses the veteran's information (including all
applicable eligibility factors) and makes a new enrollment decision. If
the veteran was in Priority Group 6 and no other eligibility factors
apply, the veteran will continue enrollment in either Priority Group 7
or Priority Group 8, depending on income level, and will be required to
make applicable copayments.
Note: For veterans who do not enroll during the 2-year post-
discharge period, eligibility for enrollment and subsequent care is
based on other factors, including a compensable service-connected
disability, VA pension status, catastrophic disability determination,
or the veteran's financial circumstances. Combat veterans are strongly
encouraged to apply for enrollment within 2 years of release from
active duty to take advantage of the special eligibility conditions for
combat veterans, even if no medical care is currently needed.
Additional information for VA health care benefits is available at:
http://www.va.gov/healtheligibility/, http://www1.va.gov/environagents/
docs/SVABENEFITS.pdf, and http://www.seamlesstransition.va.gov/res--
guard.asp.
Chairman Akaka. Thank you very much for your testimony, Dr.
Cross.
Before I ask any questions, I call on Senator Brown for any
comments.
Senator Brown. I have no opening remarks.
Chairman Akaka. Thank you, Senator Brown.
Dr. Cross, I am delighted that this Administration is now
supporting the idea of extending the window for easy access to
care for separating servicemembers from two to 5 years. Can you
please elaborate on how you see the extension of this window
enabling VA to better serve younger veterans, especially those
with mental health issues?
Dr. Cross. Yes, sir, I can. By extending this time period,
sir, we will be able to provide with very little enrollment
issues access to care for all the combat veterans that are
returning to us for a period of 5 years. I think your concern
and our concern was that sometimes the need for care, the
symptoms, particularly perhaps related to PTSD, may not show up
within that time period. The individual may not feel the need
to come see us.
This would extend that time period to make sure that if
those symptoms arise, we have an easy mechanism automatically
allowing them access to care without copays for anything
related to their combat service. We think that this is a
positive thing to do and we will work with you to support that.
Chairman Akaka. Thank you. Dr. Cross and Mr. Hall, I note
that VA has offered no legislative proposals concerning
veterans' health care. Am I to infer that there is nothing the
Administration needs from Congress? I believe Congress has
valuable input to offer and that we serve veterans best by
working together, and I just wanted to mention the lack of by
request legislation from VA. We look forward to, of course,
working together with you to help the veterans.
Dr. Cross, the Administration has chosen not to prepare
official views on our TBI legislation introduced nearly one
month ago. I am sure you would agree that enhancements can be
made to the care received by veterans with TBI. What more do
you think can be done on TBI care to improve services to
veterans who suffer with this injury? Are you willing to work
with us on improving VA TBI health care?
Dr. Cross. Senator, I would like to answer that absolutely
yes. Of course, we are willing, and if I have a moment, sir,
can I tell you where we are with TBI? We started TBI centers
back in 1992 and we developed four of them. We have expanded
them now to encompass polytrauma because of the nature of the
injuries that we are seeing coming back from OIF and OEF.
Congress has been very much involved with us in that. We want
to continue that
participation.
We added on the OIF/OEF screen so that everyone that we see
gets screened for TBI. We are screening everyone who comes in
to see us for PTSD. We are screening everyone for depression.
We are screening everyone for substance abuse. And I think that
is the advantage of our integrated health care system, that we
can do these kinds of things comprehensively, that we can, with
our electronic health record, we can institute these types of
screens so that we look for these conditions and when we
identify them, help get those individuals into the kind of care
they need.
We are multi-disciplinary and we are working on new
programs, such as the emerging consciousness program that I
just mentioned, for individuals who were severely affected, who
are in basically a non-responsive state to help them, shall we
say, wake up. Our research, I think, will lead the way for the
Nation in understanding these conditions. And so, yes, sir, we
are very proud to work with you on any of these issues.
Chairman Akaka. Mr. Hall, I note that with regard to the
legislation that would lift the ban on enrollment of Priority 8
veterans, you mentioned that enacting this measure would
threaten VA's ability to manage the priority system set forth
in law. Would your concerns be addressed if we were merely to
suspend the current prohibition for one year to test the impact
it would have on the system in light of all the substantial
funding increases VA is
slated for?
Mr. Hall. Mr. Chairman, one of our concerns is that lifting
the ban is going to create stress on our current
infrastructure. There is going to be a significant delay in
being able to provide all the services we would need to care
for the veterans we are currently seeing, the new veterans
coming back from OEF/OIF, particularly if S. 383 were enacted
with the 5-year extension, as well as the new veterans that
would be eligible if the ban were lifted. If we had the money,
it would take a while to build the infrastructure up enough to
provide care to all those folks.
Chairman Akaka. Thank you very much for your response.
Senator Craig?
STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER,
U.S. SENATOR FROM IDAHO
Senator Craig. Thank you very much, Mr. Chairman.
Thank you for holding this hearing and looking at all of
these important pieces of legislation.
Let me focus--and let me ask unanimous consent that my full
statement be a part of the record.
Chairman Akaka. It will be included in the record.
[The prepared statement of Senator Craig follows:]
Prepared Statement of Hon. Larry E. Craig, Ranking Member,
U.S. Senator from Idaho
Thank you, Mr. Chairman, for holding this hearing and good morning
ladies and gentlemen.
Mr. Chairman, as you know, I have two bills on the agenda that I've
introduced and one that I am very proud to have introduced along with
you. Of course, I think our legislation on caring for veterans with
Traumatic Brain Injuries is an important, bipartisan effort.
I know everyone on this Committee shares our concern about the
immediate, acute care needs of those veterans suffering with TBI as
well as the long-term implications of living with a traumatic brain
injury. With this bill, Mr. Chairman, I think we are attempting to
address many of those concerns as well as focus on the need to do more
research on traumatic brain injury. Unfortunately, the fact remains
that medically there is so much we don't know about TBI. I hope we can
advance this bill quickly.
As I mentioned earlier, I also have two other bills on the agenda:
S. 815, the Health Care Empowerment Act and S. 1441, a bill to
modernize our successful State Veterans Home program.
First, Mr. Chairman, I am sure you have seen CBO's preliminary cost
estimate of S. 815. Needless to say, it came in much higher than I had
expected. I want to assure my colleagues that I am still a fiscally
conservative Senator.
With that said, I still believe we must consider some way to ensure
that those who receive care at VA have confidence in that care. And if
they don't have confidence, we should consider some recourse for them.
Frankly, I have been heartened by the reaction S. 815 has received.
I have gotten numerous letters and e-mails supporting the legislation.
And, of course, a few witnesses, including those today, have offered
positive comments as well as some thoughts on changes that should be
considered.
I intend to review all of those thoughts and others while I work to
address the scope and cost of this bill before ever asking for a vote
on it.
Finally, Mr. Chairman, I'd like to say a word about the state home
bill I've just introduced. I recognize that few people have had a
chance to review it. As such, I anticipate receiving more comments in
the future on the legislation.
What's important to me, Mr. Chairman, is the goal of the bill. That
is--to transition the state home program from one focused heavily on
beds to one that also offers the options of home and community-based
care.
I hope none of you see this bill as a shot of disapproval aimed at
the state homes. It is nothing of the sort. Rather, it simply reflects
my view that this program needs to have a more forward-looking, family
oriented approach to long-term care.
At the current rate of Congressional funding, it will take us 9
more years to fund all of the new construction on VA's list today. That
doesn't include any new applications that will come in. I fear that if
we don't begin to transition to a more non-institutional approach to
care, we may find ourselves 15 years from now, staring at 30,000 state
home beds wondering what to do with half of them.
There's an old saying that goes ``when all you have is a hammer,
the whole world looks like nails.'' I fear that if the state homes only
have beds, then beds will be the way we care for aging veterans.
I believe we should begin to establish non-institutional care
programs to complement the current institutional program. In this way,
we will be able to offer veterans a less restrictive alternative long-
term care setting while supporting the idea of aging gracefully in the
home with one's family.
I hope my colleagues, VA, VSOs, and the States, are willing to work
with me on this legislation. I welcome all suggestions and, of course,
support.
With that, Mr. Chairman, thank you again for holding this hearing.
I look forward to receiving the testimony of our witnesses.
Senator Craig. Thank you, Mr. Chairman. Let me focus on one
bill that I have introduced for a variety of reasons and that I
think testimony over the last several months has proven has
some significant value, but obviously cost-wise is prohibitive.
I don't want anybody on this Committee to feel I have lost my
conservative feelings by introducing a bill that scores at $38
billion over two years.
But it was to dramatize a concern that I have heard
constantly expressed, and since the introduction of the bill
more loudly expressed by some veterans, that there are services
that VA can't provide. And, in fact, we have heard it here,
whether it is certain types of prosthetics, whether it is
certain types of concerns about brain damage or mental
problems. There is a private sector out there that in some
areas is leading VA as it relates to certain types of care.
But there seems to be an attitude that, in some instances,
if VA doesn't provide it, the veteran can't have it, and that
was where I drew a line. If we are concerned about providing
care to veterans, and I think we are, and I think VA does a
wonderful job; I don't need to sing its praises--I do 24/7, and
appropriately so. But I must tell you that in looking at some
of your comments, I must say, Dr. Cross, I understand the
Administration strongly opposes S. 815 and I appreciate some of
your reasons. However, I am a little troubled by the tone of
the statement which suggests that if VA offers care, then
veterans should take what they offer.
If veterans lose faith in care provided by VA, doesn't it
concern you that VA's position is essentially that the veteran
should be stuck with VA? Now, being stuck with a first-class
health care system ain't all bad. But where health care isn't
being provided in a New World and you are rushing to catch up
with it, it is kind of like, stand in line and wait until we
get good at it because you are only going to get it from us.
And that was the intent of S. 815. I will fine-tune this a
little bit. In fact, I would suggest that the Chairman's bill
of, which I am a cosponsor, S. 1233, moves us in that
direction. And so I would like your views and comments on this
type of an approach of non-VA-delivered care as it is reflected
in S. 1233. I would like your comments on that.
Dr. Cross. Sir, may I start with S. 815?
Senator Craig. Sure.
Dr. Cross. We are working with--we want to work with you
and Congress to make sure that we remain the veterans' first
choice, the veterans' first choice for care----
Senator Craig. And I don't disagree with that.
Dr. Cross [continuing].--just as we believe we are now.
What we are concerned about is something that is very serious
to me as a physician and this is fragmentation of care. To
promote individuals going out into other systems, whereas we
have a comprehensive, integrated system with a unique fully
integrated information system so that we have a complete
picture of that individual, that causes us some concerns when
that happens, that fragmentation, so that one system doesn't
necessarily know what the other is doing. That system doesn't
have electronic records, perhaps, in the private environment,
and so that we don't have access to what they are doing and
perhaps they don't have access to what we are doing with a
veteran.
The cost, of course, is an issue, and you have already
addressed that.
Senator Craig. Sure.
Dr. Cross. But I want to say this on the positive side. We
are spending about $3 billion per year already to identify and
care for individuals when they need something that we can't
provide in-house. We are very much attuned to that. But we want
to do it on a case-by-case basis. But I want to point out that
we are already spending about $3 billion in this effort, not an
insignificant amount, to make sure that when those cases arise,
that we will reach out to the community and provide the care if
there is something that the veteran needs that we don't offer.
And I want to emphasize again, comprehensive care,
continuity of care, but we provide the care over the lifetime
of the individual. We want to build that record for the
lifetime care of the individual. And when you put this total
package together, having the integrated system that we have, I
think is what becomes so valuable to the individual.
But yes, sir, we do recognize that there are cases that we
can't fully care for and we are quite willing, case by case, to
spend the money and do what is necessary to care for them.
Senator Craig. Well, I am trying to comprehend, Doctor, the
extend of your comments in relation to safeguarding and
protecting a health care system. You seem to be worried about
fragmentation. You seem to be worried about continuity. I
focus, and this is going to sound critical--I am worried about
an individual veteran who cannot get the service from the
system. I am not worried about fragmentation at that point and
I am sure in the heck not worried about continuity.
I am worried that veteran getting the state-of-the-art in
prosthetics, state-of-the-art in mental care and brain damage
treatment when we know there are facilities outside of the VA
that are ahead simply because they have been dealing with the
civilian sector, and now we have got a new kind of veteran
patient coming in that is a product of this war that you have
not dealt with in the past that is now being thrust upon you.
And you are running to catch up, and we are going to fund you
to the tune of billions to catch up. But in the meantime, are
they going to stand in line and wait?
I guess that is my concern. I am not worried about
fragmentation at that point and I am certainly not worried
about continuity. Those are all going to happen, because in the
broad sense, in the broad sense, VA will remain the health care
provider of first choice to all veterans.
Dr. Cross. Sir, I understand your concerns. I wanted to
emphasize, we didn't start treating TBI when the war started.
We started our centers about 15 years ago and we were treating,
of course, TBI before that. We started special centers for them
about in 1991, 1992. We looked at our outcomes. We looked at
our quality. We measured that. We are very finely attuned to
that. I think as an organizational characteristic, we do more
in the way of quality and performance measures than anybody I
am aware of. We have no intent to provide anything except the
best treatment possible for the individual, and if we can't,
case by case, we will send them elsewhere.
Senator Craig. Thank you. My time is up. Mr. Chairman, I
guess I would say that my legislation, I hope, has provoked a
reasonable and appropriate debate, as it should, because I know
that Senator Murray and I have had discussions about the best
and the highest of quality and making sure that it is out
there, and I am not always convinced that just adding money
into a current system that isn't prepared and can't handle it
at the time is the way you get there when, in fact, there is a
private system that can deliver it.
And I know that I tread on sacred ground when I talk about
any fragmentation whatsoever when it comes to VA health care.
But frankly, at this point, I don't care. I am caring about the
veteran and I am going to continue to reflect that. I look
forward to working with the Administration and certainly with
VA to see where we can do those kinds of things and find
alternative care when necessary and appropriate.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you, Senator Craig.
Senator Murray?
Senator Murray. Thank you very much, Mr. Chairman.
Dr. Cross, I wanted to ask you, when our veterans sign up
for military service, they take an unqualified oath to serve
our country and defend the Constitution, and in return for that
service and their commitment, they are promised that they are
going to receive all necessary veterans' health care when they
come home. There weren't any asterisks on the paper they
signed. There wasn't any small print that I am aware of that
they wouldn't be eligible if their income reaches a certain
level. So I wanted to ask you, if our promise to those who sign
up when they serve is not restricted, why is it right to
restrict benefits for some veterans?
Dr. Cross. Thank you, Senator. I understand your concern
and I think you are, of course, referring to the Priority 8s--
--
Senator Murray. Correct.
Dr. Cross [continuing].--and you are referring to S. 1147,
as well. We understand. Our focus was at the time on commitment
to quality and continues to be, and our focus has been and
continues to be on commitment to access. We wanted to put our
priorities to make sure that those who were injured, who have
some residual from their experience and service connection,
some injury, some illness, we wanted to make sure that within
our system, that we devoted the assets necessary to take care
of them, and that is what we did.
Senator Murray. Well, it seems to me that you had a choice
at the time. The VA recognized that they were hitting a backlog
of people and didn't have the resources to deal with it. So
rather than coming to Congress and telling us that we needed to
keep a promise to our veterans and in order to do that, we
needed additional dollars, you decided that you were going to
change the system so that by whatever income you had, that you
would be denied
service.
I believe you should have come and told us, we need
additional dollars, because as I just told you, when you sign
up, there is no asterisk. There is no fine little line that
says if you get a certain level--and in fact, as you know, some
veterans who make less than $27,000 a year are denied service.
Do you think that is high
income?
Dr. Cross. I don't consider that to be high income, but I
understand the threshold varies depending on marital status and
the number of children.
I would like to add two understandings to this that we can
discuss for a bit. It is not really a matter of money. It is a
matter of capacity, the physical facility, the staffing. All of
those things would have to be modified to some degree. It would
take time to do that. And so I wanted to emphasize it is not
just simply a matter of money.
Secondly, we are, in fact, expanding the Priority 8
enrollment through our eligibility under our 2-year provision,
and if Congress passes it, the 5-year provision, because here
is how it works. It is our policy that once a combat veteran
returns and enters our system in the 2-year eligibility period,
even though that person would ultimately be classified as a
Priority 8, he does not lose his enrollment. He can stay with
us permanently.
Senator Murray. Well, let me ask you about that, but first,
let me go back and comment that I still believe that what the
VA should have done is come and said to us, we don't have
enough resources. We need to serve those who have signed up and
we give a promise rather than making an eligibility based on
income that they never signed up for.
But on that 2-year that you are now referring to, you have
the authority to enroll our Iraq and Afghani combat veterans,
but that applies only to active duty. For our National Guard
and Reserves, it is my understanding that under the current
policy, if you are active duty, you are eligible. If you are in
Guard and Reserve, you are not. Is that correct?
Dr. Cross. Senator, I don't believe so. I think--I will ask
Walt to support me on this, but I think that is incorrect.
Senator Murray. I am told time and time again by our Guard
and Reserve members who sit on the ground in Iraq doing the
same thing as active duty that it only applies to active duty.
Mr. Hall. I can confirm that, but I don't believe that is
correct, ma'am.
Senator Murray. OK. I would like to get a written response
from you on that. We need some clarification.
Senator Sanders. Would the gentle lady yield for that?
Senator Murray. Well----
Senator Sanders. I am sorry.
Senator Murray. I want to ask one more question and I will
let you get back to that on your time, because I did want to
ask about the Gulf War study really quickly in my time
remaining. Two recent studies--one was conducted by the DOD,
one by VA and Boston University--told us that long-term brain
damage among troops exposed to nerve agents from the bombing of
an arms depot in Iraq in March 1991 caused significant brain
damage. This is overwhelming, Mr. Chairman. This says that over
100,000 men and women were exposed to sarin gas in the Gulf
War, to the so-called Gulf War syndrome, actually had brain
damage that is caused to them.
I wrote to you along with Senators Bond and Rockefeller
asking you how the VA is going to notify these Gulf War
veterans, many of them wondering for the last 14 years why they
are so ill and what is wrong with them and how we were going to
do better research and affect that. You have responded to me
and basically the answer was, we are going to study this issue.
Well, I can tell you as the daughter of someone with
multiple sclerosis, a World War II veteran, you are told
constantly, well, it is going to take another study. So I would
like you to inform us what the VA is going to do.
Dr. Cross. Well, first of all, I would like to point out
our role in the study, since we sponsored it. This was a
proactive thing that the VA has done time and again and
continues to do research to look at these questions, and I
think no other organization is doing more of that toward the
rest of these issues.
I have read the study. My staff are continuing to evaluate
it. I regret to use that phrase, but yes, we are continuing to
study it. I noticed----
Senator Murray. I just have to tell you the frustration,
because many of those Gulf War veterans came home. They were
told, oh, it is all in your head. You are making it up. They
have lived with that. They have struggled with this for a long
time and now there is a study with a direct link.
Dr. Cross. Yes.
Senator Murray. And I think it is imperative that it isn't
another study that takes another three or four years, but that
we do this quickly and rapidly and get the information to those
Gulf War veterans because there is nothing like being told it
is all in your head when actually there is a real connection
and they deserve to know the answer to that.
Dr. Cross. Senator, I agree.
Senator Murray. Thank you very much, Mr. Chairman. I hope
we can pursue that, as well, in the Committee.
Chairman Akaka. Thank you, Senator Murray.
Senator Burr?
Senator Burr. Thank you, Mr. Chairman.
Dr. Cross, Mr. Hall, let me thank you for your service.
What you do is very important. I think you can already
sense the great frustration on this dais with the status quo,
with maybe not the same urgency that we have displayed within
the VA, and I will treat you as the messenger and not
necessarily the evaluator of all the comments that are made
today.
Let me share with you some facts. One-third of our Nation's
homeless have served our country in the armed services. On any
given day, approximately 200,000 veterans are living on the
streets or in shelters. As many as 400,000 veterans experience
homelessness at some point during the course of a year. This is
the outcome. That is today.
I presented to this Congress and to the VA, it is the same
bill as I presented last year, where the VA had some concerns
over the form of assistance we had provided and preferred
grants over per diem payments. I said then, I say today, I am
more than willing to change it. I have had no contact with the
VA on the bill since last year when it was introduced, no
effort on the VA's part to reach out and to try to perfect a
bill if, in fact, one felt that it was not perfect to start
with. I have never written a perfect piece of legislation. It
requires a degree of cooperation on both sides. I am not sure
that that cooperation has existed.
Now let me go to what you said earlier to Senator Craig. It
is about outcome. Well, it is about outcome. Our veterans are
living on the streets and in shelters. What I have proposed is
not putting a shelter over their head, it is providing the
services that are absolutely essential to make sure that that
housing is permanent and not temporary.
I would like to go through some of the points that you have
raised that are objections. One, the application process fails
to require applicants to demonstrate the need for services.
Well, my legislation gives the VA full authority to establish
the criteria for the selection of eligible entities to be
provided financial assistance under this section. In fact, we
empower the VA to determine what the criteria is, and you are
being critical of us of not providing the criteria for you.
Well, you are on the front line. Who better to
write it?
Support services should not include health care because it
is duplicative services already provided by the VA. My bill
states that health care services can be provided only if such,
and I quote the bill, ``if such services are not readily
available through the Department's medical center serving the
geographical area in which the veteran's family is housed.''
Well, if it is not available, then why wouldn't we offer it? I
think that is a pretty simple point.
Next, supportive services provided by VA and other Federal
programs typically include referrals to legal services but not
actual legal services. Referral, but not services. My bill
provides legal services to assist veterans with
reconsiderations of appeals of veterans and public benefit
claim denials and to resolve outstanding warrants that
interfere with the family's ability to retain housing or
supportive services. If the attempt is to make sure that these
individuals become permanently housed, then it is a heck of a
lot cheaper for us to provide the legal services to end the
dispute than it is for us to have these individuals homeless
and actually not receiving the medical care that they need
except when it is in an emergency case or a trauma case.
The last point I want to make, the definition of veteran's
family differs from that used in 42 U.S. Code 11302, the
McKinney-Vento Homeless Assistance Act. Actually veteran family
is not defined in that section at all. McKinney-Vento defines
homelessness and we use that definition of homelessness in our
bill. A veteran family is not defined in U.S. Code there, but
it does define a homelessness definition of which we use the
exact definition.
Gentlemen, I have got to share with you that I find the
objections petty. They are not objections I would expect from a
stakeholder who wishes to see legislation that addresses the
problems. Instead, I think it suggests they come from an agency
that would like to continue the band-aid approach to the
services that affect, as I said, 200,000, 400,000 veterans who
find a home not a permanent part of their life.
We will work with you in every way, shape, or form to try
to make sure that this bill meets the criteria, meets the
definitions. But if we don't have the same goal, and that is to
make sure that individuals who are veterans don't have the
services that they need to be permanently housed versus
temporary, then those conversations will end very quickly. I
think that is a mission of the Veterans' Administration. I
believe the Secretary believes that we should do everything we
can to put these individuals in permanent housing and I am
committed to do that with or without the VA.
I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Senator Tester?
Senator Tester. Thank you, Mr. Chairman, and I, too, want
to thank the panelists for being here today.
I want to go to S. 479 first. You had mentioned the name of
a commission. This was the Omvig Act. You mentioned the name of
a commission that you said you were following. They had made
some observations and you were following up on their
recommendations. Could you give me the name of that commission
again? I didn't get it?
Dr. Cross. It would be the President's New Freedom
Commission on Mental Health.
Senator Tester. The President's what?
Dr. Cross. The President's New Freedom Commission on Mental
Health.
Senator Tester. New Freedom? And how many recommendations
did they put forth? Do you know off the top of your head, and
how many have been implemented?
Dr. Cross. It was a bunch, sir, but I don't have the number
off the top of my head.
Senator Tester. But they haven't all been implemented?
Dr. Cross. No, but we have plans for implementation.
They are well on the way.
Senator Tester. All right. Could you get me a list of the
ones that have been implemented and the ones that are in
process?
Dr. Cross. Yes, sir. We can do that.
Senator Tester. That would be good. I want to talk a little
bit about S. 994, which is a bill that I have got for mileage
reimbursement, and I would assume--I don't want to put words in
your mouth, but I would assume you are going to--I assume you
oppose it because it takes away money from health care, that
would otherwise be appropriated toward health care or used for
health care? Is that correct? And if it is not, just tell me if
you oppose it or
support it.
Dr. Cross. On S. 994, sir, we are not supporting that. We
do have some concerns. I can go through those with you.
Senator Tester. OK. What are they? What are they, quickly?
Dr. Cross. Well, it eliminates the deductible and it
relates to beneficiary travel. The size of this investment, I
think, would be--we haven't fully costed it yet--would be
certainly in the hundreds of millions of dollars. We think that
would be better spent in direct health care for our veterans.
Senator Tester. OK. If there was a separate stream
allocated for the travel reimbursement, would that take care of
some of your problems with it?
Dr. Cross. There would still be some issues, particularly
in regard to the deductible, which we think makes it an
inefficient way to carry that out. We can work with your staff
on that and go through some of the details of what our concerns
are.
Senator Tester. OK. Well, my concern is that we have got
people, especially in rural States like Montana, that have a
long ways to drive to get health care, and last time I checked,
gas went up about 30 cents a gallon this last month. And when
you are talking about 11-cent reimbursement, you are talking
about a veteran that needs health care and it takes away from
their ability to get access to the program, which is something
I think we are all concerned about on this panel.
And so my question is, if we don't reimburse them for
reasonable costs on transportation, how do you propose that the
veterans get the health care, the veterans that live in these
rural communities that are 140, 150 miles away in some cases,
round-trip, from health care?
Dr. Cross. We, of course, share that concern about the
rural environment. We, in fact, had a separate hearing on that.
Ninety-two-point-five percent right now are within 60 minutes
of a VA facility. Ninety-eight percent are within 90 minutes of
a VA facility. That is a remarkable transition that we have
executed over a period of years because we have gone from very
much of a tertiary focus to more of an outpatient primary care
focus. In that process, we have created 717 community-based
outpatient clinics and we are going to create a bunch more and
then go beyond them with what we call outreach clinics, part-
time clinics that lease space reaching out even to smaller
communities, and perhaps in the State of Montana that would be
a good example. The State of Maine would be a good example.
Senator Tester. Could I see your plans for construction of
these clinics, the additional clinics, where they are going to
be and when they are going to be built?
Dr. Cross. Yes, sir. I think we have an announcement coming
up on the community-based outpatient clinics here shortly, but
we will share that with you immediately.
Senator Tester. I would love to see them. I can tell you
that just from my perspective, 11 cents a mile doesn't even
begin to pay the gas, much less insurance, tires, depreciation,
all that stuff, and this is for disabled veterans whom it
applies to. It would seem to me that if you are concerned about
taking money away from health care, which I think is a valid
concern, you would also be promoting mandatory funding for the
VA because as long as it is discretionary, if we build a
cemetery, it takes money away from health care. If we put money
into research for prosthetics, it will take money away from
health care. And the list goes on and on and on.
So I think that it is critically important, and what I have
heard with the questions that go around this table is it deals
with access to the system and it deals with our veterans
getting the health care that they were promised. And I think
that if some veterans happen to live in Scobey, Montana, they
should still have access to that health care.
And I will tell you point blank, unequivocally, they don't.
So I would hope that when you look at these bills, every
one of them as it goes forth--whether I oppose them or I
support them is irrelevant--you need to look at it from a
standpoint of accessibility and improved veterans' health care.
I agree with what Senator Murray said. I hear it at home all
the time. Once you get in the system, once you get through the
door, it is very, very good and you need to be commended for
that. Getting through the door oftentimes is very, very
difficult for our veterans.
Thank you very much.
Chairman Akaka. Thank you very much, Senator Tester.
Senator Isakson, followed by Senator Sanders.
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator Isakson. Thank you very much, Mr. Chairman, and I
deeply apologize for being late and I apologize in advance for
leaving early in just a minute, but I am in between about five
different things.
