[Senate Hearing 110-374]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-374

    HEARING ON VA AND DOD COLLABORATION: REPORT OF THE PRESIDENT'S 
COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS; REPORT OF 
 THE VETERANS DISABILITY BENEFITS COMMISSION; AND OTHER RELATED REPORTS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 17, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard M. Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho,
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

                              ----------                              

                            October 17, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
    Prepared statement...........................................     3
Burr, Hon. Richard M., Ranking Member, U.S. Senator from North 
  Carolina.......................................................     5
Craig, Hon. Larry E., U.S. Senator from Idaho....................     8
Murray, Hon. Patty, U.S. Senator from Washington.................     9
Tester, Hon. Jon, U.S. Senator from Montana......................    10
    Prepared statement...........................................    11
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    11
Hutchison, Hon. Kay Bailey, U.S. Senator from Texas..............    12
Isakson, Hon. Johnny, U.S. Senator from Georgia..................    13
Webb, Hon. Jim, U.S. Senator from Virginia.......................    39

                               WITNESSES

Shalala, Hon. Donna E., Co-Chair, President's Commission on Care 
  for America's Returning Wounded Warriors.......................    14
    Prepared statement...........................................    18
Dole, Hon. Bob, Co-Chair, President's Commission on Care for 
  America's Returning Wounded Warriors...........................    21
    Prepared statement...........................................    26
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    29
Scott, LTG James Terry, U.S. Army (Ret.), Chairman, Veterans 
  Disability Benefits Commission.................................    43
    Prepared statement...........................................    48
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    66
Dunne, RADM Patrick W., U.S. Navy (Ret.), Assistant Secretary for 
  Policy and Planning, U.S. Department of Veterans Affairs.......    68
    Prepared statement...........................................    70
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    74
West, Togo D., Jr., Co-Chair, Independent Review Group...........    74
    Prepared statement...........................................    76
      Attachment.................................................    78
Del Negro, Ariana, wife of 1LT Charles Gatlin....................    91
    Prepared statement...........................................    92
Duffy, Col. Peter J., U.S. Army Reserve (Ret.), Deputy Director 
  of Legislative Affairs, National Guard Association of the 
  United States..................................................    98
    Prepared statement...........................................   101
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................   102
Manar, Gerald T., Deputy Director, National Veterans Service, 
  Veterans of Foreign Wars of the United States, on behalf of the 
  members of the Independent Budget..............................   105
    Prepared statement...........................................   107
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................   112
Beck, Meredith, National Policy Director, Wounded Warrior Project 
  (WWP)..........................................................   112
    Prepared statement...........................................   115
Strobridge, Col. Steven P., U.S. Air Force (Ret.), Director, 
  Government Relations, Military Officers Association of America.   117
    Prepared statement...........................................   118
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................   124

                                APPENDIX

Obama, Hon. Barack, U.S. Senator from Illinois; prepared 
  statement......................................................   133





























 
    HEARING ON VA AND DOD COLLABORATION: REPORT OF THE PRESIDENT'S 
COMMISSION ON CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS; REPORT OF 
 THE VETERANS DISABILITY BENEFITS COMMISSION; AND OTHER RELATED REPORTS

                              ----------                              


                      WEDNESDAY, OCTOBER 17, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    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, Brown, Tester, Webb, Burr, 
Craig, Isakson, and Hutchison.

   OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, U.S. 
                      SENATOR FROM HAWAII

    Chairman Akaka. The oversight hearing on DOD-VA 
Collaboration and Cooperation will come to order.
    With a big smile, I want to say aloha and welcome. Welcome 
to all of you to the Committee's hearing on issues relating to 
the findings of the President's Commission on Care for 
America's Returning Wounded Warriors, known as the Dole-Shalala 
Commission for its two distinguished Co-Chairs, the Veterans 
Disability Benefits Commission, and other groups that have 
recently examined matters regarding coordination and 
collaboration between the Departments of Defense and Veterans 
Affairs in the care and treatment of veterans from Operations 
Enduring Freedom and Iraqi Freedom.
    Today's hearing is the latest in a series of hearings we 
have held this year that focus on the issue of coordination and 
collaboration between the two departments. Since our first 
hearing last January on this subject, the problems that gained 
public attention involving Walter Reed Army Medical Center 
brought more energy to this issue. Our committee and the Armed 
Services Committee have worked together toward achieving the 
goal of wounded warriors receiving optimal care and 
experiencing a truly seamless transition from DOD to VA, but 
there is much more that needs to be done.
    The problems at Walter Reed led to the creation of the 
Dole-Shalala Commission, the Task Force on Returning Global War 
on Terror Heroes, and DOD's Independent Review Group, each of 
which we will hear from today. We will also hear from the 
Veterans Disability Benefits Commission, which had been in 
existence for some time when the stories about Walter Reed 
first broke. I note that the Commission earlier this month 
issued a comprehensive report on the overall Disability 
Compensation System. The Committee will hold a subsequent 
hearing to take testimony on that report.
    General Scott, the Chair of the Commission, has been 
invited here today to provide the views of the Commission on 
the recommendations of the Dole-Shalala Commission and to 
discuss areas of overlap between the Disability Benefits 
Commission and other entities which were created in response to 
the stories about Walter Reed.
    It is important to recall that the problems identified at 
Walter Reed were not about the quality of health care provided 
by DOD, but more about a process that created confusion and 
inequities in the delivery of disability benefits to wounded 
warriors. The stories about Walter Reed also highlighted 
existing problems in the organization of medical holdover 
detachments and in the hand-off between the military services 
and VA for wounded or seriously injured or ill servicemembers.
    The good news is that since this spring, much hard work has 
been done by DOD, VA, and the military services in seeking to 
resolve these problems. However, lately DOD and VA may have 
been recognizing the significant problems of adapting the 
departments to the stresses of the current conflicts, I am 
satisfied that real work is now underway.
    I am particularly impressed by the work of the Joint VA and 
DOD Senior Oversight Committee, co-chaired by VA's Deputy 
Secretary Gordon Mansfield, and DOD's Deputy Secretary Gordon 
England, that meets every Tuesday to work on a wide range of 
ongoing transition issues. This, as you know, is an 
unprecedented level of attention to the issue of DOD-VA 
cooperation and collaboration.
    Today's hearing gives us an important opportunity to review 
the recommendations of the Dole-Shalala Commission, the 
Disability Benefits Commission, and other reports that impact 
the interaction between DOD and VA, especially in those areas 
which still need improvement and where there is overlap or 
potential disagreement. I hope to gain a better understanding 
of the relationship among all the various recommendations with 
a particular focus on how the recommendations may relate to 
legislation developed by the White House and the response to 
the Dole-Shalala Commission. Senator Burr and I, along with the 
Chairman and Ranking Member of the Armed Services Committee, 
were briefed on this draft legislation earlier this month and I 
have many questions and concerns about it.
    I thank Senator Dole and Secretary Shalala and our other 
distinguished witnesses for joining us today. Their testimony 
will allow us to better understand the many recommendations and 
help identify areas where Congressional action is required.
    At our first hearing in January, I spoke about the stress 
that a new veteran with a life-altering wound or injury endures 
when faced with the challenge of applying for benefits and 
transitioning from one health care system to another while 
still in the process of recovery and rehabilitation. With the 
input of the many recommendations that we will hear about 
today, I believe that we can continue to make progress toward 
achieving the goal of a truly smooth and seamless transition.
    I have a longer statement that I will place in the record, 
which is available at the press table.
    [The prepared statement of Chairman Akaka follows:]
         Prepared Statement of Hon. Daniel K. Akaka, Chairman, 
                        U.S. Senator from Hawaii
    Aloha and welcome to the Committee's hearing on issues relating to 
the findings of the President's Commission on Care for America's 
Returning Wounded Warriors, known as the Dole-Shalala Commission for 
its two distinguished co-chairs; the Veterans' Disability Benefits 
Commission; and other groups that have recently examined matters 
regarding coordination and collaboration between the Departments of 
Defense and Veterans Affairs in the care and treatment of veterans from 
Operations Enduring Freedom and Iraqi Freedom.
    Today's hearing is the latest in a series of hearings we have held 
this year that focus on the issue of coordination and collaboration 
between the two Departments. That series began with this Committee's 
first hearing of the 110th Congress on January 23. Later, when stories 
broke about conditions at the Walter Reed Army Medical Center, this 
issue became more energized, and, since that time, our Committee has 
worked in close collaboration with the Senate Armed Services Committee 
to find appropriate legislative solutions for the many problems that 
have been identified. On March 2, 2007, Chairman Levin and I visited 
Walter Reed to gain a first-hand understanding of the problems. Our 
visit highlighted matters involving overlapping jurisdiction and a real 
need for our Committees to work closely together.
    On April 12, the two Committees held an unprecedented joint hearing 
to review and explore issues and problems relating to how those 
returning from combat in Iraq and Afghanistan were receiving care and 
services. That hearing set the foundation for the development of the 
Senate's proposed Wounded Warrior legislation which is currently in 
conference with the House as part of the 2008 National Defense 
Authorization bill.
    I could not be more pleased with the cooperative manner in which 
the staffs of the two Committees worked to develop this extremely 
important and comprehensive legislative package that addresses health 
care, benefits, and transition issues involving both DOD and VA. In 
crafting this legislation, the staffs met on a regular basis, received 
briefings from Army and VA leadership, visited Walter Reed to meet with 
Army and VA representatives, and were briefed on the findings of groups 
created by the Administration to look into the Walter Reed problems.
    It is important to remember that the problems identified at Walter 
Reed were not about the quality of health care provided by DOD, but 
about an overall process that created confusion and inequities in the 
delivery of disability benefits to wounded warriors. The stories about 
Walter Reed also highlighted existing problems in the organization of 
medical hold/medical holdover detachments and in the hand-off between 
the military services and VA of wounded or seriously injured or ill 
servicemembers.
    The good news is that, since this spring, much hard work has been 
done by DOD, VA, and the military services in seeking ways to resolve 
the problems which were identified. However late DOD and VA may have 
been in recognizing the significant problems of adapting their 
Departments to the stresses of the current conflicts, I am satisfied 
that real work is now underway. I am particularly impressed by the work 
of the joint VA and DOD Senior Oversight Committee, co-chaired by VA's 
Deputy Secretary Gordon Mansfield and DOD's Deputy Secretary Gordon 
England, that meets weekly to work on a wide range of ongoing 
transition issues. This is an unprecedented level of attention to the 
issue of DOD-VA cooperation and collaboration.
    Nevertheless, it is clear that much hard work lies ahead and that 
the problems faced by individual veterans and their families continue 
to demand attention and solutions. Today's hearing gives our Committee 
the opportunity to continue our work in this area.
    The problems highlighted by the situation at Walter Reed led to the 
creation of a number of entities--the Dole-Shalala Commission, which 
was established by the President on March 6, 2007, and presented its 
report on July 30, 2007; the Task Force on Returning Global War on 
Terror Heroes, also established by the President on March 6, 2007, 
which issued its report on April 19, 2007; and DOD's Independent Review 
Group, established by Secretary Gates on February 23, 2007, and which 
completed its report on April 19, 2007. The Committee will be hearing 
from each of these groups today.
    The Committee will also be hearing today from the Veterans' 
Disability Benefits Commission (VDBC), which was established by 
Congress in 2004, and which, on October 3, issued its report. The VDBC 
report provides an in-depth analysis of the benefits and services 
available to veterans, servicemembers, their survivors, and their 
families to compensate and provide assistance for the effects of 
disabilities and deaths attributable to military service. The VDBC was 
invited today to present its views on the recommendations of the Dole-
Shalala Commission and the other entities which were created in 
response to the stories about Walter Reed and to discuss areas of 
overlap between its recommendations and those of the other groups. The 
Committee will have other hearings, beginning early next year, on the 
VDBC's overall report and recommendations.
    Among the issues that the Committee will focus on today are those 
relating to the existing DOD and VA systems for providing compensation 
and other benefits to servicemembers injured during their service. This 
is a key area of overlap between the Dole-Shalala Commission and the 
VDBC.
    The Dole-Shalala Commission, on the basis of its work over a 
relatively short period of time--their first public meeting was in mid-
April and they issued their report in late July--recommended a complete 
restructuring of the DOD and VA disability systems, as one element of 
its report that includes six recommendations focused primarily on 
collaboration between DOD and VA and on the needs of newly injured 
servicemembers. It is not clear from the Commission's report what 
outside expertise the Commission relied on to reach this conclusion. 
The only suggestion we have received thus far on how this comprehensive 
revision might be carried out came in the form of draft legislation on 
which Senator Burr and I, along with our counterparts on the Armed 
Services Committee, were briefed last week. This draft legislation, 
apparently developed by the White House, would have the Congress cede 
the responsibility for the proposed comprehensive retooling of VA's 
compensation system to the Secretary of Veterans Affairs and require 
the Secretary to accomplish this monumental task over a very few 
months.
    The VDBC, in contrast, took a more systematic approach, carried out 
over a period of two and a half years, that focused exclusively on the 
complex and often inefficient service-connected disability structure. 
The VDBC conducted 26 public meetings, carried out extensive research, 
and received significant input from outside entities, including the CNA 
Corporation and the Institute of Medicine.
    As part of its effort, the VDBC articulated eight principles that 
it believes should guide the development and delivery of future 
benefits for veterans and their families. It structured its analysis by 
developing 31 research questions. The Commission's staff drafted 11 
white papers that analyzed 16 of those questions and presented options 
to the Commission for their deliberation. Attorneys conducted legal 
analyses of several of these issues and gave the Commission a 
historical context for much of the legislation that sets forth the 
benefits available to disabled veterans, their families, and survivors.
    On the basis of its analysis and considerations, the VDBC made 113 
recommendations designed to improve VA's disability compensation 
program for the 21st century. These recommendations collectively 
address the appropriateness and purpose of benefits, the benefit levels 
and payment rates, and the processes and procedures used to determine 
eligibility for benefits.
    Many significant recommendations made by the VDBC are not 
contemplated in the Dole-Shalala report and warrant further review 
before any action is taken on the Dole-Shalala recommendation related 
to the overall disability benefits system and on how the Dole-Shalala 
recommendation may relate to the legislation developed by the White 
House that I mentioned earlier.
    With respect to that draft White House legislation, I have many 
questions and concerns about it, but wish to make two general points 
about it. First, whatever legislation is finally submitted by the White 
House will not have my support as a replacement for the Wounded Warrior 
legislation that is now pending in the NDAA conference. Our Committee 
and the Armed Services Committee, and our counterparts in the House, 
have worked diligently on the Wounded Warriors legislation and I see no 
basis to scrap that effort this late in the Session. The second point I 
wish to make about the draft legislation is this: As Chairman of the 
Veterans' Affairs Committee, I will unequivocally oppose any proposal 
that would abdicate the role and responsibility of the Congress for 
dealing with the VA compensation system by giving that task to the VA 
Secretary. On that point, it is worth noting that there is no confirmed 
Secretary of Veterans Affairs at present. It is inconceivable to me 
that there would be any significant support for giving such a 
monumental task to VA, especially when there is no leadership in place.
    There are a number of other recommendations from the Dole-Shalala 
Commission that I hope to learn more about today, including those 
relating to care coordination, treatment for PTSD, providing support 
for family members who have to take time off from their jobs to be with 
their wounded family members, and recommendations relating to VA's 
vocational rehabilitation program.
    With regard to coordination of care, I am pleased by the Dole-
Shalala Commission's recommendation that each seriously injured 
servicemember be provided with a ``Recovery Coordinator'' to serve as 
the patient and family's primary point of contact throughout their 
treatment and to ensure that the servicemember is getting the care he 
or she needs. This is a concept the Committee has already embraced in 
our health care omnibus legislation, S. 1233, which is currently 
pending passage by the full Senate. It is clear that the need exists 
for care coordinators to assist patients in navigating through the two 
systems. However, I believe that if every servicemember is to be 
provided with a Recovery Coordinator, we must also ensure that their 
efforts are managed efficiently. Basic questions such as which agencies 
will hire and train them must be answered.
    We must also uncover what the real impediments are to accessing 
treatment for Post Traumatic Stress Disorder that prompted the Dole-
Shalala Commission to recommend improvements in this area. Is it 
identifying servicemembers with more severe symptoms, and getting them 
in the door, or is it that when they do present themselves at a DOD or 
VA facility, they are not being given proper care? The Dole-Shalala 
Commission says that Congress should enable VA to provide aggressive 
PTSD care, but it is my belief that VA already has the authority to 
provide the care, and that our role in Congress is to ensure that VA 
has the resources to do the job.
    In addition, the Dole-Shalala Commission recommended that the 
Family Medical Leave Act should be amended to allow up to 6 months' 
leave for a family member of a servicemember who has a combat-related 
injury. Though the Commission's recommendation as formulated does not 
fall within the jurisdiction of our Committee, other proposals 
addressing the need to support the families of those who are recovering 
from combat injuries have been made that do, so we will be looking at 
the ramifications of these approaches.
    And finally, I find the President's Commission's recommendations 
relating to VA's Vocational Rehabilitation and Employment Program 
confusing, especially the proposal to offer individuals a monetary 
incentive to complete a program of rehabilitation and the subsequent 
effect that completion would have on an individual's level of service-
connected compensation. Since the Committee has an oversight hearing of 
this program scheduled for later this month, I do not intend to pursue 
these issues at today's hearing in great depth. I will have some 
questions on these recommendations for the record and perhaps later on 
in connection with the oversight hearing at the end of the month.
    In closing, I note that, at the Committee's first hearing in 
January, I spoke about the stress that a new veteran with a life 
altering wound or injury endures when faced with the challenge of 
applying for benefits and transitioning from one health care system to 
another, while still in the process of recovery and rehabilitation. 
With the input of the many recommendations that we will hear about 
today, I believe that we can continue to make progress toward achieving 
the goal of a truly smooth and seamless transition.

    Chairman Akaka. In the interest of time and to allow others 
to speak, I will stop here and turn to the Committee's Ranking 
Member, Senator Richard Burr, for his opening remarks.

      STATEMENT OF HON. RICHARD M. BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Aloha, Mr. Chairman. I didn't know it would 
be quite as challenging linguistically on this Committee as it 
is to serve with Senator Akaka, but he has challenged me to 
learn more than just what we need to do as it relates to 
changes in the disability system. Mr. Chairman, thank you.
    I welcome all of our distinguished panelists and I 
appreciate you being here this morning. You have all spent many 
hours with one thought in mind, and that is improving the lives 
of those who served our country in the Armed Forces. You have 
given us policy suggestions that I believe can help shape how 
we care for our servicemen and women for decades to come. For 
your commitment to them and for your advocacy on their behalf, 
I am here this morning to say thank you to each and every one 
of you.
    Let me begin by making two very broad points. First, we are 
here today to review recommendations on how best to deliver 
health care, disability compensation, and rehabilitative 
benefits to those who have been injured in military service to 
our country. As we look at our strengths and our inefficiencies 
in getting the job done right, we have to keep in mind that the 
opportunities for today's professional warrior are 
fundamentally different than in earlier generations. Today, 
all-volunteer forces know that injury, even serious injury, 
need not be an impediment to continuing on with a productive 
and fulfilling life.
    I am amazed when I hear over and over how some soldiers 
with very serious injuries are able to return to their units, 
or how they plan to resume fully active lives, go to school and 
get a job. Modern technology and modern attitudes about 
disabilities not only give them that hope, they appropriately 
give them that expectation.
    Our job, then, is to give these brave men and women the 
tools they need and to remove the stumbling blocks that are in 
their way. In fact, they demand that from their government.
    Today's soldier chooses a military career and their 
expectation is the same as it would be for any professional 
working in any organization in America. If one is hurt on the 
job, one expects quick, effective, and relatively hassle-free 
physical, vocational restoration and supportive services from 
the employer.
    My second point is about our system of benefits and 
services for our veterans, servicemembers, and their families. 
Rather than use my words, I will read the Dole-Shalala 
Commission report where they said the Commission learned that, 
on the whole, we are a generous and giving Nation when it comes 
to providing for our servicemembers and veterans. Benefits 
include health care for veterans through the VA, for retirees 
through the Military Health System, and through civilian 
providers through TRICARE. In addition, we pay retirement and 
disability benefits and provide for education, adaptive 
equipment, employment hiring preferences, and more.
    The total cost of these benefits was well over $127 billion 
in 2006. So as of last year, we had a budget of over $127 
billion to assist veterans and servicemembers, more than double 
what it was just a decade ago.
    I highlight this information to suggest that the challenges 
facing many veterans today have as much to do with confusing 
bureaucratic programs operated by many different offices of the 
government as they do with the lack of benefit programs or the 
lack of resources. I will never shy away from providing our 
military men and women and our veterans with the resources they 
need, but I expect and these citizens expect that these 
resources will be used effectively to deliver needed benefits 
and services.
    There is a saying that goes, if you aren't part of the 
solution, then you must be part of the problem. So let us 
commit to talking today about meeting the challenges ahead of 
us. Secretary Shalala and Senator Dole, when you briefed us 2 
weeks ago, I was pleased to hear that officials and staff at 
the Department of Veterans Affairs and the Department of 
Defense were beginning to implement 90 percent of your 
Commission's recommendations.
    Mr. Chairman, I am committed to you, and I look forward to 
working with you, to conduct oversight of the Departments of 
Veterans Affairs and Defense to ensure that the best of these 
recommendations to improve veterans' care are implemented 
without delay.
    Senator Dole and Secretary Shalala, you also said in our 
recent briefing that 10 percent of your Commission's 
recommendations require legislative action. You called this the 
hard part. Of course, I am speaking about the recommendations 
to reform the Disability Compensation System. As you know, the 
Veterans Disability Benefits Commission has also spent the 
better part of 3 years looking at the hard part. I expect 
everyone calls it the hard part for a very good reason, and I 
think this Committee will soon find that out. I am fully aware 
that reforming the disability system will require a large up-
front cost, but if done properly, it would also be an 
investment.
    Chairman Akaka, once again, I pledge to you as the 
Committee works to better the lives and well-being of those 
wounded in defense of the country, knowing that the character 
of men and women of our Armed Forces is an investment that 
comes with little risk and great reward.
    One final thought before I conclude my statement. Almost 
every Member of Congress has had the opportunity to visit 
soldiers, Marines, sailors, and airmen who are fighting in the 
war on terror. In my own conversations with them, I can't help 
but be inspired by their love of country, their commitment to 
duty, their extraordinary optimism in the face of adversity. We 
have all referred to men and women who served with Senator Dole 
in the Second World War as ``The Greatest Generation,'' and my 
encounters with today's heroes remind me that greatness--when 
we talk about risking one's life for the freedom of others--is 
of every generation. Greatness belongs to the few whose deeds 
merit that title.
    To all who have served in combat, to the families who have 
sacrificed so that their loved ones could serve the rest of us, 
and to all who have been injured or who have died for our 
freedoms, you have my enduring respect and gratitude. No matter 
when you served or on what continent you fought, you have made 
the most supreme sacrifice. For that, and I know I speak for 
everyone in this room, we are eternally grateful.
    Again, I thank our distinguished guests this morning for 
their willingness to share their knowledge with this Committee 
and I think I speak for the Chairman when I say that we are 
anxious to go forward and to begin this process.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burr. Using 
what we call ``the early bird system,'' I am going to call next 
on Senator Craig, and he will be followed by Senator Murray.
    Senator Burr. Mr. Chairman, could I ask my colleagues to 
indulge me for one additional minute? We have been joined by a 
very special person and I just want to highlight that for our 
audience today. Sarah Wade, would you stand up for a second? I 
just want you to meet a very special person.
    Sarah Wade is the wife of Retired Army Sergeant Edward 
``Ted'' Wade. Following Ted's serious injury in Iraq on 
February 4, 2004, Sarah suspended her studies at the University 
of North Carolina at Chapel Hill to serve as an advocate for 
her husband and has recently become a public policy intern for 
the Wounded Warrior Project, a nonprofit organization dedicated 
to assisting military personnel injured in Iraq and 
Afghanistan.
    She was born and raised in Washington, D.C. Sarah currently 
resides in Chapel Hill, North Carolina, a constituent of mine 
and the wife of a very brave U.S. soldier. Thank you for being 
here, Sarah.
    [Applause.]
    Chairman Akaka. Thank you, Senator Burr.
    Senator Craig?

               STATEMENT OF HON. LARRY E. CRAIG, 
                    U.S. SENATOR FROM IDAHO

    Senator Craig. Mr. Chairman, Richard, I will be brief, but 
I do want to welcome both Secretary Shalala and Senator Dole 
before this Committee and to reminisce only briefly. If Bob 
hadn't said, Larry, there is work to be done on the Veterans 
Affairs Committee a good number of years ago, and you ought to 
go do it, I might not be here. And that work has continued. 
Thank you, Bob, for appointing me to this Committee a good 
number of years ago, and we have continued to work according to 
your wishes.
    I want to thank all of the panelists and the Commissions 
who are before us today. The work you do is critically 
important to veterans, to soldiers who will become veterans 
soon across this Nation, and we thank you for it.
    Earlier this year, Mr. Chairman, I asked a Member of the 
staff here on the Veterans Affairs Committee to submit 
testimony before Secretary Shalala and Senator Dole's 
Commission regarding the DOD-VA collaboration, especially as it 
relates to the overlapping health benefits systems. I have been 
very involved over the past few years in examining ways that 
DOD and VA can work together closely.
    We early on began to use the word ``seamless,'' but it 
became pretty obvious to me that it was a word, it was not a 
reality, not in the way we want it to be. And I would hope, Mr. 
Chairman, Richard, that as we work through this, seamless 
becomes a system and simply not a phrase, because that is 
exactly what is doable today if we can cause DOD and VA to come 
together in a way that recognizes what we want to achieve for 
America's veterans.
    I have used testimony from General Omar Bradley's 
Commission in 1956. I know Senator Dole has referred to it on 
occasion. I would hope that 51 years after today, that this 
Committee has not convened in a way that it is referring to the 
Dole-Shalala Commission as goals that should have been achieved 
but were not accomplished.
    I know government is a daunting system and sometimes very, 
very difficult to change, Mr. Chairman. We can and we must 
change it. And for the sake of America's veterans, I hope we 
can.
    So to meet that challenge, Mr. Chairman and Senator Burr, I 
accept your challenge to do just that, to look back a few years 
from now and say that we have accomplished what we set out to 
do. It is now a seamless system. When one transfers from active 
to veteran, it is simply the push of a button and the movement 
of a system. We have watched the failure too long. We have 
watched the bureaucracy be too daunting. It shouldn't require 
the wife of a soldier to become an advocate simply to work 
their way through a system that is impossible or nearly 
impossible to penetrate.
    We are moving in those directions. Now our challenge from 
the Commissions is to revisit it and revisit it on an annual 
basis, to challenge it, to oversee it, and to force it to 
change. Thank you for being with us.
    Chairman Akaka. Thank you very much, Senator Craig.
    Now we will hear from Senator Murray.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Chairman Akaka, 
Ranking Member Burr, for holding this really important hearing.
    Secretary Shalala, Senator Dole, welcome to our Committee. 
Thank you for the work you have done and for being here today 
to present the recommendations of your Commission as well as 
the other three reports that we are going to hear about today 
about how we can improve the care for our servicemembers and 
veterans as they transition from the military to the VA.
    It has been 8 months now since the Washington Post exposed 
the scandalous conditions that all of us read and were shocked 
by, mice running in walls and moldy walls and holes in ceilings 
and the bureaucratic maze that our men and women who fought so 
bravely for us faced when they got home. Obviously, no one 
should have to endure those kinds of conditions, but most of 
all, the men and women who fought so courageously for all of 
us.
    I think it is important to remember that it wasn't just 
Walter Reed. I think, as you well know, it was many of our 
facilities that were facing very bad conditions. This was 
symptomatic of the entire system, and it wasn't just 
infrastructure. It was a long time waiting to see a doctor. It 
was bureaucratic ineptitude. It was VA claims backlogs that 
were taking months and years that were really harming our men 
and women's ability to be able to take care of their families 
when they come home.
    I think all of us know that, without hesitation, these men 
and women take on the task that this Nation has given them. 
They answer the call to serve in Iraq or Afghanistan or 
wherever we send them. They have left their loved ones for 
years. They have put their careers on hold. They put their 
lives on the line, and the least we can do is make sure when 
they come home, they get prompt, respective, comprehensive 
support for the work that they have done.
    I have said, Mr. Chairman, many times that no matter how 
divided this country may be over this current war in Iraq, this 
country is extremely united behind making sure that the men and 
women who have fought for us get the care that they deserve. We 
have taken that and used it this year, and the first time in 
the Iraq supplemental war bill, putting in funding for 
veterans, $1.8 billion in emergency funding, for the first time 
counting the care of veterans as part of the cost of war, which 
I think is extremely important to do. Of course, this year's VA 
military construction bill increased funding $3.6 billion over 
the President's request as a recognition of the costs that we 
are responsible for.
    But I do think this environment that the country is in 
today, where we are all so supportive of these men and women, 
gives us a chance today to do these fundamental reforms to the 
VA and DOD that are so badly needed, and we need to really 
strike while the iron is hot.
    The Senate has already done that. We passed the Dignified 
Treatment of Wounded Warriors Act, which deals with the 
seamless transition process. That bill is now being worked out 
with the House and hopefully will be enacted soon so we can 
begin to provide some real solutions. I am interested today in 
how the Commission report ties in with that and how we can make 
sure we are doing that correctly together.
    But I am especially pleased that we are now actually 
looking at all of this and we are seeing studies and commission 
reports and recommendations by a number of different groups who 
are going to be in front of us today and I look forward to 
hearing from all of our witnesses and having a chance for us to 
really do the best with the best information we have.
    Senator Dole, Secretary Shalala, I am especially looking 
forward to your thoughts on the administration's proposed 
legislation to carry out your recommendations and I am very 
glad to see the President come to the table on this issue and 
to work with us, I hope, as part of moving forward the 
Dignified Treatment of Wounded Warriors Act, as well.
    So, Mr. Chairman, this is a very important hearing. The 
country is waiting. They want to know what we are doing and how 
we are moving forward and it is incumbent upon all of us to act 
well, so thank you very much.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Tester?

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman and Ranking Member 
Burr. I really, really appreciate the fact that you are having 
this hearing. I think it is long overdue to really take a look 
at what families and veterans have gone through to navigate 
through the bureaucracy of the DOD and the VA.
    I also want to thank everybody who is on these panels here 
today. It truly is an all-star cast of expert witnesses and I 
want to tell you I appreciate Senator Dole, Secretary Shalala 
coming today and I look forward to your testimony, as I am sure 
we all do.
    I would ask, Mr. Chairman, that my entire statement be put 
in the record, but I do want to talk about a few things.
    Over the last 10 months, I have held ten listening sessions 
with veterans throughout the State of Montana. The last one was 
last weekend in Mile City, Montana. At these listening 
sessions, I have heard about good things that have happened 
with the VA and I have heard about some things that have been, 
quite honestly, unacceptable with the VA.
    As we go forth in what we are doing here in this Committee, 
I think it is critically important that we take all the 
necessary steps. I have heard just this morning issues or words 
like complex, impenetrable, bureaucratic, ineptitude. I think 
we all know that there is room for improvement and I think that 
the people who fought for this country and put their lives on 
the line and protected us in times of war and even not deserve 
it and we owe it to them.
    Just yesterday, a fellow by the name of Dan Gallagher from 
Missoula, head of the VFW in Missoula--in fact, he is here in 
the audience today--stepped into my office and said it is just 
a matter of course that when people first apply for benefits, 
they get turned down, right out of the chute. It is just the 
way things are done. That is a bad way to do business and we 
cannot accept that kind of work ethic, quite honestly. It is 
almost like the VA is working against the veterans instead of 
working for the veterans. So, we need to make sure that good 
health care and good benefits that happen for some of our 
veterans, occur for all of our veterans.
    With that, I very much look forward to your testimony, 
Senator Dole, Secretary Shalala. And thank you, Mr. Chairman 
and Ranking Member Burr.
    [The prepared statement of Senator Tester follows:]
    Prepared Statement of Hon. Jon Tester, U.S. Senator from Montana
    Thank you, Mr. Chairman. I am glad that we are having this 
hearing--it is long overdue for us to take a look at what families are 
going through when it comes to navigating the DOD and VA bureaucracies.
    We've all heard the stories about the current system being 
complicated for injured servicemembers to navigate and stretched beyond 
the capabilities of the doctors and claims processors.
    I met yesterday with the head of the American Legion Post in 
Missoula--Dan Gallagher. Dan has spent his entire adult life helping 
Montana veterans get the care and the benefits that they're entitled 
to.
    He brought me a letter and in it, he said this:
    ``Our veterans and our returning warriors have a right to the care 
their service has earned them. We cannot let the yellow ribbons to, 
once again, become red tape.''
    My friend, Dan Gallagher, has it exactly right. But that is exactly 
what is happening to a number of vets. Not just the catastrophically 
injured vets that we've all read so much about at Walter Reed and other 
places, but all throughout the DOD and the VA.
    I want to thank the witnesses for being here, because I think they 
all share a real desire for change in the system. We've got to simplify 
where we can, and make this process a lot less painful for veterans and 
their families.
    Above all, I think this is going to require a lot more resources. 
And it will require a real attitude change within the bureaucracies. 
Folks are there to help servicemembers and families, not tell them what 
can't be done.
    With that, Mr. Chairman, let me stop and let the witnesses have 
their say.

    Chairman Akaka. Without objection, your statement will be 
included in the record.
    Senator Brown?

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you very much, Mr. Chairman, Ranking 
Member Burr. Senator Dole, thank you for your service to our 
country, both in wartime and in the Senate, and fellow 
Clevelander Madam Secretary, nice to see you today. Thank you 
for your service.
    Everyone always says the right thing about veterans at 
hearings like this and as elected officials and at all the 
right veterans' halls and all the right celebrations and all 
the patriotic gatherings. Yet this institution has made some 
terrible mistakes and some terrible choices when it comes to 
veterans' health care, I think. We have always had plenty of 
money for war. We have always had plenty of money for tax cuts, 
for especially the top one or two or 5 percent in this country.
    Yet the sacrifice in this war that we are in now has hardly 
been spread evenly in the population and so many of the people 
that have gained the most have sacrificed the least. There has 
not been enough money for body armor, not enough money for 
MRAP, not enough resources, as Senator Murray's comments point 
out, not enough resources for VA health care. We have a lot of 
work to do.
    By passing the Veterans' Organizations Independent Budget, 
the military construction bill that Senator Murray played such 
a major role in, it is very much an important first step. 
Coordination, as several have said, including Senator Craig, 
coordination and making it really seamless, more than just a 
word of DOD and VA, is so very, very important. Extending, as 
the Commission recommends, extending family and medical leave, 
establishing a caseworker that will work with families of 
soldiers to coordinate care and services is so very important. 
A timely and accurate disability rating is so very important.
    Particularly, we need to improve the diagnosis and 
treatment of PTSD and all that we have seen coming from this 
war, and I know that Senator Dole's feelings and Secretary 
Shalala's feelings are so strong about that. I have spent, as 
so many of us have, much of the last 4 years meeting with 
soldiers, welcoming the troops home, encouraging them to get 
the treatment they need when they resist for good reason: 
because they want to integrate themselves back into their 
workplace; their families; their communities. It is so very 
important that this transition be done right and this 
Commission's recommendations will help there.
    One last point. Ohio has one of the lowest average payments 
for disability compensation--well below the national average. 
We are a large State with a huge veteran population and we need 
to do better. That is partly an issue we can help fix within 
the VA. It is partly an Ohio issue. We need to work together to 
do all of that.
    I am so appreciative of the service of not just Senator 
Dole and Secretary Shalala, but our other panelists, too; and I 
thank the Chairman.
    Chairman Akaka. Thank you very much, Senator Brown. Now we 
will hear from Senator Hutchison.

            STATEMENT OF HON. KAY BAILEY HUTCHISON, 
                    U.S. SENATOR FROM TEXAS

    Senator Hutchison. Thank you, Mr. Chairman. First, I want 
to say to Secretary Shalala and Bob Dole, there has not been a 
better, more committed advocate for veterans in this Nation in 
our history than you, Bob Dole, and thank you so much for 
continuing from your great service in World War II to helping 
those who have followed you. Thank you. And Madam Secretary, 
you had another full-time job. You didn't need to take this on, 
but you did and we all so appreciate it, that you would once 
again suit up for your service outside of your regular duties, 
which we all know are huge. So thank you both very much.
    Let me say a couple of things. I am the Ranking Member on 
the Veterans Affairs and Military Construction Appropriations 
Subcommittee, so I have been dealing with the issues of 
funding, of course, for veterans, but also trying to make sure 
that we have the seamless transition. Now, you did in your 
report address this issue, suggesting that we have the rapid 
transfer of patient information between DOD and VA. But I do 
want to say that this is something where the VA is really 
leading.
    We have the state-of-the-art electronic medical records in 
the VA system. It was never brought home better than after 
Katrina in New Orleans when the whole Veterans' Hospital had to 
be vacated and not one record was lost--not one. So our 
veterans in New Orleans got superb treatment wherever they 
were, wherever they evacuated, and that is a testament to the 
system. Of the 155 VA hospitals, every one is set with the 
electronic records, so we know there is a system that works.
    However, as has been said here, it is the transition to 
DOD, and the anecdotal information that we get is phenomenal. 
In Houston, for instance, I was called because our veterans who 
were injured and therefore retired with disabilities were 
waiting months and even almost a year for their disability 
benefits. So we immediately went to the VA and they tasked 
people to go down to try to fix that hiatus because we just 
didn't have enough people processing.
    I know that because the VA system is so good, if we put our 
minds to it and we take your direction, which you also saw, and 
bring DOD up to the same standards so that people can have a 
seamless transition, that everyone will be ahead. It is 
inexcusable for someone injured in Iraq or Afghanistan to go on 
medical disability and not get their benefits for three to nine 
or 10 months. It is just inexcusable. So that is the issue that 
I think we have to address immediately and I really think it is 
in DOD and matching those up.
    So thank you for your service. Thank you for being here to 
report to us, and we will follow up, I assure you, on your 
recommendations. Thank you.
    Chairman Akaka. Thank you very much, Senator Hutchison.
    Now we will hear from Senator Isakson.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Well, thank you very much, Chairman Akaka. 
I appreciate you and the Ranking Member doing this. Senator 
Dole, it is a pleasure to see you again. Secretary Shalala, 
thank you for your service to the country.
    My remarks will be limited to the seamless transition 
issue. I want to commend you on your recommendations and the 
focus on that and point out what I have in a couple of previous 
hearings that we have had.
    General Schoomaker did a great job in Augusta with the 
Augusta VA, called the Uptown VA Hospital, and the DOD 
facility, Eisenhower Medical Center, created a seamless 
transition of treatment and rehabilitation for wounded warriors 
coming back that is really second to none. In fact, I told the 
story previously, and I will tell it one more time at the risk 
of being repetitive because I think it is so important.
    I met a Sergeant Harris when I was at the Augusta VA. She 
had gone to Iraq and on the second day of her deployment had a 
Traumatic Brain Injury from an exploding IED. She came back to 
the States. DOD treated her. They could not correct it, so she 
was severed from the military and went to the VA hospital. They 
corrected the Traumatic Brain Injury and reenlisted her in the 
military and she was on active duty at the Augusta Eisenhower 
Medical Facility, which shows when you have a good seamless 
transition and continuous care it is of immeasurable benefit to 
our wounded warriors.
    So I commend you on your recommendations on that, your 
recommendations on electronic records and evaluations. All are 
critically important to seeing to it our veterans get the very 
best and the timeliness of care, and I thank you again for both 
of your service to the country.
    Chairman Akaka. Thank you very much, Senator Isakson. I am 
pleased to welcome our first panel. We are fortunate to have 
two highly distinguished public servants testifying before the 
Committee today.
    I am honored to welcome the Co-Chairs of the President's 
Commission on Care for America's Returning Wounded Warriors, 
former Senator Bob Dole of Kansas and Donna Shalala, Secretary 
of Health and Human Services during the Clinton administration.
    Senator Dole and Secretary Shalala were called by the 
President to lead an evaluation of the care and services 
provided to America's wounded servicemembers when they return 
home from battle. They are here today to share their findings 
and recommendations with the Committee.
    Senator Dole and Secretary Shalala, we are pleased to have 
you here today and look forward to your testimony. Your full 
statements will appear in the record of the hearing and you may 
begin with your statement, Secretary Shalala.

   STATEMENT OF HON. DONNA E. SHALALA, CO-CHAIR, PRESIDENT'S 
  COMMISSION ON CARE FOR AMERICA'S, RETURNING WOUNDED WARRIORS

    Ms. Shalala. Thank you very much, Chairman Akaka, Ranking 
Member Burr, distinguished Members of this Committee. Before I 
begin, let me introduce one member of the Commission who has 
joined us, Ed Eckenhoff, who runs the National Rehabilitation 
Hospital, a private rehabilitation hospital here in Washington, 
D.C., one of the leading experts on rehabilitation in this 
country; and Marie Michnich, who was our Executive Director, 
who is at the Institute of Medicine of the National Academy of 
Sciences; and Dr. Sue Hosek from the RAND Corporation, one of 
the leading experts in military health, who was our Research 
Director; and Dr. Karen Geiss from the Medical College of 
Wisconsin, who was the Deputy Executive Director of our 
Commission. We had a very short period of time so we literally 
grabbed talented people from all over this country to come join 
us to do our work.
    It was a privilege to serve on the President's Commission 
with Senator Dole. We never had a disagreement. He is fun to 
work with, but more importantly, he knows this system and cares 
deeply about what happens to these young men and women who come 
back from conflict.
    Of our nine Commissioners, four were severely injured in 
current or past conflicts and one was the wife of a soldier 
from Iraq. This was not a Commission of the usual suspects. It 
was a Commission that had a very high percentage of young 
people who had current information and current experiences and 
included people who had not been on commissions before but took 
a fresh look at these issues.
    We presented six groundbreaking patient- and family-
centered recommendations, and one of the important things about 
our recommendations is they were not bureaucracy-centered. They 
were patient-centered and family-centered. We tried to look at 
the issues from the point of view of the people that were 
directly affected, as opposed to the people that provided just 
the services.
    Our report, which is called ``Serve, Support, and 
Simplify,'' we believe is not only short, but it is a blueprint 
for and certainly a very clearly outline for the kinds of 
changes we believe must take place.
    Let me also emphasize, as General Scott will, that our 
recommendations stand on the report of others. We built upon 
other recommendations. We looked carefully at the Bradley 
Commission and all the previous commissions as well as more 
recent commissions.
    Our six recommendations do not require massive new programs 
or a flurry of new legislation. We identified with the six 
recommendations 34 specific action steps that must be taken to 
implement the six recommendations. Only six of the 34 require 
Congressional action, and that is what I want to focus on 
today. I want to talk about those six that require action by 
Congress and then Senator Dole will discuss how the 
recommendations will work together to create a new system.
    The first action step calls for Congress to simplify the 
DOD and VA disability systems. I realize in this town the word 
``simplify'' is not often used, but I think that our point here 
is it ought not to take an expert to understand the system. Any 
injured soldier or member of their family ought to be able to 
understand what is going to happen to them and what benefits 
are available to them and how the disability system works.
    Right now, DOD and VA assess each servicemember's 
disability for completely different reasons. DOD needs to 
determine if they can continue to do their job despite their 
medical condition. If they can't, then they must discharge the 
servicemember. The degree of disability, the length of time 
spent in service depends on the amount of military compensation 
and benefits.
    DOD generally only rates a condition that prevents the 
servicemember from doing their job. The VA determines how 
disabled a veteran is based on every medical condition that 
occurred was made worse while in the military service. The 
degree of disability is part of how the VA determines what 
benefits, services, and the amount of compensation the veteran 
will get.
    Over the years, this evaluation system has become really 
convoluted as we tried to fix problems and that is the point we 
are making today. People of good will in this Congress and in 
the agencies, every time they had a problem they added a new 
regulation, a new requirement, a new piece of legislation, and 
that is why the system is so convoluted and so complex today.
    We recommend simplifying the system. DOD retains their 
authority to determine fitness to serve. If a servicemember 
whose health conditions make them unfit for duty, they would be 
separated from the military with a lifetime annuity payment 
based on their rank and years of military service. They don't 
have to wait 20 years. If they get severely injured, they have 
been in for 11 years, they can't any longer serve in the 
military. They would leave the military with an annuity payment 
based on their rank and that 11 years of service.
    This recommendation brings DOD in line with other employers 
of choice. That is the way the employment system works where 
you have an annuity system in this country, and it is a very 
important step in maintaining a volunteer Army, from our point 
of view.
    We also believe that only one physical exam should be 
performed rather than the two required now--one by each 
department--and that that physical should be performed by DOD. 
The VA then would assume all responsibility for establishing 
the disability rating based on that physical and for providing 
all disability compensation.
    So you split the two responsibilities based on their 
expertise and the appropriate role for each department, but it 
is the VA that makes the disability determination. It is a much 
simpler system. It supports those that are transitioning 
between active duty and veteran status and it puts the DOD in 
the right frame. They provide the necessary military strength 
and expertise to keep our Nation safe and secure. They can 
determine their own fitness standard for serving.
    Now, obviously, there are some soldiers that the DOD will 
find a job for even though they have an injury--an amputation, 
for example--and that is really for them to work out with those 
soldiers. They have an interest in doing that. They would like 
to keep people employed. But if the decision is that that 
soldier, sailor, or Marine should go over to the VA system, 
they would leave with an annuity. They would go to the VA 
system and get their disability rating, the disability payment, 
and some other things that we recommend.
    The second action step out of the six is that we recommend 
health coverage for servicemembers who are found unfit because 
of conditions that were acquired in combat, supporting combat, 
or preparing for combat. We believe that Congress should 
authorize comprehensive lifetime health care coverage and 
pharmacy benefits for those servicemembers and their families 
through DOD's TRICARE program, and the important phrase here is 
``and their families.''
    Many of these young people can take a job, but finding a 
job that has benefits that will cover their families is 
probably a real challenge. This will change their lives if this 
benefit is available. We really believe it will help them to 
find employment because they will have a lot more choices.
    Our third action step is to ask Congress to clarify the 
objectives for the VA disability payment system by revising the 
three types of payments which are currently provided to many 
veterans. The primary objective should be to return the 
disabled veteran to normal activities insofar as possible and 
as quickly as possible by focusing on education, training, and 
employment. We recommend changing the existing disability 
compensation payments for injured servicemembers to include 
three components: Transition support, earnings loss, and 
quality of life.
    Transition payments are, of course, temporary payments to 
help with expenses as disabled veterans integrate into civilian 
life. Veterans should receive either 3 months of base pay if 
they are returning to their communities and not participating 
in further rehabilitation, or an amount to cover living 
expenses while they are participating in education or work 
training programs. We also believe that the time for 
participating in these training programs should be expanded to 
72 months for those who may need to attend part-time. Most of 
the students in this country are not going to school full-time. 
They are going to school part-time, and our veterans, our 
investments in these veterans ought to reflect what is 
happening in the larger society.
    Second, earnings loss payments. We should make up for any 
lower earning capacity remaining after transition and after 
training. That is what we mean by modernizing the system. 
Earnings loss payments should be credited to Social Security 
earnings and would end when the veteran retires and claims 
Social Security benefits. Now, the President has a slightly 
different recommendation in this area.
    In addition, we believe that quality of life payments 
should be provided to disabled veterans, and these payments are 
based on a more modern concept of disability, and that is our 
point about the current disability system. It is very old 
fashioned. No one except this government is paying disability 
payments this way any longer. Everybody has quality of life 
payments as part of the payment scheme. We need to take into 
account an injury's impact on an individual's total quality of 
life, independent of the ability to work. And if you look at 
the private sector payments, they combine these two when 
someone has a disability.
    We also call for the disability status of veterans to be 
reevaluated periodically, and we see this as a positive 
provision that would ensure that all disabled veterans are seen 
by a health professional at least every few years. What we 
don't want is for the payment to go out of date for an 
individual veteran.
    By simplifying and modernizing the DOD and VA disability 
systems, we will make the systems less confusing, we will 
eliminate payment inequities, and we will provide a foundation 
with appropriate incentives for injured veterans.
    Our fourth action step asks you to authorize the VA to 
provide lifetime treatment for PTSD for any veteran deployed to 
Iraq or Afghanistan that needs such services. This presumptive 
eligibility for the diagnosis and treatment of PTSD should 
occur regardless of the length of time that has transpired 
since the exposure to combat events.
    One of the things that we learned from talking to young 
veterans is that when they get out, they want to get out, and 
many of them are asked but they don't answer because they want 
to go home. They have got to be able to come back and get 
evaluated. We are involved in very intense urban fighting, 
often against civilian combatants, and many servicemembers 
witness or experience acts of terrorism. Many of these 
servicemembers have deployed multiple times. We need to make 
sure that those services are available forever for these 
servicemembers.
    Next, we ask Congress to strengthen support for military 
families. The fact that a wife has to give up whatever she is 
doing, whether it is school or a job, and other family 
members--we met husbands, we met mothers that were giving up 
their positions. We have asked that they be provided benefits, 
as well, as caregiving benefits. We have asked for more 
intensity in the family support systems that are made 
available. We have asked that the Family and Medical Leave Act, 
which Congress has been supportive of, goes from 12 weeks to up 
to 6 months for a family member of a servicemember who has come 
back with a related injury and meets the eligibility 
requirements.
    The military does a very good job of getting family members 
to the bedside of an injured servicemember. That is not the 
problem. It is once they get there and the kinds of services 
that we provide for them and what we say to them about their 
lifetime responsibilities in attendant care. That is our 
responsibility as a Nation. They will do it if they must, but 
it seems to us fundamentally unfair that we are not providing 
more support to these family members, and we have made a series 
of recommendations.
    Mr. Chairman, I believe the government can work to improve 
the lives of its citizens. I also believe that when we fix 
problems, we often add to their complexity. I, of course, had 
to manage the Medicare program, which is an example of that 
kind of complexity. Here, we have a chance to think clearly 
about the system and to simplify it, make it more 
straightforward, make it fairer, and invest resources where 
they will really make a difference.
    Thank you very much, and I will yield to my colleague, 
Senator Dole.
    [The prepared statement of Ms. Shalala follows:]
     Prepared Statement of Donna E. Shalala, Co-Chair, President's 
      Commission on Care for America's Returning Wounded Warriors
    Good morning Chairman Akaka and distinguished Members of the 
Committee. Thank you for the opportunity to testify today, along with 
my fellow Co-Chair, Senator Bob Dole, about the recommendations our 
Commission presented to the President, Congress and the public in late 
July.
    It was a true privilege to serve on the President's Commission on 
Care for America's Returning Wounded Warriors, especially with Senator 
Dole, whose knowledge of and experience with veterans' issues was 
invaluable during our short Commission tenure. We were joined by a 
remarkable group of commissioners, with their own unique experiences 
and expertise. Of our nine commissioners, four were severely injured in 
current or past conflicts and one was the wife of a soldier from Iraq 
who was severely burned.
    The Commission presented six groundbreaking patient and family 
centered recommendations that make sweeping changes in military and 
veterans' health care and services. At the heart of these 
recommendations is our belief in a system of care and benefits that 
enables injured or ill service men and women to maximize their 
successful transition, as quickly as possible, back to their military 
duties or civilian life. Our report--Serve, Support, Simplify--is a 
bold blueprint for such a system. I respectfully request that this 
report be submitted for the record.
    Let me take a moment here to emphasize that our efforts built upon 
the recommendations and reports of others--most of them here today. We 
are united in our call for change. We were not duplicative of these 
recommendations, but added to them in significant ways.
    Our six recommendations do not require massive new programs or a 
flurry of new legislation. We identify 34 specific action steps that 
must be taken to implement the six recommendations. Only six of these 
34 items require legislation, and that's what I will focus on today.
    I will summarize the actions that require legislation, and, then, 
Senator Dole will discuss how all of our recommendations would work 
together to create the best system of care to return our wounded 
warriors to optimal health and productivity.
    Our first action step calls for Congress to simplify the DOD and VA 
disability systems. Right now, these Departments assess each 
servicemember's disability for different reasons. DOD needs to 
determine if servicemembers can continue to do their job despite their 
medical condition. If they can't, then the DOD must discharge the 
servicemembers. The degree of disability and the length of time spent 
in service determine the amount of military compensation and benefits. 
DOD generally only rates the condition that prevents the servicemembers 
from doing their job. VA determines how disabled a veteran is based on 
every medical condition that occurred or was made worse while in 
military service. The degree of disability is part of how the VA 
determines what benefits, services, and amount of compensation the 
veteran will get. Veterans can ask the VA to rate additional 
disabilities at any time.
    Over the years, the disability evaluation system has become 
convoluted as we tried to fix problems. What we created is a system 
that is confusing and takes too long. In our national survey of injured 
servicemembers, less than half understood the DOD's disability 
evaluation process. And, only 42 percent of retired or separated 
servicemembers who had filed a VA claim understood the VA process. The 
system is dysfunctional and we need to fix it.
    We recommend that DOD retain authority to determine fitness to 
serve. Servicemembers whose health conditions make them unfit for duty 
would be separated from the military with a lifetime annuity payment 
based on their rank and years of military service. This recommendation 
brings the DOD in line with other employers of choice--an important 
step in maintaining an all volunteer professional military force.
    We believe that only one physical exam should be performed, rather 
than the two required now--one by each Department--and it should be 
performed by the DOD. The VA should assume all responsibility for 
establishing the disability rating based on that physical and for 
providing all disability compensation.
    It is a much simpler system that better supports the needs of those 
transitioning between active duty and veteran status. It modernizes the 
system and allows the two Departments to focus on their unique and 
separate missions. DOD must provide the necessary military strength and 
expertise to keep our Nation safe and secure. DOD should determine 
fitness standards and provide for the health and readiness of the 
military workforce. As an employer, DOD must also provide retirement 
benefits. The VA's mission is to care for our Nation's veterans by 
providing appropriate benefits and services.
    In our second action step, we recommend health care coverage for 
servicemembers who are found unfit because of conditions that were 
acquired in combat, supporting combat, or preparing for combat. 
Congress should authorize comprehensive lifetime health care coverage 
and pharmacy benefits for those servicemembers and their families 
through DOD's TRICARE program.
    We believe this action item would help these individuals find 
employment that best fits their needs and talents instead of making a 
career choice based on whether family health care coverage is provided.
    In our third action step, we would like Congress to clarify the 
objectives for the VA disability payment system by revising the three 
types of payments currently provided to many veterans. The primary 
objective should be to return disabled veterans to normal activities, 
insofar as possible, and as quickly as possible, by focusing on 
education, training, and employment. We recommend changing the existing 
disability compensation payments for injured servicemembers to include 
three components: transition support, earnings loss, and quality of 
life.
    ``Transition Payments'' are temporary payments to help with 
expenses as disabled veterans integrate into civilian life. Veterans 
should receive either 3 months of base pay, if they are returning to 
their communities and not participating in further rehabilitation; or 
an amount to cover living expenses while they are participating in 
education or work training programs. We also believe that the time 
allowed for participating in these training programs should be expanded 
to 72 months for those who might need to attend part-time.
    ``Earnings Loss Payments'' make up for any lower earning capacity 
remaining after transition and after training. Initial evaluation of 
the remaining work-related disability should occur when training ends. 
Earnings loss payments should be credited as Social Security earnings 
and would end when the veteran retires and claims Social Security 
benefits.
    In addition, we believe that ``Quality of Life Payments'' should be 
provided to disabled veterans. These payments are based on a more 
modern concept of disability that takes into account an injury's impact 
on an individual's total quality of life--independent of the ability to 
work.
    We also call for the disability status of veterans to be 
reevaluated every 3 years and compensation adjusted, as necessary. We 
see this as a positive provision that would ensure all disabled 
veterans are seen by a health professional at least every few years.
    By simplifying and modernizing the DOD and VA disability systems, 
Congress will make the systems less confusing, eliminate payment 
inequalities, and provide a foundation with appropriate incentives for 
injured veterans to return to productive life.
    Our fourth action step calls on Congress to authorize the VA to 
provide lifetime treatment for PTSD for any veteran deployed to Iraq or 
Afghanistan in need of such services. This ``presumptive eligibility'' 
for the diagnosis and treatment of PTSD should occur regardless of the 
length of time that has transpired since the exposure to combat events.
    The current conflicts involve intense urban fighting, often against 
civilian combatants, and many servicemembers witness or experience acts 
of terrorism. Five hundred thousand servicemembers have been deployed 
multiple times. The longer servicemembers are in the field, the more 
likely they are to experience events--which can lead to symptoms of 
PTSD. The consequences of PTSD can be devastating. The VA is a 
recognized leader in the treatment of combat-related PTSD, with an 
extensive network of specialized inpatient, outpatient, day hospital, 
and residential treatment programs. Therefore, we ask that any veteran 
of the Iraq or Afghanistan conflicts be able to obtain prompt access to 
the VA for diagnosis and treatment.
    Next, we ask Congress to strengthen support for our military 
families.
    In our travels across the country, it become abundantly clear that 
we not only needed to help the severely injured, we needed to help 
their loved ones too. These loved ones are often on the front lines of 
care and they are in desperate need of support. Therefore, we call upon 
Congress to make servicemembers with combat related injuries eligible 
for respite care and aide and personal attendant benefits. These 
benefits are provided in the current Extended Care Health Option 
program under TRICARE. Presently, DOD provides no other benefit for 
care-giving. Yet we know that many families are caring for their 
injured servicemember at home--and many of these servicemembers have 
complex injuries. These families, forced into stressful new situations, 
don't need more anxiety and confusion, they need support. Families are 
unprepared to provide 24/7 care. Those that try, wear out quickly. By 
providing help for the caregiver, families can better deal with the 
stress and problems that arise when caring for a loved one with complex 
injuries at home.
    We also recommend that Congress amend the Family and Medical Leave 
Act (FMLA) to extend unpaid leave from 12 weeks to up to 6 months for a 
family member of a servicemember who has a combat-related injury and 
meets other FMLA eligibility requirements. According to initial 
findings of research conducted by the Commission, approximately two-
thirds of injured servicemembers reported that their family members or 
close friends stayed with them for an extended time while they were 
hospitalized; one in five gave up a job to do so.
    Getting family members to the bedside of an injured servicemember 
is not the problem. The services have developed effective procedures to 
make this happen, and the private sector has stepped up to provide 
temporary housing. Because most injured servicemembers recover quickly 
and return to duty, the family member's stay may be short. However, for 
those whose loved one has incurred complex injuries, the stay may last 
much longer. Extending the Family and Medical Leave Act for these 
families will make a tremendous difference in the quality of their 
lives. Congress enacted the initial Family and Medical Leave Act in 
1993, when I was Secretary of Health and Human Services. Since then, 
its provisions have provided over 60 million workers the opportunity to 
care for their family members when they need it most--without putting 
their jobs on the line.
    We are pleased to see that many Members of Congress have embraced 
this proposal and we hope to see it enacted soon.
    Mr. Chairman, I believe that government can work to improve the 
lives of its citizens. But sometimes, we fix problems by adding more 
complexity that in turn creates problems. What we've done with the 
Commission's recommendations is strip some of that away to simplify the 
system, to go back to basic principles and to make necessary programs 
more patient and family centered.
    We have been truly heartened by the response our report has 
received in the White House, the halls of Congress and throughout the 
country. The Nation has rallied behind the need to help those who have 
put their lives on the line in service to our country. We have met with 
the White House and the Departments of Veterans Affairs and Defense and 
are pleased to report that they are moving forward on implementing 
those recommendations requiring administrative action. We are 
optimistic that Congress will do the same for those recommendations 
that require legislation.

