[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


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate


                    U.S. GOVERNMENT PRINTING OFFICE
37-463                      WASHINGTON : 2007
_____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001

                     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

                              ----------                              

                              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

                              ----------                              


                        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:]

    [GRAPHIC] [TIFF OMITTED] T7463.001
    
    [GRAPHIC] [TIFF OMITTED] T7463.002
    
    [GRAPHIC] [TIFF OMITTED] T7463.003
    
    [GRAPHIC] [TIFF OMITTED] T7463.004
    
    [GRAPHIC] [TIFF OMITTED] T7463.005
    
    [GRAPHIC] [TIFF OMITTED] T7463.006
    
    [GRAPHIC] [TIFF OMITTED] T7463.007
    
    [GRAPHIC] [TIFF OMITTED] T7463.008
    
    [GRAPHIC] [TIFF OMITTED] T7463.009
    
    [GRAPHIC] [TIFF OMITTED] T7463.010
    
    [GRAPHIC] [TIFF OMITTED] T7463.011
    
    [GRAPHIC] [TIFF OMITTED] T7463.012
    
    [GRAPHIC] [TIFF OMITTED] T7463.013
    
    [GRAPHIC] [TIFF OMITTED] T7463.014
    
    [GRAPHIC] [TIFF OMITTED] T7463.015
    
    [GRAPHIC] [TIFF OMITTED] T7463.016
    
    [GRAPHIC] [TIFF OMITTED] T7463.017
    
    [GRAPHIC] [TIFF OMITTED] T7463.018
    
    [GRAPHIC] [TIFF OMITTED] T7463.019
    
    [GRAPHIC] [TIFF OMITTED] T7463.020
    
    [GRAPHIC] [TIFF OMITTED] T7463.021
    
    [GRAPHIC] [TIFF OMITTED] T7463.022
    
    [GRAPHIC] [TIFF OMITTED] T7463.023
    
    [GRAPHIC] [TIFF OMITTED] T7463.024
    
    [GRAPHIC] [TIFF OMITTED] T7463.025
    
    [GRAPHIC] [TIFF OMITTED] T7463.026
    
    [GRAPHIC] [TIFF OMITTED] T7463.027
    
    [GRAPHIC] [TIFF OMITTED] T7463.028
    
    [GRAPHIC] [TIFF OMITTED] T7463.029
    
    [GRAPHIC] [TIFF OMITTED] T7463.030
    
    [GRAPHIC] [TIFF OMITTED] T7463.031
    
    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.

  

                                  