I have three quick points, Mr. Chairman. First is to thank
the VA for the recent opening of the clinic in Rome, Georgia.
These clinics provide immeasurable service, and that has been
extremely helpful to the Atlanta VA and the Atlanta region.
Secondly, Mr. Chairman, for the record, I have introduced
S. 1396, which is an authorization for a $20 million-plus
renovation of the VA hospital on Clairmont Road in Atlanta.
This is a repeat of an authorization that was made 6 years
ago--I think it was 6 years ago. It lapsed this past year while
the VA was negotiating the final bids to actually do the work.
The money has been appropriated, but because the bids that came
in were higher than expected, the negotiations took longer and
now we have a contract but no authorization. They are nodding
their heads, so I think I am saying it right.
I would appreciate the Chair and the Members of the
Committee's help in getting this authorization back through the
Committee so this VA renovation can take place. The money is
there, the need is great, as all of us have attested to in
terms of health care, and we just have a technical problem that
we have an expired authorization and money in the bank. So I
would ask for the Chair and the other Members of the Committee
to help in that if at all possible.
And then last, on behalf of Senator Chambliss and myself,
Senator Chambliss has introduced legislation to rename the
Augusta VA medical facility for Congressman Charlie Norwood,
who passed away of cancer earlier this year. Congressman
Norwood was a Vietnam veteran, served as a medic and later as a
physician in Vietnam, and worked tirelessly on behalf of the
veterans of Georgia and the Veterans' Administration. So we
hope that, too, can be expedited through the Committee, and as
I understand it, there is no opposition in the VA to doing
that.
Dr. Cross. Sir, we note that Representative Norwood was a
proud member of the military medical system. He was a military
dentist and we will defer to Congress on the naming of
facilities.
Senator Isakson. Thank you very much. Thank you, Mr.
Chairman.
Chairman Akaka. Thank you very much, Senator Isakson.
Senator Sanders?
STATEMENT OF HON. BERNARD SANDERS
U.S. SENATOR FROM VERMONT
Senator Sanders. Thank you very much, Mr. Chairman.
Let me concur with Senator Murray. It seems to me that the
fundamental issue that we are dealing with is the following,
and I would like a comment from the representatives of the VA.
We have had Secretary Nicholson coming before us and speaking
with a good deal of pride about the very high quality health
care that is provided by the VA for those people who get into
the VA. We have also heard evidence that the VA is providing
some of the most cost effective health care in the country at a
time when health care costs are soaring. That is very good
news.
It would seem to me, given those basic premises, that what
you should be coming before us and saying is, look, we have got
very good quality health care. It is cost effective. Give us
the money so that we can expand it to more veterans. That is
what you should be
saying.
And then what our job is as Members of the Senate is to
say, well, we have got to get our priorities straight. Yes,
there are a lot of needs out there. How much are we concerned
about veterans as opposed to, for example, tax breaks for
billionaires? That is not your job, that is our job.
I happen to think that every person who served in this
country is, in fact, entitled to the health care that they were
promised. Like Senator Murray, I also have introduced
legislation that says that there is something wrong when
President Bush threw about 1.5 million Category 8 veterans off
of VA health care.
Let me, Mr. Chairman, put into the record an e-mail I
recently received. ``Dear Senator Sanders, I read in the
Rutland Herald yesterday about the veterans' benefits and the
veterans that fall into the Category 8. My husband applied and
he fell into that category because he had not signed by 2003,
but he was denied any medical benefits. He needs to have
medical care because he has diabetes and we are unable to
afford health insurance for him. I am hoping you can do
something about this situation for veterans. Thank you.''
Well, I am certainly going to try to do something about it.
Once again, let me pick up from where Senator Murray left off.
A million-and-a-half veterans, people who put their lives on
the line, are no longer eligible for VA health care because
they are too wealthy, i.e., according to the President, their
incomes are over $27,000. I believe those Category 8s should be
brought back into the system. Do you?
Dr. Cross. Sir, as we discussed earlier, I share your
concerns. Our focus, though, is to make sure that the veterans
that we do take care of, that we do the very best that we can,
that we provide the adequate access and the adequate quality--
--
Senator Sanders. A question. I have heard that answer for
several years. How much more money do you need to provide the
highest quality care for all of our veterans? Nobody here does
not want the highest quality care for those returning from Iraq
and Afghanistan. We also want Category 8 veterans to get care.
How much more do you need to do that?
Dr. Cross. We are costing the bill. We haven't arrived at
the final number but we can give you that in writing.
Senator Sanders. Mr. Hall, do you have any thoughts on
that?
Mr. Hall. No, sir, I do not.
Senator Sanders. OK. I would like to receive as soon as
possible your estimates as to what it would cost to make sure
that every--that this gentleman who put his life on the line
for the country who now has diabetes, whose family cannot
afford health care, be entitled to get into the VA.
Dr. Cross. Sir, I need to remind you of one thing.
Senator Sanders. Yes?
Dr. Cross. It is not merely a matter of money. It is a
matter of capacity, the physical facility, the staffing, the
equipment and so forth that would be--it wouldn't be an
instantaneous process even if the money were to arrive today.
So----
Senator Sanders. What you are saying is it could not be
done tomorrow and it would take time. We appreciate that. But
your job is to tell us how much money you would need to provide
expanded capacity, because I start off again with the premise,
the Secretary tells us that the care is excellent and it is
cost effective. Why wouldn't the U.S. Congress be supporting an
expansion of a program which ultimately will save taxpayers
money? So I would appreciate hearing from you as to your
estimates as to how much providing health care to Category 8s
will cost.
Dr. Cross. Yes, sir. We will get you that.
Senator Sanders. Number two, let me also ask for the
information that Senator Tester asked for. Do I understand you
are going to be expanding the community clinics?
Dr. Cross. Yes.
Senator Sanders. I think that is a very good idea.
They work very well in Vermont. I would also like to know
where those clinics will be.
Thirdly, I want to pick up again on a point that Senator
Murray raised. As somebody who in the House of Representatives
was involved for many, many, many years on Gulf War illness
issues, certainly the recent study coming from, I believe,
Boston University, is a very significant one. I can well
remember, Mr. Chairman, where the VA even denied that one
soldier was impacted by sarin. They started off by denying
there was any problem whatsoever. We have been, believe me,
around the block with the VA on this for many, many years.
But if this study is, in fact, accurate, it is, as Senator
Murray indicated, very profound. It suggests that many soldiers
may have suffered brain damage which was not--one didn't know
it instantaneously, unlike a large dose of sarin. And the
impact not only for Gulf War soldiers but for the civilian
population is important, as well, because a number of
scientists have pointed out the similarity between various
illnesses associated with the Gulf War as similar to those in
the civil society, such as multiple chemical sensitivity,
chronic fatigue, fibromyalgia, and other types of illnesses. So
this is a very big deal and we hope that you will pursue that.
Dr. Cross. We absolutely will, Senator, and I wanted to
point out again that we were involved in the research----
Senator Sanders. Yes.
Dr. Cross [continuing].--and we were proactive in doing
this. The way you characterize the findings may be a bit
different than the way I read them. We would be happy to bring
our experts over and sit down and talk with you or your staff
and go through it in some more detail----
Senator Sanders. What do you understand the key findings
to be?
Dr. Cross. One of the findings was a slight anatomical
variation that was noted in one group more so than in the
other. That was perhaps the lead finding. And whatever the
consequences----
Senator Sanders. That was brain----
Dr. Cross. Yes.
Senator Sanders [continuing].--brain anomaly.
Dr. Cross. So we can go through that in more detail. It is
a very technical issue. I would be happy to go through it----
Senator Sanders. Is this consistent with the work that Dr.
Haley in Texas was doing?
Dr. Cross. I don't think it is involved with that, sir.
Senator Sanders. No, I know it is not involved, but are the
conclusions somewhat similar, do you think?
Dr. Cross. I would be stretching my knowledge if I answered
that one way or the other.
Senator Sanders. Mr. Hall, do you have any knowledge about
that?
Mr. Hall. No.
Senator Sanders. OK. Thank you very much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Sanders.
I want to thank our panelists. Thank you very much, Dr.
Cross and Mr. Hall, for your testimony and your responses. We
really appreciate it. It will be helpful to us.
Mr. Hall. Mr. Chairman, if I could clarify one thing----
Chairman Akaka. Mr. Hall?
Mr. Hall. Senator Murray had the question about the
eligibility for Reservists. Reservists are eligible.
Combat veteran Reservists are eligible upon their discharge
or separation for care on the same basis as----
Senator Murray. But after two years, the National Guard is
not.
Mr. Hall. If they are combat veterans, they are.
Senator Murray. After two years?
Mr. Hall. Upon their discharge.
Senator Murray. We are talking about Priority 8?
Mr. Hall. Pardon me? No, they are eligible under the
current two-year basis. Oh, excuse me. You are talking about
after the two years of----
Senator Murray. After two years, Priority 8 regular service
get additional health care. Guard and Reserve do not. There is
a difference between the two, after two years.
Mr. Hall. No, ma'am. Once they are enrolled, once they
are--combat veterans would come back. They would have the
eligibility as combat veterans to be enrolled as Priority 6s
and then they would--once enrolled in the system, they would
continue on as previously enrolled. If they qualified as 8s
then, they would be previously enrolled and would continue
their enrollment.
Senator Murray. If you are correct, there are a lot of
people who are misinformed throughout the system. If I am
correct, there are a lot of people who aren't getting what they
should be getting.
Dr. Cross. Senator Murray, I think we will send you a
written response to make sure we have got this absolutely clear
for you.
Chairman Akaka. Thank you very much for that clarification
and thank you again, Dr. Cross and Mr. Hall.
I would like to now welcome the representatives of the
second panel, the representatives of the veterans service
organizations to our panel today, Carl Blake with the Paralyzed
Veterans of America; Dennis Cullinan of the Veterans of Foreign
Wars; Joy Ilem of the Disabled American Veterans; Shannon
Middleton of the American Legion; and Bernard Edelman of
Vietnam Veterans of America.
I thank you all for appearing before the Committee today.
Of course, your full statement will appear in the record of the
hearing.
Mr. Blake, will you please proceed with your testimony.
STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA
Mr. Blake. Mr. Chairman, Members of the Committee, on
behalf of Paralyzed Veterans of America, I would like to thank
you for the opportunity to testify today. In light of the fact
there are numerous bills on the agenda, I will limit my
comments to only a few of the bills.
The PVA supports S. 472 that would authorize the funding
necessary to construct a new major medical facility in Denver,
Colorado. PVA has been involved in the planning and development
process for this new facility since the beginning. PVA also
appreciates the fact that the Capital Asset Realignment for
Enhanced Services, CARES, commission report identified the need
for a new spinal cord injury center in the Denver area. We hope
to remain an active partner in the development and completion
of this project to ensure that the needs of veterans and SCI
veterans are also being met.
PVA fully supports S. 479, the Joshua Omvig Veterans
Suicide Prevention Act. The instances of suicide among
veterans, particularly OEF and OIF veterans, is a serious
concern that needs to be addressed. PVA particularly
appreciates the emphasis placed on peer support counseling.
This is something that PVA as an organization does in all of
the spinal cord injury centers around the country. Every PVA
chapter designates individual members to pair up with newly
injured veterans to help them get through the early stages of
the recovery process.
I know firsthand that being able to talk to someone who has
experienced what you have experienced and has dealt with the
same problems you are dealing with can help you overcome bouts
of depression, anger, and sadness as you first come to grips
with your condition. The peer counselor serves as a motivator
to get you moving in the right direction.
PVA finds it difficult to comprehend the rationale for
establishing a precedent for veterans in the VA health care
system to leave that system and seek services elsewhere, as S.
815 would do. Over the past year, we have read, and as I am
sure every Member of Congress has, all of the accolades given
to the VA health care system. While this legislation may be
well intentioned, the potential unintended consequences far
outweigh any benefit that this bill might provide. It would
almost certainly be a diminution of established quality,
safety, and continuity of VA care if veterans were to leave the
system.
While as a consequence of enactment of this bill some
service-connected veterans might seek care in the private
sector as a matter of personal convenience, they would lose the
many safeguards built into the VA system through its patient
safety program, its evidence-based medicine, the electronic
medical records, and the medication verification program. These
unique VA features culminate in the highest-quality care
available, public or private. Loss of these safeguards that are
generally not available in private sector systems would equate
to diminished oversight and coordination of care and ultimately
may result in lower quality of care for those who deserve it
most. With all of these considerations, PVA opposes this
proposed legislation.
PVA fully supports S. 994, the Disabled Veterans Fairness
Act, which would align the mileage reimbursement rate afforded
to eligible veterans with the rate that all Federal employees
get when they are on travel. It is wholly unacceptable that
veterans have to live with the 11 cents per mile reimbursement
rate that the VA currently provides when all Federal employees
receive 48 cents per mile. In fact, PVA believes that some of
the difficulty in providing care in rural and limited access
areas, particularly rural areas, might be eliminated with a
sensible reimbursement rate. We believe that veterans would be
less likely to complain about access issues as a result of
their geographic location if they know that they will not have
to foot the majority of the travel expense out of their own
pocket. This is a change that has been long overdue and we urge
the Committee and all of Congress to take immediate action to
correct this inequity.
PVA fully supports S. 1147, the Honor Our Commitment to
Veterans Act. The provisions of this legislation are in
accordance with the recommendations of the Independent Budget.
However, we must emphasize that if this policy is overturned,
additional adequate funding must be provided to meet this
demand. It would make no sense to make this change without
providing the funding necessary.
Finally, PVA generally supports the provisions of S. 1233,
the Veterans Traumatic Brain Injury Rehabilitation Act. It is
fair to say that TBI is considered the signature health crisis
for OEF and OIF veterans. We believe that the provisions of
this legislation will enhance the ability of the VA to provide
comprehensive care for veterans with TBI. With this in mind, it
only makes sense that the VA be required to develop a
comprehensive treatment plan to address the individualized
treatment needs of these veterans. We believe that this
approach gives these severely disabled veterans the best chance
to succeed in their recovery.
Mr. Chairman, Senator Murray, again, I would like to thank
you again for the opportunity to testify and I would be happy
to answer any questions that you might have.
[The prepared statement of Mr. Blake follows:]
Prepared Statement of Carl Blake, National Legislative Director,
Paralyzed Veterans of America
Chairman Akaka, Ranking Member Craig, and Members of the Committee,
on behalf of Paralyzed Veterans of America (PVA) I would like to thank
you for the opportunity to testify today on the proposed health care
legislation. The scope of issues being considered here today is very
broad. We appreciate the Committee taking the time to address these
many issues, and we hope that out of this process meaningful
legislation will be approved to best benefit veterans.
s. 117, the ``lane evans veterans health and benefits improvement act''
PVA supports the provisions of this legislation that allow veterans
who experience mental health conditions to receive treatment from the
Department of Veterans Affairs (VA). Likewise, despite the fact that it
deals with Title 10 issues--an area that PVA does not typically work
in--we support the requirement that post-deployment medical and mental
health screening be conducted within 30 days. We would suggest that it
should be done even sooner. PVA has expressed concerns repeatedly that
pre-deployment and post-deployment screenings are not being handled
properly. In fact, we believe that it should not be a screening, but
instead, a full medical evaluation and physical. The only way to
properly assess the men and women returning from combat theaters of
operations is to examine them fully.
PVA also supports the intent of Section 103 of the legislation that
requires every servicememberber released from active duty to be given
an electronic copy of his or her military records, to include military
service, medical, and any other relevant records. We have long felt
that electronic transfer of all military service and medical records
from the Department of Defense to VA would expedite the claims process.
This provision would certainly move the departments in that direction.
However, we believe that this could take quite some time to implement
and that additional resources should be provided to meet the demands of
this legislation.
S. 383
PVA fully supports this legislation which would extend the
eligibility for hospital care, medical services, and nursing home care
from 2 years to 5 years for a veteran who served on active duty in a
theater of combat operations during a period of war after the Persian
Gulf War or in combat against a hostile force after November 11, 1998.
This provision has proven especially important to the men and women who
have recently served in Iraq and Afghanistan and have exited military
service.
However, PVA believes that the ability of the VA to provide this
essential care will continue to be threatened as long as adequate
funding is not provided to meet this specific demand. As we have stated
in testimony previously, we believe that the VA is underestimating the
number of men and women from the Global War on Terror who are seeking
care in the VA, and by extension, has not requested sufficient funding
to meet this demand. We appreciate that Congress has recognized the
need for more funding than has been requested in recent years, and we
hope that you will continue to do what is necessary to care for all of
these men and women who choose to come to the VA.
S. 472
PVA supports S. 472 that would authorize the funding necessary to
construct a new major medical facility in the Denver, Colorado area.
PVA has been involved in the planning and development process for this
new facility since the beginning. PVA also appreciates the fact that
the Capital Asset Realignment for Enhanced Services (CARES) commission
report identified the need for a new spinal cord injury (SCI) center in
the Denver area. We hope to remain an active partner in the development
and completion of this project to ensure that the needs of SCI veterans
are also being met.
We must emphasize that a new spinal cord injury center should move
forward along with any decisions concerning a new Denver VA medical
center. Any new SCI center must be operated as all current centers are,
with dedicated services and staff. The development of a new SCI center
must follow the requirements of the Memorandum of Understanding between
VA and PVA allowing for architectural review, must operate in
compliance with all existing VA policies and procedures, and must
continue the relationship between VA and PVA allowing for site visits
of SCI center facilities.
S. 479, THE ``JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT''
PVA fully supports S. 479, the ``Joshua Omvig Veterans Suicide
Prevention Act.'' The incidence of suicide among veterans, particularly
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
veterans, is a serious concern that needs to be addressed. We believe
that this legislation addresses one major hurdle by attempting to break
the stigma of mental illness. Clearly, veterans with mental illness are
at a higher risk for suicide. And yet, these veterans have been pushed
to the edge because they believe they are looked down upon because of
their mental conditions. If this program and outreach is going to
succeed, it is absolutely essential that the providers, to include
doctors, nurses, and other health professionals, are properly trained.
In some cases, the first biggest challenge that veterans with mental
illness face is a provider who does not handle such a delicate
situation properly.
PVA also appreciates the emphasis placed on peer support
counseling. This is something that PVA as an organization does in all
of the spinal cord injury centers around the country. Every PVA chapter
designates individual members to pair up with newly injured veterans to
help them get through the early stages of their recovery. I know
firsthand that being able to talk to someone who has experienced what
you have experienced and has dealt with the same problems you are
dealing with can help you overcome bouts of depression, sadness, and
anger as you first come to grips with your condition. The peer
counselor serves as a motivator to get you moving in the right
direction. I credit my own peer counselor while I went through spinal
cord rehabilitation with driving me to help other veterans.
S. 610
PVA has no objection to this legislation. The legislation is meant
to correct an apparent inequity in the statute governing full-time
retirement benefits for nurses who were recruited by the VA to do part-
time work. If this was a benefit that was promised to these nurses,
then we see no reason why they should be denied it.
S. 692, THE ``VA HOSPITAL QUALITY REPORT CARD ACT''
Although PVA has no objection to the requirements for a Hospital
Quality Report Card Initiative outlined in this legislation, we remain
concerned that this wealth of information will go unused. Collecting
this information and assessing it without acting on any findings from
that information would serve no real purpose. We would hope that the
congressional committees will use this information published in these
reports each year to affect positive change within the VA. However, we
must emphasize that additional resources should be provided to allow
the VA to properly compile this information as we believe that this
could be a major undertaking.
S. 815, THE ``VETERANS HEALTH CARE EMPOWERMENT ACT''
PVA finds it difficult to comprehend the rationale for establishing
a precedent for veterans in the VA health care system to leave that
system and seek services elsewhere, as this proposed legislation would
do. Over the past year we have read, as I am sure every Member of
Congress has, all of the accolades given to VA health care by
independent observers, newsweeklies and other publications. While we
believe VA represents the best available care, oversight is needed to
provide an additional guarantee that VA-provided services are of the
highest quality for all veterans who use VA, especially for those with
service-connected disabilities.
While this legislation may be well intentioned, the potential
unintended consequences far outweigh any benefit that this bill might
provide. There would almost certainly be a diminution of established
quality, safety and continuity of VA care if veterans were to leave the
system. It is important to note that VA's specialized health care
programs, authorized by Congress and designed expressly to meet the
needs of combat-wounded and ill veterans, such as the blind
rehabilitation centers, prosthetic and sensory aid programs,
readjustment counseling, polytrauma and spinal cord injury centers, the
centers for war-related illnesses, and the national center for post-
traumatic stress disorder, as well as several others, would be
irreparably affected by the loss of service-connected veterans from
those programs. The VA's medical and prosthetic research program,
designed to study and hopefully cure the ills of disease and injury
consequent to military service, would lose focus and purpose were
service-connected veterans no longer present in VA health care.
Additionally, Title 38, United States Code, section 1706(b)(1) requires
VA to maintain the capacity of these specialized medical programs, and
not let their capacity fall below that which existed at the time when
Public Law 104-262 was enacted.
As a consequence of enactment of this bill some service-connected
veterans might seek care in the private sector as a matter of personal
convenience; however, they would lose the many safeguards built into
the VA system through its patient safety program, evidence-based
medicine, electronic medical records and medication verification
program. These unique VA features culminate in the highest quality care
available, public or private. Loss of these safeguards, that are
generally not available in private sector systems, would equate to
diminished oversight and coordination of care, and ultimately may
result in lower quality of care for those who deserve it most. With all
of these considerations, PVA strongly opposes this proposed
legislation.
S. 874, THE ``SERVICES TO PREVENT VETERANS HOMELESSNESS ACT''
PVA has no objection to the provisions contained in the proposed
legislation. Clearly, the most important factor in combating the
problem of homelessness among veterans is preventing homelessness in
the first place. This legislation would seem to accomplish that task by
offering financial assistance to organizations or entities that provide
permanent housing and support services to very low income veteran
families. In the mean time, we believe that additional resources should
be invested in programs that actually target veterans and their
families who are experiencing homelessness as well. With more than
200,000 veterans on the street on any given night, it is time to make
real, meaningful efforts to end this problem.
S. 882
PVA supports the concept of the proposed legislation that would
establish ``navigators'' to assist veterans and disabled veterans as
they enter the VA system for health care and benefits. This legislation
would offer $25 million in grants over 5 years to support these
navigators. This legislation would particularly allow veterans service
organizations and other organizations to apply for grants so that they
could hire and train navigators to provide assistance, on an
individualized basis, to members of the Armed Forces as they transition
from military service to VA health care and as they seek benefits
provided by VA. The only point that we must emphasize is that as the VA
begins awarding these grants, it must ensure that the absolute best
qualified entities are chosen for this assistance. The VA must ensure
that rigorous qualification standards are established and subsequently
met by organizations applying for the grants. This will ensure that
veterans do not receive inadequate assistance as they navigate the VA
system.
S. 994, THE ``DISABLED VETERANS FAIRNESS ACT''
PVA fully supports S. 994, the ``Disabled Veterans Fairness Act,''
which would align the mileage reimbursement rate afforded to eligible
veterans with the rate that all Federal employees get when they are on
travel. It is wholly unacceptable that veterans have to live with the
11 cents per mile reimbursement rate that the VA currently provides
when all Federal employees receive 48 cents per mile. In fact, PVA
believes that some of the difficulty in providing care to veterans in
limited access areas, particularly rural areas, might be eliminated
with a sensible reimbursement rate. We believe that veterans would be
less likely to complain about access issues as a result of their
geographic location if they know that they will not have to foot the
majority of the travel expense out of their own pocket. This is a
change that has been long overdue, and we urge the Committee and all of
Congress to take immediate action to correct this inequity.
S. 1026
PVA generally concedes to the wishes of our local chapters, as well
as other local veterans service organization members and State
Congressional delegations on issues involving naming VA facilities. At
this time, PVA has no position on S. 1026.
S. 1043
PVA has no specific position on the proposed legislation. However,
we do concur with the principle of the legislation that the needs of
veterans in the Los Angeles area should trump any outside
considerations.
S. 1147, THE ``HONOR OUR COMMITMENT TO VETERANS ACT''
PVA fully supports S. 1147, the ``Honor Our Commitment to Veterans
Act.'' The provisions of this legislation are in accordance with the
recommendations of The Independent Budget. We have continued to
advocate for this policy to be overturned since it was put into place.
It is unacceptable that these veterans, many of whom have served in
combat, are being denied access to health care simply because the
Administration and Congress have been unwilling to provide the
necessary funding to reopen the VA health care system to them. We
believe this policy should be overturned and that adequate resources
should be provided to overturn this policy decision.
VA estimates that more than 1.5 million category 8 veterans will
have been denied enrollment in the VA health-care system by Fiscal Year
2008. Assuming a utilization rate of 20 percent, in order to reopen the
system to these deserving veterans, The Independent Budget estimates
that VA will require approximately $366 million in discretionary
dollars.
S. 1205
PVA supports this proposed legislation that would establish a pilot
program to assist veterans service organizations and other
organizations in developing and implementing peer support programs. The
peer support program would help veterans reintegrate into their local
communities. As we stated in our testimony regarding suicide prevention
and peer support, the benefits of any type of peer support or
counseling are invaluable. PVA chapters lead the charge at each spinal
cord injury center to provide peer counseling to newly injured veterans
coming through the system. The program authorized by this legislation
could allow these local level veterans service organization
representatives to expand their reach and provide better support to the
veterans who need the most assistance.
Veterans service organizations understand better than any other
entity that community reintegration is vital because most of their
members have likely experienced this situation. We believe it makes
perfect sense to tap into this knowledge and expertise to help new
veterans return to civilian life easier.
S. 1233, THE ``VETERANS TRAUMATIC BRAIN INJURY
REHABILITATION ACT''
PVA generally supports the provisions of S. 1233, the ``Veterans
Traumatic Brain Injury Rehabilitation Act.'' It is fair to say that
traumatic brain injury (TBI) is considered the signature health crisis
for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veterans. We believe that the provisions of this legislation will
enhance the ability of the VA to provide comprehensive care for
veterans with TBI. With this in mind, it only makes sense that the VA
be required to develop a comprehensive treatment plan to address the
individualized treatment needs of these veterans. We believe that this
approach gives these severely disabled veterans the best chance to
succeed in their recovery.
PVA is concerned about the authority provided by Section 4 of the
legislation. We understand that outside facilities and programs can
bring some level of expertise to this population of veterans. However,
we would hope that the VA would see fit to invest the majority of its
resources in improving its own TBI programs, even as it taps into
outside expertise. We do appreciate the effort of the legislation to
ensure that outside facilities meet certain standards before the
services are acquired. We would hope that this provision would ensure a
level of care that should be expected from any facility treating these
veterans.
Meanwhile, we think that the legislation also unnecessarily
rewrites contracting authority that already currently exists in the fee
basis statute. The legislation seems to explain medically unfeasible
and geographic inaccessibility in new language, when the VA already has
authority to follow these guidelines under fee basis. This would simply
require the VA to more judiciously apply its own regulation.
PVA supports the establishment of a research, education, and
clinical care program to provide intensive neuro-rehabilitation to
veterans with severe traumatic brain injury. We would hope that this
program will be coordinated with the polytrauma centers that are
currently providing complex care to severely disabled veterans, to
include veterans with TBI.
Likewise, we support the provision for a pilot program to assess
the effectiveness of assisted living services for these veterans. PVA
believes that age-appropriate VA non-institutional and institutional
long-term care programming for young OIF/OEF veterans, particularly the
severely disabled including veterans with TBI, must be a priority for
VA. New VA non-institutional care programs must come on line and
existing programs must be re-engineered to meet the various needs of a
younger veteran population. VA's non-institutional long-term care
programs will be required to assist these younger severely injured
veterans who need a wide range of support services such as: personal
attendant services, programs to train attendants, peer support
programs, assistive technology, hospital-based home care teams that are
trained to treat and monitor specific disabilities, and transportation
services. These younger veterans need expedited access to VA benefits
such as VA's Home Improvement/Structural Alteration (HISA) grant, and
VA's adaptive housing and auto programs so they can leave institutional
settings and go home as soon as possible. PVA also believes that
linking these assisted living programs to the polytrauma centers and
possibly the proposed research, education, and clinical care program is
a must.