    On behalf of the Commission, I want to thank the Committee again 
for the opportunity to discuss our recommendations. I look forward to 
joining Senator Dole in answering your questions.

STATEMENT OF HON. BOB DOLE, CO-CHAIR, PRESIDENT'S COMMISSION ON 
         CARE FOR AMERICA'S RETURNING WOUNDED WARRIORS

    Senator Dole. Mr. Chairman, thank you very much, and my 
colleagues, thank you very much. I want to tell you, Senator 
Isakson, I talked to Doug Bernard yesterday about what is 
happening in Augusta and it really appears to be a great 
program. I think what you need are more participants. You have 
got the facilities. I am not sure there is anything we can do 
about that, but I am going to meet with the Executive Director 
tomorrow.
    And I want to thank Senator Brown because my Great 
Grandfather comes from Montpelier, Ohio, so I have got a little 
Ohio strain in my system somewhere.
    And Mr. Chairman, Senator Inouye and I were both in Italy 
in World War II and we were wounded a week apart and a hill 
apart and we ended up in the same hospital--in Percy Jones 
General Hospital in Michigan--with former Senator Phil Hart, 
whom the Hart Building is named after. Phil Hart was a 
remarkable guy and he wasn't so badly injured, so he used to 
run errands for us and do all these things. He is married to 
Jane Briggs, and, at that time, the Briggs family owned the 
Detroit Tigers. So, we were able to go to baseball games--had 
free tickets and all that. Now they have renamed that facility 
the Hart-Dole-Inouye Building. Not that that gets us anywhere, 
but if we are ever there, I assume we can get in. [Laughter.]
    So, that is a little history. What I am trying to point out 
here: it is a different generation. And let me say right up 
front, because you are going to hear from maybe some of the 
veterans' groups who have some problems--and we suggest that is 
a good thing to have a discussion--some are pushing back a 
little because of the changes we are making. There is always a 
fear that somebody may lose something or that somebody may gain 
from our recommendations.
    And I will confess, we believe we are talking about a 
different generation. If you can see these young men and 
women--we met with some yesterday at the White House--their 
attitude, and you have got Ted Wade and his wife in the 
audience, and what they want to do with their future. So, we 
front-loaded these recommendations with more money for 
education, more money for family services, recognizing for the 
first time that quality of life should be compensable. If you 
lose your sight or lose a limb, you have gone from a ten to, 
what, a five, four, three. I don't know. But we recognize that 
may be considered now by some, and we are going to directly 
address the issue, as Secretary Shalala has already pointed 
out.
    So, if these young men and women who are making sacrifices 
today, and as Senator Murray said, we can have different views 
on what is happening in Iraq, but we ought to have the same 
view on how we treat those who return. And one thing we never 
discussed in our Commission was politics. I knew the 
Secretary's affiliation and she knew mine. I don't think we 
ever knew the others, and we didn't really care. And we never 
talked about cost. Cost is never an object. Whatever you think 
of the war, President Bush, or whatever, the President gave 
three words, said, ``whatever it takes,'' and that was sort of 
our charge.
    I must say, I have been around a long time. I have been 
around the White House a long time, as I said yesterday, not as 
long as I wanted to be around the White House----
    [Laughter.]
    Senator Dole [continuing]. But, I was around a long time--
many administrations. But the White House staff is really 
working hard on our recommendations and recommendations from 
the Disability Commission in hopes that Congress will take some 
action this year, if possible. There is a conference report 
floating around that if the Veterans Committee would sign off, 
some of these provisions might be included in that conference 
report. What is the number, S. 1606? It is the defense 
authorization bill. But in any event, that is a technical 
matter that you can take care of.
    But as Secretary Shalala pointed out, what we didn't want 
to do is load you up with 350 recommendations. Secretary Gates 
told us when we met with him a couple of months or 3 months 
ago, he had 351 recommendations on his desk at that time--just 
DOD recommendations. So, we felt the best way to approach this 
is to try to simplify it, as the Secretary said, and reduce the 
number of recommendations and have some action steps and put 
the pressure on the administration to do about 90 percent of 
these things without legislation.
    So we come to Congress with a fairly limited list of things 
to do, and there is some push-back. It may be that this 
generation of young men and women, who I believe are now the 
greatest generation--I think we passed the baton to this 
generation--if they would do a little better than we did, that 
is OK. These are grandsons and sons of Vietnam veterans and 
World War II veterans, and if their son or grandson does a 
little better, has better educational opportunities, better 
family opportunities, that is good. That shows we are making 
progress. It shows we recognize the sacrifices that these young 
men and women make.
    So there shouldn't be any dollar costs, and we never talked 
about dollars. We didn't have anybody to ask, what is all this 
going to cost? I assume somebody here will think of that. We 
guessed maybe a billion dollars the first year and maybe more 
the second and third years. But again, we just wanted to do it 
right.
    One thing that I want to stress before I forget it, we also 
believe that if you can't find the best care at a VA facility 
or a DOD facility, you ought to be able to go to a private 
facility. If you live in Idaho or Kansas or Montana or 
wherever, you may not have a facility close by, but if there is 
a facility close to some disabled veteran where they can 
provide--whether it is PTI or PTSD or whatever it might be--
excellent treatment, that ought to be available. You shouldn't 
have to drive 400 or 500 miles and spend the night and do all 
those things in order to get excellent treatment. And I say 
that because Ed Eckenhoff here, who was on our Commission and 
who has a serious disability, is the Director of the National 
Rehabilitation Center and he has treated--how many?
    Mr. Eckenhoff. Last fiscal year, 46.
    Senator Dole. But how many Iraqi-Afghan veterans have you 
treated?
    Mr. Eckenhoff. 46.
    Senator Dole. Oh, 46. So they get excellent care, and you 
can look at some of the recoveries that are remarkable, because 
I am not downgrading the VA or the DOD, but I was saying in 
some cases, the private sector opportunity ought to be 
available.
    One thing we found, because I think the Washington Post 
story was a wake-up call for all of us, regardless of our party 
or whatever, veterans or non-veterans, it pointed out that we 
had a problem. It was primarily a facilities problem, but it 
became a patient problem if you were an outpatient and had to 
stay in a place like that. Building 18 is not part of the 
Walter Reed campus, but it is part of Walter Reed and it never 
should have happened. So the President appoints a commission. 
Congress has hearings. A lot of good things have happened, but 
we still haven't passed anything that is going to make a real 
difference.
    I don't want to take a lot of time, and you have already 
put my statement in the record, but I want to recite just three 
cases to give you an example of what can happen.
    First is a soldier injured when his Bradley Fighting 
Vehicle rolled over on an improvised explosive device and he 
was airlifted to Baghdad and received the first of over 40 
operations. He was then taken to Landstuhl Regional Medical 
Center for additional medical care. And then he ended up at 
Brooke Army Medical Center's burn center, which is the best in 
the world. It is a great place and I am certain many of you 
have visited there. In addition to his burn injury, he also had 
Traumatic Brain Injury and his wife joined him and left their 
son with his grandmother in Kansas.
    Over the next 2 years--some of the things that Senator 
Murray has pointed out--the family had to deal with many issues 
including military pay and a permanent change of station move, 
while maintaining their personal support, much needed to help 
their soldier get better. Then, when the soldier finally came 
home, he was severely limited in what he could do. The wife 
became his full-time caregiver. Now, obviously she doesn't 
object to that, but it shouldn't be necessary. She should be 
able to pursue her job, her school, her education. So, there 
are some provisions for care: we provide for respite care and 
additional benefits to make certain that a spouse--it could be 
a husband or a wife--can move on with their life and still be 
there.
    The second story is about a Marine corpsman who was hit by 
a rocket when his base in Iraq was attacked and he woke up a 
few days later in Bethesda Naval Medical Center, and after 
several operations and amputation of his left arm, he was 
transferred to Walter Reed for therapy and eventually retired.
    The third story is about an officer whose convoy is 
ambushed by insurgents and rocket-propelled grenades and one 
grenade exploded in the leg well of the vehicle and severely 
injured his right leg. The second exploded at the rear of the 
vehicle, causing shrapnel wounds of his neck, shoulders, arms, 
and back, and he was evacuated and finally reached Landstuhl. 
After his two-and-a-half years at Walter Reed, they were able 
to salvage his leg and he is on the temporary disability 
retired list.
    Now, the reason I cite these three stories, they have 
several things in common. The medical care and compassion that 
these individuals received in the theater was exceptional. You 
go back and look at World War II. For every one killed, there 
was maybe one survivor. For every one killed today, I think the 
number of survivors is 14 or 16. It is way up there. We have 
made a lot of progress from the battlefield, and you want to 
give a lot of credit to these medics who are out there on the 
battlefield rescuing these young men and women.
    So, the survival rate is very high because of improved 
technology, improved care, improved transportation. It took me 
8 weeks to get from Italy to Miami, Florida--my first stop--and 
now you can be wounded in Baghdad on a Tuesday and be in bed at 
Walter Reed on a Friday. That is just how it has improved. It 
meant life for many people who would have otherwise not made 
it.
    But, here are some of the things that happened. Each of 
these individuals encountered problems with difficult and 
inflexible systems. They had complex injuries and required 
lengthy rehabilitation. They each had case manager after case 
manager. We had a young man on our Commission, Jose Ramos, who 
lost an arm in Iraq. He had so many case workers, he couldn't 
remember their names. Now, you wonder why they don't keep their 
appointments and don't see the doctor and don't get out on 
time. Jose is just a great guy, and I want to thank the 
initiator of the provision of the Recovery Care Coordinator, 
which Secretary Shalala initiated, where this one care 
coordinator will follow that patient from the time they walk 
into Walter Reed Hospital, or wherever it may be--and about 26 
percent of people go to Walter Reed, that is their first stop--
and they will follow them all the way through until they go 
back to the unit, go home, or go to the VA.
    To me, that is a big, big improvement as far as moving the 
process along--giving that person not only the responsibility, 
but the authority to be there on the take-off and be certain 
that they are part of the team. And, I think that it is not 
expensive. We are talking about 50 to 100 Recovery 
Coordinators. It is not a big, big bureaucracy. And they are 
going to be trained by the Public Health Service and the DOD 
and the VA, and to the credit of the administration, that 
program is already underway. They have already started the 
training. I don't know when the first ones are going to be 
available, but very soon. I thank Secretary Shalala for that.
    In addition, they had trouble scheduling outpatient visits 
and follow-up care was difficult. The amount of paperwork, as 
somebody mentioned, was enormous. The VA does have the best IT 
system of anyplace, any hospital, but DOD is a little behind. 
We had a very fine man on our Commission, Dr. Martin Harris 
from the Cleveland Clinic, and that is what he does. He is an 
expert. And he is working now with the DOD and the VA, and we 
think we can make their systems compatible without spending a 
lot of big money and do it very quickly.
    We are also going to have a Web site where you just punch a 
button and you can find out all the services that may be 
available for a particular veteran. When is that going to be 
available? They are testing it right now. I have to check with 
the experts--we call them the three wise ladies--behind me 
here.
    In any event, the rest of my statement is in the record. We 
know that Congress may not agree with everything we 
recommended. We both have been around government a long time 
and members of our Commission are certainly aware of that. We 
would like to think it is a perfect product, but we know that 
is not the case. And, certainly we want the VSOs, the Veteran 
Service Organizations, to weigh in. But we want to make certain 
that everybody understands that we are talking about a new 
generation of young men and young women who are making 
sacrifices. It is a different time, different opportunities, 
different injuries, different technologies, and we think, 
maybe, some different compensation. They may get a few more 
dollars than maybe somebody in Vietnam. But our charge was only 
Iraq and Afghanistan. We only had 4 months. We didn't have time 
to go back and look at the other 25 million veterans and say, 
well, we ought to do this, this, and this.
    I am just very honored. We have a great staff and we had a 
lot of help from the DOD and the VA. I think they really try. I 
have been going to Walter Reed as a patient for, I don't know, 
30 years or more. I think it is a great place and they have 
great doctors. One thing we were concerned about, since they 
are going to close, is: during the transition the quality of 
care would drop off and some poor guy coming here from Iraq 
with a bad injury would not get first-rate treatment.
    So, our sixth recommendation is--and I am certain everybody 
agrees with--that you keep Walter Reed up and running as a 
first-class A-1 hospital until somebody finally turns off the 
lights. So, up until that final day when the move is made, they 
are available to take care of anybody with any kind of an 
injury that they deal with at Walter Reed. We also say that if 
they need--you know, a lot of these doctors don't want to stay 
on a ship that is going to sink in about 4 years--so, we want 
to provide some incentives, some additional pay, to keep those 
doctors--whether they are Army doctors or contract doctors or 
nurses or therapists--keep them there during this transition.
    But, I know most everybody here and I know that you are 
concerned about veterans. We all are. It is not a partisan 
issue. Some veterans have problems. I started working with 
veterans when I was a young county attorney in Russell County, 
Kansas, as a service officer for the VFW and the American 
Legion, and later, the Disabled American Veterans. And so, we 
have had problems. We have always had problems. That is why 
they had the Bradley Commission. That is why we have had about 
ten commissions since then. It is always a work-in-progress.
    Obviously, we think we can fix it. It probably won't be 
perfect, but we need your help. Nothing is going to happen 
unless Congress steps up to the plate and says, you know, this 
is a pretty good idea, or maybe we ought to change it, or maybe 
it is not a good idea. But, I really believe you are going to 
like most of it, and it is because of the hard work and 
dedication of the staff members.
    We had two amputees on the Commission. Ed is disabled. I 
have a slight disability, and then we had the wife of this 
young sergeant who was burned over 70 percent of his body. So 
we had a representative Commission, as Secretary Shalala said, 
and I think we are going to continue working. We are 
volunteers. We will be happy to come back. We will be happy to 
sit down with staff. I know Karen and Sue and Marie will be 
happy to sit down with staff and go into details. We want to 
thank you for giving us this opportunity.
    [The prepared statement of Senator Dole follows:]
Prepared Statement of Bob Dole, Co-Chair President's Commission on Care 
   for America's Returning Wounded Warriors before the United States 
                                 Senate
    Good morning Mr. Chairman and Members of the Committee. It is a 
pleasure to appear before you today, along with my fellow Co-Chair 
Donna Shalala.
    We look forward to working with you, and the other individuals here 
today, to support this Nation's goal of assuring that our service men 
and woman receive the benefits and services they deserve.
    It has been an honor to serve on this Commission, especially with 
Secretary Shalala. I have said it before and I will say it here today, 
she's been a ``Triple A'' co-chair. She has boundless energy and kept 
us going as we tackled this important challenge. It has been a great 
experience to work with her and our fellow commissioners.
    Our recommendations were guided by the Commission chaired by 
General Omar Bradley in 1956, which said: ``Our philosophy of veterans' 
benefits must be modernized and the whole structure of traditional 
veterans' programs brought up to date.''
    Problems accompany change--wars change, people change, techniques 
change, injuries change, and we need to keep our military and veterans 
health care system up-to-date. I find it remarkable that 50 years later 
we are finding so much of what General Bradley had recommended is still 
relevant today.
    Secretary Shalala has outlined the action steps to be taken by 
Congress. I will now tell you how our recommendations--all of them--
work to create a system that serves, supports, and simplifies.
    First, let me review our recommendations:

    1. Immediately Create Comprehensive Recovery Plans to Provide the 
Right Care and Support at the Right Time in the Right Place
    2. Completely Restructure the Disability Determination and 
Compensation Systems
    3. Aggressively Prevent and Treat Post Traumatic Stress Disorder 
and Traumatic Brain Injury
    4. Significantly Strengthen Support for Families
    5. Rapidly Transfer Patient Information Between DOD and VA
    6. Strongly Support Walter Reed by Recruiting and Retaining First 
Rate Professionals Through 2011.

    Now let me tell you how they would work using the experiences of 
three wounded warriors.
    The first is a soldier who was injured when his Bradley Fighting 
Vehicle rolled over an improvised explosive device. He was airlifted to 
Baghdad where he received the first of over 40 operations. He was then 
taken to Landstuhl Regional Medical Center for additional medical care 
and stabilization, after which he was taken to Brook Army Medical 
Center's burn center. In addition to his burn injuries, he also had a 
Traumatic Brain Injury. His wife joined him at Landstuhl and traveled 
with him to Brook, leaving their son with his grandmother in Kansas.
    Over the next 2 years, this family had to deal with many issues 
including military pay and a permanent change of station move, while 
maintaining the personal support needed to help their soldier get 
better. When the soldier finally came home, severely limited in what he 
could do, the wife became his full time caregiver.
    My second story is about a Marine corpsman who was hit by a rocket 
when his base in Iraq was attacked. He lost consciousness and woke up a 
few days later at Bethesda Naval Medical Center after several 
operations and amputation of his left arm. He was transferred to Walter 
Reed for occupational and physical therapy and eventually medically 
retired.
    My third story is about an officer whose convoy was ambushed by 
insurgents using small arms fire and rocket-propelled grenades. One RPG 
exploded in the leg well of his vehicle, severely injuring his right 
leg. The second RPG exploded at the rear of his vehicle causing 
shrapnel wounds to his neck, shoulders, arms, and back. He was 
evacuated to Al Assad, then Balad, and finally Landstuhl with 
operations on his leg at each stop. He was ultimately evacuated Walter 
Reed. After 2\1/2\ years of rehabilitation and additional operations to 
salvage his leg, he is on the temporary disability retired list.
    These stories have several things in common. The medical care and 
compassion that these individuals received in theater was exceptional. 
Today's military trauma care saves lives that would have been 
impossible in previous wars. The military medical evacuation system 
that removes injured servicemembers from the field of battle to a 
military treatment facility in the U.S. within 36 hours after the 
injury is nothing short of remarkable.
    However, each of these individuals encountered problems with 
difficult and inflexible systems. They each had complex injuries and 
required lengthy rehabilitation.
    They each had case manager after case manager. One told us he had 
over 10 and could never remember what they were managing, never mind 
their names. Communication between the providers of care and services 
and the servicemember were spotty at best and, often, didn't happen at 
all.
    Scheduling outpatient visits for necessary follow up and care was 
difficult. The amount of paperwork was enormous, never ending, and 
redundant. Patients and their families had no single point of contact. 
Processing for a medical discharge took months and delayed patient and 
family decisions. At Walter Reed, outpatients exceeded the facility's 
capacity to house them, creating the problems of Building 18.
    Had our recommendations been in place, each of these individuals 
would have had a recovery coordinator assigned at the time they arrived 
at a stateside military hospital. The recovery coordinator would have 
developed a recovery plan along with the patient's medical team and 
other personnel designed to return the patient to optimal functioning.
    The recovery plan would make the best treatment and services 
available--including those in the VA or the private sector. The plan 
would not stop after the patient's discharge from the hospital, but 
continue to guide recovery through outpatient care, rehabilitation, and 
any necessary retraining or education. The recovery coordinator would 
serve as a single point of contact for the patient and family.
    We recommended that the recovery coordinator be part of an elite 
unit of the Public Health Service. We did so because we thought it best 
to place these individuals outside of either the DOD or VA. Part of 
this reasoning was because we were concerned that VA or DOD employees 
would not be allow to effectively reach out to the other Department, 
marshalling needed services, with any degree of authority.
    We also recommended that Walter Reed be supported until it closes. 
Perhaps some of the difficulties with outpatient clinic appointments 
and medical hold and holdover at Walter Reed would not have been so 
problematic if our recommendation had been in effect.
    Fortunately, only one of the individuals I mentioned had a 
Traumatic Brain Injury and none have developed Post Traumatic Stress 
Disorder. We recommended that the DOD and VA aggressively prevent and 
treat TBI and Post Traumatic Stress Disorder.
    New ways of protecting our servicemembers from these devastating 
conditions would be developed and implemented. Military leaders, VA and 
DOD medical providers, family members and caregivers would have access 
to educational programs to better understand these problems and how to 
help.
    Health care providers in both the DOD and the VA would be using the 
most contemporary clinical practice guidelines to assess and evaluate 
servicemembers and veterans for these conditions.
    More mental health professionals would be available in the DOD and 
VA. Anyone concerned he or she might have PTSD could go to the VA, an 
internationally recognized expert in combat related PTSD, to get care.
    Families, such as the one in my first story, also need support and 
help. With our recommendations, the grandmother, who took a leave of 
absence from her job to stay with her grandson, would be able to take 
an additional 3 months under an enhanced provision within the Family 
Medical Leave Act.
    The wounded warrior's wife would be able to get respite care or aid 
and attendant care through the ECHO program within TRICARE. As the 
primary caregiver for her wounded husband, she needs assistance, 
assistance that currently does not exist in the DOD.
    She would also get training and counseling to help care for her 
husband.
    All three injured individuals had to deal with mountains of 
paperwork--paperwork that was frequently lost or unavailable at 
critical process decision points. In this day of electronic everything, 
it is frustrating to fill out form after form, repeating the same 
information over and over again.
    But the problem with information technology should not be solved by 
starting over--that will just delay things. Instead, we have 
recommended that DOD and VA be held to a scorecard for documenting the 
progress of information sharing. While we all want interoperability of 
medical records, we don't have to wait for this goal to become reality. 
Much can be made visible now.
    We have also recommended the development of a web portal that will 
provide tailored information to each servicemember and veteran specific 
to their situation. We understand that this effort is currently 
underway and we are ready to try the product.
    We have also recommended a complete reform of the current 
disability evaluation and compensation system as Secretary Shalala has 
just told you.
    Under this recommendation, each of our wounded warriors would be 
evaluated as to whether they could perform any military duty by the 
DOD. If not, each would be medically discharged with an annuity based 
on rank and time in service. They each would get TRICARE for themselves 
and their family.
    The single medical exam performed by the DOD to determine fitness 
to serve would also serve as the exam used by the VA to determine the 
disability rating using an updated rating schedule. The disability 
rating determines what VA benefits and services the veteran could 
receive, and the VA's disability compensation.
    Each would get to select one of two transition payments to take 
effect upon discharge. They could elect to get 3 months of basic pay, 
or enroll in an educational or training program with an enhanced 
stipend for up to 72 months.
    At the end of the 3 months or after completing the educational 
program, each would get a quality of life payment based on their 
specific injuries. They would also get an additional payment to make up 
for any earnings loss.
    We realize that adopting a new system requires a leap of faith for 
many. We are therefore, recommending that two studies be done in the 
short term. We need to determine the right amount of transition pay. We 
also need to determine what a quality of life payment would look like. 
Once these are completed, and we should not take forever, reforming the 
current disability evaluation and compensation system should move 
forward.
    For those of you familiar with the Commission's members, you will 
recognize the individuals in the stories. One is Chris Edwards, whose 
wife, Tammy Edwards, served as a Commissioner. The other stories belong 
to Jose Ramos and Marc Giammatteo, two of our other Commissioners. I 
want to personally thank all the Commissioners for their dedication and 
hard work.
    I have one last story. This soldier was hit by machine gun fire 
when he tried to assist a wounded comrade. It took 9 hours to evacuate 
him from the battlefield and 24 hours to further evacuate him to a 
field hospital. It took almost 2 months after his injury to evacuate 
him to a stateside Army Hospital. He underwent 9 operations, survived a 
blood clot and, over a period of 3 years learned to adapt to his 
disability through rehabilitation, with his mother at his side. His 
community chipped in to pay his hospital bills and one private sector 
surgeon performed 7 additional operations at no charge.
    Of course, this last guy is me. I only bring my story up to show 
the differences between now and then. We should always try to improve 
on what has gone before. This may mean that some of the more recent 
wounded warriors get benefits that I don't and that's OK.
    I really believe that these are really bold recommendations and 
doable, but it requires a sense of urgency and strong leadership.
    We stand ready to assist you in any way as we work together to 
create a system that serves our bravest men and women who have made the 
ultimate sacrifice for our Nation.

    Thank you.
                                 ______
                                 
  Responses to Written Questions Submitted by Hon. Daniel K. Akaka to 
              Senator Bob Dole and Secretary Donna Shalala
Comprehensive Recovery Plans
    Question 1. The idea of a coordinated recovery plan is one I 
embrace fully. The Committee-reported bill on traumatic brain injury 
includes this concept. However, I am trying to understand more fully 
the Commission's recommendation for a single recovery coordinator. The 
final report of the Commission urged the development of a corps of 
recovery coordinators within the Public Health Service. At the hearing, 
you talked about a much larger role for VA in this process, with VA 
taking the lead in all respects. When did this change and was the 
Commission involved in this change?
    Response. In our recommendations regarding the Recovery Plan and 
Coordinator, we recommended placing the Coordinators within an elite 
unit of the Public Health Services. Since our report was issued, we 
understand that the VA has requested that the Coordinators be placed 
within the VA and trained by a cadre of personnel from the PHS, VA and 
DOD. The Commission was not involved in this change.
    Question 2. Should VA assume the responsibility for the Recovery 
Care Coordinators, does this mean that VA will be responsible for 
coordinating the care of seriously injured servicemembers upon their 
arrival at a military hospital? As I understand it, some of these 
servicemembers will either return to active duty and not be enrolled in 
the VA system for years or spend months or years in the DOD medical 
system going through recovery and rehabilitation. My question is, do 
you believe this care coordination role is one VA should be performing 
prior to a servicemember's separation from the military?
    Response. We thought long and hard before placing the Coordinators 
outside of the two Departments. We were concerned that placing the 
individuals wholly within either the VA or the DOD would make it 
unlikely that the Coordinators would be able to function as we 
envisioned. The Coordinators must be able to operate across the two 
Departments and the private sector to access the best care and services 
for an injured servicemember. Their work should commence as soon as 
possible after the injury and continue throughout the recovery period, 
which can indeed be quite long. We were concerned that if the 
Coordinators resided within the VA, the services would not allow them 
full access to DOD/service resources or the ability to bring them to 
bear for the injured servicemember (and vice versa). We were also 
concerned that belonging to either department might constrain the use 
of private sources of care.
Impact on VA Claims Process
    Question 3. Your report recommends that VA update the entire 
disability rating schedule to reflect current injuries and modern 
concepts of the impact of disability on quality of life. Given that a 
comprehensive overhaul of the rating schedule has not been done in over 
50 years, I agree that such an endeavor is long overdue. However, at a 
time when VA already faces a sizable claims backlog, imposing a new 
rating schedule would require an expansive commitment to re-training 
staff to use the new schedule. Did your study consider the impact such 
a enormous undertaking would have on the already overburdened claims 
process?
    Response. Most of the current backlog is from veterans already 
receiving disability compensation and applying for an increase. Under 
our system, with the 3-year automatic review, the workload would be 
more predictable and more easily managed. Failing to update, and 
appropriately maintain, the current disability rating system is a 
disservice to our injured servicemembers. PTSD and TBI are not 
adequately addressed in the current VASRD. Quality of life is reflected 
in some of the ratings, but not others. The schedule does not reflect 
significant advances in medical technology for amputation and other 
conditions. Yes, current raters would need to be trained in a new 
system--a system that will ultimately benefit veterans. The added 
resources needed to make the transition would be modest in comparison 
to the budget for veterans' disability programs.
Expert Consultation
    Question 4. As you noted in your Op-Ed in Tuesday's Washington 
Post, the VA disability system is confusing. The Veterans' Disability 
Benefits Commission had the support of Mr. Robert Epley, who has served 
in various capacities at VA, including former Director of the 
Compensation and Pension Service. Can you please tell me who from VA 
was available to assist the Commission by providing expert advice?
    Response. Dr. Gail Wilensky, one of our Commissioners, was the co-
chair of the 2003 President's Task Force to Improve Health Care 
Delivery for Our Nation's Veterans. This 2-year effort focused 
considerable attention on improving the seamless transition to veteran 
status. As one of the nation's leading health economists and policy 
experts, Dr. Wilensky also has expertise in disability systems. The 
three Commissioners who were in the system and became advocates for 
other servicemembers--Tammy Edwards, Marc Giammatteo, and Jose Ramos--
gave us a most important servicemember's perspective. Our 
recommendations covered both the DOD and VA disability (and retirement) 
systems and our staff included senior staff from both systems. In 
addition, we consulted with the Veterans' Disability Benefits 
Commission senior staff, Admiral Cooper and his senior staff, GAO's 
veterans' disability analysts, several of the experts who served on the 
Institute of Medicine panels, and officials in the Office of the 
Undersecretary of Defense for Personnel and Readiness and the military 
services. Our research director, Susan Hosek, had significant expertise 
from her 35 years as a RAND researcher, including 6 years as director 
of RAND's preeminent defense manpower research group. She was also a 
member of the President's Task Force to Improve Health Care Delivery 
for Our Nation's Veterans.
Survey
    Question 5. Over 40 percent of those who responded to the survey 
were active duty servicemembers and thus not yet eligible for VA 
disability compensation. These servicemembers would likely not have had 
the sort of contact with VA to be able to make a knowledgeable response 
to survey questions regarding the VA compensation system.
     How were their responses weighted in comparison to 
recently separated or medically retired veterans who had actual 
experience with VA?
     Do you know how many survey respondents had actually 
sought VA disability compensation?
     I understand that the response rate to the telephone 
survey was less than thirty percent and that, for some subsets of the 
survey, the response rate was in the single digits. How does such a low 
response rate affect the validity of the survey?
    Response. As of the end of May 2007, 10,185 servicemembers met the 
criteria for our survey: (1) medically evacuated from theater to the 
U.S. for deployment-related injuries or illnesses or (2) subsequently 
diagnosed with PTSD and (3) separated/retired for no more than 2 years. 
The last criteria was necessary because of DOD survey regulations but 
data on the flow of casualties out of theater indicated that this 
criterion eliminated very few. Of these, only 1,715 had separated or 
retired from military service. We included all of these individuals in 
the sample for the survey and they accounted for 29 percent of the 
sample and 26 percent of the responses. We developed weights so that we 
could present findings that were representative of the population we 
sampled. The survey's questions about VA disability evaluation were 
asked only to the separated/retired group. We also separately tabulated 
the results for the other questions since we knew that this group--most 
of whom were injured relatively early--may have had different 
experiences.
    Among survey respondents who had separated or retired, 89 percent 
had filed a VA disability claim and almost all the others planned to do 
so. Of those who had filed, 58 percent had completed the process by the 
time of the survey.
    The overall response rate was 30 percent and there was almost no 
difference across sub-groups (e.g., military service, component, age, 
rank, sex, category of injury). There were two reasons for non-
response: inability to locate the respondent during the 2-week period 
the survey was in the field and refusal by those we were able to 
locate. We located 50 percent of the sample and completed interviews 
with 60 percent of them. Only 15 percent refused the survey outright. 
Our response rates were at least comparable to rates on similar DOD 
surveys of military personnel, even though these surveys are in the 
field for months, not weeks, and involve more follow-up. The response 
rates were well above what we anticipated based on experience with this 
population.
Different Eras vs. Different Systems
    Question 6. Should the disability system be changed in the manner 
in which you recommended, how do we reconcile veterans from different 
eras receiving different benefits? Do we run the risk of disadvantaging 
older veterans from World War II, Korea and Vietnam?
    Response. As with all transitions, some individuals may be more 
comfortable with their current status and not wish to change. This 
should be allowed. For those that wish to come under the new system, 
they should be allowed an election period. Going forward, all medically 
discharged servicemembers would come under the new system. Ultimately, 
the decision rests with Congress.
Disability Appeals
    Question 7. Should VA be given responsibility for making the sole 
disability determination for servicemembers being medically retired 
from the military, what process did you envision for servicemembers to 
appeal a VA disability decision with which they disagree?
    Response. Under our recommendations, the DOD determines fitness to 
serve and, when a member is found medically unfit and no longer 
``employable'' in any military capacity, provides a retirement annuity. 
Prior to discharge, the servicemember could appeal the finding of unfit 
and petition for retention, as they do now. The discharged 
servicemember, now technically a veteran, would get his or her 
disability rating from the VA. The current system of disability rating 
appeal within the VA can still be used to adjudicate any challenge.
    Question 8. What do you believe would be the impact on VA's 
resources if it took on the responsibility for handling these claims 
that are now managed by DOD?
    Response. While we were not able to actually quantify the exact 
impact, we believe that there is a net efficiency in having only one 
physical exam (by DOD) and one disability evaluation determination (by 
VA). As our survey shows, all servicemembers who are medically 
discharged from military service currently file a VA disability claim 
and the number of new VA claims will not change under the new system. 
Since DOD will conduct a physical exam that meets VA requirements for 
disability evaluation, there will be many fewer physical exams 
performed by the VA.
VA Information Technology
    Question 9. I could not agree more with the Commission's assessment 
that VA and DOD need to move quickly to get clinical and benefit data 
to users. I note your action plan established a 12-month time line for 
VA and DOD to make this happen. This is certainly a noble goal but, as 
I am sure you know, DOD and VA have been working toward sharing health 
information for the past decade without great success and VA internally 
has been working a similar process for benefits information for well 
over a decade.
    How does the Commission envision the Departments meeting such a 
short time line for comprehensive data sharing?
    Response. Commissioner Martin Harris, CIO for the Cleveland Clinic 
and an expert in health information systems, worked closely with our 
staff experts to evaluate the two departments' plans for information 
interoperability and progress in implementing those plans. Given 
progress to date, the Departments agreed with Dr. Harris' conclusion 
that they most information can be made available in the short term 
(viewable), thus the year time line. The departments should be held 
accountable for data-exchange outcomes, not process. We have provided a 
scorecard to use in this regard. We fully understand the frustration 
with the slow progress in achieving interoperability. We were 
encouraged with the recent electronic availability of the DD214.
Unemployment Compensation for Ex-Servicemembers
    Question 10. With respect to your Commission's suggestion for 
``transition payments'' during the first 3 months following discharge 
from active duty. How do those payments relate to the benefits 
available through the Unemployment Compensation for Ex-Servicemembers 
(UCX) program?
    Response. The UCX is a state based and run unemployment 
compensation program. It provides income for ex-servicemembers after 
active duty while they search for a job. Because this is a state run 
program, eligibility and benefits vary. Our recommendation was for 
those servicemembers found unfit and medically retired. They would 
receive a standard 3 months of full pay while transitioning between 
active duty and work. This would supplement UCX for those who meet the 
state requirements.