Lastly, we fully support the inclusion of research on TBI as part
of existing research programs. If the long-term effects of the injuries
of these veterans have not even been identified yet, it is essential
that the VA makes its best effort to stay ahead of the needs of these
men and women as they arise. The best way to accomplish that is through
additional research.
THE ``COMPREHENSIVE VETERANS BENEFITS IMPROVEMENT ACT''
As with S. 1147, PVA supports the provision of this proposed
legislation that would overturn the policy decision to prohibit
Category 8 veterans from enrolling in the VA health care system.
However, we must emphasize that if this policy is overturned additional
adequate funding must be provided to meet this demand. It makes no
sense to make this change without providing the funding necessary to
meet the new demand.
PVA fully supports Section 102 of the proposed legislation in
accordance with the recommendations of The Independent Budget. We are
particularly pleased with the emphasis that Category 4 veterans with
catastrophic disabilities that are non-service connected be exempted
from paying copayments and fees. This has been a long-standing
initiative of PVA. The veterans affected by this proposal are not
casual users of VA health care services. Because of the nature of their
disabilities they require substantial, ongoing care and a lifetime of
services. Private insurers don't offer the kind of sustaining care for
spinal cord injury found at the VA even if the veteran is employed and
has access to those services. Other Federal or state health programs
fall far short of VA. In most instances, VA is the only and the best
resource for a veteran with a spinal cord injury, and yet, these
veterans, supposedly placed in a priority enrollment category, have to
pay fees and copayments for every service they receive as though they
had no priority at all. It is certainly time for Congress to correct
this financial penalty.
Mr. Chairman and Members of the Committee, PVA once again thanks
you for the opportunity to testify. We look forward to working with you
to ensure that veterans continue to have access to the best health care
services in America.
I would be happy to answer any questions that you might have.
Chairman Akaka. Thank you very much, Mr. Blake.
Mr. Cullinan?
STATEMENT OF DENNIS CULLINAN, DIRECTOR, NATIONAL LEGISLATIVE
SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED STATES
Mr. Cullinan. Chairman Akaka, Senator Murray, on behalf of
the 2.4 million men and women of the Veterans of Foreign Wars
and our Auxiliaries, I thank you for this opportunity to
testify at today's hearing on veterans' health care
legislation.
The VFW has no objections to S. 610 and S. 1233. We support
all other bills under discussion today with the exception of S.
815, which I will address momentarily. On behalf of the VFW
membership, I will be very pleased to outline our strong
support for S. 1233. For the sake of timeliness, I will limit
my presentation to these two initiatives.
S. 815, the Veterans Health Care Empowerment Act, the VFW
strongly opposes this legislation, which would allow any
veteran to elect to receive contracted care basically wherever
and whenever they choose. As we have acknowledged in our
comments on previous legislation, there are certainly cases
where contract care is appropriate, even essential.
Indiscriminate use of it, however, will place the utilization
of VA's own health care resources at risk.
First, we reiterate our concerns with the cost of such
care. Fee-based care is more expensive than that of VA and we
believe that it would do great harm to those veterans who elect
to stay in the high-quality VA health care system by taking
funding away from the system as a whole.
Second, we have strong concerns about the viability of the
health care system should this bill be enacted. VA has four
essential missions, all of which depend on one another and
which greatly improve the quality of care for all Americans,
not just veterans. It serves as the health care system for its
Nation's sick and disabled veterans, first and foremost.
Second, it acts as the primary education and training ground
for America's health care professionals.
Third, it provides world class research opportunities in
the development of new medical technologies. And fourth is the
back-up to the Department of Defense health care system during
times of national emergency. We cannot lessen one of these
missions without sacrificing elements of the others. Reducing
the number of veterans seeking care from VA would undermine the
others, affecting all Americans.
Further, contract care would present problems especially
with the continuum of care and VA's ability to monitor and
track the health care needs of veterans over their entire
lives. It would also potentially erode the quality of the care
VA provides, especially with respect to illnesses and
disabilities veterans suffer such as gunshot wounds, the use of
prosthetics, SCI, and so forth. VA is uniquely qualified to
treat these particular maladies.
Although this legislation aims to expand the coverage
available to veterans, we believe it would only dilute the
quality and quantity of services provided to new and existing
veterans today and into the future.
Next under discussion is S. 1233, the Veterans Traumatic
Brain Injury Rehabilitation Act of 2007. The VFW is pleased to
support this legislative initiative introduced by you, Chairman
Akaka, as well as Ranking Member Craig, to provide enhanced
intervention, rehabilitative treatment, and services to
veterans with traumatic brain injury. Traumatic brain injury,
or TBI, is the signature wound of the current war in Iraq and
Afghanistan. Improvements in body armor and more rapid and
effective medical interventions are resulting in individuals
surviving bomb blasts and the like and other concussive
injuries that would not have been possible in the previous
conflicts.
Tragically, though, along with amputations, many of these
survivors now suffering with TBI, resulting in varying degrees
of cognitive impairment, reduced concentration and ability to
focus on more than one thing at a time, and emotional distress.
This has profoundly negative implications for these injured
warriors as well as their families and dependents.
While in all likelihood, TBI has been one of the injuries
of modern warfare, it went unrecognized and there may be no
doubt that it has never been as prevalent as it is today. The
severity of the resulting impairment, the psychological and
physiological consequences, and the duration of the disability
are at this point in time but vaguely understood. Modern
medicine and medical science are just now addressing TBI.
It is for this reason that the measures called for in S.
1233 are so important. The VFW supports all the recommendations
and findings contained in this bill. We place special emphasis
on Section 3's requirement that the Secretary develop and
implement individual rehabilitation plans, as well as Section
5's establishment of severe traumatic brain injury research,
education, and a clinical care program under the Department of
Veterans Affairs.
Mr. Chairman, this concludes my testimony. Thank you.
[The prepared statement of Mr. Cullinan follows:]
Prepared Statement of Dennis M. Cullinan, Director, National
Legislative Service, Veterans of Foreign Wars of the United States
Mr. Chairman and Members of This Committee:
On behalf of the 2.4 million men and women of the Veterans of
Foreign Wars of the United States (VFW) and our Auxiliaries, I would
like to thank you for the opportunity to testify at today's hearing on
veterans health care legislation.
S. 117
The VFW is pleased to support this legislation, introduced by
Senator Obama, which makes a number of improvements in the care and
treatment of those servicemen and women who are separating from
service.
Title I of this bill would require these men and women to receive a
mental health evaluation within 30 days of their return from
deployment, and would extend medical care and services to these
veterans based upon the results of these evaluations regardless of
whether they are directly connected with a service connection if they
seek treatment within 5 years of separation.
This is important because it gives the benefit of the doubt to
these veterans for their illnesses and mental health problems they may
suffer, and provides them access to these essential services without
having to endure the VA disability claims process for access to care
beyond their initial 2 years of eligibility. The bottom line is that if
veterans are having problems, under this legislation, they would be
cared for.
We support other sections of this legislation that would require
the Department of Defense to provide servicemembers with an electronic
copy of their medical and military records. This has been a long-time
goal of the VFW, and we view it as an essential component of the
seamless transition. We understand that DOD has made limited progress
in this regard, but the time for action is now. We also support this
bill's efforts to improve outreach to members of the National Guard and
Reserves, and its reporting requirements to provide meaningful
statistics on the health care and services provided to veterans of the
Global War on Terrorism.
S. 383
Introduced by Senator Akaka, the VFW is pleased to support S. 383,
legislation that would extend the period of eligibility for health care
for combat service during the Persian Gulf War from 2 years to 5 years.
Currently, veterans OEF/OIF veterans who enroll in the VA health
care system are included as category six veterans and are entitled to
use VA as their health care provider for 2 years following their
discharge. For those who enroll after this 2-year period, they are
enrolled as any other veteran would be and, if they fall in category 8,
are excluded from the system.
As we learn more about the illnesses, disabilities and health care
needs of those returning, this is an important change, and would allow
many of these veterans to receive the care and benefits they need. For
those suffering from mental health issues--such as PTSD--the symptoms
they show might not immediately manifest themselves, or they may need
time to come to terms with the knowledge that they need treatment. If
they fall outside the 2-year window and qualify for health care under
category 8, they cannot access VA health care unless they can
demonstrate a service connection--a process that takes, on average, 6
months or more.
For those suffering from the effects of mental health illnesses, or
for veterans who are affected by Traumatic Brain Injuries, changing the
law to extend their eligibility is a compassionate and right thing to
do.
S. 472
The VFW is pleased to support this legislation, introduced by
Senator Allard that would authorize $523 million to construct a
replacement VA Medical Center in Denver, CO. This facility, to be built
on the former Fitzsimons Army hospital site, has received prior year's
authorization for a portion of the construction costs.
The VFW has long supported the Capital Asset Realignment for
Enhanced Services process (CARES) and we continue to support the
process, especially in how it prioritizes VA's construction needs.
Table 4-9 of VA's 5-Year Capital Plan identifies and prioritizes VA's
construction needs, and Denver's project is ranked 3rd on the list.
Accordingly, Congress must authorize and appropriate sufficient funding
to complete this project.
S. 479--THE JOSHUA OMVIG SUICIDE PREVENTION ACT
The VFW is pleased to support this legislation, which aims to
create a comprehensive program of suicide prevention among veterans.
Due to the nature of high-stress combat in the current war and the
beginning of a de-stigmatization of mental-health disorders, many
veterans are beginning to seek the care they need, and diagnosis of
post-traumatic stress disorder (PTSD) are on the increase, but more can
be done.
This legislation, introduced by Senator Harkin, would require VA to
train its employees to identify suicide risk factors and protocols for
responding to veterans who are at risk. Additionally, it would create
programs of outreach among veterans and--importantly--their families, a
critical system of support.
These programs are essential because we can and must do more to
ensure that no veteran slips through the cracks, and that they all have
access to the highest quality mental health services they need to make
them whole. It is a national tragedy that so many are suffering, but
with a proactive VA, we can all make a positive impact on the lives and
care of thousands of our returning heroes.
S. 610
The VFW has no objection to this legislation, introduced by Senator
Rockefeller that would make changes to the retirement annuity for
certain health-care professionals within VA.
S. 692
Introduced by Senator Obama, the VFW is pleased to support the VA
Hospital Quality Report Card Act, legislation that would require VA to
develop and implement a system to measure data about its health care
facilities.
This data would be of great service. It would allow veterans to
compare the quality of service VA provides, letting them make informed
judgments about their health care. It would allow VA to identify areas
of improvement, and it would provide essential data for Congress to
better use its essential oversight authority.
S. 815--VETERANS HEALTH CARE EMPOWERMENT ACT
The VFW strongly opposes this legislation, which would allow any
veteran to elect to receive contracted care whenever they choose. As we
have acknowledged in our comments to previous legislation, there are
certainly cases where contract care is appropriate. Indiscriminate use
of it in place of utilizing VA's own health care resources, however, is
misguided.
First, we reiterate our concerns with the costs of such care. Fee-
basis care is more expensive than that of VA, and we believe that it
would do great harm to those veterans who elect to stay in the high-
quality VA health care system by taking away funding for the system as
a whole.
Second, we have strong concerns about the viability of the health
care system should this bill be enacted. VA has four essential
missions, all of which depend on one another, and which greatly improve
the quality of care for all Americans, not just our veterans. (1) It
serves as the health care system for this Nation's sick and disabled
veterans; (2) It acts as the primary education and training grounds for
America's health care professionals (48,000 medical residents and
students receive training at VA each year); (3) It provides world-class
research opportunities and the development of new medical technologies,
and; (4) It is the backup to the Department of Defense health system in
national emergencies.
We cannot lessen one of these missions without sacrificing the
others. Reducing the number of veterans seeking care from VA would do
irreparable damage to the others, affecting all Americans.
Further, contract care would present problems, especially with the
continuum of care and VA's ability to monitor and track the health care
needs of veterans over their entire lives. It would also potentially
erode the quality of care VA provides, especially with respect to the
illnesses and disabilities veterans suffer from, such as gunshot wounds
or prosthetics, and for which VA is uniquely qualified to treat.
Although this legislation, introduced by Senator Craig, aims to
expand the coverage available to veterans, it would only dilute the
quality and quantity of the services provided to new and existing
veterans today and into the future. That is unacceptable.
S. 874
The VFW supports S. 874, ``The Services to Prevent Veterans
Homelessness Act of 2007,'' introduced by Senator Burr of this
Committee. A great tragedy and embarrassment, now confronting, this
Nation is the high level of homelessness among the veteran population.
This legislation, directing the Secretary of Veterans Affairs to
provide financial assistance to eligible private nonprofit
organizations or consumer cooperatives to provide and coordinate the
provision of various supportive services for very low-income veteran
families occupying permanent housing, addresses this issue. It is
directed toward preventing homelessness from occurring in the first
place. We also support that the Secretary is required to conduct a 2-
year study of the effectiveness of the assistance program in meeting
the needs of very low-income veteran families.
S. 882
The VFW supports this legislation, introduced by Senator Menendez,
which would create a pilot program to improve the seamless transition
for separating servicemembers. It would award grants to organizations
who help veterans, especially those with serious wounds, women and
members of the Guard and Reserves with applying for benefits and
services within VA.
Expanding outreach efforts so that all our veterans understand the
benefits that they are entitled to is a worthy goal, and would be of
great benefit to those who truly need VA's services to transition back
into society.
S. 994
The VFW supports and appreciates S. 994, the Disabled Veterans
Fairness Act introduced by Senator Tester together with Senator
Salazar. This bill eliminates a $3 per round trip deductible charged by
the Secretary of Veterans Affairs in connection with the veterans
beneficiary travel program. It further directs the Secretary, in
determining the amount of such allowance or reimbursement, to use the
mileage reimbursement rates for the use of privately owned vehicles by
government employees traveling on official business. For many veterans
who live far from a VA hospital or community health center,
transportation remains the single biggest obstacle to care. Today,
disabled veterans are eligible to have only a small fraction of their
transportation costs reimbursed.
This legislation will go a long ways in addressing this unfortunate
situation.
S. 1026
The VFW supports this bill introduced by Senator Chambliss to
designate the Department of Veterans Affairs Medical Center at 1
Freedom Way in Augusta, Georgia, as the ``Charlie Norwood Department of
Veterans Affairs Medical Center.'' Congressman Norwood was a lifetime
VFW member and a staunch supporter of veterans as well as our active
duty military.
S. 1043
The VFW has no objection to this legislation introduced by Senator
Feinstein directing the Secretary of Veterans Affairs to report to
Congress on the master plan of the Department of Veterans Affairs (VA)
relating to the use of VA lands of the West Los Angeles Department of
Veterans Affairs Medical Center, California, as originally required
under the Veterans Programs Enhancement Act of 1998. This bill also
requires an alternative report, on the development of the master plan,
if the master plan does not exist as of the date of enactment of this
Act and further prohibits the Secretary from implementing any portion
of the master plan until 120 days after its receipt by the
congressional veterans' and appropriations committees.
S. 1147
The VFW applauds the introduction of S. 1147 by Senator Murray of
this Committee. The Honor Our Commitment to Veterans Act directs the
Secretary of Veterans Affairs to administer the health care enrollment
system of the Department of Veterans Affairs so as to enroll any
eligible veteran who applies. The fact that tens of thousands of so
called category 8 veterans are denied access to VA medical care simply
because their incomes exceed an unreasonably low threshold is a
travesty. This bill would rectify this situation.
S. 1205
The VFW supports S. 1205. A bill, introduced by Senator Smith, to
require a pilot program on assisting veterans service organizations and
other veterans' groups in developing and promoting peer support
programs that facilitate community reintegration of veterans returning
from active duty. The effectiveness of peer support has been well
documented in the wake of the Vietnam conflict. Specifically, for
mental health disorders like PTSD and depression, peer-support programs
have shown that participation yields improvement in psychiatric
symptoms and decreased hospitalizations, the development of larger
social support networks, enhanced self-esteem and social functioning,
as well as lower services costs. Unfortunately peer support is not as
readily available as might be expected. This bill to increase the
presence of the VFW and other VSOs and members of the veteran's
community in this vital area is a very sound initiative to provide much
needed support to veterans in need on a highly cost effective basis.
S. 1233
The final bill under discussion today is S. 1233, the Veterans
Traumatic Brain Injury Rehabilitation Act of 2007. The VFW is pleased
to support this legislative initiative introduced by Chairman Akaka and
Ranking Member Craig to provide enhanced intervention, rehabilitative
treatment and services to veterans with traumatic brain injury.
Traumatic Brain Injury or TBI is the signature wound of the current war
in Iraq. Improvements in body armor and more rapid and effective
medical interventions are resulting in individuals surviving bomb
blasts and other concussive injuries that would not have been possible
in previous conflicts. Tragically, though, along with amputations many
of these survivors now suffer from TBI resulting in varying degrees of
cognitive impairment, reduced concentration and ability to focus on
more than one thing at a time and emotional distress. This has
profoundly negative implications for these injured warriors as well as
their families and dependents.
While in all likelihood TBI has always been one of the injuries of
modern warfare, it went unrecognized. And there may be no doubt that it
has never been as prevalent as it is today. The severity of resulting
impairment, the physiological and psychological consequences and the
duration of this disability are at this point in time but vaguely
understood. Modern medicine and medical science are just now addressing
TBI.
It is for this reason that the measures called for in S. 1233 are
so important.
The VFW supports all of the recommendations and findings contained
in this bill. We place special emphasis on Section 3's requirement that
the Secretary develop and implement individual rehabilitation plans as
well as Section 5's establishment of severe traumatic brain injury
research, education and clinical care program within the Department of
Veterans Affairs.
Mr. Chairman, this concludes my testimony. I would be happy to
respond to any questions you may have.
Thank you.
Chairman Akaka. Thank you very much, Mr. Cullinan.
Ms. Ilem?
STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS
Ms. Ilem. Thank you, Mr. Chairman and Members of the
Committee. We appreciate the opportunity to testify on behalf
of the Disabled American Veterans. As your staff requested, I
am focusing on only a few of the proposals being considered by
the Committee today, specifically the measures of special
interest to DAV and its members.
I will begin with S. 383, a bill that would extend combat
veterans' eligibility for VA health care from two to five
years. DAV has a resolution calling for this extension of
eligibility. This bill would help to ensure that our newest
generation of combat veterans, those from Iraq and Afghanistan,
are given ample time to access VA's specialized programs and
services, if needed. We believe this is especially important
with regard to mental health as well as for veterans with mild
traumatic brain injuries. Therefore, DAV fully supports this
measure and we look forward to its
enactment.
We are also pleased to support. S. 479, the Joshua Omvig
Veterans Suicide Prevention Act. The hearing recently held by
this Committee clearly illustrated the need to address this
issue of suicide in the veteran population, especially among
our newest generation of combat veterans. The testimony
provided by Joshua Omvig's parents and other members of that
particular witness panel was very moving and brought out the
need for improvement in VA's programs designed to help veterans
who are struggling with readjustment issues following wartime
service. Every possible thing that can be done to prevent such
personal tragedies is warranted. This measure is very thorough
and highlights the need to provide targeted outreach, mandatory
training, and peer counseling for veterans who may be at risk.
We commend the Committee for its efforts on addressing this
very difficult issue.
Likewise, DAV is pleased to support S. 994, the Disabled
Veterans Fairness Act. DAV has a longstanding resolution
supporting repeal of the beneficiary travel reimbursement
deductible for service-connected veterans and to increase
travel reimbursement rates. The lack of travel reimbursement
can act as a barrier to gaining essential health care for sick
and disabled veterans. S. 994 offers a fair and equitable
resolution to this problem. We would recommend, however, that
the Committee authorize funding for VA's travel reimbursement
program in an appropriation separate from medical services.
Mr. Chairman, we are also pleased to support S. 1233, the
Veterans Traumatic Brain Injury Rehabilitation Act of 2007. We
commend you and Senator Craig for working together on this very
important issue. This comprehensive measure would enhance and
strengthen VA's rehabilitation programs for veterans with
severe and moderate traumatic brain injury, or TBI. S. 1233
would help VA to develop the needed expertise, programs, and
capacity to meet the lifeline needs of veterans with these
devastating injuries.
Finally, Mr. Chairman, I would like to call your attention
to
S. 815, the Veterans Health Care Empowerment Act. DAV, along
with the other veterans service organizations that author the
Independent Budget, have already expressed our concerns to the
Committee about the potential negative consequences of this
bill, if enacted, but let me summarize them again today.
S. 815 would authorize health care for veterans with
service-
connected disabilities at virtually any private medical
facility rather than requiring VA to meet their needs. If this
bill were enacted, some service-connected veterans might, in
fact, choose private care in lieu of VA as a personal
convenience. But in doing so, they would lose the many
safeguards built into the VA system for their benefit. VA is
well known for its patient safety program, use of evidence-
based medicine, and reliance on the electronic medical record.
These unique qualities, along with VA's policies, combine to
produce the highest documented quality of care, public or
private. We fear loss of these critical safeguards would equate
to diminished clinical oversight and coordination of service-
disabled veterans' care and ultimately might result in a lower
quality of care for those who need it most.
Additionally, VA has to its credit done an excellent job of
holding down costs by effectively managing in-house health
programs and services. We know this Committee wants to ensure
service-disabled veterans have timely access to the best care
available. We believe VA can deliver that level and quality of
care. We recognize and acknowledge that VA is not always
perfect in addressing veterans' needs, but we believe it is
working hard to address identified shortcomings. Congress has
historically protected VA's specialized medical programs, such
as its world renown PTSD, spinal cord injury, amputation, and
blind rehabilitation programs. If enacted, this bill may
negatively impact those unique programs. For this and other
reasons, we cannot support this bill. We do, however, encourage
Congress to continue thorough oversight of VA programs and
services rather than authorize outsourcing of care as a
solution.
That completes my statement. Thank you.
[The prepared statement of Ms. Ilem follows:]
Prepared Statement of Joy J. Ilem, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman, Ranking Member Craig and other Members of the
Committee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this important legislative hearing of the Committee on
Veterans' Affairs. DAV is an organization of 1.4 million service-
disabled veterans, and along with its auxiliary, devotes its energies
to rebuilding the lives of disabled veterans and their families.
You have requested testimony today on fifteen bills primarily
focused on health care services for veterans under the jurisdiction of
the Veterans Health Administration, Department of Veterans Affairs
(VA). While my oral remarks will focus on only those bills about which
we are particularly concerned, this statement reviews our position on
all of the proposals before you today. The comments are expressed in
numerical sequence of the bills, and we offer them for your
consideration.
S. 117--LANE EVANS VETERANS HEALTH AND BENEFITS
IMPROVEMENT ACT OF 2007
S. 117 would establish eligibility for a mental health evaluation
on demand by any veteran who served on or after September 11, 2001, and
would require VA to provide that evaluation within 30 days of its
request. It would also establish eligibility for these veterans for
hospital, outpatient and nursing home care, and for marital and family
counseling, for a 2-year period from commencement of such services.
Remaining sections of the bill would require a series of data gathering
and reporting by the Secretaries of Veterans Affairs and Defense, of
the populations of active duty personnel and veterans defined in the
bill as ``Global War on Terror'' veterans--essentially those who have
served in a number of theaters of war, conflicts and other deployments
since September 11, 2001.
DAV is generally supportive of any effort to improve access to care
for sick and disabled veterans. Also, accurate data to aid
understanding of these populations' needs by the agencies responsible
for their care is beneficial in any population that benefits from
Federal programs. Nevertheless, some of the emphases of this bill seem
problematic. The bill would require a comprehensive medical and mental
health evaluation by a qualified professional within thirty days of
request. We appreciate the intent of the provision to secure timely
assessments, but based on our review of VA's general efforts to meet
its workload requirements within those constraints, it is doubtful VA
could routinely meet this requirement within available resources.
With respect to the data gathering and reporting requirements of
the bill, we believe thousands of staff hours and millions of dollars
for other support likely would be necessary to enable VA and DOD to
comply with these requirements, assuming they would be able to comply.
Also, some of the reporting cycles in the bill would be highly
challenging for both agencies to meet, given the amount of work the
bill would require to assemble the databases that would reveal those
facts. Since these new requirements would need to be accomplished from
within available funding, this bill troubles us. We ask the Committee
to further study the proponent's goals to see if other approaches may
be fashioned to produce the desired results sought.
S. 383--A BILL TO EXTEND THE PERIOD OF ELIGIBILITY FOR HEALTH CARE FOR
COMBAT SERVICE IN THE PERSIAN GULF WAR OR FUTURE HOSTILITIES, FROM 2
YEARS TO 5 YEARS AFTER DISCHARGE OR RELEASE
Servicemembers after having served in combat theaters often
experience unique health care challenges related to military service.
Therefore, the DAV believes these brave men and women deserve open
access to the unique and specialized services provided by VA. This bill
would help ensure that our newest generation of combat veterans
returning from Operations Iraqi Freedom and Enduring Freedom (OIF/OEF)
gains access by extending the period of eligibility for VA health care
services and programs.
The members of our most recent National Convention in Chicago,
Illinois, passed Resolution No. 217 supporting legislation to extend
the period of eligibility for free health care for combat veterans for
conditions potentially related to their combat service from 2 years to
5 years after military service. Especially in regard to mental health
sequalae related to combat exposure, veterans may not recognize within
the current 2-year window allowed that they need VA services. This bill
gives such veterans and their families the benefit of the doubt and is
in the best spirit of supporting veterans' needs without pre-judging or
shortchanging them. Therefore, the DAV proudly supports this measure
and looks forward to its enactment.
S. 472--A BILL TO AUTHORIZE A NEW MAJOR MEDICAL FACILITY PROJECT IN
DENVER, COLORADO, IN THE AMOUNT OF $523 MILLION
S. 472 would authorize a major medical facility project in Denver,
Colorado. The DAV has no resolution from its membership concerning this
issue; however, we would not oppose the enactment of this bill.
S. 479--THE JOSHUA OMVIG VETERANS SUICIDE PREVENTION ACT
S. 479 would establish a broad based suicide prevention initiative
in the VA. We support the goals of this bill and are pleased to endorse
it. We do ask that the Committee consider modifying the bill to make
clear that the suicide prevention programs the bill would establish are
intended to be applied to programs within the Department and for
veterans who are enrolled in VA health care under section 1705 of Title
38, United States Code, and to veterans otherwise in close contact with
other programs of the Department (i.e., the Veterans Benefits
Administration regional offices, the Readjustment Counseling Service
Vet Centers, etc.). We do not believe the bill is intended to be
applied to all veterans, irrespective of their circumstances.
S. 610--A BILL TO ESTABLISH JANUARY 23, 2002, AS THE EFFECTIVE DATE OF
THE MODIFICATION OF TREATMENT FOR RETIREMENT ANNUITY PURPOSES OF PART-
TIME SERVICE PERFORMED BEFORE APRIL 7, 1986, BY VA NURSES, PURSUANT TO
THE VA HEALTH CARE PROGRAMS ENHANCEMENT ACT OF 2001
S. 610 would retroactively authorize full-time work credits for
Federal retirement purposes for VA registered nurses who worked part-
time and retired from active service prior to April 7, 1986. This bill
would address the opinion of the Office of Personnel Management that a
prior act of Congress failed to establish clear policy that these
nurses be included in Congressionally mandated service recalculations
for part-time VA nurses. Although these particular VA nurses retired
long ago, in equity DAV believes these individuals, who provided vital
services to sick and disabled veterans during their professional
careers, deserve this benefit as accorded to other VA part-time nurses
at that time. We applaud the sponsor's efforts to champion this cause
for this small group of VA retirees.