    Chairman Akaka. Thank you very much, Senator Dole. Without 
objection, your statement will be included in the record.
    Senator Dole. I don't know what it says. I forgot to read 
it. [Laughter.]
    Chairman Akaka. Thank you both for your statements and we 
do have questions here.
    One of the Commission's recommendations is that Congress 
enable all veterans who need PTSD care to receive it from VA. 
We have worked very hard this year to ensure a solid level of 
resources so that VA could continue to improve their efforts in 
PTSD. But, I am unaware of any existing impediment in law or 
otherwise which now bars veterans from getting care for PTSD. 
My question to you is, what exactly is the basis for this 
recommendation?
    Ms. Shalala. Well, I think we want to make sure that there 
is a presumption that anyone can walk in forever, whether or 
not they have gotten care before, and we want to make it clear 
that there ought not to be a time constraint, because we know 
that PTSD can show up a year later or 2 years later.
    And one of the points that Senator Dole keeps making is 
that this is a different generation. Many of them want to go 
home immediately. They are asked the question, is there 
something we should know? Are you feeling, you know, any 
symptoms after coming back? They all answer no, and then a year 
later or 6 months later or 2 years later, it shows up. So, I 
think that making it very clear that they have access to 
services, lifetime services, is extremely important.
    Chairman Akaka. Thank you.
    Senator Dole. Could I ask Sue to make a point on that?
    Chairman Akaka. Please state your name, also.
    Senator Dole. Sue Hosek with the RAND Corporation.
    Ms. Hosek. Yes. Currently, veterans get 2 years' 
eligibility at the VA after they leave the service, but after 
that time--and PTSD symptoms can appear after that time--they 
first have to go through the process of being declared 
eligible, and our concern was that some of these people need to 
be seen immediately and not wait for the disability evaluation 
to occur.
    Chairman Akaka. Thank you. Thank you very much. You know 
that----
    Ms. Shalala. It ought to be clearly a walk-in service so 
that people can be seen right away.
    Senator Burr. Well, we have a polytrauma center in Richmond 
which does a good job with PTSD and TBI.
    Ms. Shalala. Which we visited.
    Chairman Akaka. I do appreciate that your Commission was 
tasked with focusing on improving the care and benefits for 
those returning from the wars in Iraq and Afghanistan. My 
question to both of you gets to the crux of the challenge we 
face as we work to effect meaningful disability reform. Do you 
believe there should be a separate disability process for 
servicemembers who are wounded, injured, or become ill in a 
combat zone versus those who suffer disabilities elsewhere?
    Senator Dole. No. Our view is once you are in uniform, you 
don't have to be shot at to be injured, or while in the line of 
duty. If it is somebody who is derelict in his duties and, you 
know, drugs or something like that are involved, then there is 
a question. But, I think I have gotten it right--it is across-
the-board.
    And ``combat-related'' is not a narrow definition. Maybe 
General Scott can elaborate on that when he comes up here. But, 
as soon as you sign up in the Army, you are getting ready for 
combat. You may never get there, but you are training for it, 
so it is a pretty broad term.
    Chairman Akaka. What is your opinion--this has to do with 
quality of life--what is your opinion of the recommendation 
made by the Veterans Disability Benefits Commission that until 
a systematic methodology is developed for evaluating and 
compensating for the impact of disability on quality of life, 
that there should be an immediate interim 25 percent increase 
to compensation rates?
    Senator Dole. My view is that we are going to--this is 
going to be done very quickly. There is going to be a 
commission determining what a quality of life payment would be 
for, say, an amputee or someone who lost sight, somebody with 
severe burns; and that commission is going to report back to 
Congress. Congress has to have a say, and should have a say. 
And that is not going to be very far off. So, I think by the 
time we start one system, getting ready for the other system, I 
am not certain--if it is going to take 4 or 5 years, I would 
say maybe it is a good idea. But this ought to be done in 6 
months.
    Ms. Shalala. Quality of life payments are well established 
in the private sector. An internal study ought to set some 
standards for us, and I agree with Senator Dole to keep the 
pressure on, getting the facts and getting this set up.
    Senator Dole. You know, this is going to be a significant 
amount added to somebody's loss of earnings. We have got two 
new benefits here. The transition payment, which Secretary 
Shalala discussed--there is going to be a commission to look at 
that, whether it ought to be 3 months of base pay, whether it 
will be something else.
    And then we have got this quality of life payment, which is 
based on, I assume, the kind of injury. But we are talking 
about things that maybe you won't be able to do. You know, 
people have a social life. Maybe you won't be able to dance, or 
maybe you can't play the piano like before. Maybe there are 
things you can't do that really affect your quality of life. We 
think it is time it is recognized and paid for.
    Chairman Akaka. Thank you. Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    Let me just point to the fact that I think this is a great 
team. Both of you bring unusual experience and expertise and 
you have a passion that blends very well. I sat here listening 
to the Chairman and your comments. It reminded me of the words 
of Thomas Jefferson when he said, ``I am not an advocate of 
frequent changes in laws and constitutions, but laws and 
institutions must advance to keep pace with the progress of the 
human mind.''
    Really, the heart of what you have talked about recognizes 
the fact that we have got generations in this system. And are 
we the ones that are going to recommend--do you put the focus 
on the current and the future ones and begin to distinguish the 
challenges that our troops are faced with coming out of the 
conflicts today, and the types of wounds that they have got and 
the uniqueness of that, in comparison to everybody else in the 
system. And isn't it time that we begin to recognize that there 
are two systems, because there are two sets of injuries.
    Senator Dole. Now that is--go ahead.
    Senator Burr. No. I want to go to the fact that some of the 
veterans' organizations have expressed concern with creating a 
new disability system even though it only applies 
prospectively, and I----
    Senator Dole. If you like what you are in, you can stay 
there.
    Senator Burr. That is right. What are the challenges that 
you two see associated with a swift implementation of the 
recommendations to this new disability system?
    Senator Dole. For you to persuade these people who are 
opposed to it to get on board. There are not many. I mean, I 
think there are some legitimate concerns that I think you can 
all address. But just to say that, ``Well, we don't want any 
change, we like this 600 pages of band-aids we have been 
putting on over the years''--but again, I want to make the 
generational divide. Somebody has to stand up and say it is a 
different kind of warfare; it is a different generation. We 
have got to look ahead, as General Bradley did in 1956, and 
say, well, it is about time after, what, 51 years or whatever 
it is. Maybe we ought to move ahead.
    What you need to do, really, is to get a group of these 
young men and women, the Wades, for example, and others, to 
tell you how they feel about it, because they are different 
than our generation. I never thought I got enough money, of 
course. I am an average American veteran. You never think you 
get quite enough. But we think we have addressed some of those 
concerns and we want to work with the veterans' groups.
    Have you got anything to add there?
    Ms. Shalala. You know, the problem with change is that 
everybody thinks you are doing it because you are trying to 
save money. You start out with this kind of attitude that if 
you take on a system, particularly a complex system, you are 
trying to reduce the budget. In this case, that is not what we 
are trying to do at all.
    Are there managerial challenges to creating this 
transition? Not really. I have implemented very complex 
changes--welfare reform, for example; major changes in the 
Medicare system; Social Security Disability went through a 
major change. It is possible at a managerial level to implement 
a transition, because you are only dealing with new people 
coming in. Anyone that has the current system and loves it can 
keep it--anyone who has already been evaluated. What you are 
doing is introducing a new system, and if it is only focused on 
the new people, it is relatively easy to put in place.
    And, as I have indicated, there is private sector 
experience here. You are not inventing something that hasn't 
been tried in the private sector. In the case of family 
support, we are simply saying, add more resources. Be more 
sensitive to women and to heads of households. Don't think of 
the family members as people who have to coordinate care. Give 
them the option of going on with their professional lives, in 
many cases, and having the kind of support system and quality 
support system they think their loved one deserves and needs.
    So, some of it is an investment in resources, but most of 
it is things that we know how to do. We certainly have to work 
with the definitions. But the numbers will be relatively small 
in the transition.
    Senator Burr. Secretary Shalala, did any of the Commission 
members worry about whether the VA could handle two disability 
systems?
    Senator Dole. I don't think so, and we had VA people 
detailed to us. Top-level people worked with our three wise 
ladies and I don't think----
    Senator Burr. So, we can be fairly confident that the 
Commission came to a consensus that this was not a problem. We 
can handle two systems.
    Let me ask one last thing. My time has run out, but the 
White House made a proposal yesterday--they publicly made their 
proposal. There were differences. There were changes from that 
of your recommendation. Could you highlight those changes? I 
know you alluded to one of them dealing with the Social 
Security earnings.
    Ms. Shalala. Right. They spend more money. They eliminate--
they allow you to keep your Social Security at the same time, 
for example, was one change that they recommended. I am not 
sure that I have all of them----
    Senator Dole. They expand TRICARE, too.
    Ms. Shalala. They expand TRICARE more dramatically than we 
did. Whatever they did, they added as opposed to restricted our 
recommendations, and while we discussed that at some point--
yes, the main thing was the earnings loss component, that that 
earnings loss component should disappear when the veteran 
begins to receive Social Security. The administration has 
altered that proposal and not made the loss of earnings subject 
to the FICA tax and they don't stop that earnings--that income 
when the person gets on Social Security. So they make it for a 
lifetime.
    Senator Dole. That is one big objection one or two of the 
VSOs had, so that has been resolved.
    Senator Burr. Well, my hope, and I believe I can speak for 
the entire Committee, is that we know if we can find consensus 
between the VSOs and the administration and both of the 
Commissions that are recommending, we can get legislation as 
quickly as what you said, Senator Dole.
    Ms. Shalala. And, I think we want to be very clear about 
the veterans' groups who we have all worked with. I haven't 
worked as extensively as Senator Dole. We would not have the 
kind of substantial system we have in this country without 
their advocacy. I fully understand that they should question 
every proposal rigorously, because they are absolutely in the 
right place in terms of who they represent.
    We are simply saying, look, we think that we can make it 
even better for future generations. We can simplify it. We all 
ought to be able to understand this. This system took me--I 
spent a lifetime understanding health care systems and complex 
organizations. It took me a while to kind of get my arms around 
and try to understand it. We ought not to have government 
programs that require expertise to understand.
    Senator Burr. Thank you both.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray?
    Senator Murray. Thank you, Mr. Chairman.
    Thank you both for really taking the time to look at this 
through the patients' eyes and the veterans' eyes rather than 
through the bureaucratic lens that too often, I think, gets 
focused on the system. I really appreciate the work that you 
and the Commission did on this.
    I heard Senator Tester say earlier, too often, it is like 
the veteran is fighting the system rather than the system 
working for you, and just listening to it, it sounds like you 
are trying to change that mindset of the VA, which is really 
important.
    One of my concerns is we do not have a Secretary of the VA 
currently. We haven't received a recommendation from the 
administration or anyone sent over here for that position. Are 
you concerned that the implementation of this, which is going 
to put a lot of pressure on the VA to do, it is going to take 
somebody at the top to really keep that culture that you are 
talking about, are you concerned that we don't have a head of 
the VA right now and are you working with the administration to 
get someone?
    Ms. Shalala. I am not.
    Senator Dole. I think we were asked that question 
yesterday, which is a good question. Right now, Deputy 
Secretary Gordon Mansfield meets every week with Gordon England 
of DOD and they have these weekly meetings and they are really 
moving ahead with these recommendations. In fact, they have 
been given a mandate by the White House to move ahead. But 
obviously, the sooner we have somebody on board who is really 
going to push this program----
    Senator Murray. And who comes with the right mindset, too.
    Senator Dole. I think that is going to be very soon.
    Senator Murray. Okay.
    Senator Dole. It will be up to, of course, your 
confirmation, but I think you will have a nominee----
    Senator Murray. Well, I would assume, though, that you 
would want the nominee to have that culture and mindset that 
you are speaking about, as well, so----
    Senator Dole. We hope the nominee is asked before he is 
nominated or she is nominated that they have looked at this and 
they have looked at the other commission and they can support 
it vigorously.
    Senator Murray. Some of the critics are concerned that a 
lot of your recommendations are Executive Branch implemented, 
not Legislative Branch implemented. Are you concerned about 
that at all?
    Ms. Shalala. Well, I think that reflects a certain 
shrewdness on our part to try to make sure----
    Senator Murray. Oh, you trust us less than them?
    Ms. Shalala. No. No, not that. But we wanted to move 
immediately. We actually divided up what required legislation 
and what didn't require legislation.
    Senator Murray. Is there a time line for the 
administration----
    Ms. Shalala. We expect, I think, almost everything to be 
done within a year. We did not give them a lifetime for 
implementation, and each of us is checking on--for instance, 
Dr. Harris is right on top of the IT recommendations. Senator 
Dole has been over on a regular basis to ask questions. Our 
staffs have been over to see how the implementation is going. 
So, we did not walk away from this and we did divide up the 
recommendations so that--I am a big believer in identifying the 
short-term things that you can do internally and then the 
longer-term things that require legislation----
    Senator Dole. Right. We could probably provide a list to 
the Committee of what the administration----
    Senator Murray. Has done already?
    Ms. Shalala. And an update on all of that.
    Senator Murray. I think that would be helpful.
    Ms. Shalala. But we actually thought about it, to make sure 
that things were getting done.
    Senator Murray. OK. Well, specifically, I wanted to ask 
you, one of the biggest differences between your report and the 
report produced by the Veterans Disability Benefits Commission 
is the way in which you do compensate combat-injured versus 
non-combat-injured veterans. The way I hear you, your approach 
creates benefits specifically for combat and combat-related 
injuries and the Veterans Disability Benefits Commission 
compensates veterans based on the severity of their disability, 
not on the circumstances or the location. I am a little bit 
confused about what you consider to be combat injury. Is 
everything--if you are training for combat and you are here--is 
that considered combat injury?
    Ms. Shalala. Our definition of combat-related is very broad 
and it only applies to two provisions under our disability 
plan. The first is: that those found unfit due to combat-
related injury or illness would receive a lifetime TRICARE 
coverage; and the second is, that these individuals would 
receive quality-of-life payments from the VA for life, as well. 
That definition includes those training for combat----
    Senator Murray. So, if you are training here, that would 
be----
    Ms. Shalala. If you are training for combat its part of our 
definition. So it is very broad.
    Senator Murray. What if you----
    Senator Dole. We tried line of duty; we tried combat-
related. We want to make it broad. And we were told by DOD, 
well, once you sign up for whatever it is, whatever service, 
you are, in effect, training for combat someday. So----
    Senator Murray. Okay, so it includes training. What about 
in-theater non-combat----
    Ms. Shalala. Yes.
    Senator Murray. Your vehicle rolls over----
    Ms. Shalala. Yes.
    Senator Murray [continuing]. Is that considered combat?
    Ms. Shalala. Absolutely. Absolutely. And you could look at 
the two systems we recommended. We were focused on these 
Afghanistan and Iraqi wars, trying to set up a system. But 
again, we believe we have one plan and we used as broad a 
definition as we could. But, that is, in part, for Congress to 
decide.
    Senator Murray. OK. One other quick question. You have 
recommended a single medical exam, which I think makes a whole 
lot of sense. But, I am worried that that means, perhaps, the 
government could arbitrarily cut off a veteran without giving 
him a chance to appeal. Can you tell me how a veteran would 
deal with an appeal? Do they have the opportunity to disagree 
with the disability rating?
    Ms. Shalala. They would always have an appeal. We asked DOD 
to do the exam based on standards that they and the VA agree 
to. So there is a single exam----
    Senator Murray. And once they leave DOD, they have that 
exam----
    Ms. Shalala. They have that exam. They take it over to VA--
--
    Senator Murray. Do they have a chance then----
    Ms. Shalala [continuing]. And VA then looks at the whole 
person.
    Senator Murray. OK. Do they have a chance then to appeal 
that?
    Ms. Shalala. There is always an appeal process. I don't 
know of a program without an appeal process.
    Senator Dole. In fact, we make certain that the DOD 
examiner understands that one can have disabilities and still 
be fit for duty. But, we want that examiner to hand over to the 
VA everything that may be wrong with that individual, so they 
can make an appropriate rating.
    Ms. Shalala. And that is why the two agencies define what 
is covered in the physicals. So, the whole thing goes over to 
VA and then the disability determination is done over there.
    Senator Murray. Okay.
    Senator Dole. I think there is a feeling, Senator Murray, 
that the VA is a little more generous, too, with the ratings, 
so from the standpoint of the veteran, I think that is a plus.
    Ms. Shalala. And the advantage is there, because DOD is 
only making a fit/unfit [determination], though they are making 
a comprehensive exam. But you don't leave the DOD without your 
annuity in hand----
    Senator Murray. Okay.
    Ms. Shalala. Even if you have only had 5 years or 3 years, 
based on your rank, you leave with an annuity that you have 
forever, no matter what happens over at the----
    Senator Murray. And just so I understand, too, you have 
this one-time decision that you can stay with the current 
system or transition to this. Is there any provision for 
somebody who decides down the road a couple of years that that 
doesn't work for them, or do you just say--I mean--it is going 
to be a very confusing time for people to have to make that 
decision.
    Ms. Shalala. It is soldiers and sailors and Marines from 
October 1 of 2001 on, and what you are asking is if they have 
already had their rating, if they decide later they want to 
come into the new system whether they could. We didn't 
stipulate----
    Senator Dole. We left it open.
    Ms. Shalala. We left that question open and that obviously 
is something that Congress----
    Senator Murray. I believe in the administration's draft 
legislation they are saying----
    Ms. Shalala. The administration said, ``no.'' We left that 
open.
    Senator Murray. You didn't----
    Ms. Shalala. Our recommendation was to leave it----
    Senator Murray [continuing]. Are you----
    Ms. Shalala [continuing]. We left it open for Congress to 
make that decision.
    Senator Murray [continuing]. Are you concerned, then, with 
a massive----
    Ms. Shalala. No.
    Senator Murray [continuing]. With a big change----
    Ms. Shalala. I am not concerned with big numbers if you go 
from 2001 on. I think most people will probably stick with 
their current system if they have already gone through the 
evaluation process, and----
    Senator Dole. We have a young man on the Commission, Jose 
Ramos, who is in the current system and I think it is working 
for him. If he wanted to change----
    Ms. Shalala. He could.
    Senator Dole. He could do that, right?
    Senator Murray. He has a one-time chance to make that 
decision under the administration's legislation.
    Ms. Shalala. Yes, under the administration's legislation. 
Under ours, we left that open, which means the Congress just 
makes a judgment about that. And, when you are in a transition 
period, you may make a different decision, just for the 
transition period of maybe a certain number of years, as 
opposed to long-term.
    Senator Murray. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Webb?

                 STATEMENT FROM HON. JIM WEBB, 
                   U.S. SENATOR FROM VIRGINIA

    Senator Webb. Thank you, Mr. Chairman, and Senator Dole and 
Secretary Shalala. I did watch your testimony from my office. I 
have a couple of questions from the testimony, and I want you 
to know that I am not walking in here cold right now. Further, 
I didn't move down to this seat to get away from Senator 
Tester. It is the only seat that has a microphone.
    With respect to PTSD, I, as many know, worked on the 
Veterans Committee on the House side for four years as a 
committee counsel and when we were doing a lot of pioneering of 
that program and I would support what you are doing on that 
because PTSD sort of oscillates through your life. There are 
relatively few, in the experiences that we had, who would be 
leaving the military and be diagnosed with PTSD, and yet down 
the road, in my experience, it sort of popped up in about an 8-
year cycle and then about a 20-year cycle with people who had 
served in Vietnam, so I would fully support that.
    I would like to make a point just from having watched the 
testimony and having worked in this area off and on all of my 
adult life. It is one I hope we don't lose as we start 
analogizing to the civilian employment structure, and that is 
that a volunteer force is not per se a career force. This is 
not a direct analogy to civilian employment. There are a lot of 
people who enlist in the military for reasons other than normal 
employment opportunity--because they love their country or they 
have got a family tradition, people who don't really intend to 
stay for a career.
    It is for that reason that I have very strong feelings 
about readjustment assistance in addition to the types of 
things that we have been talking about here. I know, Senator 
Dole, you mentioned many times in your testimony about the need 
to focus on education, the fact that cost shouldn't be an issue 
when we look at that. You mentioned these people since 9/11, we 
keep calling them the new greatest generation.
    I introduced a bill--this is not directly under the purview 
of your recommendations, but it is important when we are 
talking about how we are going to help people transition into 
the future. I introduced a bill to give the people who have 
served since 9/11 the same G.I. educational benefits as the 
people who came back from World War II received. It is not true 
today, and I think that it is a great oversight in the 
veterans' law that we have not done that.
    I was wondering, Senator Dole, if you could mention to us 
how important the educational piece was for you in terms of 
putting together your life after having served.
    Senator Dole. Well, there were 16 million of us in World 
War II and I think 8.5 million took advantage of the G.I. Bill. 
The G.I. Bill was signed down in the Mayflower Hotel, in room 
320, and one of the big principals happened to be the National 
Commander of the American Legion, who happened to be a Kansan 
at that point. In any event, it made a big difference--not only 
the education piece, but the other benefits that were in the 
G.I. Bill; and it barely passed the Congress, as you probably 
remember, no more than four or five votes. It wasn't something 
that just sort of swept through the Congress. There was a lot 
of debate about it, and I don't know what the objections could 
have been.
    I think it is the single most important piece of 
legislation when it comes to education, in how it changed 
America, than anything I can think of. Because, if you get a 
college education, then you want your children to get a college 
education, and a lot of us didn't have any money. Our parents 
didn't have any money. And suddenly, we had this opportunity. 
They even gave me a left-handed typewriter, a recording machine 
that I could take to class because I wasn't able to write then 
with my left hand. I had the best notes in class. I was very 
popular around test time every year. And they ought to take the 
same care of the veterans today.
    Senator Webb. Well, the program they have today is 
basically a peacetime program. The individual sort of has to 
pay in $100 a month for the first year. They all pretty much 
have to, even though it is supposedly voluntary. We have been 
doing analysis. It doesn't even take care of, say, 20 percent 
of what the costs would be at one of the better institutions, 
where after World War II, people got everything.
    We had the VA testifying in front of us when I mentioned 
this and they said that to do the World War II G.I. Bill today 
would be too complicated because you had to look at different 
tuition payments and different schools, and I just have a hard 
time believing that. We put, I think, 7.8 million people 
through regular college after World War II and they did it with 
a stubby pencil on the back of a memo pad, they were able to 
figure it out. So I can't----
    Senator Dole. I am reminded that the vocational 
rehabilitation program provides, I think--one of our Commission 
members is a Harvard student, and, of course, it costs quite a 
bit to go to Harvard. I have never known why, but----
    [Laughter.]
    Senator Dole [continuing]. So, there is money there----
    Senator Webb. I benefited from that program after Vietnam. 
I was in vocational rehabilitation when I went to law school. I 
think we can--I hope we can--get your support for this for all 
people. For instance, on something like PTSD, there are a lot 
of these things that aren't manifesting themselves immediately 
that would come under the rubric of the type of issues that you 
are talking about today, and the No. 1 thing that I can think 
of in terms of trying to help people readjust back into 
civilian life is a good education.
    Ms. Shalala. And Senator Dole came out with a great idea, 
and that is for every year people stay in, we increase the 
stipend, which actually incentivizes people to stay in for 
longer than a year in the program. I think that is very 
important.
    Senator Dole. Ten percent a year. We give them a 10-percent 
increase.
    Ms. Shalala. You look at the drop-out rate in the education 
programs that you are currently funding and it looks like an 
inner-city high school.
    Senator Webb. People can't keep up. They can't go to 
community college on the Montgomery G.I. Bill.
    Ms. Shalala. And I had a young man who contacted me because 
he wanted to go to the University of Miami. When he called, he 
was in Miami, though he called up to Tampa. They offered him 
enough money to go to a community college, but he wanted a 
specialized kind of course. Now, we have made an effort to 
accommodate him and get him fit together with our programs, 
because I was hardly going to turn him away.
    Those kinds of investments will make a huge difference in 
the long run for us, and we just have to fit it with modern 
systems. There is lots of aid available in the States and from 
the Federal Government, but it is the wrap money to make sure 
it is possible for them to go full-time. So, that is why we 
want to extend the time for those that go part-time, but we 
also have to know what we are doing and it should not be to 
keep people down at a certain income level.
    But the incentive system, I think is terrific, because it 
encourages--you get more resources as you stay in school.
    Senator Webb. Thank you very much. Mr. Chairman, if I may 
say one other thing, years ago when I worked on the veterans' 
programs, Senator Dole had an incredible reputation. I am not 
saying anything people don't already know, but wherever he was 
traveling, he was known to go to the VA hospitals in that area 
and not allow media to go with him, just to go in and talk to 
veterans. Again, I am not saying anything people don't know, 
but we couldn't have a better person and a greater national 
treasure doing this job. Thank you.
    Chairman Akaka. Thank you very much, Senator Webb.
    Senator Tester?
    Senator Tester. Thank you, Mr. Chairman, and I want to 
apologize to the panel for having to go to a Banking markup 
meeting. There are some things that I want to visit and I will 
be as brief as possible.
    Montana, as you both know, is a very rural State. You both 
know we have a high percentage of folks in the military. We 
have a high percentage of veterans. I think out of 930,000 
people, we have about 110,000 veterans. It is extremely rural. 
And I think, Senator Dole, in your comments, you talked about 
disabled veterans in rural areas being able to access private 
care in the areas of TBI and PTSD. Do you see that being 
applicable in other areas? I am talking about specialty care, 
routine care, anything like that--do you see any benefits of 
allowing that to happen in rural or frontier areas?
    Ms. Shalala. I do certainly. I visited some of the 
conversions and actually helped fund some of the conversions of 
hospitals to rehabilitation centers in Montana. You have some 
very interesting ways of using existing facilities, and there 
is no question in my mind that for certain kinds of 
rehabilitation that you would have some facilities. We would 
have to do a treatment plan and make sure that it fits with 
whatever the treatment plan is, so that people go home and use 
existing facilities and take advantage of doctors in rural 
areas or in the small towns. But, I certainly have spent enough 
time in Montana looking at the health care system to know that 
if you had a treatment plan, a way of getting accountability to 
make sure that you are measuring progress, we certainly should 
take advantage of what is available.
    Senator Dole. There is a Sergeant Edmondson that I think 
maybe Senator Burr is familiar with in New Bern, North 
Carolina, who has a bad TBI. He was able to negotiate to go to 
the Rehabilitation Institute of Chicago for treatment, where he 
made remarkable progress. Now, I know we don't have any cities 
like that in Kansas or Montana, or facilities like that. Then 
again, Ed Eckenhoff on our Commission has had 46 Iraq-Afghan 
veterans in the rehabilitation center here. So, the answer is, 
we live out in the country and we have got to make it easy for 
these people from the standpoint of their cost; and some are in 
wheelchairs, so it is hard to travel. We would like to have 
them get there and back in the same day, if possible.
    Ms. Shalala. We have a lot of experience in telemedicine. 
Senator Murray has been interested in it a long time, and 
taking advantage of that. Medicine has changed, so the key is 
the treatment plan, the accountability, and our ability to 
tailor it to what works for an individual.
    Senator Tester. Thank you. Thank you for your answers. I 
couldn't agree more, although I will tell you from a 
telemedicine standpoint, when it comes to PTSD or TBI, I have 
some concerns about that.
    Ms. Shalala. In fact, you need a place with expertise in 
those areas. I also want to make it clear that most of the 
expertise in this country in TBI and PTSD is in the veterans 
hospitals and in the military. The research that is going on, 
the clinical research that is going on, while there are some 
private sector centers, there's nothing like what is going on 
in the military and in veterans hospitals in this country.
    Senator Tester. Well, I certainly appreciate that. I can 
tell you that my opinion has changed dramatically over the 
last--since the first of January--in that, I think that in 
rural areas there is a real need that is not being met because 
of distance; and so, thank you for your answers and thank you 
for your testimony, too.
    Chairman Akaka. Thank you very much, Senator Tester.
    Before going to panel two, let me ask the Members if anyone 
has any questions for a second round.
    [No response.]
    Chairman Akaka. Thank you very much. I want to thank our 
first panel very, very much. Your testimony, your comments, 
your advice and recommendations have been very helpful.
    Senator Dole. Thank you.
    Chairman Akaka. Thank you.
    I now welcome our second panel. Lieutenant General Terry 
Scott joins us today as Chairman of the Veterans Disability 
Benefits Commission. Under General Scott's leadership, the 
Veterans Disability Benefits Commission recently completed an 
extensive 2-year review of the benefits and services provided 
to disabled veterans by the Departments of Defense and Veterans 
Affairs.
    Patrick Dunne is Assistant Secretary for Veterans Affairs 
for Policy and Planning. He appears before this Committee today 
representing the Task Force on Returning Global War on Terror 
Heroes, an interdepartmental panel assembled to address 
administrative barriers to the care of wounded servicemembers.
    Former VA Secretary Togo West joins us today as Co-Chair of 
the Department of Defense's Independent Review Group on 
Rehabilitative Care and Administrative Processes at Walter Reed 
Army Medical Center and National Naval Medical Center. 
Secretary West served as Secretary of the Army and Secretary of 
Veterans Affairs during the Clinton Administration. He will 
present the Independent Review Group's perspective on how DOD 
can improve the care of wounded servicemembers.
    I thank all of you for joining us today and look forward to 
your testimony. Your full statements will appear in the record 
of the hearing, and in the interest of time, please try to 
limit your direct statement to 5 minutes.
    So at this time, I would like to call on General Scott for 
your statement.

 STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, U.S. ARMY 
   (RET.), CHAIRMAN, VETERANS DISABILITY BENEFITS COMMISSION

    General Scott. Chairman Akaka, Ranking Member Burr, Members 
of the Committee, it is a great pleasure to appear before you 
again today representing the Veterans Disability Benefits 
Commission. I had the opportunity to testify before you in the 
joint session with the Armed Services Committee last April and 
it is a real pleasure to be back.
    I would like to introduce some of the Commissioners who 
were able to be present here today, Commissioner Brown, 
Commissioner Carroll, Commissioner Cassiday, Commissioner 
Grady, Commissioner Jordan, Commissioner McGinn, Commissioner 
Surratt, and Commissioner Wynn. This lady and gentlemen devoted 
a lot of time to the two-and-a-half years that the Commission 
was meeting, and we met once a month in Washington until the 
last couple of months and we met twice a month from then on. 
Also, I would like to recognize the efforts of the Executive 
Director, Mr. Ray Wilburn, who has done a tremendous job of 
keeping things moving when the Commissioners were not present.
    Sir, you asked today that I focus directly on areas of 
overlap between the recommendations of our Commission and those 
of the President's Commission on Care for America's Wounded 
Warriors, the Dole-Shalala Commission, and the Task Force on 
Returning Global War on Terror Heroes (also known as the 
Nicholson Task Force), and the DOD Independent Review Group 
(known as the Marsh-West Group).
    You also asked for our views on how to improve the VA and 
DOD collaboration and cooperation, and how could we resolve the 
longstanding issue of creating a VA-DOD Electronic Health 
Record. So, per your request, sir, that is what I am going to 
address here today.
    First, let me say that there is a tremendous amount of 
consistency in the findings and recommendations of these four 
reports. I prepared for the record, and passed to your staff, a 
matrix that listed the four commissions and the subject areas 
that they covered. I commend that to the staff and to the 
Members if they have the time to read it, because it lays out 
in detail how each of the four commissions addressed each of 
the important issues.
    It is, of course, well known that the scope of these four 
commissions was quite different, and this resulted in some 
variations in some areas of the recommendation. For instance, 
our commission was not chartered to address the issues at 
Walter Reed, per se, and we did not.
    All of us want to see improvements in benefits and services 
for the injured and disabled servicemembers and veterans. I 
might make a couple of points here. We found nine areas with 
considerable overlap among the reports and some areas with some 
limited overlap or some differences, or perhaps it was 
differences of interpretation.
    The Veterans Disability Benefits Commission believes that 
all disabilities and injuries should be compensated based on 
the severity of the disability, and I believe that was covered 
in the question and answer portion of the last session, so I 
will go on from that.
    Our Commission also believed that VA disability 
compensation should not end and be replaced with Social 
Security at retirement age, and we provided some hypotheticals 
as to what effect that would have on the severely-disabled 
veterans. So, I will be glad to respond to questions on that 
later, but that may be a moot issue since, apparently, the 
legislation will not have that in it.
    I will talk briefly, sir, about the VA and DOD disability 
process. All four reports address the problems with the process 
used when servicemembers are determined to be fit or unfit for 
military duty. We conducted a detailed analysis of those 
separated or retired as unfit for duty during the 7-year period 
from 2002 to 2006 and compared their ratings with ratings 
subsequently completed by the VA. We found that the combined 
ratings by the VA were higher, on average, than the ratings by 
the services. When comparing the ratings for individual 
diagnosis, VA ratings were statistically significantly higher 
than those of the services.
    We concluded that there should be a realignment of the 
process, and that is essentially the same conclusion reached by 
the Dole-Shalala Commission, the Independent Review Group, and 
the Nicholson Task Force. We also believe that the services 
should determine if the servicemember is fit or unfit, and VA 
should be responsible for assigning disability ratings. The 
Dole-Shalala Commission made the same recommendation.
    In redesigning the VA disability process and specifying the 
benefits available for those servicemembers, we should 
recognize that the overwhelming proportion of servicemembers 
medically discharged as unfit do not meet the several 
definitions of severely disabled.
    Our Commission did not specify which department should 
conduct this single examination. In fact, we believe that in 
some locations, it might be best determined by the capabilities 
of the two departments at that local level.
    All four study groups recommended developing a case 
management system for severely injured servicemembers and their 
families to ensure that the right care and support at the right 
time and in the right place. A single case manager should have 
overall responsibility. The other commissions agreed.
    Family support is addressed by all of the study groups 
except the Nicholson Task Force. The families of the severely 
injured are assisting in the care and rehabilitation of these 
wounded warriors. Our Commission recommended that VA be 
authorized to provide similar services to those provided by DOD 
to families of the severely injured. We also recommended 
extending the CHAMP VA medical care to caregivers of 100 
percent disabled veterans, and providing a caregiver allowance. 
We recommended eliminating any TRICARE co-pays and deductibles 
for the severely disabled because we do not believe the injured 
should have to pay in any way for their injuries.
    Regarding Post Traumatic Stress Disorder and Traumatic 
Brain Injury.--All four reports recommend improvements in 
awareness; research; treatment; staffing; and diagnosis 
examination of Post Traumatic Stress Disorder and Traumatic 
Brain Injury. Our Commission focused more on compensating and 
rating these conditions, and we recommend a holistic approach 
to PTSD be established that couples compensation, treatment, 
and vocational assessment. We also believe that reevaluation 
should occur every 2 to 3 years to gauge treatment 
effectiveness and encourage wellness. Regarding Traumatic Brain 
Injury, we recommend including medical criteria for this 
diagnosis as a priority in the revision of the VA schedule for 
rating disabilities.
    Regarding ancillary benefits.--Our Commission recommended 
increases to several benefits that have not kept pace with the 
cost of living, extending eligibility in some cases to burn 
victims, and expanding the auto and housing allowances. We also 
recommended eliminating the premiums for Traumatic 
Servicemembers Group Life Insurance, as we do not believe that 
the servicemember should have to insure themselves for 
traumatic injuries. Perhaps most importantly, our Commission 
recommends establishing a pre-stabilization allowance similar 
in theory to that recommended by the Dole-Shalala Commission.
    Regarding quality of life.--As was mentioned in the Q and A 
before, both our Commission and the Dole-Shalala Commission 
recommend a compensation payment for the impact of disability 
on quality of life. Current compensation payments do not 
provide payment above that required to offset earnings loss. 
Therefore, there is currently no compensation for the impact of 
disability on quality of life for most veterans. While 
permanent quality of life measures are developed and 
implemented, we recommend that compensation payments should be 
increased up to 25 percent with priority to the more severely 
disabled, and we provide some hypotheticals that show how that 
might be.
    In other words, the 100 percent disabled person might get a 
25 percent boost for quality of life, whereas the 10 percent 
disabled might get a very much smaller boost in payments for 
quality of life. So, it would be scaled based on the severity 
of the disability--it is an ``up to 25 percent,'' not a flat 25 
percent across the board, as has been quoted in some of the 
media.
    Vocational rehabilitation.--All but the Independent Review 
Group addressed vocational rehabilitation. Both the Dole-
Shalala Commission and our Commission found that the 
effectiveness of the program is not currently assessed and that 
graduates are not followed except for a very brief time period. 
Both Commissions recommend either an incentive bonus of up to 
25 percent--that would be the Dole-Shalala--or exploring 
incentives as a way to encourage completion of vocational 
rehabilitation. The Nicholson Task Force focused on using 
existing programs and opportunities in that regard.
    Concurrent receipt.--Regarding concurrent receipt of 
military retirement and VA disability, our Commission found 
that these two are different programs with entirely different 
missions. DOD retirement recognizes years of service and VA 
disability payments compensate for impairment in earnings and 
should compensate for impact on quality of life. Over time, 
Congress should eliminate the ban on concurrent receipt for all 
military retirees and for all servicemembers who are separated 
from the military due to service-connected disabilities. 
Priority should be given to those veterans who separate or 
retire with less than 20 years of service, with a disability 
rating of greater than 50 percent, or a disability as a result 
of combat.
    Payment offsets should also be eliminated for survivors of 
those who die in service or retirees who die of service-
connected causes so that these survivors can receive both the 
VA Dependency and Indemnity Compensation, known as DIC, and DOD 
survivors' benefit, known as SBP.
    The Dole-Shalala Commission also recommends that DOD 
compensate for years of service, while VA compensates for 
disability.
    Hazards exposures and presumptions.--Our Commission and the 
Nicholson Task Force both addressed hazards and exposures, but 
in different ways. Our Commission recommended a new presumption 
process as proposed by the Institute of Medicine. The new 
process includes enhanced registries of servicemembers and 
veterans based on exposure, deployment, and disease histories. 
And sir, I commend, particularly to the staff but also to the 
Members, this report done by the IOM. This subcommittee was 
chaired by Dr. Jonathan Simmet from Johns Hopkins, and I think 
that he provided all of us with some truly innovative ideas 
about how to address the issue of presumptions of disability.
    Improving VA and DOD collaboration.--In addition to 
assessing the areas of overlap among the four reports, you 
asked my views on how to improve collaboration and cooperation 
between VA and DOD. We found many encouraging signs and also 
areas which need improvement. The Joint Executive Council has 
demonstrated how both departments can benefit from coordinated 
planning and increased cooperation. The results are evident in 
specific initiatives, including the integration of the North 
Chicago VA Medical Center and the Naval Health Clinic-Great 
Lakes. This coordinated treatment of severely injured in 
dedicated polytrauma centers is also very effective. However, 
we believe the JEC planning effort can be significantly 
improved by including specific milestones and designating 
responsible officials for each.
    Successfully transitioning servicemembers to civilian life 
is crucial and ensuring that servicemembers understand the 
benefits and services that are available to them is essential. 
The Transition Assistance Program and the Disabled Transition 
Assistance Program briefing should be mandatory and adequately 
funded.
    After leaving service, many veterans find it difficult to 
prove that injuries and diseases that occur later in life are 
the result of military service. We believe that all separating 
servicemembers should receive a separation examination to 
establish a baseline for medical conditions.
    There is one way of expediting disability benefits in 
effect now. It is called a Benefits Delivery at Discharge 
process. It is available at 140 military facilities and these 
claims are processed at two VA locations. We believe that this 
Benefits Delivery at Discharge should be available to virtually 
all separating members, including Guard and Reserve.
    One cause for delay in claims processing, even in the BDD 
process, is the availability of the discharge document. Our 
Commission recommends that DOD immediately provide VA with an 
authenticated electronic document so that processing can begin 
right away.
    Lastly, sir, on IT compatibility.--All the reports address 
the absolute necessity for the VA and the DOD to have 
compatible information systems, but also to recognize that this 
will not solve all problems. Much has been said about the goal 
of seamless transition, which is not a current reality. Not all 
of DOD's medical and personnel records are electronic, and 
those that are electronic are not yet fully compatible between 
the services, much less between VA and DOD. There has been an 
agreement to create a joint Inpatient Electronic Record that 
would be instantly accessible. We do believe that development 
and implementation of this information system should be 
expedited and that a detailed management plan should be 
developed with a lead agent designated and with specific 
milestones and plan completion dates.
    In conclusion, VA and DOD have much to gain by greater 
coordination. Servicemembers and veterans have even more to 
gain by the two departments working together. A lot of valuable 
work has been done. However, a great deal of work remains, and 
the only way the goal of a reasonably seamless transition will 
ever be realized is if the two departments are required to 
develop realistic challenging goals with specific milestones.
    Congress should review these plans and oversee progress. 
Congress also has a responsibility to ensure that sufficient 
funding is provided to accomplish the goals and objectives 
contained in these IT plans.
    Sir, that ends my oral statement and I will gladly answer 
any questions after the other presentations.
    [The prepared statement of General Scott follows:]
  Prepared Statement of James Terry Scott, LTG, USA (Ret), Chairman, 
                Veterans' Disability Benefits Commission
    Chairman Akaka, Ranking Member Burr, and Members of the Committee: 
It is my pleasure to appear before you today representing the Veterans' 
Disability Benefits Commission.
    You asked that I focus directly today on areas of overlap between 
the recommendations of our Commission and those of the President's 
Commission on Care for America's Returning Wounded Warriors (the Dole-
Shalala Commission), the Task Force on Returning Global War on Terror 
Heroes (the Nicholson Task Force), and the DOD Independent Review Group 
(the Marsh/West Group.) You also asked for views on how to improve VA 
and DOD collaboration and cooperation and to resolve the long standing 
issue of creating a VA/DOD electronic health record.
    First, let me say that there is a tremendous amount of consistency 
among the findings and recommendations of the four reports. The scope 
of the four efforts was quite different and this resulted in variations 
in some areas. But we all want to see improvements in benefits and 
services for injured and disabled servicemembers and veterans. Our 
Commission generally agrees with the advice provided by the Independent 
Review Group and the Task Force and more recently by the Dole-Shalala 
Commission, but we differ with two of the Dole-Shalala suggestions. We 
believe that all disabilities and injuries should be compensated based 
on severity of disability and not be limited to combat or combat-
related injuries. Nor does our Commission believe that VA disability 
compensation should end and be replaced with Social Security at 
retirement age.
    For our own purposes, we prepared a matrix comparing the findings 
and recommendations of the four reports which I am pleased to share 
with the Committee. I caution that the matrix is not intended to be 
exhaustive nor a verbatim listing of all findings and recommendations. 
Rather it is a broad overview that I found useful.
    The matrix contains a description of each study group's focus and a 
brief summary of findings and recommendations and a summary of topics 
that overlap. The major topics with considerable overlap are: VA/DOD 
Disability Process; Case Management; Family Support; IT Compatibility; 
PTSD; TBI; Ancillary Benefits; Quality of Life; and Vocational 
Rehabilitation. Other topics with limited overlap include: Concurrent 
Receipt; Hazards and Exposures; Combat/Combat Related, Social Security, 
and Walter Reed. Our Commission addressed all of these topics except 
Walter Reed, which was not within the scope of our charge.
                       va/dod disability process
    All four reports addressed the problems with the process used when 
servicemembers are determined to be fit or unfit for military duty. Our 
Commission conducted a detailed analysis of those separated or retired 
as unfit for duty during the 7-year period from 2000 through 2006 and 
compared their ratings with ratings subsequently completed by VA. We 
found that the combined ratings by VA were higher, on average, than 
ratings by the Services. For example, individuals rated zero percent by 
the Services were rated an average of 30 percent by VA and those rated 
30 percent by the Services were rated an average of 56 percent by VA. 
Among individuals rated by the Services as zero, 10, or 20 percent, VA 
rated them 30 percent or higher 61 percent of the time. This was 
largely because VA rated 2.4 to 3.3 more conditions than the Services. 
When comparing the ratings for individual diagnoses, VA ratings were 
statistically significantly higher than the Services for 10 of 13 
frequent diagnoses analyzed.
    We concluded that there should be a realignment of the process and 
this is essentially the same conclusion reached by the Dole-Shalala 
Commission, the Independent Review Group, and the Nicholson Task Force. 
We also believe that the Services should determine if the servicemember 
is fit or unfit and VA should be responsible for assigning disability 
ratings to all conditions found as part of a single, comprehensive 
examination. The Dole-Shalala Commission made the same recommendation.
    In redesigning the VA/DOD disability process and specifying the 
benefits available for these servicemembers, it may be appropriate to 
focus specifically on the severely disabled. However, we should also 
recognize that the overwhelming proportion of servicemembers medically 
discharged as unfit do not meet the several definitions of severely 
disabled. During the 7-year period 2000 through 2006, there were 83,008 
servicemembers medically discharged as unfit. DOD rated 81 percent of 
these as 0 through 20 percent disabled and provided separation pay. 
Only 5,060 (6.1 percent) were rated by DOD as 50 percent through 100 
percent and, of these, only 1,478 (1.8 percent) were rated 100 percent. 
The process and the benefits should be appropriate for all 
servicemembers found unfit, not just the severely disabled.
    Our Commission did not specify which department should conduct the 
single examination; in fact we believe that this should be determined 
more by the capabilities of the two departments at the local level. Our 
Commission extensively reviewed the examination process used by VA with 
the advice of the Institute of Medicine and made recommendations 
relating to the use of templates, training and certification of 
examiners, and quality assurance. Completion of a thorough and 
comprehensive examination is essential for accurate ratings and these 
recommendations should be addressed no matter which department conducts 
the examinations.
                            case management
    All four study groups recommended developing a case management 
system for severely injured servicemembers and their families to ensure 
the right care and support at the right time and in the right place. A 
single case manager should have overall responsibility. The Dole-
Shalala Commission also recommended comprehensive recovery plans. 
Improving case management is a key topic upon which there is strong 
agreement.
                             family support
    Family support is addressed by all of the study groups except the 
Nicholson Task Force. The families of the severely injured are 
assisting in the care and rehabilitation of these wounded warriors. 
Some are sacrificing jobs, careers, homes, and health insurance, and 
facing a tremendous impact on their own health in order to support 
their injured family members. Our Commission recommended that VA be 
authorized to provide similar services as currently provided by DOD to 
families of the severely injured. We also recommended extending ChampVA 
medical care to caregivers (currently this benefit is provided only to 
dependents of 100 percent disabled veterans, not caregivers) and 
providing a caregiver allowance. We also recommended eliminating any 
TRICARE copays and deductibles for the severely disabled because we do 
not believe the injured should have to pay in any way for their 
injuries. We feel that our recommendations would more fully meet the 
needs of the families and caregivers of all severely disabled. The 
Dole-Shalala Commission would limit TRICARE coverage to only families 
of those unfit due to combat-related injuries.
                              ptsd and tbi
    All four reports recommend improvements in awareness, research, 
treatment, staffing, and diagnosis/examination of Post Traumatic Stress 
Disorder (PTSD) and Traumatic Brain Injury (TBI). Our Commission 
focused more on compensating and rating these conditions and recommend 
that a ``holistic'' approach to PTSD be established that couples 
compensation, treatment, and vocational assessment. We also believe 
that re-evaluation should occur every 2 to 3 years to gauge treatment 
effectiveness and encourage wellness. Regarding TBI, we recommend 
including medical criteria for this diagnosis as a priority in the 
revision to the VA Schedule for Rating Disabilities.
                           ancillary benefits
    Our Commission recommended increases to several benefits that have 
not kept pace with cost of living, extending eligibility in some 
instances to burn victims, and expanding auto and housing allowances. 
We also recommended eliminating the premiums for Traumatic 
Servicemembers' Group Life Insurance (TSGLI) as we do not believe 
servicemembers should have to insure themselves for Traumatic Injuries. 
Perhaps most importantly, our Commission recommends establishing a pre-
stabilization allowance of up to 50 percent of current compensation for 
up to 5 years to address the real out-of-pocket expenses for the 
severely disabled. The Dole-Shalala Commission recommended a transition 
pay of 3 months' base pay or longer-term payments if participating in 
rehabilitation, education, or training. This is conceptually similar to 
our Pre-stabilization recommendation.
                            quality of life
    Both our Commission and the Dole-Shalala Commission recommend a 
compensation payment for the impact of disability on quality of life. 
We believe the level of compensation should be based on the severity of 
disability and should make up for average impairments of earnings 
capacity and the impact of disability on functionality and quality of 
life. It should not be based on whether it occurred during combat or 
combat training; or the geographic location of injury, or whether the 
disability occurred during wartime or a time of peace. Current 
compensation payments do not provide payment above that required to 
offset earnings loss. Therefore, there is currently no compensation for 
the impact of disability on quality of life for most veterans. While 
permanent quality of life measures are developed and implemented, we 
recommend that compensation payments should be increased up to 25 
percent with priority to the more seriously disabled.
                       vocational rehabilitation
    All but the Independent Review Group addressed vocational 
rehabilitation. Both the Dole-Shalala Commission and our Commission 
found that the effectiveness of the program is not currently assessed 
and graduates are not followed except for a very brief time period. 
Both commissions recommend either an incentive bonus of up to 25 
percent (Dole-Shalala) or exploring incentives as a way to encourage 
completion. The Nicholson Task Force focused on using existing programs 
and opportunities.
                           concurrent receipt
    Regarding concurrent receipt of military retirement and VA 
disability payments, our Commission found these to be two different 
programs with entirely different missions. DOD retirement recognizes 
years of service and VA disability payments compensate for impairment 
in earnings and should compensate for impact on quality of life.
    Over time, Congress should eliminate the ban on concurrent receipt 
for all military retirees and for all servicemembers who are separated 
from the military due to service-connected disabilities. Priority 
should be given to veterans who separate or retire with less than 20 
years of service and a service-connected disability rating of 50 
percent or greater or disability as a result of combat. Payment offset 
should also be eliminated for survivors of those who die in service or 
retirees who die of service-related causes so that the survivors can 
receive both VA Dependency and Indemnity Compensation (known as DIC) 
and DOD Survivors Benefit Plan (known as SBP.)
    The Dole-Shalala Commission also recommends that DOD compensate for 
years of service while VA compensates for disability.
                         hazards and exposures
    Our Commission and the Nicholson Task Force both addressed hazards 
and exposures but in different ways. The Nicholson Task Force 
recommended creating a center of excellence and a registry for embedded 
shrapnel or fragments from blast injuries. Our Commission recommended a 
new presumption process as proposed by the Institute of Medicine. The 
new process includes enhanced registries of servicemembers and veterans 
based on exposure, deployment, and disease histories.
                   improving va and dod collaboration
    In addition to assessing areas of overlap among the four reports, 
you asked my views on how to improve collaboration and cooperation 
between VA and DOD. Our Commission made several recommendations that we 
believe would enhance benefits and services for servicemembers and 
veterans, both while they are transitioning from the military to 
civilian status and for many years in the future. We found many 
encouraging signs and also areas which need improvement.
    The Joint Executive Council (JEC) established by statute has 
demonstrated how both departments can benefit from coordinated planning 
and increased cooperation. We applaud the results that are evident in 
specific initiatives. These include the integration of the North 
Chicago VA Medical Center and the Naval Health Clinic Great Lakes 
(named last week for astronaut James Lovell), in the coordinated 
treatment of severely injured in dedicated poly trauma centers, and in 
shared rehabilitation units. These are all indications of how joint 
efforts can benefit both departments and improve service to veterans 
and servicemembers. However, we believe that the JEC planning effort 
can be significantly improved by including specific milestones and 
designating responsible officials for each. We also suggest that 
transition coordination and effectiveness could be improved by 
including the Department of Labor and the Social Security 
Administration in some capacity in the JEC since these organizations 
have major transition roles.
    Successfully transitioning servicemembers to civilian life is 
crucial and ensuring that servicemembers understand the benefits and 
services that are available to them is essential. Information is 
disseminated through the Transition Assistance Program (TAP) and the 
Disabled Transition Assistance Program (DTAP.) We believe that the TAP 
briefings should be mandatory for all separating servicemembers, 
especially the Guard and Reserves and those in medical hold status. 
Currently, these briefings are not mandatory in all Services. In 
addition, we found that funding for these briefings has been static for 
the last decade and we recommend that adequate funding be provided. All 
servicemembers should be knowledgeable about benefits prior to leaving 
the service.
    After leaving service, many veterans find it difficult to prove 
that injuries and diseases that occur later in life are the result of 
military service. The veteran, with the assistance of VA, has to 
produce evidence that the condition originated in service. This is made 
more difficult because not all separating servicemembers receive 
separation examinations; only those who intend to file a claim for VA 
disability benefits. We believe that all separating servicemembers 
should receive a separation examination to establish a baseline for 
medical conditions. An entrance examination is required to enter active 
duty and a separation examination should be required to leave active 
duty.
    Application for disability benefits is expedited through the 
Benefits Delivery at Discharge (BDD) process which is currently 
available at some 140 military facilities and these claims are 
processed at two VA locations. Two problems exist with the BDD process: 
(1) it is not available unless the individual has an established date 
of discharge and is within 180 days of that date; and (2) it is not 
available at all locations. Those on medical hold or on the temporary 
disability retired list are often precluded from participating in BDD 
and Guard and Reserves often separate at locations where BDD is not 
available. We believe that BDD should be available to virtually all 
separating servicemembers, including Guard and Reserves.
    One cause for delay in claims processing even in the BDD process is 
availability of the DD-214 discharge document. Our Commission 
recommends that DOD immediately provide VA with an authenticated 
electronic document so that processing can begin right away.
                            it compatibility
    All of the reports address the absolute necessity for VA and DOD to 
have compatible information systems. All recognize the importance of 
this capability but also recognize that this will not solve all 
problems.
    Much has been said over the past several years about ``seamless 
transition.'' This is an admirable goal but it is not a current 
reality. Not all of DOD's medical and personnel records are electronic 
and those that are electronic are not yet fully compatible between the 
Services, much less between VA and DOD. The AHLTA and VistA systems are 
not compatible. AHLTA may provide a more modern platform than VistA, 
but significant functions in the older VA system are not available to 
DOD users. For example, inpatient discharge summaries and digital 
images are not yet available in AHLTA. Therefore, DOD cannot easily 
transfer these types of information to VA upon a servicemember's 
discharge or transfer for medical care without paper copies first being 
scanned. In January 2007, VA and DOD announced an agreement to create a 
joint inpatient electronic record that would be instantly accessible to 
clinicians in both departments. As far as we know, the departments have 
not committed to a completion date although the Nicholson Task Force 
identified January 31, 2008 as the date for completion of an analysis 
of alternatives.
    Veterans Benefits Administration continues to use paper claims 
folders and has no long-term plan to convert them to electronic 
records. Both VA and DOD will have to continue to use paper records 
well into the future. Plans need to be made to convert existing paper 
records and finally be able to exclusively use electronic records at 
some time in the future.
    Our Commission believes that development and implementation of 
compatible information systems should be expedited. We also agree with 
the Government Accountability Office that a detailed project management 
plan should be developed with a lead agent designated and with specific 
milestones and planned completion dates. We understand why the 
departments are reluctant to establish planned completion dates since 
they will be expected to achieve those goals. However, we believe that 
planned completion dates for specific actions are absolutely essential 
in order to estimate resource requirements and to monitor progress.
    Compatible electronic systems will greatly enhance the ability of 
both departments to share information and work together. This critical 
interface will also improve claims processing and avoid some of the 
unfortunate cases that ``slip through the cracks'' during the 
transition from VA to DOD.
    In conclusion, VA and DOD have much to gain by greater coordination 
and collaboration but servicemembers and veterans have even more to 
gain by the two departments working better together. A lot of valuable 
work has been done by VA and DOD and they should be commended for the 
progress made. However, a great deal of work remains and the only way 
that the goal of a reasonably seamless transition will ever be realized 
is if the two departments are required to develop realistic, yet 
challenging, goals with specific milestones. Joint ventures, sharing 
agreements, and integrations should be the norm rather than the 
exception. Congress should review the plan and oversee progress. 
Congress also has the responsibility to ensure that sufficient funding 
is provided to accomplish the goals and objectives contained in the 
plan.