S. 692--THE VA HOSPITAL QUALITY REPORT CARD ACT OF 2007
S. 692 would establish a ``hospital report card'' covering a
variety of activities of hospital care occurring in the medical centers
of the Department. Validation of the delivery of high quality care to
service-disabled veterans is important. Therefore, we support this
bill. We believe that veterans under VA care have the same rights as
private sector patients to review the quality and safety of the care
they receive while hospitalized. We do note, however, that the purposes
of this bill do not cover the grand majority of overall patient care
workload in VA health care, namely primary (outpatient) care and
extended care services provided in VA's nursing home care units and its
various contracted programs. Nevertheless, this is a good bill and one
that is supported by DAV. We do note for the Committee's purposes, that
the term ``VA hospital'' was supplanted by the term ``VA medical
center'' in prior legislation. You may wish to consider conforming this
bill accordingly, should the Committee decide to approve and report it.
S. 815--THE VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007
This measure, which seeks to provide health care benefits to
veterans with service-connected disabilities at virtually any private
medical facility, raises a number of concerns for the DAV. We and
several other veterans service organizations sent a letter describing
our concerns about this measure, which I will outline.
While well intentioned, this measure could result in a series of
potential unintended consequences chief of which is the diminution of
established quality, safety and continuity of VA care, as well as to
rekindle debate on the so-called ``Medicare subvention'' policy
proposal that Congress and the Administration have been unable to
resolve in 10 years.
It is important to note that VA's specialized health care programs,
authorized by Congress and designed expressly to meet the special needs
of combat wounded and ill veterans, such as the blind rehabilitation
centers, prosthetic and sensory aid programs, readjustment counseling,
polytrauma and spinal cord injury centers, the centers for war-related
illnesses, and the national center for post-traumatic stress disorder,
as well as several others, would be irreparably affected by the loss of
service-connected veterans from those programs. The VA's medical and
prosthetic research program, designed to study and hopefully cure the
ills of disease and injury consequent to military service, would lose
focus and purpose were service-connected veterans no longer present in
VA health care. Additionally, Title 38, United States Code, section
1706(b)(1) requires VA to maintain the capacity of these specialized
medical programs, and not let their capacity fall below that which
existed at the time when Public Law 104-262 was enacted.
In light of the escalating costs of health care in the private
sector, VA has, to its credit, done an excellent job of holding down
costs by effectively managing its in-house health programs and services
for veterans. While as a consequence of enactment of this bill some
service-connected veterans might seek care in the private sector as a
matter of personal convenience, they would lose the many safeguards
built into the VA system through its patient safety program, evidence-
based medicine, electronic medical records and medication verification
program. These unique VA features culminate in the highest quality care
available, public or private. Loss of these safeguards, that are
generally not available in private sector systems, would equate to
diminished oversight and coordination of care, and ultimately may
result in lower quality of care for those who deserve it most.
An additional possible consequence if this measure were enacted
would be to most likely shift care for service-connected veterans from
discretionary to mandatory spending. While we are devoted to proposals
that Congress move VA health accounts into the mandatory funding arena,
we could not support a bill that would move VA from a primary provider
of health care to an insurer, even if funding for that function were
made mandatory.
We believe that mixing complex chronically ill service-disabled
veterans with other veterans in VA care creates a needed critical mass
and properly balanced case mix. A diverse case mix with the variety of
acute and chronic clinical patients that motivates excellence in the
academic health center environments cements solid relations between
those tertiary VA facilities and their health professions schools--
another guarantor of quality of care.
We know this Committee wants to ensure service disabled veterans
have access to the best care available. We believe VA can deliver that
level of care. We recognize that VA is not always perfect, but we
believe VA is working hard to address its shortcomings and in the long
term offers the highest quality care available to veterans with special
needs. If there are problems with VA care we would encourage VA to
address these problems and for Congress to support critical oversight
of programs and services, rather than recommending outsourcing of care
as a solution.
S. 874--THE SERVICES TO PREVENT HOMELESSNESS ACT OF 2007
S. 874 would direct the VA to provide financial assistance for
supportive services for very low-income veterans' families in permanent
housing. Under the bill VA would provide grants to certain eligible
entities such as private nonprofit organizations or consumer
cooperatives to provide various supportive services.
Funding for the supportive services would be taken from amounts
appropriated to the VA for medical care. Amounts would be $15 million
for Fiscal Year 2008; $20 million for Fiscal Year 2009; and, $25
million for Fiscal Year 2010.
The DAV statement of policy specifies that we will not oppose
legislation unless it is evident that it will jeopardize benefits for
service-connected disabled veterans. As such, while we support the
intent of the bill to better address homeless veterans' needs, and to
help them move toward independent living, we would strongly oppose
offsetting the costs associated with S. 874 against other vital VA
health care programs. Also, with regard to the health care and
counseling services this bill would provide, we are concerned that as
well-intentioned as it may be, that a grant under which health care
services would be provided by private providers versus VA providers
raises questions about cost, quality, continuity and safety similar to
our views on other proposals with these goals.
S. 882--A BILL TO REQUIRE A PILOT PROGRAM ON THE FACILITATION OF THE
TRANSITION OF MEMBERS OF THE ARMED FORCES TO RECEIPT OF VETERANS HEALTH
CARE BENEFITS UPON COMPLETION OF MILITARY SERVICE
This measure seeks to ensure that military servicemembers receive a
continuity of care and assistance in and after the transition from
military service to veteran status. Specifically, this bill would
require the VA to conduct a 5-year pilot program to assess the
feasibility and advisability of awarding grants to ``eligible
entities'' to assist transitioning military servicemembers,
particularly those with serious wounds, injuries, or mental disorders,
women members, and members of the National Guard and Reserves, in
applying for and receiving VA health care benefits and services.
Further, this bill requires at least one location of the pilot
program to be in the vicinity of: (1) a military medical treatment
facility that treats OIF/OEF servicemembers who are seriously wounded;
(2) a VA medical center located in a rural area; and (3) a VA medical
center located in an urban area.
The DAV believes that both VA and DOD have complementary and
critical roles in ensuring servicemembers and returning combat veterans
scheduled for discharge, receive prompt, comprehensive quality care and
services from each agency; however, there remains a clear need for
additional services and better coordination for transitioning
servicemembers from military to veterans status and reintegration into
the community as a productive member of society. However, DAV has no
resolution on this issue, and does not accept grants from the U.S.
Government.
S. 994--THE DISABLED VETERANS FAIRNESS ACT
S. 994 would make significant changes to the VA beneficiary travel
program, authorized under section 111 of Title 38, United States Code.
The VA beneficiary travel program is intended by Congress to assist
veterans in need of VA health care to gain access to that care. As you
are aware, the mileage reimbursement rate is currently fixed at eleven
cents per mile, but actual reimbursement is limited by law with a $3.00
per trip deductible capped at $18.00 per month. The mileage
reimbursement rate has not been changed in 30 years, even though the VA
Secretary is delegated authority by Congress to make rate changes when
warranted. The law also requires the Secretary to make periodic
assessments of the need to authorize changes to that rate.
Unfortunately, no Secretary has acted to make those changes, despite
the obvious need to update the rate of reimbursement to reflect rises
in travel and transportation costs.
In 1987, the DAV, in coordination with VA's Voluntary Service
Program, began buying and donating vans to VA for the purpose of
transporting veterans for outpatient care. Since that time, the DAV
National Transportation Network has formed a very significant and
successful partnership with VA and DAV. We have donated almost 1,800
vans to VA facilities at a cost exceeding $20 million. These vans and
their DAV volunteer drivers and medical center volunteer transportation
coordinators have transported nearly 520,000 veterans over 388 million
miles. We plan to continue and enhance this program, not only because
the VA beneficiary travel rate is so low, but also we have found our
transportation network serves as a truly vital link between veterans
and crucial VA health care. Its absence would equate to the actual
denial of care for many eligible veterans.
DAV has a long-standing resolution (Resolution No. 212) supporting
repeal of the beneficiary travel pay deductible for service-connected
veterans and to increase travel reimbursement rates for all veterans
who are eligible for reimbursement. We believe S. 994 offers a fair and
equitable resolution to this dilemma about which we have been concerned
for many years. We urge this Committee to approve and enact legislation
this year to reform the VA beneficiary travel program. Bringing
reimbursement rates into line with those paid to Federal officials and
Federal employees, is a fair resolution.
Mr. Chairman, given the situations and dislocations of the families
of severely injured veterans of OIF/OEF who now are in VA facilities
for long-term rehabilitation, DAV hopes Congress also will address and
appropriate funding consistent with enabling the immediate family
members of these several hundred veterans to be reimbursed their travel
and lodging expenses while their loved ones remain incapacitated. These
families are suffering greatly and are making extreme sacrifices in
relocating to be close to their loved ones, often far from home,
without good accommodations, and without any authorized reimbursement
for their expenses. We believe consideration of some relief, even if
temporary, is warranted.
S. 1026--A BILL TO DESIGNATE THE VA MEDICAL CENTER IN AUGUSTA, GEORGIA,
AS THE ``CHARLIE NORWOOD DEPARTMENT OF VETERANS AFFAIRS MEDICAL
CENTER''
S. 1026 would name the VA medical center in Augusta, Georgia, as
the Charlie Norwood Department of Veterans Affairs Medical Center. The
DAV has no resolution from its membership concerning this issue;
however, we would not oppose the enactment of this bill.
S. 1043--A BILL TO REQUIRE THE SECRETARY OF VA TO SUBMIT A REPORT TO
CONGRESS ON PROPOSED CHANGES TO THE USE OF THE WEST LOS ANGELES,
CALIFORNIA, VA MEDICAL CENTER
S. 1043 would require the VA to submit a report to Congress on
proposed changes to the use of the West Los Angeles Department of
Veterans Affairs Medical Center in California. Since this deals with a
local matter, we do not have a resolution on this issue.
S. 1147--HONOR OUR COMMITMENT TO VETERANS ACT
This bill would legislatively moot Title 38, section 1705, thereby
rescinding the Secretary's authority to establish and operate a system
of annual enrollments for VA health care, and it would make every
American veteran entitled to enrollment for VA health care on request.
Over 1,000,000 veterans have unsuccessfully attempted to enroll in VA
health care since the cutoff of new enrollments for Priority 8 veterans
occurred in 2003. While we certainly support the proponent's premise
that every veteran who wants it should be able to enroll in VA health
care, without a major infusion of new funding, enactment of this bill
would worsen VA's financial situation, not improve it, and would likely
have a negative impact on the system as a whole. We recommend the
Committee defer action on this bill until after Congress enacts
mandatory, guaranteed or assured funding for VA health care.
S. 1205--A BILL TO REQUIRE A PILOT PROGRAM ON ASSISTING VETERANS
SERVICE ORGANIZATIONS AND OTHER VETERANS GROUPS IN DEVELOPING AND
PROMOTING PEER SUPPORT PROGRAMS THAT FACILITATE COMMUNITY REINTEGRATION
OF VETERANS RETURNING FROM ACTIVE DUTY, AND FOR OTHER PURPOSES
This bill would establish a pilot grant program with veterans
service organizations, and other organizations, to provide
``navigators'' to aid veterans in obtaining the VA health care services
they need. While we appreciate the sponsor's intention to provide
veterans service organizations more means to outreach to and provide
veterans greater opportunity to reintegrate after serving their
deployments, DAV does not accept grants from the U.S. Government.
Our programs are operated by the generosity of private donors and
through paid memberships by our members and their families. DAV already
employs a cadre of 260 National Service Officers, whose job is to
outreach to veterans in every community. Also, DAV has an army of
volunteers on the ground in VA health and benefits offices and working
in our National Transportation Network nationwide. Our DAV members and
volunteers are in touch with literally millions of veterans to help
raise awareness about VA benefits and services.
S. 1233--VETERANS TRAUMATIC BRAIN INJURY
REHABILITATION ACT OF 2007
Mr. Chairman, we commend your efforts in crafting S. 1233. The
provisions of S. 1233 would greatly enhance and strengthen VA's
rehabilitation program for veterans with severe and moderate Traumatic
Brain Injury (TBI). TBI is a life-altering and devastating injury. Even
with the best of care and the most seamless transition back to home,
TBI can disrupt and test the resources of even the most resilient and
financially secure families.
The consequences of TBI usually involve a range of disabilities and
symptoms, which are often not clearly delineated. Indeed, the
International Classification of Diseases and Health Problems, commonly
known as ICD, does not list a single code for TBI but does contain
codes for many of the common consequences of TBI, such as epilepsy. The
neurological, cognitive, and behavioral changes due to TBI are complex,
varied, and diverse and may change in severity or develop over time.
Longer-term neurological problems often include movement disorders,
seizures, headaches, and sleep disorders. Common residual cognitive
problems include memory, attention and concentration impairments.
Depending on the area of the brain injured, judgment, planning,
problem-solving and other executive functioning skills may also be
impaired. Visual perception problems and language impairments are usual
but often go undiagnosed. Prevalent behavioral issues include
personality changes, aggression, agitation, learning difficulties,
shallow self-awareness, altered sexual functioning, impulsivity, and
social dis-inhibition. Many individuals self-medicate with alcohol to
deal with the dis-inhibitory symptoms and disruption to their sleep
cycle.
S. 1233 would take many significant steps to ensure that veterans
with TBI receive high quality rehabilitation in their communities and
to encourage VA to develop the needed expertise and capacity to meet
the lifelong needs of veterans with this injury. Therefore, DAV
supports this bill.
Rehabilitation and Community Reintegration Plan
Section 3 of the bill would require VA providers to develop and
implement a detailed comprehensive multidisciplinary and individualized
rehabilitation and community reintegration plans. This plan would be
based upon an assessment, and periodic reassessment, of the physical,
cognitive, vocational, and psychosocial impairments of veterans and the
family support needs of veterans after discharge from inpatient care.
It is appropriate that the individualized plan be developed and
discussed with the injured veteran and his or her family, to the
maximum extent feasible, before the veteran is discharged from
inpatient acute rehabilitation. This provision would be empowering for
veterans and their families and could help improve rehabilitation
outcomes.
Section 3 also would give veterans and their families the option to
trigger a review of the rehabilitation and reintegration plan and its
implementation. Affording an injured veteran, and in cases of
incapacity, family members or guardians, with an opportunity to request
a review of the rehabilitation plan would ensure that veterans and
families, have a systemic way to maximize an injured veteran's
functioning.
In developing a rehabilitation plan for an active duty
servicemember, S. 1233 would require VA providers to collaborate with
Department of Defense (DOD) providers. We support the clear objective
of this provision to address a significant vulnerability in injured
active duty servicemembers must navigate a labyrinth to receive
continued post-acute rehabilitative care from VA, with DOD approval.
Implicit in the provision is the promise that collaboration would
prompt each agency to address any challenges in coordinating the
delivery of services before the servicemember is transferred.
Access to High Quality and Community Based Rehabilitative Services
Section 4 of S. 1233 would require the VA to implement the
individualized rehabilitation plan through non-VA providers in
situations where VA lacks the capacity to provide the intensity of
required care or the distance from the veteran's home to a VA facility
renders treatment infeasible. The provision also requires that non-VA
providers be accredited by an independent peer-review program for
specialized TBI programs. This provision clarifies that veterans have a
right to community based rehabilitation, but only when VA cannot
provide the care and when the non-VA provider is accredited.
We support the two key implied presumptions in this provision; (1)
that the VA must have the capacity to be the provider of choice and (2)
that proximity to care is a key component to ongoing rehabilitation and
community reintegration.
We support the implicit goal of this bill to give VA an incentive
to develop its capacity to provide high quality care. VA's four lead
Polytrauma Rehabilitation Centers have achieved and maintained, without
qualification, accreditation from the Commission on the Accreditation
of Rehabilitation Facilities for acute inpatient TBI rehabilitation
program but not a single VA facility has achieved accreditation for
outpatient, home-based, residential or community based TBI
rehabilitation. We urge this Committee to encourage VA to seek such
accreditation at Level II and Level III polytrauma sites.
Research, education, and clinical care program on TBI
Sections 5 and 8 of S. 1233 would expand VA's TBI research,
education and clinical programs. Section 5 would give VA providers, in
collaboration with the Defense and Veterans Brain Injury Center, the
incentive to conduct innovative research and intensive treatment to
increase the functioning of such veterans with severe TBI, who are
minimally conscious. While the number of veterans in this population is
small, it is imperative that we care for these very vulnerable
veterans. This proposed program for intensive neuro-rehabilitation is
highly commendable.
Because the screening, diagnosis and treatment of mild or moderate
TBI is so significant we would urge the Committee to address the issue
of education on this issue in a separate and more expansive provision.
We would welcome the opportunity to work with the Committee to discuss
ways to enhance VA's current screening program, to establish a VA TBI
registry which would include OEF/OIF veterans at risk for TBI, to
develop outreach programs to target veterans with mild TBI, and
identify effective treatments for veterans with mild TBI.
Section 8 also improves VA's research program on two prevalent
conditions which result from TBI, seizures and visually related
neurological conditions, by encouraging the VA to use its research
programs to study the diagnosis, treatment and prevention of these
conditions. The proposed provision also leverages the expertise of
federally funded model TBI treatment systems by requiring the VA to
collaborate with these academic and non-VA based programs. We support
this provision and also support expanding VA's capacity to diagnose and
treat veterans who develop epilepsy. Given our understanding of the
relationship between TBI and epilepsy, we believe VA needs a national
program for epilepsy care, and we encourage the Committee to support
the revitalization of VA Epilepsy Centers of Excellence.
Expanding Residential and Long-term Care Options for Veterans with TBI
Section 6 of S. 1233 would establish a 5-year pilot TBI assisted
living program to assess the effectiveness of assisted living programs
in enhancing the rehabilitation, quality of life and community
integration of veterans with TBI. The provision also ensures that VA
continues to provide case management for the care of these veterans. We
support this provision, since it will help veterans with TBI to have
more independent lives in their communities. In that connection, we
call your attention to the July 2004 VA report to Congress in response
to Public Law 106-117, The Veterans Millennium Health Care and Benefits
Act, which authorized VA to establish a pilot program to determine the
``feasibility and practicability of enabling veterans to secure needed
assisted living services as an alternative to nursing home care.'' We
believe veterans suffering from mild-to-moderate TBI, as well as their
families, would benefit from assisted living arrangements. We also
believe the report to Congress in 2004 validated an important role for
assisted living facilities in VA long term care.
Section 7 would require VA to provide age-appropriate nursing home
care for younger veterans who need such care. While it is our hope that
the number of young veterans who are so disabled by TBI as to require
nursing home care is small, we applaud the Committee for ensuring that
these disabled veterans have care that is consistent with their needs.
Other Issues in Need of Legislative Action
S. 1233 is an important bill which takes significant and bold steps
toward improving access and quality of care for veterans with TBI. As
the Committee moves forward during this Congress to continue its
oversight and legislative efforts in the area of TBI we would welcome
the opportunity to work with the Committee on the following areas:
Ensuring all enrolled (new and established) OIF/OEF
veterans are screened, assessed and treated for their mild or moderate
TBI.
Expanding vocational rehabilitation programs for veterans
with TBI.
Development of specialized substance use disorder programs
to help veterans with TBI who self-medicate.
Develop specialized outreach and education programs
related to TBI for members of the National Guard and Reserves.
Developing an independent patient advocacy system for
veterans with TBI.
Development of support programs to help families of
veterans with TBI.
Mr. Chairman, again, the members and auxiliary of DAV appreciate
being represented at this hearing today, and I appreciate being asked
to testify on these bills. I will be pleased to respond to any of your
or other Members' questions.
Chairman Akaka. Thank you very much, Ms. Ilem.
Ms. Middleton?
STATEMENT OF SHANNON MIDDLETON, DEPUTY DIRECTOR, VETERANS
AFFAIRS AND REHABILITATION COMMISSION, THE AMERICAN LEGION
Ms. Middleton. Mr. Chairman and Members of the Committee,
thank you for this opportunity to present the American Legion's
views on the several pieces of legislation being considered by
the Committee today. The American Legion commends the Committee
for holding a hearing to discuss these very timely and
important issues. I will address just a few of the bills in my
comments.
The American Legion supports the intent of S. 117, the Lane
Evans Veterans Health and Benefits Improvement Act of 2007.
Specifically, the American Legion is in support of tracking
veterans who serve in the Global War on Terror in a new
database. This bill will make data on these veterans more
accessible upon request and these veterans require their own
tracking system since the exposures and experiences they
encounter are different from veterans of the First Gulf War.
They have experienced more combat time, multiple deployments,
continuous urban warfare, and blast traumas. Also, more women
have participated. Differentiating veterans who served in OIF
and OEF, those who served in both, and those who served in
neither will also be important when anticipating long-term
health effects.
S. 479, the Joshua Omvig Veterans Suicide Prevention Act,
seeks to reduce the incidence of suicide among veterans. This
bill contains very important components that will likely
mitigate the incidence of suicide among veterans by promoting
outreach to educate veterans and their families about available
services, making services available on a continuous basis, and
training VA employees on suicide prevention.
Family education and outreach is significantly important,
since family members may notice changes in the veterans before
anyone else. When the family and the veteran know what services
are available, it is easier to seek assistance. It is even more
important that VA ensures that these veterans gain access to
mental health services when they need them.
Designating a point of contact at each VA medical facility
that will work with local emergency rooms, law enforcement,
local mental health organizations, and veterans service
organizations will make mental health coordination easier and
timely. Outreach into those who will provide support to
veterans and making the community more aware of VA's mental
health services will also facilitate the goals of research and
help to establish best practices.
S. 1147, Honor Our Commitment to Veterans Act, seeks to
lift the health care enrollment restriction on Priority Group 8
veterans that has been instituted since 2003. The American
Legion opposes any decision to deny enrollment to any eligible
veteran. A more efficient method of ensuring that VA can
continue to provide quality care to veterans would be to ensure
that VA is sufficiently funded to care for their needs, not
limiting access for those who have incomes that fall above
means test thresholds. The American Legion supports the lifting
of the current health care enrollment restriction for Priority
Group 8.
The American Legion supports the provisions of S. 1233, the
Veterans Traumatic Brain Injury Rehabilitation Act of 2007.
Among other things, the bill mandates that VA establish a
research, education, and clinical care program to address
severe traumatic brain injury. This is a very important
component in providing the best quality of care for those who
suffer from this type of injury. Since not much information is
available on long-term effects of combat-related traumatic
brain injury, research on the current war's veterans will be
beneficial in establishing standards of care provided to
veterans.
The American Legion supports research that would improve
care available for veterans with service-connected injuries and
that would attempt to ascertain possible secondary health
outcomes. Since many of the symptoms of secondary conditions
have delayed onset or have subtle manifestations, research on
improving the diagnosis, treatment, and prevention on traumatic
brain injury will ensure the best quality care for future
generations of combat
veterans.
Again, thank you, Mr. Chairman, for giving the American
Legion this opportunity to present its views on such important
issues. We look forward to working with you and the Committee
to enhance the access to quality health care for all veterans.
[The prepared statement of Ms. Middleton follows:]
Chairman Akaka. Thank you very much, Ms. Middleton.
Prepared Statement of Shannon Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Commission, The American Legion
Mr. Chairman and Members of the Committee:
Thank you for this opportunity to present The American Legion's
view on the several pieces of legislation being considered by the
Committee today. The American Legion commends the Committee for holding
a hearing to discuss these very important and timely issues.
S. 117, THE LANE EVANS VETERANS HEALTH AND BENEFITS IMPROVEMENT ACT OF
2007
The American Legion supports the intent of S. 117. Specifically,
The American Legion is in support of tracking veterans who serve in the
Global War On Terrorism (GWOT) in a new database. This bill would make
data on these veterans more accessible upon request. GWOT veterans
require their own system, since the exposures and experiences they
encountered are different from veterans of the first Gulf War. GWOT
veterans experience more combat time, multiple deployments, continuous
urban warfare, blast traumas and more women have participated. The
veterans of the 1991 Gulf War experienced widespread oil well fires,
possible nerve agent exposure and a shorter combat time.
This bill also addresses the need to differentiate veterans who
served in OIF and OEF, those who served in both and those who served in
neither. The environmental exposures may differ and the combat
experiences may differ. The American Legion suggests that under the
Health, Counseling and Related Benefits section (section 3), the
conditions should also be tracked according to whether the veteran
served in OIF, OEF or both or in neither--not just by inpatient
outpatient status. This would demonstrate trends in illnesses
developing among the groups. It should also show a breakdown by gender
to determine if there are manifestations of illnesses specific to each
gender, i.e., birth defects or developmental disorders in their
offspring.
S. 383, A BILL TO EXTEND THE PERIOD OF ELIGIBILITY FOR HEALTH CARE FROM
TWO YEARS TO FIVE YEARS AFTER DISCHARGE OR RELEASE
The American Legion has no official position on extending the
period of eligibility for healthcare for combat veterans after
discharge or release. However, past combat experiences--to include the
Vietnam War and the Gulf War--demonstrated that many ailments have
delayed manifestation and may be difficult to associate with military
service years later. Extending the eligibility period would increase
the likelihood that subtle symptoms of combat-related ailments would be
detected by professional who have the expertise to recognize the
relationship between the veteran's combat experience and symptoms that
manifest later.
S. 472, A BILL TO AUTHORIZE A NEW MAJOR MEDICAL FACILITY PROJECT
IN DENVER, CO
Although The American Legion has no official position on this
proposal, we believe that VA should do everything in its power to
improve access to its health care benefits.
s. 479, the joshua omvig veterans suicide prevention act
This bill seeks to reduce the incidence of suicide among veterans.
It contains very important components that will likely mitigate the
incidence of suicide among veterans by promoting outreach to educate
veterans and families about available services, making services
available on a continuous basis and training VA employees on suicide
prevention.
Family Education and Outreach is significantly important, since
family and friends may notice changes in the veteran's mental health
first. The American Legion receives contact from veterans themselves
who openly admit they need immediate help because of thoughts of
harming themselves. When the family and the veteran know what services
are available, it is easier to seek assistance. It is even more
important that VA ensures that these veterans gain access to mental
health services when they need them.
Designating a point of contact--like a suicide prevention
counselor--at each VA medical facility that will work with local
emergency rooms, law enforcement, local mental health organizations and
veterans service organizations will make mental health coordination
easier and timely.
Outreaching to those who provide support to veterans and making the
community more aware of VA's mental health services will also
facilitate the goals of research and establishing best practices. The
more veterans seek VA care, the more research opportunities VA will
have to develop strategies to enhance prevention mechanisms.
S. 610, A BILL TO ESTABLISH JANUARY 23, 2002, AS THE EFFECTIVE DATE OF
THE MODIFICATION OF TREATMENT FOR RETIREMENT ANNUITY PURPOSES OF PART-
TIME SERVICE PERFORMED BEFORE APRIL 7, 1986, BY VA NURSES, PURSUANT TO
THE VA HEALTH CARE PROGRAMS ENHANCEMENT ACT OF 2001
The American Legion has no position on this issue.
S. 692, THE VA HOSPITAL QUALITY REPORT CARD ACT OF 2007
This bill seeks to establish the Hospital Quality Report Card to
ensure quality measures data on VA hospitals are readily available and
accessible.
The state of VA health care/medical facilities are an important
issue for The American Legion. Each year the organization is mandated
by resolution to conduct a series of site visits to various VA medical
facilities and submit a report to the President, Congress and the VA.
The bill is similar in scope to our report--A System Worth Saving.
Periodic assessments would enable VA to get a clearer picture of its
system-wide needs and assist lawmakers in determining adequate funding
for the VA health care system.
S. 815, THE VETERANS HEALTH CARE EMPOWERMENT ACT OF 2007
This bill seeks to provide health care benefits to veterans with
service-connected disabilities at non-VA medical facilities that
receive payments under the Medicare program or the TRICARE Program.
Although The American Legion has no official position on this issue, we
believe that veterans should receive their medical care from the VA--
except when there is very limited access to VA health care, as in the
case of rural veterans.
S. 874, THE SERVICES TO PREVENT HOMELESSNESS ACT OF 2007
The American Legion would like to submit its views on this bill for
the record at a later date.
S. 882, A BILL TO REQUIRE A PILOT PROGRAM ON THE FACILITATION OF THE
TRANSITION OF MEMBERS OF THE ARMED FORCES TO RECEIPT OF VETERANS HEALTH
CARE BENEFITS UPON COMPLETION OF MILITARY SERVICE
This bill would establish a pilot program for facilitating the
receipt of VA health care benefits for those separating from the
military. The American Legion supports efforts to assist servicemembers
with transitioning to VA and accessing their veteran benefits. The
bill--which targets the severely injured, women veterans, rural
veterans, the National Guard and Reserves, and those with mental health
conditions--may improve access to timely care for many who would
otherwise face difficulty receiving coordinated care.
Services offered by veterans service organizations can enhance the
ability of the ``Veteran Navigator,'' since they are linked to the
communities and provide other means of assisting veterans. For
instance, The American Legion has a program designed to assist severely
injured servicemembers reintegrate into their communities by linking
veterans and their families to local resources to address many of their
needs.
S. 994, THE DISABLED VETERANS FAIRNESS ACT
This bill seeks to eliminate the deductible and to change the
method of determining the mileage reimbursement rate under the
beneficiary travel program administered by the Secretary of VA in an
effort to increase it to the rate authorized for government employees
on official business.
Although The American Legion has no official position on the
beneficiary travel program, we have historically supported an increase
in the mileage reimbursement rate paid to veterans for travel to
medical appointments. It is currently 11 cents and has not increased
since 1978. With the rising cost of gas, this rate presents a hardship
for veterans who have to travel long distances for their appointments.
The American Legion has encountered many veterans over the years who
expressed frustration, anger, and desperation due to financial strain
caused by accommodating this inadequate reimbursement rate.
S. 1026, A BILL TO DESIGNATE THE VA MEDICAL CENTER IN AUGUSTA, GA, AS
THE ``CHARLIE NORWOOD DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER''
The American Legion has no position on this initiative.
S. 1043, A BILL TO REQUIRE THE SECRETARY OF VA TO SUBMIT A REPORT TO
CONGRESS ON PROPOSED CHANGES TO THE USE OF WEST LA VA MEDICAL CENTER
The American Legion has no official position on this issue.
However, since the issue of land at West LA VA Medical Center has had
no resolution for decades, The American Legion would support a mandate
requiring VA to submit a master plan detailing its intended utilization
of the land.
S. 1147, HONOR OUR COMMITMENT OF VETERANS ACT
In 2003, former VA Secretary Anthony Principi instituted a
restriction for enrollment of new Priority Group 8 veterans, therefore,
prohibiting access to VA medical care to hundreds of thousands of
Priority Group 8 veterans due primarily to limited resources. The
American Legion disagrees with the decision to deny access to any
eligible veterans.
The American Legion believes that a more effective method of
ensuring that VA can continue to provide quality care to veterans would
be to ensure that VA is sufficiently funded to care for their needs,
not limiting access for those who have incomes that fall above means
tests thresholds. These veterans are required to make copayments, in
addition to identifying their third-party health insurance that will
reimburse VA for reasonable charges. Many of these Priority Group 8
veterans may very well be VA employees, Medicare beneficiaries, TRICARE
or TRICARE for Life beneficiaries, or enrolled in the Federal Employees
Health Benefits Program. The American Legion supports the lifting of
the current prohibition on healthcare enrollment restriction for
Priority Group 8 and exploring effective means to improve third-party
reimbursement collections.
S. 1205, A BILL TO REQUIRE A PILOT PROGRAM ON ASSISTING VETERANS
SERVICE ORGANIZATIONS AND OTHER VETERANS GROUPS IN DEVELOPING AND
PROMOTING PEER SUPPORT PROGRAMS THAT FACILITATE COMMUNITY REINTEGRATION
OF VETERANS RETURNING FROM ACTIVE DUTY AND FOR OTHER PURPOSES
The American Legion has no position on this issue. However, there
is concern that the bill does not mention any standardized training or
oversight to ensure that the organizations selected are qualified to
provide peer support services.
S. 1233, VETERANS TRAUMATIC BRAIN INJURY
REHABILITATION ACT OF 2007
The American Legion supports the provisions of this bill.
Section 3 discusses community reintegration plans for veterans with
traumatic brain injury. It requires the Secretary of VA to develop an
individualized plan for each veteran to address his or her specific
rehabilitation needs. This plan must be available prior to the
veteran's discharge for the medical facility. It prescribes for the
designation of a case manager who would be responsible for implementing
the plan. Identification of a case manager and reintegration plan would
ensure that these veterans receive the necessary rehabilitation in a
timely manner and provide a contact that could coordinate on behalf of
the veterans in the event that the plan needs to be enhanced or
amended. It also assigns accountability in the event that the veterans
does not receive the care he or she was promised.
Section 4 requires VA to authorize the use of non-VA facilities
under very specific conditions: if the VA is unable to provide needed
treatment for any reason and if the veteran lives at a distance that
would make it difficult to implement the plan. The American Legion
believes that it is acceptable for veterans to receive medical care
from non-VA facilities in the absence of available VA healthcare, or
when traveling presents a hazard or hardship for the veteran.
Section 5 mandates VA establish a research, education, and clinical
care program to address severe traumatic brain injury. This is a very
important component in providing the best quality of care for those who
suffer from this type of injury. Since not much information is
available on long-term effects of combat-related traumatic brain
injury, research on the current war's veterans would be beneficial in
establishing standards of care provided to veterans of future
conflicts.
Section 6 discusses the creation of a pilot program to assess the
effectiveness of providing assisted living services for veterans with
traumatic brain injury to enhance rehabilitation, quality of life and
community integration of veterans. This will be especially important in
rural areas where there may be a lack of specialty care and veterans
may be forced to travel long distances.
Section 7 discusses age-appropriate nursing home care. Younger
veterans are generally more technologically advanced. Facilities
providing long term care for them should provide an environment that
reflects their interests.
Section 8 discusses research on traumatic brain injury. The
American Legion supports research that would improve care available for
veterans with service-connected injuries and that would attempt to
ascertain possible secondary health outcomes. Since many of the
symptoms of secondary conditions have delayed onset or have subtle
manifestations, research on improving the diagnosis, treatment and
prevention on traumatic brain injury will ensure the best quality care
for future generations of combat veterans.
Again, thank you Mr. Chairman for giving The American Legion this
opportunity to present its views on such an important issue. The
hearing is very timely and we look forward to working with the
Committee to enhance access to quality health care for all veterans.
Mr. Edelman?
STATEMENT OF BERNARD EDELMAN, DEPUTY DIRECTOR, POLICY AND
GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA
Mr. Edelman. Good morning, Mr. Chairman, Senator Murray.
Vietnam Veterans of America appreciates the opportunity to
testify before you here this morning on behalf of our officers,
our Board of Directors, our members, and their families who
want to thank you and your colleagues for the work you are
doing and the initiatives you are taking on behalf of our
Nation's veterans.
This morning, I would like to focus our comments on three
bills that we support and endorse and one bill that we have
major concerns about.
S. 1147, the Honor Our Commitment to Veterans Act, would
reopen the VA health care system to Priority 8 veterans. I
think some history is instructive here. Back in 1996, when
Congress passed the Veterans Health Care Eligibility Reform
Act, the VA was able to implement major cornerstones of its
plan to reform how it provided health care. The rationale
behind this initiative was to ensure a patient base that would
support the infrastructure that was needed to develop a modern,
integrated health care system.
This the VA has accomplished, and in the process a mediocre
and inefficient system has been transformed into a national
model.
However, the law gave the Secretary of Veterans Affairs the
authority and indeed the responsibility to determine
eligibility for enrollment based on available resources in any
given fiscal year. Although the law did not mandate a level of
funding or standard of care, it did establish an annual
enrollment process and categorized veterans into priority
groups.
In January 2003, as you all know, the Secretary of Veterans
Affairs made a decision to temporarily suspend priority
veterans from enrolling. This temporary decision is hardly
temporary. No VA planning document that we have read accepts or
accommodates Priority 8s in the near future.
We strongly urge that this Committee and your colleagues
get behind this most important piece of legislation and truly
honor the commitment we as a Republic have made to those who
have donned the uniform and served our country. Of course, we
recognize the bottom line is funding and the funding Congress
provides to enable the VA to accommodate those Priority 8
veterans who want to avail themselves of the VA's health care
services. We recognize the realities of pay-go, but we hope you
will recognize the inherent justice in reopening the VA health
care system to those who have earned the right to utilize it.
They also will not, we believe, overly burden the system. In
fact, it is our understanding that Priority 7 and 8 veterans
account for some 40 percent of third-party collections by the
VA.
S. 1233, the Veterans Traumatic Brain Injury Treatment Act,
would be instrumental in assuring troops afflicted with this
debilitating condition that help is there for them. We believe
it is a sensible, comprehensive piece of legislation for long-
term TBI rehabilitation and it should go a long ways toward
healing the wounded from these latest military ventures.
S. 479, the Joshua Omvig Veterans Suicide Prevention Act,
attempts to grapple with one of the tragic consequences of war.
Too many of our young people whom we have sent off to fight
halfway around the globe return markedly different. Some of
them, as you know, have taken their lives. This is a tragedy
for their family. It is a tragedy for this country. We heartily
endorse S. 479.
We have major issues, though, with S. 815, the Veterans
Health Care Empowerment Act of 2007, because it has a great
potential to undercut the VA health care system and it is
simply not worth the risk. If enacted, this bill would
effectively erode the VA's ability to service veterans by
permitting service-connected veterans to receive care and
medical services for any condition at any hospital or medical
facility or from any medical provider eligible to receive
payments under Medicare or TRICARE. We do not believe the VA
health care system is inefficient or corrupt. It is at a point
in time when the VHA is meeting the needs of the veterans it
serves.
One out of ten VA health care dollars today goes to
clinicians and facilities outside the VA system through what is
called fee-basis. The VA is also instituting a scheme called
Project HERO, which is the acronym for Healthcare Effectiveness
through Resource Optimization. The VA is attempting to get a
better handle on the dollars spent by VA medical centers for
care provided outside the system. We believe that HERO and S.
815 will only serve to hurt what has developed into one of the
best and finest managed-care systems in the world.
Please keep this in mind. The VA's electronic health record
system is simply not matched by other public sector or private
sector hospitals, clinics, or doctors. If you want to create an
administrative nightmare, try to maintain an effective,
efficient VA health care system and at the same time let
veterans go wherever they wish for their health care. This is
only going to create chaos, we believe, and more problems than
it solves, and it solves very little.
That concludes my oral testimony. Thank you for the
opportunity to speak with you today.
[The prepared statement of Mr. Edelman follows:]
Prepared Statement of Bernard Edelman, Deputy Director, Policy and
Government Affairs, Vietnam Veterans of America
Chairman Akaka, Ranking Member Craig, and Members of the Senate
Committee on Veterans' Affairs, Vietnam Veterans of America (VVA)
appreciates the opportunity to testify before you here today. On behalf
of our officers, our Board of Directors, our members and their
families, we want to thank you for the important work you are doing,
and the initiatives you are taking, on behalf of our Nation's veterans.
We would like to focus our comments this morning on four of the
bills up for your consideration that we endorse: S. 117, the ``Lane
Evans Veterans Health and Benefits Improvement Act of 2007''; S. 479,
the ``Joshua Omvig Veterans Suicide Prevention Act''; S. 1233, the
``Veterans Traumatic Brain Injury Rehabilitation Act of 2007''; and,
most assuredly, S. 1147, the ``Honor Our Commitment to Veterans Act.''
And also one bill, S. 815, the ``Veterans Health Care Empowerment Act
of 2007,'' that we feel will only serve to undermine the VA health care
system.
S. 1147, the ``Honor Our Commitment to Veterans Act,'' would re-
open the VA health care system to Priority 8 veterans. These are
veterans with an income of less than $28,000 a year who are not
afflicted with a service-connected disability and who agree to make a
copayment for their health care and prescription drugs.
Back in 1996, when Congress passed the Veterans Health Care
Eligibility Reform Act, the VA was able to implement major cornerstones
of its plan to reform how it provided health care. The rationale behind
this initiative was to ensure a patient base that would support the
infrastructure needed to develop a modern, integrated health care
system. This the VA has accomplished, and in the process a mediocre,
inefficient system has been transformed into a national model.
However, the law--that's Public Law 104-262--gave the Secretary of
Veterans Affairs the authority and responsibility to determine
eligibility for enrollment based on available resources in any given
fiscal year. Although the law did not mandate a level of funding or a
standard of care, it did establish an annual enrollment process and
categorized veterans into ``priority groups'' to manage enrollment.
On January 17, 2003, the Secretary made the decision to
``temporarily'' suspend Priority 8 veterans from enrolling. While this
decision may be reconsidered on an annual basis, every budget proposal
from the Administration since has omitted funding for Priority 8
veterans not previously enrolled and has attempted to discourage use by
and enrollment of those ``higher income'' veterans.
Priority 8 veterans are, for the most part, working- and middle-
class Americans without compensable disabilities incurred during their
military service. In its budget proposal for Fiscal Year 2007, the VA
estimated that some 1.1 million of these ``higher income'' veterans
would be discouraged from using their health care system because of an
enrollment fee and increased copays for prescription drugs. Thankfully,
you in Congress have not let this scheme get much beyond the proposal
phase.
We strongly urge that you get behind this most important piece of
legislation and truly honor the commitment we have made that honors our
veterans. Of course, we recognize that the bottom line is funding--the
funding Congress provides--to enable the VA to accommodate those
Priority 8 veterans who want to avail themselves of the VA's health
care services. We recognize the realities of ``pay-go.'' But we hope
you will recognize the inherent justice in reopening the VA health care
system to those who have earned the right to utilize it. They will not
overly burden the system; in fact, Priority 7 and 8 veterans account
for some 40 percent of all third-party collections by the VA.
TBI/Traumatic brain injury suffered by our troops in Afghanistan
and Iraq has become so relatively common that its acronym, TBI, is
becoming almost as infamous as PTSD. This affliction is not new; it has
only been so codified because of the carnage caused by IEDs, improvised
explosive devices, and another acronym that has been incorporated into
the dialect of war.
It is our understanding that the Administration is going to order
the military to screen all returning troops for mild to moderate cases
of TBI; those whose brain injuries are more serious are quite obvious
to clinicians. S. 1233, the ``Veterans Traumatic Brain Injury Treatment
Act of 2007,'' would be instrumental in assuring troops afflicted with
this debilitating condition that help will be there for them. It is a
sensible, comprehensive piece of legislation for long-term TBI
rehabilitation; it should go a long way toward healing the wounded from
these latest military ventures.
S. 479, the Joshua Omvig Veterans Suicide Prevention Act, attempts
to grapple with one of the unfortunate consequences of war. Too many of
our young men and women whom we've sent off to fight halfway around the
globe return markedly different. The lingering trauma of things they've
experienced haunts them. These memories affect their daily living, and
too many succumb to the emotional numbing and hurt. To not support this
bill would do a grave injustice to those troops still fighting their
demons.
The potential of S. 815, the ``Veterans Health Care Empowerment Act
of 2007,'' to harm veterans by undercutting the VA health care system
is simply not worth the risk. If enacted, this bill would effectively
erode the Veterans Health Administration (VHA) by permitting service-
connected veterans to receive hospital care and medical services for
any condition at any hospital or medical facility or from any medical
provider eligible to receive payments under either Medicare or the
TRICARE program. If you want to destroy the VA system, S. 815 is a good
start.
We do not believe the system is inefficient or corrupt. It is at a
point in time when the VHA is meeting the needs of the veterans it
serves. Besides, one out of every ten VA health care dollars today goes
to clinicians and facilities outside the VA system, and through a
scheme called Project HERO--the acronym for Healthcare Effectiveness
through Resource Optimization--the VA is attempting to get a better
handle on the dollars spent by VA medical centers for care provided
outside of the system. We believe that HERO--and S. 815--would only
serve to hurt what has developed into one of the best managed-care
systems in the Nation.
And keep this in mind: The VA's electronic health records are not
matched by other public sector and private hospitals, clinics, and
doctors. If you want to create an administrative nightmare, try to
maintain an effective, efficient VA health care system and at the same
time let veterans go wherever they wish for their health care. This
will only create more problems than it solves, and it solves very
little.
As for the other bills under consideration by the Committee today:
VVA supports wholeheartedly S. 383, which would extend the
period of eligibility for VA health care for combat service from two
years to five. This is a no-brainer. With a shooting war going on, we
have the obligation and responsibility of keeping our promises to those
who don the uniform. When they come home, when they leave the military,
they need to know that their government hasn't forgotten about them,
that as they establish themselves in civilian life they can avail
themselves of VA health care.
We understand that Congress has previously sought to fix a
glitch that occurred in calculating the retirement pay for annuitants
who worked part-time as VA nurses. S. 610 would accomplish this. VVA
has no opposition to this provision.
S. 692, the ``VA Hospital Quality Report Card Act of
2007,'' would require the VA to provide grades for its medical centers
on measures such as effectiveness, safety, timeliness, efficiency,
patient-``centeredness'' and equity. Health care quality researchers
have long thrived trying to objectively define some of these measures.
As this Committee knows, the VA has a number of performance measures it
regularly assesses in order to reward its medical center and network
directors, among others. Some of these outcomes, such as immunizations
for flu, foot care and eye care for diabetics, set the ``benchmark''
for care in the community. In addition to these internal performance
measures, VHA voluntarily submits to Joint Commission on Accreditation
of Healthcare Organizations, Commission on Accreditation of
Rehabilitation Facilities, and managed care quality review standards.
VVA understands the importance of quality measurement; there is an
expression with which we agree, ``what's measured, matters.'' We also
agree that VA officials should be held to the highest degree of
accountability, and whatever measures are available to allow this to
better occur we wholeheartedly endorse. But perhaps before enacting
this clearly well intended legislation, which could require significant
retooling of quality measurement systems in VA, the Committee should
hold a hearing to identify gaps and deficiencies in current performance
and quality measurement systems. It would also be useful to understand
how report cards would be used and reported to improve VHA processes
and performance rewards. Would poor grades be dealt with by changes in
management? With more funding? How would good grades be rewarded? Such
questions should be addressed before requiring a significant new
quality measurement program to be installed.
VVA understands that S. 874 would pay certain providers
for delivering medical care, mental health care, case management and
other services to very low-income veterans who have permanent housing.
VVA supports efforts to target veterans who may be at risk of becoming
homeless, but these individuals are often difficult to identify until
it is too late. In addition, funding for VA mental health, in addition
to homeless grant and per diem providers, is also already too scarce.
VVA supports the addition of this benefit if VA is funded appropriately
to provide it without taking resources away from these other programs.
While the VA Secretary has had the discretion to raise
beneficiary travel rates, no Secretary has chosen to do so in decades.
The result is an almost meaningless benefit for veterans who seek it.
S. 994 would allow the VA to reimburse certain veterans for travel at a
rate that the government pays its own employees. That sounds fair to
VVA.
VVA has no objection to S. 1043, under which Congress
would require a report on proposed land use changes on the campus of
the West LA VA Medical Center.
S. 1205 would require the VA to develop a pilot program to
make grants to veterans service organizations and other veterans groups
to develop peer-support groups to assist with veterans' reintegration.
As an organization whose creed is ``Never again will one generation of
veterans abandon another,'' VVA has expended considerable resources in
assisting newly minted veterans as well as some new veterans groups--
particularly Veterans of Modern Warfare--in developing a robust program
to advocate for their members' needs. We have certainly not done so
contemplating financial gain. Assisting veterans' reintegration with
peer-support groups is and should be a function of VSOs; organizations
should not have to compete for funding for providing veterans'
services, which would significantly change the nature of the game.
Designating the VA medical center in Augusta, Georgia, the
``Charlie Norwood Department of Veterans Affairs Medical Center''
acknowledges the contributions of a recently deceased Member of
Congress who served in the military as well as in the House of
Representatives. VVA applauds the spirit and endorses the intent of
this bill.
Additional legislation to enhance the VA's programs for
homeless veterans, introduced by Senator Akaka, deserve support, too.
It is a national disgrace that so many veterans--upwards of 200,000,
according to most estimates--do not have a place to call home. There
are many causes of homelessness; in the case of too many veterans,
their experiences in combat are likely one of the reasons they have
``dropped out'' of society and self-medicate with alcohol and other
drugs. Furthermore, it is our position that VA Homeless Grant and Per
Diem funding must be considered a payment rather than a reimbursement
for expenses, an important change that will enable the community-based
organizations that deliver the majority of these services to operate
effectively.
Per Diem dollars received by service centers are not capable of
supporting the ``special needs'' of the veterans seeking assistance.
Currently they are receiving less than $3.50 per hour per veteran that
the veteran is onsite. The work of assisting the homeless veterans who
utilize these services goes on long after they have left the service
center, a center that is providing a full array of services and case
management.
These service centers are unique and indispensable in the VA
process. In many cases they are the front and first exposure to the VA
and VA Homeless Grant and Per Diem programs. They are the door from the
streets and shelters to substance abuse treatment, job placement, job
training, VA benefits, VA medical and mental health care and treatment,
and homeless domiciliary placement. Veteran-specific service centers
are vital in that most city and municipality social services do not
have the knowledge or capacity to provide appropriate supportive
services that directly involve the treatment, care, and entitlements of
veterans. Additionally, since many local municipalities have removed
``supportive services'' from their HUD Continuums of Care, providing
staffing dollars through a VA Homeless Grant and Per Diem staffing
grant program, similar to the Special Needs Grant process, to those
agencies operating service centers, would allow the service centers to
provide these vital services with appropriate level of qualified
personnel. Without consideration of staffing grants the result may well
be the demise of these critical services centers. Some are currently
assisting upwards of 50 veterans a day, with more than 900 individual
veterans seeking services annually.
The VA acknowledges this problem exists. It is yet to be
specifically identified by them as to how many awarded service center
grantees have been affected by either the inability to establish these
centers or retain operation because of this very funding issue. If we
intend to fully address the issue of veterans who remain on the
streets, then we urge you to not make light of this very important
element in this bill. It will be especially critical to the new
veterans who find themselves in this very disturbing situation of life.
They deserve our best efforts.
In addition, as highlighted in the 2006 recommendations made by the
Secretary's Advisory Committee on Women Veterans, a survey of homeless
women veterans showed that fewer women veterans are seeking services in
VA domiciliary settings and residential treatment facilities because of
concerns about safety, privacy, and what is a male-dominated
environment. Ideally, separate area/space designed for women veterans
will support this need. Flexibility in design will allow appropriate
utilization of space.
We also advocate that all VA domiciliary settings be evaluated with
regard to gender-specific needs related not only to the safety and
security, but also to positive therapeutic environments and successful
treatment modalities.
This concludes our testimony. VVA is appreciative of having been
afforded the opportunity to testify on the merits of these bills. We
would be pleased to respond to any questions you might have.
______
Vietnam Veterans of America's Views on Rural Veterans Health Care
The topic of accessibility to VA medical services for veterans who
live in rural areas has been percolating of late. We believe that S.
1146, the ``Rural Veterans Health Care Improvement Act of 2007,''
offers pragmatic solutions to address the problems of access to health
care experienced by too many rural veterans. The bill would increase
travel reimbursement for veterans who travel to VHA facilities to the
rates paid to Federal employees. The current reimbursement rate was
established decades ago and does not adequately compensate for the
costs of gasoline, ``wear and tear'' on the vehicle or increased
insurance that might be necessary in order to travel to distant medical
centers. In the same vein, the grant program for rural veterans service
organizations to develop transportation programs could be an innovative
way to strengthen community resources that may already assist with
veterans' travel needs.
The establishment of centers of excellence for rural health
research, education, and clinical activities, another component of this
bill, should fill a gap in VA health care and should lead to innovation
in long-distance medical and telehealth care. These centers have
brought the synergies of clinical, educational and research experts to
bear in one site. Such centers have allowed VA to make significant
contributions to the fields of geriatric medicine and mental illness.
It would require demonstrations of rural treatment models.
Demonstrations on treating rural veteran populations would be extremely
useful in assessing effective ways to offer health care to individuals
who are generally poorer, more likely to be chronically ill, and
almost, by definition, more likely to have challenges in access to
regular health care.
And establishing partnerships--with the Indian Health Service and
with the Department of Health and Human Services--also should add to
greater cooperation and collaboration in meeting the needs of rural
veterans.
We would caution, however, that we would not like to see these
demonstration projects exploring more opportunities to do widespread
contracting out of veterans' health care services. Demonstration models
should be assessed according to a number of outcomes such as quality of
care, cost, and patient satisfaction and the results reported to
Congress.
Chairman Akaka. Thank you very much, Mr. Edelman. I thank
all of you.
I would like to ask one question and then ask Senator
Murray for any questions she might have. This question is to
all of you. While the bills being considered today address
very, very different issues, many have a common thread of
pushing VA to contract for more and more care in the community.
My question to you is, do you each believe that VA care should
and can be the very best? When is it desirable for VA to
purchase outside care? Mr. Blake?
Mr. Blake. Well, I would say the short answer, Mr.
Chairman, is yes, it should be and it is the best. We have
testified on a number of occasions as it relates to fee-basis,
and kind of as a way to quickly address Senator Craig's
question earlier about individual veterans who maybe are not
able to get a particular kind of service, it has been our
contention all along, and we have testified to this also on the
issue of rural health care, that the VA has the authority to
meet the needs of these veterans if it is not being met within
the VA health care system now under their fee basis
regulations.
However, we have testified in the past that we don't
believe the VA is very judicious in how it applies its
regulations. It is overly conservative, if anything, which on
its face goes against principally what we believe against
contracting out health care. But we also recognize that there
are situations where it is absolutely necessary.
Now, doing it on a broader basis is far more problematic in
our eyes for reasons that we have outlined here in our
testimony and in previous forums.
Chairman Akaka. Thank you. Mr. Cullinan?
Mr. Cullinan. Thank you, Mr. Chairman. It is the VFW's
contention, as well, that the VA must be maintained as the
premier health care provider in the world. Having said that, I
would associate myself with something Senator Craig said
earlier, that when it comes to the individual needs of veterans
in need, by all means, we should take advantage of such things
as contract care, fee-basis care, and so forth. Our objection,
as you know, with S. 815 was the fact that it was too broad in
scope and has the very definite potential of undermining the
system. But when it comes to those cases where the care is not
accessible or in those instances when the care is--VA is simply
unable to provide a certain care modality, then fee-basis
contract care is the way to go.
Chairman Akaka. Ms. Ilem?
Ms. Ilem. I would echo my colleagues' comments, but just
add to that that in terms of contracting care, especially for
PTSD or some other mental health issue, one of the concerns
that we would have is if there is the cultural competence. VA
is a unique system. They have done a lot of work in very
specialized areas in terms of mental health and combat-related
trauma and the most effective treatments. And so at all times,
whenever possible, we want VA to provide that care because we
feel they are the very best, and as Dr. Cross pointed out, as
well, within traumatic brain injury, the unique setting is that
these veterans have a polytrauma, often other very severe
injuries associated with their brain injury which the private
sector likely hasn't seen, as well, and they are very
complicated cases.
But in individual cases, if VA is unable to provide that
care for some reason, you know, certainly we want veterans to
get access to that care. We just don't want that to be--we want
the VA to take primary responsibility. If there is a problem
with a veteran in getting some type of care or they are not
doing a good job, that issue should be addressed and it should
be maintained within the system. VA should be responsible for
that care and continue that lifetime relationship with that
patient who will ultimately be responsible for their care, most
likely. Thanks.
Chairman Akaka. Ms. Middleton?
Ms. Middleton. Yes, sir. Well, I will have to echo all
three of my colleagues. The American Legion also believes that
when absolutely necessary, care should be provided by non-VA
health care providers in the community, and that is in the case
of maybe rural veterans or in the case where travel for the
veteran might present a danger to him. If coordinating care
might be just complicated because of the special needs of the
veteran, then non-VA care would be appropriate. But we, as I
said, echo the other VSOs that it should be provided by the VA.