                                    Veterans' Disability Benefits Commission
                Table 1.--Commission/Task Force Comparisons: Primary Topics and Areas of Overlap
----------------------------------------------------------------------------------------------------------------
                                       Veterans'
                                      Disability      Independent Review
        Study Group Topic              Benefits              Group          GWOT Task Force          PCCWW
                                      Commission
----------------------------------------------------------------------------------------------------------------
VA/DOD Disability Process.......  Realign disability  DOD should          Joint process       Restructure
                                   evaluation          overhaul the DES    whereby VA/DOD      disability &
                                   process--Services   system by           cooperate in        compensation
                                   determine fitness   implementing a      assigning a         systems--DOD/VA
                                   for duty, VA        single physical     disability          should create a
                                   rates disability.   exam (as            evaluation,         single,
                                                       described by GAO    determining         comprehensive
                                                       2004). The          fitness for         standardized
                                                       services should     retention, level    medical exam that
                                                       consistently be     of disability       DOD administers,
                                                       determining         retirement & VA     DOD maintains
                                                       fitness for duty    compensation.       authority over
                                                       & VA provides                           fitness & pays
                                                       disability                              for years of
                                                       rating. DOD                             service while VA
                                                       should also                             establishes
                                                       expand the                              rating,
                                                       Disability                              compensation &
                                                       Advisory Council,                       benefits.
                                                       Conduct quality
                                                       assurance reviews
                                                       on previous 0-20
                                                       percent & EPTS
                                                       cases, Evaluate
                                                       loss of function
                                                       due to burns
                                                       similar to
                                                       amputation.
Case Management.................  Intensive case      Create tri-Service  System of case &    Comprehensive
                                   management with     policy &            co-management.      Recovery Plans &
                                   an identifiable     guidelines for                          Coordinators with
                                   lead agent.         case management                         HHS as lead.
                                                       services &
                                                       training, Assign
                                                       single primary
                                                       care physician &
                                                       case manager.
Family Support..................  Authorize VA to     Provide family      None..............  Strengthen support
                                   provide family      education on                            for families
                                   services, Extend    benefits, Survey                        through TRICARE
                                   health care &       families on their                       Respite Care &
                                   allowance to        needs, Assign                           Aid and Attendant
                                   caregivers,         family advocates.                       Benefit,*
                                   Eliminate SBP-DIC                                           Caregiver
                                   offset, Eliminate                                           training, Extend
                                   TRICARE co-pays &                                           FMLA for 6
                                   deductibles for                                             months, All
                                   severely injured                                            combat-related
                                   families.                                                   injured families
                                                                                               should have full
                                                                                               TRICARE coverage.
IT Compatibility................  Expedite            Streamline          Enhance VA          Rapidly transfer
                                   development &       transition by       computerized        patient
                                   implementation of   rapidly             Patient Record      information,
                                   compatible          developing a        System &            Create a
                                   information         standard            electronic          MyeBenefits Web
                                   systems with a      automated system    enrollment, VA      site.
                                   detailed plan,      interface for a     needs to develop
                                   milestones, &       bilateral           a patient
                                   lead agency, Use    exchange of         tracking
                                   IT to improve       clinical and        application
                                   claims cycle time.  administrative      compatible with
                                                       info between DOD    DOD, Create a TBI
                                                       & VA (Described     database, Improve
                                                       in 2003 PTF).       VA's access to
                                                                           military health
                                                                           records & create
                                                                           an interface with
                                                                           DOD, Create OIF/
                                                                           OEF identifiers
                                                                           and markers for
                                                                           polytrauma,
                                                                           Improve IT
                                                                           interoperability
                                                                           between VA & HHS
                                                                           Indian Health
                                                                           Services.
PTSD............................  Holistic approach   Functional/         Provide Outreach &  VA should care for
                                   that couples        cognitive           Education to        all OIF/OEF vets
                                   treatment,          measures &          Community Health    with PTSD & (with
                                   rehabilitation,     screenings upon     Centers on VA       DOD) improve
                                   compensation & re-  entry & post-       benefits &          prevention,
                                   evaluation for      deployment,         services (to        diagnosis &
                                   wellness, Revise    comprehensive &     reach vets with     treatment, reduce
                                   Rating Schedule     universal           PTSD).              PTSD stigma. DOD
                                   for PTSD,           clinical practice                       should address
                                   Baseline level of   & coding                                its mental health
                                   benefits, PTSD      guidelines for                          shortage,
                                   exam process,       blast injuries                          Disseminate
                                   Examiner & rater    and TBI with PTSD                       clinical practice
                                   training &          overlay to                              guidelines to all
                                   certification,      include recording                       providers.
                                   research on         of exposures to
                                   Military Sexual     blast in patient
                                   Trauma.             record. VA/DOD
                                                       create center of
                                                       excellence for
                                                       TBI and PTSD
                                                       treatment,
                                                       research &
                                                       training.
TBI.............................  Update the Rating   Functional/         Screen all GWOT     DOD/VA should
                                   Schedule for TBI.   cognitive           veterans for TBI.   prevent,
                                                       measures &                              diagnose, & treat
                                                       screenings upon                         TBI, Partner with
                                                       entry & post-                           the private
                                                       deployment,                             sector on TBI
                                                       comprehensive &                         care, Disseminate
                                                       universal                               clinical practice
                                                       clinical practice                       guidelines to all
                                                       & coding                                providers.
                                                       guidelines for
                                                       blast injuries
                                                       and TBI with PTSD
                                                       overlay to
                                                       include recording
                                                       of exposures to
                                                       blast in patient
                                                       record. VA/DOD
                                                       create center of
                                                       excellence for
                                                       TBI and PTSD
                                                       treatment,
                                                       research &
                                                       training.
Ancillary Benefits..............  Adjust & extend     DOD should partner  Expedite Adapted    Transition (3
                                   A&A, Extend auto    with VA to          Housing and         months of base
                                   & housing           provide             Special Home        pay or long-term)
                                   allowances to       treatment,          Adaptation          payments,
                                   veterans with       education &         Grants, Expand      Earnings-loss
                                   severe burns,       research in         HUD National        payments, All
                                   Eliminate TSGLI     prosthesis care,    Housing Locator,    unfit combat-
                                   premiums, Improve   production &        Enhance capacity    related injured
                                   SDVI & VMLI,        amputee therapy,    to provide Dental   should receive
                                   Increase benefits   Allow VA patients   care through VA &   full TRICARE
                                   to original         to use Military     private sector.     coverage.
                                   intention, Adjust   and private
                                   automatically for   prosthetist.
                                   inflation,
                                   Provide a
                                   Stabilization
                                   Allowance,
                                   Research
                                   additional
                                   ancillary
                                   benefits.
Quality of Life.................  Compensate for 3    Survey patients on  None..............  Determine
                                   consequences:       their needs.                            appropriate QOL
                                   work disability,                                            payments.
                                   loss of
                                   functionality &
                                   QOL, VA develop
                                   measures for QOL
                                   loss, but in the
                                   meantime create
                                   up to 25 percent
                                   QOL payment,
                                   Research health-
                                   related QOL &
                                   need for
                                   additional
                                   ancillary
                                   benefits,
                                   Increase SMC to
                                   address impact on
                                   QOL.
Vocational Rehabilitation &       Test VR&E           None..............  Extend VR&E         VR&E effectiveness
 Employment (VR&E).                incentives,                             evaluation          is not well
                                   Review & revise                         determination       established and
                                   12-year time                            time limit,         should offer
                                   limit, Expand                           Expand              completion
                                   VR&E to all                             eligibility for     incentives of up
                                   medically                               SBA Patriot         to a 25 percent
                                   separating                              Express Loans,      bonus.
                                   servicemembers, &                       Increase Career
                                   allow all service                       Fairs & integrate
                                   disabled veterans                       Hire Vets First
                                   access to VR&E                          Campaign, Provide
                                   counseling, VR&E                        Credentialing,
                                   should screen all                       Certification,
                                   IU applicants,                          Financial Aid
                                   increase VR&E                           Education
                                   staffing,                               Assistance, &
                                   tracking, &                             Employment
                                   resources.                              rights, Develop
                                                                           Wounded Warrior
                                                                           Intern & Wounded
                                                                           Veterans
                                                                           Readjustment Work
                                                                           Experience
                                                                           Programs.
Concurrent Receipt..............  Eliminate the ban.  None..............  None..............  Create a DOD
                                                                                               Annuity payment
                                                                                               based on rank &
                                                                                               years of service.
Hazards & Exposures.............  Create a new        None..............  Create an embedded  None.
                                   structure for                           Fragment
                                   Presumption based                       Surveillance
                                   on casual                               Center and
                                   relationship                            Registry.
                                   using four
                                   categories.
Combat/Combat-Related...........  Benefits based on   None..............  None..............  Benefits and
                                   severity of                                                 process
                                   disability, not                                             specifically for
                                   on circumstances                                            combat/combat-
                                   or location.                                                related injuries
                                                                                               only.
Social Security/Disability        Compensation for    ..................  ..................  Compensation for
 Compensation for Earnings.        earnings loss                                               Earnings Ends
                                   continues for                                               when retirement
                                   life.                                                       Social Security
                                                                                               begins.
Walter Reed National Military     None..............  Accelerate BRAC     None..............  Recruit & retain
 Medical Center (WRNMMC).                              construction                            first-rate
                                                       projects for                            professionals for
                                                       WRNMMC & new                            WRAMC through
                                                       complex at                              2011 with
                                                       Belvoir, New                            resources and
                                                       command and                             incentives to
                                                       control structure                       hire civilian
                                                       for WRNMMC, Apply                       health care
                                                       regulatory relief                       professionals &
                                                       to A-76 process,                        admin staff.
                                                       Survey patients &
                                                       families, Staff &
                                                       train Med
                                                       Hold(over)
                                                       personnel,
                                                       reevaluate
                                                       efficiency wedge,
                                                       Assign a senior
                                                       facility engineer
                                                       to oversee non-
                                                       medical
                                                       maintenance,
                                                       Modernize
                                                       facility
                                                       assessment tools
                                                       & prioritize
                                                       repairs.
----------------------------------------------------------------------------------------------------------------
* This refers to the Aid and Attendant benefit under TRICARE's Extended Care Health Option, and not VA's Aid and
  Attendance benefit.


           Table 2.--Other Veterans' Commissions & Task Forces: Purposes, Findings and Recommendations
----------------------------------------------------------------------------------------------------------------
                                                                                       Report      Findings &
            Entity                 Chairperson       Charged by          Purpose        Date     Recommendations
----------------------------------------------------------------------------------------------------------------
IRG on Rehabilitative Care &    Former VA         Secretary of      Review continuum   4/11/07  Problems
 Admin @ Walter Reed &           Secretary Togo    Defense.          of care,                    resulted from a
 National Naval (Bethesda).      West & Former                       leadership &                failure of
                                 Army Secretary                      oversight                   leadership,
                                 & Congressman                       issues                      loss of
                                 John Marsh.                         resulting in                resources &
                                                                     deficiencies                spending
                                                                     reported at                 authority under
                                                                     Walter Reed                 BRAC,
                                                                     Scope: Walter               contracting
                                                                     Reed patients &             out, nursing
                                                                     families.                   and other staff
                                                                                                 shortages,
                                                                                                 challenges of
                                                                                                 signature
                                                                                                 injuries, &
                                                                                                 failure of the
                                                                                                 Medical
                                                                                                 Holdover
                                                                                                 system. Other
                                                                                                 reports have
                                                                                                 recommended
                                                                                                 changes to the
                                                                                                 MEB/PEB process
                                                                                                 over the last
                                                                                                 10 years, but
                                                                                                 none have been
                                                                                                 implemented,
                                                                                                 which the IRG
                                                                                                 endorsed as
                                                                                                 well as a
                                                                                                 combined DOD/VA
                                                                                                 evaluation
                                                                                                 system.
Task Force on Returning Global  R. James          Executive Order   Improve the        4/19/07  There were 25
 War on Terror (GWOT) Heroes.    Nicholson,        of the            delivery of                 recommendations
                                 Secretary of      President.        Federal                     . Action areas
                                 Veterans                            services and                included health
                                 Affairs.                            benefits to                 care, case
                                                                     GWOT                        management,
                                                                     servicemembers              continuity of
                                                                     & veterans.                 care, TBI
                                                                     Scope: All GWOT             screening, VA
                                                                     servicemembers              Liaisons at
                                                                     & veterans.                 military
                                                                                                 facilities,
                                                                                                 small business
                                                                                                 loans,
                                                                                                 education,
                                                                                                 career
                                                                                                 training,
                                                                                                 employment
                                                                                                 rights,
                                                                                                 financial aid,
                                                                                                 housing
                                                                                                 locator,
                                                                                                 electronic
                                                                                                 tracking
                                                                                                 between
                                                                                                 systems,
                                                                                                 dental, rural
                                                                                                 health, VA/DOD
                                                                                                 joint
                                                                                                 disability
                                                                                                 process &
                                                                                                 exams, VR&E
                                                                                                 extension, &
                                                                                                 home
                                                                                                 adaptation.
                                                                                                 Recommendations
                                                                                                 can be
                                                                                                 accomplished
                                                                                                 within existing
                                                                                                 authority &
                                                                                                 resources.
                                                                                                 Outreach should
                                                                                                 cover TAP/DTAP
                                                                                                 attendance, job
                                                                                                 fairs, vets
                                                                                                 preference, & a
                                                                                                 GWOT
                                                                                                 newsletter,
                                                                                                 comprehensive
                                                                                                 database of
                                                                                                 Federal
                                                                                                 services &
                                                                                                 benefits.
President's Commission on Care  Former Senator    Executive Order   Recommend          7/25/07  There were 6
 for America's Returning         Bob Dole &        of the            Improvements                recommendations
 Wounded Warriors (PCCWW).       Former HHS        President.        for transition,             : (1)
                                 Secretary Donna                     high-quality                Immediately
                                 Shalala.                            services for                creating a
                                                                     returning                   comprehensive
                                                                     wounded troops,             recovery plan
                                                                     access to                   with a lead
                                                                     benefits &                  Recovery
                                                                     services.                   Coordinator;
                                                                     Scope: Wounded              (2) Completely
                                                                     OIF/OEF                     restructure the
                                                                     servicemembers,             disability
                                                                     veterans,                   systems so DOD
                                                                     families.                   determines
                                                                                                 fitness and VA
                                                                                                 disability
                                                                                                 benefits; (3)
                                                                                                 Aggressively
                                                                                                 prevent & treat
                                                                                                 PTSD & TBI; (4)
                                                                                                 Significantly
                                                                                                 strengthen
                                                                                                 support for
                                                                                                 families with
                                                                                                 amendments to
                                                                                                 TRICARE & FMLA;
                                                                                                 (5) Rapidly
                                                                                                 transfer
                                                                                                 patient info, &
                                                                                                 develop a
                                                                                                 Federal
                                                                                                 benefits Web
                                                                                                 site, and; (6)
                                                                                                 Strongly
                                                                                                 support Walter
                                                                                                 Reed by
                                                                                                 recruiting &
                                                                                                 retaining 1st-
                                                                                                 rate
                                                                                                 professionals
                                                                                                 through 2011.
Veterans' Disability Benefits   LTG James Terry   PL 108-136......  Appropriateness    10/3/07  113
 Commission.                     Scott (USA,                         of Benefit,                 recommendations
                                 Ret.).                              level of                    that focused
                                                                     Benefit,                    on:
                                                                     Determination               compensation
                                                                     Standards.                  for quality of
                                                                     Scope: All                  life & a 25
                                                                     disabled                    percent
                                                                     servicemembers,             allowance until
                                                                     veterans,                   VA develops
                                                                     families.                   measures; line
                                                                                                 of duty;
                                                                                                 earnings
                                                                                                 disparity for
                                                                                                 service
                                                                                                 connected
                                                                                                 veterans with
                                                                                                 mental
                                                                                                 disorders &
                                                                                                 young entry; VA
                                                                                                 Rating Schedule
                                                                                                 revisions,
                                                                                                 especially for
                                                                                                 PTSD, TBI, &
                                                                                                 IU; A holistic
                                                                                                 approach for
                                                                                                 PTSD that
                                                                                                 couples
                                                                                                 compensation,
                                                                                                 treatment,
                                                                                                 rehabilitation,
                                                                                                 & re-
                                                                                                 evaluation;
                                                                                                 caregiver
                                                                                                 health care &
                                                                                                 an allowance;
                                                                                                 presumption
                                                                                                 standards for
                                                                                                 exposures; DOD
                                                                                                 disability
                                                                                                 evaluations and
                                                                                                 separation
                                                                                                 exams with
                                                                                                 Services
                                                                                                 determining
                                                                                                 fitness for
                                                                                                 duty & VA
                                                                                                 adjudicating a
                                                                                                 rating;
                                                                                                 concurrent
                                                                                                 receipt and
                                                                                                 survivor
                                                                                                 concurrent
                                                                                                 receipt; IT
                                                                                                 interoperabilit
                                                                                                 y; & joint
                                                                                                 ventures,
                                                                                                 sharing
                                                                                                 agreements, &
                                                                                                 integration.
----------------------------------------------------------------------------------------------------------------
* Final report.


                     Table 3.--Total Recommendations
------------------------------------------------------------------------
    Veterans'
    Disability        Independent
     Benefits         Review Group     GWOT Task Force        PCCWW
    Commission
------------------------------------------------------------------------
           113                 20                25                6
------------------------------------------------------------------------
* 23 action items.

                           Executive Summary

    The Veterans' Disability Benefits Commission was established by 
Public Law 108-136, the National Defense Authorization Act of 2004. 
Between May 2005 and October 2007, the Commission conducted an in-depth 
analysis of the benefits and services available to veterans, 
servicemembers, their survivors, and their families to compensate and 
provide assistance for the effects of disabilities and deaths 
attributable to military service. The Department of Veterans Affairs 
(VA) expended $40.5 billion on the wide array of these benefits and 
services in fiscal year 2006. The Commission addressed the 
appropriateness and purpose of benefits, benefit levels and payment 
rates, and the processes and procedures used to determine eligibility. 
The Commission reviewed past studies on these subjects, the legislative 
history of the benefit programs, and related issues that have been 
debated repeatedly over many decades.
    Congress created the Commission out of concern for a variety of 
issues pertinent to disabled veterans, disabled servicemembers, their 
survivors, and their families. Those matters included care for severely 
injured servicemembers, treatment and compensation for Post Traumatic 
Stress Disorder (PTSD), the concurrent receipt of military retired pay 
and disability compensation, the timeliness of processing disabled 
veterans' claims for benefits, and the size of the backlog of those 
claims. Another area of concern was the program known as Individual 
Unemployability, which allows veterans with severe service-connected 
disabilities to receive benefits at the highest possible rate if their 
disabilities prevent them from working. The Commission gave these 
issues special attention.
    The Commission received extensive analytical support from the CNA 
Corporation (CNAC), a well-known research and consulting organization. 
CNAC performed an in-depth economic analysis of the average impairment 
of earning capacity resulting from service-connected disabilities. In 
addition, to assess the impact of disabilities and deaths on quality of 
life, CNAC conducted surveys of disabled veterans and survivors. To 
gain insight into claims processing issues, CNAC surveyed raters from 
VA and representatives of veterans' service organizations who assist 
veterans in filing claims. CNAC also completed a literature review and 
a comparative analysis of disability programs similar to those provided 
by VA.
    The Commission received expert medical advice from the Institute of 
Medicine (IOM) of the National Academies. Required by statute to 
consult with IOM, the Commission asked the institute to conduct a 
thorough analysis of the VA Schedule for Rating Disabilities (hereafter 
the Rating Schedule) and a study of the processes used to decide 
whether one may presume that a disability is connected to military 
service. In addition, the Commission examined two studies that IOM 
conducted for VA about the diagnosis of PTSD and compensation to 
veterans for that disorder. Unfortunately, a third IOM study--of the 
treatment of PTSD--was not completed in time to be considered by the 
Commission. Additionally, the Commission conducted eight field visits 
and held numerous public sessions.
                           guiding principles
    The Commission wrestled with philosophical and moral questions 
about how a Nation cares for disabled veterans and their survivors and 
how it expresses its gratitude for their sacrifices. The Commission 
agreed that the United States has a solemn obligation, expressed so 
eloquently by President Lincoln, ``. . . to care for him who shall have 
borne the battle, and for his widow, and his orphan . . .''\1\
---------------------------------------------------------------------------
    \1\ Lincoln, Abraham, Second Inaugural Address, March 4, 1865, 
http://www.ourdocuments.gov/doc.php?flash=true&doc=38.
---------------------------------------------------------------------------
    In going about its work, the Commission has been mindful of the 
1956 Bradley Commission principles, which have provided a valuable and 
historic baseline. This Commission's report addresses what has changed 
and what has endured over those five decades and throughout our 
Nation's wars and conflicts since the Bradley report. Many of the 
changes--social, technological, cultural, medical, and economic--that 
have taken place during that time span are significant and must be 
carefully considered as our Nation renews its compact with our disabled 
veterans and their families. This long-term context, a history of both 
significant change and key elements of constancy from the 1950's to the 
21st century, provides the solid basis for this Commission's 
principles, conclusions, and recommendations.

    This Commission identified eight principles that it believes should 
guide the development and delivery of future benefits for veterans and 
their families:

    1. Benefits should recognize the often enormous sacrifices of 
military service as a continuing cost of war, and commend military 
service as the highest obligation of citizenship.
    2. The goal of disability benefits should be rehabilitation and 
reintegration into civilian life to the maximum extent possible and 
preservation of the veterans' dignity.
    3. Benefits should be uniformly based on severity of service-
connected disability without regard to the circumstances of the 
disability (wartime v. peacetime, combat v. training, or geographical 
location.)
    4. Benefits and services should be provided that collectively 
compensate for the consequence of service-connected disability on the 
average impairment of earnings capacity, the ability to engage in usual 
life activities, and quality of life.
    5. Benefits and standards for determining benefits should be 
updated or adapted frequently based on changes in the economic and 
social impact of disability and impairment, advances in medical 
knowledge and technology, and the evolving nature of warfare and 
military service.
    6. Benefits should include access to a full range of health care 
provided at no cost to service-disabled veterans. Priority for care 
must be based on service connection and degree of disability.
    7. Funding and resources to adequately meet the needs of service-
disabled veterans and their families must be fully provided while being 
aware of the burden on current and future generations.
    8. Benefits to our Nation's service-disabled veterans must be 
delivered in a consistent, fair, equitable, and timely manner.

    With these principles clearly in mind, the Nation must set the firm 
foundation upon which to shape and evolve a system of appropriate--and 
generous--benefits for the disabled veterans of tomorrow.
    The Commission believes that just as citizens have a duty to serve 
in the military, the Federal Government has a duty to preserve the 
well-being and dignity of disabled veterans by facilitating their 
rehabilitation and reintegration into civilian life. The Commission 
believes that compensation should be based on the nature and severity 
of disability, not whether the disability occurred during wartime, 
combat, training, or overseas. It is virtually impossible to accurately 
determine a disease's origin or to differentiate the value of sacrifice 
among veterans whose disabilities are of similar type and severity. 
Setting different rates of compensation for the same degree of severity 
would be both impractical and inequitable.
    Disabled veterans require a range of services and benefits, 
including compensation, health care, specially adapted housing and 
vehicles, insurance, and other services tailored to their special 
needs. Compensation must help service-disabled veterans achieve parity 
in earnings with nonservice-disabled veterans. Compensation must also 
address the impact of disability on quality of life. Money alone is a 
poor substitute for the consequences of the injuries and disabilities 
faced by veterans, but it is essential to ease the burdens they 
experience.
    It is the duty of Congress and VA to ensure that the benefits and 
services for disabled veterans and survivors are adequate and meet 
their intended outcomes. IOM concluded that the VA Rating Schedule has 
not been adequately revised since 1945. This situation should not be 
allowed to continue. Systematic updates to the Rating Schedule and 
assessments of the appropriateness of the level of benefits should be 
made on a frequent basis.
    Excellent health care should be provided in a timely manner at no 
cost to veterans with service-connected disabilities (i.e., service-
disabled veterans) and, in the case of severely injured veterans, to 
their families and caregivers.
    The funding and resources necessary to fully support programs for 
service-disabled veterans must be sufficient while ensuring that the 
burden on the Nation is reasonable. Care and benefits for service-
disabled veterans are a cost of maintaining a military force during 
peacetime and of fighting wars. Benefits and services must be provided 
promptly and equitably.
                  results of the commission's analysis
    The analyses conducted by the Commission with the assistance of IOM 
and CNAC provide a consistent and complementary picture of many aspects 
of veterans' disability compensation.
                 ensure horizontal and vertical equity
    For veterans to receive proper compensation for their service-
connected disabilities, the VA Rating Schedule must be designed so that 
ratings result in horizontal and vertical equity in terms of 
compensation for average impairments of earning capacity. Horizontal 
equity means that persons with the same ratings percentage should have 
experienced the same loss of earning capacity. Vertical equity means 
that loss of earning capacity should increase in proportion to an 
increase in the degree of disability. A comparison of the earnings of 
disabled veterans with those of veterans who lacked service-connected 
disabilities revealed that the average amount of earnings lost by 
disabled veterans generally increased as disability ratings increased. 
In addition, mortality rates rose with degree of disability. Thus, 
vertical equity is achieved. The average earnings loss was similar 
across different types of disabilities except for PTSD and other mental 
disorders, indicating that horizontal equity also is generally being 
achieved at the level of body systems.
                ensure parity with nondisabled veterans
    Overall, disabled veterans who first apply to VA for compensation 
at age 55 (the average age) receive amounts of money that are nearly 
equal to their average loss of earnings as a consequence of their 
disabilities among the broad spectrum of physical disabilities.
    The earnings of a representative sample of nondisabled veterans 
were compared with the sum of earnings plus compensation of disabled 
veterans to determine the extent to which disability compensation helps 
disabled veterans achieve parity with their nondisabled counterparts. 
Among veterans whose primary disabilities are physical, those who are 
granted Individual Unemployability are substantially below parity; 
those who are rated 100 percent disabled and who enter the system at a 
younger age (45 years or less) are slightly below parity; and those who 
enter at age 65 or older are above parity. For those whose primary 
disabilities are mental, the sum of earnings plus VA compensation is 
generally below parity at average age of entry, substantially below 
parity for severely disabled individuals who enter the system at a 
younger age, and above parity for those who enter at age 65 or older. 
Also, among veterans whose primary disabilities are mental, those rated 
10 percent disabled are slightly below parity. Thus, parity is 
generally present with respect to earnings loss except among 
individuals whose primary disabilities are mental, among the younger 
severely disabled, and among those granted Individual Unemployability.
                 compensate for loss of quality of life
    Parity in average loss of earnings means that disability 
compensation does not compensate veterans for the adverse impact of 
their disabilities on quality of life.
    Current law requires only that the VA Rating Schedule compensate 
service-disabled veterans for average impairment of earning capacity. 
However, the Commission concluded early in its deliberations that VA 
disability compensation should recompense veterans not only for average 
impairments of earning capacity, but also for their inability to 
participate in usual life activities and for the impact of their 
disabilities on quality of life. IOM reached the same conclusion; 
moreover, it made extensive recommendations on steps to develop and 
implement a methodology to evaluate the impact of disabilities on 
veterans' quality of life and to provide appropriate compensation.
    The Commission concluded that the VA Rating Schedule should be 
revised to include compensation for the impact of service-connected 
disabilities on quality of life. For some veterans, quality of life is 
addressed in a limited fashion by special monthly compensation for loss 
of limbs or loss of use of limbs. Some ancillary benefits attempt to 
ameliorate the impact of disability. However, the Commission urges 
Congress to consider increases in some special monthly compensation 
awards to address the profound impact of certain disabilities on 
quality of life and to assess whether other ancillary benefits might be 
appropriate. While a recommended systematic methodology is developed 
for evaluating and compensating for the impact of disability on quality 
of life, the Commission believes that an immediate interim increase of 
up to 25 percent of compensation should be enacted.
    A survey of a representative sample of disabled veterans and 
survivors was conducted to assess their quality of life and other 
issues. The survey found that among veterans whose primary disability 
is physical, their physical health is inferior to that of the general 
population for all levels of disability, and their physical health 
generally worsens as their level of disability increases. Physical 
disabilities did not lead to decreased mental health. For veterans 
whose primary disability is mental, not only were their mental health 
scores much lower than those of the general population, but their 
physical health scores were well below population norms for all levels 
of mental disability. Those veterans with PTSD had the lowest physical 
health scores.
    The survey also sought to address two specific issues through 
indirect questions. There are concerns that service-disabled veterans 
tend not to follow medical treatments because they fear it might impact 
their disability benefits. This premise was not substantiated. 
Likewise, when questioned whether VA benefits created a disincentive to 
work, only 12 percent of respondents indicated they might work or work 
more if not for compensation benefits; thus, this is not a major issue.
                       update the rating schedule
    The Rating Schedule consists of slightly more than 700 diagnostic 
codes organized under 14 body systems, such as the musculoskeletal 
system, organs of special sense, and mental disorders. For each code, 
the schedule provides criteria for assigning a percentage rating. The 
criteria are primarily based on loss or loss of function of a body part 
or system, as verified by medical evidence; however, the criteria for 
mental disorders are based on the individual's ``social and industrial 
inadaptability,'' meaning the overall ability to function in the 
workplace and everyday life.
    IOM concluded that it has been 62 years since the VA Rating 
Schedule was adequately revised and made a series of recommendations 
for immediately updating the Rating Schedule and requiring that it be 
revised on a systematic and frequent basis. The Commission generally 
agrees with these recommendations; however, the Commission does not 
agree that the revision should begin with those body systems that have 
not been revised for the longest time period. Rather, the Commission 
recommends that first priority be given to revising the mental health 
and neurological body systems to expeditiously address PTSD, other 
mental disorders, and Traumatic Brain Injury. A quick review by VA of 
the Rating Schedule could be completed to determine the sequence in 
which the other body systems should be addressed, and a timeline should 
be developed for completing the revision.
    To emphasize the importance and urgency of revising the Rating 
Schedule, the Commission urges Congress to require that the entire 
schedule be reviewed and updated as needed over the next 5 years. 
Congress should monitor progress carefully. Thereafter, the Rating 
Schedule should be reviewed and updated on a frequent basis.
                       individual unemployability
    The Individual Unemployability (IU) program enables a veteran rated 
60 percent or more but less than 100 percent to receive benefits at the 
100 percent rate if he or she is unable to work because of service-
connected disabilities. IU has received considerable attention recently 
because the number of veterans granted IU increased by 90 percent. The 
Commission found this increase to be explained by the aging of the 
cohort of Vietnam veterans.
    develop ptsd-specific rating criteria and improve ptsd treatment
    Concerning PTSD and other mental disorders, it is very clear that 
having one set of criteria for rating all mental disorders has been 
ineffective. IOM recommended separate criteria for PTSD. Similarly, the 
CNAC survey of VA raters found that raters believe separate criteria 
for PTSD would enable them to rate PTSD claims more effectively. In 
addition, the earnings analysis described above demonstrates that there 
is a disparity in earnings of those with PTSD and other mental 
disorders and that the current scheme for rating all mental disorders 
in five categories of severity--10, 30, 50, 70, and 100 percent--does 
not result in adequate compensation. It is also unclear why 31 percent 
of those with PTSD as their primary diagnosis are granted IU, 
especially since incapacity to work is part of the current criteria for 
granting 100 percent for PTSD and other mental disorders. It would seem 
that many of these veterans should be awarded 100 percent ratings 
without IU. The Commission agrees with the IOM recommendation that new 
Rating Schedule criteria specific to PTSD should be developed and 
implemented based on criteria from the Diagnostic and Statistical 
Manual of Mental Disorders.
    The Commission believes that a new, holistic approach to PTSD 
should be considered. This approach should couple PTSD treatment, 
compensation, and vocational assessment. The Commission believes that 
PTSD is treatable, that it frequently recurs and remits, and that 
veterans with PTSD would be better served by a new approach to their 
care. There is little interaction between the Veterans Health 
Administration, which examines veterans for evaluation of severity of 
symptoms and treats veterans with PTSD, and the Veterans Benefits 
Administration, which assigns disability ratings and may or may not 
require periodic reexamination. It is evident that PTSD reexaminations 
have been scheduled with less frequency in recent years due to the 
backlog of disability claims. It is also evident that case management 
of PTSD patients could be improved through greater interaction between 
the therapy received in Vet Centers and treatment in VA medical 
centers. IOM concluded that the use of standardized testing and the 
frequency of reexaminations should be recommended by clinicians on a 
case-by-case basis, but did not suggest how that would be achieved. The 
Commission suggests that treatment should be required and its 
effectiveness assessed to promote wellness of the veteran. 
Reexaminations should be scheduled and conducted every 2 to 3 years.
    improve performance of vocational rehabilitation and employment
    The Commission believes that the goal of disability benefits, as 
expressed in guiding principle 2, is not being met. In spite of the 
studies done and recommendations made in recent years, the Vocational 
Rehabilitation and Employment (VR&E) program is not accomplishing its 
primary goal. The Commission believes that recent studies have provided 
the necessary analyses and that VA possesses the necessary expertise to 
remedy this failure. Simply put, VA must develop specific plans and 
Congress must provide the resources to quickly elevate the performance 
of VR&E.
                        allow concurrent receipt
    The Commission carefully reviewed whether disabled veterans should 
be permitted to receive both military retirement benefits and VA 
disability compensation. The Commission also reviewed whether the 
survivors of veterans who die either on active duty or as a result of a 
service-connected disability should be allowed to receive both 
Department of Defense (DOD) Survivor Benefit Plan (SBP) and VA 
Dependency and Indemnity Compensation (DIC). Currently, military 
retirees with service-connected disabilities rated 50 percent or higher 
are authorized to receive both benefits, which are being phased in over 
the next few years. Survivors are not authorized to receive both 
benefits. The Commission is persuaded that these programs have unique 
intents and purposes: military retirement benefits and SBP are intended 
to compensate for years of service, while VA disability compensation 
and DIC are intended to compensate for disability or death attributable 
to military service. It should be permissible to receive both sets of 
benefits concurrently.
    In addition, the Commission believes that those separated as 
medically unfit with less than 20 years of service should also be able 
to receive military retirement and VA compensation without offset. 
Currently, those receiving ratings of less than 30 percent from DOD 
receive separation pay, which must be paid back through deductions from 
VA compensation for the unfitting conditions before VA compensation is 
received. Those receiving DOD ratings of 30 percent or higher and a 
continuing disability retirement have their DOD payments offset by any 
VA compensation. Priority among medical discharges should be given to 
those separated or retired with less than 20 years of service and 
disability rating greater than 50 percent or disability as a result of 
combat.
           allow young, severely injured veterans to receive
                  social security disability insurance
    Among the benefits available for disabled veterans, those not able 
to work may be eligible for Social Security Disability Insurance 
(SSDI). To be eligible for SSDI, an individual must have worked a 
minimum number of quarters, be unable to work because of medical 
conditions, not have income above a minimum level, and be less than 65 
years of age. At 65, SSDI converts to normal Social Security at the 
same amount. Some very young servicemembers who are severely injured 
may not have sufficient quarters to qualify for SSDI. The Commission 
recommends eliminating the minimum quarters requirement for the 
severely injured. Only 61 percent of those granted IU by VA and 54 
percent of those rated 100 percent by VA are receiving SSDI. 
Considering the very low earnings by those rated 100 percent and the 
exceptionally low earnings of those granted IU, it is apparent that 
either these veterans do not know to apply for SSDI or are being denied 
the insurance. Increased outreach should be made and better 
coordination between VA and Social Security should result in increased 
mutual acceptance of decisions.
           realign the va-dod process for rating disabilities
    The Commission also assessed the consistency of ratings by DOD and 
VA on individuals found unfit for military service by DOD under 10 
U.S.C. chapter 61. Some 83,000 servicemembers were found unfit between 
2000 and 2006. DOD rated 81 percent of those individuals as less than 
30 percent and discharged them with severance pay, including over 
13,000 who were found unfit by the Army and given zero percent ratings. 
79% of these servicemembers later filed claims with VA and received 
substantially higher ratings. The reasons for the higher ratings are 
that VA rates about three more conditions than DOD, and at the 
individual diagnosis level VA assigns higher ratings than DOD.
    The Commission finds that the policies and procedures used by VA 
and DOD are not consistent and the resulting dual systems are not in 
the best interest of the injured servicemembers nor the Nation. 
Existing practices that allow servicemembers to be found unfit for pre-
existing conditions after up to 8 years of active duty and that allow 
DOD to rate only the conditions that DOD finds unfitting should be 
reexamined. Servicemembers being considered unfit should be given a 
single, comprehensive examination and all identified conditions should 
be rated and compensated.
    The Commission agrees with the President's Commission on the Care 
of Returning Wounded Warriors that the DOD and VA disability evaluation 
process should be realigned so that the military determines if the 
servicemember is unfit for service and awards continuing payment for 
years of service and health care coverage for the family while VA pays 
disability compensation. However, in accordance with one of our key 
guiding principles, the Commission believes that benefits should not be 
limited to combat and combat-related injuries. Nor does the Commission 
believe that VA disability compensation should end and be replaced with 
Social Security at retirement age.
               link benefits to cost-of-living increases
    In its review, the Commission found that the ancillary and special-
purpose benefits payments and award limits are not automatically 
indexed to cost of living. A few of these benefits have not been 
increased in many years, and as a result, some no longer meet the 
original intent of Congress. The Commission recommends that Congress 
raise ancillary and special-purpose benefits to the levels originally 
intended and provide for automatic annual adjustments to keep pace with 
the cost of living.
 simplify and expedite the processing of disability claims and appeals
    VA disability benefits and services are not currently provided in a 
timely manner. Court decisions, statutory changes, and resource 
limitations have all contributed to this unacceptable situation. 
Numerous studies over the years have assessed the processing of both 
claims and appeals and have made numerous recommendations for change. 
Still, veterans seeking disability compensation face a complex process. 
The population of veterans is steadily decreasing with the passing of 
veterans of World War II and the Korean War. Yet, the aging of the 
Vietnam Era veterans means that they are filing original and reopened 
claims in large numbers. Technology offers opportunities for 
improvement, but it is unlikely to solve all problems. The Commission 
believes that increased reliance on best business practices and maximum 
use of information technology should be coupled with a simplified and 
expedited process for well-documented claims to improve timeliness and 
reduce the backlog. The Commission is aware that a significant increase 
in claims processing staff has been recently approved but is also aware 
that the time required for training and the slow development of job 
experience will limit the speed with which results can realistically 
occur.
    The Commission believes that claimants should be allowed to state 
that claim information submitted is complete and waive the normal 60-
day timeframe permitted for further development.
                     improve transition assistance
    A smooth transition from military to civilian status is crucial for 
veterans and their families to quickly adjust to civilian life. This 
goal, often expressed as ``seamless transition,'' has yet to be fully 
realized, although VA and DOD have made significant improvements during 
the past few years. The two departments' medical and other systems are 
not truly compatible, and both departments will have to rely on paper 
records for many years. Perhaps the single most important step that can 
be taken to assist veterans, particularly those who are disabled and 
their families, and to reduce the lengthy delays plaguing claims 
processing would be to achieve electronic compatibility. In addition, 
the Commission believes that making VA benefit payments effective the 
day after discharge will help ease the financial aspect of transition.
  improve support for severely disabled veterans and their caregivers
    Severely disabled servicemembers who are about to transition into 
civilian life need far more support and assistance than is currently 
provided. An effective case management program should be established 
with a clearly identified lead agent who has authority and 
responsibility to intercede on behalf of disabled individuals. The lead 
agent should be an advocate for servicemembers and their families. In 
addition, VA should be authorized to provide family assistance similar 
to that provided by DOD up until discharge. TRICARE deductibles and 
copays are costs incurred by the severely disabled; the Commission 
believes that these costs should be waived. In addition, consideration 
should be given to expanding health care and providing an allowance for 
caregivers of the severely disabled. Currently, health care is only 
provided for the dependents of severely disabled veterans but not for 
parents and other family members who are caregivers.
          implement a new process for determining presumption
    Various processes have been used to create presumptions when there 
are uncertainties as to whether a disabling condition is caused by 
military service. Presumptions are established when there is evidence 
that a condition is experienced by a sufficient cohort of veterans and 
it is reasonable to presume that all veterans in that cohort who 
experience the condition acquired the condition due to military 
service. The Commission asked IOM to review the processes used in the 
past to establish presumptions and to recommend a framework that would 
rely on more scientific principles. IOM conducted an extensive analysis 
and recommended a detailed and comprehensive approach that includes the 
creation of an advisory committee and a scientific review board, 
formalizing the process and making it transparent, improving research, 
and tracking military troop locations and environmental exposures. 
Perhaps most importantly, the approach includes using a causal effect 
standard for decisionmaking rather than a less-precise statistical 
association. The Commission endorses the recommendations of the IOM but 
expresses concern about the causal effect standard. Consideration 
should also be given to combining the advisory committee on 
presumptions with the recommended advisory committee on the Rating 
Schedule.
                               conclusion
    The Commission made 113 recommendations. All are important and 
should receive attention from Congress, DOD, and VA. The Commission 
suggests that the following recommendations receive immediate 
consideration. Congress should establish an executive oversight group 
to ensure timely and effective implementation of the Commission 
recommendations.
                        priority recommendations
Recommendation 4.23--Chapter 4, Section I.5
    VA should immediately begin to update the current Rating Schedule, 
beginning with those body systems addressing the evaluation and rating 
of Post Traumatic Stress Disorder and other mental disorders and of 
Traumatic Brain Injury. Then proceed through the other body systems 
until the Rating Schedule has been comprehensively revised. The 
revision process should be completed within 5 years. VA should create a 
system for keeping the Rating Schedule up to date, including a 
published schedule for revising each body system.
Recommendation 5.28--Chapter 5, Section III.3
    VA should develop and implement new criteria specific to Post 
Traumatic Stress Disorder in the VA Schedule for Rating Disabilities. 
VA should base those criteria on the Diagnostic and Statistical Manual 
of Mental Disorders and should consider a multidimensional framework 
for characterizing disability due to Post Traumatic Stress Disorder.
Recommendation 5.30--Chapter 5, Section III.3
    VA should establish a holistic approach that couples Post Traumatic 
Stress Disorder treatment, compensation, and vocational assessment. 
Reevaluation should occur every 2-3 years to gauge treatment 
effectiveness and encourage wellness.
Recommendation 6.14--Chapter 6, Section IV.2
    Congress should eliminate the ban on concurrent receipt for all 
military retirees and for all servicemembers who separated from the 
military due to service-connected disabilities. In the future, priority 
should be given to veterans who separated or retired from the military 
under chapter 61 with

     fewer than 20 years service and a service-connected 
disability rating greater than 50 percent, or
     disability as a result of combat.
Recommendation 7.4--Chapter 7, Section II.3
    Eligibility for Individual Unemployability (IU) should be 
consistently based on the impact of an individual's service-connected 
disabilities, in combination with education, employment history, and 
medical effects of an individual's age or potential employability. VA 
should implement a periodic and comprehensive evaluation of veterans 
eligible for IU. Authorize a gradual reduction in compensation for IU 
recipients who are able to return to substantially gainful employment 
rather than abruptly terminating disability payments at an arbitrary 
level of earning.
Recommendation 7.5--Chapter 7, Section II.3
    Recognizing that Individual Unemployability (IU) is an attempt to 
accommodate individuals with multiple lesser ratings but who remain 
unable to work, the Commission recommends that as the VA Schedule for 
Rating Disabilities is revised, every effort should be made to 
accommodate such individuals fairly within the basic rating system 
without the need for an IU rating.
Recommendation 7.6--Chapter 7, Section III.2
    Congress should increase the compensation rates up to 25 percent as 
an interim and baseline future benefit for loss of quality of life, 
pending development and implementation of a quality-of-life measure in 
the Rating Schedule. In particular, the measure should take into 
account the quality of life and other non-work-related effects of 
severe disabilities on veterans and family members.
Recommendation 7.8--Chapter 7, Section III.2
    Congress should consider increasing special monthly compensation, 
where appropriate, to address the more profound impact on quality of 
life of the disabilities subject to special monthly compensation. 
Congress should also review ancillary benefits to determine where 
additional benefits could improve disabled veterans' quality of life.
Recommendation 7.12--Chapter 7, Section VI
    VA and DOD should realign the disability evaluation process so that 
the services determine fitness for duty, and servicemembers who are 
found unfit are referred to VA for disability rating. All conditions 
that are identified as part of a single, comprehensive medical 
examination should be rated and compensated.
Recommendation 7.13--Chapter 7, Section V.3
    Congress should enact legislation that brings ancillary and 
special-purpose benefits to the levels originally intended, considering 
the cost of living, and provides for automatic annual adjustments to 
keep pace with the cost of living.
Recommendation 8.2--Chapter 8, Section III.1.B
    Congress should eliminate the Survivor Benefit Plan/Dependency and 
Indemnity Compensation offset for survivors of retirees and in-service 
deaths.
Recommendation 9.1--Chapter 9, Section II.5.A.b
    Improve claims cycle time by
     establishing a simplified and expedited process for well-
documented claims, using best business practices and maximum feasible 
use of information technology; and
     implementing an expedited process by which the claimant 
can state the claim information is complete and waive the time period 
(60 days) allowed for further development.
    Congress should mandate and provide appropriate resources to reduce 
the VA claims backlog by 50 percent within 2 years.
Recommendation 10.11--Chapter 10, Section VII
    VA and DOD should expedite development and implementation of 
compatible information systems including a detailed project management 
plan that includes specific milestones and lead agency assignment.
Recommendation 11.1--Chapter 11
    Congress should establish an executive oversight group to ensure 
timely and effective implementation of the Commission's 
recommendations. This group should be co-chaired by VA and DOD and 
consist of senior representatives from appropriate departments and 
agencies. It is further recommended that the Veterans' Affairs 
Committees hold hearings and require annual reports to measure and 
assess progress.
    One commissioner submitted a statement of separate views regarding 
four aspects of the report. His statement is in Appendix L.
                         additional resources:
    Electronic access to the complete report of the Veterans' 
Disability Benefits Commission is available at: http://
www.vetscommission.org
    Also available on the Commission's Web site are:

     Bios of the Commissioners
     Commission Charter
     Commission Charter (renewed, 2-21-2007)
     Public Law 108-136 establishing the Commission
     Extension of the Commission's Charter in Public Law 109-
163
     Legislative History of VA Disability Compensation Program, 
Economic Systems Inc., Dec 2004
     Appendices to the Legislative History (Dec 2004)
     Literature Review of VA Disability Compensation Program, 
Economic Systems Inc., Dec 2004
     Appendices to the Literature Review (Dec 2004)
     Commission's Approved Research Questions, October 14, 2005
     Institute of Medicine (IOM) Summary of the PTSD Review 
contracted by the Veterans Health Administration, Mar 2006
     A History and Analysis of Presumptions of Service 
Connection (1921-1993)
     An Updated Legal Analysis of Presumptions of Service 
Connection (1993-2006)
     Center for Naval Analyses (CNA) Literature Review (Final), 
May 2006
     Appendix to the CNA Literature Review (Final), May 2006
     Veterans' Claims Adjudication Commission (VCAC), also 
known as the Melidosian Commission Report (1996)
     Blue Ribbon Panel on Claims Processing: Proposals to 
Improve Disability Claims Processing in the Veterans Benefits 
Administration, November 1993
     Bradley Commission Report 1956
     IOM Report to VA on Post Traumatic Stress Disorder: 
Diagnosis and Assessment, 2006
     Testimony of Chairman Scott at a Joint Hearing of the 
Senate Armed Services & Veterans' Affairs Committees, April 12, 2007
     CNA Report: Findings from Raters and VSOs Surveys, May 
2007
     IOM Report to VA on PTSD Compensation and Military 
Service, 2007
     A 21st Century System for Evaluating Veterans for 
Disability Benefits, IOM Final Report, June 2007
     Improving the Presumptive Disability Decision-Making 
Process for Veterans, IOM Final Report, and Executive Summary August 
2007
     CNA Final Report: Final Report for the Veterans' 
Disability Benefits Commission: Compensation, Survey Results and 
Selected Topics, August 2007
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
  James Terry Scott, LTG, USA (Ret.), Chairman, Veterans' Disability 
                          Benefits Commission
    Before addressing the specific questions asked, I would like to 
make it clear that my comments are my own and do not represent the 
views of the other members of the Commission. The Commission completed 
its work and submitted its report on October 3, 2007.
                     differences in recommendations
    Question. Please compare your Commisson's recommendation to provide 
a quality of life payment as part of disability compensation with the 
Dole-Shalala commission's recommendation to revamp the entire 
disability system?
    Response. First, it is important to emphasize the results of the 
overall analysis that the Veterans' Disability Benefits Commission 
conducted of the entire VA and DOD system for determining compensation 
for injuries, diseases, and deaths attributable to military service. 
Our Commission addressed the entire system, not just how the system 
addresses those found unfit for military duty As a result of our 
comprehensive analysis, we made a series of broad recommendations 
intended to significantly improve the existing system, including a 
realignment of the processes used by DOD and VA when a servicemember is 
found by DOD to be unfit for military duty. If implemented, our 
recommendations would result in important and major changes.
    Our Commission's efforts relied extensively on analysis conducted 
for our Commission by the Institute of Medicine (IOM) of the National 
Academies and by the CNA Corporation (CNAC). Taken together, their work 
provides a picture of a disability system that needs considerable 
improvement but one that is generally sound. For example, IOM concluded 
that an effective system should ensure vertical and horizontal equity 
to compensate disabled veterans for average loss of earnings capacity. 
Horizontal equity would ensure that veterans with different types of 
disabilities but with similar severity of disabilities would have 
similar loss of earnings. Vertical equity would ensure that as rating 
severity increases, earnings loss would also increase. CNAC's analysis 
concluded that general loss would also increase. CNAC's analysis 
concluded that there is general parity overall with average VA 
compensation for all made service-disabled veterans about at parity 
with earnings loss and that there is not much difference among physical 
disorders. They did find significant exceptions with PTSD and other 
mental disorders and those who experience severe disabilities at a 
young age; these groups receive compensation that does not achieve 
parity with earnings loss.
    IOM concluded that compensation should be provided for more than 
work disability or earnings loss; it would also compensate for loss of 
ability to engage in usual life activities and loss of quality of life. 
The CNAC analysis provided that current compensation payments generally 
provide parity with respect to earnings loss but that there is not 
compensation for quality of life. In addition, the CNAC analysis 
provided an accurate assessment of the extent to which disability 
impacts on quality of life and demonstrated that health declined as 
degree of disability increased. CNAC also found that mental disorders 
impacted on physical health to an extent unanticipated. Thus, the CNAC 
analysis supported the independent conclusions of the IOM concerning 
compensation for impact of disability on quality of life. The Dole-
Shalala Commission also recommended that compensation should recognized 
effects on quality of life.
    Our Commission asked the IOM to address whether some other system 
of evaluating disability would be preferable to the use of the VA 
Rating Schedule. Specifically, IOM was asked to compare and contrast 
the Rating Schedule to the American Medical Association Guides to the 
Evaluation of Permanent Impairment. IOM found that the Guides are 
designed for use by physicians, measures and rates impairment and, to 
some extent, daily functioning, but not disability or quality of life, 
and does not provide mental ratings. IOM recommended updating and 
improving the Rating Schedule rather than adopting an impairment 
schedule developed for other purposes.
    Concerning the recommendation by the Dole-Shalala Commission to 
``completely restructure'' the disability and compensation system, my 
interpretation is that the overall focus of their report is on the 
processes currently used to determine whether a servicemember is fit or 
unfit for duty and to provide benefits and compensation for those found 
unfit. They recommended that the existing processes be restructured so 
that DOD determines fitness for duty and, for those unfit, DOD provides 
payment for time of service; VA rates the disability and compensates 
for disability. Our Commission essentially recommended the same 
realignment. The Dole-Shalala Commission recommended specifically that 
DO administer a single, comprehensive examination that could be used by 
both DOD and VA. Our Commission agreed that a single, comprehensive 
examinations be conducted but felt that either DOD or VA could 
administer the examination, depending on local capability of the 
clinical staffs. However, we extensively reviewed the examination 
process with the advice of the Institute of Medicine and made several 
recommendations to improve the examinations and ensure consistency and 
reliability. These recommendations include greater use of templates, 
improved training and certification of examiners, and enhanced quality 
control. These recommendations should be implemented no matter which 
department conducts the examinations.
                          dual rating schedule
    Question. Based on the Commission's work, do you believe that it is 
either necessary or appropriate to have two different disability 
ratings schedules, one for veterans of the current conflicts and one 
for veterans of earlier eras?
    Response. Our Commission believes that there should be a single 
process used and the benefits available should be appropriate for all 
veterans. The processing steps may vary somewhat in the case of 
servicemembers found unfit for duty, but in general, all veterans' 
claims should be processed similarly and in a timely manner. Our 
Commission also believes that the payment rate of disability 
compensation should be based on severity of disability without regard 
to the circumstances of the disability. This is Principle 3 of our 
Commission's 8 principles. We do not believe that veterans' 
compensation should be different if the injury occurs during wartime or 
peacetime, during combat or combat-related duties, in the United States 
or abroad, or other distinctions. We believe that military service is a 
24-hour a day responsibility as demonstrated by the fact that 
servicemembers are subject to the Uniformed Code of Military Justice 
continuously during active duty. In addition to issues of equity, such 
distinctions among circumstances would require subjective judgment on 
the part of rating officials and would serve to add further complexity 
into an already complex process.
    All veterans should be evaluated using the same criteria, namely 
the VA Rating Schedule and that no attempt should be made to develop 
and apply different criteria or a different Rating Schedule to veterans 
who served during different periods of time. It is clear that VA has 
not been successful in keeping one rating schedule up to date. Our 
Commission recognized that VA had undertaken a project to revise the 
rating schedule as a result of a critical 1989 GAS report and had 
published a notice of its intent to update the entire schedule in 
August 1989. IOM carefully reviewed the revisions to the rating 
schedule and found that only 373 of 798 diagnostic codes (47 percent) 
had been revised since 1990. A substantial proportion (281, or 35 
percent) of the schedule's diagnostic codes had not been revised at all 
since 1945 and 18 percent (144 codes) were revised between 1945 and 
1989. Our recommendation 4.23 concerning updating the VA rating 
schedule said that the revision of the rating schedule should be 
completed within 5 years and our report (Prepublication page 80) 
indicated that five years is a realistic timetable. Our Commission felt 
that it would be important to establish a deadline that cold reasonably 
be met, considering VA's lack of progress in the past. We meant that 
deadline to be a maximum, not an estimate for how long the revision 
should take. In retrospect, we should have expressed this more 
carefully as an outside limit. We did not estimate how long a complete 
revision should take.
    I believe that practical consideration also argue against 
attempting to create and maintain two separate processes and benefits. 
It is well known and accepted that VA has had an ongoing problem with 
timeliness of claims processing and with a continuing and growing 
backlog of claims well beyond the volume of pending claims needed to 
sustain efficient operations. During the period 2000-2006, VA received 
some 1.2 million original claims while DOD separated or retired some 
83,000 servicemembers as unfit for military duty. Thus, the number of 
unfit separations and retirements were only 6.9 percent of all original 
claims.
    I am also aware of proposals that would restrict benefits, 
particularly TRICARE family health care, to those with very strictly 
defined serious disabilities who are separated or retired as unfit. 
During the period of 2000 to 2006 reviewed by our Commission, less than 
two percent (1,478 of 83,008) of those separated or discharged as unfit 
were rated by DOD as 100 percent disabled and only six percent (5,060 
of 83,008) were rated 50 percent or higher. Currently, servicemembers 
found unfit and rated 30 percent disabled or higher are eligible for 
TRICARE. The Dole-Shalala Commission recommended that all those fond 
unfit because of combat-related injuries should receive comprehensive 
health care for themselves and their families. As discussed previously, 
I do not believe a distinction should be made regarding combat-related 
injuries, but I agree with providing TRICARE to everyone found unfit.

    Chairman Akaka. Thank you very much, General.
    Admiral Dunne?

 STATEMENT OF REAR ADMIRAL PATRICK W. DUNNE, U.S. NAVY (RET.), 
ASSISTANT SECRETARY FOR POLICY AND PLANNING, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Admiral Dunne. Good morning, Mr. Chairman and distinguished 
Members of the Committee. Thank you for the opportunity to 
discuss the recent activities to serve our Nation's veterans 
through improved processes and greater collaboration with DOD.
    On April 19, the President's Task Force on Returning Global 
War on Terror Heroes issued its 25 recommendations to improve 
health care, benefits, employment, education, housing, and 
outreach using existing authority and resource levels. This 
report was unique in that it also included an ambitious 
schedule of action and target dates. Thanks to outstanding 
interagency cooperation, 56 of 58 action items have been 
completed or initiated.
    The results of these initiatives support seamless and world 
class health delivery. VA and DOD drafted a joint policy 
document on co-management and case management of severely 
injured servicemembers. This will enhance individualized 
support for the wounded, severely injured, or ill servicemember 
and his or her family throughout the recovery process.
    To assist OEF/OIF wounded servicemembers and their families 
in navigating through the transition process, VA hired 106 new 
Transition Patient Advocates. These men and women, often 
veterans themselves, work with case managers and clinicians to 
ensure that patients and families can focus on recovery.
    VA also revised its electronic health care enrollment form 
to include a selection option for OEF/OIF to ensure proper 
priority of care.
    DOD and VA work collaboratively to expand access to 
servicemembers' electronic health records by jointly developing 
the electronic capability to transfer digital radiographs from 
Walter Reed, Bethesda, and Brooke to VA's polytrauma centers. 
The capability for electronic transmission of historic health 
care data from DOD MTFs to VA medical centers is complete in 
the domains of allergies, outpatient medications, laboratory 
results, and radiology. Additionally, a contract was recently 
awarded for an independent assessment of Inpatient Electronic 
Health Records in VA and DOD.
    In response to the report on the President's Commission on 
Care for America's Returning Wounded Warriors, we are preparing 
a statement of objectives to contract for studies of quality of 
life and long-term transition benefits.
    An MOU was signed by DOD, HHS, and VA to define the role of 
the Public Health Service in the Recovery Coordinator Program. 
Two members of the Public Health Service Commission Corps are 
detailed from HHS to VA and are working with us to establish 
the Recovery Coordinator Program.
    Rulemaking is underway to revise the ratings schedule 
provisions for evaluating disability due to Traumatic Brain 
Injury and burns.
    Two weeks ago, the Veterans Disability Benefits Commission 
issued its report and recommendations. While some of the 
recommendations are similar to existing ones, others are new 
and we are carefully studying them.
    To oversee the implementation of these recommendations, VA 
and DOD established the Wounded, Ill, and Injured Senior 
Oversight Committee on May 3. This Committee is co-chaired by 
the Deputy Secretary of Veterans Affairs and Deputy Secretary 
of Defense and meets weekly.
    In a collaborative effort with DOD, VA made great strides 
in addressing issues surrounding PTSD and TBI across the full 
continuum of care. The focus has been to create a 
comprehensive, effective, and individual program dedicated to 
all aspects of care for our patients and their families. VA and 
DOD have partnered to develop clinical practice guidelines for 
PTSD, major depressive disorder, acute psychosis, and substance 
abuse disorders. Our Senior Oversight Committee also approved a 
National Center of Excellence for PTSD and TBI.
    VA and DOD are also working closely to redesign and 
establish one Disability Evaluation System. A pilot program is 
being finalized to ensure no servicemember is disadvantaged by 
this new system and that the servicemember receives high-
quality medical care and appropriate compensation and benefits. 
The proposed new system will be much more efficient, and I have 
provided additional details in my written testimony.
    VA now has 153 Benefits Delivery at Discharge sites to 
speed up processing of applications for compensation. VA also 
processes the claims of OEF/OIF veterans on an expedited basis.
    Collaborating with DOD, we have accomplished a great deal, 
but there is still much more to do. We at VA are committed to 
strengthening our partnership with DOD to ensure our 
servicemembers and veterans receive the care and benefits they 
have earned.
    I will be happy to answer your questions.
    [The prepared statement of Admiral Dunne follows:]
 Prepared Statement of Hon. Patrick W. Dunne, Rear Admiral, U.S. Navy 
           (ret) Assistant Secretary for Policy and Planning
    Good morning, Mr. Chairman and distinguished Members of the 
Committee. Thank you for holding this hearing and providing the 
opportunity to discuss the recent activities of the Department of 
Veterans Affairs (VA) to improve benefits and services to our Nation's 
veterans through improved processes and greater collaboration with the 
Department of Defense (DOD).
    The level of attention currently focused on our wounded 
servicemembers and their families is unprecedented--and rightly so. 
Over the past 7 months, I have had the privilege of being engaged in 
many activities dedicated to ensuring our returning heroes from 
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
receive the best available care and services. I join my colleagues from 
VA in striving to provide a lifetime of world-class care and support 
for all our veterans and their families.
    On March 6, 2007, by Executive Order, the President established the 
interagency Task Force on Returning Global War on Terror Heroes. VA 
Secretary Nicholson was appointed to Chair the Task Force and I was 
proud to support him as the Executive Secretary. On April 19, 2007, the 
Task Force issued its report to the President. The Task Force made 25 
recommendations to improve the delivery of Federal services and 
benefits to returning servicemembers. The Report contained 
recommendations in the areas of health care, benefits, employment, 
education, housing and outreach that could be achieved with existing 
authority and resource levels. The report was unique in that it also 
included an ambitious schedule of milestones and actions necessary to 
implement its recommendations. We continue to monitor implementation 
and I am pleased to inform you that, thanks to outstanding interagency 
cooperation, as of August 28, 56 of 58 action items have been completed 
or initiated.
    The results of actions taken in response to recommendations in the 
Task Force Report are having a positive impact on the lives of 
servicemembers, veterans, and their families. I would like to highlight 
some of the progress achieved.
    In response to a Task Force recommendation, the Small Business 
Administration launched the Patriot Express Loan Initiative. This 
program provides a full range of lending, business counseling, and 
procurement programs to separating servicemembers, veterans, spouses, 
survivors, and eligible dependents. This program has already approved 
more than $23 million in loans since it began in mid-June.
    Several initiatives have and will continue to support seamless and 
world-class health care delivery. VA and DOD have drafted a joint 
policy document on co-management and case management of severely 
injured servicemembers. The goal is to provide individualized, 
integrated, interagency and intergovernmental support for the wounded, 
severely injured or ill servicemember and his/her family throughout the 
process of treatment, rehabilitation, and renewal. VA and DOD will work 
together to minimize fragmentation of Federal clinical and non-clinical 
services, improve the coordination of medical and rehabilitative care, 
and ensure access to all needed resources.
    To assist OEF/OIF wounded servicemembers and their families in 
navigating through the transition process, VA hired 100 new Transition 
Patient Advocates (TPA). These men and women, often veterans 
themselves, recognize the difficulty in understanding the many 
different programs and processes which come into play. VA TPAs work 
with case managers and clinicians to ensure that patients and families 
can focus on recovery.
    VA also revised its electronic health care enrollment form to 
include a selection option for OEF/OIF to ensure proper priority of 
care.
    Many advances are the result of improved records management and 
greater sharing and Information Technology (IT) interoperability with 
DOD. In response to Task Force recommendations, DOD and VA worked 
collaboratively to expand access to servicemembers' electronic health 
records by jointly developing the electronic capability to transfer 
digital radiographs from Military Treatment Facilities (MTFs) at Walter 
Reed, Bethesda, and Brooke to VA Polytrauma Rehabilitation Centers. The 
capability for electronic transmission of historical health care data 
from DOD MTFs to VA Medical Centers is complete in the domains of 
allergies, outpatient medications, laboratory results, and radiology. 
Additionally, a contract was recently awarded for an independent 
assessment of inpatient electronic health records in the Departments of 
Veterans Affairs and Defense. The contract will provide recommendations 
for the scope and elements of a joint electronic inpatient medical 
record.
    In July of this year, the Report of the President's Commission on 
Care for America's Returning Wounded Warriors was issued. This 
Commission had a greater scope than the Task Force and was not 
constrained by existing authority and resources. We are preparing the 
statement of objectives to contract for studies of Quality of Life and 
long-term transition benefits. An MOU was signed by DOD, HHS and VA to 
define the role of the Public Health Service in the Recovery 
Coordinator program. Two members of the Public Health Service 
commissioned corps are detailed from HHS to VA and are working with VA 
and DOD to establish the Recovery Coordinator program. Rulemaking is 
underway to revise the Rating Schedule provisions for evaluating 
disability due to Traumatic Brain Injury and scars.
    Two weeks ago, the Veterans Disability Benefits Commission issued 
its report and recommendations. While some of the recommendations are 
similar to existing ones, others are new, and we are reviewing them 
carefully.
    To ensure a seamless continuum of benefits and health care services 
to wounded, ill, and injured servicemembers, the Departments of 
Veterans Affairs and Defense began an integrative effort, and 
established the Wounded, Ill, and Injured Senior Oversight Committee 
(SOC) on May 3, 2007. The SOC, composed of senior military and civilian 
officials from both Departments, was established for a 12-month time 
period, and was tasked to ensure the recommendations of the task forces 
and committees were properly reviewed, coordinated, implemented, and 
resourced. The Committee is co-chaired by the Deputy Secretary of 
Veterans Affairs and Deputy Secretary of Defense, and meets weekly to 
streamline processes, mitigate potential conflicts, and expedite the 
two Departments' efforts to improve support of injured servicemembers' 
recovery, rehabilitation, and reintegration.
    Senior Veterans Affairs and Defense officials serve on the SOC. 
This includes the Service Secretaries, the Chairman of the Joint Chiefs 
of Staff, the Service Chiefs, and VA's Under Secretary for Health, 
Under Secretary for Benefits, Assistant Secretary for Policy and 
Planning, and Deputy Assistant Secretary for Information and 
Technology. The driving principle guiding the SOC's efforts is the 
establishment of a seamless continuum that is efficient and effective 
in meeting the needs of our wounded, ill, and injured servicemembers/
veterans and their families.
    Supporting the SOC decisionmaking process is an Overarching 
Integrated Product Team (OIPT), composed of the Under Secretary of 
Benefits, Assistant Secretary of Policy and Planning, and other senior 
officials from VA and DOD. The OIPT reports to the SOC and coordinates, 
integrates, and synchronizes the work of eight Lines of Action and 
recommends sourcing solutions for resource needs.
    The diagram below depicts the structure supporting the SOC. The 
Lines of Action, which have Senior Executive Service Co-Leads from both 
Departments, establish plans, set and track milestones, and identify 
and enact early, short-term solutions.


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    The Lines of Action (LOA) and their goals are:
     LoA #1: Redesign the Disability Evaluation System
    Goal: To develop a single, supportive, and transparent disability 
evaluation system.
     LoA #2: Address Traumatic Brain Injury/Psychological 
Health
    Goal: To provide servicemembers with lifelong standardized and 
comprehensive screening, diagnosis, and care for all levels of 
Traumatic Brain Injury and Post Traumatic Stress Disorder, in 
conjunction with education for patients and family members.
     LoA #3: Fix Case Management
    Goal: To coordinate health care, rehabilitation, and benefits, 
delivery of services and support that will effectively guide and 
facilitate servicemembers and their families through necessary 
processes.
     LoA #4: Expedite Data Sharing
    Goal: To ensure appropriate beneficiary and medical information is 
visible, accessible, and understandable through secure and 
interoperable information management systems.
     LoA #5: Facilities
    Goal: To provide servicemembers and families with the best possible 
facilities for care and recovery.
     LoA #6: ``Clean Sheet'' End-to-End Review
    Goal: To honor our servicemembers by providing wounded, ill, and 
injured personnel and their families the best quality care and a 
compassionate, fair, timely, and non-adversarial disability 
adjudication process--enabling servicemembers to return to the fullest, 
most productive and complete quality of life possible.
     LoA #7: Comprehensive Legislation and Public Affairs
    Goal: To coordinate the development of comprehensive legislation 
that will provide the best possible care and treatment for injured 
servicemembers and families. Additionally, to keep the public informed 
of significant accomplishments and events.
     LoA #8: Personnel, Pay, and Financial Benefits
    Goal: To provide compassionate, timely, accurate and standardized 
personnel, pay, and financial support practices for Wounded, Injured 
and Ill to ensure appropriate data sharing, quality control, and 
support benefits.

    In a collaborative effort with DOD, VA has made great strides in 
addressing issues surrounding Post Traumatic Stress Disorder (PTSD) and 
Traumatic Brain Injury (TBI) across the full continuum of care. The 
focus of these efforts has been to create and ensure a comprehensive, 
effective, and individually focused program dedicated to prevention, 
protection, identification, diagnosis, treatment, recovery, and 
rehabilitation for our military members, veterans, and families who 
deal with these important health conditions.
    Since June 2007, a collaborative team of VA and DOD experts known 
as the ``Red Cell'' has worked to: (1) create an integrated, 
comprehensive Department of Veterans Affairs/Defense program to 
identify, treat, document, and follow-up those who experience TBI or 
PTSD conditions while either deployed or in garrison; and (2) determine 
how to build resilience, both in people and in organizations, to 
prevent issues from developing and to reduce their impact if they do 
occur.
    VA and DOD have partnered to develop clinical practice guidelines 
(CPG) for PTSD, Major Depressive Disorder, Acute Psychosis, and 
Substance Use Disorders. These guidelines help practitioners determine 
the best available and most appropriate care.
    Our Senior Oversight Committee also has approved a National Center 
of Excellence for PTSD and TBI. It will include liaisons from both VA 
and DHHS, as well as an external advisory panel organized under the 
Defense Health Board to provide the best advisors across the country to 
the military health system. This center will facilitate coordination 
and collaboration between VA and the Military Services, promoting and 
informing best practice development, research, education and training.
    As of the first half of fiscal year 2007, approximately 263,900 
returning veterans have sought care from VA medical centers and 
clinics. Of these, about 38 percent have received at least a 
preliminary diagnosis of a mental health condition, and 18 percent have 
received a preliminary diagnosis of PTSD, making it the most common, 
but by no means the only mental health condition related to the stress 
of deployment. Professionals with special expertise in PTSD are 
available in all medical centers to serve veterans with PTSD. Most are 
best served in outpatient programs, but for those with more severe 
symptoms, VA has inpatient and residential rehabilitation options 
across the country.
    VA has taken several actions at multiple levels to promote the 
recruitment and retention of mental health professionals in the 
Veterans Health Administration (VHA). In February 2007, both an 
Education Debt Reduction Program and an Employee Incentive Referral 
Initiative began. The new mental health Education Debt Reduction 
Program currently provides up to $38,000 of education loan repayment 
for qualified student debt. The Employee Incentive Referral program 
provides a bonus to VA employees who refer mental health providers who 
are hired into VA positions. These initiatives have already generated 
significant interest.
    At the local level, opportunities have been developed for VA 
facilities to engage in local advertising and recruitment activities 
and to cover interview-related costs, relocation expenses, and provide 
limited hiring bonuses for exceptional applicants. VA has also 
established opportunities for supporting individual training and 
education activities for mental health employees, demonstrating an 
investment in staff can also have a positive impact on retention.
    Rates of hiring have increased significantly in recent months, 
suggesting that the enhanced recruitment efforts are having a positive 
impact. Since fiscal year 2005, VA has authorized 4,367 new Mental 
Health Enhancement positions. As of August 31, 2007, 81 percent of 
these positions have been filled.
    In terms of treating TBI, VA offers comprehensive primary and 
specialty health care to our veterans, and is an acknowledged national 
leader in providing specialty care in the treatment and rehabilitation 
of TBI and polytrauma. Since 1992, VA has maintained four specialized 
TBI Centers. In 2005, VA established the Polytrauma System of Care, 
leveraging and enhancing the existing Brain Injury Polytrauma expertise 
existing at these TBI centers to meet the needs of seriously injured 
veterans and active duty servicemembers from operations in Iraq, 
Afghanistan, and elsewhere. The Secretary of Veterans Affairs recently 
announced the decision to locate a fifth Polytrauma Center in San 
Antonio TX.
    The Departments of Veterans Affairs and Defense are also working 
closely to redesign and establish one Disability Evaluation System 
(DES) for use by servicemembers. A pilot program is being explored via 
tabletop exercise to ensure that no servicemember is disadvantaged by 
this new system, and that the servicemember receives the high quality 
medical care and appropriate compensation and benefits for the 
residuals of his or her disabilities incurred or aggravated by military 
service. An operational pilot program should be completed in the second 
quarter of 2008. If it is as successful as we plan, this pilot program 
will be expanded beyond the Washington Capital Region to become the DES 
system, worldwide.
    The proposed new system will be much more efficient. It will 
produce more consistent outcomes and, with VA and DOD working together 
as a team, the new system will be a seamless, single process for users. 
We envision it cutting in half the time it takes for a servicemember to 
go through the DES, from the time the member is referred to a Medical 
Evaluation Board (MEB) to the time the member is discharged from active 
military service and receives his or her first payment from VA.
    An important improvement in this proposed system is that the 
servicemember will only be required to have one medical examination or 
series of medical examinations, depending on the severity of the 
potentially disqualifying conditions to meet the requirements of both 
DOD and VA. Currently, a service-specific medical examination is 
required for the purpose of determining a servicemember's ability to 
continue on active military service based on the residual unfitting 
disability and the servicemember's, rank, rating, or military 
occupational skills, and a VA medical examination is also required for 
the purpose of evaluating the residual of the disability under VA's 
Schedule for Rating Disability and assigning a percentage evaluation to 
the disability. Under the current system, if servicemembers are found 
unfit and are separated or retired, they must complete the second VA 
exam to determine whether the claimed medical conditions are service-
connected and represent impediments to full employment capability.
    Under the proposed new DES system, the one-medical-examination 
process collects information required by both Departments. Under this 
system, when the servicemember transitions to civilian life, VA will 
already have the information needed to immediately start paying the 
veteran the appropriate amount of compensation for the residuals of his 
or her disability incurred or aggravated by military service.
    Over the last 5 years, the Veterans Benefits Administration (VBA) 
service coordinators conducted more than 38,000 briefings attended by 
more than 1.5 million active duty and reserve personnel and their 
family members. Additionally, through the Benefits Delivery at 
Discharge program, servicemembers at 153 military bases in the United 
States, Germany, and Korea are assisted in filing for disability 
benefits prior to separation. This fosters continuity of care between 
the military and VA systems and speeds up VA's processing of their 
application for compensation. Claims decisions can be completed prior 
to separation, and veterans can begin receiving VA compensation 
payments, without delay, upon separation from the military. VBA also 
processes the claims of OEF/OIF veterans who apply for VA disability 
compensation or pension on an expedited basis.
    Thank you for providing me this opportunity to share with you 
recent activities in the Department of Veterans Affairs. I will be 
happy to answer any questions you may have.
                                 ______
                                 
  Response to written questions submitted by Rear Admiral Patrick W. 
Dunne, U.S. Navy (Ret.), Assistant Secretary for Policy and Planniing, 
                  U.S. Department of Veterans Affairs
    Question 1. According to recent testimony by Mr. Dominguez, DOD's 
Principal Under Secretary of Defense for Personnel and Readiness, DOD 
and VA are working closely to redesign and establish one disability 
evaluation system for use by servicemembers. I understand that this 
redesign was done without the benefit of knowing the recommendations of 
the Veterans Disability Benefits Commission. How is the redesign being 
carried out, what information was considered, and what are the expected 
outcomes? Does the redesign of the Disability Evaluation System include 
improved processes for all separating servicemembers or just those 
separating as a result of being found unfit or continued service?
    Response. The Department of Veterans Affairs (VA)/Department of 
Defense (DOD) Disability Evaluation System (DES) pilot program will 
begin on November 26, 2007. The intent of the DES pilot is to evaluate 
a stream-lined process designed to improve the timeliness and 
effectiveness of the DES program. This pilot program integrates VA and 
DOD processes thereby maximizing resources, eliminating duplication, 
and improving case management practices. The pilot will operate within 
the parameters of titles 10 and 38, United States Code and will be used 
for personnel who are separating through the medical evaluation board 
(MEB)/physical evaluation board (PEB) process.
    VA and DOD designed a program that would remove current burdens on 
servicemembers by simplifying the process and producing a single 
disability rating. A key feature of the DES pilot is the use of one 
comprehensive medical examination, using VA-based protocols, that is 
administered by DOD. This single medical exam will meet the needs of 
the PEB in determining a servicemember's fitness for duty and the needs 
of VA for determining a total service-connected disability rating.
    To ensure a seamless transition of our wounded, ill, or injured 
servicemembers from DOD care, benefits, and services to the VA system, 
the DES pilot will test enhanced case management methods; identify 
opportunities to improve the flow of information; and identify 
additional resources, which may be necessary to facilitate successful 
transitions for servicemembers and families.

    Chairman Akaka. Thank you very much, Secretary Dunne. 
Secretary West?

 STATEMENT OF TOGO D. WEST, JR., CO-CHAIR, INDEPENDENT REVIEW 
    GROUP, REPORT ON REHABILITATIVE CARE AND ADMINISTRATIVE 
PROCESSES AT WALTER REED ARMY MEDICAL CENTER AND NATIONAL NAVAL 
                         MEDICAL CENTER

    Mr. West. Mr. Chairman, Ranking Member Senator Burr of my 
home State of North Carolina, Senator Murray, and Members of 
the Committee, thank you for including the Independent Review 
Group in your hearing today. I am aware--we are aware--that you 
are focusing on disability issues, but you asked us to speak to 
questions of overlap or cooperation between DOD and the 
Department of Veterans Affairs that are touched on by our 
report and that would assist in providing the best of care to 
returning servicemembers and veterans.
    I will do that quickly. You have my statement. I won't take 
the time to go through it. I want to make two points about two 
issues that we touch on that certainly have to do with 
cooperation between DOD and VA.
    First of all, let me say this issue of how the two 
departments, the two largest in terms of personnel in our 
government, can cooperate to support servicemembers and 
veterans is not a new one, of course. We were talking about it 
when I was the Secretary of Veterans Affairs, also when I was 
Secretary of the Army, and that is now turning out to be a 
while back. Indeed, it was before me.
    Something that was said here today, I think, is well worth 
saying. Let me speak specifically to the issue of electronic 
records. VA has certainly outdistanced the Department of 
Defense on that score. The fact is that the transition to an 
essentially paperless health records system is in many ways a 
marvel. DOD is not there, and although I have heard some 
encouraging statements both today and in past weeks, it is not 
clear to me how quickly they will get there.
    As General Scott pointed out--and I know you noticed his 
comment, it is not just that DOD as a whole is not where VA is 
in getting its medical records online, as it were; it is that 
the individual services are not there. They can't even talk 
with each other within the Department of Defense. Indeed, the 
Army has three systems that can't talk to each other.
    And so, when we talk about the objective of getting some 
kind of useful collaboration between the two departments on 
something that is as essential as the ability to put health 
care records in an electronic means and make them available so 
that they can go where a servicemember or former servicemember 
or veteran needs them to go within the two systems, we are 
talking about something that is not yet upon us, and I am 
concerned we will have difficulty getting to. I understand that 
the DOD part of it is a concern of another committee, but it is 
the concern of the entire Senate, as well.
    The Secretary of Defense and his people have made it clear 
that they understand our recommendations and the 
recommendations of the other commissions. But, I say to you, 
that is an area that is going to take a lot of pressure. 
Perhaps I will leave it at that and you can ask me questions 
about it later.
    Secondly, we had some strong language in the Independent 
Review Group's report, as everyone else has had, concerning the 
disability review process. We said then, and in our testimony 
several subsequent times, that it makes no sense not to have 
one system. It is no surprise, as I say in my comments, that a 
department of government, several departments of government, 
can offer good rationales for having the complicated systems 
they have. Three levels of review--for example, in the Army 
before you get a decision, before you even get to VA, if you 
are a servicemember who is eventually discharged and needs to 
continue in the VA system. Their reasons are good: that the 
local commanders can make a better decision as to who is fit to 
return, yet you need a level further after that to decide, and 
so on.
    But, the servicemembers and their families--as you have 
heard from Senator Dole and Secretary Shalala, for example--to 
servicemembers and their families, it looks like an 
incomprehensible nightmare. We, as a government, should be able 
to resolve that.
    I am encouraged by what we are hearing in terms of moving 
forward with a plan to proceed. Indeed, the members of the 
Independent Review Group are meeting tomorrow with Assistant 
Secretary Cassell to talk further about DOD's efforts to 
resolve its internal process. But that again is an area that 
will require continued oversight and urging, because we have 
talked about and considered improving the disability review 
process, as it involves both DOD and VA for a number of years 
there, as well. It is not a new issue this year.
    Finally, the Independent Review Group was the first body 
called into action when the national scandal known as the 
Walter Reed situation broke. Shortly after Secretary Gates took 
over, he asked our group, which I have to say, in contrast to 
what Senator Dole and Secretary Shalala were able to say about 
their group, ours was the normal suspects--a couple of formers: 
former Secretaries of the Army; some former military doctors 
too; one a former Surgeon General of the Air Force; and the 
other former Congressman Schwartz, who is also a doctor who 
served as a military doctor; but also a former Navy nurse, Rear 
Admiral Kathy Martin, who was a Deputy Surgeon General; and a 
former Commander of Bethesda National Naval Medical Center; as 
well as a former command sergeant, and two other private 
citizens.
    I mention that to say that our focus as we met and did our 
deliberations, despite what the formal letters of reference may 
have said in terms of what we were called on to do, were to 
essentially find out what happened, find out why it happened, 
and find out what needed to be done to fix both that problem 
and its implications in other active duty facilities, as well. 
We were not asked to look at VA, and indeed in an early draft 
of our terms of reference there is a specific line that told us 
to stay away from looking at the Department of Veterans 
Affairs. At the suggestion of several of us, including me, that 
was taken out. We understood what our area was, but, of course 
it would make sense for us to look at the overlap at the place 
of transition.
    And so, our report heavily focuses on DOD and the many 
things that need to be done there. But, I have to conclude by 
saying with respect to that effort, that we found that where 
DOD and VA have been making efforts to cooperate and to 
collaborate, and there have been a number of them, the 
Department of Veterans Affairs has been better able to move 
ahead. You haven't asked me for a comparison and I am not 
really offering one, but I am pointing out that the difficult 
challenge continues to lie in pushing that large department, 
which has so many different actors who have to participate, to 
bring their activities to the point where they can work 
together and mesh together with VA.
    So, I thank you for this hearing. I thank you for including 
us in it. I know you have had hearings like this before--I have 
heard them referred to--and so have others. But wherever the 
Senate or House of Representatives gathers in a Committee or in 
full session to consider these problems of our servicemembers 
and our veterans, there on that day is another opportunity for 
the improvement of what we can do for them. Thank you.
    [The prepared statement of Mr. West follows:]
        Prepared Statement of Hon. Togo D. West, Jr., Co-Chair, 
                        Independent Review Group
    The report by the Independent Review Group is replete with findings 
and recommendations covering a wide range of issues and circumstances 
which have come to our attention. They converge around four core 
concerns. Let me pose them as questions.
    Firstly, who are we--as a country, as an Army, as a health care 
center--here at Walter Reed? Unfortunately, if one considers reports we 
have heard from servicemembers and their families about the lapses in 
support to them during their rehabilitation phase of care, we would 
conclude that we may be answering that question in ways that are not 
attractive to us as an Army or as a Nation. We say so much about 
ourselves by the attitudes we display toward those who look to the 
Nation for support during the most vulnerable times of their lives. We 
have included a number of findings and recommendations involving the 
assignment and training of caseworkers, increases in the numbers of 
caseworkers and adjustment of the caseworker to patient ratio, 
assignments of primary care physicians, and attention to the nursing 
shortages.
    Secondly, who and what are we to become? The Base Realignment and 
Consolidation (BRAC) process and the A-76 process have caused 
incalculable dislocation in Walter Reed operations and threaten the 
future of both installations.
    Thirdly, how are our servicemembers doing? At every turn, the IRG 
has encountered servicemembers, their families, health care 
professionals, and thoughtful observers who point out how challenging 
the traumas associated with TBI (Traumatic Brain Injury), and PTSD 
(Post Traumatic Stress Disorder) have become; and how challenging they 
have been in terms of both DOD and Department of Veterans Affairs 
diagnosis, evaluation, and treatment. We believe there is a need for 
greater and better coordinated research in this area. We have made a 
detailed recommendation with respect to a center of excellence and 
increased attention to cooperative efforts by both the Department of 
Defense and the Department of Veterans Affairs.
    Fourth, how long? The IRG has operated with what is, for me, a rare 
sense of unity and consensus in our effort. If there is one issue, on 
which we are even more unified than all others, it is that the horrors 
that are inflicted on our wounded servicemembers and their families in 
the name of the physical disability review process, known in the 
Department of Defense as the MEB/PEB process, simply must be stopped.
    It is no surprise to you on the Committee, or to us on the IRG, 
that each part of the governmental process can make sound arguments to 
defend and explain why three, and in the case of the Army four, 
separate Board proceedings--with associated paperwork demands on the 
wounded servicemember and family, accompanied by delays and economic 
dislocation for assisting family members, and characterized prominently 
by inexplicable differences in standards and results--are justified. 
We, however, are a Nation which values the every day good sense of the 
common man or woman--that is why we call it common sense. And common 
sense says that from our servicemembers' and families' point of view 
this must seem a wildly, incomprehensible way to settle for 
servicemembers and families the question of whether the member must 
leave the service and, if so, under what conditions. We recommend one 
combined physical disability review process for both DOD and VA. (See 
Attachment for specific areas that require collaboration between the 
DOD and VA.)
    Virtually every finding and recommendation we make, then can be 
traced to these four concerns: (1) leadership and attitude; (2) the 
transition from Walter Reed Army Medical Center to Walter Reed National 
Medical Center; (3) the extraordinary use of IED (improvised explosive 
devices) in the current wars and their impacts on the brains and 
psyches of our servicemembers; and (4) the long-standing and seemingly 
intractable problem of reforming the disability review process.
    It is important to note that at the conclusion of the IRG 
investigation, Army officials said the service has resolved, or is in 
the process of resolving, 24 of the 26 findings listed in the report.
    To be sure, it was the degradation in facilities that first caught 
the eye of media reporters. Important as that is, however, we believe 
that there is far more to be dealt with here than applying paint to 
rooms or even in crawling around basements to deal finally with 
electrical problems. We had experts of every sort assigned to us, and 
talented and experienced health professionals as part of the 
Independent Review Group itself.
    None of these concerns, however, is our bottom line: not BRAC, not 
facilities, not even the search for failures, breakdowns, or culprits. 
Rather our bottom line is this:

    (1) We are the United States of America.
    (2) These are our sons and daughters, brothers and sisters, uncles 
and aunts, even a grandparent or two who lie and sit wounded.
    (3) Their families are our families, we are their neighbors, and 
we, their fellow citizens and residents.
    (4) Their anguish is our anguish.
    (5) We can and must do better.
                                 ______
                                 
                               Attachment
Finding:
    There are inconsistencies within the Department of Defense and the 
Department of Veterans Affairs regulatory systems which deal with the 
functional loss of limb due to Traumatic Injury and burn. Currently, 
the disability system does not adequately compensate for the functional 
and physiological loss of limb in burn patients.
Discussion:
    The Code of Federal Regulations, Title 38, Part IV (Veterans 
Affairs Schedule for Ratings and Disabilities) does not address 
specific disability ratings for burn injuries. It does thoroughly cover 
amputations. It also addresses many skin injuries such as scarring, 
disfigurement and dermatitis. There exists a gap for addressing issues 
specific to burn injuries. Burned skin needs extra protection from the 
sun and elements; it does not sweat normally and needs extra 
precautions (for example: ultraviolet protective clothing and salves) 
for warm/hot environments. Because there are not specific disability 
ratings for burn patients, they do not qualify for home or vehicle 
modification as an amputee patient would.
Recommendations:
    1. The Secretary of Defense should request the Secretary of 
Veterans Affairs to update the Code of Federal Regulations, Title 38, 
Part IV to account for the unique disabilities and needs of traumatic 
amputees and burn victims, focused on a loss of function and post-
service needs. This would require an expedited process for publishing 
the change.
    2. The Secretary of Defense should review the Physical Evaluation 
Board determinations of all burn cases, dating back to 2001, within 1 
year after the update to United States Code 38.
Finding:
    When an amputee leaves the Department of Defense medical system, 
the follow-on care, the amputee receives, may not be as technologically 
advanced outside the military medical system.
Discussion:
    The Department of Defense, from clinical necessity, has been on the 
cutting edge of prosthetic replacement for traumatic amputation. The 
Department of Veterans Affairs has largely been focused on patients who 
lost a limb (or limbs) through disease or accident instead of combat. 
In addition, many amputees in the Veterans Affairs system are much 
older than those who have suffered an amputation due to combat.
    The Sun-Times News Group recently reported, MAJ (RET) Tammy 
Duckworth, currently the Director of the Illinois Department of 
Veterans Affairs, testified before the U.S. Senate Committee for 
Veterans Affairs on March 27, 2007 and stated, ``The U.S. Department of 
Veterans Affairs is absolutely not ready to treat amputee patients at 
the high tech levels set at Walter Reed. Much of the technology is 
expensive and most of the Veterans Affairs personnel are not trained on 
equipment that has been on the market for several years, let alone the 
state-of-the-art innovations that occur almost monthly in this field. I 
recommend that the VA expand its existing SHARE program that allows 
patients to access private prosthetic practitioners. There is simply 
not enough time for U.S. Department of Veterans Affairs to catch up in 
the field in time to adequately serve the new amputees from Operations 
Iraqi and Enduring Freedom during these critical first 2 years 
following amputation. Perhaps after the end of current wars in Iraq and 
Afghanistan, the VA will have time to advance its prosthetics 
program.'' Travel for prosthetic care also includes Department of 
Defense beneficiaries follow up post amputation patients often requires 
travel to medical centers with competent prosthetics departments. Often 
a patient does not live in a geographic area where TRICARE Prime is 
offered. The TRICARE Prime travel benefit covers per diem and travel if 
a patient is referred to care more than 100 miles away from their home. 
TRICARE Standard does not offer a travel benefit.
Recommendations:
    1. The Secretary of Defense should pursue partnerships with the 
Secretary of Veterans Affairs to provide treatment; promote education 
and research in prosthesis care, production, and amputee therapy.
    2. The Secretary of Defense should pursue a partnership with the 
Secretary of Veterans Affairs to expand the Department of Veterans 
Affairs' existing program to allow patients to access the military 
health system and private prosthetic practitioners.
    3. Review TRICARE regulations (CFR 199.17) and update specifically 
to change them so that the geographic home of the patient does not 
limit access to benefits for prosthetic care and treatment.
Finding:
    There are serious difficulties in administering the Physical 
Disability Evaluation System due to a significant variance in policy 
and guidelines within the military health system.
Discussion:
    There is much disparity among the Services in the application of 
the Physical Disability Evaluation System that stems from ambiguous 
interpretation and implementation of a Byzantine and complex disability 
process. It is almost as if a peacetime, draft-era program is being 
applied to an all-volunteer force engaged in war.
    The Governing Statute, implementing publications and regulatory 
guidelines: Code of Federal Regulation: Title 10, USC chapter 61, 
provides the Secretaries of the Military Departments with the authority 
to retire or separate members for physical disability. Code of Fed reg 
Title 38, provides the authority for the VA. DOD Directive 1332.18, 
Separation or Retirement for Physical Disability; DOD Instruction 
1332.38, Physical Disability Evaluation; DOD Instruction 1332.39, 
Application of Veterans Affairs Schedule for Rating Disabilities, and 
applicable service specific regulations or instructions set forth the 
polices and procedures implementing the statute. For each respective 
service, the governing service specific guidelines include: Department 
of the Air Force, AFI 36-3212, Physical Evaluation for Retention, 
Retirement, and Separation; Department of the Army, AR 635-40, Physical 
Evaluation for Retention, Retirement, or Separation; Department of the 
Navy, SECNAV Instruction 1850.4E and Department of the Navy Disability 
Evaluation Manual. A Government Accounting Office (GAO) Report (2006), 
acknowledged the differences among the services and recommended 
improved oversight of the physical disability evaluation system, to 
which the Department of Defense agreed and indicated an intent to 
implement.
    ``The Government Accountability Office noted that eligibility 
criteria for disability programs need to be brought into line with the 
current state of science, medicine, technology and labor market 
conditions.''
    During the course of its review, the Independent Review Group 
identified no less than five Government Accountability Office reports 
and one Presidential Task Force report that noted deficiencies and made 
recommendations to improve the physical disability evaluation system. 
These reports include:

     November 2004 Government Accountability Office Report: VA 
and DOD Health Care: Efforts to coordinate a single physical exam 
process for servicemembers leaving the military
     September 2005 Veterans Affairs and Department of Defense 
Health Care: VA has policies and outreach efforts to smooth transition 
from DOD Health Care, but sharing of Health Information remains 
limited.
     June 2006 Government Accountability Office Report: VA and 
DOD Health Care: Efforts to provide seamless transition of care for OEF 
and OIF servicemembers and veteran's.
     March 2006 Military Disability System: Improved oversight 
needed to ensure consistent and timely outcomes for reserve and active 
duty servicemembers.
     March 2007 Government Accountability Office Report: DOD 
and VA Health Care: Challenges encountered by injured servicemembers 
during their recovery process.
     2003 President's Task Force to Improve Health Care 
Delivery for Our Nation's Veterans.

    Despite the comprehensive findings and recommendations in these 
reports, the Group found little evidence of action on the 
recommendations.
Recommendations:
    1. The Secretary of Defense should provide recommendations to 
Congress to amend Title 10 United States Code, Chapter 61, and Title 38 
United States Code, to allow the ``fitness for duty'' determination to 
be adjudicated by the Department of Defense and the disability rating 
be adjudicated by the Department of Veterans Affairs.
    2. Following the changes to the United States Code, the Secretary 
of Defense, should quickly promulgate regulatory guidelines and policy 
to the Service Secretaries.
Finding:
    The current Medical Evaluation Board/Physical Evaluation Board 
process is extremely cumbersome, inconsistent, and confusing to 
providers, patients, and families.
Discussion:
    The physical disability evaluation system is the means by which 
servicemembers are retired or separated due to physical disability in 
accordance with the aforementioned references. The Department of 
Defense Directive (DODD) 1332.18, Section 3.2 outlines four elements of 
the physical evaluation disability system: the physical evaluation; 
appellate review; counseling; and final disposition. According to the 
Department of Defense regulations, the physical evaluation process 
consists of the Medical Evaluation Board and the Physical Evaluation 
Board. The Department of Defense and the Department of Veterans Affairs 
use the Veterans Administration Schedule for Rating Disabilities.
    The Veterans Administration Schedule for Rating Disabilities 
(VASRD) is primarily used as a guide for evaluating disabilities 
resulting from all types of diseases and injuries encountered as a 
result of, or incident to, military service.
    Not all the general policy provisions set forth in the rating 
schedule apply to the military. Consequently, disability ratings 
consistently vary between the Department of Defense and Department of 
Veterans Affairs. The Services rate only conditions determined to be 
physically ``unfitting,'' compensating for loss of a military career. 
The Department of Veterans Affairs may rate any service-connected 
impairment, thus compensating for loss of civilian employability. 
Additionally, the term of rating is different among the Department of 
Defense and the Department of Veterans Affairs. The Services' ratings 
are permanent upon final disposition. The Department of Veterans 
Affairs ratings may fluctuate with time, depending upon the progression 
of the condition. Further, the Services' disability compensation is 
determined by years of service and basic pay; while Veterans Affairs 
compensation is a flat amount based upon the percentage rating 
received.
Recommendations:
    1. The Under Secretary of Defense (Personnel & Readiness) should 
completely overhaul the physical disability evaluation system to 
implement one Department of Defense level Physical Evaluation Board/
Appeals Review Commission with equitable Service representation and 
expand what is currently the Disability Advisory Council.
     According to a Government Accountability Office report, a 
problem with the current organization is that the Council only ``aims'' 
to meet quarterly, but did not meet for a full year, to discuss issues 
raised by the Services. This recommended concept would have 
consolidated operational oversight and responsibility of the Physical 
Evaluation Board process, including the current Service level Physical 
Evaluation Board and Appeals Review levels of jurisdiction. This action 
allows for streamlining of personnel and resources, and eliminates the 
intra and inter-Service disparities of the disability ratings and 
provides a forum for implementing immediate corrective action. This 
recommended concept incorporates Veterans Affairs representation and 
ensures a seamless transition from the Department of Defense into the 
Department of Veterans Affairs health system.
    2. The Under Secretary of Defense (Personnel & Readiness) should 
conduct a quality assurance review all (Army, Navy/Marine Corps, and 
Air Force) Disability Evaluation System decisions of 0, 10, or 20 
percent disability and Existed Prior to Service (EPTS) cases since 2001 
to ensure consistency, fairness, and compliance with applicable 
regulations.
    3. The Secretary of Defense and the Secretary of Veterans Affairs 
should establish one solution. Develop and utilize one disability 
rating guideline that remains flexible to evolve and be updated as the 
trends in injuries and supporting medical documentation/treatment 
necessitate. Revise the current process of updating the disability 
ratings system to include an operation update that pushes changes to 
the field on a weekly, or as needed basis.
Finding:
    A common automated interface does not exist between the clinical 
and administrative systems within the Department of Defense and among 
the Services, causing a systemic breakdown of a seamless and smooth 
transition from Department of Defense to the Department of Veterans 
Affairs.
Discussion:
    Servicemembers should not be burdened with the arduous navigation 
requirements of our current system. The complexity of the physical 
disability evaluation system is further perpetuated as the 
servicemembers transition into the Veterans Affairs system. Currently 
there is not a seamless transition.
    A ``seamless transition'' from military service to veteran status 
is especially critical in the context of health care, where readily 
available, accurate, and current medical information must be accessible 
to health care providers.
    For the administrative aspects of this process, no one system 
currently exists. The Department of Defense does not have an integrated 
automated system that supports the standardization of the clinical and 
administrative requirements of the physical disability evaluation 
system. Absent a corporate solution, the Services have created 
individual systems to track the servicemembers within the physical 
disability evaluation system. This exacerbates the process variation.
    The Air Force currently does not have an automated system. The Army 
currently uses the Medical Evaluation Board Internal Tracking Tool 
(MEBITT). The Navy uses the Medical Board On Line Tri-Service Tracking 
System (MedBOLTT). Each system serves its Service independently for 
Medical Evaluation Board processing; yet do not interface with the next 
step of the Physical Evaluation Disability System, or Physical 
Evaluation Board.
    The Army Physical Evaluation Board uses the Physical Disability 
Case Processing System (PDCAPS) to track Army cases once they enter the 
Physical Evaluation Board stage of the process. Using the Army as an 
example of the lack of interface between systems, during the Medical 
Evaluation Board phase of the process, the Medical Evaluation Board 
Internal Tracking Tool is used. During the Physical Evaluation Board 
phase, the Physical Disability Case Processing System is used. These 
two systems, unique to one Service, result in numerous disparities 
within the Army since the systems do not interface. From a clinical 
perspective, all medical documentation should be available to the 
servicemembers' providers throughout the entire process. This includes 
the transition into the Veterans Affairs system where there is no 
continuity other than what records the servicemember carries to the 
Veterans Affairs. This issue has been continually addressed without 
resolution.
    ``The Department of Veterans Affairs and the Department of Defense 
should develop and deploy, by fiscal year 2005, electronic medical 
records that are interoperable, bidirectional and standards-based''. 
[Refer to Recommendation 3:1 of President's Task Force. (2003) Final 
report to improve health caredelivery for our Nation's veterans. 
Washington, DC.] The same report recommends a single separation 
physical and electronic transmittal of the Department of Defense Form 
214 (DD214) to the Department of Veterans Affairs. These 
recommendations have yet to come to fruition and as a result, there is 
a significant amount of redundancy still required at this point 
starting at the physical examination.
Recommendation:
    The Secretary of Defense, in conjunction with the Secretary of 
Veterans Affairs, should direct the transition process be streamlined 
for the servicemember separating from the Department of Defense and 
entering the Department of Veterans Affairs.

     As already identified in the Government Accountability 
Office report (2004), implement the single physical exam. Review the 
1998 Department of Defense memorandum of understanding (MOU) between 
the Department of Defense and Department of Veterans Affairs, implement 
a common physical for use by the Services and the Department of 
Veterans Affairs for those servicemembers in the physical disability 
evaluation system, and allow flexibility in the timelines test or 
procedures that would eliminate redundant efforts.

    Rapidly develop a standard automated systems interface for both 
clinical and administrative systems that allows bilateral electronic 
exchange of information. Review and implement the recommendations of 
the 2003 President's Task Force.