They are the people who can provide the best quality care for
those who have military-related injuries.
Chairman Akaka. And Mr. Edelman?
Mr. Edelman. Yes, sir. I will associate our position with
that of my colleagues here. There is a need for fee-basis care
when the care cannot be provided by VA, particularly for
individual veterans' needs, particularly for rural veterans. We
have no problem with that, nor should we. At the same time, the
integrity of the VA health care system, which we have all
worked to buildup over these past several years, should not be
undermined by indiscriminate use of fee basis or outsourcing of
contract care.
Chairman Akaka. Thank you very much.
Senator Murray?
Senator Murray. Thank you, Mr. Chairman. I just have a
couple of questions.
One of them is on a bill that we were not able to get on
the calendar today but it has to do with veterans who live in
rural areas. We heard several Senators talk about the
challenges that they face, and last year, we recognized the
disparity for our veterans who live in more remote communities
with the passage of the Office of Rural Health to put an office
within the VA to start looking at how we better implement care
and policies for veterans who live in more rural communities.
It was a good start. I think much more needs to be done.
And Senator Salazar has introduced legislation, Rural
Veterans Health Care Improvement Act, to build on that and to
develop some demonstration projects and centers of excellence
and a transportation grant program and I just wondered if any
of you could comment quickly on whether or not you support
that. I know you weren't prepared for it. It is not on the
agenda. But I wanted to make sure we were all aware of it.
Mr. Cullinan. Senator Murray, on behalf of the VFW, we are
familiar with that issue and how problematic it really is and
we are certainly supportive as described of an initiative which
would have VA undertake a look into what can be done.
And the thing I would add to that, and one thing that
should be done right away is Senator Tester's bill, which would
provide for increased beneficiary travel. That alone would
solve the problem for many, many veterans in the----
Senator Murray. Right, and I believe that is incorporated
in Senator Salazar's legislation, as well.
Does anyone else want to comment on that? Mr. Blake?
Mr. Blake. Senator, I think this sounds a lot like a bill
that he introduced in the previous Congress and we worked with
Senator Salazar's office and made some comments about concerns
that we had, particularly as it relates to broader contracting,
recognizing that we have concerns there. Having not seen the
bill, I won't comment as far as an actual position, but we
certainly will work with you and Senator Salazar and all the
Members of the Committee to develop the best bill. I mean, we
recognize that rural health care is probably one of the most
important issues facing this Committee and all of Congress
right now and how to address the needs of the men and women who
are kind of scattered to the four winds,
so to speak.
Senator Murray. Well, maybe if I could ask, Mr. Chairman,
if I could just get some quick written comments back from all
of you on that legislation, that would be great, because I did
want to ask one other question on the Priority 8 veterans.
The issue of funding has come up over and over again, and
the VA, although they didn't testify to it today, has estimated
it to be a cost of over a billion dollars. The Independent
Budget estimated it at $366 million. Can anyone comment on why
the disparity
in that?
Mr. Blake. Well, Senator, I don't necessarily know what
exactly the disparities would be other than to say that our
cost estimate is based on the assumption of needed
discretionary dollars, considering that those new Category 8s
would also add money into the system through their co- pays and
associated fees that may be necessary, whereas I believe the
VA's estimate--I believe, I am not absolutely certain--is just
an actual total cost for that group of
veterans.
Senator Murray. It doesn't count into their third-party
insurance?
Mr. Blake. As I understand it. The other thing to consider
is, and I would have to go back and review the budget, the
Administration's budget submission from earlier this year, but
our dollar figure reflects the fact that although most
estimates pinpoint more than a million veterans being denied
enrollment since this policy was put into place in 2003, the
real factor is that the utilization rate for Category 8
veterans is only about 20 percent.
So you can cost out a cost for the million-plus veterans
that would be denied enrollment, but looking back at
historically how it has worked out, you would only assume that
about 20 percent of those veterans would use the system. So
there would be a cost associated with 20 percent of that
million-plus veterans. So our cost estimate for the Independent
Budget reflects that, as well.
Senator Murray. OK. I really appreciate that, and maybe the
VA could give us back a response, as well, on that, because
that is a critical issue and I do think we have to really look
at the reality of what that would do.
So I appreciate your comment.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
We may have follow-up questions that we will include in the
record. I want to thank you all again. You know that we look to
you to hear your ideas about our bills and I thank you so much,
for what you have testified before us and responded to us will
certainly help. Thank you very much.
Now, I would like to call on our third panel to come
forward. Our third panel of witnesses to today's hearing is
Meredith Beck of the Wounded Warrior Project; Dr. John Booss,
representing the American Academy of Neurology; and Jerry Reed,
Executive Director of Suicide Prevention Action Network USA.
I thank you all for appearing before the Committee today.
You know that your full statements will appear in the record of
the hearing.
Meredith Beck, will you please proceed with your statement.
STATEMENT OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, WOUNDED
WARRIOR PROJECT
Ms. Beck. Mr. Chairman, thank you for the opportunity to
testify before you today regarding pending health legislation.
The Wounded Warrior Project is a nonprofit, nonpartisan
organization dedicated to assisting the men and women of the
Armed Forces, who have been severely injured during the recent
conflicts. As a result of our direct daily contact with these
wounded warriors, we have gained a unique perspective on their
needs and the obstacles they face as they attempt to recover
and reintegrate into their respective communities.
First, WWP is pleased that the Chairman and Senator Craig
have highlighted the issues surrounding traumatic brain injury
with the introduction of S. 1233, the Veteran Traumatic Brain
Injury Rehabilitation Act of 2007. The signature wound of the
war, as it has come to be known, TBI is an extremely
challenging injury to treat and poses some new and complex
issues for the Department of Veterans Affairs.
As such, and because the families of wounded servicemembers
have named increased access to treatment options as their
number one request, WWP supports the concept included in the
legislation allowing TBI patients to use private facilities for
rehabilitation. At the same time, however, we would like to see
a provision added authorizing and encouraging the VA to
collaborate with experienced private sector hospitals in
addition to medical universities so that the Department can
continue to develop long-term rehabilitation capabilities and
perhaps one day become the facility of choice for severely
injured TBI patients.
We are also extremely concerned with the method by which
the legislation determines the TBI patients' eligibility for
such a health care benefit. According to the provision as
currently written, the Secretary would have the discretion to
enter into individual agreements with facilities to provide
care based in part on geographic location. But no care criteria
for the participating private facilities are enumerated.
Even more importantly, by determining eligibility based on
geographic proximity to a VA facility and the discretion of the
Secretary for the Department's ability to provide the necessary
services, the legislation would limit the range of patients who
can qualify for placement in a private facility and thus not
provide the options for care that our wounded warriors and
their families are seeking.
While WWP does not question the intent or the effort of the
VA to care for these patients, we are concerned that the
understandable need to further develop their capability for the
benefit of future patients may disqualify current patients who
would otherwise benefit from private rehabilitation.
For example, several weeks ago, many of you heard the
testimony of Denise Mettie before this Committee regarding her
son, Evan's, experiences in both DOD and VA facilities. As you
may recall, Evan bypassed the VA polytrauma system for a period
of time and experienced several setbacks once he finally
reached the VA's Tier 1 facilities. After much discussion,
debate, and effort, Evan was finally sent to the Kessler
Institute for Rehabilitation, a private facility in New Jersey
where only after a few weeks it had been discovered that Evan
is not blind in one eye, as it was believed. His nystagmus has
almost completely stopped, and he even gave a physical
therapist a thumbs up with his left hand, which he has not used
for almost a year. Of course, no one can guarantee that type of
progress for every wounded veteran, but whether in a VA
facility or a private rehabilitation hospital, every one of
them deserves the chance to try.
For these and other reasons, WWP is grateful for Senators
Akaka's and Craig's leadership on this legislation and we would
like to continue to work with you to enhance S. 1233 to better
meet the needs of the severely wounded servicemembers,
veterans, and their families.
With respect to S. 383, a bill to extend the period of
eligibility for health care for 2 years to 5 years after
discharge, WWP is generally supportive of the provision. Often,
especially in cases of delayed onset PTSD or mild to moderate
TBI, veterans do not quickly recognize that they are in need of
assistance or care. In other cases, veterans are simply not
prepared to navigate another bureaucratic system after having
just escaped the burdensome and administrative process of the
Department of Defense.
WWP cautions, however, that while we want to make sure that
every service-connected veteran is able to access the care he
or she needs, extending the period of presumptive eligibility
for VA care will add more veterans to an already overburdened
system. Therefore, if this provision is adopted, Congress must
ensure that the required resources are added, as well.
In theory, WWP generally supports the concept behind S.
815, the Veterans Health Care Empowerment Act of 2007, but has
concerns about the implementation of and the long-term effects
of such action on the VA. This legislation would allow service-
connected veterans to receive health care at any facility or
through any provider eligible to receive Medicare or TRICARE
payments. As mentioned previously in our testimony, the top
request of wounded veterans and their families is to have more
involvement and choice in their care and this legislation would
certainly help to accomplish that goal.
However, we are concerned that, as written, the VA would
play no role in the coordination of care for the veterans who
choose outside facilities, and without proper management by the
VA, such a system could lead to confusion and contradiction
among physicians in the provision of the care to the wounded.
In addition, the legislation does not include any specifics on
the implementation of such a large policy shift and therefore
the final plan could differ greatly from that sought by
Congress.
At this time, WWP unfortunately has grave concerns
regarding S. 1147, the Honor Our Commitment to Our Veterans
Act, which would require the Secretary to lift the current
freeze on the enrollment of Category 8 veterans into the VA
health care system. According to the Veterans Health Care
Eligibility Reform Act of 1996, the legislation would first
authorize the VA to provide health care services to veterans
without service-connected disabilities or low income. If
sufficient resources are not available to provide care that is
timely and acceptable in quality for all priority groups, the
Act requires VA to limit enrollment based on the priority
groups
themselves.
Just over the past several weeks, many in this room have
identified waiting times for appointments, quality of care, and
limited resources as just some of the challenges facing the VA.
With the addition of relatively higher-income non-service-
connected veterans, Congress would be placing an additional
strain on a system it has called overburdened and complicated.
With that said, those at the VA are working very hard to
accommodate their current patients and WWP asks that we work
with them to improve the care for those currently in the
system, especially those who are severely injured, before
adding another category of veterans.
Mr. Chairman, thank you again for this opportunity to
testify and I look forward to your questions.
[The prepared statement of Ms. Beck follows:]
Prepared Statement of Meredith Beck, National Policy Director,
Wounded Warrior Project
Mr. Chairman, Senator Craig, Members of the Committee, thank you
for the opportunity to testify before you today regarding pending
health legislation.
The Wounded Warrior Project (WWP) is a non-profit, non-partisan
organization dedicated to assisting the men and women of the United
States Armed Forces who have been severely injured during the War on
Terrorism in Iraq, Afghanistan and other hot spots around the world.
Beginning at the bedside of the severely wounded, WWP provides programs
and services designed to ease the burden of these heroes and their
families, aid in the recovery process and smooth their transition back
home. As a result of our direct, daily contact with these wounded
warriors, we have gained a unique perspective on their needs and the
obstacles they face as they attempt to recover and reintegrate into
their respective communities.
Today, I would like to comment on several pieces of legislation
listed on the hearing agenda. First, WWP is pleased that the Chairman
and Senator Craig have highlighted the issues surrounding Traumatic
Brain Injury (TBI) with the introduction of S. 1233, Veterans Traumatic
Brain Injury Rehabilitation Act of 2007. The ``signature wound of the
war'' as it has come to be known, TBI is an extremely challenging
injury to treat and poses some new and complex issues for the
Department of Veterans Affairs (VA). As accurately stated in the
legislation, those who are severely injured require individualized,
comprehensive care, and, while the VA has made tremendous progress in a
short period of time, they are still in the process of establishing an
extensive, long term continuum of care that can be accessed throughout
the Nation. As such, and because the families of wounded servicemembers
have named increased access to treatment options as their number one
request, WWP supports the concept included in the legislation allowing
TBI patients to use private facilities for rehabilitation. At the same
time, however, we would also like to see a provision added authorizing/
requiring the VA to collaborate with experienced private sector
hospitals in addition to medical universities so that the Department
can continue to develop long-term rehabilitation capabilities and,
perhaps, one day become the facility of choice for severely injured TBI
patients.
We are also extremely concerned with the method by which the
legislation determines the TBI patient's eligibility for such a health
care benefit. According to the provision as currently written, the
Secretary would have the discretion to enter into individual agreements
with facilities to provide care based on in part on geographic
location, but no care criteria for the participating private facilities
are enumerated. Even more importantly, by determining eligibility based
on geographic proximity to a VA facility and the discretion of the
Secretary for the Department's ability to provide the necessary
services, the legislation will limit the range of patients who can
qualify for placement in a private facility and thus not provide the
options for care that our warriors and their families are seeking.
While WWP does not question the intent or effort of the VA to care
for these patients, we are concerned that their need to further develop
their capability for the benefit of future patients may disqualify
current patients who would otherwise benefit from private
rehabilitation. For example, several weeks ago many of you heard the
testimony of Denise Mettie before this Committee regarding her son,
Evan's, experiences in both DOD and VA facilities. As you may recall,
Evan bypassed the VA Polytrauma System for a period of time and
experienced several setbacks once he finally reached one of the VA's
Tier I facilities where he had seemed to plateau, if not regress, in
terms of improvement. After much discussion, debate, and effort Evan
was finally sent recently to the Kessler Institute for Rehabilitation,
a private rehabilitation facility in New Jersey where, after only a few
weeks it has been discovered that Evan is NOT blind in one eye as was
believed, his Nystagmus has almost completely stopped, and he even gave
his physical therapist a thumbs up with his left hand which he has not
used for almost a year. Of course no one can guarantee that type of
progress for every wounded veteran, but, whether in a VA facility or a
private rehabilitation hospital, every one of them deserves the chance
to try. For these and other reasons, WWP is grateful for Senators Akaka
and Craig's leadership on this legislation and we would like to
continue to work with you to enhance S. 1233 to better meet the needs
of severely wounded servicemembers, veterans, and their families.
With respect to S. 383, a bill to extend the period of eligibility
for health care from 2 years to 5 years after discharge or release from
the Armed Forces, WWP is generally supportive of the provision. Often,
especially in cases of delayed-onset Post Traumatic Stress Disorder or
mild to moderate Traumatic Brain Injury, veterans do not quickly
recognize that they are in need of assistance or care. In other cases,
veterans are simply not prepared to navigate another bureaucratic
system after having just ``escaped'' the burdensome administrative
process of the Department of Defense. WWP cautions, however, that while
we want to make sure that every service-connected veteran is able to
access the care he or she needs, extending the period of presumptive
eligibility for VA care will add more veterans to an already
overburdened system. Therefore, if this provision is adopted, Congress
must ensure that the required resources are added as well.
In theory, WWP generally supports the concept behind S. 815, The
Veterans Health Care Empowerment Act of 2007 but has concerns about the
implementation of and the long-term effects of such action on the VA.
This legislation would allow service-connected veterans to receive
healthcare at any facility or through any provider eligible to receive
Medicare or TRICARE payments. As mentioned previously in our testimony,
the top request of wounded veterans and their families is to have more
involvement and choice in their care, and this legislation would
certainly help accomplish that goal. However, we are very concerned
that, as written, the VA would play no role in the coordination of care
for the veterans who choose outside facilities. Without proper
management by the VA, such a system could lead to confusion and
contradiction among physicians in the provision of care to the wounded.
In addition, the legislation does not include any specifics on the
implementation of such a large policy shift, and, therefore, the final
plan could differ greatly from that sought by Congress.
At this time, WWP has grave concerns regarding S. 1147, The Honor
Our Commitment to Veterans Act, which would require the Secretary to
lift the current freeze on the enrollment of Category 8 veterans into
the VA healthcare system. According to The Veterans' Health Care
Eligibility Reform Act of 1996, the legislation which first authorized
VA to provide health care services to veterans without service-
connected disabilities or low incomes, if sufficient resources are not
available to provide care that is timely and acceptable in quality for
all priority groups, the Act requires VA to limit enrollment based on
the priority groups.
Just over the past several weeks, many in this room have identified
waiting times for appointments, quality of care, and limited resources
as just some of the challenges facing the VA. With the addition of
relatively higher income, non-service connected veterans, Congress
would be placing an additional strain on a system it has called
overburdened and complicated With that said, those at the VA are
working very hard to accommodate their current patients, and WWP asks
that we work with them to improve the care for those currently in the
system, especially those who are severely injured, before adding
another category of veterans.
Finally, WWP is concerned that while well-intentioned, S. 882,
requiring a pilot program to facilitate the transition of members of
the Armed Forces to VA healthcare upon completion of service, and S.
1205, requiring a pilot program to assist veterans service
organizations in developing peer support programs would create programs
redundant to those already provided by the government or non-profit
groups. For example, each of the services within the DOD operates its
own organization to care for their respective wounded servicemembers.
The Marine for Life Program currently offers services to transitioning
Marines including job opportunities and information on veterans'
benefits. In addition, many non-profits, including WWP, operate
successful peer support programs funded through individual donations.
This type of assistance is not only beneficial to the warrior, but is
also an important means by which those in the community can support our
returning veterans. Because many of our families often state they are
confused by the number of different entities approaching them and,
``need a case manager to manage their case managers,'' WWP would
suggest improved coordination and integration among existing
organizations and agencies before adding more layers and a review of
current services, both governmental and non-profit to determine the
best use of limited funds.
Mr. Chairman, thank you again for this opportunity to testify, and
I look forward to your questions.
Chairman Akaka. Thank you very much for your testimony.
Dr. Booss?
STATEMENT OF JOHN BOOSS, M.D., PROFESSOR EMERITUS OF NEUROLOGY
AND LABORATORY MEDICINE, YALE UNIVERSITY SCHOOL OF MEDICINE; ON
BEHALF OF THE AMERICAN ACADEMY OF NEUROLOGY
Dr. Booss. Thank you and good morning.
Chairman Akaka. Good morning.
Dr. Booss. I am John Booss, an Air Force veteran and the
former National Director of Neurology for the Department of
Veterans Affairs. I am proud to have had over 30 years of
service to the VA. I am Professor Emeritus of Neurology and
Laboratory Medicine at Yale University School of Medicine and a
fellow of the American Academy of Neurology, the AAN.
On behalf of the AAN and the more than 20,000 neurologists
and neuroscience professionals we represent, I applaud you for
introducing S. 1233. It will improve the rehabilitation of
veterans with traumatic brain injury, or TBI.
TBI involves neurological cognitive behavioral changes
which are complex and diverse and may change in severity or
develop over time. Longer-term neurological problems include
post-traumatic epilepsy, headache, sleep disorders, and sensory
complications.
First, some general comments on S. 1233. We strongly
support the team approach. Individualized rehabilitation plans
based on a comprehensive assessment of a veteran's physical,
cognitive, vocational, and psycho-social impairments using a
multi-disciplinary team that includes specialists in neurology
are essential to the rehabilitative process. We endorse
involving the veteran and the family in the plan. TBI is a
devastating and life-altering condition for veterans and their
families. Families of veterans with TBI need support and
education and they should be part of the rehabilitative team.
Families also should not have the burden of traveling
significant distances to access VA quality care. The AAN
supports the use of non-VA facilities in cases where the VA is
unable to provide easily accessible care as long as those
facilities conform to the high standards of VA care.
We underscore the importance of the sections of the bill
which provide for long-term care needs of those veterans for
assisted living and long-term care.
I turn now to Section 8. Section 8 improves research on
visually related neurological conditions and seizure disorders,
which are frequent complications from TBI. The American Academy
of Neurology is particularly supportive of the bill's
recognition that seizure disorders will be a significant and
frequent problem of TBI and that research on treatment is
necessary. We do not have long-term data on post-traumatic
epilepsy from the current conflicts, but the statistics from
the Vietnam era are alarming.
Research in VA and DOD found that 53 percent of veterans
who suffered a penetrating head wound in Vietnam developed
epilepsy within 15 years. The relative risk for developing
epilepsy more than 10 to 15 years after the injury was 25 times
higher than their age-related civilian counterparts. Indeed, 15
percent did not manifest epilepsy until 5 or more years after
their combat injury.
Neurologists are concerned, too, that the rate of post-
traumatic epilepsy from blast TBI will also be high.
Given the high rate of post-traumatic epilepsy that
veterans with TBI are likely to endure, the VA must have a
strong national epilepsy program. We believe that Section 8
takes a step in recognizing that need.
Decades ago, the VA was, in fact, the national leader in
the care and research for patients with epilepsy, but since
that time, the VA epilepsy centers have languished due to a
lack of funds. We appreciate S. 1233's proactive recognition of
epilepsy as a significant consequence of TBI and support VA
research in this area. The Academy believes that this could
help lead the way to centers of excellence much in the way the
VA leads on Parkinson's disease and multiple sclerosis. This
could restore the VA to its earlier prominence in taking care
of veterans with epilepsy.
In conclusion, the Academy wholeheartedly supports S. 1233
as needed legislation. Epilepsy is a major concern for those
with TBI and we look forward to working with you to ensure that
America's veterans who suffer TBI have access to a system that
provides lifelong care and support.
Thank you for the opportunity to provide our support and
comments on S. 1233.
[The prepared statement of Dr. Booss follows:]
Prepared Statement of John Booss, M.D., Professor Emeritus of Neurology
and Laboratory Medicine, Yale University School of Medicine; on Behalf
of the American Academy of Neurology
Good morning, Mr. Chairman and Members of the Committee. My name is
Dr. John Booss. I am a veteran of the Air Force and the former National
Director of Neurology at the Department of Veterans Affairs (VA), and
proud to have over thirty years of service to the VA. I am currently a
Professor Emeritus of Neurology and Laboratory Medicine at Yale
University and a fellow of the American Academy of Neurology (AAN). On
behalf of the AAN, I am pleased to present our support of S. 1233. The
AAN, which represents over 20,000 neurologists and neuroscience
professionals, believes that our veterans deserve the best possible
care for neurological injuries sustained in their service to our
country.
I applaud this Committee for holding hearings earlier on how the
conflicts in Iraq and Afghanistan have created an emerging epidemic of
traumatic brain injury (TBI) among combat veterans. TBI, which has been
called the signature wound of the wars, involves neurological,
cognitive and behavioral changes which are complex, varied, diverse and
may change in severity or develop over time. Longer-term neurological
problems often include post-traumatic epilepsy, headaches, sleep
disorders and sensory complications.
The AAN strongly supports the ``team approach'' laid out in section
3 of S. 1233. Each veteran who suffers a TBI should receive ongoing
individualized, comprehensive and multidisciplinary rehabilitation
after inpatient services. Rehabilitation plans that are based upon a
comprehensive assessment of the veteran's physical, cognitive,
vocational, and psychosocial impairments, using a multidisciplinary
team that includes neurologists (as required by S. 1233), are essential
to rehabilitative success.
We support the provision in section 3 which requires involving the
family and veteran in the development and review of the rehabilitation
plan. TBI is a devastating and life-altering event which affects the
veteran and his or her family. Families of veterans with TBI need
support and education, and should be part of the rehabilitative team to
the greatest extent possible.
We also support the periodic assessment of the rehabilitation plan.
The consequences of a TBI may change over time and new symptoms may
develop. For example, individuals with TBI may develop post-traumatic
seizures months or years after the injury. Epilepsy requires regular
monitoring. For many patients, changes in their anti-seizure
medications are required. This makes this periodic assessment crucial.
The AAN also appreciates the recognition of seizure disorders as a
common outcome of TBI in S. 1233. Post-traumatic epilepsy is going to
be a significant long-term consequence of TBI.
Although we do not have data on post-traumatic epilepsy from the
current conflicts, the statistics from the Vietnam era are alarming.
VA-funded research conducted in collaboration with the Department of
Defense found that 53 percent of veterans who suffered a penetrating
TBI in Vietnam developed epilepsy within 15 years. For these service-
connected veterans, the relative risk for developing epilepsy more than
10 to 15 years after their injury was 25 times higher than their age-
related civilian cohorts. Indeed, 15 percent did not manifest epilepsy
until five or more years after their combat injury. As neurologists, we
believe that the rate of epilepsy from blast TBI will also be high.
Given the high rate of post-traumatic epilepsy that veterans with
TBI are likely to endure, the AAN believes that Congress should
authorize and the VA must establish a strong national epilepsy program
with Research, Education and Clinical Centers, to include Epilepsy
Centers of Excellence. We are concerned that the VA lacks a national
program for epilepsy with clear guidelines on when to refer patients
for further assessment and treatment of epilepsy. VA Centers of
Excellence have been the model of innovation in the delivery of highly
specialized health care and research for other disabling and chronic
diseases in the veteran population. VA has infrastructure to address
many of the other common consequences of TBI, such as psychosocial
changes and vision problems but not post-traumatic epilepsy.
At one point, the VA was a national leader in care and research for
patients with epilepsy. As early as 1972 the VA recognized the need for
VA health centers that specialized in epilepsy. But starting in the
1990s these epilepsy centers have languished due to lack of funds.
Six strategically located facilities could develop the necessary
capacity to function as centers of excellence in research, education,
and training in diagnosis and treatment of epilepsy. For example, a VA
health care facility affiliated with a medical school that trains
residents in the diagnosis and treatment of epilepsy, including
epilepsy surgery, would be able to attract the participation of
clinicians and scientists capable of driving innovation in the
prevention and treatment of post-traumatic epilepsy.
Because so many of our recent veterans are returning to rural
areas, access to state-of-the art care for post-traumatic epilepsy will
be a challenge of the VA. Epilepsy Centers for Excellence could help
address this challenge by expanding the VA's telemedicine capacity.
Through the transmission and review of neurological diagnostic tests,
such as EEGs and MRIs, the VA Epilepsy Centers of Excellence could
provide a nationwide monitoring program to improve the quality of life
for veterans with post-traumatic epilepsy who live in rural areas.
We appreciate that S. 1233 contains a provision to establish a
broad TBI research, education and clinical care program. Still, more
research into epilepsy is needed. Without a strong national program on
epilepsy, post-traumatic epilepsy may not receive adequate focus and
support. As you move S. 1233 forward in the legislative process, we ask
that you clarify that these centers must include a significant focus on
the prevention, diagnosis and treatment of epilepsy. We ask that you
give the VA an incentive to establish the VA Epilepsy Centers of
Excellence with a clear statutory foundation and the authorization of
appropriations.
Both the American Academy of Neurology and I thank you for the
opportunity to provide our support and comments on S. 1233.
Chairman Akaka. Thank you very much, Dr. Booss.
Mr. Reed?
STATEMENT OF JERRY REED, EXECUTIVE DIRECTOR,
SUICIDE PREVENTION ACTION NETWORK USA
Mr. Reed. Chairman Akaka, thank you for inviting me to
speak regarding the Joshua Omvig Veterans Suicide Prevention
Act,
S. 479. My name is Jerry Reed and I serve as the Executive
Director of the Suicide Prevention Action Network, USA. SPAN
USA is the Nation's only suicide prevention organization
dedicated to leveraging grassroots support among suicide
survivors, those who have lost a loved one to suicide, and
others to help advance public policies that help prevent
suicide. We strive to turn grief to action by engaging those
touched by suicide to help us open minds, change policy, and
ultimately to save lives.
Before I begin, I would like to thank Randy and Ellen Omvig
for their courage in speaking out on this important public
health issue. Like other survivors, their courage will make a
difference. I would also like to thank your Committee and
Senators Harkin and Grassley for their leadership on this issue
here in the Senate.
The Veterans Health Administration estimates that of the
approximately 31,000 suicides in the United States each year,
1,000 of these suicides occur among veterans receiving care
within the VHA, and as many as 5,000 suicides per year among
all living veterans. These figures suggest that at least 16
percent of suicides in this country in a given year are
veterans. Other studies suggest a slightly higher rate.