    Chairman Akaka. Thank you very much, Secretary West.
    We have some questions for you. General Scott, we have seen 
proposed legislation that would require the Secretary of 
Veterans Affairs to conduct a 6-month study relating to 
disability benefits, and after providing Congress with the 
results of the study, to write regulations to implement the 
study's findings so as to create a total change to the VA 
disability system. Based on your Commission's review of VA's 
disability process, do you believe that a total system reform 
can be carried out in 6 months and be done on an administrative 
basis with no Congressional hearings or legislative action?
    General Scott. Mr. Chairman, you are going to have to find 
a whole lot faster moving commissioners than the group that I 
represented was if you can get that done in 6 months.
    I am not sure how long it would take to do the study that 
you mentioned. There was a question before about whether a 
study be completed in a brief period of time to take a look at 
quality of life. Quite frankly, one of the reasons that our 
Commission recommended an immediate interim fix to quality of 
life, which is upping the payment based on level of disability, 
was that we didn't have a lot of confidence that a quick study 
could be done that would address it and it might drag on and on 
and on. We recognize, as did Dole-Shalala, that some of these 
people need some more immediate help than might occur a few 
years down the line.
    In regards to a complete study of the Veterans' Disability 
Rating System, we offered in our Commission report some 
priorities. One of them was to sort out the TBI, PTSD, and 
other contributing mental ailments, so that it was clearer as 
to how diagnosis and evaluation might occur in that. And then 
we offered some other priorities, such as those parts of the 
schedule that had not been touched in many years might need 
some attention.
    But our estimate was that a system as complex as the 
schedule of disabilities was going to take a significant amount 
of time to--I don't know whether the term is, ``redo it,'' 
``change it,'' whatever; but I think we all recognize there is 
a significant challenge involved.
    So, in my personal view, sir, it probably couldn't be done 
very well in 6 months. We recommended that the Congress put a 
time line on the VA that the entire schedule of disabilities be 
redone within a 5-year period. That was our guess as to how 
long it might take to do the entire thing. But again, sir, we 
offered some priorities where one might start and we would hope 
that those would be done in a more expeditious fashion.
    Chairman Akaka. Part of my question was whether it can be 
done on an administrative basis without Congressional hearings 
or legislative action.
    General Scott. Sir, I think that from my own experience as 
a military officer over the years and my experience since that 
time, it would be that it was going to take all branches of 
Government working together to make this thing work. So, it 
appears to me, my personal opinion, that Congress has an 
important role in overseeing this rewrite, not micromanaging, 
but overseeing. I believe it is the responsibility of this 
Committee and the like Committee in the House to do just that, 
sir.
    Chairman Akaka. Thank you. Secretary West, the Independent 
Review Group endorsed the consolidation of the DOD and VA 
disability systems so as to create a single comprehensive 
medical exam resulting in a single disability rating. However, 
the Independent Review Group did not recommend reforms to DOD 
disability retirement pay. What are your views on the Dole-
Shalala recommendation that DOD disability retirement pay be 
based solely on rank and years of service and not on the degree 
of disability?
    Mr. West. Mr. Chairman, I looked at those recommendations. 
I speak for myself. The IRG has not taken a position on it. But 
they are reasonable. The division of labor is reasonable. And 
so, I don't have a problem with it. I think that makes sense. I 
understand that this Committee is trying to work through 
competing, or not necessarily competing, but several different 
recommendations in that area. I think for us, what is important 
is that we move as quickly as possible to get the clearest 
possible resolution for retiring and for veterans.
    I have some other views about some other parts of that, but 
let me just confine my answer to what you asked me.
    Chairman Akaka. Thank you very much.
    Admiral Dunne, in my opening remarks, I stated how pleased 
I was that the Under Secretaries of VA and DOD were meeting 
weekly to address many of the issues we are discussing today. 
Would you please comment on all the things that SOC has done 
and is planning to do to address the recommendations of the 
Dole-Shalala Commission, the Independent Review Group, and the 
VA Task Force?
    Admiral Dunne. Mr. Chairman, the Senior Oversight 
Committee, in order to deal with the recommendations, has 
created eight different groups and assigned them their 
recommendations based on those responsibilities.
    The first work group is the Disability Evaluation System. 
In response to the recommendations on a single comprehensive 
physical--at yesterday's weekly meeting we actually came to a 
final decision on that single comprehensive physical and that 
will be used in the pilot for the DES system, which we will 
commence during the month of November.
    Another work group is looking at TBI and psychological 
health. The Senior Oversight Committee has been briefed on and 
approved the National Center of Excellence for TBI and 
Psychological Health and the intent is to have the ribbon-
cutting for that at the end of November.
    We have also overseen the development of clinical practice 
guidelines for PTSD, for major depressive disorder, and for 
substance abuse disorders, and also the Senior Oversight 
Committee has reviewed programming of some $900 million to 
support TBI and psychological health prevention, treatment, and 
continued research.
    Another work group is looking at case management. They are 
working now on the development of the Recovery Coordinator 
Program, working together with HHS as well as DOD and VA. The 
Memorandum of Understanding between the three agencies is 
already in existence and has been approved. The memorandum 
establishing the program will be approved this month. And we 
are also in the process of developing what we are calling a 
Federal Individual Recovery Plan, which will take the 
servicemember or veteran from their first point of entry back 
into the United States where they start their care and 
recovery, all the way through their reintegration into the 
community or their return to duty, if they are able to recover 
sufficiently to return to duty.
    The fourth work group is looking at data sharing between VA 
and DOD, and the Senior Oversight Committee is monitoring all 
the actions that are in place right now to have all essential 
health and administrative data viewable between our two 
agencies by October 31, 2008, which would meet the criteria 
that was mentioned earlier this morning of getting it done 
within a year's time.
    We also have a contract in place to develop an analysis of 
alternatives for an Electronic Inpatient Health Record, and we 
are looking to the possibility of having some head start 
opportunities coming out of that contract in advance of the 
final deliverable, where we could do just that--get a head 
start on complete interoperability--so that, instead of just 
having viewable records, we have computable records between the 
two agencies.
    The data sharing group is also developing a plan for a 
single web portal that the Dole-Shalala Commission recommended 
so that veterans could go online and see all the benefits that 
are available to them, and track their own progress.
    And we are also developing an IT plan to support the 
Federal Recovery Plan, which the case management group is 
putting into place. This IT plan would be within the Web site 
that is being created so that those personnel who need to track 
an individual soldier or sailor could go online and review that 
and keep up to date with the progress.
    The facilities work group has approved the DOD housing 
inspection standards for medical hold and holdover personnel, 
and they are also in the process of preparing the inspection 
report on all medical hold and holdover facilities, which will 
be submitted to Congress later this year.
    A sixth work group is looking at a complete clean sheet 
review of the entire process: disability process; benefits 
process; et cetera; to say, what if there wasn't anything in 
place right now? What if there weren't any laws? What would you 
see as the ideal organization's benefits package to put in 
place?
    Another work group is working on legislation, and you have 
the immediate product of their work now--creating the 
legislation to implement the Dole-Shalala recommendations.
    And an eighth work group is looking at personnel pay and 
financial benefits. Some examples there are: DOD and VA are now 
sharing information--patient administrative data--when an 
active duty servicemember comes to a VA facility. We have seen 
problems in the past where, administratively, pay purposes, et 
cetera, have been complicated, because they somehow seem to 
fall through the cracks. We believe that we have taken care of 
that now.
    We are also looking at implementing what we have learned to 
be the best practices for operating the TSGLI insurance system 
for the benefit of the severely injured veterans.
    Chairman Akaka. Thank you very much.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    General, Admiral, Mr. Secretary, welcome. We can't thank 
you all enough and your Commission members that are here and 
those that aren't here for their time and commitment.
    I want to take an opportunity to voice a personal 
frustration. This is the most powerful country in the world. 
Between our military and our veterans, we have some of the 
brightest people that exist on the planet. We are going to be 
tasked with helping to do the hard part--that 10 percent that I 
think everybody agrees legislatively has to be done, whether 
you just can't get there, you can't get the critical mass 
administratively--somehow the authority of Congress says, OK, 
we are going to do this.
    The sad part is that I don't get a sense even if we did the 
legislation, that it happens tomorrow--I would only share with 
you my frustration. What takes so damn long? As powerful, as 
bright as we are, we are still talking about the DOD 
technologically getting up to where a community hospital is 
today. We have got community hospitals across the country that 
do remote monitoring of congestive heart patients that save 
money, increase the quality of life, yet we can't track 
somebody in the system and hand it off electronically to 
another system, and both have existed for decades.
    I share that with you only because it is a frustration, I 
think, of all of us, as I know it is with you. I feel like we 
put you in an untenable position to sit in front of the table 
knowing that your reluctance is--well, history tells us, you 
can't do it that quick.
    My only suggestion to all of us in the room and to those 
that read the testimony from this hearing is: we don't have any 
choice. We have to do it and we have to do it quick. If we 
don't, then we are the ones that have caused a quality of life 
issue with the veterans that are in the system. We have to fix 
it and we have to fix it now.
    Now let me move to some very quick questions, if I can. 
General, the Commission recommends that all applicants for 
individual unemployment benefits first be screened by 
vocational rehabilitation and employment counselors. In support 
of this recommendation, the Commission cited a 2005 GAO report 
that found only 495 of 219,000 veterans in receipt of 
individual unemployment benefits had been evaluated by 
vocational counselors. My specific question is, what happens 
if, after being screened, the VA determines that employment is 
feasible, but only if a veteran receives vocational 
rehabilitation services?
    General Scott. Well, in our report, we made a number of 
recommendations to how we could enhance the VR&E services to 
disabled veterans. Our thinking on the screening process is 
that, basically, before we award individual unemployability to 
a veteran, that the person should be screened to see if he or 
she is employable. In other words, we should----
    Senator Burr. I guess my question, going right to the heart 
is, if the determination is that they are employable, but they 
choose not to do the vocational rehabilitation proposals that 
have been laid out for them to become employable, then what do 
we do?
    General Scott. Well, we talked about that in a different 
context. When we talked about PTSD, we said that treatment, 
compensation, evaluation and VR&E should all occur, and they 
should be linked. So, I would say that if the problem happened 
to be recalcitrance, in many cases, I think we should link 
treatment with compensation. Now, I have no information that 
leads me to believe that recalcitrance is a problem, but if it 
is, that is a way that it might be addressed.
    Senator Burr. Most of, I think, the recommendations of the 
Commission have overwhelming support. I want to go to one where 
Commissioner Brady had a different view and it dealt with 
different compensation levels being appropriate for some 
veterans based upon the circumstances of their injury. For 
example, Commissioner Brady wrote the sacrifice made by 
soldiers entered in combat is greater than the sacrifice made 
by servicemembers injured in an off-duty motorcycle accident. 
Can you enlighten us on why the Commission did not recommend 
that compensation rates take into account the veteran's injury 
or the circumstances of the veteran's injury?
    General Scott. Senator Burr, I will be happy to. First of 
all, let me say that all the Commissioners made major 
contributions to the final document. I can also say--and I 
think the Commissioners that are present will back me up--that 
we did not all agree on every aspect of every issue. We were 
able to achieve a consensus, which is found in the report. 
There are a few things in there that I can assure you that 
almost all the Commissioners would have worded a different way.
    So, having said that, the Commission as a group views 
service kind of like this: we are in a 24-hour a day, 7-day a 
week service environment. I will use myself as an example. 
During the 32 years that I was on active duty, I was subject to 
the Uniform Code of Military Justice: 24/7; on leave; on duty; 
in the U.S.; out of the U.S. If we are going to continue to 
require our servicemembers to work to a 24/7 standard, then we 
have to look after them in that way--24/7. That is the 
consensus of the Commission.
    Not to get too far afield here, but, we could be like the 
Dutch army, where everybody is a union member. They all work 
from eight to four and get a couple of hours off for lunch. If 
we went to a standard like that instead of the 24/7, I think 
there would be a case for looking at some sort of 
differentiation. But, if you are on duty 24 hours a day, then 
you should be protected 24 hours a day, and so----
    Senator Burr. Rest assured, I am not a proponent of the 
Dutch system, nor am I questioning the recommendation and the 
fact that you didn't draw that distinction. I am trying to 
short-cut the process we will go through, because I am sure an 
issue will arise dealing with, ``is there an off-duty 
difference versus combat.'' Understanding where the Commission 
was, as a whole, is extremely important.
    Admiral, very quickly, a common theme among the Commissions 
that testified today and mentioned in your report is the need 
for a formal system of case management or a central individual 
to coordinate all the servicemembers' needs as they transition 
from DOD to VA. Real specifically, from what you have seen on 
the task force, do you feel that VA's recent move to create 
Recovery Coordinators, and I think you mentioned Federal 
Recovery Plans, as well--is that a silver bullet, or, is this 
just another piece of the process that we have got to get 
right?
    Admiral Dunne. Well, I think it is an essential part of the 
process, Senator. We have already moved out, and put on the VA 
side, Transition Patient Advocates in place. 106 of them have 
been hired so far, and I think they are essential to helping 
the family focus on recovery, and let the Transition Patient 
Advocates worry about those administrative things that have to 
happen in order for the recovery to take place properly. But, 
that is at the scene.
    We also need the Recovery Coordinators who are going to be 
the next level up, Federal Recovery Coordinators who will start 
at day one with that servicemember and track them through all 
the way to the end. And they will be overseeing and monitoring 
the efforts of the Transition Patient Advocates or the Army 
Triad, et cetera, who also have key and essential jobs to make 
sure that our veterans and servicemembers are taken care of. 
So, they are going to have to be working together.
    Senator Burr. Admiral, as you are well aware, the VA-
assigned case managers to our service personnel when they came 
in. I think Senator Dole was the one that said one of his 
Commission members who went through the process had so many 
case managers they couldn't remember the last one's name, so 
they wouldn't have known who to call. I only point that out to 
you to say we have been here before. We have had the right 
focus. For whatever reason, I think the administrative side of 
it didn't recognize the need for that personal bond, much the 
same as a patient-doctor relationship. Somebody without a 
medical home has a very difficult time accessing preventative 
care. Somebody who doesn't have an entryway into the VA today 
has a very difficult time, and we know that to be the fact. It 
is another challenge that we have got to address in a different 
forum.
    Mr. Secretary, I am delighted to be reminded that you 
remember your home of North Carolina. I am sure your mother 
would be proud to know that.
    I am going to give you an opportunity to expand on your 
answer to the Chairman. You had possibly some additional 
observations about the Dole-Shalala legislation. You limited 
your answer to just the specific area. If there are other areas 
you would like to address, I would like to give you that 
opportunity.
    Mr. West. Thank you, Senator. I didn't mean to sort of 
appear to promise some areas of disagreement. I don't have any, 
just some reactions. But I am reminded, before I do, of 
something you said about your frustration with hearing that 
whatever we say has to be done, it seems to take forever to do 
it in a Nation like this.
    When we try to change these huge institutions like VA and 
DOD, you have heard the analogy before, I am reminded with the 
Admiral sitting here, about trying to turn a huge ship and it 
looks like it never happens. It doesn't mean that we take our 
hands off the wheel. It doesn't mean that we lessen our efforts 
to turn, because we know eventually we get it turned.
    And so frustrating as it may be when I recite how far DOD 
has in some respects against it, at the same time, when I 
listen to these task forces that are meeting, there are two, it 
seems to me, big areas of optimism. One is the fact that the 
two Gordons continue to meet on this. Gordon England has a 
reputation as a problem solver and a doer at DOD. He has 
certainly got the confidence of the President, who has had him 
in two different departments and in two different parts of the 
Department of Defense, Navy, DOD, Homeland Security, and the 
like, and we all know Gordon Mansfield and his record of 
achievement at VA. That is not the point, though. The point is 
the power of their offices. They run those departments for 
their principals who are trying to do other things, and as long 
as they are engaged, we will make progress on these things.
    The other is, there are no good things about what happened 
at Walter Reed except that it caused us as a Nation to focus on 
the problems you are discussing. I was just listening to the 
caseworker discussion. We found at Walter Reed that part of the 
problem that was discussed in the press about soldiers who were 
expected to keep their appointments when they were in 
rehabilitation and they had had the kind of surgery that made 
it very difficult for them to know who was their doctor that 
they had to go see and what their appointments were and who was 
going to help them to do it and how unfair it is to the 
families is that you needed someone who was following that 
whole thing throughout. The solution, of course, could be if it 
were the same person who could follow the servicemember and 
family all the way through. That is why this focus on 
caseworkers is a continuing thing that we need to try to do and 
to get right.
    In terms of the various recommendations by the Dole-Shalala 
report, they had the opportunity to hear from us. We completed 
our work as they were starting. That was the time line that had 
been given us and the idea was that our stuff should--it is 
going to be available to inform them, and we are very happy 
with their elements. I did not mean to suggest anything. I 
think it was the particular topic that was being addressed at 
the time, responsibilities between DOD and VA as we looked at 
the joint scheme.
    One reaction I had was the discussion between who should do 
the physical examination. This effort is combined into one 
thing. I am reminded that one of the things we found as we 
talked to servicemembers at Walter Reed, also at Bethesda and 
elsewhere, was their mistrust of the system, of the doctors in 
the system, that the doctors somehow were biased against them--
certainly the Army doctors, in some way, that perhaps their 
notes weren't reflecting everything that they should reflect. 
An important part of the treatment and the determinations is 
what is in the notes of the attending physicians as they look 
at them along the way. It has a big impact on decisions that 
later get made by reviewing authorities.
    It may be well that servicemembers would be more inclined 
to see VA doctors doing that one single examination. I think 
the better answer is the one I heard given here, which is that 
even more, it may be even best if we look to see what the 
abilities are in a given area where the examination is to be 
given between the two services. It may not be so good as to 
make it an iron-clad process where it is a DOD physician every 
time that does it. I think there is a little area there we want 
to be careful about. I am sorry I took so much time.
    Senator Burr. No, and I didn't mean to infer that you had 
disagreements with Dole-Shalala. I thought you had some 
additional things you wanted to say. You are in a unique 
situation, having served as Secretary of the Army and the 
Secretary of the Veterans Administration, but all of you are in 
a unique situations from the standpoint of the studies you have 
just done and the service that you have given.
    Mr. Chairman, I hope that they will continue to make 
themselves available to the Committee relative to questions 
that we might have that help us to sort through this at a 
faster pace than what Senate historical standards are, as well. 
I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray?
    Senator Murray. Yes. Mr. Chairman, thank you very much. I 
think none of us want to have the sound and fury of the Walter 
Reed scandal to be the sound and fury of this year, then 2 
years come back here and we have done nothing. So, I think we 
all want to see progress made, and to that point, General 
Scott, you, in your recommendations with your Commission, seek 
to establish an oversight group to make sure that the 
Commission recommendations are followed on. That is not part of 
what we heard from the Dole-Shalala Commission. Can you tell us 
why you believe an oversight commission is important?
    General Scott. This goes back, Senator, to an earlier 
comment about how long is it going to take to get some of these 
things done. It seemed to our Commission that oversight at a 
couple of levels was critical. One of them: is we thoroughly 
endorse the SOC with Deputy Secretary England and Deputy 
Secretary Mansfield. But, we also believe that there are some 
specific areas where additional oversight may be needed and we 
suggested that the Congress may wish to establish an oversight 
group or committee to keep up with these many, many 
recommendations from all these groups, to make sure that none 
of the important ones fall in the cracks. We don't want to find 
ourselves all back here in 2 years saying, well, gee, we talked 
about this before but nothing ever happened.
    So, taking nothing away from the two departments and taking 
nothing away from the Senior Oversight Council, it seems to us 
that in some of these areas, oversight--you can call it 
independent oversight or you could call it another level of 
oversight--might be valuable to make sure that some of these 
things don't just go away. That was the intent of the 
recommendation, ma'am.
    Senator Murray. OK. Thank you very much for that.
    Secretary Dunne, the Senate has acted on legislation. We 
came together--the VA and the DOD Committee. We put together 
the Dignified Treatment of Wounded Warriors Act. It has passed 
out of the Senate. Has the administration taken a position on 
that legislation?
    Admiral Dunne. Senator, I think the best way I can describe 
reaction to the legislation is based on my experience of the 
past 7 months and looking at the comprehensive plan that the 
Senior Oversight Committee is putting in place right now to 
address such activities as the TBI, PTSD, case management, et 
cetera, and creating a Center of Excellence--putting that into 
action already on PTSD and TBI.
    My best understanding is with the legislation which I 
participated in drafting, which was sent over here yesterday, 
to reflect the recommendations of the Dole-Shalala Commission, 
and what I have learned as a member of the Senior Oversight 
Committee. I think that I would say, that is the best 
legislative approach to take.
    Senator Murray. So, they are not commenting, or they are 
commenting in opposition to it?
    Admiral Dunne. I don't believe that we have an 
administrative position right now.
    Senator Murray. OK. One other quick question. All of the 
other task forces emphasized and talked about family support 
except for the President's Task Force. I understand you were 
limited in your scope. The President said he didn't want to 
spend any new money, so you were not looking to expand 
anything. I know that put a big damper on it. But, can you tell 
me what the VA's recommendations are on family support 
programs?
    Admiral Dunne. Well, one of our key assets is using the Vet 
Centers, which we have over 200 of them throughout the country, 
and they are available, legislatively have been made available 
to families and dependents, as well as servicemembers, for 
counseling; dealing with the challenges of deployments; et 
cetera; and also, where necessary, bereavement counseling for 
the families.
    Senator Murray. I am sure you have seen the other reports. 
They focus a lot on what the real stresses for families today 
in the current military are and how families are the support 
groups, and all the issues from health care to being there for 
someone who is critically ill for a long period of time. Did 
your task force not look at all at some of this extra support, 
additional support, needed support, for those families?
    Admiral Dunne. The task force responded to the request that 
we received from the different information sources we sought, 
including our Web site, e-mails coming in, et cetera, and----
    Senator Murray. That sounds so bureaucratic. I am just 
asking you, don't you think that there are a lot of families 
out there who, in today's world, really need additional 
services?
    Admiral Dunne. I absolutely do, and one of the ways we are 
dealing with that is with the Transition Patient Advocates, who 
have the ability to communicate with the family and determine 
where there is a need, where there is a special circumstance, 
et cetera, and for them to find an answer to that special 
circumstance anywhere within VA--that they need to go to get 
the answer.
    Senator Murray. Well, don't you think a lot of them are 
getting lost today because they don't know where to go?
    Admiral Dunne. I am confident that my fellow workers at VA 
are doing their utmost to make sure that nobody falls through 
the cracks.
    Senator Murray. And you wouldn't think that the VA needs 
today to look differently at veterans' families than they have 
in the past?
    Admiral Dunne. We need to continue to emphasize that the 
family is a very essential element to the recovery of our 
veterans and active duty personnel and we need to work with 
them to make sure that they can focus on recovery and not on 
administrative procedures.
    Senator Murray. Mr. Chairman, my time has expired, but I do 
think in today's world, with what we are asking of our men and 
women who serve us and the fact that many of them have families 
today, they end up being the caregivers. That is something we 
have to really focus on. Thank you very much, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Murray.
    I want to thank this panel very much for your testimony, 
your responses, as well as your recommendations. It will be 
helpful to our Committee as we proceed here. In case we receive 
any further questions, we will be submitting them to you for 
the record. So, thank you again, and thank you to the rest of 
the Commissioners who are here for your service to our country.
    I now welcome our third and final panel and want to extend 
our welcome to each of you.
    I extend a welcome and aloha to Ms. Ariana Del Negro, the 
wife of an Army Ranger who suffered a Traumatic Brain Injury 
while serving in Iraq in 2006. Ms. Del Negro traveled all the 
way from my home State of Hawaii to testify before the 
Committee today. Ms. Del Negro also testified at a field 
hearing I held this August in Honolulu where she shared the 
challenges that she and her husband have faced in obtaining 
proper medical care for his injuries. I thank Ms. Del Negro for 
traveling a great distance to share her and her husband's 
experience with us and for the record.
    Also testifying on the third panel are Colonel Peter Duffy, 
who is the Deputy Director of Legislative Programs for the 
National Guard Association of the United States; Gerald Manar, 
the Deputy Director of VFW's National Veterans Service, who is 
representing the views of the Independent Budget; Meredith 
Beck, National Policy Director of the Wounded Warrior Project; 
and Colonel Steve Strobridge, Director of Government Relations 
for the Military Officers Association of America.
    I thank all of you for being here today and look forward to 
hearing your perspectives on the proposals and recommendations 
put forth in the reports of those who appeared on today's 
earlier panels. Of course, your full statements will appear in 
the record of the hearing.
    May I ask Ms. Del Negro to begin with your statement.

                STATEMENT OF ARIANA DEL NEGRO, 
                   WIFE OF 1LT CHARLES GATLIN

    Ms. Del Negro. Thank you very much. As you mentioned, my 
name is Ariana Del Negro and I am here representing most of the 
families who are entering the awkward transition stage between 
active duty and veteran status.
    As Chairman Akaka mentioned, my husband, Charles Gatlin, a 
First Lieutenant and scout platoon leader of his infantry 
battalion, was wounded September 28, 2006, after a vehicle-born 
improvised explosive device detonated less than 20 yards from 
where he was standing. My husband is a very accomplished 
soldier. His prior service was in the Old Guard. He deserved 
better care when he came home.
    He was subsequently returned to Hawaii approximately 4 
weeks after his injury. It was immediately frustrating. At our 
first doctor's appointment they didn't know what a VB-IED was; 
they also took no initiative to get him the care he needed. My 
husband, an Army Ranger, a 200-pound man who was responsible 
for collecting intelligence to ensure the safety of his fellow 
soldiers, admitted he was having anxiety at his first 
neurologist appointment. The response from the neurologist, 
``See me in 2 weeks,'' was inappropriate--absolutely 
inappropriate.
    My husband could not drive when he came home. He had severe 
vertigo. He leaned to the left. He had hand and facial tics and 
he couldn't keep eye contact when speaking. My husband used to 
work in the Pentagon in the public tour program. There was no 
room for error with speech. He developed a stutter and it 
significantly compromised his communication abilities. I had to 
act on his behalf as his agent. He was unable to follow 
conversations. He did not receive any education about his 
injury.
    I work in the health care field and made sure to 
familiarize myself with the complexities of the injury and the 
required standard of care that should be delivered. Throughout 
this process, initially at Tripler Army Medical Center, that 
standard of care was not administered. There was no 
coordination of care. There was no communication between 
providers. And the providers we were able to see, and only able 
to see after we demanded that those appointments be made, did 
not have any consensus between them.
    Subsequently--this was January of 2007--we finally had a 
meeting with my husband's providers. They still did not have a 
coordinated care plan established, and it was at that time that 
we continued with our insistence that he be referred to the 
Defense and Veterans Brain Injury Center in San Diego for 
treatment. Our request for referral was finally granted January 
31, 2007, 5 days before the Washington Post articles were 
released.
    Our experience represents exactly what those articles 
captured. It was humbling to see that we were not an exception 
but more the rule, and it was very sad. I am from Bethesda, 
Maryland. I work in the health care industry for a very large 
online health care resource. We have no children and I 
telecommute to New York for work. The responsibilities that me 
and my husband were asked of were not fair. If they were not 
fair for us, who were more independent and capable, what does 
that mean for these other families, for those whose husbands 
return far worse off than my husband, for those with children 
who have to work to supplement the family's income and who 
don't know that the care they are receiving is not what they 
need?
    I urge you to continue to support these families, 
specifically by extending resources to them. I would not have 
known about the Defense and Veterans Brain Injury Center had I 
not done extensive research and actively reached out to those 
providers.
    I must mention that we received care at the Sharp 
Rehabilitation Program, which coordinated with Balboa Naval 
Medical Center. The treatment at Sharp was impeccable. It 
represented the complete antithesis of the treatment we 
received at Tripler and my husband came home a husband. I am no 
longer a caregiver, I am a wife. Because of Sharp, which was a 
civilian program--because they had 20 years of experience, we 
managed to survive as a family. That is the bottom line. That 
is the most important message. We can sit here all day and 
discuss the importance of policy, but unless some of these 
things are implemented immediately, we will continue to fall 
through the cracks.
    Thank you.
    [The prepared statement of Ms. Del Negro follows:]
   Prepared Statement of Ariana Del Negro, wife of 1lt Charles Gatlin
    Mr. Chairman, Committee Members, thank you for allowing me the 
opportunity to participate in this vital forum on the issue of 
providing coordinated care to servicemembers, veterans, and their 
families. My name is Ariana Del Negro and I represent one of the many 
families with a loved one injured in Iraq or Afghanistan who are now 
entering the awkward and unfamiliar transition phase between active 
duty and veteran status. I am here today not only to tell you about the 
numerous obstacles my husband and I faced when he first returned home 
from Iraq, but also to describe the excellent care he ultimately 
received for his Traumatic Brain Injury (TBI). My husband and I believe 
that there is much work to be done and hope that sharing our 
experiences will help create a model of care for servicemembers and 
veterans with TBI and their families that establishes: (1) strong 
support networks and access to information; (2) timely, comprehensive, 
and coordinated care; and (3) appropriate funding for the continued 
research and training required to provide a high standard of long-term 
care to the ever-increasing numbers of warriors suffering from TBI.
    The wounds suffered from these injuries extend beyond the soldier; 
the frustrations with gaps in care and lack of support also wound the 
families fighting for their loved ones. These servicemembers, veterans, 
and families need our help, and the responsibility to provide them with 
that help falls on the Nation for whom these warriors bravely fought.
                               our story
    My husband, 1LT Charles Gatlin was the Scout/Sniper Platoon Leader 
of his Infantry Battalion. He was honored to hold this highly coveted 
position, one which was reserved for the ``best'' lieutenant in the 
Battalion. He took pride in having the degree of skill and 
professionalism required for the position, particularly because his 
work gathering intelligence helped both to ensure the safety of his 
fellow soldiers and to meet the larger objective of unifying a 
politically and religiously diverse area. My husband commands deep 
respect from his soldiers and continues to perform his job (albeit in a 
different capacity) with the highest degree of excellence and 
professionalism.
    On September 28, 2006 in Kirkuk, Iraq, my husband suffered a 
closed-head TBI after a very large vehicular-borne improvised explosive 
device (VBIED) detonated less than 20 yards from where he was standing. 
He was exposed to three concussive forces: first, the explosion; then 
the engine block from the vehicle which struck him on the back of the 
head as he was thrown into the air; and finally when he hit his head 
again after falling to the ground on his back, where he remained 
unconscious for at least 10 minutes.
    The screening and care my husband received in the battlefield and 
in the theater was excellent, proficient, and per protocol. Within 1 
hour of his injury, my husband was medevaced to Balad Medical Hospital 
where he was admitted in serious condition. After 3 days in the 
intensive care ward, he was eventually discharged from the hospital and 
returned to his base in Kirkuk in hopes that his initial TBI symptoms 
would subside enough that he could return to the field of combat within 
a few weeks. I believe that my husband was returned to his base in 
Kirkuk instead of being medevaced to Landstuhl Regional Medical Center 
in Germany because of his insistence that he be back with his men in 
the field. During the 4 weeks my husband spent back in Kirkuk, he had 
to depend on his medic and roommate, CPL Joshua Harmon. CPL Harmon 
tended to him, helped him dress, assisted him when moving from room to 
room, and checked his pupils each night. (Sadly, on August 22, 2007, 
CPL Harmon and nine of his fellow Scout platoon members died in a 
helicopter crash outside of Kirkuk, Iraq. To CPL Harmon and his family, 
and to the families of his fallen comrades, thank you.)
    After spending approximately 4 weeks in Kirkuk without resolution 
of his symptoms, my husband was returned back to his home base in 
Hawaii. He could barely keep his balance, let alone figure out where he 
was supposed to go and whom he was supposed to see for his medical 
care. Unfortunately, the system he reported to, Tripler Army Medical 
Center, did not know either.
    My husband had sustained what is now known as the ``signature 
wound'' of the Global War on Terror. However, he was injured before 
this phrase was coined and before the full implications of the injury 
were recognized. The general lack of awareness of TBI at the time of 
his injury, coupled with its ``silent'' symptoms, were significant 
barriers when my husband first sought medical treatment upon his return 
from Iraq.
    A closed-head TBI is literally a hidden injury; an injury with the 
potential for subtle yet devastating symptoms that go unnoticed by 
those who are unfamiliar with the individual's functioning prior to his 
or her injury. Health care professionals are used to having physical 
evidence of an injury, but mild, closed-head TBIs typically do not show 
up on brain scans and referrals for treatment must be made on the basis 
of neurological exams, self- and family-reported symptoms, and the 
results of neuropsychological testing.
    When he first returned home from Iraq, my husband complained of 
debilitating headaches, chronic vertigo, memory lapses, anxiety, and 
hearing loss. He leaned to the left, developed hand and facial tics, 
and could not maintain eye contact when speaking. Two weeks later, as 
some symptoms worsened, new symptoms emerged. He developed a 
significant stutter, had difficulty recalling words, and frequently 
dropped objects. Unable to drive, this fiercely independent man lost 
his autonomy and was forced to depend upon others for his basic needs. 
It was also at this time that he began to withdraw socially, avoiding 
public and busy areas. His time was mostly spent sitting, staring 
blankly. Watching my husband, an exceptionally accomplished and strong 
man, struggle with such simple tasks was very difficult.
                         early disappointments
    The phrase ``twice wounded,'' often used to describe the struggles 
wounded warriors face when seeking care in the military health care 
system may seem cliched, but it is exactly what my husband experienced 
after he returned from Iraq. He describes the struggles we encountered 
at Tripler as being as painful as sustaining the injury itself.
    Treating TBI requires a multidisciplinary approach from as many as 
nine specialists. However, the single most important component of 
treatment is effective communication and coordination among these 
providers. Although Tripler had the resources required to effectively 
treat TBI, they lacked that crucial coordination. Coupled with 
Tripler's lack of experience managing TBI and post-concussive syndrome 
(a diagnosis made when a patient continues to exhibit symptoms from TBI 
beyond 1 month), this lack of coordination compromised and slowed my 
husband's recovery. Despite his worsening symptoms, we had to fight for 
every referral he needed--audiology, vestibular testing, ophthalmology, 
speech therapy, etc. And, even after we were referred to and met with 
these specialists, no two specialists agreed about what my husband 
needed; we spent our days shuttling from one appointment to the next, 
only to discover that the recommendations made by one provider were 
deemed unnecessary by another.
    Many of the providers we saw had little or no experience with 
blast-related TBI. When my husband told the doctors treating him at 
Tripler that his injury was caused by a VBIED, they asked him what a 
VBIED was. Likewise, when my husband--the brave infantryman who had 
insisted on remaining in Kirkuk after his injury--actually summoned up 
the courage to acknowledge to his neurologist that he was experiencing 
anxiety, his neurologist simply responded: ``See me in 2 weeks.'' Had 
this neurologist instead taken the time to find out what my husband's 
responsibilities were in Iraq and what he witnessed, he would perhaps 
have realized that exposure to these stressors meant my husband was at 
increased risk for depression, anxiety, and other psychological issues. 
In my husband's case, these risks were exponentially compounded by the 
fact that several symptoms associated with post-concussive syndrome 
secondary to TBI are psychological in nature. Whether due to a lack of 
combat experience, poor training, or overwhelming caseloads, these 
doctors simply did not have the knowledge or skills to treat my 
husband's injuries.
    Similarly, because doctors cannot see physical evidence of TBI, 
they sometimes wrongly conclude that servicemembers suffering from TBI 
are malingering and trying to shirk their duties and avoid returning to 
Iraq or Afghanistan. One of the physicians treating my husband in 
Hawaii made exactly this kind of accusation against my husband, which 
added salt to an already open wound.
    My husband was unable to drive, which placed responsibility for 
taking him to each and every one of his appointments and to and from 
work on me, his lone caregiver. Because of the adverse cognitive and 
communication effects of his injury, I also had to act as his 
representative, speaking and processing information on his behalf. But 
the system at Tripler was far from encouraging and supportive of my 
efforts. Many of the people we encountered seemed to be less than 
pleased with a wife who was outspoken, informed, and persistent. One 
physician even went so far as to suggest that my husband was receiving 
poor care because of my outspokenness.
    Finally, after 14 long and frustrating weeks of struggling with the 
system to get my husband the care he needed, our request for referral 
to the Defense and Veterans Brain Injury Center (DVBIC) at Balboa Naval 
Medical Center in San Diego, CA, for thorough evaluation and 
comprehensive treatment was granted. After waiting another 6 weeks for 
the paperwork to be finalized, we finally arrived in San Diego. All 
told, it took us more than 5 months to get access to this excellent 
level of specialized health care. These were five valuable months lost 
in the crucially important acute rehabilitation stage of TBI.
        fine example of excellent care and invaluable education
    The care in San Diego represented the complete antithesis of what 
we received in Hawaii. The DVBIC at Balboa coordinates its care with 
the Community Re-Entry Program at Sharp Rehabilitation Center, a center 
with more than 20 years of experience in rehabilitative care. The 
providers at Sharp and at Balboa addressed all of my husband's needs 
(physical, occupational, and speech therapy), integrated our requests 
into their rehab program, and provided amazing support to both of us. 
My husband finally received the care he should have received all along. 
He underwent intensive rehabilitation 7 hours a day, 4 days a week. We 
had biweekly coordination meetings with all of my husband's providers 
who met with us to discuss his progress, make suggestions, and ask for 
feedback.
    The care my husband received in San Diego represented what we 
should have been receiving all along. I use the term ``we'' because the 
caregiver and family unit are integral to a successful rehabilitative 
process. In stark contrast to the care in Hawaii, where my involvement 
was discouraged, the program in San Diego integrated the caregiver into 
the rehabilitative process.
    And, importantly, they educated us. We learned that our situation 
was not unique and that many closed-head TBI patients face similar 
obstacles and frustrations that compound their symptoms. Shortly after 
coming home from Iraq, for example, my husband commented that because 
he was not missing a limb and/or did not have scars on his head or 
body, he questioned whether he was as seriously wounded as those with 
visible injuries; a question reinforced by his experiences with some of 
the doctors he encountered at Tripler. The education we received at the 
DVBIC and Sharp provided affirmation to my husband that he was 
seriously injured and deserved the best care possible. They explained 
that the adverse effects of his injury would have resolved faster had 
some of the frustration with his medical care been avoided. They also 
explained that my husband probably would have made greater progress 
during rehabilitation had he been referred earlier in the treatment 
process. Although he likely would have recovered to the same degree, he 
would have done so at a much faster rate. Importantly, they also 
explained that there may be some symptoms that will never resolve and 
that the success of his rehabilitative therapy depends on our ability 
to set reasonable goals and maintain realistic expectations.
    My husband left San Diego a changed man. He regained his ability to 
accomplish complex tasks, his speech was fluid, he was able to run, and 
he passed a driving evaluation. He was able to regain his autonomy, 
enabling me to (semi-) retire from my roles of caregiver and chauffeur. 
Now I can be a wife and he can be a husband. He has since returned to 
duty in an administrative capacity as his Battalion's Rear-Detachment 
Executive Officer in Hawaii. Although he still suffers from 
intermittent headaches, vertigo, fine motor skill deficits, and some 
memory problems, they are less intense than when he first came home. He 
has applied the lessons we learned in San Diego and is learning to 
accept and compensate for his limitations.
    Throughout this process, my husband and I have done our best to 
keep a sense of perspective, returning time and time again to our sense 
that we are one of the lucky families. My husband and I are both well-
educated and make a good living. Working in the health care industry, I 
have been able to rely upon my medical background to find appropriate 
resources. My husband was also fortunate to receive remarkable support 
from his Command. His Commander, MAJ William J. O'Brien, in the spirit 
of a true Infantryman, dedicated a significant amount of time and 
effort to ensure that my husband received the care he rightly deserved. 
Without MAJ O'Brien's support, and the support of the 25th Infantry 
Division, it's likely that I would be sharing a different story with 
you today.
    However, if it has been this difficult for my husband and me, we 
cannot imagine what it must be like for the other families--those with 
warriors who return far worse off than my husband; families with 
children; families with mothers who have to work outside the home to 
help support their families; and those who do not know that the care 
they are receiving is far inferior to what they need and, importantly, 
deserve.
       support for families at all stages in the recovery process
    The success we had at Sharp Rehabilitation demonstrated that in 
addition to providing adequate funding and training, it is important 
that systems be created to provide support for servicemembers, 
veterans, and their families. Our frustrations with my husband's 
initial care alienated us; we had nothing to compare our own experience 
with, and had no communication with other families in similar 
situations. Less than 1 week after our request for referral to the 
DVBIC was honored, The Washington Post published the first in its 
series of articles on Walter Reed, chronicling the frustrations wounded 
servicemembers, and their families faced trying to navigate through a 
complicated and bureaucratic system. The Washington Post articles were 
bittersweet: the sweet of knowing we were not alone coupled with the 
bitter of knowing we were not an exception. These articles also 
validated my belief that it is not just the individual servicemember 
who bears the brunt of injury. The unrealistic expectations that the 
system places on the caregiver add further burden to an already 
stressful and taxing situation.
    It is critically important that servicemembers and their families 
are proactively made aware of the resources that are available to them; 
they should not have to seek them out. I would not have known about the 
DVBIC unless I had actively sought out information and made contact 
with both Walter Reed and San Diego. I would not have known that my 
husband was not getting the appropriate standard of care if I did not 
have a medical background and if I hadn't done extensive research to 
educate myself on TBI. I made sure that I was armed with knowledge for 
each doctor's appointment and I did the best I could to educate my 
husband. What is clear from our own experience is that there are many 
families in need. These families need immediate access to resources, 
they need advocates, and they need support. It is one thing to develop 
resources but it is another to actually utilize them. If the families 
do not know that these resources exist, they are unlikely to ever be 
able to reap benefits from those programs.
    I am pleased that the reports from The President's Commission on 
Care for America's Returning Wounded Warriors (commonly referred to as 
the Dole-Shalala Commission), as well as the Veterans Disability 
Benefits Commission, recognize the pivotal role of family in the 
treatment process and I strongly advocate for an amendment to the 
Family Medical Leave Act, extending unpaid leave from 12 weeks to 6 
months for caregivers tending to the needs of a servicemember. I 
believe, however, that the legislation should go one step further to 
include those tending to the needs of wounded veterans, particularly 
since many of the diagnoses for TBI and PTSD are made after 
servicemembers are separated from active duty.
             the importance of timely and coordinated care
    Our success with Sharp's Community Re-entry Program was the result 
of receiving excellent individualized care and education from a 
multidisciplinary group of providers who worked well together and 
integrated the family unit into the decisionmaking process; in essence, 
they practiced ``relationship-based health care''. This medical model 
is outlined in pending legislation, such as the Veterans Traumatic 
Brain Injury Rehabilitation Act of 2007 (S. 1233).
    My husband was very high-functioning after his injury and was not 
an injured servicemember for whom the military typically considered 
intensive rehabilitation necessary. However, the increasing awareness 
of the deleterious and long-term consequences of TBI--namely through 
the adoption of the DVBICs across the country--my husband was finally 
properly identified as someone who could benefit from such care.
    Our experience at the Sharp Rehabilitation Center also demonstrates 
the importance of extending civilian health care services to 
servicemembers and veterans. Programs such as the one at Sharp have 
experience with these types of injuries, have an effective program in 
place, and clearly yield excellent results. More initiatives need to be 
taken to institute similar programs partnering military, veteran, and 
civilian health care services. In addition, consideration must be given 
to properly pairing the offerings of a rehabilitation center with the 
specific needs of a servicemember/veteran with TBI. Employing the 
valuable resources of these non-Department facilities could help reduce 
the heavy burden on the Department of Veterans' Affairs (VA)--a burden 
likely to grow in parallel with the number of wounded.
        staffing shortages and lack of training compromise care
    As noted in Dole-Shalala Commission Report, the chances of recovery 
from TBI are greatest when prompt and correct care is administered. 
Communicating this message to health care providers is pivotal to 
ensure that all servicemembers and veterans have immediate access to 
care. Meeting this objective, however, is contingent on providing 
appropriate, timely, and comprehensive training to health care 
professionals, with an emphasis on the signs and symptoms of TBI and 
PTSD. It is also dependent upon adequate long-term funding.
    This also speaks to the staffing shortages of health care providers 
in the military and VA systems. Tripler Army Medical Center is the 
largest military medical treatment facility in the entire Pacific 
Basin, covering an eligible population of 400,000 servicemembers, 
veterans, and their families. Yet, when my husband first arrived at 
Tripler for care, there were only three neurologists in the entire 
hospital. Furthermore, there was only one full-time neuropsychologist, 
a provider described in a Veterans Health Initiative as ``the key 
player in diagnosing cognitive impairments'' in patients with post-
concussive syndrome. Neuropsychological testing is a labor-intensive 
process and the results of the testing require careful and detailed 
analysis to ensure a fair assessment. Given the recent findings of the 
Neurocognition Deployment Health Study that deployment to Iraq 
increases the risk of neurological compromise, the caseload for these 
neuropsychologists will undoubtedly increase.
                        more research is needed!
    There is little doubt that more research on blast-related TBI is 
needed, particularly as it relates to the effects of exposure to 
multiple primary blasts and long-term outcomes. TBI in a combat 
environment is a complex injury. A thorough understanding of the 
nuances of the injury, whether physically evident or otherwise, is 
absolutely essential to identify effective therapies and maximize 
outcomes. Currently, much of the evidence on blast-related TBIs is 
derived from animal studies, which have helped researchers understand 
the pathophysiologic effects of the injury; however, the implications 
of these findings in the clinical setting have not been well studied. 
As the number of closed-head TBI wounds increase, so too does the need 
for allocated funding to support clinical research and new practice 
guidelines.
    For example, much of the data on TBI are largely based on older 
studies, evaluating outcomes of patients who sustained a TBI in an 
automobile accident, a fall, or a sports injury. These studies do not 
take into consideration that a blast-related TBI may injure cells at a 
more severe, microscopic, sub-cellular level. Injury to this fine of a 
degree may influence outcomes and possibly require longer periods for 
maximum recovery than TBIs suffered in a non-combat setting.
    Although much has been learned about the recovery and treatment 
process for TBI, much remains unknown, particularly about the long-term 
effects of these injuries. For example, how long should care be 
administered? When is a patient considered fully recovered? What will 
the long-term consequences of closed-head TBI be--epilepsy? 
Parkinson's? Alzheimer's? Answers to these questions remain ambiguous 
at best. Applying the tragic lessons learned from exposure to Agent 
Orange, we should prepare for the likelihood of long-term adverse 
effects from this conflict as well.
   transitioning from active duty to veteran status--action is needed
    Although my husband is still on active duty, our experience 
represents what many young veterans suffering TBI have had to face 
before being discharged from the service. We fear that without major 
reform, the obstacles and frustrations we faced within the Army's 
medical system will not be significantly different from those we may 
encounter when we enter the VA health care system. Although the VA and 
Department of Defense (DOD) systems are separate entities, the two 
departments share similar bureaucratic problems. We need to learn from 
the experiences of servicemembers and families such as ours in order to 
avoid similar obstacles within the VA system. The continuum of care 
must begin on the battlefield, move to the military health care system, 
and continue through the VA.
    We are encouraged by recent initiatives proposed by Congress, the 
DOD and the VA to improve the care and support for servicemembers, 
veterans, and their families, particularly as it relates to developing 
a strong collaboration between the two departments to streamline the 
transition process. There is little doubt that the systems to 
accomplish these goals are in place; however, they are still in the 
early stages of implementation and, as with any natural process, it 
will take time for them to mature to the degree desired. While the 
development of these initiatives are imperative for the future, we must 
not lose focus and overlook the fact that today's servicemembers and 
veterans continue to face a number of obstacles and hardships. Unless 
immediate action is taken, these individuals will continue to fall 
through the large cracks borne of years of neglect and empty promises.
                               conclusion
    Although The Washington Post articles in February 2007 have turned 
much-needed public attention to the hardships that both servicemembers 
and veterans face, they were hardly the first warnings about these 
problems. For years, the Government Accountablity Office has issued 
reports documenting the significant backlog in the VA disability 
system, the outdated nature of the VA Schedule for Rating Disabilities, 
and the incompatibility of electronic health records between the VA and 
DOD systems. Concerns regarding blast-related TBIs were also addressed 
prior to The Washington Post articles. On August 11, 2006, the Armed 
Forces Epidemiology Board presented its findings on the acute and long-
term health implications of TBI in military servicemembers to the 
Assistant Secretary of Defense for Health Affairs. The Board's 
recommendations closely mirror those made in the Dole-Shalala 
Commission Report.
    I ask of you: why did it take a series of articles in The 
Washington Post for these concerns to suddenly be regarded as serious? 
And, if only little progress has been made in response to reports over 
the course of the past few years, why should we believe that 
recommendations in the new reports will suddenly transform the status 
quo? Reform has been needed for years and some of the recommendations 
made in these reports will take still more years to implement. Where 
does that leave today's and tomorrow's generation of veterans?
    I am aware that this continues to be an ongoing learning process, 
but I also believe that measures need to be put in place to ensure that 
these changes are made, to assess the efficacy of these programs, and 
to set specific benchmarks. Thus far, we have a wealth of data and an 
abundance of recommendations. However, until these recommendations are 
actually integrated into the existing system and successfully applied, 
they will remain nothing more than notes on a page.
    In the end, my husband and I hope that you and your colleagues will 
work to make other returning servicemembers and veterans just as 
fortunate by implementing systems that: (1) provide family members with 
support and assistance navigating the system; (2) that facilitate 
coordinated care; and (3) that fund further long-term research of the 
devastating injuries of TBI and PTSD. It is time that the excellence 
that these servicemembers and veterans dedicated and displayed in the 
field of combat be matched by the system for which they sacrificed.

    Chairman Akaka. Thank you very much, Ms. Del Negro.
    Colonel Duffy?

STATEMENT OF COL. PETER J. DUFFY, USAR (RET.), DEPUTY DIRECTOR 
   OF LEGISLATIVE AFFAIRS, NATIONAL GUARD ASSOCIATION OF THE 
                         UNITED STATES

    Colonel Duffy. Chairman Akaka, Ranking Member Burr, and 
Members of the Committee, it is my distinct pleasure to appear 
before you on behalf of the National Guard Association of the 
United States (NGAUS), to address certain recommendations of 
particular concern to the welfare and benefit of our wounded 
National Guard members and their families, as set forth in the 
report of the President's Commission on Care for America's 
Returning Wounded Warriors, hereinafter referred to as the 
report.
    This brief submission will address four recommendations of 
the report relative to improving care for our wounded members. 
NGAUS supports all recommendations of the report with 
additional recommendations of its own to improve the subject 
care. NGAUS urges this Committee to continue to differentiate 
between the medical needs of our active duty members and our 
veterans, particularly with respect to geographical barriers.
    It is important to note that National Guard members 
returning from deployment can be extended on active duty for 
treatment by military treatment facilities before being 
discharged. In most cases, our members, upon returning from 
deployment, are quickly discharged from active duty and then 
eligible as veterans for care at the Department of Veterans 
Affairs health facilities. Once discharged, most of our members 
continue in the Selected Reserve and, as such, are eligible to 
enroll in TRICARE Reserve Select beyond the six-month 
Transitional Assistance Management Program. However, once 
discharged, our members are no longer eligible for treatment at 
military treatment facilities.
    Report recommendation one.--Immediately create 
comprehensive recovery plans to provide the right care and 
support at the right time in the right place. The needs of our 
wounded National Guard members and their families are 
geographically spread across the full area of our country, its 
Commonwealths and Territories. Once released from medical hold, 
our wounded members return to their civilian communities, not 
to military installations. These communities are often in areas 
isolated from a Department of Veterans Affairs treatment 
facility. Obtaining continuing treatment at a DVA facility for 
many of our veterans will mean having to travel significant 
distances. This travel may require the veteran and possibly an 
accompanying family member to take time off from work, thereby 
further straining an employer-employee relationship already 
stressed by previous deployments.
    Although perhaps most often associated with States west of 
the Mississippi, geographical barriers to treatment can occur 
in States as small as Rhode Island and as far East as Maine. 
Maine Representative Michael Michaud, Chairman of the Health 
Subcommittee of the House Veterans Affairs Committee, indicated 
this session at a hearing of his Subcommittee that some of his 
veterans in the State of Maine must travel 9 hours to be 
treated at facilities in Boston. In recommending the creation 
of Comprehensive Recovery Plans to provide the right care and 
support at the right time, in the right place, the report 
speaks to the need to expand DVA treatment for our National 
Guard members in their communities. If necessary, this may mean 
authorizing DVA to contract with civilian health care providers 
and other facilities to remove the geographical barriers 
peculiar to the National Guard veterans. Our members and their 
families deserve no less.
    Report recommendation three.--Aggressively prevent and 
treat Post Traumatic Stress Disorder and Traumatic Brain 
Injury. Without a shifting of care to the communities, the 
geographical barriers to treatment may be insurmountable for 
the psychologically wounded and for those suffering from 
Traumatic Brain Injuries (TBI). Experts have written that 
individuals experiencing moderate to severe brain injuries 
require a continuum of care that, at some point, will involve 
community-integrated rehabilitation that will include 
neurobehavioral programs, residential programs, and home-based 
programs.
    For those requiring behavioral readjustment or treatment 
for Post Traumatic Stress Disorder and willing to seek the 
same, eliminating time and distance factors will intuitively 
expedite and ease the transition from non-recognition to 
treatment. Physicians say that the sooner these behavioral 
conditions can be recognized and treated, the more successful 
and mitigating the treatment will be. DVA needs to have access 
to all available behavioral health care resources in 
communities throughout the country to provide the care our 
National Guard veterans and their families are requiring in a 
convenient location.
    In addition to removing geographical barriers for 
psychological health, it is essential that mandatory cognitive 
screening both pre- and post-deployment be implemented to 
establish a baseline against which any delta in cognitive 
functioning occurring during deployment can be determined for 
purposes of expeditiously diagnosing and treating TBI and 
possibly PTSD conditions. The screening technology exists and 
needs to be implemented immediately.
    Report recommendation four.--Significantly strengthen 
support for families. NGAUS strongly supports amending the 
Family and Medical Care Leave Act as recommended in the report 
to authorize family caregivers for our wounded members to take 
leave from employment for up to 6 months. A visit to Walter 
Reed will quickly show that our seriously wounded National 
Guard members are actively attended by family members for 
extended periods. These family members should not be penalized 
with the loss of employment for attending to the needs of our 
heroes with their care and support.
    Under current law, an employee would only be allowed a 
total of 12 weeks during a 12-month period to provide such 
care. In too many cases, the serious injuries suffered in the 
Global War on Terror are requiring far more than 12 weeks of 
treatment. As our members convalesce in military treatment 
facilities or in their communities over these extended periods, 
the care of their loved ones is an irreplaceable comfort to 
them and an immeasurable aid in the recovery process. Extending 
the 12-week period to 26 weeks under the FMLA would provide the 
caring family members with the assurance that he or she will 
not be terminated from reemployment during that extended period 
of care should it be needed.
    Report recommendation five.--Rapidly transfer patient 
information between DOD and VA. The recommendation that DOD and 
the VA must move quickly to transfer clinical and benefit data 
to users will require interoperability of the AHLTA and VISTA 
electronic recordkeeping systems used by DOD and DVA, 
respectively. Although this moment of interoperability is 
reported by DOD's contractors to be close at hand, the medical 
needs of our National Guard members have been overlooked with 
this effort that does not require the records of civilian 
health care providers treating our members to be entered into 
the DOD AHLTA database.
    Currently, although the technology exists, there is no 
mandate from DOD to scan or otherwise enter hard copies of our 
National Guard members' medical records from their civilian 
health care providers into the DOD AHLTA database. Please keep 
in mind that our National Guard members in a non-deployed 
status do not receive their medical care from military 
treatment facilities but from civilian physicians.
    Failure to scan National Guard members' civilian treatment 
records into the AHLTA database will continue to keep military 
physicians in the dark when treating our members relative to 
preexisting conditions and medication histories found in their 
civilian medical records. Lack of ready access to this 
information in emergency treatment situations during 
deployments puts the National Guard patient at risk while being 
treated by military physicians.
    The recommendation of the report needs to go further to 
include the mandatory transfer of all MTF treatment records for 
National Guard members into the DOD and DVA electronic records 
system. If these records were required to be entered into the 
AHLTA system, then they would also be accessible to the DVA 
once interoperability of the DOD and DVA systems is attained.
    In conclusion, we at NGAUS hope that we have both 
reinforced and amplified, where needed, the recommendations of 
the report of the President's Commission on Care for America's 
Returning Wounded Warriors relative to the needs of the 
National Guard.
    Thank you again for this opportunity to address this 
Committee and for all that you do for our Nation's veterans. 
Thank you.
    [The prepared statement of Col. Duffy follows:]
Prepared Statement of Col. Peter J. Duffy, USAR (Ret), Deputy Director 
of Legislative Affairs, National Guard Association of the United States
    Chairman Akaka, Ranking Member Craig, and Members of the Committee, 
it is my distinct pleasure to appear before you on behalf of the 
National Guard Association of the United States (NGAUS) to address 
certain recommendations of particular concern to the welfare and 
benefit of our wounded National Guard members and their families as set 
forth in the Report of the President's Commission on the Care for 
America's Returning Wounded Warriors (hereinafter referred to as the 
Report). This brief submission will address four recommendations of the 
Report relative to improving care for our wounded members. NGAUS 
supports all recommendations of the Report with additional 
recommendations of its own to improve the subject care. NGAUS urges 
this Committee to continue to differentiate between the medical needs 
of our active duty members and our veterans particularly with respect 
to geographical barriers.
    It is important to note that National Guard members returning from 
deployment can be extended on active duty for treatment at Military 
Treatment Facilities before being discharged. In most cases our members 
upon returning from deployment are quickly discharged from active duty 
and then eligible as veterans for care at the Department of Veterans' 
Affairs health facilities. Once discharged, most of our members 
continue in the Selected Reserve and as such are eligible to enroll in 
TRICARE Reserve Select beyond the 6 month Transitional Assistance 
Management Program (TAMP). However, once discharged, our members are no 
longer eligible for treatment at Military Treatment Facilities
  report recommendation 1--immediately create comprehensive recovery 
 plans to provide the right care and support at the right time in the 
                              right place
    The needs of our wounded National Guard members and their families 
are geographically spread across the full area of our country, its 
Commonwealths and territories. Once released from medical hold, our 
wounded members return to their civilian communities not to military 
installations. These communities are often in areas isolated from a 
Department of Veterans Affairs (DVA) treatment facility. Obtaining 
continuing treatment at a DVA facility for many of our veterans will 
mean having to travel significant distances. This travel may require 
the veteran and possibly an accompanying family member to take time off 
from work thereby further straining an employer/employee relationship 
already stressed by previous deployments.
    Although perhaps most often associated with states west of the 
Mississippi, geographical barriers to treatment can occur in states as 
small as Rhode Island and as far east as Maine. Maine Representative 
Michael Michaud, Chairman of the Health Subcommittee of the House 
Veterans' Affairs Committee, indicated this session at a hearing of his 
Subcommittee that some of his veterans in the state of Maine must 
travel 9 hours to be treated at facilities in Boston.
    In recommending the creation of comprehensive recovery plans to 
provide the right care and support at the right time in the right 
place, the Report speaks to the need to expand DVA treatment for our 
National Guard members in their communities. If necessary, this may 
mean authorizing VA to contract with civilian heath care providers and 
other facilities to remove the geographical barriers peculiar to the 
National Guard veteran. Our members and their families deserve no less.
report recommendation 3--aggressively prevent and treat post traumatic 
               stress disorder and traumatic brain injury
    Without a shifting of care to the communities, the geographical 
barriers to treatment may be insurmountable for the psychologically 
wounded and for those suffering from Traumatic Brain Injuries (TBI).
    Experts have written that individuals experiencing moderate to 
severe brain injuries require a continuum of care that at some point 
will involve community integrated rehabilitation that will include 
neurobehavioral programs, residential programs, residential programs 
and home based programs.
    For those requiring behavioral readjustment or treatment for Post 
Traumatic Stress Disorder and willing to seek the same, eliminating 
time and distance factors will intuitively only expedite and ease the 
transition from non recognition to treatment. Physicians say that the 
sooner these behavioral conditions can be recognized and treated, the 
more successful and mitigating the treatment will be. DVA needs to have 
access to all available behavioral health care resources in communities 
throughout the country to provide the care our National Guard veterans 
and their families are requiring in a convenient location.
    In addition to removing geographical barriers for psychological 
health care, it is essential that mandatory cognitive screening both 
pre and post deployment be implemented to establish a baseline against 
which any delta in cognitive functioning occurring during deployment 
can be determined for purposes of expeditiously diagnosing and treating 
TBI and possibly PTSD conditions. The screening technology exists and 
needs to be implemented immediately.
 report recommendation 4--significantly strengthen support for families
    NGAUS strongly supports amending the Family and Medical Leave Act 
(FMLA) as recommended in the Report to authorize family care givers for 
our wounded members to take leave from employment for up to 6 months. A 
visit to Walter Reed will quickly show that our seriously wounded 
National Guard members are actively attended by family members for 
extended periods. These family members should not be penalized with the 
loss of employment or attending to the needs of our heroes with their 
care and support.
    Under current law an employee would only be allowed a total of 12 
weeks during a 12 month period to provide such care. In too many cases 
the serious injuries suffered in the Global War on Terror are requiring 
far more than 12 weeks of treatment. As our members convalesce in 
military treatment facilities or in their communities over these 
extended periods, the care of their loved ones is an irreplaceable 
comfort to them and an immeasurable aid in the recovery process. 
Extending the 12 week period to 26 weeks under the FMLA would provide 
the caring family member with the assurance that he or she will not be 
terminated from reemployment during that extended period of care should 
it be needed.
 report recommendation 5--rapidly transfer patient information between 
                              dod and va.
    The recommendation that DOD and the VA must move quickly to 
transfer clinical and benefit data to users will require 
interoperability of the AHLTA and VISTA electronic recordkeeping 
systems used by DOD and DVA respectively. Although this moment of 
interoperability is reported by DOD's contractors to be close at hand, 
the medical needs of our National Guard members have been overlooked 
with this effort that does not require the records of civilian health 
care providers treating our members to be entered into the DOD AHLTA 
database.
    Currently, although the technology exists, there is no mandate from 
DOD to scan or otherwise enter hard copies of our National Guard 
members' medical records from their civilian health care providers into 
the DOD AHLTA database. Please keep in mind that National Guard members 
in a non deployed status do not receive their medical care from 
Military Treatment Facilities (MTF) but from civilian physicians. 
Failure to scan National Guard members' civilian treatment records into 
the AHLTA database will continue to keep military physicians in the 
dark when treating our members relative to pre existing conditions and 
medication histories found in their civilian medical records. Lack of 
ready access to this information in emergency treatment situations 
during deployments puts the National Guard patient at risk while being 
treated by military physicians.
    This recommendation of the Report needs to go further to include 
the mandatory transfer of all non MTF treatment records of our National 
Guard members into the DOD and DVA electronic record systems. If these 
records were required to be entered into the AHLTA system, then they 
would also be accessible to the DVA once interoperability of the DOD 
and DVA systems is attained.
    In conclusion, we at NGAUS hope that we have both reinforced and 
amplified, where needed, the recommendations of the Report of the 
President's Commissions on Care for America's Returning Wounded 
Warriors relative to the needs of the National Guard.

    Thank you again for the opportunity to address this Committee and 
for all that you do for our Nation's veterans.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Daniel K. Akaka to Col. 
 Peter J. Duffy, USAR (Ret.), Deputy Director of Legislative Affairs, 
            National Guard Association of the United States
    Dear Chairman Akaka, Ranking Member Burr and Members of the 
Committee, thank you for the opportunity to respond to the following 
question:
                       mental health contracting
    Question. The Dole-Shalala report very broadly notes that 
``Congress should enable all veterans deployed in Afghanistan and Iraq 
who need PTSD care to receive it from VA.'' While the Dole-Shalala 
report did not include specifics on this recommendation, your 
organization believes this should take the form of contracting with 
outside providers. In your view, are there other options, such as 
bringing on more mental health providers and positioning them in 
communities that would address this concern?
    Response. PTSD among our Reserve Component veteran population has 
reached alarming levels. A JAMA article released November 14, 2007 
entitled, ``Longitudinal Assessment of Mental Health Problems Among 
Active and Reserve Component Soldiers Returning from the Iraq War'' 
identified 42 percent of Reserve component veterans of Operation Iraqi 
Freedom (OIF) and 20.3 percent of active duty personnel as requiring 
mental health treatment based upon their responses to the Post 
Deployment Health Re-Assessment completed 3-6 months after return from 
deployment.
    The medical community says that PTSD is treatable but stresses that 
early recognition and treatment offer the best opportunities for 
success. Although veterans suffering from PTSD can receive 2 years of 
care from the VA, many face geographical barriers in rural areas that 
delay and even frustrate their efforts to obtain the same. In serious 
cases of PTSD, this delay can prove fatal. The most desirable option 
for successfully treating veterans suffering from PTSD is the 
supplemental mental health contracting afforded by S. 38 that would 
allow veterans under the auspices of the VA to be treated conveniently 
and expeditiously in or near their communities by qualified mental 
health care providers within and without the VA.
    According to a roster compiled by the VHA Office of Public Health 
and Environmental Hazards, 751,273 Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF) veterans with out-of-theater dates 
through May 2007, have left active duty and have become eligible for VA 
health care. According to the subject roster, 389,036 of these new 
veterans (52 percent) are from the ranks of our Reserves and National 
Guard while 362,237 (48 percent) are from the ranks of our active 
forces.
    Applying the percentages from the JAMA study, 42 percent of the 
population of 389,036 OIF and OEF Reserve Component veterans (163,395) 
and 20.3 percent of the population of 362,237 OIF and OEF active duty 
veterans (73,737) are arguably requiring or have required mental health 
treatment from the VA through May 2007. The treatment needs of this 
growing new veteran group and the mental health care needs of the pre-
2002 veteran population have overwhelmed mental health care facilities 
of the VA. They will continue to do so unless all mental health care 
providers in the country can be engaged in treating our veteran 
population.
    The need for the rapid delivery of mental health care in the widely 
scattered communities of our surging veteran population is urgent. 
Unfortunately, the VA does not and will not have that capability 
without mobilizing all mental health providers in every community with 
a nearby veteran population. Because it is impractical for the VA to 
hire all mental health providers or to build clinics in every 
community, the solution must lie in authorizing the VA to contract, 
when necessary, with mental health care providers in remote areas 
having a veteran population in need of mental health care. This is what 
S. 38 would provide for veterans and their families.
    S. 38 is modeled after similar programs operating in Montana, 
Washington and South Dakota where the VA has been contracting 
successfully with Community Mental Health Centers in delivering 
behavioral health care to our members in those expanded geographically 
areas. Because the mental health contracting program has been proven 
effective, it should be made available to all areas of the country 
where it is needed. The pilot program proposed by S. 2162 is 
appreciated but it will only serve to delay nationwide implementation 
of a necessary program that has already been successfully piloted.
    Please note that S. 38 already builds into its matrix the features 
of the proposed pilot program of S. 2162. If the civilian provider 
effectively addresses the needs of our members, the VA will continue to 
use that provider, but only as long as the need persists. Any decision 
to contract with outside mental health care providers would be driven 
by need recognized by the VA. Each regional VA facility would be able 
to evaluate the effectiveness of any contracted behavioral care 
provider. The VA would retain oversight and control of the process.
    Five years into this war, the geographically dispersed behavioral 
needs of our members and families are not being met by the VA. Those 
needs cannot endure another pilot program in ten regions. Veterans in 
rural areas outside the pilot areas would still be neglected. Denying 
those veterans and their families outside of the ten pilot regions the 
same treatment options as those within the ten regions is neglectful 
and unfair. Moreover, without participation across the country, 
information on the availability of the pilot programs will be difficult 
to disseminate. For the VA to claim that it alone can address these 
needs in house is admirable, but ultimately neglectful of our veterans' 
mental health needs.
    The question may arise within the Committee that if the contracting 
programs in Montana, Washington and South Dakota have worked work so 
well, why have they been they limited to those states? The answer to 
that question lies in the reluctance of the VA to contract with local 
care providers, not in the lack of quality care available in the 
civilian community. The Committee should recall the testimony of Tammy 
Duckworth on this point.
    This Committee heard testimony from witnesses on November 6 about 
the difficulty the VA has had in finding qualified physicians in the 
remote area of Marion, Illinois. Ms. Duckworth, Director of the 
Illinois Department of Veterans' Affairs, testified about a lack of 
health care consistency across the VA especially in rural communities. 
She criticized the reluctance of the VA to access local physicians 
despite having the authority to do so. S. 38 would send a clear message 
that it may be necessary for the VA to care for the behavioral needs of 
our veterans by contracting with mental health care providers in the 
civilian community.
    Contracting with local health care providers will not toll the 
death knell for the VA. S. 38 does not seek to tear down the brick and 
mortar of the VA but to offer an affordable and viable alternative in 
addressing the historical surge of PTSD cases in our veteran 
population. Using civilian providers in remote areas when necessary 
will save the VA the costs of hiring staff and acquiring space in 
remote areas not otherwise having a large veteran population.
    Using local civilian providers when necessary would also give the 
veteran consumer a closer and more immediate choice once he or she 
overcomes the reluctance to recognize the need for treatment. That 
reluctance, once overcome, could return to the detriment of the veteran 
if time and distance barriers delay treatment. A distant VA facility 
might also require the veteran and family members to take time off from 
work which would only further stress an employment relationship already 
stressed by a previous deployment. Local treatment would avoid leaving 
the veteran and family member the choice of distant treatment for a 
poorly understood illness or continued employment. It is in the best 
interest of the veteran to remove the time and distance barriers to 
make mental health treatment as convenient as possible.
    It is important to reemphasize that S. 38 does not require the DVA 
to contract with civilian providers. It only authorizes the VA to do so 
with the force of a statute that breaks internal and perhaps regional 
adhesions that are blocking innovation and response in this crisis.
    The downside risk posed by S. 38 is minimal. PTSD is not unique to 
the military. Licensed civilian psychiatrists are fully capable of 
recognizing and treating PTSD without having to enter an employment 
relationship with the VA to do so. To require them to be employed with 
the VA as a condition to treat our veterans at government expense would 
waste a needed capability.
    There is a sense that the VA and some veteran support organizations 
are pushing back against this legislation out of fear that it would 
diminish the VA when the contrary would be true. S. 38 would expand the 
outreach of the VA throughout a state in a qualitative and cost-
effective manner that would inure to the benefit of our veterans and 
their families. Insistence on the VA's paternal model of delivering 
health care, although very effective in most cases, should yield, in 
this instance, to the behavioral health care needs of our veterans and 
families who need the geographical outreach in mental health treatment 
that S. 38 would provide.
    NGAUS is and will remain a staunch supporter of the Department of 
Veterans Affairs (DVA). The DVA is and will remain the backbone of 
service and benefits to our veterans. NGAUS is committed to a robust 
DVA that would only be made more robust by authorizing it to engage all 
available behavioral health care providers within and without DVA to 
enable it to provide the necessary surge capacity in meeting the 
burgeoning behavioral health care needs of our veterans and their 
families.

    Chairman Akaka. Thank you very much, Colonel Duffy.
    Mr. Manar?

    STATEMENT OF GERALD T. MANAR, DEPUTY DIRECTOR, NATIONAL 
   VETERANS SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
   STATES, ON BEHALF OF THE MEMBERS OF THE INDEPENDENT BUDGET

    Mr. Manar. Mr. Chairman and Members of the Committee, thank 
you for the opportunity to speak with you about transition 
issues affecting the men and women who serve our Nation with 
perseverance, courage, and honor.
    For more than 20 years, the members of the Independent 
Budget--AMVETS, Paralyzed Veterans of America, the Disabled 
American Veterans, and the Veterans of Foreign Wars--have 
annually assessed the state of the VA and made recommendations 
to Congress, which would, if adopted, better help the 
Department of Veterans Affairs help veterans. Interestingly, in 
recent years, many of our recommendations on the VA budget, 
health care, construction, and other issues have been closer to 
VA's actual needs than were reflected in the budgets submitted 
to Congress. We are not new to this work. Our organizations 
have been working with and serving America's veterans for more 
than 100 years.
    With this as background, I would like to take a few minutes 
to discuss the recommendations of the President's Commission on 
Care for America's Returning Wounded Warriors, and in contrast, 
the recommendations of the Veterans Disability Benefits 
Commission.
    The President's Commission was created in March 2007 and 
ended its work in July 2007. They did a significant amount of 
work in a little over 4 months. Where they were strongest was 
in those areas of their principal interest--care for injured 
servicemembers at the end of their military service and their 
transition from active duty to civilian life. Where they were 
weakest, in our view, is in the area of reforming the VA 
compensation program.
    Our written testimony outlines in great detail those 
transition recommendations we believe are most effective, and 
most likely to help disabled servicemembers. We would like to 
use our short time this morning discussing some of the problems 
we note with the President's Commission and the alternatives 
provided by the Disability Commission.
    The President's Commission recommends creation of a two-
tiered system of benefits, one for combat veterans and one for 
all other veterans. We find this an unacceptable distinction, 
one which is not supported in history, law, or the veteran 
community.
    We are all veterans equally. This is not a new concept. The 
Bradley Commission adopted a guiding principle in April 1956, 
which said, in part, that providing compensation on a uniform 
basis to people with equal handicaps is the best possible way 
to discharge our obligation to them. Fair and equal treatment 
of all veterans, disabled and non-disabled, according to their 
service-connected needs should be the guiding principle in all 
our programs.
    The Veterans Disability Benefits Commission, in their 
Guiding Principle Three, stated that compensation must be based 
on severity of disability and not where or how it was incurred, 
and Congress, no less, supports this principle since it 
eliminated separate compensation for disabilities incurred in 
combat with legislation in 1972.
    This does not mean that distinctions cannot be made among 
veterans. In fact, the opposite is true, and this is a theme 
that runs through the Disability Commission report--that the 
more seriously disabled a veteran is, the more treatment, 
support, and benefits he or she should receive.
    The President's Commission recommends the creation of 
transition payments, and with this we concur--not necessarily 
in the form that they propose, but rather as a separate 
benefit, totally unrelated to compensation. All of us in this 
room who are veterans have had the opportunity to be released 
from active duty, and after the first joy of the moment has 
passed, we wonder what we are going to do. Now, some of us have 
planned ahead and we have lined up jobs, but many veterans come 
home, they take a break, and then they start looking for work.
    There is every reason to support a recommendation that 
Congress create a specific transition benefit, unrelated to 
compensation. The idea that was proposed by the President's 
Commission to have a transition benefit for 3 months in lieu of 
compensation from VA for service-connected disabilities is 
unacceptable to us; but a transition benefit focused on helping 
bridge the few months following service is certainly within the 
realm of our support.
    In addition, the President's Commission, their proposals, 
if adopted, would require a new rating schedule--a new rating 
schedule which, in their view, could be done in 6 months. I 
submit to you that I could sit down and in a matter of a week 
or two come up with a new rating schedule. That doesn't 
necessarily mean that it is better, it would simply be 
different.
    The Veterans Disability Benefits Commission, on the other 
hand, has provided in their report an ordered and deliberate 
process for evolving and reforming the ratings schedule that 
the VA currently uses, and we commend their recommendations for 
your consideration.
    In addition, the President's Commission would, under their 
new separate program for compensating our future veterans, 
create a new rate schedule. It is totally devoid of any 
suggestion of what this rate schedule would look like or how it 
would be made up.
    Finally, there are so many other things that the VA does, 
and should be looked at from time to time, that the President's 
Commission has not even addressed. For instance, the Veterans 
Disability Benefits Commission, with the help of the Institute 
of Medicine, has come up with a plan, a scheme, for 
regularizing, if you will, the designation of disabilities that 
are presumptively related to service. Although we don't agree 
with the entire proposal, the point is that they come up with a 
process for reform, for evolving into something which is better 
than what currently exists, and that is what we support.
    If we adopt--if you adopt--the President's Commission's 
recommendation to create a second separate disability 
compensation program, what you are forcing the VA to do is to 
run two disability compensation programs for at least the next 
70 years. Imagine that, two separate programs with a workforce 
either required on an individual basis to master both programs 
or to separate the workforce to deal with both. This is an 
unnecessary imposition on the VA and on America's veterans.
    I would like to leave you with this thought. The 
President's Commission served 4\1/2\ months to arrive at their 
recommendations. In our view, nearly all of the recommendations 
dealing with VA compensation are mere bullets. They are hollow. 
They lack substance and definition. If their program is simple, 
it is because the things that make a compensation program work 
have not been added to it yet.
    On the other hand, the Veterans Commission served, studied, 
argued, and decided everything in public for 30 months. They 
did the heavy lifting necessary to support their 
recommendations with substance and process. Its report has been 
described today as 600 pages of band-aids. Well, this 544-page 
document lays a solid foundation and a clear path forward for 
reform of the VA compensation program. We do not agree with all 
the recommendations, but we can say, conclusively, that we 
agree with the framework that they have laid down to effect 
change in an ordered, evolutionary way.
    Thank you for your time this afternoon and I will take 
questions when you have them.
    [The prepared statement of Mr. Manar follows:]
   Prepared Statement of Gerald T. Manar, Deputy Director, National 
         Veterans Service, Veterans of Foreign Wars of the U.S.
    Thank you for this opportunity to provide the views of the members 
of the Independent Budget--AMVETS, Disabled American Veterans, 
Paralyzed Veterans of America and the Veterans of Foreign Wars of the 
United States--on VA and DOD collaboration, the Report of the 
President's Commission on Care For America's Returning Wounded 
Warriors, the Report of the Veterans Disability Benefit Commission and 
other related reports.
    It seems that every few years another study is commissioned to 
examine some of the problems involving benefits and delivery of 
benefits available to service disabled veterans. With the Veterans 
Disability Benefits Commission (VDBC), a pattern has emerged that our 
Nation requires a more comprehensive review every 50 years or so to 
help us all refocus on the entire system of benefits, note the things 
that are working well and devise solutions to those that no longer 
fully address the needs of the men and women who stood ready in both 
peace and war to defend our Nation, even at the possible cost to 
themselves of disability or death.
    Six years after terrorists attacked us on American soil, we remain 
deeply embroiled in armed conflict in both Iraq and Afghanistan. Over 
3,800 men and women have been killed and nearly 28,000 wounded. Another 
29,000 were treated for diseases and injuries not arising from combat, 
disabilities so debilitating that they required air transport from the 
region in order to receive appropriate medical treatment.\1\ There is 
no accounting for the thousands of other service men and women who were 
treated and returned to duty in that troubled region of the world.
---------------------------------------------------------------------------
    \1\ http://icasualties.org/oif/; October 12, 2007.
---------------------------------------------------------------------------
    Thousands of soldiers, Marines, sailors and airmen have returned 
home with catastrophic injuries. It was their difficulty in obtaining 
treatment, proper housing, adequate benefits and services, as well as 
basic help in the transition from military service to civilian life 
that caught our attention earlier this year. What was most disturbing 
was that the problems coming to light in 2007, while perhaps 
exacerbated by the current conflict, have existed to some extent for 
decades. The Presidents Commission on Care for America's Returning 
Wounded Warriors (PCCWW), created in March 2007 and reporting 4 months 
later, examined how the Armed Services treat those with serious 
injuries and help them through discharge from service and transfer to 
the Department of Veterans Affairs.
    While this testimony will focus primarily on the recommendations of 
the PCCWW and VDBC on transition issues, we will also address the 
recommendations of both commissions on benefits provided by the 
Department of Veterans Affairs for disabilities arising while 
performing military service.
    You have before you enough ideas, suggestions and recommendations 
to create another title in the U.S. Code and keep regulation writers at 
both the Department of Defense and the Department of Veterans Affairs 
busy for the next 10 years. It is little wonder that you have asked 
those of us at this table to help you parse the cornucopia of proposals 
and make coherent the competing voices.
    There are many good things presented in these reports: some are 
simple, others complex beyond imagination. Some will help DOD and VA 
help service men, women and veterans while others would create more 
problems. Some are inexpensive while others will place additional 
burdens on the Treasury.
    We offer you our views, not to make your task easier, but rather, 
to help make the correct path more visible.
                     they are all veterans equally
    One of the Guiding Principals adopted by the VDBC was that benefits 
should be awarded based on the severity of the service-connected 
disability and not on the circumstance under which it was acquired. 
This principle is not new. At one time VA paid higher benefits to 
veterans with service connected disabilities incurred in combat. 
However, Congress recognized the inequity of paying veterans with 
identical disabilities different amounts of compensation solely because 
one received his injury in combat and the other did not; as a 
consequence, Congress equalized the rates for all veterans in 1972.
    The Veteran Service Organizations we represent today endorse the 
current government policy and completely reject the notion that 
injuries acquired in combat are any more disabling, any more worthy of 
compensation, than those incurred elsewhere in service to our country. 
We agree with the VDBC that benefits should be based only on the 
severity of disability.
                               transition
    Care for seriously disabled servicemembers.--We support the PCCWW 
recommendations which would:

     Develop integrated care teams
     Create individualized recovery plans
     Develop and assign Recovery Coordinators
     However, we oppose the idea that Recovery Coordinators 
should be Public Health Service employees. We believe that properly 
trained VA employees, with substantial support from both DOD and VA, 
can be effective in supporting seriously disabled servicemembers and 
veterans.

    We believe that these services should be provided to all seriously 
disabled servicemembers regardless of where their disabilities were 
acquired. A soldier paralyzed from the neck down from an accident in 
Germany or Korea is no less deserving of these services than is someone 
who was paralyzed by an IED in Iraq.
    Transfer of patient information across systems.--We support the 
PCCWW recommendations that would:

     Make patient information available to all personnel who 
need it
     Continue efforts for a fully interoperable information 
system between DOD and VA
     Provide internet access to personal treatment records and 
health care information through secure Web sites for servicemembers and 
veterans.

    Strengthen support for families of seriously disabled 
servicemembers and veterans.--We support the PCCWW recommendations that 
would:

     Expand eligibility for TRICARE respite care and aid and 
attendance
     Expand caregiver training for families
     Cover family members under the Family Medical Leave Act 
(FMLA)
     However, TRICARE, caregiver training and expanded coverage 
under the FMLA should be available to all seriously disabled 
servicemembers and not just OIF/OEF servicemembers.

    Improve care for servicemembers with Post Traumatic Stress Disorder 
(PTSD) and Traumatic Brain Injury (TBI).--We support the PCCWW 
recommendations that would:

     Address the shortage of mental health professionals in 
both DOD and VA
     Establish and expand networks of experts in PTSD and TBI
     Improve dissemination of clinical practice guidelines
     Increase availability of treatment for PTSD for Iraq and 
Afghanistan veterans from the VA
     While we support increased availability of mental health 
providers through the VA for veterans suffering from PTSD, the PCCWW 
recommendation that ``all Iraqi and Afghanistan veterans who need PTSD 
care [should] receive it from VA'' is problematic. First, all veterans 
who are discharged today may receive free treatment for virtually any 
problem within 2 years of discharge. In addition, this recommendation 
would allow any new veteran, regardless of the source of PTSD (e.g. 
pre-service car wreck) to move ahead of veterans with service related 
PTSD. Further, we are already receiving complaints from older veterans 
who believe that they are being forced to wait longer for appointments 
because of priorities given to newer veterans.

    We believe the better approach would be to vastly increase the 
numbers of mental health professionals at VA to provide better and 
timelier service to all veterans with PTSD. While increasing mental 
health staff, VA should use its fee-basis authority whenever old or 
young veterans must receive care immediately.
    Finally, VA should improve its ability to triage veterans with 
mental health symptoms to ensure that those who might be a danger to 
themselves or others are seen immediately and by an appropriate 
professional.
    Again, we believe that every disabled servicemember should be 
eligible for every benefit and service required by the severity of the 
disability they have and not by the place or circumstance under which 
it was incurred.
    Enhance the Joint Executive Council (JEC).--We support the 
recommendation of the VDBC to:

     Develop a strategic plan with specific milestones
     Designate lead officials responsible for each milestone
     Include DOL and SSA in the JEC

    VA and DOD should develop a joint intensive case management program 
for severely disabled veterans with an identifiable lead agent.--We 
support the recommendation of the VDBC.
    Congress should adequately fund and mandate the Transition 
Assistance program DOD-wide.--We support the recommendation of the 
VDBC.
    Benefits Delivery at Discharge (BDD) should be available to all 
disabled servicemembers including Guard, Reserve and medical hold 
patients.--We support the recommendation of the VDBC.
    DOD should mandate separation examinations for all servicemembers; 
the examination should conform with VA protocols and directives.--We 
support the recommendations of the VDBC.
    DOD should provide TRICARE free of charge for severely injured 
servicemembers and their families.--We support the recommendation of 
the VDBC.
    We commend the other recommendations from the VDBC dealing with 
transition issues to you for consideration.
                        post service transition
    Both the PCCWW and the VDBC understand the need to ensure that 
services and benefits do not stop as disabled servicemembers make the 
transition to civilian life. Too often, the only ``transition'' 
disabled servicemembers received was a Transition Assistance Program 
briefing or a bit of counseling from the VA or a veteran service 
officer at a BDD site. The recommendations discussed earlier, if 
adopted, should make the transition process much better for disabled 
servicemembers.
    However, most veterans are not seriously disabled at discharge and 
are not processed through the Disability Evaluation System. While they 
know what their education benefit eligibility might be, they have 
little knowledge of vocational rehabilitation, home loan guarantees and 
the like from VA.
    Vocational rehabilitation.--Both the PCCWW and the VDBC recommended 
changes in vocational rehabilitation which, in our view, should be 
seriously considered for implementation.

     Veterans with service connected disabilities causing 
employment handicaps should be encouraged to undertake and complete 
training that will help them find not just gainful employment but a 
career for life.
     Further, vocational rehabilitation should not be a one-
time benefit. Disabilities often worsen throughout life and some 
veterans may need vocational rehabilitation services a second time. 
Helping a disabled veteran remain productively employed should be a 
goal of VA. We believe that a disabled veteran should be able to 
utilize vocational rehabilitation more than once.
     Vocational rehabilitation subsistence allowance rates are 
inadequate to support veterans as they obtain the training needed to 
help them adjust to the employment handicap caused by their service-
connected disabilities. We support increases in subsistence allowance 
rates.

    Transition payments.--As the claims backlogs have increased at the 
VA, it seems that a growing number of people, including some Members of 
Congress, have voiced the opinion that these veterans should not be 
made to wait for VA to decide their claims for benefits. Their greatest 
concern has been for the recently discharged veteran who often has 
little income, perhaps some disability and no job. In the last year, 
some have even suggested that VA should simply pay the veteran whatever 
it is they claim.
    We oppose the use of the disability compensation program to pay 
what amounts to a transition benefit or bonus. We do, however, support 
the idea of a transition payment independent of VA compensation. We 
urge Congress to consider creating such a payment, a form of deferred 
compensation, independent and separate from VA compensation, to help 
men and women during the initial few months following their discharge 
from service.
   reengineering va disability compensation--revolution or evolution?
    In 2004 the Congress enacted legislation creating the Veterans 
Disability Benefits Commission:

        ``The purpose of the Veterans' Disability Benefits Commission 
        is to carry out a study of the benefits under the laws of the 
        United States that are provided to compensate and assist 
        veterans and their survivors for disabilities and deaths 
        attributable to military service, and to produce a report on 
        the study.'' \2\
---------------------------------------------------------------------------
    \2\ Public Law 108-136, Section 1502. See also, http://
www.vetscommission.org/index.asp. Charter.

    The first few meetings of the Veterans Disability Benefits 
Commission (VDBC) (starting in May 2005) were met with skepticism and 
wariness by some of us in the veteran community. We were well aware of 
the forces which led to the creation of that commission and were deeply 
concerned that at least some Commissioners harbored secret agendas 
which, if adopted, would lead to the dismantling of programs designed 
to help treat and compensate veterans for the residuals of disabilities 
incurred or aggravated while in service to our country.
    During the 28 public sessions spanning 55 days of public hearings, 
it became apparent that Commissioners were willing to work hard to 
learn about compensation benefits: what they are; how the program 
evolved to where it is today; and what problems exist. Further, we were 
gratified to note that Commissioners were willing to reconsider their 
opinions as facts were brought to light by the Center for Naval 
Analyses and the Institute of Medicine. We watched extensive fact 
gathering and more extensive debates on issues that were critical to 
the establishment of a foundation for later decisions.
    While we have disagreed with some decisions made by the commission 
we could tell the veterans we represent that the commission was well on 
the way to producing a thoughtful and constructive report which 
addressed many problems without harming veterans.
    A few weeks ago the VDBC released its final report. Of the 
commission's 114 recommendations, fully 83 percent deal with 
compensation benefits or factors related to compensation benefits. Even 
when the commission drifted a little afield and made recommendations 
dealing with transition issues, it is clear that most deal with 
ensuring that VA has the information it needs as soon as possible to 
process claims from veterans.
    The President's Commission on Care for America's Returning Wounded 
Warriors, on the other hand, was created in March 2007 and delivered 
its report less than four and a half months later. It produced 24 
recommendations; 8 of the 24 recommendations were focused on discarding 
the current compensation program and substituting a new program 
requiring a new rating schedule, new rates for disability benefits, new 
theories of what could be service connected, how long compensation 
payments would continue and so on.
    While there are a few ideas presented by the PCCWW that may have 
merit, the discussion, below, describes those that are most 
objectionable.

     Two-tiered system.--The PCCWW recommends the creation of a 
two-tiered system of compensation for service connected disabilities, 
one for combat injured veterans and one for all others. Under their 
proposal, combat injured veterans would be eligible for quality of life 
payments while those not injured in combat would be denied. This means 
the paralyzed veterans mentioned earlier in this paper would receive 
substantially disparate compensation even though their quality of life 
would be the same.
     Delay of compensation.--The PCCWW would delay compensation 
benefits for a minimum of 3 months and possibly for years while the 
veteran receives ``transition'' payments. In our view, it is for 
Congress to decide whether newly discharged veterans should be granted 
a transition benefit for a short period following service. Since the 
transition benefit is not based on disability but would be, in fact, 
available to all new veterans, it should not replace compensation paid 
for disability incurred or aggravated while in military service. If 
Congress agrees that vocational rehabilitation rates are too low and do 
not encourage veterans to remain in vocational rehabilitation, then it 
should raise those rates to appropriate levels.

     Average impairment of earnings capacity.--In its report, 
the PCCWW says that:

        ``Congress has directed that the VA disability compensation 
        system should replace lost civilian earnings.'' \3\
---------------------------------------------------------------------------
    \3\ PCCWW Report, pg. 109.

---------------------------------------------------------------------------
    What the law actually says is:

        ``The ratings shall be based, as far as practicable, upon the 
        average impairments of earning capacity resulting from such 
        injuries in civil occupations.'' \4\
---------------------------------------------------------------------------
    \4\ 38 U.S.C. 1155.
---------------------------------------------------------------------------
    The seemingly subtle difference between ``earnings'' and ``average 
impairment of earning capacity'' is significant. We commend to you the 
discussion in the VDBC report on this topic. We can say, however, that 
this focus on earnings rather than average impairment of earning 
capacity opens the door for some of the draconian recommendations by 
the PCCWW discussed below. What the commission recommends is nothing 
short of throwing out a compensation program, designed, refined and 
tested over 70 years to pay disabled veterans based on the average 
impairment of earnings capacity to one based solely on loss of 
earnings. This, in turn, opens the door for means testing, taxing and 
curtailing compensation.
     Means testing compensation.--The PCCWW would substitute a 
payment scheme that is means tested in place of the current 
compensation program (``. . . the amount would be recalculated 
periodically as veterans' condition or earnings change.'' Figure 11) 
(``. . . once transition payments end, disabled veterans should receive 
earnings-loss payments--to make up for any lower earning capacity 
remaining after training.'' Draft, page 6). This means that veterans 
with identical disabilities would receive different benefits or, in 
some cases, no compensation at all. The commission suggests that the 
DOD disability annuity payment, as well as the quality of life payment, 
would continue for life. However, only about 10 percent of all veterans 
(those discharged through the DES) would receive the annuity. While not 
all veterans have service-connected disabilities for which they receive 
compensation, a significant percentage of those receiving compensation 
today would not be eligible for the annuity.
    Further, since the PCCWW proposes that only combat injured veterans 
would be potentially eligible for quality of life payments, those non-
combat injured veterans no longer eligible for compensation because of 
means testing would receive nothing at all.
     Taxing compensation.--The PCCWW would tax disability 
compensation payments to veterans. In a word, we find this proposal to 
be outrageous. We are speaking of men and women who sacrificed not only 
their time and energy in defense of our Nation but who continue to 
suffer from the residuals of injury or disease incurred during that 
service. Under this proposal, veterans would be taxed to marginally 
mitigate a reduction of their benefits when they can no longer work. 
Outrageous.
     Termination at retirement.--The PCCWW proposes the 
termination of compensation benefits at ``retirement'' to be followed 
by Social Security. A recent article in the Washington Post showed that 
more people work past ``retirement'' than ever before; and the trend is 
increasing. Further, a Center for Naval Analysis study conducted for 
the VDBC shows that current compensation rates generally replace lost 
earnings if paid over a veteran's lifetime. If the PCCWW recommendation 
is adopted, veterans will not have earnings replaced by compensation 
prior to ``retirement'' unless compensation rates are substantially 
increased.
     Abuse of reexamination process.--The PCCWW recommends that 
veterans be recalled for examination every 3 years throughout their 
lifetime to determine whether their disability has worsened or 
improved. VA already has the authority to reexamine veterans whose 
disabilities could improve. This authority has existed for many 
decades. If it is not often used now it is more a function of VA trying 
to manage its workload by reducing review examinations in the face of 
extremely high backlogs than it is anything else.
    Further, this proposal is a transparent attempt to not just 
identify those individuals whose disabilities may improve over time but 
to harass those veterans whose disabilities are static. And since 
failure to report for an examination is a basis for terminating 
compensation, this practice would, if adopted, result in the 
termination of benefits to many veterans whose disabilities are either 
static or worsened primarily because they do not always notify the VA 
when they move.
    For these reasons, and others, we strenuously object to the 
proposals by the PCCWW to throw out the current compensation program 
and put in its place a program which will be harmful to the vast number 
of men and women who have volunteered to serve our Nation, and who are 
fighting even now in Iraq and Afghanistan.
    The Veterans Disability Benefits Commission has exhaustively 
examined the current compensation program, affirmed its strengths and 
pushed forward many thoughtful and constructive recommendations for 
evolving it into a mechanism to better serve America's new generations 
of veterans. Their approach is to retain the best parts of the 
disability compensation program and create a process for measured and 
deliberate reform and improvement. We urge you to carefully consider 
their recommendations.
    We trust that this is the first of several hearings on these 
reports and other proposals affecting the transition of servicemembers 
from warrior to respected veteran. We appreciate the opportunity you 
have afforded us today.

    I will be happy to answer any questions you may have for me.
                                 ______
                                 
  Response to written questions submitted by Hon. Daniel K. Akaka to 
 Gerald T. Manar, Deputy Director, National Veterans Service, Veterans 
 of Foreign Wars of the United States, on behalf of the Members of the 
                           Independent Budget
                          easy access to care
    Question. The Dole-Shalala Commission recommends that veterans with 
PTSD have immediate access to VA evaluations and treatment. You noted 
in your testimony that such an opportunity does, in fact, exist now in 
the two year window of easy access to VA care and treatment following 
release from active duty. In your view, how well is this two-year 
authority working?
    Response. According to VA, by the end of FY 2007 nearly 800,000 OIF 
and OEF veterans left active duty and became eligible for VA health 
care since FY 2002. Nearly 300,000 (37 percent) of those veterans 
obtained VA health care since their discharge. Further, slightly more 
than 120,000 veterans (40.1 percent of those seeking treatment) were 
seen for complaints of a mental disorder. Finally, half of those seen 
for mental health issues were diagnosed with PTSD.
    Clearly, OIF and OEF veterans know that health care is readily 
available from VA as demonstrated by the 37 percent who obtain it. 
Further, they know that they can receive free health care for virtually 
any condition without the need to demonstrate a connection with their 
military service.
    While some observers may be concerned that more OIF/OEF veterans 
have not sought treatment from VA, we must be mindful of the fact that 
most of these men and women are in the prime of their lives when it is 
significantly less likely that they will have medical or psychological 
conditions requiring treatment.
    We believe that the current law opening up VA health care to all 
OIF/OEF veterans for 5 years following discharge is working and no 
additional legislation will likely result in greater participation by 
these men and women.
    If Congress is concerned that this group of veterans is 
underutilizing VA health care opportunities, it could provide an 
increase in funds for advertising and outreach.

    Chairman Akaka. Thank you very much, Mr. Manar.
    Ms. Beck?

 STATEMENT OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, WOUNDED 
                     WARRIOR PROJECT (WWP)

    Ms. Beck. Thank you, sir. Mr. Chairman, thank you for the 
opportunity to testify today regarding the various reports, 
commissions, and task forces completed to date addressing the 
needs of our Nation's wounded servicemembers. The Wounded 
Warrior Project has direct daily contact with these wounded 
warriors and we have a unique perspective on their needs and 
the obstacles they face as they attempt to reintegrate into 
their communities. With respect to the reform of the Disability 
Evaluation System, the Wounded Warrior Project strongly 
supports the spirit and intent for which the Dole-Shalala and 
the Veterans Disability Benefits Commissions were established. 
WWP agrees with the finding of both reports that the current 
benefits system places too little emphasis on veterans' 
recovery, rehabilitation, and reintegration into the community. 
For those who are able, incentives to participate in vocational 
rehabilitation programs, educational opportunities, and 
reintegration to the workforce could lead to a better, 
healthier life. In addition, under the current system, 
individual unemployability ratings are necessary for some, but 
others are often burdened at a young age to choose between 
potentially beneficial vocational experience and needed 
compensation.
    Periodic evaluation, gradual reduction in compensation 
rather than abrupt termination, and improvements in the 
compensation structure for warriors with PTSD or TBI would 
result in a more effective system that enables wounded warriors 
to successfully reintegrate to civilian life. WWP believes 
these principles must be taken into consideration during 
discussions on modernizing the current disability compensation 
system and any significant changes should require ultimate 
Congressional approval.
    WWP also strongly supports removing the Department of 
Defense from the disability ratings process. DOD and the VA 
ratings systems are currently confusing and overly-burdensome. 
Currently, DOD assesses the veteran's fitness for duty. 
Following this determination, the VA performs yet another 
physical to rate the veteran for all service-connected 
injuries. Unfortunately, these ratings are not assigned in a 
vacuum. Lost records, lack of resources, ineffective training, 
and inconsistencies in the interpretation of regulations by 
both agencies are often cited as reasons for the extended 
period of time required to assign a disability rating. A system 
such as that proposed by the Commissions would encourage a more 
efficient and fair evaluation and remove one of the most 
frustrating aspects of an already difficult process.
    WWP agrees that comprehensive changes are needed within the 
compensation and benefits delivery system. However, we are 
deeply concerned that the inclusion of provisions to overhaul 
the existing veterans disability compensation system in the 
same package as health and transition-related recommendations 
would be a distraction from these important health proposals. 
Any legislation implementing compensation-related 
recommendations must be carefully crafted through a thoughtful 
and deliberate process to ensure the most beneficial outcome 
for those who have sacrificed in service to this country.
    However, as many of us recognize, the current disability 
ratings system suffers from significant shortcomings which have 
become more apparent with the passage of time. We must use our 
passion to encourage honest discussion to resolve these issues.
    WWP is very pleased that the Dole-Shalala panel recognized 
the need for education and training of family members. 
Specifically for the family members of those with severe TBI, 
who often have to leave their jobs. WWP also supports payments 
to caregivers similar to those already in place in the San 
Diego VA Medical Center for Spinal Cord Injury patients. This 
program offers training and makes eligible for payment those 
family members who have become certified as personal care 
attendants. This often removes at least part of the financial 
burden incurred by those with severe injuries.
    WWP also strongly supports the Dole-Shalala recommendation 
to implement a recovery plan that promotes prompt care in, 
quote, ``the most appropriate facility.'' With respect to 
Traumatic Brain Injury, legislation currently exists to 
facilitate such a recommendation. Section 203 of the Senate 
version of H.R. 1538, the Dignified Treatment of Wounded 
Warriors Act, would allow the Secretary of the VA to refer 
patients to non-department facilities if the Secretary is 
unable to provide the required treatment or, even more 
importantly, when the Secretary determines that such a referral 
is optimal for recovery and rehabilitation. In order to comply 
with our obligation to offer these wounded warriors the best 
care possible for their respective injuries, these facilities 
must be readily available as an option for their care.
    With respect to DOD-VA collaboration, there are still many 
issues to address, but WWP has been very impressed with the 
level of involvement of the leadership of both DOD and VA in 
the Senior Oversight Committee formed to address these issues. 
As recommended by the Dole-Shalala Commission, the SOC is in 
the process of improving the case management process through 
the creation of a Recovery Coordinator. However, the Recovery 
Coordinator can only be successful if he or she has the 
authority to break through the current barriers within both 
agencies.
    Part of that authority would have to include the overlap of 
benefits and services about which WWP and other organizations 
have previously testified and which is included in the Senate 
version of H.R. 1538, as well. An overlap would allow the 
Recovery Coordinator to access DOD and VA systems necessary to 
ensure the proper care and rehabilitation of severely injured 
servicemembers. Each agency has its own strengths. Why would we 
base their access to care on the status of the servicemember as 
active duty or retired, rather than on his medical condition?
    The skills and previous experience of the Recovery 
Coordinator are extremely important to their success. In the 
past, both agencies have based their hiring criteria for 
similar positions solely on education level. WWP is concerned 
that the agencies will once again rely on education level alone 
and exclude eminently qualified candidates with good problem-
solving skills and institutional knowledge.
    It is not only DOD and VA who need to cooperate more fully 
or collaborate more fully. Others, such as the Social Security 
Administration, Medicare, and the Department of Labor and 
private entities need to be included more fully in these 
discussions. For example, an injured servicemember recently 
contacted WWP because he was understandably confused. He had 
been rated as unemployable by the VA, but was told he did not 
qualify for Social Security disability benefits because he was 
able to work. Additionally, the Social Security Administration 
has had a difficult time accessing DOD records necessary to 
evaluate his claim. These agencies must work together to 
resolve inconsistencies in their policies, or the often-stated 
goal of seamless transition will never be achieved.
    Finally, it is imperative that a joint permanent structure 
be in place to evaluate changes, monitor systems, and make 
further recommendations for process improvement. This office 
must be structured to minimize bureaucracy and must have a 
clearly defined mission with the appropriate authority to make 
necessary changes or recommendations as warranted. With the 
passage of time, as veterans' issues fade from the national 
spotlight, it will be necessary to have that joint structure in 
place to ensure the future agency coordination.
    Thank you, and I look forward to your questions.
    [The prepared statement of Ms. Beck follows:]
  Prepared Statement of Meredith Beck, National Policy Director, The 
                     Wounded Warrior Project (WWP)
    Mr. Chairman, Senator Burr, Members of the Committee, thank you for 
the opportunity to testify today regarding the various reports, 
commissions, and task forces completed to date addressing the needs of 
our Nation's wounded servicemembers. My name is Meredith Beck, and I am 
the National Policy Director for the Wounded Warrior Project (WWP), a 
non-profit, non-partisan organization dedicated to assisting the men 
and women of the U.S. Armed Forces who have been injured during the 
current conflicts around the world. As a result of our direct, daily 
contact with these wounded warriors, we have a unique perspective on 
their needs and the obstacles they face as they attempt to reintegrate 
into communities across America.
    Due to the broad range of topics covered by this hearing, I would 
like to limit my comments to those that WWP finds most pressing.

                          Commission Reports:

    With respect to the reform of the disability evaluation system, the 
Wounded Warrior Project strongly supports the spirit and intent for 
which the Dole-Shalala and Veterans Disability Benefits Commissions 
were established. WWP agrees with the finding of both reports that the 
current benefits system places too little emphasis on veterans' 
recovery, rehabilitation, and reintegration into the community. For 
those who are able, incentives to participate in Vocational 
Rehabilitation programs, educational opportunities, and reintegration 
into the workforce could lead to a better, healthier life. In addition, 
under the current system, Individual Unemployability ratings are 
necessary for some, but others are often burdened at a young age to 
choose between a potentially beneficial vocational experience and 
needed compensation. Periodic evaluation; gradual reduction in 
compensation rather than abrupt termination; and improvements in the 
compensation structure for warriors with Post Traumatic Stress Disorder 
(PTSD) or Traumatic Brain Injury (TBI) would result in a more effective 
system that enables wounded warriors to successfully reintegrate to 
civilian life. WWP believes these principles must be taken into 
consideration during discussions on modernizing the current disability 
compensation system. Any significant changes should require ultimate 
Congressional approval.
    WWP also strongly supports removing the Department of Defense (DOD) 
from the disability rating process. DOD and the Department of Veterans 
Affairs rating systems are currently confusing and overly burdensome. 
Currently, the Department of Defense assesses a servicemember's fitness 
for duty and then assigns a rating based on the injury that made him/
her unfit. Following this determination, the Department of Veterans 
Affairs performs yet another physical examination to rate the veteran 
for all service-connected injuries, and, depending on the rating level, 
the veteran could then become eligible for a myriad of benefits. 
Unfortunately, ratings are not assigned in a vacuum--lost records, lack 
of resources, ineffective training, and inconsistencies in the 
interpretation of regulations by both agencies are often cited as 
reasons for the extended period of time required to assign a disability 
rating. A system such as the ones proposed by the Commissions would 
encourage a more efficient and fair evaluation and remove one of the 
most frustrating aspects of an already difficult process.
    WWP would like to make another recommendation. A servicemember 
should not be retired until he or she has a VA rating in place. This 
would prevent severely injured servicemembers from experiencing a long 
gap between their military retirement and eventual receipt of VA 
compensation. Additionally, as DOD would be responsible for paying 
servicemembers until their retirement, DOD would be encouraged to 
quickly share medical records to expedite the process.
    WWP believes that a comprehensive review of the disability 
compensation and benefits delivery system is needed. However, we are 
deeply concerned that the inclusion of provisions to overhaul the 
existing veterans' disability compensation system in the same package 
as health and transition-related recommendations is an unnecessary 
distraction from these important health and transition proposals. Any 
legislation implementing compensation-related recommendations must be 
carefully crafted to ensure the most beneficial outcome for those who 
have sacrificed in service to this country. However, as many of us 
recognize that the current disability ratings system suffers from 
significant shortcomings, which have become more apparent with the 
passage of time, we must use our passion to encourage honest discussion 
to resolve these issues. Veterans deserve a thoughtful and deliberate 
process for reform of the disability compensation system, with 
appropriate Congressional oversight.
    WWP is very pleased that the Dole-Shalala panel recognized the need 
for education and training of the family members. Specifically for the 
family members of those with severe TBI who often have to leave their 
jobs. WWP also supports payments to caregivers similar to those already 
in place at the San Diego VA Medical Center for Spinal Cord Injury 
patients. This program offers training and makes eligible for payment 
those family members who become certified as personal care attendants. 
This often removes at least part of the financial burden incurred by 
those with severe injuries.
    WWP also strongly supports the Dole-Shalala recommendation to 
implement a recovery plan that promotes ``prompt'' care in ``the most 
appropriate facility.'' With respect to Traumatic Brain Injury, 
legislation currently exists to facilitate such a recommendation. 
Section 203 of the Senate version of HR. 1538 would allow the Secretary 
of the VA to refer patients to non-department facilities if the 
Secretary is unable to provide the required treatment, OR, even more 
importantly, for whom the Secretary determines that such a referral is 
optimal for their recovery and rehabilitation. In order to comply with 
our obligation to offer these wounded warriors the best care possible 
for their respective injuries, these facilities must be readily 
available as an option for their care.
                          dod/va collaboration
    With respect to DOD/VA collaboration, while there are still many 
issues to address, WWP has been very impressed with the level of 
involvement of the leadership of both DOD and the VA in the Senior 
Oversight Committee (SOC), formed to address these issues. As 
recommended by the Dole-Shalala Commission, the SOC is in the process 
of improving the case management process through the creation of a 
recovery coordinator. However, the recovery coordinator can only be 
successful if he/she has the authority to break through the current 
barriers within both agencies. Part of that authority would have to 
include the overlap of benefits and services about which WWP has 
previously testified, and which is included in the Senate version of 
H.R. 1538, The Dignified Treatment of Wounded Warriors Act. An overlap 
would allow the recovery coordinator to access DOD and VA systems 
necessary to ensure the proper care and rehabilitation of severely 
injured servicemembers. Each agency has its own strengths. Why base 
access to care on the status of a servicemember as active duty or 
retired, rather than on the medical condition?
    The skills and previous experience of the Recovery Coordinator are 
extremely important to their success. In the past, both agencies have 
based their hiring criteria for similar positions solely on education 
level. WWP is concerned that the agencies will, once again, rely on 
education level alone and exclude eminently qualified candidates with 
good problem solving skills and institutional knowledge.
    It is not only DOD and VA who need to collaborate more fully. 
Others such as the Social Security Administration, Medicare, the 
Department of Labor, and private entities need to be included in these 
discussions. For example, an injured servicemember recently contacted 
WWP because he was understandably confused. He had been rated as 
unemployable by the VA, but was told he did not qualify for Social 
Security Disability benefits because he was able to work. Additionally, 
the Social Security Administration had a difficult time accessing DOD 
records necessary to evaluate his claim. These agencies must work 
together to resolve inconsistencies in their policies or the often 
stated goal of ``seamless transition'' will never be achieved.
    Finally, it is imperative that a joint, permanent structure be in 
place to evaluate changes, monitor systems, and make further 
recommendations for process improvement. This office must be structured 
to minimize bureaucracy and must have a clearly defined mission with 
the appropriate authority to make necessary changes or recommendations 
as warranted. With the passage of time, as veterans issues fade from 
the national spotlight, it will be necessary to have a joint structure 
in place to ensure future agency coordination.
    Mr. Chairman, thank you again for the opportunity to testify before 
you today, and I look forward to answering your questions.