What the statistics show us is that suicide is not just a
mental health problem experienced by one. It is a public health
problem experienced by many. As the recent VA OIG report
states, suicide is not a single illness with one true cause. It
is a final outcome with multiple potential antecedents,
percipients, and underlying causes.
Regarding substance abuse and suicide, it is estimated that
25 percent of those who die by suicide are intoxicated at the
time of death, and studies suggest that between 34 and 56
percent of individuals who die by suicide met the criteria for
alcohol abuse or dependence. Accordingly, I wish to state my
agreement with the VA OIG report recommendation that the VA
ensure that sustained sobriety should not be a barrier to
treatment in specialized mental health programs for veterans,
returning combat veterans. This specific recommendation may be
a provision to consider for inclusion.
A majority of veterans who complete suicide are not
currently receiving medical care through the VHA. Therefore,
family members and friends of veterans need to recognize the
warning signs for suicide and learn about services for their
loved ones before it is too late. The VA's awareness and
outreach program must be focused not just on veterans who seek
care at the VA, but also on veterans who have returned to their
home communities, family members of veterans, and veterans
service organizations.
Beyond outreach and education, I support the provisions in
S. 479 that encourage peer support programs. While there is no
substitute for licensed mental health professionals with
respect to diagnosis and treatment of PTSD, depression, and
anxiety, it is often fellow veterans who provide the support
needed to convince a veteran to visit a licensed professional.
With respect to the provision that each VA facility
designate a suicide prevention counselor, my understanding is
that the VA is in the process of filling these positions as we
speak. I would recommend that any report on VA suicide
prevention programs and activities as outlined in Section 4 of
the bill include information on the total number of suicide
prevention counselors to date, where they are located, what
their job descriptions entail, and how they are reaching out to
veterans who do not receive care through the VHA. In short,
what are the counselors expected to accomplish and how do we
measure if they are successful? Having outcomes is key.
Regarding best practices, agencies and departments of the
Federal Government should work together and not act in a vacuum
with respect to information sharing. These entities should also
work with the Suicide Prevention Resource Center. The SPRC is a
federally funded and already established center to provide
prevention support, training, and resources to assist
organizations and individuals to develop suicide prevention
programs, interventions, and policies. The capacity of the SPRC
to conduct these activities with respect to veterans should be
increased.
With respect to the telephone hotline provision, an
additional 800 number has been recommended by some. I do not
believe adding an additional hotline is the correct approach or
the only approach. For most individuals in suicidal crisis,
what is most important when utilizing a hotline is simply
knowing that someone is listening and that they are not alone.
A caller needs a competent counselor at the other end of the
line who can conduct a lethality assessment and provide
direction on next steps.
Already in existence, the federally funded National Suicide
Prevention Lifeline is a 24-hour, toll-free suicide prevention
service available to all those in suicidal crisis who are
seeking help. Individuals seeking help can simply dial 1-800-
273-TALK. They will be seamlessly routed to the certified
provider of mental health and suicide prevention services
nearest to where they are calling from. The network is
currently comprised of over 120 individual crisis centers
around the country. I think we should build on what Congress
has already funded and let 1-800-273-TALK be the door all
callers in crisis, including veterans, enter.
Once callers dial the number, an option can easily be
provided to be transferred to a VA call center if the
individual wants the services and support of the VHA. For the
non-VA crisis centers, the VA could easily provide up-to-date
information on all VA suicide prevention counselors, hospitals,
medical centers, CBOCs, and peer support groups where
appropriate. This national network of crisis centers should
reliably be able to transfer cases to a VHA call center as
appropriate.
I want to close by restating my strong support for the
Joshua Omvig Veterans Support Act and look forward to its
inclusion in a larger veterans' health care bill. We can all
work together to open minds, change policy, and save lives.
Enactment of the provisions in S. 479 will hopefully bring us
one step further in this journey with respect to veteran
suicide prevention.
Thank you for the opportunity to speak with you today.
[The prepared statement of Mr. Reed follows:]
Prepared Statement of Jerry Reed, Executive Director,
Suicide Prevention Action Network USA
Chairman Akaka, Ranking Member Craig and Members of the Committee:
Thank you for inviting me to speak regarding the Joshua Omvig
Veterans Suicide Prevention Act (S. 479). My name is Jerry Reed and I
serve as the Executive Director of the Suicide Prevention Action
Network USA. SPAN USA is the Nation's only suicide prevention
organization dedicated to leveraging grassroots support among suicide
survivors (those who have lost a loved one to suicide) and others to
advance public policies that help prevent suicide. We strive to turn
grief to action by engaging those touched by suicide to help us open
minds, change policy and ultimately to save lives.
Before I begin I would like to thank Randy and Ellen Omvig for
their courage in speaking out on this important public health issue.
Like other survivors, their courage will make a difference.
The Veterans Health Administration (VHA) estimates that of the
approximately 31,000 suicides in the U.S. each year, 1,000 of these
suicides occur among veterans receiving care within the VHA and as many
as 5,000 suicides per year among all living veterans. These figures
suggest that at least 16 percent of suicides in a given year are
veterans. Other studies suggest a slightly higher rate.
What the statistics show is that suicide is not just a mental
health problem experienced by one; it is a public health problem
experienced by many. As the recent VA OIG report states ``[s]uicide is
not a single illness with one true cause, it is a final outcome with
multiple potential antecedents, percipients, and underlying causes.''
While the text of S. 479 does not address the issue of substance
abuse specifically, it is estimated that 25 percent of those who die by
suicide are intoxicated at the time of death and studies suggest that
between 34 and 56 percent of individuals who die by suicide met the
criteria for alcohol abuse or dependence. Accordingly, I wish to state
my agreement with the VA OIG report recommendation that the VA ensure
that sustained sobriety should not be a barrier to treatment in
specialized mental health programs for returning combat veterans. This
recommendation may be a provision to consider for inclusion.
A majority of veterans who complete suicide are not currently
receiving medical care through the VHA. Therefore, family members and
friends of veterans need to recognize the warning signs for suicide and
learn about services for their loved ones before it is too late. The
VA's awareness and outreach program must be focused not just on
veterans who seek care at the VA, but also on veterans who have
returned to their home communities, family members of veterans, and
veterans service organizations (VSO).
Beyond outreach and education, I support the provisions in S. 479
that encourage peer support programs. While there is no substitute for
licensed mental health professionals with respect to diagnosis and
treatment of PTSD, depression, and anxiety, it is often fellow veterans
who provide the support needed to convince a veteran to visit a
licensed professional.
With respect to the provision that each VA facility designate a
suicide prevention counselor, my understanding is that the VA is in the
process of filling these positions. I'd recommend that any report on VA
suicide prevention programs and activities, as outlined in Section 4 of
the bill, include information on: the total number of suicide
prevention counselors to date; where they are located; what their job
description entails; and how they are reaching out to veterans who do
not receive care through the VHA. In short, what are these counselors
expected to accomplish and how do we measure if they are successful.
Having outcomes is key.
Regarding best practices, agencies and departments of the Federal
Government should work together and not act in a vacuum with respect to
information sharing. These entities should also work with the Suicide
Prevention Resource Center (SPRC). The SPRC is federally funded and
already established to provide prevention support, training, and
resources to assist organizations and individuals to develop suicide
prevention programs, interventions and policies. The capacity of SPRC
to conduct these activities with respect to veterans should be
increased.
With respect to the telephone hotline provision, an additional
``800 number'' has been recommended by some. I do not believe adding an
additional hotline is the correct approach.
For most individuals in a suicidal crisis, what is most important
when utilizing a hotline is simply knowing that someone is listening
and that they are not alone. A caller needs a competent counselor at
the other end of the line who can conduct a lethality assessment and
provide direction on next steps.
Already in existence, the federally funded National Suicide
Prevention Lifeline (NSPL) is a 24-hour, toll-free suicide prevention
service available to all those in suicidal crisis who are seeking help.
Individuals seeking help can dial 1-800-273-TALK (8255). They will be
seamlessly routed to the certified provider of mental health and
suicide prevention services nearest to where they are calling from. The
network is comprised of over 120 individual crisis centers across the
country.
I think we should build upon what Congress has already funded and
let 1-800-273-TALK be the door all callers in crisis, including
veterans, enter. Once a caller dials the number, an option can be
provided to be transferred to a VA call center if the individual wants
the services and support of the VHA. For the non-VA crisis centers, the
VA should be providing up-to-date information on all VA suicide
prevention counselors, hospitals, medical centers, outpatient clinics,
and peer support groups and, where appropriate, this national network
of crisis centers should reliably transfer cases to the VHA call
center.
I want to close by restating my strong support for the Joshua Omvig
Veterans Suicide Prevention Act and look forward to its inclusion in a
larger veterans' health care bill. We can all work together to open
minds, change policy, and save lives. Enactment of the provisions in S.
479 will hopefully bring us one step further in this journey with
respect to veterans' suicide prevention.
Thank you for the opportunity to speak with you today.
Chairman Akaka. Thank you very much, Mr. Reed.
My first question is for Dr. Booss and Ms. Beck. This has
to do with working with the private sector, collaborating with
them. In your view, how can VA better collaborate with the
private sector in order to adopt and exchange best practices
for TBI and rehabilitation care?
Dr. Booss, and Ms. Beck after him.
Dr. Booss. Thank you, Mr. Chairman. I think that is an
extremely important point, because I think that it is vitally
important that the VA and the private sector and the university
sector interact so that there is a mutually supportive
integration of the advancement of care.
I think one of the ways that the VA has worked very well
has been to work to integrate private practitioners and also
university practitioners into their outpatient clinic systems,
often on a WOC--that is a without compensation basis--and I
think that is a benefit to veterans and I think it is also a
benefit to the broader community.
In terms of specific initiatives, I think that as the
Congress goes forward, I think looking toward those areas that
would best benefit, I think there is a risk. The risk is if the
VA is not doing something as well as might be wished by the
private sector, that the push ought to be to push VA to do it
better rather than to push it out into the private sector. So I
think that is a very important question.
Chairman Akaka. Thank you very much for that. Ms. Beck?
Ms. Beck. I agree with Dr. Booss on his final point that
our whole goal in this is to encourage the VA to become the
facility of choice for these servicemembers, and by working
together with the private sector on a broad and constant basis,
we think that they can do that. The VA has excellent
capabilities in many areas and they have made tremendous
progress in TBI, especially in their Tier 1 facilities.
But as they have said and as they are establishing their
Tier 2 and Tier 3 components, we would strongly encourage them
to work with the private sector, whether it is developing
criteria for the private sector hospitals that would be
treating veterans and TBI patients, but exchanging ideas on
those. Exchanging doctors is a possibility, and that is, as I
have said, the number one request of our servicemembers and
their families.
Chairman Akaka. Thank you so much for your responses.
Mr. Reed, we like to look for the best ways of preventing
suicide, and the question that comes to mind, and this is a
searching one, what more can be done that is being done
already, specifically in areas of outreach and education, as
you mentioned in your testimony, to let veterans know what
services and assistance are available to them so that we can
prevent the tragedy of suicide? So we are looking at outreach
and education. What more can be done?
Mr. Reed. Senator, I think the Congress back in the 105th
Congress took a very bold step when they passed a resolution
that said suicide is a national problem that warrants a
national solution. That really opened up the dialogue for this
country to talk about something that has been claiming 32,000
people a year for a long, long time and another 1.4 million who
make an attempt every single year. The stigma and the barriers
to even talk about suicide or thoughts of suicide were
enormous, and I think we have begun to talk about it, and we
have done some national polling to measure our success. The
American people are willing to talk about it. When you talk
about it, then you encourage research into it and you promote
access to services for those conditions.
We know that 90 percent of suicides have a mental illness
or a substance abuse relationship. Just like any other organ
that has an illness, when the brain has an illness, those who
suffer should be just as eligible for treatment and for
services.
So I think we are starting to talk about it. A veteran
should know there is no shame in these feelings. There are
services available and there should be no more stigma for that
intervention than there should be for a heart ailment, a kidney
ailment, or a liver ailment. So I think we just have to give
the Nation permission when they struggle to go for help. It is
a completely normal and acceptable thing to seek help for.
Chairman Akaka. I want you to know that I really appreciate
your presence and your testimonies, your responses, as well.
Our attempt here is to try to bring as many voices as we can to
help us ensure that VA can provide the kinds of services that
we need. I like your statements about helping VA do the best
they can before we move on to look at other sectors, as well.
We are trying to make many improvements, as you know, by
raising the funding level of VA, and that is not the only
answer but it helps. We have addressed that by passing a budget
resolution that increases VA health care by more than $3
billion.
So we are looking towards working together with the VA and
all of you to try to help our veterans across the country. We
have a tremendous task before us. As we all know, we owe it to
our veterans, and we are going to do the best we can to do
that.
In closing, I again want to thank all of our witnesses for
appearing today. We truly appreciate your taking the time to
give us your views on all of the issues and the legislation we
have before us. I reiterate that the hearing record will remain
open for 2 weeks to provide time for additional views.
Again, I want to say thank you for being with us and the
hearing is now adjourned.
[Whereupon, at 11:38 a.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Wayne Allard,
U.S. Senator from Colorado
Thank you, Mr. Chairman, for affording me the opportunity to
present before the Committee an issue of great importance to the
veterans of Colorado. I strongly support the replacement of the current
Denver VA medical center with a new facility at the former Fitzsimons
Army Medical Center. I have introduced S. 472 with my colleague,
Senator Salazar, to authorize the remaining funds needed to complete
this new facility.
Last month, Secretary Nicholson announced the VA's commitment to
this project after funds were appropriated, allowing for the initial
land purchase to begin. This announcement was a strong victory for
Colorado's veterans and full authorization of the hospital would
demonstrate the government's continued commitment to our veterans.
The Denver VA hospital was built more than fifty years ago and
medical technology has far surpassed what the builders of the Denver VA
originally envisioned. This facility, which hosted the first liver
transplant in 1963, has provided tremendous care over the years, but
simply does not have the infrastructure to continue to provide our
veterans the care they need through the 21st century. While I cannot
say enough about the care and service our veterans receive at the
current facility, many changes and improvements can and should be made,
and a new facility is the only way to accomplish these goals.
This new VA hospital to be located at the Fitzsimons campus and the
former home of the Fitzsimons Army Medical Center will carry on a
strong tradition of providing exceptional medical care for our Nation's
best and bravest citizens. The current Fitzsimons campus first began
treating wounded veterans in 1918, specializing in assisting those that
were victims of chemical weapons during World War I. The facility
continued to grow through the 20th century and became one of the
premiere Veterans hospitals through World War II. Fitzsimons was even
unofficially deemed the ``White House of the West'' when President
Eisenhower spent seven weeks in the facility while recovering from a
heart condition in 1955.
The new facility will serve as an example of successful
collaboration between numerous parties and will be the culmination of
years of hard work. The Denver VA, the University of Colorado Health
Sciences Center and the University of Colorado Hospital already have a
complex and rewarding partnership in meeting veterans' healthcare needs
in the region, and all are partnered together on this unique project.
The University of Colorado, who currently owns the land for the new
hospital, strongly supports the move of the existing Denver VA medical
facility to the Fitzsimons Campus in Aurora, Colorado and looks forward
to strengthening their partnership with the Veterans' Administration.
This project allows each entity to focus on its strengths.
Of course, the biggest endorsement of this new facility comes
ultimately from the end-users: our veterans. The United Veterans
Committee of Colorado, a coalition of 45 federally chartered veterans
service organizations, strongly supports the relocation of the Denver
VA medical center to the Fitzsimons campus and has worked closely with
my office and the Colorado Congressional delegation over the years to
ensure its success.
In the past year, the VA reached an agreement with the Fitzsimons
Redevelopment Authority, the entity that manages the land at the former
Fitzsimons Army Medical Center, and Congress granted the needed
authorization to begin site acquisition and construction of the new
hospital. This was an important first step, but full authorization of
the project is still required to assure the project's completion. To
that end, I have introduced S. 472, in order to meet this need.
Specifically, the language of bill S. 472 authorizes the Secretary to
carry out the entire project and provides authority to the VA purchase
the land with current year dollars.
There was a time when it looked like this project was in peril.
Thankfully, in 2005 Secretary Nicholson brought a much-needed, fresh
perspective to this project. He made it a priority and made it clear to
the entire Colorado delegation that he would pursue every opportunity
to make the project a reality. I commend his efforts and thank him for
his support. It is also important to mention the hard work and
diligence of those in Colorado who have also worked to ensure the
success of this new hospital. Without the extraordinary efforts put
forth by the Fitzsimons Redevelopment Authority and its chairman, City
of Aurora Mayor Ed Tauer, an agreement would not have been reached on
the ultimate location of the hospital.
Again, I thank you, Chairman Akaka, for the opportunity to speak
here today. I would also like to recognize the strong support my
colleague Senator Salazar has shown for this project. Without a
bipartisan effort we would not be this close on realizing our goal. I
look forward to working with the Committee on my legislation and making
this project a reality.
______
Prepared Statement of Ann Huston, Executive Director and CEO,
American Therapeutic Recreation Association
On behalf of the American Therapeutic Recreation Association
(ATRA), I am submitting the following statement in support of ``The
Traumatic Brain Injury Rehabilitation Act of 2007'' (S. 1233),
including recommendations to improve the impact of the legislation on
returning soldiers with serious injuries and rehabilitative needs.
BACKGROUND ON ATRA
The American Therapeutic Recreation Association (ATRA) is the
largest, national membership organization representing the interests
and need of recreational therapists. Recreational therapists are health
care providers using recreational therapy interventions for improved
functioning of individuals with illness or disabling conditions.
According to the U.S. Department of Labor, Bureau of Labor Statistics,
in 1996 there were approximately 38,000 recreational therapists.
``Employment of recreational therapists is expected to grow faster than
the average for all occupations through the year 2006 because of
anticipated expansion in long term care, physical and psychiatric
rehabilitation and services for people with disabilities.''
By way of background, in 1917, the American Red Cross developed
convalescent houses in military hospitals and in 1931 began hiring
recreation hospital workers. The formative years of the recreational
therapy profession occurred from 1945-1953 following World War II with
the development of formal undergraduate education programs, and the
establishment of three professional organizations for hospital
recreation workers. ATRA was formed in response to recreational
therapists' demand for an independent organization solely representing
the needs of the therapeutic recreation profession within health care
delivery system.
The Practice of Recreational Therapy
Recreational therapy plays a critical role in the comprehensive
rehabilitation of individuals with disabling conditions by contributing
to the broad spectrum of health care through delivery of treatment
services and through the provision of physical and recreational
activities--each of which is instrumental in improving and maintaining
physical and psycho-social functioning, preventing secondary health
conditions, enhancing independent living skills and overall quality of
life.
Recreational Therapy services utilize various methods to promote
the independent physical, cognitive, emotional and social functioning
of persons requiring rehabilitation as a result of trauma or disease,
by enhancing current skills and facilitating the establishment of new
skills for daily living and community functioning. Recreational therapy
is particularly important in terms of community reintegration once a
disabling condition has been incurred.
Recreational therapy also includes components that enable
individuals to become more informed and active partners in their health
care. Prescribed activity assists individuals in coping with the stress
of illness and disability and prepares them for managing their
disability so they may achieve and maintain optimal levels of
independence, productivity, and well being. Quality services include
the provision of recreational opportunity and physical activity (e.g.
wheelchair sports, exercise and swimming programs) which allow
individuals with functional deficits to prevent declines in physical,
cognitive, social, and emotional health status, and therefore, reduce
the need for medical services.
With an academic degree in recreational therapy, a qualified
provider may work in a variety of organizations and settings such as VA
polytrauma centers as well as free-standing rehabilitation hospitals,
rehabilitation units in general hospitals, psychiatric hospitals, long-
term care or skilled nursing facilities, home health care agencies,
amongst many others.
Recreational therapists are standard treatment team members in
psychiatric rehabilitation, substance abuse treatment, physical
rehabilitation and long term care services in both in-patient and out-
patient settings. The Centers for Medicare and Medicaid Services (CMS)
includes recreational therapy in the mix of treatment and
rehabilitation services used to determine compliance with the Federal
Government's commitment to quality care in rehabilitation, skilled
nursing and long term care facilities.
Recreational Therapy as a Viable Option
The therapeutic recreation profession is in support of cost-
effective health care services for individuals with disabilities. The
number of Americans requiring health and rehabilitation services
continues to increase due to an aging population, disabling conditions,
improved treatment services, and greater survival rates. Therefore, the
need to access a broad range of available services is crucial.
The provision of quality services that lead to expected outcomes
while reducing overall health care costs is the bottom line in
therapeutic recreation services. Recreational therapy should be
included as a viable option to meet the needs of consumers with
disabilities. Ultimately, the ability to choose the most appropriate
mix of health care options will afford the provider the most cost-
effective approach to meet the unique needs of individuals with
illnesses and disabilities. Reducing the length of stay and hospital or
system recidivism, promoting independent community living, and
maximizing individual productivity in society are all positive outcomes
of recreational therapy services.
SUPPORT FOR S. 1233
ATRA is enthusiastic about the introduction of S. 1233, the
``Traumatic Brain Injury Rehabilitation Act of 2007,'' and thanks the
sponsors for ensuring that veterans have access to quality
rehabilitative care in the most appropriate setting.
The VA is the largest employer of recreational therapists in the
Nation and ATRA has gained from the VA's involvement in the
professional association. ATRA has had VA employees serve as team
leaders, task force chairs, committee members and ATRA board members.
Two VA employees currently serve as board members to ATRA.
In the four VA Polytrauma Centers (Minneapolis, Palo Alto, Tampa,
Richmond), recreational therapists are identified as ``core staff.''
Each Polytrauma Center is required to have at least one recreational
therapist as a core team member and some have more recreational
therapists based on bed census, each providing services to veterans
returning from the Iraq war. This ``team involvement'' is an integral
part of rehabilitation for these patients. In addition, ATRA hosts the
national VA Institute at the ATRA Annual Conference each year,
coordinated by the VA Recreation Therapy Central Office staff.
One of the key components that RT adds for these patients is
community reintegration or transitional living skills. These skills are
introduced and the basics taught at the Polytrauma Centers but the
skills need to be fine-tuned and customized at the local VA facilities
when the patient returns to his local community. Some of the Polytrauma
Centers have recognized this need and added more recreational
therapists.
Comprehensive Team and Rehabilitation Plan
ATRA is particularly pleased to see that S. 1233 would provide each
veteran with traumatic brain injury (TBI) a comprehensive and flexible
rehabilitation team and plan to include neurologists, physiatrists,
physical therapists, occupational therapists, recreational therapists
and other rehabilitation providers with a goal of regaining and then
maintaining the veteran's maximum level of independent function. ATRA
believes that ``team involvement'' is an integral part of the
rehabilitation treatment plan for these patients.
In addition, it is a customary practice of rehabilitation care
plans to require an individual rehabilitation plan, as the bill does,
upon discharge from inpatient rehabilitation care. Such plans focus on
optimal function for the individual in the community and specify
functional progress. They also often rely on numerous providers and
community support. Therefore, ATRA strongly supports this type of plan
requirement, recognizing the difficulty of continuing such plans for
the long term needs of TBI survivors.
Private Partnerships
Very importantly, S. 1233 also provides each veteran with TBI
access to the best, most appropriate and most accessible care, whether
through the VA or through an outside provider.
The VA has an excellent history of providing quality care to its
wounded warriors and, as stated before, ATRA knows that the VA's four
TBI Lead Centers and regional referral centers are no exception.
Additionally, we recognize current VA efforts to create residential
facilities and community-based long term rehabilitation care with
nearly 21 polytrauma rehab networks being put into place.
However, it is important to acknowledge that gaps in coverage and
care still exist. In particular, we note the VA's capability to provide
community-based care to successfully reintegrate these soldiers into
society. ATRA supports the Committee's efforts to allow more
collaboration between the VA and the private sector in order to ensure
the best and most accessible care for our veterans. Therefore, ATRA
supports provisions allowing private facilities to provide care on an
outpatient basis in the community where VA cannot feasibly supply the
service needed.
We also strongly support the supplementation of VA rehabilitation
services in the community for TBI soldiers with professionals who may
be utilized from the private sector who are not part of VA system.
Examples would be recreational therapist involvement with veterans with
TBI/polytrauma injuries and physical or recreational therapists who are
familiar with brain injury and could provide local therapy when other
providers and treatment is unavailable.
Rehabilitation Research
Additionally, while we are supportive of the bill's provisions on
research of intense rehabilitation needs of TBI soldiers, we would
suggest broader language authorizing research on therapies, cognitive
and physical, to determine the most efficacious therapies for TBI
soldiers.
The problem of physical and cognitive disability in America is
substantial as noted in the 1997 IOM Report, Enabling America. The need
to enhance medical rehabilitation research to attack the problem is
paramount and was a key conclusion of the IOM Report. Between 25 and 30
million individuals have impairments which limit substantially their
ability to perform activities of daily living (ADLs) and 7 percent of
all individuals age 65 to 75 (24 percent of those over age 85) have
disabilities limiting their ADL function.
There are civilian agencies with well-established TBI research
programs with which the VA should collaborate. The mission of the
National Center for Medical Rehabilitation Research (NCMRR) within the
National Institutes of Health is to plan, coordinate and stimulate
rehabilitation research within NIH and across other Federal agencies.
As such, we think NCMRR would enhance the VA's ability to identify the
most efficacious therapies for TBI soldiers and suggest that this
program be carried on in conjunction with NCMRR's TBI clinical trials
network. In addition, the TBI centers and TBI model systems, funded by
the National Institute of Disability and Rehabilitation Reseach (NIDRR)
within the Department of Education has significant and valuable
capacity with which the VA should seek to coordinate their TBI efforts.
Assisted Living
Finally, recreational therapists support the inclusion of the pilot
program to assess the effectiveness of providing assisted living
services to veterans. The provision will give veterans who might
otherwise be forced into institutional long-term care an opportunity to
live in group homes or under other arrangements. For veterans with TBI,
such a provision will maximize rehabilitation, independence, quality of
life, and community reintegration of veterans with TBI who are unable
to manage routine activities of daily living. The effect of such a
pilot program will only be enhanced by the other provisions of this
bill that buildupon the rehabilitation plan and focus on community
reintegration to maximize the independence of these returning veterans.
CONCLUSION
In conclusion, ATRA strongly supports the Traumatic Brain Injury
Rehabilitation Act of 2007 (S. 1233) and applauds the Committee's
commitment to improving access to and quality of care for veterans with
traumatic brain injury. ATRA thanks Chairman Akaka and Ranking Member
Craig, the sponsors of S. 1233, for ensuring that veterans have access
to quality rehabilitative care in the most appropriate setting and we
stand ready to assist the sponsors and the Committee in passing this
much needed legislation.
ATRA thanks the Veterans' Affairs Committee for the opportunity to
submit comments.
______
Prepared Statement of the American Academy of
Physical Medicine and Rehabilitation
The American Academy of Physical Medicine and Rehabilitation
(AAPM&R) submits the following statement in support of ``The Traumatic
Brain Injury Rehabilitation Act of 2007'' (S. 1233). Additionally, we
would like to offer recommendations to improve the impact of the
legislation on returning soldiers with serious injuries and
rehabilitative needs.
BACKGROUND ON AAPM&R
AAPM&R is the national medical society representing approximately
7,800 physiatrists, physicians who are specialists in the field of
physical medicine and rehabilitation. Physiatrists treat adults and
children with acute and chronic pain, persons who have experienced
catastrophic events resulting in paraplegia, quadriplegia, or traumatic
brain injury, rheumatologic conditions, musculoskeletal injuries, and
individuals with neuralgic disorders such as strong multiple sclerosis,
polio, amyotrophic lateral sclerosis (ALS) or any other disease process
that results in impairment and/or disability.
During World War II, programs in rehabilitation medicine were begun
by Howard Rusk, M.D., in a number of Army Air Force hospitals. After
the War, Dr. Rusk and Frank Krusen, M.D., were consultants to the
Department of Veterans Affairs as it expanded its health care programs
to meet the increased demand for services from the War. Paul Magnuson,
M.D., who founded the Rehabilitation Institute of Chicago in 1954, was
Medical Director of the VA when its expansion of rehabilitation
services took place. Rusk and Krusen established the specialty of
Physical Medicine and Rehabilitation just after the war.
Today, AAPM&R offers well developed expertise in rehabilitation for
traumatic brain injury and amputations of upper or lower extremities,
two of the disabilities afflicting soldiers returning from battle.
AAPM&R members are also experts in the rehabilitation of spinal cord
injured (SCI) patients and were involved in the creation of federally
funded traumatic brain injury (TBI), burn and SCI model care systems in
the 1970s and 1980s and, more recently, involved in the development and
use of high technology in prosthetics.
AAPM&R physicians are trained to provide the medical rehabilitation
needed by military personnel returning with TBI, SCI, amputations, and
other severe disabilities. These physicians provide a comprehensive
approach to the restoration of function and return to the community.
Multidisciplinary services are utilized where needed including physical
therapy, occupational therapy, speech therapy, psychological services,
vocational rehabilitation, job placement, recreational therapy and
independent living assistance.
Today many specialists in PM&R provide services in the VA health
care system and many residents train in VA affiliated PM&R residency
training programs. For example, the AAPM&R President-elect, David Cifu,
M.D., is Chairman of the Medical College of Virginia Department of
Physical Medicine and Rehabilitation and is a VA physician and head of
the polytrauma rehabilitation center at Richmond, Virginia.
Additionally, one of our members, Barbara Sigford, M.D., works at the
Minneapolis VA Polytrauma Center, where she is chief of Physical
Medicine and Rehabilitation Services for the Veterans Health
Administration.
SUPPORT FOR S. 1233
AAPM&R supports the ``Traumatic Brain Injury Rehabilitation Act of
2007'' (S. 1233) and thanks the cosponsors for their commitment to
ensuring that veterans with TBI have access to quality rehabilitative
care. The bill focuses on the needs of TBI victims for outpatient
services to enable reintegration in the community. The bill establishes
a number of programs to facilitate this optimum rehabilitation
including a comprehensive assessment and plan for rehabilitation, the
use of private sector resources when the VA system has insufficient
capacity to serve TBI victims or when the VA program available is too
remote to be feasible for the patient
Since approximately 20 percent of soldiers wounded in Iraq or
Afghanistan have TBI, amputations or spinal cord injury, and TBI is the
most prevalent of the three, focusing a special effort on TBI victims
is good policy. Despite the expansion of polytrauma rehabilitation
centers, networks and clinical teams for outpatient care, the system is
likely to have gaps in the outpatient service system given the numbers
of victims, the duration of their disabling condition and the paucity
of TBI experts. Focusing on these gaps is essential.
We suggest some areas however, in which we believe the bill might
be strengthened to better achieve its goals.
REHABILITATION PLAN
S. 1233 would provide each veteran with TBI a comprehensive
assessment by a rehabilitation team (including neurologists,
physiatrists, social workers, mental health specialists, occupational
therapists, physical therapists, vocational rehabilitation specialists
and rehabilitation nurses) and a plan with the goal of regaining, and
then maintaining, the veteran's maximum level of independent function
in the community.
The legislation's requirement of an individual rehabilitation plan
upon discharge from inpatient rehabilitation care is the customary
practice of physical medicine and rehabilitation. These plans are
intended to specify functional progress and focus on optimal function
for the individual in the community. They often rely on numerous
providers and supports available in the community. AAPM&R strongly
supports this type of plan requirement, recognizing the difficulty of
continuing such plans for the long term needs of TBI victims which may
well reach 50 years.
Private Partnerships
S. 1233 would also provide all veterans with TBI access to the
best, most appropriate care, whether through the VA or a private sector
facility when the VA is unable to supply the necessary services or the
VA facility is too remote from the veterans' residence. The VA has an
excellent history of providing quality care to its wounded warriors.
Additionally, AAPM&R recognizes current VA efforts to create
residential facilities and community-based long term rehabilitation
care with nearly 21 polytrauma rehabilitation networks being put into
place.
However, it is important to acknowledge that gaps in the capability
of the VA health system to provide the community-based care necessary
to successfully reintegrate its soldiers into society will likely
exist. AAPM&R supports the bill's efforts to allow more collaboration
between the VA and the private sector in order to ensure that care is
accessible to all TBI victims of the wars in Iraq and Afghanistan. The
private sector involvement intended by the provision, particularly if
expanded as we suggest below, will strengthen the ability of the VA to
respond to possible gaps in outpatient rehabilitation care.
We suggest an addition to the legislation which we believe would
make the use of private sector services more effective. The legislation
is limited to arrangements with ``facilities'' to assist the VA in
delivering rehabilitation services to veterans with TBI on an
outpatient basis. We believe there may be instances when a TBI victim
may need a specialist in rehabilitation medicine who is not available
within the VA system to provide outpatient care. In such instances the
professional may not be affiliated with a rehabilitation hospital or
other ``facility''. They may be in a professional group practice.
Examples would be physical medicine and rehabilitation physicians who
understand brain injury and can serve as consultants or primary
physicians; neuropsychologists who may be needed for counseling;
occupational or physical therapists who are familiar with brain injury
and could provide necessary therapy services.
OTHER COMMENTS AND SUGGESTED ADDITIONS
AAPM&R recognizes that it is appropriate for Congress to focus on
traumatic brain injuries, as it is among the most prevalent polytrauma
conditions and has a dramatic impact on the veteran's long-term
outcomes. Additionally, too little is known today about the nature of
TBI, its sequelae, and the therapies to potentially treat it. Nearly
eight years ago, the National Institutes of Health held a consensus
conference on TBI, Chaired by Kris Ragnarsson, M.D., of Mt. Sinai
Hospital, New York City, New York, which reported that far too little
was known from research about therapies. We fear that little has
changed in the last eight years.
However, we also believe that there is a need for post acute
rehabilitation services, particularly on an outpatient basis, for other
victims of polytrauma. AAPM&R would encourage the Committee to consider
expanding the focus of S. 1233, or passing additional legislation, to
connect veterans with other polytraumatic conditions, such as
amputations, spinal cord injury or burns, to the necessary post acute
rehabilitation services.
Additionally, while AAPM&R is supportive of the bill's provisions
on research of intense rehabilitation needs of TBI soldiers, we would
suggest broader language authorizing research to determine the most
efficacious therapies, cognitive or physical, for TBI victims. We
suggest that this program be carried on in conjunction with the TBI
clinical trials network of the National Center for Medical
Rehabilitation Research within the National Institutes of Health and
the model systems of TBI supported by the National Institute on
Disability and Rehabilitation Research in the Department of Education.
CONCLUSION
AAPM&R supports the ``Traumatic Brain Injury Rehabilitation Act of
2007'' (S. 1233). We encourage the Committee to expand the scope of the
legislation to allow VA contracting with appropriately licensed or
credentialed private practice professionals with TBI expertise, broaden
the research authority and cover other conditions and disabilities such
as amputations, spinal cord injuries, and burns so that all veterans
may have access to the highest quality and most appropriate
rehabilitative care in order to live as independently as possible.
We thank you for this opportunity to submit comments.
______
Prepared Statement of the American Congress
of Rehabilitation Medicine
The American Congress of Rehabilitation Medicine (ACRM) submits
this written statement in support of S. 1233, the Traumatic Brain
Injury Rehabilitation Act of 2007.
The mission of the American Congress of Rehabilitation Medicine
(ACRM) is to enhance the lives of persons living with disabilities
through a multidisciplinary approach to rehabilitation, and to promote
rehabilitation research and its application in clinical practice. ACRM
serves people with disabling conditions by promoting rehabilitation
research and facilitating information dissemination and the transfer of
technology. We value rehabilitation research that promotes health,
independence, productivity, and quality of life for people with
disabilities, injuries, and chronic illnesses. We are committed to
research that is relevant to consumers, educates providers to deliver
care through best practices, and supports advocacy efforts that ensure
adequate public funding for rehabilitation and disability research
priorities.
ACRM strongly supports S. 1233, recognizing the immediate need for
improved capacity to provide comprehensive, quality care to our
Nation's veterans with traumatic brain injury (TBI). Recent press
reports have repeatedly highlighted the high incidence and tragic
consequences of TBI both in soldiers returning from Iraq and
Afghanistan and, by extension, in the civilian population. The Centers
for Disease Control and Prevention (CDC) estimates that 5.3 million
Americans live with the consequences of TBI, many of whom never seek
medical help, resulting in systematic under-counting of so-called
``mild'' or ``moderate'' traumatic brain injury.
INDIVIDUAL REHABILITATION AND REINTEGRATION PLANS
Although each person with a traumatic brain injury is unique, most
people experience cognitive, behavioral, emotional and physical
challenges. Cognitive limitations may include memory loss, impaired
thinking, s slowed learning, and difficulty concentrating. Physical
limitations may include spasticity, limits in walking, hemiparesis,
speech impairments, loss of the use of one's arms and hands, severe
fatigue, headaches, changes in sense of smell and taste, balance
problems, seizures and endocrine disorders. Behavioral and emotional
consequences may include depression, anxiety, and impulsive behavior
that may be dangerous to both the individual with brain injury and
others.
Because of the complexity of treating TBI, S. 1233 would require
that all veterans with TBI be provided case-managed individual
rehabilitation and community reintegration plans. ACRM believes these
multidisciplinary, long-term plans are vital to the rehabilitation of
individuals with TBI as the extended needs of TBI-impacted individuals
go beyond the medical response. The needs extend into the social,
psychological, physical, and vocational arenas.
PRIVATE PARTNERSHIPS
ACRM also applauds provisions in the legislation that would allow
the VA to contract with private providers when it is not feasible for
the VA to provide TBI care for a particular individual. It is important
that veterans with TBI receive the most appropriate and accessible care
possible, whether that care is provided through VA facilities or
through a non-VA provider. ACRM believes this provision will open the
door to the development and strengthening of partnerships between the
VA and private rehabilitation providers that will significantly benefit
our returning soldiers. Stronger partnerships between the VA and the
private rehabilitation provider system will enable veterans with TBI to
receive long term services in close proximity to their support network,
including their families, friends and communities.
TRAUMATIC BRAIN INJURY RESEARCH
ACRM strongly supports the provisions in S. 1233 that focus on
research on traumatic brain injury. Currently, many answers are not
available from research findings that address even basic questions
asked by people with TBI and their families. The relative lack of
research in this area limits the recovery of people with TBI and
hampers clinicians trying to best treat their patients. Despite
existing research efforts in both the military and civilian sectors,
the pool of ``solid answers'' remains too small.
Under S. 1233, in carrying out TBI-related research, the VA would
be required to collaborate with TBI Model Systems funded by the
National Institute on Disability and Rehabilitation Research (NIDRR),
under the Department of Education. ACRM applauds the Committee for
recognizing the expertise and valuable research available through
NIDRR-funded programs.
Currently, NIDRR funds 16 national TBI Model Systems. These Model
``Systems'' are essentially TBI centers that provide regional TBI
treatment capacity as well as collect and analyze longitudinal data
from people with TBI. The Model Systems also conduct valuable outcomes
research on evidence-based TBI rehabilitation services. A Model System
must demonstrate outstanding care to individuals with traumatic brain
injury, from the emergency medical services, to acute care in the
hospital, to long-term rehabilitation and community integration.
Additionally, NIDRR currently funds several research and training
centers which focus on improved outcomes for TBI rehabilitation
services. This research helps ensure that people with TBI regain their
maximum level of function and return to independent living. All of
these civilian resources will be invaluable to the VA as it accelerates
the development of treatment systems for returning veterans with TBI.
If not for the collaboration required in this bill, ACRM believes that
it would take the VA years to develop the treatment and research
capacity that the NIDRR-funded Model Systems and the TBI centers
currently possess.
THE NEED FOR ADDITIONAL TBI RESEARCH FUNDING
AND COLLABORATION
Compared to both the civilian and military need, the funding
available for these TBI systems and centers in the past several years
has been very modest and has not kept pace with the growing needs of
the TBI survivor community. ACRM is concerned, however, that the
requirement that the VA collaborate with the NIDRR-funded TBI Model
Systems and TBI centers may be a hollow promise if additional funding
is not available through the VA budget. The legislation does not
authorize additional funding for the systems and centers and the NIDRR
budget simply has not funded them adequately to date. In fact, NIDRR
has been flat-funded for over 4 years. In order to ensure that the VA's
partnerships with NIDRR-funded programs are as efficacious as possible,
ACRM suggests that S. 1233 be modified to include authorization of an
additional $19 million in Fiscal Year 2008 and in subsequent years to
the TBI Model Systems and TBI centers including:
$6 million to supplement the research efforts of the TBI
Model Systems Centers;
$3 million to fund three additional Rehabilitation
Research and Training Centers on TBI;
$3 million for Field-initiated Research projects on TBI;
$4 million for 4 centers to develop and evaluate
technology to improve outcomes and quality of life;
$2 million to train diverse professional disciplines for
the rehabilitation of individuals with TBI; and
$1 million for a Knowledge Translation Center to evaluate
and report on these TBI projects to Congress and ensure that clinicians
incorporate the outcomes studies into clinical practice.
ACRM believes this additional funding for evidenced-based research
and regional TBI treatment capacity will benefit our returning veterans
with TBI, and, in-turn, all individuals with an acquired brain injury.
This additional funding would be extremely timely and an important
national investment.
CONCLUSION
In conclusion, ACRM strongly supports S. 1233, the Traumatic Brain
Injury Rehabilitation Act of 2007, and thanks Chairman Akaka, Ranking
Member Craig, and the Committee and the bill's cosponsors for their
commitment to serving our veterans with TBI. ACRM looks forward to
working with Congress toward enactment of this important legislation.
Thank you for this opportunity to submit comments.
______
Prepared Statement of the 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, believes strongly that Congress must facilitate greater
cooperation between the military and civilian health care sectors to
ensure returning servicemembers with TBI get the right care, right now.
TBI is a growing public health problem in U.S. military and civilian
populations. Reports indicate 12,274 servicemembers have sustained a
TBI in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom
(OEF) as of March 24, 2007, and some projections estimate that number
could ultimately grow as high as 150,000.
The standard of care for TBI is early, intensive acute treatment
and rehabilitation, followed by timely post acute rehabilitation of
sufficient scope, duration and intensity to restore maximum function
and accommodate residual disability. To optimize their independence and
maintain the best possible health throughout their lives, individuals
with brain injury need access to a full continuum of TBI care.
The BIAA supports S. 1233, as it sets forth a pivotal mechanism for
enhancing cooperation between the private sector and the VA health care
system. Such cooperation is vitally necessary in order to provide
access to, and choice within, the full continuum of care that returning
servicemembers with TBI need and deserve.
Efforts within the Department of Defense and the Department of
Veterans Affairs (VA) to increase TBI research and treatment capacity
in response to the influx of returning servicemembers with brain
injuries should be recognized and applauded. Nevertheless, there is a
broad consensus that most VA medical facilities have not yet attained
the TBI specialty care capacity that is available from private TBI
rehabilitation facilities. These civilian facilities have been
developing and refining brain injury treatments, including cognitive
rehabilitation, for more than three decades, and are ready on a
widespread basis to stand side-by-side with the Department of Defense
and the Department of Veterans Affairs to help provide the highest
quality services to returning servicemembers with TBI, both now and in
the long-term.
The BIAA also strongly supports language and provisions in the bill
recognizing that rehabilitation for individuals with TBI should be
individualized, comprehensive, and multidisciplinary with the ultimate
goal of maximizing independence and reintegration into the community.
The bill's recognition of the importance of family support to
rehabilitation and the need for lifelong case management for veterans
with TBI also represents a significant step forward. Further, the BIAA
strongly recommends that all allied health professionals, including
case managers and support staff, who work with servicemembers with TBI
obtain brain injury specialty training and certification.
Research on TBI should be intensified and accelerated on a national
level, in large part by augmenting existing research programs of the
National Institute on Disability and Rehabilitation Research (NIDRR)
TBI Model Systems. Line-item funding of $30 million should be allocated
in Fiscal Year 2008 to continue and expand NIDRR's applied research
results through TBI Model Systems. The BIAA applauds instructions
within S. 1233 for research on TBI to be pursued through collaboration
with existing NIDRR TBI research grantees. It is extremely important,
and makes the most sense in terms of health care quality and cost
efficiency, for the VA to use the extensive work regarding TBI that has
been done in the civilian sector and is ongoing in the areas of TBI
research, treatment and rehabilitation services. The BIAA further hopes
that adequate funding will be appropriated to support this
collaborative research, in addition to increased funding of $30 million
for TBI Model Systems overall. Clearly, there is a pressing national
need to increase research efforts on TBI in general, and in particular,
to leverage the existing civilian TBI research and treatment capacity
to improve outcomes measurement capabilities and augment care systems
in both the military and civilian sectors.
The Brain Injury Association of America appreciates the opportunity
to comment on S. 1233, and stands ready to assist the Committee in all
efforts to help improve access to the full continuum of care for
returning servicemembers with traumatic brain injuries.
______
Prepared Statement of the Commission on Accreditation
of Rehabilitation Facilities
The Commission on Accreditation of Rehabilitation Facilities
(``CARF'') submits the following statement for the record in support of
S. 1233, the Traumatic Brain Injury Rehabilitation Act of 2007.
BACKGROUND
CARF is a forty-one-year-old nonprofit organization that
establishes standards and assesses conformance with these standards for
the continuous improvement of service quality to persons with
disabilities and other needs. CARF's mission is to promote the quality,
value, and optimal outcomes of rehabilitation and other human services
through a consultative accreditation process that centers on enhancing
the lives of persons served. CARF uses an independent, professional,
nonprofit peer review system recognized by multiple Federal and state
agencies, national and international associations, all Canadian
provinces, several major insurers, advocacy groups, and professional
organizations.
Of great relevance at the moment is the eleven-year partnership
between CARF and the Veterans' Administration. In 1996, CARF and the VA
initiated an agreement to promote continuous quality improvement in
rehabilitation services through national accreditation. Since the first
VA accreditations in medical rehabilitation, employment and community
services, and behavioral health in 1997, the scope and number of CARF-
accredited VA programs and services has grown to include both mandated
and voluntary accreditations across the rehabilitation and human
service continuum.
The partnership between the VA and CARF has expanded accreditation
both in the types of programs and the number of programs. This increase
in diversity of accredited programs was in direct response to veterans'
needs and the VA and CARF developed new programs or new standards,
respectively. However, as successful as the VA-CARF collaboration has
been, there are many VA programs that are not CARF accredited, nor
accredited by other organizations. CARF looks forward to continuing its
work with the VA to help ensure that--through accreditation--veterans,
including those with traumatic brain injuries (TBI) and their families,
receive the high quality services they deserve.
CARF SUPPORT FOR S. 1233
CARF strongly supports the Traumatic Brain Injury Rehabilitation
Act of 2007 (S. 1233) and the Committee's efforts to ensure that
veterans with TBI have access to the highest quality and coordinated
care in the most appropriate, least restrictive setting. We applaud the
Committee's emphasis on comprehensive, long-term rehabilitation and
community integration for TBI survivors for once the immediate medical
needs of those with brain injuries are met, the physical, behavioral,
cognitive psychosocial, vocational, and often residential needs must be
addressed.
VA and Private Partnerships
S. 1233 would provide all veterans with TBI access to the most
appropriate services, whether through VA facilities or through non-VA
providers. The legislation recognizes that while the VA provides
excellent medical and rehabilitative care for veterans, such care for
TBI survivors is complex, long-term in nature, and not always
accessible in the veteran's community environment, where their support
system is strongest. Therefore, the legislation would allow the VA to
enter into agreements with private providers to implement a veteran's
individualized rehabilitation plan when VA services are not feasible or
accessible.
CARF applauds the bill's requirement that all private partners be
accredited by, or meet the standards of, an independent, peer-reviewed
organization that accredits specialized rehabilitation programs for
adults with traumatic brain injury. CARF believes that this independent
accreditation requirement is vital to ensuring quality of care for our
wounded warriors receiving services outside the VA health system. The
proposed requirement parallels the move to accreditation by CARF of the
VA's own programs serving the rehabilitation needs of veterans.
CARF has developed a comprehensive set of standards for TBI
programs, focusing on the unique medical, physical, cognitive,
psychosocial, behavioral, vocational, educational, and recreational
needs of persons with acquired brain injuries. These standards
encompass specialty programs for persons with brain injury provided in
a variety of settings including brain injury home- and community-based
rehabilitation programs, outpatient rehabilitation programs,
comprehensive integrated inpatient rehabilitation programs, residential
rehabilitation programs, long-term residential services, and vocational
services. Currently, CARF accredits 288 programs within the VA
nationwide, including five comprehensive brain injury programs,
multiple inpatient rehabilitation, vocational rehabilitation, and
homeless veterans' health care programs.
The CARF accreditation process is a rigorous one, involving the
development of consensus quality standards subjected to peer review.
The accreditation process is also based on peer review with a strong
focus on the person served by the program and the impact that those
services actually have on the recipient of care.
We are confident that CARF-accredited TBI programs meet the
Department's, the Committee's, and our veterans' high standards of
quality and comprehensive care.
Individual Rehabilitation and Community Reintegration Plans
CARF strongly supports the legislation's requirement of
individualized rehabilitation and reintegration plans for each veteran
with TBI leaving inpatient therapy.
It is commonplace for inpatient rehabilitation programs, and
required by CARF-accredited inpatient rehabilitation programs, to
provide patients with reintegration plans that not only address the
future medical needs of the individual, but his/her psychological,
transitional residential, social, and vocational needs as well. And,
because some of our returning veterans have unique injuries and
complicated behavioral and psychological issues, a case management
model for outpatient, community rehabilitation is extremely
appropriate.
Given CARF staff and surveyors' significant expertise in the areas
of social, medical, and vocational services and TBI rehabilitation,
CARF would like to serve as a resource to the Committee and the
Department as they develop and implement these individual
rehabilitation and reintegration plans.
Assisted Living Services
CARF supports the Committee's effort to examine the effectiveness
of long-term residential services for veterans with TBI. However, CARF
has concerns regarding the use of the term ``assisted living.''
The legislation defines assisted living services as ``services of a
facility in providing room, board, and personal care and supervision of
residents for their health, safety and welfare.'' However, CARF is
concerned that the popular interpretation of the term ``assisted
living'' commonly describes a facility that has adequate staff to
assist the residents with very limited and often aging-related needs.
However, given our experience with TBI rehabilitation, CARF
recognizes the more extensive and specific residential needs of these
individuals. We suggest that the Committee use the term ``brain injury
long-term residential services'' If you do not get them to understand
that these are Brain Injury programs first rather than residential
programs first then I think they will still have assisted living
facilities saying they can do brain injury work to describe the types
of facilities which could best serve veterans with TBI and in which
these pilot programs would take place. In this manner, if the VA
requires accreditation of these assisted living providers, it will more
likely engage accreditation organizations that will truly understand
the residential and long-term needs of TBI survivors.
CARF currently accredits 262 brain injury residential and 261 long-
term residential brain injury programs in the private sector and would
appreciate that opportunity to work with the Committee to identify the
types of residential programs most appropriate for returning soldiers
with TBI and therefore, most appropriate for these pilot programs.
CONCLUSION--SUPPORTING VA FUTURE DIRECTIONS
In conclusion, CARF is vested in growing and changing with the VA
as its programs and services move into the twenty-first century. To
maximize the quality of services and amount of care the VA provides to
veterans, CARF standards can be used to help align the VA to deliver
the greatest amount of consumer benefit possible from each dollar of
funding the service networks receive. CARF will continue to anticipate
changes in the field and begin developing specific service unit
standards as veterans' needs change and service delivery progresses.
CARF strongly supports S. 1233 and applauds the Committee's
commitment to improving access to and quality of care for veterans with
traumatic brain injury. We are pleased to see language in the bill that
recognizes the value of independent accreditation as a means of
ensuring quality and look forward to working with Congress toward
enactment of this important legislation.
______
[Note: The following is an e-mail from a Vermont resident sent to
Senator Bernard Sanders on May 17, 2007.]
Dear Senator Sanders: I read in the Rutland Herald yesterday about
the Veterans benefits and the veterans that fall into the catagory
``8''. My husband applied and he fell into that catagory because he had
not signed by by 2003, he was denied any medical benefits. He needs to
have medical care because he has diabetes and we are unable to afford
health insurance for him. I am hoping you can do something about this
situation for veterans. Thank you.
______
Epilepsy Foundation,
Landover, MD, May 22, 2007.
Hon. Daniel K. Akaka,
Chairman, Committee on Veterans' Affairs,
412 Russell Senate Office Building,
Washington, DC.
Dear Chairman Akaka: On behalf of the over 3 million Americans with
epilepsy, the Epilepsy Foundation is pleased to support S. 1233, The
Veterans Traumatic Brain Injury Rehabilitation Act of 2007. The
Foundation is deeply concerned with the high incidence of epilepsy that
results from traumatic brain injury. Although we do not have data on
post-traumatic epilepsy from the current wars, the statistics from the
Vietnam era are alarming. VA-funded research conducted in collaboration
with the Department of Defense found that 53 percent of veterans who
suffered a penetrating TBI in Vietnam developed epilepsy within 15
years. For these service-connected veterans, the relative risk for
developing epilepsy more than 10 to 15 years after their injury was 25
times higher than their age-related civilian cohorts. Indeed, 15
percent did not manifest epilepsy until five or more years after their
combat injury.
Because of these alarming statistics from the Vietnam War, the
Epilepsy Foundation is thankful that S. 1233 addresses the periodic
assessment of the rehabilitation plan. The consequences of a TBI may
change over time and new symptoms may develop. For example, individuals
with TBI may develop post-traumatic seizures months or years after the
injury. Because epilepsy requires regular monitoring and, for many
patients, frequent changes in their anti-seizure medications, this
periodic assessment is crucial. The Foundation strongly supports the
``team approach'' laid out in section 3 of S. 1233. Each veteran who
suffers a TBI should receive ongoing individualized, comprehensive and
multidisciplinary rehabilitation after inpatient services.
Rehabilitation plans that are based upon a comprehensive assessment of
the veteran's physical, cognitive, vocational, and psychosocial
impairments, using a multidisciplinary team that includes neurologists
(as required by S. 1233), are essential to rehabilitative success.
Additionally, we support the provision in section 3 which requires
involving the family and veteran in the development and review of the
rehabilitation plan. TBI is a devastating and life-altering event which
affects the veteran and his or her family. Families of veterans with
TBI need support and education, and should be part of the
rehabilitative team to the greatest extent possible.
Perhaps the most important aspect of S. 1233 is the recognition of
seizure disorders as a common outcome of TBI (Sec. 8). We know that
post-traumatic epilepsy is going to be a significant long-term
consequence of TBI, and this language will help create awareness of the
growing problem.
Given this high rate of post-traumatic epilepsy that veterans with
TBI are likely to endure, the Epilepsy Foundation believes that
Congress should also authorize, and the VA must establish a strong
national epilepsy program with research, education and clinical-care
components, to include Epilepsy Centers of Excellence. We are concerned
that the VA lacks a national program for epilepsy with clear guidelines
on when to refer patients for further assessment and treatment of
epilepsy. VA Centers of Excellence have been the model of innovation in
the delivery of highly specialized health care and research for other
disabling and chronic diseases in the veteran population. VA has
infrastructure to address many of the other common consequences of TBI,
such as psychosocial changes, vision problems and movement disorders
but not post-traumatic epilepsy.
I personally look forward to working with you on moving this
legislation forward. Please feel free to contact me or Donna Meltzer,
Senior Director of Government Affairs at 301-918-3764 or
[email protected]. Thank you again for your leadership and commitment to
our Nation's veterans.
Sincerely,
Tony Coelho,
Immediate Past Chair,
Epilepsy Foundation Board of Directors.