    Chairman Akaka. Thank you very much, Ms. Beck.
    Now we will hear from Colonel Strobridge. Colonel?

STATEMENT OF COL. STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR, 
 GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA

    Colonel Strobridge. Thank you, Mr. Chairman, Ranking Member 
Burr, and distinguished Members of the Committee. Thank you for 
this opportunity to present the Military Officers Association's 
views on the needs of America's returning warriors.
    I would start by recognizing the tremendous efforts by this 
Committee and by the Armed Services Committee, as well, to 
ensure that we do the right thing by these veterans. Senior DOD 
and VA leaders also deserve great credit for their 
unprecedented cooperation in working to address the many 
serious problems encountered by these members and their 
families.
    As you know, most of the problems aren't new. They have 
been identified in multiple previous studies. What is different 
now is the degree of leadership involvement and commitment to 
finding fixes. That kind of top-down leadership is the only way 
to break down the barriers of departmental parochialism, and it 
is gratifying to us to see it happening.
    But, we are concerned about ensuring continuity of those 
efforts into next year and beyond, when most of the leaders who 
have been driving those efforts will be departing. Often, a new 
administration faces a lag in installing new leaders and many 
new appointees face a significant learning curve. That raises 
the potential for the change process to lose momentum during 
the transition. For that reason, the continuing leadership and 
oversight of this Committee will be crucial to sustaining long-
term success.
    The Committee has seen the findings of all the various 
study groups on the wounded warrior issues and MOAA thinks they 
have been pretty much on target with most of their 
recommendations. We strongly endorse the use of a single DOD 
and VA separation physical and reform of the Military 
Disability Retirement System as recommended by the Veterans 
Disability Benefits Commission. In that regard, we very much 
support the pilot program now being implemented by DOD and VA 
under which the services determine fitness for continued 
service, the VA is the single agency assigning disability 
ratings, and DOD must accept those ratings for military 
disability retirement purposes.
    We strongly agree with the findings of all the panels on 
case management needs, the importance of TBI and PTSD screening 
assessments, care and rehabilitation, and updating the VA 
ratings system to more appropriately reflect those conditions' 
effect on veterans and their families.
    We are concerned that there are a number of gaps, as 
Meredith mentioned, in coverage between DOD active duty retired 
and VA health programs. Some of the examples are: cognitive 
therapy; and per diem for caregivers, which ceases when a 
member is retired and is not available from the VA. Those 
significantly detract from disabled veterans' continuity of 
care. Rather than trying to chase down all the individual 
shortfalls, we think it is essential to authorize temporary 
overlap of both coverages. To us, that means continuing active 
duty-level TRICARE coverage for at least 3 years for all 
service-disabled personnel and their families and also 
authorizing VA care for active duty wounded warriors.
    As the Committee considers possible benefit adjustments or 
recommends against creating a differential benefit system for 
members who are disabled in combat versus other service-
connected causes, I think you have heard the different panel 
members. I think we have all kind of said the same things--that 
there is a little bit of confusion, I think, in terms of what 
some people mean when they say, ``combat disabled.'' When we 
have asked people, everybody has pretty much said, anything 
that is service-connected should be compensated. If a member 
becomes a quadriplegic in service, the effect on the member's 
life is the same whether that was caused by a bullet or a 
military vehicle or a slip on an icy street. Similarly, we 
should sustain the longstanding principle that military service 
is 24/7 duty that we discussed earlier for the purposes of 
determining service connection in disabilities.
    Like Meredith said, we believe it will be particularly 
important to establish a Joint Seamless Transition Office, 
permanently staffed with full-time personnel from both DOD and 
VA to oversee development, fielding, and sustainment of 
initiatives such as the Electronic Medical Record and the 
Electronic Separation Document. It is ironic that when I worked 
in DOD in 1988, I was initiating action for a joint DD Form 
214. I got promoted and left the office a year later, called 
back and said, what is the status, and the answer was, ``huh?'' 
That is the problem that you have. We have to build a structure 
of responsibility that won't evaporate with the departure of 
the incumbent or the departure of the incumbent's boss.
    Finally, we urge the leaders of the Veterans Affairs 
Committees and Armed Services Committees to continue that 
example of top-down leadership collaboration in addition to the 
recent efforts in the Executive Branch. We know all of the 
committees and staffs are working hard to do the right thing, 
but we also know that frustration with past joint efforts and 
some of their lack of success can foster skepticism about the 
future, and that is a big concern. A renewed commitment by 
committee leaders to bipartisan, bicameral collaboration would 
establish an important guideline for the difficult road ahead.
    We appreciate this opportunity to offer our comments and 
pledge our continued support on all of these issues to ensure 
the Nation completes its obligations to our wounded warriors 
and their families. Thank you.
    [The prepared statement of Col. Strobridge follows:]
Prepared Statement of Col. Steven P. Strobridge, USAF (Ret.), Director, 
     Government Relations, Military Officers Association of America
    Mr. Chairman and distinguished Members of the Committee, I am 
honored to appear before you today on behalf of the Military Officers 
Association of America (MOAA), to present our views on various 
Commission recommendations on the wounded warrior care, transition 
support, the disability evaluation process and related matters.
    MOAA does not receive any grants or contracts from the Federal 
Government.
                           executive summary
    Urgency of Joint Congressional Action and Oversight.--Military and 
VA systems have been caught unprepared for the large wave of wounded 
and traumatized veterans returning from Iraq and Afghanistan, and these 
veterans' needs will only grow in the future. Sustained bipartisan, 
bicameral congressional leadership focus and cooperation will be vital 
to successfully address continuing problems, especially with a change 
of leadership coming soon in the Executive Branch, and attendant 
introduction of new DOD and VA leaders who will be far less sensitized 
to the urgency of leadership-driven changes currently underway or 
contemplated.
    VA-DOD Disability Evaluation Reform.--MOAA strongly endorses the 
recommendation of the Veterans' Disability Benefits Commission (VDBC) 
that DOD and VA should realign the disability evaluation process so 
that the Services determine fitness for duty, and servicemembers who 
are found unfit are referred to VA for the disability rating.
    All conditions that are identified as part of a single, 
comprehensive medical exam should be rated and compensated. In 
revamping the DES, the Services must include all unfitting conditions 
as rated by the VA in assessing whether the servicemember is to be 
medically retired or separated. (See Items 6, 12 and 46 in the attached 
matrix.)
    MOAA does not support elimination of the military disability 
retired pay system, as some would interpret the Dole-Shalala 
recommendations as implying. Rather, we support DOD's acceptance of VA-
determined disability percentages in calculating military disability 
retired pay.
    Traumatic Brain Injury/PTSD Care, Treatment and Service 
Connection.--MOAA strongly supports the recommendations of the Dole-
Shalala Commission and other panels on TBI/PTSD care, coordination and 
rehabilitation. (See Items 3, 4, 15, 22, 23, 33, 37 and 38 in the 
matrix.)
    Establish Joint Seamless Transition Agency/Office.--MOAA strongly 
supports establishment of a separate, joint DOD-VA Seamless Transition 
Agency staffed with full-time DOD and VA professionals to oversee the 
development, fielding, completion and assessment of seamless transition 
imperatives. (See Item 50 in the matrix.)
    Overlap in Active Duty and VA Health Coverage.--MOAA strongly 
recommends authorization of at least 3 years of eligibility for active 
duty TRICARE benefits for wounded warriors after leaving service. This 
will protect them from loss of urgently needed services--such as 
cognitive therapy and caregiver per diem--that now terminate when they 
leave active duty. (See Item 34 in the matrix.)
    Caregiver Support and Case Management.--MOAA strongly endorses the 
recommendations of the commissions and task forces on caregiver 
support/assistance and case management for wounded warriors. (See Items 
2, 10, 13, 21, 29, and 34 in the matrix.)
    Reaffirmation of the ``24-7'' Principle in Assessing Service-
Connection of Disabilities.--MOAA strongly recommends the Committee 
reaffirm its longstanding commitment to the principle that all service 
men and women who are disabled in the line of duty--the ``24/7'' rule--
are entitled to service-connected compensation, or if eligible, 
military retirement, if the disability did not result from misconduct.
    Collaboration and Oversight of Congressional Committees.--MOAA 
notes that parochial departmental concerns in the past have extended 
beyond the executive branch, and strongly recommends that leaders of 
the Committees on Veterans Affairs and Armed Services make a concerted 
effort with their House counterparts to develop a more collaborative 
framework to assess, oversee, prioritize, and fund cross-jurisdictional 
issues affecting wounded warriors and their families who are having 
such unacceptable difficulties getting fair and effective outcomes from 
DOD and VA bureaucracies.
                              introduction
    Last February, a series of articles in the Washington Post titled 
``The Other Walter Reed'' profiled shocking cases of wounded 
servicemembers who became lost in military health care and 
administrative systems upon being transferred to outpatient 
rehabilitative care.
    Subsequently, the national media were flooded with stories of 
seriously wounded troops warehoused in substandard quarters, waiting 
weeks and months for medical appointments and evaluation board results, 
confused by a maze of benefit and disability rules, and lowballed into 
disability separations rather than being awarded the higher benefits of 
military disability retirement.
    There were interviews with family members--spouses, children, and 
parents--who quit their jobs and virtually lived at military hospitals 
to become caregivers to seriously wounded troops. Left with diminishing 
resources and unfamiliar with military benefit and disability rules, 
they were severely disadvantaged in trying to represent the interests 
of their wounded spouses and children who couldn't stand up for 
themselves.
    These issues drew the attention of the President and Congress, 
leading to the appointment of special commissions and task forces 
charged with investigating the problems and identifying needed 
solutions. The details of sorting out the multiple overlapping 
proposals to fix the bureaucratic snafus among multiple Federal 
departments can be mind-numbing, whether you're a legislator, a 
lobbyist, a Federal administrator, or an average citizen.
    The key to success will be to stay focused on the top priorities, 
and recognize that the government must bear responsibility for these 
long-term costs of war.
    MOAA is very grateful for the work of the Dole-Shalala Commission, 
the Veterans Disability Benefits Commission, the Marsh-West Independent 
Review Group, VA Interagency Task Force on Returning Veterans, and the 
Mental Health Task Force. Attached to this statement is a summary of 
the major recommendations of these panels and MOAA's positions and 
recommendations on them. We are very pleased to say that with 
relatively few exceptions, as noted, MOAA endorses the vast majority of 
these groups' recommendations.
          urgency of joint congressional action and oversight
    Military and VA systems have been caught unprepared for the large 
wave of wounded and traumatized veterans returning from Iraq and 
Afghanistan, and these veterans' needs will only grow in the future.
    Sustained bipartisan, bicameral congressional leadership focus and 
cooperation will be vital to successfully address continuing intra- and 
inter-agency problems. With a change of leadership coming soon in the 
Executive Branch, and attendant introduction of new DOD and VA leaders 
who have not been a party to developing urgent leadership-driven 
changes currently underway or contemplated, the importance of 
congressional oversight cannot be overstated.
               disability evaluation system (des) reform
    Current gross disability rating disparities between the services 
and between DOD and the VA must be resolved. The Independent Review 
Group appointed by the Secretary of Defense found huge disparities 
between the disability retirement (vs. separation) statistics between 
the services for returning veterans. The percentage of returning 
veterans who received military disability ratings of 30 percent or 
higher (and thus qualified for lifetime retirement benefits) was far 
lower among the Army and Marine Corps, who had the greatest exposure to 
combat injuries. The disability retirement rate for the Navy was nearly 
three times higher than the Army's, feeding perceptions that seriously 
combat-wounded soldiers were being ``low-balled'' to save the 
government money, as shown on the following chart.
                    disability retirement disparity
    Percent of disabled members awarded disability retirement (30+ 
percent DOD disability rating)

    Army 13%
    Navy 36%
    USMC 18%
    USAF 27%

    MOAA believes strongly that members with significant, lifelong, 
service-caused disabilities should be retired rather than separated 
with no military benefits. There must be a common rating standard that 
accounts for all service-connected disabilities and provides fair 
compensation and benefit packages commensurate with the level of 
disability. Wounded members should be retained on active duty until the 
disabling condition is stabilized, rather than expediting separation 
and shifting care responsibility to the VA.
    Further, the process of assigning fair and consistent disability 
ratings is too important to be left to five independent agencies (four 
services and the VA). While the services need to be the arbiters of 
what conditions render a soldier, sailor, airman or Marine unfit for 
continued service, the percentage disability rating should be 
determined by the VA, and the VA system must be made as uniform as 
possible across the country. (In this regard, MOAA is concerned at 
studies that have shown large disparities in disability ratings by VA 
offices in different states/regions.)
    MOAA strongly endorses the recommendation of the Veterans' 
Disability Benefits Commission (VDBC): that DOD and VA should realign 
the disability evaluation process so that the Services determine 
fitness for duty; and servicemembers who are found unfit are referred 
to VA for the disability rating.
    All conditions that are identified as part of a single, 
comprehensive medical exam should be rated and compensated. MOAA 
strongly recommends that in revamping the DES, the Services must 
include all unfitting conditions as rated by the VA in assessing 
whether the servicemember is to be medically retired or separated. (See 
Items 6, 12 and 46 in the attached matrix.)
    MOAA does not support elimination of the military disability 
retired pay system, as some would interpret the Dole-Shalala 
recommendations as implying. Rather, we support DOD's acceptance of VA-
determined disability percentages in calculating military disability 
retired pay.
  wounded warrior care and treatment: focus on traumatic brain injury 
            (tbi) and post traumatic stress disorder (ptsd)
    TBI and PTSD affect 25% to 50% of returning veterans, according to 
a number of government and other studies. And the percentage rises with 
prolonged and repeated exposure through multiple and extended 
deployments. But reluctance to disclose mental health conditions deters 
many members and families from testing and treatment.
    Traditional military ``can-do'' and ``tough-it-out'' attitudes that 
are the pride of the warrior ethos actually work against the future 
well-being of the warrior who doesn't understand the potential long-
term consequences of failing to at least find someone to talk to. 
Officers and senior NCOs who fear that acknowledgement of such 
conditions may affect their security clearances or future leadership 
opportunities are particularly vulnerable through such reluctance.
    Even less visible and likely to go unidentified are the secondary 
effects on family members who also suffer the long-term effects of 
living with victims of war-related stress.
    We must get a better handle on cause and effect, starting with 
crash efforts to destigmatize mental health conditions and publicize 
opportunities for confidential discussions.
    We also must dramatically improve diagnosis and treatment capacity 
and methodology. One key is to dramatically improve testing for the 
effects of Traumatic Brain Injury, including routine baseline pre- and 
post-deployment neurocognitive assessments; and testing as soon as 
possible after any exposure to high-risk blast or concussive events.
    MOAA strongly endorses the recommendations of the commissions/task 
forces on Traumatic Brain Injury and PTSD care and rehabilitation. (See 
Items 3, 4, 15, 22, 23, 33, 37 and 38 in the matrix.)
                joint seamless transition agency needed
    Widely reported breakdowns in the management of care at Walter Reed 
Army Medical Center reflect the fact that policies and administrative 
procedures for the care, rehabilitation, outprocessing and 
transitioning of our wounded warriors are not working ``seamlessly'' 
for them and their families.
    DOD and VA have critical, complementary roles in the transition 
process. The pace of the two departments' collaborative and cooperative 
efforts continues to be hampered by bureaucratic and parochial 
barriers.
    The key, we believe, is a coordinated top-down strategy which 
engages both departments' leadership from a single point of attack. 
Recent leadership initiatives generated at the secretarial level have 
had galvanizing effects on the two agencies' staffs, and there has been 
unprecedented cooperation and progress in recent months.
    However, MOAA is very concerned for the viability of these newly 
energized efforts beyond the next 15 months, given the inevitable 
leadership turnover that will attend any new administration.
    The JEC does not appear to have the authority to direct change in 
both departments, only to forge broad agreements and report to 
Congress. We are into the fifth year of the war on terror, and the 
hand-off between the departments for those who are in the greatest need 
is far from seamless, despite recent, more strenuous leadership 
efforts.
    This effort is too important to be someone else's part-time job. 
MOAA believes strongly that there is an overriding need to establish a 
permanent joint office, with permanently assigned staff from both 
departments, whose full-time mission is to devise, implement, oversee 
and sustain the joint mission of serving our warriors rather than 
serving their respective departments' bureaucratic prerogatives.
    Acting Secretary of Veterans Affairs, Gordon Mansfield, a 
distinguished disabled Vietnam veteran, endorsed a joint transition 
agency in testimony before the House Veterans' Affairs Committee on 28 
September 2006.
    Some elements of seamless transition oversight and implementation 
that should come under this office include:

     Bi-Directional Electronic Medical Records
     A Single Separation Physical and Electronic Separation 
Document (DD-214)
     Coordination of Policy/Procedures for Special Needs Health 
Care, including implementation of a case management system and patient-
centered recovery plan program
     Coordination of multiple agency inititiatives on Traumatic 
Brain Injury (TBI) and PTSD diagnosis, treatment and Rehabilitation
     Expansion of Joint DOD-VA Research
     Improvement and Expansion of the Benefits Delivery at 
Discharge program.

Joint Bi-Directional Electronic Health Record
    MOAA and our colleagues in The Military Coalition recently were 
briefed on efforts underway to improve the transfer of medical records 
between DOD and the VA. There are significant signs of progress, in our 
view, on this complex issue. However, we are concerned that full 
electronic record ``jointness'' won't be completed until 2012 at best. 
That is just too long to wait. MOAA strongly endorses accelerated 
completion of this critical seamless transition function.
Joint DOD-VA Physical
    A ``one stop'' separation physical supported by an electronic 
separation document (DD-214) is a cost-saving initiative that is an 
essential component of the seamless transition model. Although 
prototypes exist in some facilities, one has yet to be accepted as a 
standard throughout the two departments. It must become the ``gold 
standard'' of effective and efficient transitions.
Polytrauma Centers and Traumatic Brain Injury
    TBI is the signature injury of OIF/OEF--its impact on combat 
veterans ranges from mild to severe. Developing best practices for 
identification and treatment is essential, including research on the 
long-term consequences of mild TBI. The goal of achieving optimal 
function of each individual TBI patient requires improved interagency 
coordination between VA and DOD.
    MOAA is pleased to note that the VA is establishing a fifth Level 
One polytrauma center. The new center and the four existing VA 
Polytrauma Rehabilitation Centers require special attention in order to 
ensure the needed resources are available, to include specialized 
staff, technical equipment and adequate bed space in order to ensure 
top-quality care for severely injured servicemembers and veterans.
    MOAA strongly supports establishment of a separate, joint DOD-VA 
Seamless Transition Agency to oversee the development, fielding, 
completion and assessment of seamless transition imperatives. (See Item 
50 in the matrix.)
                    assistance for family caregivers
    The unprecedented quality and rapid delivery of battlefield health 
care, along with widespread use of body armor and other protective 
equipment, means that unprecedented numbers of warriors who would have 
died of their wounds in previous wars are surviving to return to their 
families. Unfortunately, many of these heroes face long and arduous 
recovery periods, and many require significant levels of care for 
months or years, and some, for the rest of their lives.
    In this tragic situation, many spouses, parents, siblings, and 
other family members find themselves having to take on roles as full-
time caregivers and representatives of severely injured/disabled 
personnel who are unable to navigate military and VA personnel and 
compensation bureaucracies on their own. Many give up their jobs and 
careers to care for a loved one, in come cases having to rely on the 
goodwill of charities and communities to meet various necessities of 
their loved ones' new lives.
    MOAA believes strongly that the government has an obligation to 
change this situation and develop new programs to meet the extreme 
needs of these special cases. There must be institutionalized outreach 
programs to provide information and navigation assistance on 
administrative proceedings, appeal options, and benefit programs. In 
the more severe cases, compensation is appropriate and essential to 
recognize family members' sacrifice of their own incomes and careers to 
care for service-disabled members.
    For the longer term, the VA needs to establish fair compensation 
for caregivers forced into hardship situations. For the short term, 
MOAA strongly recommends authorization of at least 3 years of 
eligibility for active duty TRICARE benefits for wounded warriors after 
leaving service. This will protect them from loss of urgently needed 
services--such as cognitive therapy and caregiver per diem--that now 
terminate when they leave active duty. (See Item 34 in the matrix.)
    MOAA strongly endorses the recommendations of the commissions and 
task forces on caregiver support/assistance and case management for 
wounded warriors. (See Items 2, 10, 13, 21, 29, and 34 in the matrix.)
                        retroactive case review
    In addition to making more sensitive decisions in the future, 
equity demands a review of discharge and retirement cases already 
completed for warriors wounded or otherwise disabled in Iraq or 
Afghanistan, while their case histories are still fresh. Multiple 
examples of severely disabled soldiers whose separation with zero 
disability ratings created the pressure for change, but that change 
can't just be prospective. It must include retroactive review and re-
adjudication for those whose examples brought the inequities to public 
attention.
    In the same vein, an even more sensitive situation is coming to 
light. There are numerous cases of exemplary soldiers and marines who, 
after multiple tours in Iraq or Afghanistan, became ``changed men''--
disciplinary cases who experienced demotion, incarceration, and adverse 
separation characterizations that now bar them from eligibility for VA 
treatment, compensation and rehabilitation for conditions many would 
not have incurred if not for their wartime service.
   lengthy claims processing delays are intolerable and must be fixed
    The workload and complexity of VA disability claims continues to 
increase. As of mid-February 2007, there was a backlog of 626,429 
claims. VA projects that by the close of this year there will be at 
least 800,000 claims in the system. Moreover, disability claims 
processing time rose to nearly 6 months (177 days) on pending claims in 
2006 against an original performance goal of 100 days. It's our 
understanding that VA has moved the goalposts and its new performance 
goal for completing initial claims is 125 days.
    MOAA endorses the VDBC's recommendation on improving the VA claims 
processing system. (See Item 48.) MOAA recommends that the Committee 
work with its Armed Services Committee counterparts to ensure this 
review is completed as soon as possible. (See Item 8 in the matrix.)
                             moaa concerns
    MOAA applauds the work of the commissions and task forces that have 
examined wounded warrior care, treatment, transition, and services. As 
indicated elsewhere in this statement, MOAA endorses most of the major 
recommendations of these panels. We do, however, have some concerns 
about certain recommendations, while recognizing that in some cases a 
commission's recommendation was limited by its charter and time.
    military service is a ``24/7'' enterprise, and is substantively 
                   different from civilian employment
    Under current law, the term ``service-connected'' means generally, 
``with respect to disability or death, that such disability was 
incurred or aggravated, or that the death resulted from a disability 
incurred or aggravated, in the line of duty in the active military, 
naval, or air service.'' (38 U.S.C. Sec. 101(16)) An injury or disease 
incurred ``during'' military service ``will be deemed to have been 
incurred in the line of duty'' unless the disability was caused by the 
veteran's own misconduct or abuse of alcohol or drugs, or was incurred 
while absent without permission or while confined by military or 
civilian authorities for serious crimes.'' (38 U.S.C. Sec. 105)
    This statutory framework has withstood the test of time and 
thorough past reviews. MOAA is confident that the statutes reflect the 
will of Congress and the American people regarding the unique nature 
and the inherent sacrifices involved in military service.
    Disability and survivor benefits should continue to reflect the 
unique nature of that service in defense of the Nation.
    MOAA understands that the Dole-Shalala Commission was empowered to 
examine only wounded warrior issues. However, we cannot support 
establishment of separate disability evaluation processes and benefit 
differentials for combat or operations-related disabilities vs. other 
service-connected disabilities. (See Items 6, 30 and 46 in the matrix.)
    MOAA strongly recommends that the Committee reaffirm its 
longstanding commitment to the principle that all service men and women 
who are disabled in the line of duty--the ``24/7'' rule--are entitled 
to service connected compensation, or, if eligible, military 
retirement, unless the disability was a result of misconduct.
             collaborative congressional leadership needed
    MOAA was pleased to note that a rare joint hearing was held earlier 
this year between the Senate Veterans Affairs and the Armed Services 
Committees to receive the views and preliminary recommendations of the 
Veterans Disability Benefits Commission. In the House, there have been 
joint hearings on educational benefits under the Montgomery GI Bill.
    But it's no secret that on some issues, jurisdictional firewalls in 
the Legislative Branch as well as the Executive Branch inhibit 
effective collaboration on some of the core issues affecting VA and DOD 
interaction. In this regard, we have been dismayed on many occasions at 
the continuing skepticism of Veterans Affairs and Armed Services 
Committee staffs in both chambers about the extent of joint cooperation 
between the committees that's likely or feasible on various topics of 
common interest.
    We recognize the enormous challenges involved in crafting and 
revising public laws that cross jurisdictional lines. We also can 
appreciate the budgetary and political histories that have arisen from 
difficult interactions over multiple past congresses.
    But MOAA believes strongly that there is bipartisan, bicameral 
agreement among all of the committees on the need for far greater 
communication and collaboration between DOD and VA to achieve positive 
outcomes for wounded veterans in such great need.
    We've been extremely encouraged by the personal efforts of the 
Secretaries of Veterans Affairs and Defense, demonstrating that 
determined leadership initiative can, in fact, cut through longstanding 
parochial red tape and generate a genuine cooperative effort among 
staffs whose main experience has been colored by ``stove-piped'' 
perspectives.
    But those efforts can be undermined in the longer term if there is 
not decisive, determined, top-down congressional leadership direction 
to develop joint congressional staff consensus on priorities, policy 
direction, and funding responsibilities on these vital matters.
    MOAA strongly recommends that leaders of the Senate Committees on 
Veterans Affairs and Armed Services make a concerted effort with their 
House counterparts to develop a more collaborative framework to assess, 
oversee, prioritize, and fund cross-jurisdictional issues affecting 
wounded warriors and their families who are having such unacceptable 
difficulties getting fair and effective outcomes from DOD and VA 
bureaucracies.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
    Colonel Steven P. Strobridge, USAF (Ret.), Director, Government 
          Relations, Military Officers Association of America
                   retroactive review of dod ratings
    Question. The Disability Benefits Commission report suggests that 
many servicemembers may have been given low ratings by the DOD Physical 
Disability Evaluation System to save DOD from having to pay them 
medical retirement benefits. Your testimony supports retroactive case 
review for certain veterans who are dissatisfied with the rating 
assigned them by DOD. What criteria would you suggest be used to 
determine who is eligible for a reevaluation?
    Response. At a minimum, we believe there should be a retroactive 
review of all medical separations since Oct. 7, 2001--that is, 
servicemembers who had service-caused or service-aggravated medical 
conditions that precluded further service and whose disabilities were 
rated by the service as less than 30 percent disabling. This would 
catch the most egregious situations in which a member was wrongly 
denied a medical retirement and the attendant annuity, health coverage 
and other benefits associated with military retirement.
    Other members who were medically retired with less than 20 years of 
service should be notified of their right to appeal to their service 
Board for Correction of Military Records if they believe the physical 
disability evaluation by their parent service inappropriately denied 
consideration of any service-caused condition(s) that also would have 
precluded their continued service in uniform.

    Chairman Akaka. Thank you very much, Colonel.
    I have a question for all of our panelists. If the VA 
disability system is revised from the current form, should 
different consideration be given to those veterans whose 
disability was incurred in a combat zone versus those who were 
disabled elsewhere? Let me start with Ms. Del Negro.
    Ms. Del Negro. I have conflicting feelings about that. 
During the initiation of the MEB process for my husband, we 
were in a room. Actually, the first time he showed up for Part 
I of his physical, the soldiers were sitting on the floor. They 
didn't even take them into the back. Some of them were combat-
wounded soliders. It was very appalling to my husband to see 
these gentlemen sitting on the floor.
    At the same time, however, while I would like to think that 
combat-related injuries would receive greater compensation, I 
think that creating a second line of differentiation between 
veterans will create even more bureaucratic obstacles, slowing 
down the process. By virtue of that, I would say that I would 
discourage the making differences between combat and non-combat 
injuries. Perhaps a caveat to that would be that if one is a 
Purple Heart recipient, that there would be some sort of 
additional severance associated with it, but that it would not 
influence health care benefits.
    Chairman Akaka. Thank you. Colonel Duffy?
    Colonel Duffy. Yes, sir. I agree with Ariana. I thought 
that was very well said. In creating another category that the 
veteran has to prove, you are creating more work for the 
veteran, more work for the administration in judging a claim. A 
servicemember is under the care and custody of the military 24/
7. Any injury that occurs during that period should be 
compensated.
    In the civilian world, if an employee is hurt at work, 
there is a Workers' Compensation system that covers that 
employee as a work-related injury. Anything that happens during 
the day is work-related for a servicemember and should be 
compensated.
    Chairman Akaka. Thank you. Mr. Manar?
    Mr. Manar. Simply said, ditto. I have talked about this. We 
have all, I think, arrived at the same conclusion--that the 
distinction here should be based on the severity of disability, 
the level of disability, not where or how it was incurred. If 
someone spends a year in Iraq and comes back with Post 
Traumatic Stress, are they any more or less deserving of 
treatment than the female soldier who was raped in Germany or 
Japan? If someone steps on an IED and has a leg amputated below 
the knee in Falujah, are they any more or less worthy of 
compensation and benefits and care than someone who has their 
leg amputated because of diabetes in the U.S. or because of an 
automobile accident while they were serving in Japan?
    So, our view is that there is no distinction. The 
distinction is on the level of severity. With greater severity 
of disabilities, then they should receive greater compensation, 
greater care, of course, for their service-connected 
disabilities.
    Chairman Akaka. Thank you, Mr. Manar.
    Ms. Beck?
    Ms. Beck. My brother is a Marine Corps helicopter pilot, 
and whether he is deployed or at home with his children, they 
still share the same fear and anxiety of when he would be 
deployed or a possible accident whether he is deployed or not 
in combat. As a result, as General Scott said, if you are 
covered by the UCMJ, you should be covered by the good things, 
too.
    Chairman Akaka. Colonel Strobridge?
    Colonel Strobridge. Sir, we very strongly believe there 
should be a single system. Let me give you one example of a 
real case of a person to show how good intentions can go awry. 
This individual was disabled preparing for a combat mission out 
on the wing of an airplane doing pre-flight, slipped off the 
wing, fell on a piece of equipment, broke his back, became a 
paraplegic. When he applied for combat-related special 
compensation under this new program, it was denied. Even though 
he was preparing for a combat mission, the determination was 
the reason he broke his back was the ice, so it was weather, 
not combat, that caused the disability.
    I don't think that was ever envisioned when Congress 
established combat-related special compensation, but that is 
what can happen to these kinds of determinations. And to us, it 
is to avoid that kind of hair-splitting that it is very 
important to say it is the disability, not how you got it. As 
long as it was service-connected: if it was service-connected, 
you deserve the same compensation.
    Chairman Akaka. Ms. Del Negro, are there any issues that 
were not addressed by today's other witnesses that you think 
merit attention?
    Ms. Del Negro. Do you have a few minutes? No, I am just 
kidding. [Laughter.]
    There are a number of issues, and I will do my best to keep 
this brief. As I said, my husband and I endured this process 
before the Washington Post articles came out, which seemed to 
bring the onslaught of all these reports and recommendations, 
even though the same reports and the same recommendations had 
been around for a decade.
    However, when my husband is released from active duty, the 
recommendations that are made in this report--given the amount 
of time they will take to implement--will not be available to 
my husband because he will have already been separated from 
active duty. So, I would like to see that some of these changes 
be made retroactive to affect and benefit some of those 
recently separated.
    In addition, the Recovery Coordinator plan proposed by the 
Dole-Shalala Commission report is difficult because you are 
already dealing with staffing shortages, as documented by a GAO 
report dated September 27, showing that over 50 percent of the 
Warrior Transition Units that are being employed by the Army 
have less than--or are missing--two or one of the critical 
triad positions, including case managers. So, if you can't even 
fill slots of case managers, how are you proposing to fill 
slots of Recovery Coordinators that are also going to require 
training?
    Furthermore, I would like to reiterate previous comments 
regarding the Family Medical Leave Act. I think it is 
absolutely imperative that it be extended. I had the 
opportunity to meet with President Bush, my husband and I both, 
in Hawaii; and he was generous enough to ask how he could help, 
and my response was that he could sign that amendment when it 
graced his desk. I emphasized that that was one way he could 
help servicemembers and their families. However, I also think 
it will benefit the veterans and their families in the long-
term. We do not know the long-term implications of the injuries 
sustained in this conflict.
    Traumatic Brain Injury, the focus today primarily mentions 
moderate to severe brain injury. We don't know the implications 
of mild Traumatic Brain Injury, particularly as it is related 
to blast injuries. The basis of conclusions so far on mild 
Traumatic Brain Injury are based on pre-clinical studies 
evaluating rats. We need more data before we can conclude that 
those individuals are not going to require long-term care.
    In addition, there is no definition of severely injured. 
What is severely injured? If you are admitted to a military 
hospital or classified as SI, does that mean that you will get 
all these benefits? I think that that really places us in a 
precarious situation, to define what severely injured is.
    Lastly, the integration of the data between the DOD and VA 
systems, no one mentioned today the security of the data. In 
the last few years, there have been reports about problems with 
the VA and release of data, and while developing an e-benefits 
page and what-not may help, it does not address the security 
issues. Thank you.
    Chairman Akaka. Thank you very much.
    I am going to now call on Senator Burr. I may have a second 
round, but Senator Burr?
    Senator Burr. Thank you, Mr. Chairman. We may both have 
second rounds, but I know we have kept our witnesses here too 
long and let me thank all of you.
    Ms. Del Negro, thank you for your family's sacrifice, your 
husband's service to the country. How is he doing?
    Ms. Del Negro. He is doing fantastic.
    Senator Burr. Great.
    Ms. Del Negro. Absolutely great.
    Senator Burr. I apologize that you have had to weave your 
way through and navigate through a system that took some time 
getting the right degree of benefit. I can only say that we are 
learning. The Committee is well aware of the progress that 
needs to be made and we are committed to work with the Veterans 
Administration. Armed Services is committed to work with the 
Department of Defense, which seems to be the area that your 
husband was in through his transition.
    To try to understand that it is a little different today 
and that we are dealing with different injuries; that we have 
got to have the right responses; let me ask you just to expand 
on one thing that I didn't quite understand--the distinction of 
seriously injured. When we have an injured veteran, there is no 
difference in the treatment, the health care that is delivered 
to them. What was the purpose of highlighting seriously 
injured?
    Ms. Del Negro. I believe the Veterans Commission report 
identified that basis of service, as Mr. Manar addressed, 
should not be based on whether or not the injury was combat or 
not combat-related, but it should be related to----
    Senator Burr. OK. I just wanted to make sure I hadn't 
missed something relative to----
    Ms. Del Negro. Sorry.
    Senator Burr. Colonel Duffy, thank you for being here. Your 
testimony regarding unique issues surrounding the seamless 
transfer of medical records for Guard and Reserves has 
intrigued me. I went to your testimony and I will read from it, 
``Although this moment of interoperability is reported by DOD 
contractors to be close at hand, the medical needs of our Guard 
members have been overlooked with this effort that does not 
require the records of civilian health care providers treating 
our members to be entered into the DOD AHLTA database.'' Is 
that a HIPAA problem that we have? Is there a privacy health 
insurance, health privacy issue?
    Colonel Duffy. There is potentially a HIPAA problem with 
any medical record, but to overcome a HIPAA problem, the 
patient only needs to consent--and the military could certainly 
require that consent--for a soldier to be deployable.
    Senator Burr. So could this----
    Colonel Duffy. They would need to know all the medical 
information on that servicemember.
    Senator Burr [continuing]. Could this be as simple as we 
are not asking Guard and Reserves to sign a release on their 
health care privacy, or is it--go ahead.
    Colonel Duffy. It is at least a two-fold issue. Yes, any 
HIPAA issue would have to be overcome with an authorization, 
which could be voluntarily given, or, in the case of a 
servicemember, I suppose involuntarily, required to be given.
    But, there is also the technology. The contractor who runs 
the AHLTA program, Northrop Grumman, has informed us the 
technology is there. They have just not been asked to do it. 
Civilian medical records--and there is some concern that any 
treatment within the Guard is not being scanned into the DOD 
AHLTA system--not just civilian medical records, but should any 
treatment be given at a Guard medical installation. The 
technology is there. They are just lacking the mandate. Tell us 
to do it and we will do it.
    Senator Burr. You have triggered the right degree of fault. 
So, let us take it from here and see what we can do to try to 
find a solution to something that I would think would be 
extremely helpful, not only to Guard and Reservists, but on the 
back end of the system--to have within DOD, within VA, the 
complete records of individuals that will end up back in the 
system.
    Colonel Duffy. Absolutely. And sir, may I say just one 
thing. I think at a hearing earlier this year, you had patients 
at Walter Reed come, one of whom testified that when he was 
sent from Iraq to Walter Reed, his medical records were placed 
on his stomach. I think we all heard that. And then they were 
not there when he returned Stateside--a big concern if he is 
later filing a disability claim with the Veterans 
Administration and doesn't have those records.
    Senator Burr. We share your concern.
    Mr. Manar, let me say from the start, I have looked at all 
these proposals on disability changes and I am, hopefully like 
the Chairman, I am in neutral. I am in the middle somewhere 
still trying to assess them. But, you made a statement that I 
have just got to ask you some questions on. If the President's 
Commission recommendations were adopted, the VA would have to 
run a dual system for 70 years, and you alluded to the fact 
that they couldn't do that. Did I----
    Mr. Manar. They are having difficulty running the current 
program.
    Senator Burr [continuing]. Let me just say this. If a dual 
system is better for future veterans, which has not been 
determined yet, but were it, would you object to a dual system? 
If you were convinced that it would benefit the next 
generation?
    Mr. Manar. First, let me answer that by saying I will be 
speaking for myself here. If it could be shown to me, proven, 
if you will, that a new system is better for future veterans, 
then I wouldn't oppose it. But, I would also ask, why not make 
it available to all veterans?
    Senator Burr. That is certainly something the Dole-Shalala 
Commission threw out within the organizations and felt that 
there was enough push-back, according to Senator Dole, that 
they would make it available to the future generations and an 
option to the past. I agree with you. If it is better, then 
everybody ought to be offered it.
    But let me just share with you, 13 years ago when I got to 
Washington, we have this--government employees all have an 
opportunity for their retirement funds in the TSP, whatever 
that stands for, and it had three options as far as I can 
invest in. I remember the first day I asked, why are there not 
more options, and they said, well, that is what there has 
always been. [Laughter.]
    And they made a change in the head of the TSP and we now 
have, Colonel, nine or something different options--
international funds and all this--and now Federal employees are 
actually in better shape about their retirement funding because 
of the additional options that were added to the Thrift Savings 
Plan.
    I only point that out to you because what we have is a 
unique opportunity, a unique opportunity to look at the 
population that is the most affected right now and figure out 
how do we integrate them through the system? How do we deliver 
the best quality of care and learn what we have been doing 
wrong and transition it for the ones that are still in the 
system? How do we look at the disability process and try to 
figure out, is there a better way to do it? Is there a way that 
is fairer? Is there a way that is more efficient? And that we 
take the opportunity to make that transition.
    I wish I could tell you how many man hours my office spends 
with veterans on disability claims because nobody understands 
how the process happens. And its usually on the close calls, 
which requires a call from me, or a call from the Senator from 
Hawaii, and if I fail, I am going to get the Senator from 
Hawaii to call on my behalf.
    But it shouldn't happen like that. It is pretty clear cut. 
Clearly, when you have got two different entities making 
disability determinations, one has to look at it and say, how 
can two different entities come up with two different 
conclusions? Because they are judging two different things. We 
understand that now. Is that right? Probably not for the 
future. Colonel, I was glad to hear you say, one is great.
    Ms. Beck, let me ask you, you support the idea of Recovery 
Coordinators. As you know, these coordinators hopefully would 
overcome the barriers of DOD and VA. The Commission's 
recommendation is that these coordinators be employees of an 
independent Public Health Service, but the decision has now 
been made that the coordinators are to actually be VA 
employees.
    One, what do you feel about Recovery Coordinators? Two, 
what do you feel about them as a VA employee versus an 
independent entity, and would they be able to exert a 
sufficient amount of authority over DOD employees if they are 
VA employees?
    Ms. Beck. Regarding the Public Health Service question--in 
an ideal world, that might work; but in the real world, having 
a Marine going to a Public Health servant before he can go to 
another Marine--it is not going to happen. So, the idea of 
having them be a VA employee and their authority would actually 
probably rely on, one, as I mentioned, that overlap of benefits 
to be able to legally access both sides. We can talk about it 
all day, but if they have legal obstacles to doing that, then 
they are not going to be able to do it.
    The other issue is, that Steve and I have discussed, is the 
option to allow to have that oversight structure in place--to 
ensure that they have the ability to maneuver within the 
Department of Defense and within the VA; and honestly, within 
the Social Security Administration, Medicare, and the 
Department of Labor. So, you are going to have to have those 
entities in place because these problems are going to happen. 
We all know they are going to happen. And, without some sort of 
ability to address those problems in the future, we are going 
to find ourself in the same place 5 years from now.
    So yes, we do support the idea of a Recovery Coordinator. 
You are going to have to find someone who has the ability and 
the initiative and problem solving skills to do this because it 
is not easy. Sarah, as you mentioned, she is her husband's 
recovery coordinator and that is not fair. She is his wife and 
she should be. So, that would be our one concern--that they not 
be able to have that buy-in from the other agencies.
    Senator Burr. I thank you for that. I also thank you for 
the fact that it was clear from your testimony, you are focused 
on outcome and not process. I am not sure that we can say that 
enough up here, because this is about outcome. It is not about 
whether we follow what the process is. It is about what comes 
out on the other end. And I think there is a tendency that we 
look at things from the wrong end. Maybe it is time we work 
backwards a little bit and say, what is the optimum outcome 
that we want and how do we get it?
    I actually think we are going through that process on a lot 
of things right now. It is difficult to absorb it all. I know 
it is for all of us who are asked to play a part in it. So, I 
implore all of you to stick with it, because anything short of 
attempting to do this, somebody will lose.
    Colonel, let me ask you one last thing. You raised, I 
think, a very important issue and that is without some type of 
permanent transitioning structure, how can any of us leave the 
jobs we are in and believe that: (1) a task will be completed, 
or (2) it will continue to evolve into what it should over 
time. Let me ask it from another side. Do you have any worry 
that creating a new bureaucracy within this difficult hand-off 
between DOD and VA will impede our ability to actually make 
this transition?
    Colonel Strobridge. Well, sir, I guess the only thing you 
can go by is based on experience, and not having one doesn't 
work. So, having been in OSD and looking at the structures now 
and talking with the folks there, you have some folks for whom 
this is a part-time job--they have other things to do, and you 
never know when something else is going to crop up that pulls 
them away from this. Right now, there is a lot of leadership 
emphasis on making sure this gets done.
    Senator Burr. How quick would this have to happen from your 
standpoint? What is the time line that it would have to happen 
where you would say, you know what? It has happened. We don't 
need another bureaucracy.
    Colonel Strobridge. Well, there is a provision in the 
Senate version of the defense authorization bill that would 
establish a joint office specifically to oversee the Joint 
Medical Record, which we certainly think is a good start. There 
would be some other things that probably ought to come under 
that, not the least of which is the Transition Coordinators.
    One of the issues that you have right now, you can have the 
greatest person in DOD who is assisting these folks through the 
DOD system; then, they hand them over to the VA and they are 
done; and now somebody picks them up at the VA who doesn't have 
the background. So, to us, part of that office's responsibility 
should be saying, what do we need to do to get them through--
not just to the point of VA--but until they are stable in the 
VA system.
    Senator Burr. Well, as somebody said, we are hopeful that 
Gordon and Gordon are actually mapping out all the transitional 
things that need to exist, and then it is an implementation and 
an oversight function.
    Colonel Strobridge. And a maintenance, yes, sir.
    Ms. Beck. Sir, can I make one point on that? It would be 
imperative that if you create such a structure, and to avoid 
the bureaucracy that you are talking about, that you actually 
absorb the functions of all the little offices that have popped 
up throughout the Department of Defense and the VA. Because 
right now, the VA doesn't normally know where to go when they 
have a problem within the Department of Defense, because there 
are so many different areas where they could try to resolve 
their problems.
    Senator Burr. Nor do we sometimes. Thank you.
    Chairman Akaka. Thank you very much, Senator Burr.
    I have more questions, but at this point, I just looked at 
the time and I want to praise all of you for your patience 
today. In a few minutes, it will be 4 hours that we have been 
here, and thanks so much for all of that. I am going to submit 
my questions for the record.
    Again, thank you so much for your time, for traveling this 
far. All of your testimonies and your responses will be helpful 
to this Committee and what we will be doing in the future and I 
thank you very much. I thank all the witnesses today. It is not 
every hearing that we get to hear from so many distinguished 
guests like you.
    I want you to know that we really appreciate you taking the 
time to give us a better understanding of the recommendations 
of the various groups so that we have a clearer sense of what 
is needed to move closer to making the transition back to 
civilian life as seamless as possible. You have been a big help 
in doing this.
    With all of that and just about 4 hours, this hearing is 
now adjourned.
    [Whereupon, at 1:25 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


  Prepared Statement of Hon. Barack Obama, U.S. Senator from Illinois
    Mr. Chairman, I want to thank you as well as Ranking Member Burr 
for holding this important hearing today. I also want to welcome and 
thank distinguished Members of the various commissions as well as our 
partners and friends in the VSO community.
    While there are different views in Congress about the war in Iraq, 
there should be no disagreement about the tremendous sacrifice being 
made by the men and women who are serving in Iraq and Afghanistan. They 
have performed valiantly under exceedingly difficult circumstances. 
They have done everything that we have asked of them. And when they 
come home, they should be able to expect the care and benefits they so 
richly deserve. Our military families and recovering servicemembers 
should not have to wage a second war at home to get that next doctor's 
appointment or receive that first disability check.
    Like most Americans, I was outraged to learn of the disgraceful 
conditions and obstacles confronting those who have served us with 
honor. That is why I am proud to have introduced bipartisan 
legislation, the Dignity for Wounded Warriors Act of 2007 (S.713), to 
address both the immediate and systematic problems uncovered in a 
recent Washington Post series about Walter Reed Army Medical Center.
    This comprehensive legislation addresses problems not only at 
Walter Reed but throughout the military medical system. The bill sets 
new standards for all outpatient medical facilities--including a ``zero 
tolerance'' policy for pest infestations and overdue work orders; 
streamlines the paperwork and red tape currently imposed on 
servicemembers and their families--especially with regard to the 
disability review process; increases caseworker ratios to provide extra 
support to servicemembers and their families; increases access to 
mental health services, including a new 24-hour hotline; and provides 
important new protections for family members, including health care and 
mental health services while on invitational job orders--as well as 
Federal employment protections for their jobs. In my view, a mother 
should never have to choose between caring for an injured son and 
keeping her job.
    I am proud that many of these provisions passed the Senate recently 
in a larger package focused on helping our wounded warriors, and I hope 
the House and Senate will complete its conference soon and submit this 
legislation for the President's signature. But more action is needed. 
The pace of change is too slow within the Pentagon and VA, and we have 
to consider other fundamental reforms that will help ensure our wounded 
warriors and our veterans are getting the care and benefits they 
deserve.
    I look forward to hearing from the panelists, especially the 
recommendations from the President's Commission on Care For America's 
Returning Wounded Warriors and the Veterans Disability Benefit 
Commission. I think we can all agree on the need to pursue some of 
these recommendations, such as the Dole-Shalala commission's call for 
better prevention and treatment of PTSD and TBI; and for providing much 
more robust support for our recovering warriors as they transition from 
the military to the VA. But Congress must also avoid ceding its 
important role in revising other complicated policies, such as the 
current disability rating system within the military and the VA. I 
share the Chairman's concerns, for example, over any proposal that 
would effectively cut Congress out of this important work.
    Mr. Chairman, we owe it to our returning servicemembers and 
veterans to get this right. I look forward to working with you and our 
panelists to consider the range of options and find the best approach 
to giving these heroes what they deserve.

    Thank you.
  

                                  
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